We met at nine
We met at eight
I was on time
No, you were late
Ah yes, I remember it well.
We dined with friends
We dined alone.
A tenor sang
A baritone.
I remember it well.

I Remember It Well. Maurice Chevalier & Hermione Gingold

A classic demonstration of how my memory works at 65. Although Thank Heaven for Little Girls, from the same movie, Gigi, has become more than a little…creepy.

Hey. Remember me? For those of you who are newish to SBM, I was a twice-a-month blogger for a decade here until I ran out of steam in 2017. For you older readers: surprise. I discovered Antidote. Any errors in the blog? Well, to err is human, to really screw up takes a computer.

Dr. Gorski recently asked if I would be interested in an entry covering something related to COVID 45. I thought of saying no and let the rest of the entry be blank, but that would not work as, obviously, I said yes. For those who are unaware of my bona fides, I am an Infectious Disease doctor, on my 36th, and last, year of practice.

This post covers my memories and opinions from the last 2.5 years of COVID 45. As my wife would let you know, my opinions are as reliable as my memories, so take what follows with a grain of Dash.

Is it too soon for a COVID 45 retrospective? Perhaps. I suspect COVID is going nowhere in my lifetime, as the current, likely undercounted, surge indicates. But there are two endpoints that could mark the end of the COVID pandemic. One is that the infection goes away. Never gonna happen. The other is when as a society we transition back to normal and at some level decide to live with COVID. I marked that point when the US resumed mass killings. Sadly, back to business as usual.

I do not see why COVID would vanish. One, its genetic plasticity is remarkable. So many mutations acquired so rapidly. I can’t think of a virus that has been as effective as COVID at spitting out genetically divergent progeny. HIV was close. I have it in my brain, but can’t find the reference, that HIV, being like humans a sloppy reproducer, undergoes one mutation at every base pair during each replication in just one T cell. That is a lot of mutations, since during active disease, millions of T cells are infected. COVID seems to right up there.

And more spooky is Omicron, which came out of left field. While there was a genetic progression from the initial strain through Delta, Omicron came into the world like Venus, fully formed and with “…more than 50 mutations when compared with the original SARS-CoV-2 virus isolated in Wuhan, China”.

Omicron’s origin is still a mystery, so who knows what other coronavirus is hiding in humans or animals, mutating away, waiting to jump into the general population. Just like influenza.

It is impressive how the R0, the number of people that a single infected person can be expected to infect, goes up with each variant. I suspect the increasing infectivity, but not virulence, is a result of our half-assed approach to COVID infection control. With semi-masking, semi-social distancing, and semi-vaccination, we have probably been selecting for more infectious strains of COVID. That has likely been the case with HIV. In the old days, when patients would report hundreds or even thousands of contacts, it was easy for HIV to get transmitted. With safer sex, only the more infectious, and likely more virulent, HIV gets through. COVID has gone from an R0 of 1.5 to 7 or more. This ain’t no measles, this ain’t no pertussis, but this ain’t no fooling around. Influenza, in comparison runs an R0 slightly less than 2. Infectious diseases have always been evolution in action, and evolution in COVID is scary quick. That also raises the question: rather than half-assed COVID infection control, should we strive for no-assed or full-assed COVID infection control? The internet is silent on the topic.

The other reason COVID is going nowhere is the relative lack of immunity after vaccination and disease. The vaccine is still great for preventing severe illness and death, both good endpoints, but with emerging variants partially evading prior immunity and large, in both numbers and BMI, populations of unvaccinated people, this virus will continue to circulate forever. Omicron seems particularly good at causing reinfection.

Unless COVID pulls an English Sweating Illness and just disappears:

Sweating sickness had disappeared by late Elizabethan times. Its reign of terror barely lasted a century.

I would not hold my breath. Although not inhaling is one way to avoid COVID. Clinton may have been on to something.

