In war on a novel virus, declarations of a turning point in 30 days. Really?

cvirussurrenderWith the fight against the Covid-19 pandemic now framed as one of the planet’s major battles, it may be worth considering  the historical record on the timing of turning points in matters of war.

The American Revolutionary War, historians note, hit a crucial point at Saratoga — 14 months after the conflict became official with rebels’ declaration of independence. A key moment of the Civil War occurred at Gettysburg — two years and a few months after an attack at Fort Sumter tore the nation apart. In World War I, the tides did not seem to shift until the clash at Marne —  four years after an assassin’s bullet had plunged the world into war. And in World War II, it is a matter of some controversy, but many experts cite the brutal Battle of Stalingrad as a turning point — roughly 3.5 years after Germany launched a global calamity with its invasion of Poland.

The novel coronavirus, in roughly three months, has killed more than 50,000 Americans, with experts conceding that toll is likely an undercount.

The disease fatalities are closing in on the total of American deaths in Vietnam (58,000+) and they have exceeded those in 9/11 (~3,000) and the Korean War (~37,000). They still are not in the territory of the Civil War (600,000+), World War I (116,000+), or World War II (400,000+).

So are we near a turning point in this war, in mere months and not years?

It’s been barely a month since many states started in mid-March taking stern public health measures against Covid-19. Yet Georgia, home to the CDC,  has broken ranks and partially reopened, allowing its residents to return to more normality at gyms, bowling alleys, tattoo parlors, nail salons, and beauty and barber shops. Gov. Brian Kemp has been assailed — including from his GOP allies in the White House — for relaxing restrictions he imposed barely weeks ago to combat the viral illness that has killed at least 900 Georgians.

So, here the nation goes, faster than most public health experts would advise — with some of its leaders deciding the country reached a turning point in the campaign against Covid-19. State by state, county by county, and city by city, officials will face tough choices with huge levels of uncertainty, especially as the coronavirus closures have staggered the economy, with U.S. joblessness skyrocketing to levels unseen in living memory.

Even as leaders try to bolster public sentiment by noting that disease trend lines suggest that tough measures taken thus far are “bending the curve” — preventing hospitals and medical capacities from getting overwhelmed and reducing infections, hospitalizations, and deaths — doctors and epidemic experts warn that Covid-19 won’t magically disappear.

This pandemic — as has occurred in lethal flu outbreaks in 1918 and 1957 — likely will have several waves of reoccurrence, especially if the public takes too casually preventive measures and if medical scientists cannot make significant advances with treatments or vaccines. The 1918 pandemic, which took a record toll estimated at as many as 50 million globally, felled more people in its second wave.

The United States faces high risk of seeing a dire Covid-19 coda later this year, warned Robert Redfield, the physician and longtime Baltimore-based virus expert who heads the Atlanta-based federal Centers for Disease Control and Prevention. He told the Washington Post, in a quote that angered President Trump, but which Redfield confirmed as accurate:

“There’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through. And when I’ve said this to others, they kind of put their head back, they don’t understand what I mean. We’re going to have the flu epidemic and the coronavirus epidemic at the same time.”

As reporter Lena Sun of the newspaper also wrote:

“Having two simultaneous respiratory outbreaks would put unimaginable strain on the health-care system, he said. The first wave of covid-19, the disease caused by the coronavirus, has already killed [tens of thousands] across the country. It has overwhelmed hospitals and revealed gaping shortages in test kits, ventilators and protective equipment for health-care workers. In a wide-ranging interview, Redfield said federal and state officials need to use the coming months to prepare for what lies ahead. As stay-at-home orders are lifted, officials need to stress the continued importance of social distancing, he said. They also need to massively scale up their ability to identify the infected through testing and find everyone they interact with through contact tracing. Doing so prevents new cases from becoming larger outbreaks. Asked about protests against stay-at-home orders and calls on states to be “liberated” from restrictions, Redfield said: ‘It’s not helpful.’”

