THOUGHTS ABOUT THE PANDEMIC OF 2020: CORONAVIRUS

It is said that knowledge is cumulative. The media, print, visual and electronic have found one topic that they blast at the public all day and all night. It is the first epidemic of the “new century” which is already twenty years old. It comes at a time when the United States is about seven and a half months from a presidential election which will be vicious and bitter. Other nations, in Europe in particular have had or will have elections in the near future and the media elite have been having a fit over a move towards more right wing or conservative governments.

The twentieth century has taught medical professionals as well as public health specialists much about epidemics. Several particular epidemics are worth considering at this time. In particular, we should understand that public health measures, such as contact tracing may be useful in some circumstances and not in others. Classically, venereal diseases could be susceptible to contact tracing due to the necessity for intimate contact between individuals. An infected person, male or female, generally would be able to identify whom they caught the disease from. That named party could then be sought out, encouraged to have treatment and hopefully, to identify other contacts. In this manner a venereal disease outbreak could be brought under control. However, it is not simple as all victims of the disease may not show symptoms and not even be aware that they have it. Gonorrhea, in females, may be asymptomatic who may then unknowingly spread this disease.

Venereal diseases are only one instance of disease which can be transmitted from human to human. With the development of antibiotics the bacterial venereal diseases have been brought under control and essentially eliminated as major diseases. Viral diseases, however, have resisted easy treatment and the world was afflicted in the last quarter of the twentieth century with the Human Immunodeficiency Virus (HIV) which led to the development of Acquired ImmunoDeficiency Syndrome (AIDS). Panic was the order of the day and early in its existence it was thought to be particularly common in people of Haitian origin, and subsequently, Haitians were banned from being blood donors. The national blood supply, at that time was unsafe and many hemophiliacs developed, as a result of transfusion HIV infection and subsequent AIDS. In the1980’s, this disease was lethal with no known treatment. Supportive antibiotics could be used to treat various adventitious or opportunistic infections such as pneumocystis carini.However, antibiotics were at best a stopgap measure as the “gay plague” killed thousands of gay people. With the development of retroviral medications, AIDS became a chronic disease which is no longer lethal. Of note, however, was the behavior of victims of AIDS during its lethal heyday. Some victims refused to practice safe sex, not caring in particular if they spread a lethal disease to uninfected individuals. Additionally, some members of the gay community felt that being uninfected in some manner detracted from their authenticity as community members, AIDS today, thankfully is no longer lethal in compliant patients, and in fact, may not even be transmittable in patient who have no detectable viral load. Contact tracing in this epidemic was of benefit, as again, the sexual nature of its transmission required intimate contact. However, contact tracing was made difficult if not impossible by State privacy laws which were passes to protect patient privacy due to the stigma this disease had.

Franklin D. Roosevelt was struck with Polio in 1923 after going on a cruise up the Hudson River with the Boy Scouts, a group of which he was a supporter. It manifested itself shortly after he arrived at his family ’s summer home on Campobello Island, Canada. He was a vigorous, healthy, muscular, athletic man who went for a swim in the cold waters off the island, felt tired afterwards and woke up paralyzed the next morning. Despite years of therapy, doctors’ notes indicate that he never has any improvement at all throughout the reminder of his life.The Polio virus is of interest because there were polio epidemics in the United States and other countries which produced close to mass hysteria as this was a disease that caused terrible neurologic damage, ending in death or permanent paralysis of varying degree of severity. People were warned to stay out of crowds, not leave their homes and various other measures to stop the spread of this terrible disease. Research subsequently discovered that the Poliomyelitis virus actually caused two diseases, namely gastrointestinal polio and bulbar polio. The former caused gastrointestinal upset of varying degree of severity for a short period of time and led to complete recovery as the victim produce antibodies which ended the virus’ activity. Many of the victims of gastrointestinal polio never know that they have been infected with the polio virus. They were the lucky ones. The same virus also caused bulbar poliomyelitis which attacked in an ascending manner the anterior horns of the Spinal Cord, which is responsible for motor function. Motor neurons in the anterior horn were destroyed resulting in paralysis. If antibodies developed rapidly enough, the disease could be stopped very early, but if not, the virus ascended up the spinal cord causing more damage, hence, the name anterior ascending poliomyelitis. If the virus reached the cervical spinal cord and destroyed C-3,4,5, neurons, the diaphragm was paralyzed and the victim could no longer breath. The Iron Lung was developed to breathe for these patients as intermittent positive pressure ventilators (IPPV) were not widely available. Additionally many of these patients were able to utilize accessory muscles of respiration to breath, particularly using the sterno-cleido-mastoid muscles, which together with the iron lung enabled these patients to survive but no improvement ever occurred. Polio which ascended higher in the Central Nervous system and reached the medulla rapidly cause death due to destruction of the respiratory center. Polio came to an end with the introduction of the Salk and subsequent Sabin Vaccines which have almost completely eliminated this dreaded disease.

