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The amount of information distributed in print, social media, Internet and television on the COVID-19 crisis is, likely, unprecedented. Indeed, almost everything regarding this virus is unprecedented, from how murky its origins are even today (even intelligence agencies are investigating); its unpredictable but extremely high infectivity; its completely erratic disease behavior, from being completely asymptomatic to leading to rapid death; and, ultimately, its still-undetermined death toll.
This worldwide pandemic is also unprecedented in that it led in almost all countries of the world to significant shutdowns of national economies, with considerable certainty, causing the most severe worldwide recession since the Great Depression in the 1930 and, possibly, even exceeding it. In the U.S., we, within a few short weeks, have gone from the best economy in the history of the world and what is considered full employment (the lowest unemployment in the history of the country for every population sub-group) to over 30 million unemployed citizens. Moreover, all of this is happening with a presidential as well as congressional election looming in approximately six months which, of course, contaminates every decision-making process by local and federal governments.
We, therefore, here want to summarize, hopefully in completely non-partisan fashion, how we, currently, perceive the COVID-19 crisis. The emphasis is, however, on the word “currently” because, as will become apparent in this article, there is still surprisingly much missing in our knowledgebase about the virus that, at this stage of the crisis, one would have expected already to be known. At the other extreme, many facts concerning the virus, currently widely accepted as common wisdom, appear anything but fully supported by evidence. In other words, though all politicians, on both sides of the isle, constantly stress their dedication to “science,” most have absolutely no idea how valuable scientific evidence is really gathered and interpreted. That process is, however, of crucial importance in order to acquire actionable knowledge and, this is, unfortunately, where our (and other countries’) political systems have gone badly astray in their responses to the pandemic.
The one thing we know for sure about the COVID-19 virus is that it comes out of China. But everything beyond this is pure speculation. COVID viruses, in general, have a primary reservoir in bats. As the appendix -19 indicates, there are many different COVID viruses known in bats. Indeed, some have previously caused severe human infection (2003, Severe Acute Respiratory Syndrome, SARS, 2012, Middle East Respiratory Syndrome, MERS). In other words, a few among those many known COVID viruses have crossed the threshold from infecting bats to infecting humans and COVID-19 is clearly one of those.
It is now increasingly clear that at least parts of the Chinese government were aware of this fact already in early December of 2019. Yet, by December 31, 2019, when medical sources in Taiwan and Hong Kong warned that COVID-19 could cause human-to-human communal infections, the Chinese government, supported by the World Health Organization (WHO), still, vigorously denied this fact. Evidence in the meanwhile reported in news media suggests presence of COVID-19 infections in the U.S. and France already as early as in December of 2019. To separate China from the upcoming catastrophe, the WHO, however, named the virus SARS-CoV-2 (widely now called COVID-19) rather than, as is usually common practice, by its country of origin. The virus, indeed, originally was called the Chinese Wuhan virus.
As CHR ponders the essence of the COVID-19 crisis, questions arise. Image by Aaron Green via Unsplash.
We do not know why they, likely, lied. Explanations proposed in the media included among many others, economic competition; i.e., the Chinese government did not want only the Chinese economy to be adversely affected by the virus and, therefore, wanted to make certain other parts of the world would be equally affected. Proposed evidence in support: China closed air traffic from Wuhan, where everything apparently started, to the rest of China in December but, the Chinese government and the WHO argued against closing of Chines air-traffic to the rest of the world, including the U.S. Another probable too benevolent explanation was that, recognizing the seriousness of the situation, the Chinese government started “vacuuming up” worldwide necessary supplies, including allegedly purchasing one billion face masks.
We are not certain that those were the motivations (though there, of course, could have been multiple motivations) because those two motivations, and certainly the first, would represent a crime against humanity that deserves legal as well as economic punishment. Moreover, the argument also does not make economic sense in view of China’s strong national dependency on exports to the rest of the world. Our suspicion, therefore, is that there must have been another, better motivation and the only potential explanation we can come up with for the Chinese government’s outrageous behavior (the WHO only acted as a vassal to China) is an attempt at avoiding losing face. In Asian culture, loss of face is a very strong motivation. Assuming this to represent the underlying motivation, the question arises what would have caused loss of face for the Chinese government to an extent that warranted its extreme subsequent behavior?
COVID-19, indeed, arising in a free-air sea-food market, as had been the Chinese government’s explanation for the endemic spread of the virus would be embarrassing but, considering it happened before in China and the Middle East, it would not be face-losing event. It, however, most-definitely would be face-losing, if the virus had been the product of one of the county’s high-security infectious disease research laboratories run by the Chinese government. And there were two such laboratories in Wuhan, where the pandemic started, among them the Wuhan Institute for Virology, likely the world’s primary such laboratory for COVID research.
