COVID-19: A Way Forward

Since the beginning of the coronavirus pandemic and the ongoing Personal Protective Equipment (PPE) shortages I have quietly wondered, "Where is the American Medical Association (AMA)?" Why weren't health care workers and their patients the FIRST consideration of the AMA rather than the making of CPT codes? Is it because the words "physician" and "patient" do not appear in their mission statement?

With an estimated 22 million people currently unemployed in the United States and with states making plans to reopen their economies, a medically cogent path forward out of this pandemic is desperately needed.

It is with that background that I had the opportunity to read this opinion piece by Paul Kempen, MD, PhD that I took the liberty of republishing here. Admittedly, there are no perfect answers right now, but we all need to do our part to bring some semblance of normalcy to our lives again since this situation is likely to continue for some time (I have taken the liberty of making minor edits and have added a few hyperlinks for clarity):

Personal Health is a Personal Responsibility to Enable National Health

Paul Kempen, MD, PhD

"It really amazes me as a physician and health care expert, that while the government and general population expect doctors, nurses - yes, ALL hospital health care workers (HCW) down to the janitor - to go to work every day to care for severely and clearly infected patients, the expectation that the general population cannot even perform daily tasks in low risk environments seems severely misplaced. Being out of doors has even been declared “illegal” in some places. We have seen the country “closed for business” and production capabilities, lives and personal welfare, decimated. If all HCWs are able to work in clearly infected environments, why are citizens unable to protect themselves in low risk environments? Why are there not clear and effective educational and production mechanisms for ensuring regular daily living activities promoted in all media at this time? I have NEVER seen a public educational clip on HOW to correctly wear a mask but have repeatedly seen “experts” without and improperly wearing masks. Are factories and businesses still (really) unable to provide PPE and distancing between workers? WHY? If we can put a man on the moon, we cannot provide education and PPE?

Of course, the lack of Personal Protective Equipment (PPE) has been the serious issue. Government/CDC/WHO “Expert Action” has been unable to address to date the singular outstanding shortage of N95 masks, gowns, and hand disinfectant, or provided accurate and specific instruction/education on personal protective measures. Instead, concentrating on ventilator production (to treat disease) and “testing” to identify infections remains “the answer”. In medicine, we typically test to identify infection based on symptoms - as a healthy, negative tested individual is not protected by the test (due to false negatives) and can become infected by those providing tests to hundreds per hour.

These deflective and reassuring measures apparently resulted politically from “overstated need” by “hot spot Governors” looking for “quick answers” and sound-bytes. Even our CDC “health care experts” got it wrong (or was this merely political decisions): CDC statements initially recommended that civilians should NOT wear masks (because of the shortage), when clearly, masks are the single most important protection against air-born, respiratory infection dissemination. The first thing I personally did when I heard of COVID in January was to order ten N95 masks. Even today, 4/16/2020, three months after the first diagnosed infections were reported in January, this country still does not have enough N95 masks for every citizen. Why? Sending in Navy Hospital ships to NY and LA flies in the face of “Carnival line contagion” episodes: After admitting only 40 patients, the USNS Comfort was infected. The USS Mercy was similarly infected. Will it be also “quarantined”? The medical personnel would have been better utilized on land based stations - but that big red “X” would have not been able to provide the political statement and reassurance in NY harbor.

We have been through infectious hysteria before: The HIV epidemic in the 1980s, which led to important “universal precautions” for self-protection. The SARS (2003) and MERS (2012) Corona infections occurred and should have led to testing and treatment mechanisms decades ago. Flu epidemics occur every year and kill 30-60,000 people-just like COVID and our lessons here should be applied for all future flu seasons-which are coming. Needed measures now include production and education to enable return to economic stability - the ONE essential of any country “at War”:

Instead of forcibly pulling citizens without masks off of a subway train, the CDC and government experts should have ramped up N95 mask production in January to insure at a minimum, one N95 mask per citizen per week. (Editor's note: To be fair, hind sight is aways 20/20) Make N95 masks universally available at no cost to everyone now, including child sizes. They can be disinfected repeatedly by baking at 180 degrees F for 30 minutes. This should NOT require 30 days for each state to insure production for each member of state’s society. (This is much cheaper than $1,200 checks for every tax payer!) Educational commercials should appear hourly and instruct ALL citizens how to wear masks appropriately, the difference in mask types and identify mask type abilities to protect you. Mandating everyone appearing on television to be wearing appropriate masks correctly, as examples to foster compliance, is as possible as legally forcing everyone on an airplane to undergo instruction on how to fasten a seat belt in 2020.

Surgical and home-made masks catch (only most) personal, exhaled droplets and protect to a limited degree those around you. N95 masks will, when correctly worn, eliminate 95% of particles in your INHALED air from reaching you if worn correctly. HCW are “fitted” for N95 masks when hired under OSHA mandates, that is, specifically instructed in proper use. Civilians need this instruction also.

Cut your beard off, shave daily to maximize N95 mask “fit” and effectiveness. Wear masks at all times when not alone and do not touch your face unless immediately after hand washing. Wash your hands frequently (whenever possible contamination occurs), shower and change clothing daily to reduce personal contamination.

If you show signs of infection, contact your doctor for definitive advice and wear at minimum a surgical mask at all times while avoiding others. DO NOT go to hospitals or drive through testing sites if healthy - these sites are high risk areas and those testing hundreds of civilians per hour may well be a significant vector for transmission from infected to those heathy. The tests require invading your body and with unknown hygiene - i.e. out there on the streets where there is no ability to wash hands between individual tests (and I am sure they do not change PPE between each person, given the shortage).

Testing, currently unavailable and with unknown reliability, should be reserved for those with probable/known infection and done in facilities with hand washing between individual tests, unless self testing kits become readily available and are dropped off/mailed in bio-infection labeled and protective packaging (which seems unlikely or reliably possible for general populations).

In addition, we should be testing ALL deaths for COVID presence, instead of declaring all deaths automatically as COVID, as appears to be the current methodology. This is needed to yield REAL numbers.

Insure production of ALL treatment/prophylaxis drugs in sufficient quantities and allow doctors the ability to practice prevention, prophylaxis and treatment tailored to the individual patient and their wishes with all available products - including “compassionate” and “off label” prescriptions.

Serious COVID infections occur in under 5% of all infections. Healthy children and young adults appear resilient. Release this mostly-healthy “herd” now, or when the “surge” is over and create the “herd immunity”. In any “war” the young and healthy are sent to fight and maintain the economy, but please, also provide the needed weapons to them (masks and sanitizers). They will volunteer! Perhaps this group is resilient because they are self-immunized by yearly non-lethal common cold coronavirus encounters which account for 20% all yearly colds creating crossover immunization/disease mitigation.

It is time we all recognize your health is YOUR responsibility. Quit smoking, overeating, passing “joints” and crack pipes and other high risk behaviors. The “opiate epidemic” suddenly disappeared from the news with the COVID19 emergence but it is not gone! As a nation, we must insure our economy and production to maintain wartime abilities. Not just tanks and jets, but drugs, testing, ventilators and PPE should have national priority for “in-country” self-sustaining production. Most drugs marketed in the USA are made from Chinese imported materials at this time. This must change. We must take charge of ourselves and our national security in war and disease. We must stop the media and government hysteria and work with facts, real facts, and not politically motivated reassurances made in the moment as acts of reassurance. Restart the economy to provide PPE and drugs tomorrow for all who need them.

In 1933, the worst year of the Great Depression, President Franklin Roosevelt stated in his inaugural address: “So first of all, let me assert my belief that the only thing we need to fear is fear itself - nameless, unreasoning, unjustified terror, which paralyzes needed efforts to convert retreat into advance.”

This was great advice then and seems especially pertinent on 4/16/2020 before we create another modern great depression. If we are at war, we need our economy to provide for the common good and protection of life, liberty and the pursuit of happiness. The media must be used to serve the people and not continue to create paralyzing terror."

I welcome thoughtful comments to this piece.

-Wes