The concept of herd immunity was always a chimera. There is no such thing as natural herd immunity. There is no population where everyone is simultaneously infected and the herd becomes immune. And even if everyone were to be infected all at once, susceptible populations would keep being born. Herd immunity can only happen when an entire population, preferably the world as in smallpox, is vaccinated. You and I know that isn’t going to happen in the remaining lifetime of the human species.

COVID looks to be a perfect storm for perpetual disease: genetic variation, marginal immunity, half-assed infection control, and a susceptible population. Like what we have seen for the at least 500 years with influenza. As the French say, Plus c’est la même chose plus c’est la même chose.

Good news. Heat kills COVID, with 99.9% of the virus killed at 104 F. So COVID will likely disappear from Phoenix and parts of India in the near future. Or mutate to become heat tolerant. I always look on the bright side of life.

I thought at the start of the epidemic we would have a 1.5 million dead in the US. I thought 1.5 million, while appalling, wasn’t too bad given I had spent most of my career fretting about a recurrence of a 1919 influenza pandemic with a 5% mortality rate, or flying spaghetti monster forbid, a bird flu variant, which if it maintained virulence, could kill 2/3 of the infected. Not yet. But maybe one day. See “look on bright side” note above.

Thanks to the vaccines, we will eventually get to 1.5 million dead albeit slower than I anticipated. The mRNA technology is amazing and the speed with which they developed a safe and effective vaccine still boggles my mind. It is a technology that I think would allow for the rapid development of vaccines to a wide variety of pathogens that we could then refuse to take.

From what I can tell, there is no Omicron-specific vaccine as, at least in animal models, it adds nothing to the standard three shots. I don’t know. I would still think that, like flu, the more the vaccine matches the circulating strain, the more benefit, depending on your endpoint; preventing disease, spread, hospitalization or death. If the past is prologue, matching the vaccine to the virus should be a good thing. But, as noted above, Omicron may be an exception.

But I, for one, am a little tired of the death. I started in ID 1986, right when HIV as taking off. Remember, association is not causation. The first decade or so of practice was spent watching a seemingly endless number of young men die. No one cared. Or few did. I think it was Randy Shilts who said something to the effect that if AIDS had killed young, freckle-faced children, people would care more about the cause and treatment of AIDS.

Wrong.

What the COVID 45 has really brought home is large swaths of Americans don’t give a rat’s ass about anyone else, a county of Marie Antoinettes. Engage in behaviors that would slow the spread of a fatal disease? Qu’ils mangent du COVID.

Like all ID docs, I prefer prevention over treatment, and preventing, or at least decreasing, the spread of COVID is simple. Mask and vaccine.

Masks prevent spread of COVID. Vaccines prevent spread of COVID. Not perfectly. But as you learn in a lifetime of infection control, there is no one intervention that stops the spread of infection. Prevention requires the sum of many imperfect interventions.

I find neither masking nor getting vaccination that big a deal and, unlike so many of my fellow citizens’, I like knowing I am not going to sicken and kill others. I cannot wrap my head around the idea that so many feel otherwise. Until, of course, it comes back to bite them. Death bed conversions are a little too late, although not uncommon.

And really, most people look better with a mask on. Everyone looks good from the eyes up. Ugly, and beauty, reside under the mask. Someone I have known only during COVID takes of their mask to eat and I think whoa. For aesthetic reasons, masks should be permanent. Who wants to see my robust forest of elderly nose hairs? Or am I oversharing?

The six-foot rule? I never bought into that one. In the hospital, where the infected patient is spewing infected droplets while lying in bed not moving in a room with hospital air handling, six feet of distance to prevent droplet spread is reasonable. The patient isn’t going anywhere and the air is being turned over rapidly. Air handling was likely why I did not get COVID in the early months of the pandemic when we were short on proper personal protective equipment (PPE).

In the real world? I think of people like Pig Pen, always in a haze of potential pathogens. In crowds you are always moving in and out of each others Pig Pen pathogen cloud. It is also clear the air circulation can move infectious virus aerosols farther than 6 feet, adding yet another reason to avoid being downwind of some people.

