Right now, in medicine, nothing else matters as much as COVID-19

This horrible virus is not going away anytime soon. There, I said it.

We are currently in the acute phase of our response to the virus, fighting it at the peak of the curve with everything we have, which unfortunately is not much. Social distancing is our main weapon, which works by cutting off the virus’s access to fresh hosts, buying us precious time to process patients through our hospitals. Once there, we don’t have much to offer to patients with severe disease, besides a handful of experimental therapies with weak data supporting their use, lots of oxygen, tincture of time, and thoughts and prayers. COVID-19, the disease caused by the novel coronavirus, typically takes weeks to recover from: In the case of severe disease, if intubation and mechanical ventilation are required to sustain life, the statistics are quite grim for recovery at all.

We are not actually engaged in an epic battle against coronavirus, we are on a salvage mission

We already lost the battle. The only chance we had as a society at something that resembled victory was containment, and we failed. Poor leadership, poor planning, underestimating the threat, widespread denial, and the misguided “American exceptionalism” way of thinking got us to where we are today. People are dying by the thousands and the economy is shut down. The virus has already won. We are only able to limit the damage now, and save what is left of our society. It’s a salvage mission.

We cannot beat COVID-19 with the weapons we currently have

To actually vanquish this virus, we need a vaccine. Nothing else will do. Social distancing, when done properly, is great for containment, but it doesn’t actually eliminate the virus. Social distancing just slows down the rate that the virus can spread through society. Unless we never relax our policies of isolation, getting exposed to the virus is inevitable until it is eradicated from Earth, which can only be done with an effective vaccine.

But what about herd immunity?

The idea of “herd immunity” is not new: This is how our current vaccines help keep everyone safe, even if they’re not 100% effective. If enough people are immune to a disease, and a few are not, the disease has a hard time spreading like wildfire because almost everyone it meets is already immune. So, if enough people get COVID-19 and recover to develop immunity, won’t that stop the virus in its tracks?

In theory, the answer is yes…however the cost is unfathomable. For herd immunity to develop, the majority of the population will need to be exposed to the virus. Some experts estimate that about 60-70% of the population will need to be immune before we can rely on herd immunity to protect the rest of us from COVID-19. Other estimates place that number as high as 85% of the population. The problem comes when we look at the numbers, and just how much life would need to be lost to get to that 60-85%.

Let’s just focus on the numbers for the US, although keep in mind that this experiment would need to be extrapolated to the Earth’s population of roughly 7.8 billion people. It is estimated that there are about 328 million people living in the United States right now. For herd immunity to develop, a large proportion of people will need to have been infected, recover, and be immune to reinfection. (Let’s ignore the fact that we are not certain that infection and recovery actually grants immunity, but most infectious disease experts think it does.) So if we use 70% as the estimate for the percentage of people that will need to be immune to COVID-19 to grant herd immunity, that would mean that roughly 230 million Americans will need to have recovered from the virus. (Also for the sake of this example let’s ignore the significant number of people who get the virus and do not recover.)

Using the estimated mortality of COVID-19 of three-percent (likely a huge underestimate for various reasons*), this would mean that about 6.9 million Americans will need to die to pave the road to herd immunity. Not to mention that not everyone that recovers from COVID-19 makes a full recovery; many will have chronic health problems due to the virus that will last the rest of their lives. But wait, let’s make this estimate even more conservative: Since we know that deaths from coronavirus are rare in patients younger than 50, let’s just cut that 6.9 million number in half. Absolute best-case scenario for letting things run their course and getting herd immunity the old-fashioned way: about 3.5 million dead. Now remember, this is for the US only; extrapolate these numbers out to the entire world’s population and we get about 115 million deaths–but likely much more given mortality estimates have been above 10% even in many developed nations. Herd immunity through mass infection doesn’t sound like a good idea anymore, does it?

*There are so many reasons why projections are so difficult with respect to this disease. We don’t know the true prevalence because of lack of testing. We don’t know the true mortality since many fatal cases are undiagnosed. Also, mortality lags behind diagnosis by about two weeks for this disease, so as incidence (new cases) starts to slow down, the mortality (deaths) can continue to rise for two weeks or longer. Therefore, we won’t really know what any of these numbers truly are until weeks after the peak of the pandemic. The above figures are just my rough speculation.

This won’t just be bad for another month or so…it will last much longer

Experts think that we are at or nearing the peak of our curve now, and it is hard to imagine what comes next. But fighting the coronavirus isn’t like a movie, where after the climactic final battle the enemy is slain and the heroes are immediately rewarded with peace and prosperity. If we survive this frenzied phase of our battle against COVID-19, we are merely rewarded with the same levels of social distancing and death that we had a few weeks ago. We still need to go back down that same curve we climbed up.

After the peak of infection, followed about two weeks afterwards by the peak in deaths, we will still need to maintain the same precautions that we have been doing since mid-March. If we relax social distancing while the virus is still out there, it will simply come roaring back in a few weeks and we will be exactly where we are now. Actually we will be worse, since the healthcare system will still be at maximum capacity at the start of a second wave of virus, supplies will still be low, the economy will still be in the dumpster, and the morale of society will spiral lower when faced with the inevitable resurgence of the virus.

Best case scenario: We “win” (survive) the epic battle at the peak of infection, and are allowed to go back into hiding for many months until a vaccine is available.

