“Believe nothing, no matter where you read it or who has said it, not even if I have said it, unless it agrees with your own reason and your own common sense.” - Buddha
“It is hard to tell up from down these days, and it’s hard to know where, or how, we’ll land.” - Louisa Thomas, writer, New Yorker referring to Olympian Simone Giles
In my Germ Gems post last week, I applied the first five of my “10 Rules of Internal Medicine” to the issue of preparing for the inevitable—the next pandemic. As I suggested in Part 1, common sense can guide doctors, public health experts, and patients in making tough decisions. Moreover, lessons learned from mistakes made in the COVID-19 pandemic are particularly instructive. This week I apply 6 through 10 of the “Rules” for decision-making in preparing for the next pandemic.
Rule 6. Never trust anyone completely, especially purveyors of conventional wisdom. I emphasized the fundamental importance of trust in the doctor-patient relationship in several of my earlier Germ Gems posts (for example, August 26, 2020, “Trust and Hope in the COVID-19 Era”). Nonetheless, we all must be mindful of the fact that in providing their best advice, doctors not infrequently must rely on incomplete knowledge about the pathogenesis of a disease or what outcomes to expect. As the COVID-19 pandemic has made dramatically clear, the learning curve about a new disease can be steep. New data and evidence constantly are pouring in. In addition, recommendations regarding treatments and preventative measures (such as, vaccines and changes in behavior) are continuously evolving.
Therefore, never hesitate to question your physician about any treatment regimen or recommendation. Moreover, if a doctor’s recommendations get you started down the wrong path to a diagnosis or treatment, you need to change course, and your doctor needs to provide you a clear explanation as to why. In my experience, patients understand this (it’s common sense), and they appreciate when matters are caught early, before any real harm is done.
Conventional wisdom refers to widely accepted ideas and beliefs, often held by the majority of experts within a field; it is a source of information that is commonly used in making medical decisions. Relying too heavily on this form of guidance, however, can be potentially dangerous because the scientific evidence underlying it may not be all that solid. A case in point is phlebotomy or bloodletting.
This practice began around 3000 years ago with the Egyptians and was considered valuable in the treatment of almost everything (conventional wisdom). In 1799, George Washington was on his deathbed suffering from pneumonia and acute laryngitis. The three physicians caring for him all agreed that the best treatment for him was bloodletting. Thus, the first president of the United States was bled to death.
But an infinitely more deleterious source of information than conventional wisdom is medical disinformation. Transmitted by the Internet and promulgated by social media sources such as Facebook, Twitter, and Instagram, medical disinformation is a major threat to global Public Health. In fact, I may need to amend Rule 6 to read: “When making medical decisions, never trust social media.”
Rule 7. Most things are what they seem to be, except when they’re not. Because of its element of surprise, this is one of my favorite Rules of Internal Medicine. When everything is pointing in one direction and lo and behold a curveball comes along and the unexpected happens (e.g., a different diagnosis), it is quite humbling. The COVID-19 pandemic has been full of such surprises (see the Germ Gems post on October 21, 2020, “ COVID-19 Curveballs”). In fact, when COVID-19 erupted in 2019, many epidemiologists were predicting that we’d be battling an avian influenza virus rather than a coronavirus.
One of the biggest challenges we’ve faced in the COVID-19 pandemic is the emergence of variants (mutants) of SARS-CoV-2. While development of genetic variants of the coronavirus isn’t at all surprising (this is a form of evolution in action), the variants sometimes behave like they have a mind of their own. This is especially true with the Delta variant—a mutation that the entire world is now fighting.
In a recent article in WIRED magazine, “The Delta Variant Has Warped Our Risk Perception,” staff writer Gregory Barber states that this variant is making decisions that balance safety and sanity a lot more complicated. After the euphoric reopening of restaurants, businesses, schools, etc. this past June, America experienced a summer whiplash caused by the Delta variant. Cases, hospitalizations, and deaths boomeranged and not just in America but also in many other regions of the world.
The Delta variant is significantly more contagious, and it also appears to be more virulent than the original (wild-type) virus. Nonetheless, several experts predict that Delta will soon begin to peter out. On August 4, Anthony Fauci, director of the National institute of Allergy and infectious Diseases, predicted a turnaround of Delta sometime soon. It is suggested that the recent uptick in COVID-19 vaccinations, and in some states, reinstating of mask mandates, are helping get us out of Delta’s vicious grip.
But then what? What other variants are waiting in the wings? One such variant called “Delta Plus” emerged in India, as did Delta. To date, there’s no clear evidence that Delta Plus conveys enough of a benefit to the virus to allow it to dominate the original Delta variant. More data are needed to get a clear picture about any possible advantage of Delta Plus against vaccines. It’s also too soon to say whether Delta Plus is more contagious than the original virus.
The same message, that is, “it’s too early to know,” reflects the situation with several other SARS-CoV-2 variants such as the Lambda variant that originated in Peru. In an August 10 article in Reuters Health Information, “Beyond Delta, Scientists Are Watching New Coronavirus Variants,” it is suggested that the current vaccines are holding up against Lambda, as well as several variants that have yet to earn a Greek letter.
