June, 2020

Preserve and Infect

By Michael J. Katin, MD

Note: This will be the last column relating to the SARS-CoV-2 pandemic. I hope.

It is truly amazing that in 2020, when we are about to allow artificial intelligence to drive our automobiles, it is not possible to summon the resources to adequately determine, in the age of COVID-19, the optimal way to protect the public from COVID-19 and still preserve the economy. Most of the decisions, unfortunately, are based on assumptions, made much more convoluted by being politicized.

It may be futile to continue to debate the relative merit of social restriction as opposed to allowing interaction to produce herd immunity. After more than six weeks of cowering in place, Americans have now been released to use their best judgment to avoid exposure, already leading to multiple instances of people swarming together as if it's 2019. Keeping the cork in the bottle was expected to be not sustainable, anyway.

To make matters more complicated, any crisis now is followed by the impulse to throw money at the problem. Not too long ago the National Debt was thought to be a problem that would ruin our country within the next ten years if not addressed. Those of us in the medical field were terrorized by the cuts threatened by potential cuts in the fee schedule based on the Sustainable Growth Rate guidelines, are still depleted by the reductions dictated by the Great Sequester, and the Congressional Budget Office estimates the cost of any changes in the medical fee schedule from the Centers for Medicare and Medicaid Services and any legislative initiatives to then allow determination of what will be "affordable" and what will help reduce the deficit. After all these years that the medical profession has been held responsible for maintaining the fiscal survival of the country, anything that could have possibly been saved by these measures has now been massively overwhelmed by the outpouring of funds to "prevent the next depression." In other words, spending money that we don't have will keep our economy from failing.

While that system seems to work in the short term for most people with credit card debts, ultimately there comes a day of reckoning. It may be different on the national level, when the biggest restriction may be the cost of paper and ink, but maybe this is time for an influential media organ such as this one to intervene.

Here goes: what better way to prove something works than a randomized prospective trial? Over the past decades, this has been, for all practical purposes, required to determine optimal treatment pathways, and is almost never used in socioeconomic programs, which usually affect far more people and involve far more money than any medical decisions. The goal is for outcomes to be evaluated without being adulterated by preconceived expectations or (gasp!) profit motives. On one level, this is being done to evaluate efficacy of drugs such as chloroquine, remdesivir, and intravenous Lysol. However, it would be far more valuable to study topics of sheltering in place, mask usage, and stimulus funding in a controlled way.

As a result of COVID-19 restrictions, entry of patients into clinical trials has of necessity been negatively impacted. Large research entities such as SWOG, ECOG-ACRIN, and NRG have legions of highly-trained and dedicated data managers frustrated at the dearth of work to be done over the next few months. This would be the perfect opportunity to set these individuals free to fulfill their calling.

Americans have always come through in times of crisis, and there should be no question that we will be enthusiastic about participating in studies that will settle once and for all what should be the best intervention for a pandemic. Using a catchy acronym would always be a plus -- we can request suggestions from the people who gave us memorably-named trials such as STAMPEDE, ASCENT, CheckMate, and PAOLA (well, maybe not that well-named ).

This would require temporary (possibly only 1-2 years) isolation of several communities of no more than 50,000 persons each to allow the following studies:

  1. RESCUE: RESpiratory Coverings Unless Eating. Half of a population group will be required to wear a specially-designed mouth/nose covering throughout the day except for 30-minute intervals for feeding at 7 am, 1 pm, and 6 pm. Feeding is to be done in a negative-pressure chamber. Mouth/nose coverings will be kept in place by implanted bolts. The primary end-point will be COVID-19-free-survival of the population as a whole, with a secondary end-points being BMI comparisons before and after the study and incidence of facial trauma from ripping off the mouth/nose coverings. Success of smoking cessation programs will also be compared between the two groups.
  2. DEFEND: DEtermining the Feasibility of ENforced Distancing. The entire population group will be fitted with implants that will recognize a distance of six feet from another person with an implant. Half the implants will deliver a painful but harmless electrical shock when this detection occurs. This will result in half of the subjects being encouraged to maintain a six-foot distance from anyone, while allowing the other half to wallow in the cesspool of society. The primary end-point will be COVID-19-free-survival of each group, and a secondary end-point will be determination of the number of videos placed on social media regarding pranking.
  3. DONATE: Depositing Otherwise Needed Assets to Enable. Matched communities will be randomly assigned to receive $25,000 per person versus nothing. Primary outcome is to determine if anyone in the enriched community even any longer cares about COVID-19. Note: any communities with names ending in "-Beach " will not be eligible to be in the $25,000 per person category.
  4. COWCHIP: Communities Without CHInese Products. Matched communities will be randomized for one to have removal of access to all products made in China and the other to have no restrictions. The primary end point is to measure the economic parameters of each group of communities, and a secondary end point will be a comparison of the numbers of Wal-Marts, Targets, Hallmark stores, and Pier 1 stores still functioning in each community.

One downside is that by the time these studies are completed the virus will have worked its way through the rest of the country and the economy will have gone its own way and a vaccine will be available. Nonetheless, our society learns from past experience and this information will be very useful to give us a head start when, as has always occurred throughout history, another pandemic begins.

Bonus: Putting On a Mask (to the tune of Putting On the Ritz)

Do you remember where were you
When you lived through the Hong Kong Flu
Then SARS and swine flu came around
They didn't shut our country down.
Now there's a brand new crisis
The novel coronavirus
What should we devise
To keep on staying alive?

If it's true that
No one knows
Exactly what's best to do
There's one sure task
Putting on a mask

People need to stay apart
Even six feet may not be smart
But show some class
Putting on a mask

This one is too tight and this one's pouchy
This one makes me look like Tony Fauci,

COVID-19 is a bad scene
We can't get
With Chloroquine
Don't take a chance
Better get a mask.

Even if your distancing's
Social don't let your emotional
Thoughts advance
Don't leave off the mask

Even if you're using sanitizer
Even if you're covered with a visor.
I'd advise ya

Don't take chances with your health
Not just for you but everyone else
Not much to ask
Putting on a mask

Asteroid JF1 Countdown: Asteroid JF1 will be impacting with or passing by Earth May 6, 2022, which, counting May 6, is 705 days from now. Plenty of time left to stock up on batteries, plywood, and hand sanitizer.