"We'll Start Losing People We Didn't Have to Lose"
Doctors are doing everything they can to save people fighting COVID-19. But Dr. Royce Chen fears that it might not be enough.
As a COVID-19-recovered doctor in New York City, I feel fortunate that I had only a mild case. I stayed home under quarantine with flu-like symptoms and was not hospitalized. When Dr. James Goodrich, head of pediatric neurosurgery at Montefiore Medical Center in New York City, died from complications related to COVID-19, I reacted with a combination of sadness, survivor’s guilt, and fear for my city, my country, and my fellow healthcare workers. Will more Dr. Goodriches die in the next few weeks? What about my father? Or my friend? Or my friend’s mother? What can we do to prevent these awful outcomes?
Although I’m glad that President Trump has abandoned his recommendation that we reopen the country by Easter, I still worry that erratic speeches from the world’s most powerful leader are sending the dangerous message that social distancing is not critical. If we relaxed the one tool we have to battle the COVID-19 pandemic, it would be a catastrophe.
Some people have asked me why countries like Taiwan and South Korea have thus far done better with COVID-19 than the United States. The simple answer is preparation and geography. Taiwan is a small island country loaded with masks and tests, and it is led by a high-tech government that has the trust of its people. Taiwan differs from New York City and the US in that they have never allowed the disease to gain a foothold. Most cases have been quickly identified and isolated, vastly reducing the spread through the population. This is a country that knows where every case is.
On the other hand, the US is a large country that started out woefully underprepared in terms of testing and personal protective equipment, like gowns, masks, and face-shields. We are gearing up for a completely different situation from Taiwan. There is rampant community transmission. We have no idea how much.
Last week, the official New York City numbers had about 18,000 people testing positive. Today, we have more than 57,000 positive cases. Because asymptomatic infections are widespread and testing remains limited, the true numbers of people infected in New York City may actually be closer to 250,000 to 600,000 or higher based on certain predictive models.
Given that there are also 1,584 deaths in NYC as of today, you might say that the true fatality rate is really a lot lower than the 1% to 3% that is reported. Are doctors blowing this out of proportion? Is it possible that the fatality rate is really only 0.2% to 0.5%? Is it possible that the fatality rate is not that much higher than seasonal flu? Maybe.
The problem is that even if the fatality rate is much lower than is reported, it doesn’t change the fact that tons of people are infected right now. After all, 0.2% to 0.5% of a very large number is still a disaster. Today, the conservative estimates for deaths in the US is 100,000 to 240,000 people. The estimate without social distancing is 1 to 2 million deaths. By comparison, seasonal flu causes approximately 30,000 to 50,000 deaths each year. There are other important differences, too:
Does flu infect 40% to 60% of the population all at the same time? No.
And does flu cause the severity/complications of infection that we are seeing at such a high rate with COVID-19? No.
So, many more people need hospitalization and intensive care/ventilation at the same time. Pediatric floors and operating rooms have been turned into COVID-19 ICUs. At this point, I know of several people in their 40s who are intubated. This is not my typical experience with flu. Most of these younger people will recover. But they may have permanent lung problems as a result of the severe lung injuries.
Doctors in our country would be far less worried if we had a giant surplus of tests (to quickly identify and isolate all cases), masks, ventilators, and ICU beds. Our healthcare system and our great doctors and nurses would be able to treat most people without so many deaths.
But this is not the case. We do not have the giant surplus. We have no idea where all the cases are. They’re everywhere. We are running low on vents and beds. We are low on personal protective equipment. Healthcare workers themselves are getting infected and being quarantined, thus depleting our workforce further. Most will recover, but some will be hospitalized, and some will end up in the ICU needing vents themselves. Some will die.
In New York City, we’re not yet out of ICU beds and ventilators, but we might be soon. We’re bracing for a peak of cases that is projected to hit in the next one to three weeks. Hopefully our massive efforts to increase beds, establish fever clinics, split ventilators, and redeploy healthcare workers can keep up with the heavy demand that is starting to tax the system. Hopefully we will have enough beds for the other non-Covid-19 patients that need ICU care.
If we don't, then that's when we start losing the people that we didn't need to lose. And if we stop social distancing, we will be hammered by a deluge of infected patients. Maybe 20% of them will need hospitalization, and then maybe 20% of them will need ICUs and ventilators that we won’t have.
If we relax our policies on social distancing while the pandemic rages on, we are effectively saying that we’re okay with letting older and immunocompromised people die because our great country doesn't have enough resources to give A+ care to all. We’re okay with letting some younger people and healthcare workers die. Let them die because the cost to the economy is greater than the value of keeping these people alive.
I have a major ethical problem with that rationale. As doctors, we need to do what we can to save every life that we can. And in our country, that can’t be accomplished without social distancing at this point in time.
If we get to a point where this slows down in the summer, some medication proves effective, then great. If we’re lucky enough to get a break, we should make sure that we have a giant surplus of supplies at the ready for when COVID-19 returns. As a country, we need to realize that masks and vents and other protective equipment must be produced in the United States because essentially all of this stuff is armor, and in the event of international biowarfare, we’d be similarly shorthanded. We should ramp up our technological capabilities to track outbreaks and supplies.
Maybe when it comes back it won’t be as bad because there will be herd immunity or even a vaccine. Maybe it will just go away altogether. But until then, the only clear ethical choice to me is:
First, do a good job taking care of the health of our citizens (healthcare workers treat, everybody else social distances), then
Work on reviving the economy.
Current NYC Stats: 1Point3Acres. (2020). "COVID-19 in the U.S. and Cananda."
NYC Case Estimates: Science. (2020). "Substantial Undocumented Infection Facilitates the Rapid Dissemination of Novel Coronavirus (SARS-CoV2)."
Fatality estimates: CDC Morbidity and Mortality Weekly Report. (2020). "Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020." cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm