One Rural Doctor's Thoughts On Covid-19

photo by Bess Blakey

This article has been shared with permission from the author, who just happens to be my father. He has been a physician for many years, and serves as the medical director at a small hospital in a little town in Idaho. These words are relevant to all of us, especially to those of us that live in areas that haven't been hit hard yet by the Covid-19. 

If you don't have time to read all of this, read the end.

SOME THOUGHTS ON COVID-19 IN BOUNDARY COUNTY

by Gregory Botkin M.D.

31 March, 2020

I will begin with an apology. If you are reading this with hope of finding scientific clarity you will be disappointed. I thought the best way to do this would be to address the questions that now haunt the people of our county.

Is COVID here? 

As of this writing we have no laboratory confirmed cases in Boundary County. The hospital has sent out 17 or so. 13 came back negative, four are pending. I think it a mistake to estimate viral presence by lab results. We may have had COVID in this community for weeks or months without knowing it. The signs and symptoms are often very mild.

How many of us will be infected? 

As stated above, there may already be some penetration into Boundary County. Corona Viruses are highly contagious and spread through a region pretty easily, especially if the population is immunologically naive. Isolation may slow this down. I do not believe it will stop it. I cannot guess at percentages because we have not yet been able to collect critical immunological data. That should begin to change this week as we start measuring IgG antibodies.

Are the isolation mandates reasonable? 

This is impossible to answer without good prevalence data. We hope we are slowing the surge in emergency departments and ICUs in the areas hardest hit, which now seems to be worth the sacrifice. I am watching the numbers from Singapore, wondering if lockdown really stops viral spread. Prescient governance with balanced liberties ought to be a work in progress. The ecology of COVID will be better understood in a few weeks; one would hope such intelligence would increasingly inform policy.  

Why do a few people get deathly ill with COVID while many, perhaps most, have minimal symptoms? 

We don’t know. This is being looked at very closely. We are desperately trying to find treatments that block the metabolic breakdown we see in our most severe cases. Maybe it’s personal genetics, or past infections, or environmental exposures, or some combination of these. Thankfully extreme disease seems to be rare.

Are there things I can do, besides isolation, to lessen my risk? 

There are no shortages of folk remedies for COVID. Many are biochemically plausible. Garlic, fungi, zinc, Vitamin C, strong teas, Brazil nuts, etc. We have good research explaining the anti-viral properties of some of these measures, none of it specific for COVID. Do your homework and try these protections if you are so inclined. Getting outside for exercise, work, and gardening may be the best medicine of all, especially during the beautiful springtime weather just ahead.

Why has testing been so ineffective? 

The science of building a reliable chemical test is highly complex. It takes trial and error to get it right and no one had time for that. The biochemists brought us the best tests they could make. It was an amazing bit of chemistry but far from perfect. In addition, sampling technique must be precise for reliable results, and no one knew what made for best technique. Nasopharyngeal sample? Oropharyngeal? Bronchial washings? Automated or manual processing? Then came the shortages – not because of conspiracy or mismanagement, but because you can only cook so many pancakes at once and some people have to wait. The shortages necessarily forced eccentric testing philosophies. Whom should we test? Asymptomatic juveniles? Yesterday’s trauma death? The various tabulations are going to paint very different pictures of COVID’s virulence.

We are now looking back with the realization that many of the negative tests were probably false negatives.  There are estimates of 50% error rate in China, and what we have used here in the states through the CDC may not have been any better.

Expect a change this week. A new generation of very precise tests has been cleared by the FDA and is being shipped to the front lines.

Can we have some of those tests? 

Yes and no. Our hospital has been capable of doing this kind of analysis for a couple of years. We have the instruments here to run the most accurate testing protocols available with a turn-around time of about 45 minutes. Unfortunately all the new testing reagents are going to the areas hardest hit by the pandemic. We will begin next-generation testing the moment we receive our reagents.

Will we, the Boundary County public, know the results? 

We report numbers to the CDC as mandated so they can monitor trends. I believe locals should have effortless access to local data. Names and identities must remain private, so we must take care to publish results accordingly.

If I develop cold-like symptoms could it be COVID? Are there other viruses still going around?