Only the embarrassment of something like this happening at one of China’s leading research laboratories, could have led to the degree of deceit pushed by the Chinese government since then and equated by some pundits and government sources to the deceit of the Soviet Union after the nuclear catastrophe in Chernobyl, Ukraine. Though the last thing we want to do is to engage in conspiracy theories, assuming these facts, indeed, to reflect reality, an even potentially more disturbing question arises: Was the research that led to this disaster civilian or military in nature?
We again want to reemphasize that there is currently absolutely no proof for the fact that COVID-19 escaped from a high-security research lab; nor is there any evidence that this virus was subject to militarization by virologists in a Chinese military facility but: (i) News reports have suggested that the Wuhan Institute for Virology is controlled by the Chinese military and that a new high military officer was in December dispatched to the Institute to assume administrative control after the seriousness of the situation apparently became clear to the Chinese leadership. (ii) If the Chinese military were to develop a COVID virus for nefarious military use, what would the likely properties of such a virus be? We would argue that such a virus should have four principal characteristics: be highly contagious, be “invisible” while being contagious, be deadly, and allow deniability for whoever sets it free. Do those characteristics sound familiar? They should because all four apply to COVID-19.
Investigators and governments around the world, including the U.S. government, have released statements that their investigations have conclusively confirmed that the genome of the virus has not been manipulated. We sincerely hope that this is true but would argue that, even assuming governments had absolute proof of such manipulation by Chinese military scientists, they, still, would publicly deny it because, even assuming everything to have occurred accidentally, it would still represent a war crime, and what would be the world’s choices be in response, a war?
It took a few months to recognize the unique infectivity of the virus, not only characterized by how easily it infected individuals but by the virus’ ability to be highly infective while not (yet) giving any symptoms to the viral carrier. What makes this virus so difficult to combat is the fact that, already days ahead of becoming ill, contaminated individuals, while still feeling perfectly healthy, will already be highly effective spreaders of disease. Moreover, a majority of people infected by the virus will never even develop symptoms; yet, still, be able to spread the virus aggressively to others.
How does one combat such a virus?
The answer is simple because there are only four combat strategies available to fight respiratory viruses:
(i) If a vaccine exists, the clear strategic goal must be to immunize a large enough portion of the general population to establish herd immunity, generally reached when at least ca. 60% of all people have immunity. This is clearly the most effective and desirable strategy. In case no vaccine exists, as is the case in the current COVID-19 situation, development of such a vaccine, therefore, must be a first priority.
(ii) In absence of a vaccine, early identification of the causative virus, diagnosis of initial cases and tracing and isolation of all of contacts must be the initial strategy. If this is done in early stages of an infection, it may be possible, to stop spread of the virus into communities. This is an important point to note because there exists now clear evidence that the Chinese government already in early December of 2019 knew how serious the outbreak in Wuhan was. Though there, of course, can be no guarantees, isolation of China from travel to the rest of the world might, at that time point, have successfully contained the virus in Wuhan. Allowed continuation of daily flights to most places in the world made that, however, impossible. As noted before, as now already recognized by local health authorities, first clinical cases of COVID-19 occurred on the West Coast of the U.S. and in France already as early as by mid-December.
(iii) Once a respiratory viral infection spreads into the community, there is no longer any chance of stopping its further spread, except for social separation, which most of the world chose to do in fear of overwhelming hospitals with COVID-19 patients. By that point, Northern Italy, Spain and other European countries (we on purpose do not refer to China since all numbers reported out of China cannot be trusted) had become worrisome examples for the virulence of this new virus. But there is (iv) yet another strategy, in the current COVID-19 crisis only pursued by a very small number of countries, like Sweden: allow the virus to establish herd immunity naturally by allowing low-risk patients to get infected as quickly as possible, while trying to protect high-risk patients from such infections.
We in these pages and in CHR’s COVID-19 Bulletins have repeatedly made the point that social separation is highly effective and an essential tool in combating respiratory viruses from spreading to the vulnerable; but we also have from the beginning expressed the opinion that it represents a mistaken strategy, as it was implemented in the U.S. and in many other countries, to extend the same strategy to everybody. As medicine in recent years has clearly learned how important individualization of health care is (i.e., personalized medicine), we appear to have forgotten this point in how COVID-19 has been addressed.
Simply shutting down national economies, simply, does not make sense!
Not only are the financial damages to national economies extraordinarily large and almost irretrievable but they are unnecessary. A large majority of individuals do not need to be protected from infections with COVID-19 because, they, overwhelmingly, will have only mild disease, develop immunity and will not take up hospital capacity. The patients who do overwhelm hospital capacity if all are infected at the same time, are higher risk groups which are easily identifiable by age and/or underlying medical conditions. It is mostly only these patients who must be protected from getting infected, if hospital capacities are not to be overwhelmed.
