On July 8th, I wrote a letter to the governor and my state representatives with the request that they reconsider our state’s public approach to this pandemic. Some may reasonably ask, “What gives you the right to provide an opinion or recommendation to our Governor? You are not an epidemiologist.”
Epidemiologists work with large data and models to base their policy recommendations. A family physician deals directly with patients and the current reality. Both perspectives are important. A jet pilot does not build his own aircraft; but the engineers who do had better talk to the pilots. A respectful conversation is critical for a functional result. Likewise, it is imperative that there is respectful bi-directional communication between physicians who are treating patients and public health policy makers.
I am a family physician with 27 years of experience practicing medicine in the outpatient and hospital settings. I am the director of hospital and urgent care services for our medical group. I treat all age groups with acute and chronic health problems. While I do not hold myself out as an expert of infectious disease or epidemiology, I do have a perspective to share. It is critical to evaluate the quality of medical research, available data and consultant opinions in my role as a physician and advocate for my patients. There is an important role for physicians who can assimilate many small pieces of data; weigh them against clinical realities; recognize patterns of disease; draw on current knowledge across disciplines and consider options for treatment.
It is not uncommon to find disagreement among specialists about the proper course of action - even when treating disease processes that are well understood. While much has been learned about this virus, there are still ambiguities and it is especially important to share decisions together and not by fiat. Authentic and transparent discussions must occur because patients and their families have different values, priorities and world views. Many people understand that there is not a consensus or settled science on many aspects of the public health measures taken to date. It is painfully obvious that there are political, economic, medical and social implications for public health decisions currently being made.
My letter represents a physician’s attempt to provide a balanced perspective. There is evidence that by taking an overly reductionist infectious disease viewpoint, we are missing some real harm to non COVID health issues and social determinants of health. These factors are not headlining the Johns Hopkins, Oregon Health Authority, and certainly not mainstream media reports; but they are real.
Not all data and research carry equal value. It is quite easy to find different opinions among physicians, infectious disease experts and scientists about COVID-19. Who do you believe? Physicians from the WHO, CDC, prestigious medical centers, academic centers and researchers around the world have different perspectives on the data. As knowledge about this virus has increased exponentially, opinions about the public health approach remain divergent in part, because our personal and institutional risk tolerance varies greatly. I have immersed myself in learning about this virus by reviewing many expert opinions, research studies and data across the globe. I correlate all of this with my own experience as a physician providing care for individuals with COVID-19 and all other health concerns. It is on this basis that I sent the letter to the Governor and policymakers. I have chosen to share my impressions with Evergreen patients and my community as we consider alternative options to this pandemic. A version of the letter can be found below. Live well to be well,
John Powell M.D.
July 8, 2020
Dear Governor Brown,
This letter is a request to reconsider our current Oregon public health measures to address the SARS-Cov-2 pandemic. After 3 months, it is becoming clear to many of us who follow epidemiological data and global research about this virus that the severity of COVID related illness does not warrant the current Oregon public health measures. As clinicians, we see the harm inflicted on our communities from this public health policy. Continued nonselective social isolation and restrictions violate medicine’s uncertainty principal to first do no harm. Public health messaging, endorsed by policymakers, that all citizens conform to their recommendations to avoid killing loved ones is untrue and cruel. Rising numbers of COVID cases illustrate that what we are doing is not working. Data demonstrating falling infection fatality rates, emergency department visits and hospitalizations due to COVID coupled with age severity differentials demand a more targeted and sustainable public health approach. Let us start by structuring the pandemic around our lives and not our lives around COVID-19.
Many physicians and researchers from around the globe have held contrary viewpoints that the prevalence of this disease was understated; the infection fatality rate was overstated, and new infections likely peaked earlier than realized. The data is now consistently showing that this perspective was correct. Public health authorities and publicly facing experts have been incorrect but are not self-correcting. Metrics of little value are emphasized and the resistance to change public policy has become political. I do not blame citizens for being confused. However, I am holding my physician colleagues and policymakers accountable for misrepresenting the data in the public sphere.
