(This letter was sent to the Governor and elected representatives)
COVID-19 Policy in an era of uncertainty
At this time, public policy decisions and disease modeling are based in large part upon the “known unknowns” and “unknown unknowns”. This means that much of our information about the prevalence and incidence of COVID-19 is still not reliable. As a result, there have been and there will continue to be unintended consequences of these policy decisions. It is time to account for them.
As a Family Physician in Roseburg, Oregon, I have already seen the harm of well-intended executive orders and public health policies that adversely impact the patients for whom my group provides care. Here are some examples:
1. An elderly man with diabetes had intermittent loss of consciousness and low blood sugar readings. He had an insulin pump but he had no access to his regular physician. Because he lived in an assisted living residence that was in “lock down”, he did not know where to go for help. Our staff visited him at his facility and decreased his basal insulin dose. He was referred for a telemedicine visit with our endocrinologist. We drew labs and informed him about his newly recognized heart murmur. Many more seniors will suffer decline or death due to neglect of their chronic conditions. Many patients in nursing homes and assisted living facilities have limited access to care.
2. A man that I admitted to the hospital had profound anemia and needed a blood transfusion. His “elective” endoscopy was canceled weeks before due to Oregon’s executive orders forbidding elective procedures.
3. Another man was hospitalized for worsening of his chronic obstructive lung disease (COPD). He explained that his daughter and ill granddaughter had recently moved in with him because his daughter had lost her job due to the closure of her employer’s “non-essential business”.
4. A patient needed to have his painful, broken abscessed tooth extracted. However, he could not see his own dentist because his Medicaid contracted dental office was closed to save PPE. Sometimes antibiotics and pain medication alone simply aren’t enough. We were able to secure a non-contracted dentist to provide his care.
5. An elderly woman living alone and was afraid to step outside her home for a walk or to schedule her mammogram. She had anxiety and was panicking due to the daily media headlines -assigning a number to every new COVID case and death.
6. A patient with a nephrostomy tube and a 2 cm kidney stone remains in pain because elective lithotripsy is not available.
7. A woman with moderate dementia, new to her memory care facility, whose behavior changed from a happy demeanor to violent requiring increased sedative medication after social isolation requirements separated her from her daughter.
8. A son providing care to his 95-year-old mother, who has recurrent urinary tract infections, reports that she is ill with temperature over 103. They are afraid to access the health care system due to COVID-19 fears.
9. In the last month, our local hospital lost 9 million dollars and had to furlough the equivalent of 350 employees. These job losses resulted from current restrictions on elective procedures and from patient fears of entering the hospital or visiting outpatient diagnostic sites.
I am trying to provide a sense of increased morbidity not related to COVID-19 but related to the executive orders and “shelter in place” policy, which was intended to flatten the curve and to avoid overwhelming hospitals. This policy was reasonable especially in New York City where they have closed nearly 20 hospitals due to underfunding over the last decade. However, Oregon is not New York and Roseburg is not Seattle. Most physicians understood that these social distancing measures would not eliminate COVID-19 in our population but would only reduce the rate of spread of this disease.
The opinions and recommendations of Dr. Anthony Fauci deserve respect but there have been other valid opinions and approaches to this pandemic. I refer readers to the link below to an opinion piece from Dr. John Ioannidis, professor of medicine, of epidemiology, of population health, and biomedical data science, and of statistics at Stanford University. https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/. The article appeared in “Stat” on March 17th. He identified many of the unintended consequences of the current policy implemented to control the pandemic.
The data gap remains a problem today. Current models used to project future peak disease activity and mortality rates have not been accurate. The daily headlines reporting confirmed COVID cases represent increased testing capability but the reports do not speak to the actual prevalence of the disease in our population. The widely publicized WHO and CDC mortality rates are based upon extrapolated numbers from biased testing protocols that adversely select for the most ill individuals with SARS-CoV-2. Even determining the cause of death in this pandemic has proved challenging. We are not differentiating between those that die with and those that die from SARS-CoV-2. Going forward, antibody testing will provide better information in regard to the true prevalence and mortality rates.
I am not questioning whether measures taken to date have been well-intended and worthwhile. Public authorities and Governors must consider medical, economic and social risks in real time. There are no risk-free choices. Unfortunately, we will never have enough epidemiologic data or a golden process that will result in “zero” COVID-19 deaths by June as proposed by some officials. Remaining sheltered in place while waiting for a vaccine is not a viable option and doing so, would devastate the economy, health systems, families and the health of citizens. The Oregon tax base would be even more severely compromised. My hope is that future alternative approaches will not be suppressed, dismissed or deemed dangerous by those who are seeking to project virtue. Those who propagate fear without sufficient data need to take a backseat to those who are seeking real solutions to this complex problem.
Physicians have the duty to question policy when other aspects of patient health have been adversely impacted. The demographic most at risk with COVID-19 is not the same as the pandemics of 1918 or 2009. I recall multiple patients under the age of 30 on ventilators in our local ICU in the 2009 H1N1 influenza pandemic and we did not take the types of public health measures then that we are taking now. Yes, there may have been some latent community immunity and a relatively ineffective flu vaccine in 2009 but there were also discussions about using APACHE scoring systems to ration ventilators. Fortunately, the unthinkable did not occur. We have much better intensive care capacity now.
Death and human suffering have occurred and will continue to occur as a result of the unintended consequences of current isolation measures and restriction of hospital services. The extreme measures to close schools, businesses, parks, and enforce social distancing were a cost that most were willing to accept in the short term. The pause allowed time for the development of local systems and resources to meet our community’s needs. Douglas County has risen to meet the challenge. In my view, it is time to change our approach in a targeted, rational way.
To this end, I have the following recommendations:
1. Allow hospitals and communities that have adequate capacity and systems in place to manage a COVID surge to resume normal operations – including elective procedures while continuing stringent and practical measures to prevent virus spread. This action would serve to maintain hospital system solvency and reemploy critical health workers who were furloughed due to the current circumstances. We have been fortunate that hospitals have not been overwhelmed by patient volumes. However, at this time, these policies are restricting access to essential medical care, causing harm and benefitting no one.
2. Reopen all businesses, parks and recreational opportunities in areas where the hospital(s) and the community have the ability to address capacity issues during a COVID surge. This move would soften the already devastating blow to our Oregon economy and reduce the level of unnecessary public anxiety.
3. Reopen schools and colleges to reduce achievement gaps and develop additional herd immunity among the young and healthy. This step may ultimately protect others who are elderly and with chronic conditions as they choose to resume their normal activity.
4. Continually monitor the impact of relaxing these isolation measures with active testing and ensure that adequate healthcare capacity remains as the virus activity vacillates – indefinitely.
My plea is that our political leaders and policymakers also seriously consider the importance of other health, economic and social issues. We can continue to be vigilant and fine tune our approach as needed. In Douglas County, it is now time to begin relaxing hospital restrictions and extreme public isolation measures. It is time to acknowledge the unintentional harm of our current policies. Going forward, I am confident that independent Oregonians will be able to make informed choices based upon their own risk tolerance and hopefully, better data.
John Powell MD
4/18/20
Please consider viewing the short YouTube video link from Dr. Iannidis. Although the data is a bit dated, his concern remains valid.