The day everything changed was not unexpected. Everyone in health care knew that as improvements in travel over the past century had made it easier for people to get around the world quickly, it would do the same for diseases.
To a large extent, we had forgotten how dangerous infections could be. When Alexander Fleming discovered penicillin in 1928, physicians were understandably nervous about injecting mold extract into people. When they saw it cure pneumonia patients on the brink of death, it was hailed as a miracle drug. It was assumed that antibiotics could cure anything. My own patients expected to receive an antibiotic for any illness, whether it was needed or not. As such inappropriate use increased, so did bacterial resistance. The original dose of penicillin was a mere 50-100 units. The current dose of injected penicillin for strep throat is 1.2 million units. Pseudomonas was not even recognized as a pathogen capable of causing problems before 1960. It quickly became a major problem, resistant to numerous antibiotics; it has even been cultured out of iodine bottles. Multidrug resistant tuberculosis has worried infectious disease specialists because one infected passenger can expose everyone on a commercial flight and any close contact in the airport as well. Potential curative treatment is available for these bacteria.
Viruses remained a major problem. The term “vaccine” refers to cowpox, or Vaccinia. Giving a small dose of Vaccinia provided immunity against smallpox, or Variola, which was extremely contagious with a high mortality rate. Since only humans carry smallpox, after years of global immunization efforts, it was declared eliminated in 1980. World War I had up to 11 million military and up to 13 million civilian casualties. The 1918 influenza pandemic infected an estimated 500 million, with up to 50 million deaths, twice as many as the war itself. My mother grew up in Dayton, Ohio, in the 1930s and told me that all the swimming pools in town would close in August, because that was polio season. Parents were terrified of infantile paralysis, and rightly so. My mother-in-law was a nurse, and her oldest two children were the third and fourth children in Medina County, Ohio, to receive the Salk polio vaccine; the pediatrician’s children were the first two. When I was in medical school on a pediatric rotation, we would admit two or three infants a night for possible meningitis. Within a year of starting hemophilus B immunization that number was down to one a night, and within three years we would see one every week or two. It was thrilling to see the response and know such a simple thing was having a major impact. Now we have immunizations against hepatitis B, polio, diphtheria, tetanus, pertussis, hemophilus, measles, mumps, rubella, rotavirus, meningitis, and influenza.
With every new disease, new antibiotics or immunizations or other treatments were brought out to fight it. We became complacent, so serenely sure that there was no danger in germs any more that hospitals had to keep reminding their staffs to wash their hands. I am in the fifth generation of physicians in my family, the only generation that could delude itself into thinking we would not catch anything fatal from one of our patients.
“The Andromeda Strain” was science fiction in 1971, but planning for a possible worldwide pandemic was already in progress. Multidrug-resistant tuberculosis was slow in its progression but with limited treatment options and high potential mortality. SARS and insect-borne encephalitis spread widely but remained relatively localized. Ebola, rapidly fatal, easily spread, and with no treatment other than supportive care, caused more dread. Its origin in an area with so little medical infrastructure and protective gear made many of us uneasy. When the first cases were found in the U.S., there was not always a swift and appropriate response. That a major outbreak did not occur was due more to luck than skill.
Physicians have long training in science. We are supposed to use logic to approach problems and remain calm while we treat patients. Mass casualty drills often include the need to deal with frantic families trying to find a loved one or provide information to media to mitigate rumors. This training should have prepared us for overreactions to new diseases from both the public and the authorities. Here in Ohio, Amber Vinson, a nurse, had gone to a bridal dress shop in October 2014 a few days before being diagnosed with Ebola. None of the staff or any other customers became ill, but staff quit and customers canceled orders. Their fright destroyed the business, which closed permanently three months later in January 2015.
In December 2019, when the first COVID cases were reported in China, we all knew the disease could reach around the world. When the first cases were reported in the U.S., we knew COVID had arrived and would spread here.
The panic this disease induced was largely because we felt helpless. Having become accustomed to effective treatments being available for everything, just letting the virus wreak havoc with no cure available was unacceptable. Lack of protective gear did not make anyone calmer. Masks and gowns were in short supply, with the usual profiteering rendering “front line” work even more difficult. At our hospice, even surgical masks were in short supply, and N95 masks were all but unavailable. Cloth masks were an alternative, and I personally made over 700 of them in three months.
The Amish soon quit using masks and social distancing, resuming their normal activities because they could not operate their farms and businesses otherwise. As a result, they faced what one hospital called a “tsunami” of cases as COVID swept through their population. Less than six months later an Amish community in New Holland Borough in Pennsylvania had achieved herd immunity with 90% having recovered from the infection.