Studies suggest that this vulnerable population only unlikely exceeds 25% of citizens (Florida, for example, has a significantly older population than most other states; it, therefore, may have more vulnerable individuals). This means that roughly 75%, likely, require no special protection, may get infected but will quickly recover and build up herd immunity in the community that, at some point, will also start protecting the more vulnerable.
We have also pointed out repeatedly before, in these pages that following the advice of “experts” can, at times, be dangerous. The behavioral literature clearly demonstrates that, because “experts,” through their training and constant involvement in given subjects, are highly biased to in their field prevalent opinions, following their advice uncritically can lead to misguided conclusions.
We, unfortunately, have seen this happening: The President has been receiving advice from some of the best epidemiologist and clinical virologists in the world. But it is exactly their very special expertise that made them shortsighted in their advice. Here is an example: Though mostly physicians, none of the President’s expert advisers ever presented in their briefings to the public (and, therefore, likely to the President) similar demographic models as they daily produced on COVID-19 morbidity and mortality, for example, on depression and suicide rates, on increased mortality from declining availability of routine medical care and other unintended consequences of social isolation, such as, paradoxically, increased traffic death due to increased speeding when driving. And how about the enormous medical impact poor economic conditions have on public health? In other words, when we (and, likely, the President) received advice from “experts” on how to deal with the COVID pandemic, they told us all the good things social separation would do for bringing down mortality rates (and social separation, indeed, does bring down the mortality rate from respiratory viruses); but at what cost? The medical downsides of such interventions, those experts did not present in parallel. This is like a surgeon telling a patient that the surgery has a likely 99% chance of success of curing a disease, conveniently forgetting to tell the patient that it also carries a mortality of 80% with it.
In medicine, this is called an incomplete informed consent, and this is what we, the public (and likely the President), have so-far received from so-called “experts” who are responsible for the most severe economic crisis since the great depression. Though mostly physicians, they do not see (or at least sufficiently appreciate) all the medical collateral damages from their policies of social isolation and economic shut down. They, most certainly, do not understand (and care about) the economic damage they are causing to their country, with not only enormous consequences on national mental and physical health but also multigenerational national security.
Most of the damage, unfortunately, has been done and, as of this point, is irreversible. It will be our children that will have to pay back the debt we have been accruing within just a few short weeks and will continue to create for the foreseeable future. Current generations will not be able to do so. All we can do at the present time is trying to minimize further damages, and that means that government must re-open the national economy as quickly as possible. Yes, this may mean more COVID-19 deaths; but we cannot forget all the deaths from other causes that are growing in numbers because we are trying to prevent COVID-19 deaths. The law of unforeseen consequences is an omnipotent presence in medicine.
What will be the new normal?
We, of course, do not have the privilege of knowing what the future will bring; but we are pretty certain that, at least in the near future, the “new normal” will be very different from the old. Those who believe that one day, even once most businesses (that still will exist) will have reopened, our routines will be the same as before the crisis, will be quite disappointed. Not only will many store fronts, where we used to do our shopping, be empty and barricaded up, but our booming economy of the last few years will be a thing of the past. Unemployment rates will remain high for probably some years to come. Crime will increase, as it usually does in poorer economic times, while police departments will shrink in size because of decreasing tax income for cities.
Health care will also change in many different ways. The Genie is out of the box, when it comes to virtual medicine. Consultations via the Internet will become routine. Most importantly, however, hospitals will have to find a new framework in which they function that allows for appropriate function in catastrophic scenarios, like the COVID-19 pandemic, without society having to shut down the whole economy to protect hospital infrastructures. This will probably be the centerpiece of a national health care reform that appears increasingly inevitable. Maybe most importantly, however, there is no guarantee that next year there may not be another endemic, caused by yet another virus out of China or from anywhere else in the world. We better be prepared!
Hopefully, a vaccine against COVD-19 will be available soon; but there is no guarantee that there will be one within the foreseeable future. Until we reach heard immunity against COVID-19, whether through inoculations or via the natural way of community infections. COVID-19 will stay with us and we will have to protect the vulnerable from being infected. Until then, handshaking remains passé (and maybe even beyond that) and repeated handwashing and hand sanitizing will remain the norm. Face masks will remain part of daily life and, maybe, even will become a fashion item.
Fertility rates, already at their lowest since WWII, will further decline because that is what happens in difficult economic times. IVF cycles and other fertility treatments, of course, can be expected to decline in parallel. It will be a different world; we’ll better get ready!
This is a part of the May 2020 CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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