We are stuck living in this “new normal” until there is a vaccine

Will schools and most workplaces be able to reopen without eradicating COVID-19? If the virus is still out there, would you feel comfortable going to see a movie with a hundred other people, while somebody is coughing in the row behind you? Even if a significant percentage of the population has had the virus and recovered, what about the millions of others at risk? Will you visit your elderly grandparents for the holidays without knowing if you will bring COVID-19 into their house after they have isolated themselves successfully for months?

There is also a real need for an antibody test for COVID-19. In a few months, if readily available. we could do a blood test on most of the population and see who really had the virus already and recovered. We can see who is immune, and what percentage of the population at large is not currently protected. This knowledge may bring us closer to being to reopen certain parts of society, but I am not optimistic that antibody testing is the solution to the COVID-19 problem.

What we need is a vaccine. It may take a year or longer to get a vaccine designed, tested, manufactured, distributed, and administered to most of the Earth’s population (making 7 billion doses might take awhile), but nonetheless, a vaccine is what we need. Widespread effective vaccination will be the answer to this pandemic, and will give us herd immunity without having to sacrifice millions of lives to get there. Until we have a vaccine we will need to continue social distancing, working from home, and essentially hiding from the threat of COVID-19.

Doctors, adapt to the new normal or become irrelevant!

As a physician, living through this pandemic has been quite an experience. Doctors, nurses, and other healthcare providers are in an interesting position right now: We are sorely needed on the “front lines” to help with the patients suffering from COVID-19, and at the same time our practices are suffering horribly. We live in fear of getting infected at work–or worse, bringing the infection home to our loved ones. At the same time, we are grateful to simply have a job during this time of record unemployment. We should also enjoy a more urgent sense of purpose in the work we do, at a time when so many others are stuck at home feeling impotent in the face of this disaster.

For most doctors practicing medicine in the outpatient setting, and especially procedural specialists like myself, we are looking at a long period of running an office without being able to see patients. Where I practice in New York, all elective and even semi-elective procedures have been cancelled, and we are really only performing procedures for true “life-or-death” emergencies in the hospital. All of our resources are going into dealing with COVID-19, and we just can’t spare the staff, personal protective equipment (PPE), hospital beds, ventilators, and medications to perform elective procedures right now. Not to mention the risk to the patients of contracting COVID-19 by coming to the hospital right now!

When this all happened, many doctors thought that they will just have to cancel things for a couple of weeks before it’s back to business as usual. Now that the reality of a long protracted war is starting to become apparent, I don’t think we can really just sit around and wait for this to pass. The good old days are over, and we need to deal with the reality of the COVID-19 age!

Here are the two most important things that would need to happen to return medical practice to normal in the COVID-19 age:

Hospitals would need to empty out and not be overwhelmed with COVID-19 patients.

Adequate PPE would need to be available for everyone so that no one contracts coronavirus while getting their routine mammography, or stress test, or colonoscopy. (I expect this will occur after the current surge of PPE use is over, and after the government, hospitals, private sector, and civilians around the world hoard millions of masks, gloves, and gowns…so in about a year or so if we are lucky!)

Until a vaccine is available and this damn virus is wiped off the face of the planet, there will be no “business as usual.” We as physicians need to adapt to the new reality. Practicing medicine in 2020 is now synonymous with treating COVID-19. We must all become very comfortable treating patients with this disease. All our patients are potentially COVID-19 patients. We cannot choose to stay at home and wait this thing out!

Furthermore, as physicians, it is our moral and ethical obligation to society to help any way we can during this pandemic. We have the education, skills, and experience to make a big difference in the world right now, so what are some of us waiting for? Even if we can’t go straight into harms way because of our own health issues or to protect vulnerable family members, there are still ways that we as physicians can help. Contact your local hospital to see what they need. Right now, your hospital is either in the thick of things and can probably use all hands on deck, or they should be gearing up for the inevitable surge which is coming soon.

All doctors must adapt to treat COVID-19 patients now, or we will become irrelevant. If we are waiting for the government to give the “all clear” sign, we are going to be waiting a long time. Hopefully those waiting on the sidelines have a good safe side gig to support their families and pay their student loan debt…I know that I don’t.

Right now, I am a gastroenterologist who also helps to treat the overflow of COVID-19 patients on the general medical wards. I switch back and forth between these two roles as needed throughout the day, but one-hundred percent of the time I am a doctor.

Know your enemy

Until COVID-19 is eradicated, we should be learning everything we can about this new disease. Every type of physician has something to learn about this virus. We need to know more about how it affects the body: Why do some patients have a mild course and other patients lose their life to the virus? We need good randomized trials of new treatments with adequate numbers of patients so that we can really know what we are doing with all of these potential therapies. We need good autopsy studies to learn exactly what is happening to COVID-19 patient’s lungs, kidneys, and other organs. We need to follow patients who have thankfully recovered from the disease to see what happens: Are they immune to all strains of the virus now? What is the long-term prognosis for their pulmonary function? Are there other long-term sequalae that we don’t even know about yet?

It’s difficult to formulate good research projects at the height of a pandemic, when all available bodies are taking care of patients on the front lines; but once we start inching back down that curve, we really need to use our superior human intellect to carefully study the tiny brainless killing machine that is known as the novel coronavirus.

With hard work, perseverance, and knowledge we will slay this dragon!