The rest of us tried to avoid the illness by any means we could find, depending on the experts to tell us how. We were initially told that masks were not effective. Shortly thereafter we were told that they did work after all, and officials admitted that they lied about it in order to keep supplying first responders with masks and gowns, since they were in short supply. Instead of wearing a mask, they said, just keep six feet apart since COVID cannot travel farther than that between individuals, and this six-foot measure of social distancing was established science. Six feet, or two meters, of distance was based on studies by Carl Flugge, an 1897 German hygienist trying to determine how far a tuberculosis patient without a mask could spread infectious particles when he coughed. Anyone who questioned whether data from 123 years ago about a different organism was relevant to the present problem was derided for denying science, and often forbidden to even ask such questions on social media.
Soon, rather than six feet apart or a mask, the mandate became six feet apart and a mask. Other mandates followed. We were told that COVID could live on surfaces, leading to requirements to sanitize tables, chairs, counters, railings, and everything anyone could touch, every thirty minutes. Libraries were keeping returned books in isolation for a week before reshelving them. Even though further studies showed the virus does not survive capable of causing infection on surfaces, the guidelines have not changed.
After telling us it was unsafe to send children to school, leading to a full year of virtual learning – in practice, learning virtually nothing – they then said children could return with masks and six-foot distancing. Later, we were told three feet was sufficient in a classroom. Runners on track teams were compelled to try to train and compete while wearing masks. Band members faced the absurdity of cutting a hole in a mask for the mouthpiece of a wind instrument. Swimmers were told to wear masks in the pool. When vaccines became available, we were told that they would eliminate the need for all these precautions. Now that the new school year is approaching, continued mask mandates are in the offing, even for staff and students who have been fully immunized. No explanations are offered for any of these mandates other than “it’s the science.”
A “temporary” two-week lockdown to break the chain of transmission was ordered. The lockdown was extended over and over, fourteen months in Ohio and longer in some states. We were told that these measures would be necessary until we had a vaccine, but that this would take two to five years.
Effective vaccines were developed and available less than ten months after the lockdown began. We were assured that vaccinations would get our lives back to normal. Multiple vaccines, proven effective, available free, and administered to over 100 million citizens, is now not enough, with some experts calling for renewed restrictions.
Unfortunately, the response has been worse than the disease in many respects. So many people have lost their jobs, gone bankrupt, closed a small business forever, been unable to pay rent or buy groceries. The economic cost of locking everything down has been tremendous, and may be largely irreversible. Providing “relief” in the form of unemployment benefits that were larger than a pre-COVID paycheck has created another problem. First, those funds were often not used for paying rent, because of a CDC moratorium on evictions. Courts have now stated that the CDC does not have the authority to halt evictions, but the cash flow damage was already done. Telling landlords that the rent must eventually be paid does not help them meet their own ongoing expenses. Second, this money discouraged returning to work, because many people found they could make more money with fewer expenses by staying home. Third, and the most worrisome in the long run, is that this is not a sustainable fiscal policy. Inflation is already rising as more and more money is being printed with nothing to support it.
The medical cost has in some ways been even worse. Requirements that nursing homes admit COVID- positive patients led to thousands of direct deaths. Most COVID- positive patients tend to die in the hospital receiving aggressive care, sometimes bankrupting families. For the elderly, this means extreme stress on an already tottering Medicare system. A few whose health was already poor have been referred to hospice, and some have been cared for in the inpatient unit where I work. One of my colleagues was so nervous about the risks of COVID that he was doing virtual visits rather than entering the patients’ rooms, which makes giving good care far more difficult.
Indirect deaths from COVID have increased in our hospice population. Hospital and nursing home visits were often forbidden, and socialization activities were canceled. One elderly lady told her hospice doctor in tears, “I don’t know what I did to make my daughter so mad at me – she hasn’t visited me for days and days.” She kept apologizing over and over to everyone she met, as her confusion was too advanced to understand pandemic quarantines. Patients who have dementia need human contact more than ever. Being essentially kept in solitary confinement is the exact opposite. So many have declined and died much sooner than they would have otherwise, just from loneliness.
Trying to base our actions on science is laudable, but science is not a monolith of unchanging certainties. Rather than saying that, in what may have been an effort to avoid confusion, the authorities and media have made simple definite statements. At times, they have given the public outright falsehoods. Vacillating on changing guidelines to match new information or making an announcement on when it is safe to return to normal has been widespread. Basing recommendations on fear of looking weak, or wrong, or foolish, or risking lawsuits, or on whatever the latest public opinion poll found, is not in the public interest.
One of the longest lasting harms to come from the pandemic response was the erosion of public trust in science. Politicians have long been mistrusted, but doctors and scientists were felt to be reliable. But now those doctors and scientific experts have lied and admitted it. They have promised returns to normal life after a temporary lockdown, or after we have a vaccine, or when the caseload drops, and gone back on their word. For the first time, the CDC is now included in the category of untrustworthy self-serving hypocrites by the general public, not just by a fringe of conspiracy theorists. It will take us a long time to recover that trust, if we ever can.