What We Know. What We Don’t.


Leonard Zwelling


         In this superb article sent to me by son Richard, a lot is written about what we have  learned  over these covid weeks, but there’s still a lot we don’t know. Primary among the unknowns is exactly how this virus kills people and why some breeze through the illness like a seasonal cold or less and some wind up on the ICU. I will leave the medicine to others who have been on the front lines, but it does seem likely that there are several different clinical manifestations of covid-19 with some pretty bizarre presentations from renal failure, to central nervous system clotting, to cytokine storm, to an inability to oxygenate at all.

         The clinicians and their scientific partners will figure this out over time. They will also figure out how to treat it in the early stages and even when the disease has advanced. Ventilators may or may not be required. Anti-coagulants may be. Medications that block cytokine storm may be of use in some subset of patients and cardiac as well as pulmonary support may make the difference in the very ill. I have confidence that we will figure this out.

         The larger issues still need addressing and we need to start acquiring the data now because, despite what the federal government has said, the U.S. response to the coronavirus has not been the best in the world, a world where many different strategies were employed with variable success. Australia and New Zealand chose extreme measures of mitigation and these have thus far worked, but they are moving into fall in the Southern Hemisphere and we have to see if their short-term fix will hold up. Germany quarantined its elderly and traced cases and tested and it seems to have done pretty well. By contrast, Sweden basically chose immediate herd immunity with protection for the elderly and the high school/college crowd. We should see whether this was the right call as fall approaches. For now the Swedish infection rate is the highest in Scandinavia, but we shall see if the Swedish long-term plan was the right one if Denmark and Norway have second wave cases and Sweden does not.

         The United States has no plan. All of the states seem to be plotting their own courses. The federal government came out with recommendations, but has no power to hold states to them and many red states are ignoring the phased approach recommended by the CDC, NIH and FDA experts. America wants to open and many governors are having a hard time resisting the pressure despite the fact that the threat of covid-19 and death from it has not abated in their states.

         We still don’t know if infection confers immunity to further infection and if so for how long. This is very important as it provides a window into what might happen in the fall and how many people may be susceptible to infection should the virus return. We don’t really know if it will, but we should assume so and be ready this time.

         What does ready look like?

         It does not look like sending everyone home and stopping elective surgery and research is a viable answer.

         First, we must have rapid on-site testing for coronavirus so that the test can be administered in ERs along with the ones for strep and influenza. That differential will face doctors all over the world in a matter of a few months, no doubt. Treatment varies depending upon early diagnosis. A rapid test for coronavirus must be available soon.

         Second, we need to have a reliable test for the presence of antibody and know whether that presence confers immunity. If we have the test and the antibody’s presence indicates at least transient immunity, those testing positive can get back to work and those testing negative who come in contact with a positive person can be quarantined.

         Third, people will have to get used to the masks, gloves and social distancing. You may have shaken your last ungloved hand for a while.

         Fourth, we need to learn more about protecting the vulnerable in nursing homes and other tightly packed situations.

         Fifth, we better get used to the lack of concerts, sporting arenas, movie theaters and political demonstrations en masse. They may no longer be able to be made safe.

         Sixth, the airlines better have a plan. They don’t have one yet. Both the personnel on the planes and the passengers have to devise a method of social distancing. Ending vacation travel will never fly in the U.S. Masks will be mandatory for everyone and thorough cleaning of planes will be a must. What to do about the bathrooms on the planes is still up in the air.

         Seventh, an even-handed, unbiased assessment of the benefits of mitigation must be made. It may turn out that most cases of covid-19 were acquired in households. If that is so, the mass social distancing outside the house and the lack of it within households might have been an error. We need to admit to errors. It is the only way we will get better at dealing with this virus.

         Finally, we need to get through our collective heads that this is nowhere near over. As Dr. Fauci has said, this virus will be with us for a while. We cannot run from it. There’s no place to hide.

         We started out knowing little about the virus. We still don’t know how it infected humans yet although Wuhan was ground zero and the last thing to have it before patient zero was probably a bat. How patient zero acquired it or who patient zero was (or where he/she worked) is still a mystery. Whether the transfer agent was a wet market or a major Chinese institute of virology is still not known either. Does that matter? Yes. If it was the latter, the Chinese are both liable for this worldwide mess and playing with virions they ought to let be. And by the way, what were the Chinese cooking up at the Wuhan Institute?

         We now know more. The clinicians are getting better at treatment and the race is on for drugs and vaccines. We will get there.

         There is still a lot that we don’t know. Of greatest importance is how did this really happen and how do we make sure it doesn’t happen again?

Leonard Zwelling