I think population density in a room that is more important than distancing, and then just because there are likely to be fewer infected people in the room. I still shop at off hours and wear a mask when I am in the store. We eat out at off hours as well, although I see no point in wearing a mask at the pub. What is 5 minutes of mask wearing going to prevent during a 60-minute maskless meal? Besides, it is well known that hops, barley, and alcohol are potent antimicrobials using the XKCD method, much better than ingesting bleach.

I remember in the first months of the pandemic arguing with a radiologist who was emphatic that everyone should be wearing N95 masks and that it was obvious that COVD was spread by aerosols. I argued back that the CDC said otherwise, that COVID was spread by droplets. Much later (very much later as radiologists got to work at home while I was seeing COVID patients wearing less than optimal PPE) I went back to radiologist and ate crow. That was painful and I am still a bit bitter at the CDC.

For years, I saw people at the airport, often arriving from Asia, wearing masks. I always wondered if masking was beneficial. It is. Not only has influenza vanished with masking but so did most respiratory infections. From the epidemiology so far, masks should be de rigueur during URI season. That’s not gonna happen either.

The unusual aspect of COVID disease and death is just how slow progression is. Most patients are admitted around day 8 and if they die, it is weeks into their illness. COVID is a disease that maximizes suffering for both patients and their family. Slow suffocation alone in the ICU. An awful way to go.

The slow course of the disease is also why interventions directed at the virus seem to do so little. As a clinician, I can’t tell that remdesiver, or any treatment, is doing all that much.

And here is a secret when wondering if a drug is going to help treat an acute viral infection: Ask two questions. One, is the drug given in the first two or three days of illness? Two. Does it interfere with a specific biochemical pathway important in viral reproduction? If the answer to either is no, then don’t expect the azithromycin or hydroxychloroquine or ivermectin to do squat. You know ahead of time drugs that do not meet both those criteria will do nothing. That’s how the world works.

I was surprised how effective immunomodulation was for COVID. Acute COVID serum didn’t work, likely because most patients received the serum too late in their course and when their own antibody response was kicking in. And, unfortunately, giving serum did not produce any super soldiers. But steroids and other immunomodulators are effective in treating the late inflammatory phase of COVID and that surprised me. Immumomodulation has a dismal treatment record for most infectious disease, it was nice to see it work.

We were lucky in Portland, the hospitals were bursting at the seams with COVID but was not as bad a New York or other places where admissions overwhelmed the resources. Close, but no cigar.

Still, COVID reinforced the understanding that the US healthcare “system” is a Frankenstein’s monster with the brain of Abby Normal. Delivering healthcare is usually an irrational pain, COVID made it all that worse. I just wish we had a single payer. Then, instead of being screwed up in a thousand different ways, healthcare would be screwed up in just one way. It was amazing just how FUBAR so much of the response has been. But then, lies and denial are a poor basis for tackling pandemics or wars.

Long COVID is interesting, and, upon reflection, is not a surprise. The virus binds to the ubiquitous ACE2 receptor so COVID has plenty of opportunity to damage a variety of organs and tissues. Identifying the cause of long COVID is a work in progress, but there are some explanations that I find more compelling than others. For example, I find the idea that CFS might be a form of human hibernation interesting. It fits CFS patients, who do seem to be hibernating with spring never arriving. I like the idea that long COVID is due to vagus nerve damage. It explains the symptom complex and perhaps explains why it persists. The nervous system is not particularly good at healing.

My biggest conclusion from the last 2.5 years?

Understanding reality is critical. Too many people prefer to ignore reality, with millions sick and dead as a result. The response to COVID prevention was relatively simple. COVID is relatively easy to combat. Many, however, chose not to participate both in reality and COVID prevention and treatment.

The behavioral changes required to combat climate change and our hot future are far more difficult and expensive than what was needed for COVID. No way are we going to step up the plate in time; we can’t be bothered with reality.

We are so doomed.

On that cheery note, it is nice to be back.

Author

  • Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.