Though the president persists in pursuing unfounded nostrums or mythical views as to what might occur next in the pandemic, including that Covid-19 might somehow just fade away, Dr. Anthony Fauci, of the National Institutes of Health, has agreed with Redfield about the risks of coronavirus infection waves and the need for significant and sustained improvement in testing, supplying personal protective equipment and other medical supplies to health care workers in an array of settings nationwide.

Fauci and the NIH also have pushed back against counter-factual advocacy of wonder treatments for the virus, issuing a guidance that said this:

“Currently there are no Food and Drug Administration (FDA)-approved drugs for Covid-19. However, an array of drugs approved for other indications, as well as multiple investigational agents, are being studied for the treatment of Covid-19 in several hundred clinical trials around the globe.”

This was one of two important rebukes to overzealous advocates of off-label prescribing to Covid-19 patients anti-malarial drugs, including in combination with known anti-viral medications. The FDA issued this warning statement:

“The FDA is aware of reports of serious heart rhythm problems in patients with Covid-19 treated with hydroxychloroquine or chloroquine, often in combination with azithromycin and other … medicines [affecting the heart].  We are also aware of increased use of these medicines through outpatient prescriptions.  Therefore, we would like to remind health care professionals and patients of the known risks associated with both hydroxychloroquine and chloroquine … Hydroxychloroquine and chloroquine have not been shown to be safe and effective for treating or preventing Covid-19.  They are being studied in clinical trials …Hydroxychloroquine and chloroquine can cause abnormal heart rhythms … and a dangerously rapid heart rate called ventricular tachycardia.  These risks may increase when these medicines are combined with other medicines … including the antibiotic azithromycin, which is also being used in some Covid-19 patients without FDA approval for this condition.  Patients who also have other health issues such as heart and kidney disease are likely to be at increased risk of these heart problems when receiving these medicines.”

Although the NIH also offered cautious guidelines about caring for Covid-19 patients, essentially affirming time-tested approaches, front-line clinicians — to their credit and as caseloads have allowed them — have shared their growing experiences in dealing with those with the disease. With vaccines still a distant hope and highly effective drugs not yet present, the day-to-day learnings that doctors, nurses, and other health workers can bring to bear against Covid-19 may be key.

Caregivers, by observation and with medical data, are trying to sort out why the disease — once thought to be mostly an attack on the respiratory system but now viewed as a wider menace — kills or seriously afflicts younger, seemingly healthy patients, particularly causing strokes and heart problems in them. Doctors and nurses have been perplexed that coronavirus patients may suffer unusual and big problems with harmful and even lethal blood clots during their illness. Besides ventilators, hospitals and doctors have been forced to scour for dialysis equipment because the coronavirus, especially in patients who already had renal problems, seems to attack and burden the kidneys. Seniors may show a differentiated set of symptoms of infection, with cognitive afflictions, drowsiness, falling, and collapse. And, of course, many patients appear to take a turn for the worse when their immune systems, unfamiliar with Covid-19, unleash a stormy counterattack, which itself is damaging and can kill.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the benefits they can enjoy by staying healthy and out of the U.S. health care system. The coronavirus threatens to swamp our health resources, which, in their better times, already had notable problems with infections acquired in hospitalsnursing homes, and other medical care giving facilities, as well as major challenges with medical error and misdiagnoses. That said, at this difficult moment, we need to support doctors, hospitals, and public health officials as they marshal science, evidence, and facts to battle the global menace of Covid-19.

The disease will not, presto, disappear. It will take rigorous effort to stamp it down, and we should take a dose for all of ourselves in these difficult days of the resolve and courage shown by first responders, health care workers, and too often low-paid and hard-working “essential” personnel. They have not surrendered to coronavirus-related hardships in hours, days, weeks, or a month. Should we?

Painting by John Trumbull, showing British surrender at Yorktown, 1781
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