Eight Ways to Smash, not Just Flatten, the Coronavirus Curve

As a surgeon, I sometimes deliver bad news. The reactions are predictable: denial, anger, bargaining, depression and, eventually, acceptance. Dr. Elizabeth Kubler-Ross in her classic 1969 book, “On Death and Dying,” described how we transition across these stages of grief when we receive bad news. I see the coronavirus pandemic forcing our nation along a similar journey, but we can’t languish — we must get to the final stage, acceptance, so we can act and minimize harm. We are clearly not there yet.

On January 23, 2020 Wuhan, China was quarantined. I remember hearing the news and realized this was the biggest story of the decade, if not the century. Yet the lockdown of Wuhan was sandwiched between stories of therapy animals on planes and whether Superbowl Sunday should be moved to Saturdays.

On February 3, 2020 I presented to a corporate investment committee giving my perspective, as a doctor, on why Covid19, then only in China, would cripple the US, if not the world. I predicted that the virus would spread to Europe and the US and suggested selling equities and shifting into cash. I explained the Kubler-Ross stages of grieving, and how our country and most of the world was in denial. Most in the room looked at me like I was Henny Penny saying the sky was falling. I tried to tell my doctor friends — many of them laughed at me and said I was an alarmist. My friends would not listen. I tried to prepare as best as I could on my own.

In mid-February I shared my concerns with the White House. I stressed that our biggest issue was our inability to test and that without testing we wouldn’t even be able to isolate the first few hundred Americans with the virus. If we couldn’t isolate, this would spread like wildfire. I was amazed that the CDC was controlling the testing, and this was causing significant fatal delays and mistakes. After a few days, the White House responded, apologized, and offered to talk with me. In my email reply I stated, “No need to apologize. I am sure you are very busy. I am extremely concerned about testing being so centralized. Looks like this has been resolved given latest announcement by FDA/CDC (that day’s announcement which allowed a few more sites to test). I am still concerned about whether there will be enough testing kits? I won’t take up your valuable time with a phone call, but I would suggest stockpiling kits and trying to curb exports of kits, if possible. Since vaccine and treatment are at least a year away, early diagnosis and containment will be the only control of spread. This is not a matter of if, but when and to what extent.”

I (mistakenly) believed the many CDC/FDA announcements about getting millions of kits out in a matter of days. That never materialized.

As a doctor I kept seeing patients who needed urgent care. Along the way I was beyond exhausted and had spiked some low-grade fevers. In the Detroit area, I tried to get tested for the virus and learned there were no reagents available even for a frontline doctor. Only critically ill patients being admitted with symptoms would be tested. One internist told me he had sent a middle-aged patient to the hospital with Covid19 symptoms, who had also been hugging (a later proven) Covid19 positive bowling buddy, but the hospital wouldn’t test him as he wasn’t considered sick enough. He was sent home and died 10 days later.

I noticed I have lost my sense of smell (something many Covid19 patients experience) but otherwise have felt fine. I am pretty sure that I had an extremely mild form of the virus. But I can’t get tested. The good news for me is that if I did have it, I likely have antibodies. But again, no antibody test is available for me in the US.

I am frustrated as I see how New York is overwhelmed, not yet peaking, and while we are appropriately pouring resources into NY, soon other cities including Detroit, where I live, will be overwhelmed and a full response will be impossible. We are playing wack-a-mole with limited resources in city after city. This is no way to cure the epidemic. I believe that just as we get this under control, Fall will come and it will start all over again.

If we want to control this crisis and see our kids in summer camp and school in the Fall, we must start accepting the facts. Stop the denial, anger, bargaining, depression and accept what we must do. Here it is:

1. Stop Looking to China for Facts.

China claims to be going back to work and says it is back with no more new cases of Covid19. This is simply not true. Western journalists have been kicked out or their visas not renewed. Their kids are still not going to school. There are no known business events. The pollution charts are nowhere near pre-Covid19 levels. As in the book “House of God” by Samuel Shem, if you don’t check a patient’s temperature, you don’t know if there is a postoperative fever and infection, China reports no new cases because they appear to have stopped all Covid19 testing. Meanwhile, a funeral parlor is reported to have ordered thousands of additional funeral urns, Shanghai closed all its movie theaters and social media reports about any virus situation is immediately shut down. Let’s not forget what happened to the doctors who first reported the epidemic — they are dead.

2. Go to War Time Footing

President Trump ordered GM to produce ventilators, while other companies are changing their manufacturing to help in this war. Ford is also making ventilators. The hockey company Bauer is making face masks. Mr. Trump has to go further and start ordering companies to make antibody/antigen test kits, N95 masks, scrubs, hospital needs, reagents and necessary drugs. We can’t rely on China, India or even our allies. The majority of basic, life-saving ICU drugs are made in China and the hard-hit area of Lombardy, Italy (https://podcasts.apple.com/us/podcast/the-peter-attia-drive/id1400828889?i=1000470102859). We must rely on ourselves.

3. Convert Grounded Airplanes to Mobile Hospital Beds for non-COVID Patients.

Planes are empty or grounded. It is easy to take the seats out of planes. The planes have the filtration systems. Place cots and make simple stations for multiple patients with less threatening disease. Take the more stable, less ill patients and put them into the planes. Free up space in the hospitals for the sickest. As infection rates drop in a given city, move these mobile beds, doctors, and supplies to areas of highest and increasing infectivity. We are putting a lot of effort into converting stadiums and arenas, but as the infection wanes, these makeshift, temporary hospital wards will be dismantled. A plane could move from place to place without dismantling which would save time and money. Also, this will give so many more people who want to work a sense of purpose and productivity! And the empty airports can all be converted to space for even more patients who do not need the filtered air.