Rule 8. What your doctor doesn’t know could kill you. About 1 in every 150 people who develop COVID-19 are killed by the disease, but as everyone knows the odds of dying are greatly influenced by many factors. One of the most impactful risk factors for death is patient age (a recent meta-analysis estimates that the death rate can be as high as 16% for people over 90 but 0% for children under 4).
From the beginning of the COVID-19 pandemic, researchers have been characterizing the clinical factors, such as, age, gender, and a number of underlying medical conditions, genetic influences, and socioeconomic factors, like race/ethnicity and income level, that alter (increase or decrease) the risk of severe or fatal disease. And on top of all these human or host-related factors, the virulence of the infecting SARS-CoV-2 strain and vaccination status need to be taken into account.
This overwhelming complexity is why, in his book Preventing the Next Pandemic, Dr. Peter Hoetz refers to the situation as “. . . a perfect storm of forces—extreme poverty, upticks in human migrations and urbanization, climate change, and anti-science—likely work together to promote disease emergence. We do not have an approach to sorting out attributable risk for any factor.”
But this overwhelming complexity aside, have you ever considered that the risk of dying could relate to having an ill-informed or incompetent doctor? This is the basis for Rule 8 and brings us back to the huge importance of having a doctor you trust. For me, that means a doctor who keeps up with advances but also knows when to recommend getting help, that is, a second opinion from a trustworthy specialist or, as in the case of a pandemic, a reliable source of information, such as, the Center for Disease Control and Prevention (CDC), the National Institutes of Health, the World Health Organization, or the Food and Drug Administration. The good news is that after some early missteps in responding to the COVID-19 pandemic, all of these public agencies are getting up to speed in preparing for the next pandemic.
Rule 9. Timing is everything, and sometimes time is the cure. In treatment of many medical conditions, initiating treatment in a timely manner is crucial. One of the best examples is the treatment of bacterial meningitis, a life-threatening infection of the meninges (covering of the brain) that responds to antibiotic therapy. But treatment must be given promptly, when the clinical features fit the diagnosis even before laboratory confirmation is available.
In the treatment of COVID-19, it is also clear that prompt administration of drugs found effective in randomized clinical trials can be life-saving. This is also the case for certain types of supportive care. Early in the COVID-19 pandemic, some of the most troubling mistakes were prompted by inadequate personal protective equipment and shortages of ventilators and oxygen. These problems need to be resolved in preparation for the next pandemic.
In terms of timely treatment, the administration of an effective COVID-19 vaccine can’t be beat—it nips the SARS-CoV-2 infection in the bud (before clinical manifestations are manifest). Currently, a contentious question is whether “booster” vaccines should be given. A booster vaccine is now recommended by the CDC for some immunocompromised people, namely, organ transplant recipients. And the Biden administration states that come this fall, boosters should be available for nursing home residents and healthcare workers, followed by older people. (I can hardly wait.)
As for the second part of Rule 9 (“sometimes time is the cure”), everybody was hoping that over time the infection caused by SARS-CoV-2, namely COVID-19, would die down and go away all by itself, just like the infection caused by SARS-CoV-1, called Severe Acute Respiratory Syndrome (SARS), did in 2004, after a 2-year run. But sadly, this isn’t going to happen with SARS-CoV-2.
Rule 10. Caring is always important medicine. One of the most disappointing aspects of the COVID-19 pandemic is its politicization. At a time when we should all be pulling together and helping people get vaccinated and when needed, promptly treated, anger has erupted in many areas of the U.S. and even abroad. In the U.S., anger is sidetracking both those who are against or in favor of science directing our responses to the pandemic and of government’s role in addressing the pandemic. For the most part, however, the medical and healthcare communities are in favor of science and of government support where it’s needed.
In the discipline of internal medicine, Francis Peabody, a Harvard University physician, teacher, and humanitarian was famous for his emphasis on both the science and art of medicine. In a 1927 landmark publication in the Journal of the American Medical Association “The care of the patient,” he introduced the idea that caring is the secret to caring for a patient (“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”)
In a New York Times article this past March, “14 Lessons for the Next Pandemic,” Dr. Reed Tuckson, co-founder of the Black Coalition Against COVID-19, provides one of these lessons in, “Look in the Mirror and See Who We Are.” He suggests, “This pandemic has shown us who we are, at a level of clarity that is shocking to most people. It’s hard to imagine there are many people in this country who really don’t care about others. That is the scariest thing, it takes your breath away and you can diagnose everything else that is happening in our society through that lens.”
But there’s good news in this context too. In an effort to get more COVID-19 vaccine jabs into arms, the Biden administration included the first acknowledgment of the importance of barbershops and beauty salons in communities of color. A new initiative known as “Shots at the Shop” engages Black-owned barbershops and salons to serve as health promoters and vaccine sites. In so doing, it reflects a movement within the personal-care industry that has been underway for many years. It also builds on prior local efforts before and during the pandemic.
In a recent Zoom-supported discussion at the University of Minnesota on the role of vaccine mandates in institutions of higher learning, Dr. Stephen Thomas (he goes by “Dr. T”), the director of the University of Maryland Center for Health Equity, told of the success of the program in getting people of color vaccinated. He suggested that maybe what’s needed in America is a “mandate for kindness.” It makes no difference that this idea is coming from the “personal-care” industry. It is all about caring for others.