A little known epidemic occurred during the heyday of the AIDS epidemic. There was an outbreak of antibiotic resistant Tuberculosis (TB). Many of the people afflicted with this illness refused to comply with the treatment regimen or were incapable of complying. Court orders had to be obtained to force these patients to report to hospitals or other facilities where they would take their medication regimen under direct supervision of health authorities. With the end of the AIDS epidemic, this has disappeared from the public and medical radar, However, antibiotic resistant bacteria will continue to be a problem in the future. The research for new classes of antibiotics with varying methods of destroying bacteria must urgently continue.

As mentioned above, knowledge is cumulative. However, memory may not be as generations of younger physicians, nurses and other health professionals have no or little experience with and have little knowledge of these previous epidemics. Even the murderously lethal Ebola virus, which was localized in Central Africa is something that western doctors have little to no experience with. Other minor viral outbreaks have included SARS, West Nile and Zika. But they did their damage and disappeared. They came and went. Really lethal virus such as Haartan virus and Marburg Virus never made it to the United Stats. Nor did Ebola. We were lucky.

Now in the twentieth yer of the twenty-first century from the People’s Republic of China has arrived an import which no one wanted, the Corona or Covid-19 virus. Apparently, this virus arose in the Chinese city of Wuhan. Information of its spread was not publicized until a major epidemic struck that city. It spread rapidly to the nations of Asia, Europe and the United States with hundreds of thousands of victims world wide and an increasing death toll, varying from nation to nation, depending on the public health measure taken by individual governments. Outside of China, Italy has been the hardest hit country with widespread infection and a high death toll. Public health measures to a great extent have failed in Italy as Italians have been unwilling to submit to strict quarantine and governmental actions have been too little too late. The virus is now spreading in France ,Spain, Germany where tough public health measures and quarantine and other strategies have led to these countries undergoing almost complete lockdowns. Of note is that these measures worked in China but cannot work so well in countries that are not a dictatorship or police state. Can an entire country be locked down or put in jail? Can an entire country be ordered to stay indoors? The answer is yes, but. History tells us that brutal, ruthless dictatorships can enforce these types of lockdowns with determination and a public be damned attitude and a willingness to use lethal force to enforce their actions if necessary. But this is not acceptable in most countries of the world. Therefore, voluntary cooperation of the general public is mandatory.

Panic and hysteria are neither necessary nor required. In fact, they are counterproductive. Nor should political gain be a motive of leaders or would be leaders. A public health issue is not a political issue and there should is no room for parties to seek short term political gain over a national and international tragedy.

Physicians have learned much from the past. Infectious diseases not so long ago were believed to be conquered due to the presence of antibiotics. Infectious disease medicine was going to be vanishing field, but someone forgot to tell the causative agents that they were no longer desired or needed. They are back with a vengeance and the war continues. It’s not enough to prescribe antibiotics. They have no effect on viruses. Viruses cannot live outside of living cells. Immunity will develop in affected individuals. Supportive care is available if needed. Ebola taught us that antibodies from plasma of recovered individuals can be used to treat victims who appear to be in hopeless condition. However, prevention is the best strategy at this time. Socializing must be limited, restaurants, clubs, bars, classrooms, subways, airplanes, movie theaters, sports events must be avoided and social distancing should be observed. Contact tracing may be of limited value as the disease may be caught from walking past a sneezing or coughing individual. There is nothing glamorous about being infected and if someone is infected, they should observe isolation to prevent its spread. Sub-clinical infection is another problem. The Infected individual may be unaware of the disease’s presence and therefore may take no precautions. A vaccine will be produced, hopefully, sooner rather than later which will stop this epidemic in its tracks. Maybe some people will remember, yes, in the twenty-first century there was a viral invasion but it was defeated. Scientists and public health personnel will remember its lessons and be ready for the next microbial attack.

Mankind will survive. But let use remember that we are all in this together and must work together to beat it. The price is high, the fight is hard, but there is no alternative to victory over disease. This, too, shall pass.

Garry S. Sklar, MD Las Vegas, NV March 21, 2020