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The problem was well described by a team in Italy (Mirco, 2020). [Nacoti Mirco, Ciocca Andrea, Giupponi Angelo, et al. At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. Catalyst non-issue content. March 21, 2020;1(2). doi:10.1056/CAT.20.0080.]
They conclude that Health Care as the epicenter of new cases. Look at Northern Italy and New York City. First, they both have great hospital/health care systems. [Note that the initial area in China is absent from that list]. Once the infection is spread widely, it will continue to spread because of the health care system and all the people that are involved. The list includes cleaning, first responders/police, nurses, lab techs, doctors, security, patients who want a test, patients there for another reason, nearby clinics, and folks taking away bodies.
But hospitals are good at infection control, right? If you look at the activity of air traffic control towers when they found a positive virus, you'll see what effort folks believe they have to go through to make a place safe. If a virus is highly transmissible, then it's virtually impossible to accomplish the same thing in a healthcare environment since people are coming and going and reinfecting any place you clean. One cough or sneeze, and the viruses are everywhere again. Imagine all those viruses from the machines and people flying through the air and onto surfaces. We have to assume that all hospitals are virus factories and no amount of protective equipment (except the stuff that looks like you are an astronaut) is going to protect them. So we must first assume that people in the healthcare system either are infected, were infected (and asymptomatic), or will get infected. And that includes everyone from first responders and anyone dealing with the dead.
I know that there are endless calls from health care workers asking for protective equipment to save them from infection. In fact, the equipment is protecting them from severe infection. If you get infected with a few viruses, you can beat it. If you get infected with 10,000 or 100,000 viruses, you start the process with a far higher challenge. SO we need to protect them from severe infection. But we should stop acting like the equipment is keeping them from being infected. Healthcare workers are getting sick at high numbers. What about the rest? We know that many get an asymptomatic case. There is likely an enormous number of people that developed a mild condition or were totally asymptomatic; they almost certainly have nothing to worry about. The serology test should answer that question very soon.
The conclusion that health care is spreading the illness means adding more care environments is making the problem worse. Places are expanding hospital beds into convention centers. The addition of additional hospitals is definitely going to further spread this disease since it will be impossible to make the new hospital environments sterile and free of viruses. For now, the "better" your medical/health care system, the worse the spread gets. In this case, less hospital care is more helpful in terms of slowing the spread.
Testing too, is a problem. Testing and case detection before widespread community spread made sense. That time is past. The folks who test others (often offsite) will almost certainly get infected since positive folks cough/sneeze when you stick something down their throat or up their nose. In heavily infected areas, we now only test folks who are almost certainly positive, raising the risk.
What about the protective gear for folks doing testing. The protective gear and the testing stations are far less impressive than the equipment used in China/S Korea/Singapore/Taiwan. With the amount of testing we are doing, we simply cannot provide the protection offered in the early stage in those countries. We're slowing testing now. Why are we testing except the hospitalized? Really like this is a tough diagnosis to make? Stop infecting healthy folks who are doing the testing, or the folks who follow the person who just got tested.
What about social distancing? Meanwhile, everyone else is social distancing. Is that helping? Indeed, it is having some intact but with healthcare workers, not social distancing and riding public transit, perhaps the public's social distancing is mainly keeping them away from folks in the health care chain. The real problem is many will want to escape severe social distancing and flee areas of infection to other places so they can avoid the misery and social isolation. That, too is furthering the problem; many people recently contacted a person in the health care system.
Finger wagging and admonitions may make one feel better, but they won't change human nature. And we live in a country without borders between states. One common problem with our response is the common statement, "you are being selfish." This further creates a me vs. you dichotomy and further harms the "we are all in this together" argument. We need to listen to people who are fleeing New York, not treat them like criminals. And we need to remember that we are a nation of independent thinkers; that reality isn't going to change, and we are not going to accept the police, forcing us to "behave."
Social distancing made sense in the beginning. But we have to accept that slowing the spread is related to changing the spread caused by health care; health care is the only place where people are exposed to large amounts of viruses and NOT social distancing. Health care is the likely 24/7 cause of the spread, not children going out to a playground.
