Myth 19: We can see the light at the end of the tunnel.
I miss my friends. I miss my patients. I did virtual rounds at the nursing home this week and one of my sweetest patients who *always* gives me a hug was very happy to see me on the iPad. We were saying hello and she was gushing about the pizza that her hair dresser bought for the whole facility to have for lunch today and she stopped and said, “I miss you.” Me too, sweet friend. Me too.
We have sheltered in place. We have avoided our churches, our friends, our breakfast meetings, our dinners with other families, campgrounds, favorite shopping spots. We have foregone connectedness in order to protect each other. And it is getting old.
Our economy is struggling. People have lost jobs. Families who never thought they might need help have found themselves visiting the food pantry. People are restless. They want to shop. They want to serve. They want to work. Texas has heard you. The governor has relaxed the order keeping many businesses closed and many of you are making plans to reopen, slowly, cautiously, safely. You may be tempted to think this means the worst is over. If so, you are likely wrong.
SARS CoV-2, the virus that causes Covid-19, is not gone. We haven’t had a positive test in Erath County since April 9th and that is a reason to celebrate! But no new positive tests does not mean the virus does not live here anymore. It simply means we have not tested anyone who is shedding the virus. In fact, we are barely testing anyone. Our sheltering in place has completely STOPPED flu season. We at SMSC haven’t seen hardly any cases of flu in weeks! (Happy side effect of social distancing.) We usually see cases of flu well into May. Colds are essentially non-existent now. We are seeing allergies and a smattering of ear infections and maybe some strep but that’s about it. Minimal respiratory symptoms in the population means minimal testing because, again, we don’t seek out people to test. We count on them to come to us. We had a free Covid testing site in Erath County this last Monday. We had 60 tests and not half the tests were used. Not enough symptomatic people presented for testing. More on free testing at texascovidtest.org. Today, in a county of 42,000, on the same day that Dallas County suffered it’s highest number of deaths yet, I cannot believe there is not a single person in our county shedding virus. Remember, you don’t have to have symptoms in order to infect someone else. When we open restaurants, movie theaters and the like, the fuel for the pandemic becomes more readily available for the unheralded virions lurking in an unsuspecting asymptomatic carrier. There will be more infections.
It all has to do with R0 (pronounced R naught). R0 is the number of people an infected person is expected to infect while sick. One of the most infectious viruses is Measles with an R0 of 12-18 (or higher) depending on what source your read and depending on the environment. This is why you should get your measles vaccine. It spreads like nobody’s business and is a serious disease. It’s not just a rash. But that’s a topic for another conversation. The R0 for most strains of flu is about 1.4. (Remember flu mutates all the time and some strains are more contagious that others.) Our nascent understanding of the virus that causes Covid-19 does not allow for an exact determination of its R0. Some studies suggest and R0 less than 2 while others are as high as 5.7. Meaning a patient infected with SARS CoV-2 might infect on average almost 6 people before recovering. This is astronomical. In 6 generations of infection, one person could infect 6 x 6 x 6 x 6 x 6 x 6 people. That’s 46,656 people (more than the population of Erath County) from one infected person who may not even know they are infected.
But R0 is not a constant. It changes based on many factors – some we can control and some we can’t. We still don’t know definitively what affect the weather will have on the ability of the virus to spread. (Lord, please help the Texas sun bake this virus like a road-killed armadillo on US HWY 281.) Environmental factors and thus, location, play a huge role in the R0 of a particular infection. But not just environment – our actions affect the R0 also. The R0 of a virus infecting a person who does not come into contact with another person is 0. That means, if you are sick, stay home! (Unless you can’t breathe then please go to the hospital). The R0 of SARS CoV-2 between people who are 6 feet apart is lower than if those who sit right next to each other in the restaurant. If they are all wearing masks it is astronomically lower! In fact, wearing a mask can drop the R0 to below 1. What does that mean? An R0 below 1 means the number of cases is shrinking and above 1 means the number of cases is increasing.
Think of it based on population. If every person in a population marries and has children, and they only have 2 children per couple, the number of persons in the population will remain stable. Every couple having 2 children simply replaces the 2 in the couple and the population does not grow. If every couple has 3 kids, the population increases in size. If every couple has one child, the population will shrink and eventually die out. In infectious disease, an R0 of 1 will maintain the same number of cases in a population. Less than 1 decreases the cases to extinction and more than 1 increases the case number in a population. And we can affect the R0! We can bring it below 1 by following the recommendations put forth by the CDC and the examples set by other successful countries.
Covid-19 is not going anywhere. We also aren’t going to stay-at-home-it-away. We can’t pretend that simply because we haven’t had a case in 2 and a half weeks it’s not still a threat. But we have to get back to work. We have to get back to life. But not all at once and absolutely not with reckless abandon. We have to wear masks. We have to socially distance. We have to wash our hands. We have to be cognizant of what we touch. We have to refrain from doing whatever we want so that we might protect our neighbors and loved ones.
Last night, the DFW newscasts led with a story about a 17-year-old, otherwise healthy, national honor student who died from Covid-19. That is devastating. Certainly a large swath of the population is more at risk than others from this disease but anyone can die. I recently read an article from a critical care physician working in a large hospital who detailed the severity of Covid-19 as a disease the likes he has never seen. A normal blood oxygen level is above 90%. Very sick patients with pneumonia and COPD often present to the ED with blood oxygen levels in the 70s. When this happens a patient is often is respiratory failure. Covid patients often present with an O2 saturation in the 50s. It’s a very serious illness that we should still respect and avoid as best we can.
Erath County, let’s start to interact. Let’s eat out. Let’s shop. But let’s do it in a way that keeps us and our neighbors safe. You can wear a mask. You can wash your hands. You can stay 6 feet away from others. You can limit the spread of Covid-19. Every action is a choice. As I tell my 5 and 8 year old, let’s make good choices. Otherwise, your elected officials will (wisely) return us to where we are today. For the sake of your neighbors and for the sake of your economy, fight the spread. Don’t let the virus get a foothold among us. Every single person has a role in determining the infection rate. Don’t be responsible for shutting us back down again. The light at the end of this tunnel is a long way off – I’m not even sure we can consider it a tunnel with a definite end. There is no “back to normal.” There is just life with Covid-19. We have to figure out how to live it.
Benjamin A. Marcum, M.D.