When we evaluate respiratory disease here at our hospital we screen for 17 pathogens that commonly cause upper and lower respiratory disease. This is a lab test. So we usually have a rough idea of active infectious disease in our county. There are currently a handful of pathogens that could masquerade as COVID.

If I get severely ill what can I expect? Is our hospital ready? 

I have been impressed with the work the hospital is doing to get ready for this. We have a college of well-trained and well-informed workers who are putting the pieces together with careful confidence. But please remember: when a Boundary County resident becomes ill they should expect support from a network of caregivers – not just our hospital. Your primary care provider will play a big part. Paramedics are ready for specialized transport if necessary. Suppliers will be needed for home oxygen and equipment. Our Panhandle Health District will assist us with organization, especially as we follow those who remain ill in their own homes. Kootenai Health in Coeur D’Alene or other hospitals in Spokane may be part of your care, and their state of preparedness is both smart and strong. Together we will master this, one case at a time, although none of us know how that will look.

I would like to cut through the fog and read the scientific papers myself. Can I do this? 

The journals I read are making daily updates. If you have access to the internet you can read the same reports. Look at UpToDate for clinical summaries. Their material is reliable, succinct and easily understood. Go to the American Society for Microbiology for molecular biology, epidemiology, testing and policy recommendations. The American Chemical Society covers the molecular details of the science, some of it very complex, some of it plain. These three publishers, along with many others, have established open access to their COVID-19 materials. Boundary County residents should take advantage of this unprecedented movement in scientific publishing.

What comes next? 

What comes next will be difficult. We will have some positive test results from people right here in our county. When you get that piece of news it may feel like the demon of plague has planted his feet on our soil and started swinging his scythe. We will feel even more frightened than we feel today, and we will be tempted to reach for whatever weapons we have in our defense.

In my mind something else is happening.

These positives, these members of our community who show current or recent infection, are the earliest pioneers of an emerging society. Some will be actively fighting this thing, crushing and shredding viral particles day by day, killing this disease, perhaps preventing it from coming to your door. Think about that. These souls will be quarantined, largely unaided by medical science, isolated from the community’s companionship, supported entirely by devoted (and co-infected) friends and family. Some positives will have finished that battle, perhaps effortlessly, perhaps through indescribable pain and struggle, a few having come within heartbeats of death. And some positives we may lose. These will be our most fragile neighbors, lost in that fight, lost in the same way we lose neighbors every year to influenza and norovirus and cold viruses and heart disease.

As we do more testing in Boundary County the number of positives will probably rise. This does not signal the end of our world. It does signal the need for unusual courage, careful analysis, and extraordinary compassion. Medical science cannot stop this storm. But it can assist a good community that is determined to gracefully and courteously push through to the other side. And after twenty three years of practicing medicine here I believe this is who we are.

Are you finished yet? 

Almost. I would like to tell you some of those things that crowd into my mind in hard times…because this disease, like so much in medicine, can break your heart. I would like to write some of the things I am thankful for.

I am thankful we have time to prepare. We can look at Italy and China and Seattle and try to calculate what might best serve us here. I am thankful for the personnel and infrastructure in our medical community, which I believe to be unusually solid. I am thankful for the heroes I work with, nurses and lab technicians and physicians, all these with families at home, putting on their gear and going out to do the exam, collect the samples and ascertain the extent of a patient’s illness, every time, every case. I am thankful for the brilliant and cooperative spirit I have seen in medical sciences worldwide, and for open access, for the internet, and for educational and cultural opportunities for those isolated at home.

I am thankful that winter is on the run, that the fields are ready for the farmer’s wisdom and the farmer’s seed, and that an extravagant inland northwest is about to dress herself in springtime’s glorious light and quickening perfumes.

I am thankful to be reminded of human frailty, remembering that it is common and universal, as are spontaneous expressions of human mercy. In our suffering, as in our instinctive turning to attend the suffering, we are disclosing the deeper qualities of who we truly are, and the similarities now manifest in every region of the earth confirm our enduring place in the family of man.    

I am thankful for our immune systems. I am deeply thankful that this virus touches our little ones with a light hand. I am thankful for those who have fought this virus and crushed it, for the way these raise their fatigued bodies and tested minds, and for the way they seize hold of today, ready to receive the best gifts their new world has to give.

GTB