So what then?
It may sound heartless, but we must give up quicker in our treatment strategy and accept the reality that the treatment is the problem. Hospitals have to act quickly and decisively in life and death decisions. By providing the best of care to every patient, we are ensuring that the virus spreads widely and rapidly. We are also exposing our health care workers to higher and higher levels of viruses and placing them at risk for a more severe infection. By now, we know who is likely to make it and who won't. As a public health measure and to protect the lives of others we need to be honest with the folks and family of the people who have minimal chance of survival.
We must eliminate as many people as possible from being involved in the healthcare system from the community to the last rites. Using ice rinks for morgues are just furthering the number of people who are getting infected. The virus survives the cold. Instead, we need to eliminate the bodies of the dead ASAP and limit our contact with them.
The "stay away" from the hospital message should be loud and clear. If you can stand and sing happy birthday, you don't need to get in line for a test. Stay home, rest, stay in bed. Take acetaminophen.
We need to distribute a $10 fingertip pulse oximeter so that people could decide when they need to go to the hospital. One paper (Cascella, 2020 ) implies the number might be when the pulse ox gets below 90%, and your RR is above 30, then call. This is not medical advice, but a call for the system to provide guidance to patients and a reminder that going to the hospital should be a decision made between you and your physician. We need our health care system to provide us all with clear guidance when exactly folks should come to the hospital, and based on numbers and symptoms. The health care system must settle on a standard that various for different individuals, distribute it, and expect that people follow it. [Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, Evaluation and Treatment Coronavirus (COVID-19). In: StatPearls. Vol Treasure Island (FL): StatPearls Publishing; 2020. PMID: 32150360.]
We need the instant serology ELISA test so we can identify who has antibodies so they become our first responders and treatment providers. [Amanat F, Nguyen T, Chromikova V, et al. A serological assay to detect SARS-CoV-2 seroconversion in humans. medRxiv. March 18, 2020:2020.03.17.20037713. doi:10.1101/2020.03.17.20037713.] Eventually, we should only allow "immune" people to be involved with the care of the sick or involved in testing. Thankfully this is coming to the US and to the UK!
We need to keep vulnerable out of the system since they just clog it up with more illness. The higher deaths in Italy make it even more clear that the extraordinarily elderly and those with severe illness or limited immune function must self-isolate. That also means not asking retired doctors to help unless they have antibodies per the above test. Nor should we ask any health care worker who is a high risk to participate until it is known they have antibodies. Otherwise, both are just vectors for more illnesses. The enormous numbers of infections and deaths of doctors in Italy have already demonstrated this problem. And we see it in Massachusetts. We need truth from hospitals, not unbelievable denials like, "Based on hospital data, broad implementation of CDC-guided infection control procedures at the MGH, and significant community spread in Massachusetts, we believe the vast majority of these individuals did not contract the virus at work." It would be more helpful if hospitals just admitted that this is inevitable. Given the risk of severe infection with high viral load, only those who have successfully beaten the virus should be treating patients.
Stop the lie that a lack of social distancing is the most significant cause of infection spread, and we can ignore the impact of a health care environment that is a toxic mess of viruses. Social distancing certainly helps, but is it 1%, 5%, 95%? At the least, let's be honest and willing to admit we don't know. Let's protect and emphasize the need to isolate our vulnerable population, but let's acknowledge that isolating the rest of us may be futile if the health care system is spreading the virus like wildfire.
Let's admit that we have a highly transmissible virus and a hospital system crammed with people. There is an element of our society that is spreading the virus quickly and in high numbers - just look at the number of infected and sick police and health care workers. We can assume that anyone they are in contact with is also at risk. If we are willing to take the risk of leaving the health system open, let's be ready to open up other environments where folks can have some space.
The health care system is the center of the epidemic, and the solution requires efforts that limit any interaction with a potential, current, or infected person with SARS-Cov-2. It makes no sense to put all our efforts into isolating the population and doing nothing to stop the spread that is happening due to the health care system.
Why Develop This Content: An Alternative Narrative and Analysis of COVID-19 Data