4. Immediately Stop Exporting These Limited Supply Life Saving Products

We have been shipping Covid19 test kits around the world (including China) since January and people are dying in the US because they can’t be tested. This is insanity. It was nice of us to ship masks and ventilators to China but now it is time to focus on Americans.

5. Start Producing Massive Amounts of Antibody Tests and Immediately Test all Health Care Workers and First Responders

Antibody testing is easier than testing for active infection. A simple finger stick, a few drops of blood mixed with the reagents and an answer in under 15 minutes. Simple, accurate and immediate. The FDA has approved one Korean company’s product to be sold in the US (through distributor Harry Shein). Other US companies such as Chembio, based in New York, have just sold half a million antibody test kits to Brazil. Biomedica, based in California, is selling to Europe. This is not meant as a criticism of these companies, but we need to keep these test kits here. We need a massive effort to get these antibody tests out to as many people in the US as soon as possible. We need to maximize the frontline health care workers and we need to get people back into the economy in many other jobs. As a recent Wall Street Journal editorial, my husband and I helped inspire, emphasized that we need these tests to get, and to keep, our economy going — we need to gear up and make antibody testing of the entire population a national priority (https://www.wsj.com/articles/got-coronavirus-antibodies-11585782003). Immediately.

I think I had Covid19. But I am not sure. If I could be tested, I could volunteer at a hospital and help out without fear of getting the virus. I wouldn’t require the same degree of personal protection equipment as an antibody negative individual. If Covid19 is like every other virus, then once you have had it, at least in theory, you are extremely unlikely to get it again. Every healthcare worker should be tested both for the virus and for having had the virus. Those that have had it can more easily work and help the growing influx of patients. Imagine a whole army of “supermen and women” immune to the virus (hopefully, like me). Society would begin to function again. Quarantine and lockdown restrictions could be relaxed. I believe we have reached a point where antibody testing is far more important than testing for active viral infection. Given the rampant ubiquitousness of Covid19, we should assume that anyone who has symptoms is positive. We already should consider that we are all infected or carriers of this disease. We need to figure out who has had it, who has recovered, and who is immune.

We have a tidal wave coming and we can see it. Our failure to act with testing for the virus caused the US to have the largest number of cases globally. And those are just the tested people we know about. The truth is that at least as many Americans have had the virus and cannot be tested. We need to do what the Netherlands is doing and test large samples for antibodies. They are learning, as the Italians and Koreans have said — many people have no idea how they got this virus, are asymptomatic, and, most importantly, immune.

6. Don’t Stop to Smell the Roses — Smell the Garlic

Until we have adequate testing, don’t ignore this simple symptom. Yes, there are other causes for loss of smell, but take it from someone who’s been there, the loss of smell is profound. Get a jar of chopped garlic and monitor your sense of smell along with temperature every day. If you can’t smell the garlic, even in the absence of other symptoms, quarantine for 14 days and wait for it to return. Then get the antibody test when it becomes available. Join those that can go out and help others.

7. Wear a Mask and Gloves

The CDC a few weeks ago said there was no reason to wear a mask, now they are backpedaling. What is the downside to wearing a mask? Nothing. There is so much discussion about aerosols and droplets — how big, how much, how far. Does it really matter?? The bottom line is that when we talk, sneeze, clear our throats, or cough we spread disease. Period. N95 masks protect our healthcare workers and those in close proximity to gravely ill patients. N95 masks decrease the risk of contracting the disease in high risk situations. For the average person, a simple, even homemade, mask of paper towels sandwiched between cotton can help to prevent the spread infection to others. Have you ever seen the particles floating in a ray of sunshine in your kitchen? Imagine thousands of viral particles doing the same. Just last week, Dr. Lydia Bourouiba from the Massachusetts Institute of Technology demonstrated the extent of particle travel in JAMA. The video says it all, https://jamanetwork.com/journals/jama/fullarticle/2763852. Wear a mask and decrease the risk of infecting others. Face masks also keep you from inadvertently touching your face when you are out and about. If you have gloves, wear those as well when you go out. To conserve, you can wash the gloves like your hands when you get home. Wash your hands when you remove the washed gloves. Let them dry for two days before wearing again.

8. Open Your Windows

For years, hospitals had open windows to decrease transmission rates of polio, measles, and TB. Now, we have closed window hospitals with sophisticated air flow systems. Yet, there have been numerous cases of Covid19 spreading in China in tall apartment buildings and on cruise ships, presumably through the duct systems. Ironically, in 2007, to study ways to decrease rates of influenza in case of a pandemic, British researcher Dr. Rod Escombe in “Natural Ventilation for the Prevention of Airborne Contagion” (https://core.ac.uk/download/pdf/13098227.pdf) found that just by simply opening the windows in rooms with tall ceilings resulted in twice the air flow exchange versus modern day, closed window systems. He estimated that in mechanically ventilated rooms, 39 percent of susceptible people would become infected after 24 hours of exposure to an untreated TB patient. This compared to a 33 percent infection rate in modern rooms with windows open and 11 percent in a pre-1950-style room with high ceilings and open windows. Open the windows at work (if you still have to go to an office or business) and do the same at home.

The Bottom Line

I once had the opportunity to do an arrested landing on an aircraft carrier. Seconds before the landing, they yell “Prepare, prepare, prepare!” Your heart is pounding, but in the blink of an eye, you grab your harness, push your feet firmly into the ground, tuck your head and take a deep breath. Seconds to get it right. I am yelling, “Prepare, prepare, prepare!” I hope you are listening. We have a window for action to save our people and our economy from maximum devastation. We must immediately move past denial and anger, and move to acceptance and action.