There is no nobility or safety in the “stay home, save lives” ad campaign. For those under the age of 45 there is minimal risk of dying of this virus. For those between the age of 45 and 70, they have about the same risk of dying of influenza. After age 70 the risk escalates just like it does for any other infection. The lockdown policies have resulted in over 46 million people unemployed; increased suicides, poverty, domestic abuse, homelessness, alcohol and drug abuse; delayed diagnoses and treatment for non-COVID conditions; and major adverse impacts to the mental health of our citizens.
Our youth are being seriously disenfranchised by public health officials and politicians. We knew or should have known that they had almost zero risk of dying from this virus in March. Yet, our public health policy has continued to deny them of educational, social and life experiences, and infected them with irrational fear. We did this under the false pretense that we were protecting our elderly population. Just the opposite, if more young and healthy people have immunity, we decrease our population transmission rates and risk. In other words, we sacrificed our youth to protect adults from their own fears.
Please consider these recommendations from a Family Physician who is seeing first-hand the adverse consequences of the current approach on total health in his community:
Open without special restrictions all day cares, preschools, K-12 schools and colleges. Healthy people under age 70 are at very low risk from COVID-19. This step will serve to increase community immunity to those at the lowest risk of complication and will decrease population virus susceptibility and transmission to our most vulnerable population.
Resume all school extracurricular activities; do not deprive our children of these important life experiences.
Suspend civil liability for businesses, schools and sporting events that are unable to guarantee a zero-risk environment for patrons and spectators. People must be responsible for their own health and risk tolerance for a disease with a low infection lethality rate – like COVID-19 and influenza.
Encourage reasonable precautions to reduce exposure and transmission of the virus. Emphasize good hand hygiene, avoid touching your face and stay at home if ill.
Discontinue the following measures: mask requirements for the general public, enforced quarantine measures, contact tracing, and social distancing enforcement. These measures are for the containment of a virus in the beginning; not in the middle of a pandemic. This virus was widespread in the U.S. at the time of its discovery in Washington state. The infection fatality rate of COVID is low. There are fewer susceptible in our population to this virus than previously realized. New studies have shown evidence of cross T-cell immunity from other prior “common cold” non COVID coronavirus exposures. There is now clear evidence that antibody testing significantly underestimates the prevalence of SARS-Cov-2 in the population. Contact tracing and case counts are very resource intensive and do not add actionable value at this point in the pandemic. Our lives would look exactly like they do now if we did contact tracing for influenza – chaotic.
Focus the resources gained by not pursuing all the directives in #5 to protect the vulnerable by:
Increase the testing of residents and employees as needed in assisted living sites, nursing homes and other long-term care facilities to isolate infected individuals in these high-risk groups.
Aggressively monitor employees of all long-term care facilities, hospitals, and clinic employees with symptom monitoring, and temperature measurements.
Reimburse caregivers generously and attempt to limit the number of individuals who serve the elderly and frail residents.
Physicians must have important end-of-life discussions with their severely ill and elderly patients as to their preferences about resuscitation measures and ICU care. Our communities and families should accept that many of the elderly will choose to see their grandchildren and risk illness. Many may choose to accept this risk because they will value quality of life over quantity of life. This at-risk population will need to articulate their understanding and be able to weigh their own risk tolerance.
Ensure post-hospitalization isolation support facilities for those who have been treated for or are found to test positive for COVID while hospitalized and need additional assistance before returning to their permanent place of residence.
Strongly recommend Flu vaccines for everyone.
Monitor and emphasize important information to the public such as: emergency department visits, hospitalization, and death rates due to COVID and ensure adequate care capacity. Our hospital capacity was limited before the pandemic. We need to create more hospital capacity regardless of the number of new COVID cases or how well we can keep up with contact tracing. Oregon has shown that we can do that rapidly with statewide cooperation.
We can hope for a safe and effective COVID vaccine that may eventually help the vulnerable population, but we need to understand that this may not occur anytime soon. Do not make the vaccine mandatory until safety can be assured, especially for the young. It is important to remember children have a nearly zero death risk to this virus and those under 60 have a risk less than 0.2%. A new SARS-Cov-2 vaccine should be treated like the flu vaccine. It should be voluntary.
Until an effective and safe vaccine is available for the elderly and vulnerable, strive to provide N95 masks or respirators for our at-risk population so they may choose to see their families and friends as they wish.
Thank you for your consideration.
John Powell M.D.