The first case of Covid-19 in the United States was reported a year ago, on January 20, 2020. The patient, a 35-year-old man who had recently returned from visiting his family in Wuhan, China, sought medical care because of a cough and fever. He was hospitalized and survived the infection.
Since that time, more than 23 million Americans (almost 7% of the population) have been diagnosed with the infection and at least 385,000 have died. In response, effective treatments, public health containment strategies and vaccines have been developed, but the pandemic continues to worsen, both in the US and in other parts of the world.
The one-year mark provides an opportunity to prepare for year two by examining the mistakes and accomplishments of the last 12 months. I will focus only on medical decisions and dilemmas of year one and leave to others the task of evaluating the mostly disastrous political decisions that were made — though I will note without comment that the first anniversary of the US Centers for Disease Control and Prevention laboratory confirmation of the initial case falls on the exact day that the Trump presidency ends and the Biden administration commences.
Personally, the year has been extremely humbling. We infectious disease specialists have been wrong repeatedly — a predictable problem with a once-in-a-century event, but still. We are long accustomed to dealing with talk of a devastating pandemic from SARS, MERS, influenza, Ebola and smallpox to name a few. To keep calm and carry on, we have adopted an “oh now, not so fast, let’s just wait and see” tone better suited to the gentleman physicians who populated Victorian novels than 21st century global village realists.
And, for many years, our Mister Rogers tone was the right one. But not this time. During late January and early February 2020, perhaps because of misleading information from China, we soft peddled the threat. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, called the risk to most Americans “miniscule” and articulated more concern about seasonal flu than the new coronavirus. He advised people to wash their hands and stay away from crowded places but to not bother wearing a mask.
I and countless others echoed this advice which was based on a well-articulated medical literature on influenza — which ultimately was proven to be incorrect. It is uncertain whether an “everyone must wear masks” decree would have influenced many people’s behavior at that early moment in the pandemic, given the paucity of US cases, but it was and remains a glaring misjudgment.
It was not the only mistake. From mid-February on, scientists stumbled to develop and deliver a reliable and widely available diagnostic test. And then came the political dawdling and decision to let the states fight among themselves for PPE supplies and ventilators.
Even leaving aside the hydroxychloroquine debacle, therapies to treat Covid-19 patients have fallen short: We have a mediocre, very expensive drug, remdesivir, directed at the virus itself. It must be given intravenously. Its uncertain efficacy has led to its exclusion from the World Health Organization treatment guidelines. Another category of therapy aimed at improving the immune response to infection includes the expensive antibody infusions the President and his buddies received. Full scale, definitive trials are still pending but this approach clearly has a role for patients with risk for severe disease.
Thankfully, the cheap old standby, dexamethasone, a steroid typically used to treat inflammation and a handful of illnesses, has reduced mortality in just about every study to date. Plus medical care overall has also lowered the rate of death among those diagnosed.
These problems are sobering reminders of how difficult it can be to make decisions when incomplete information leads to incomplete understanding of an actively evolving situation.
On a much smaller scale, though, this is the challenge for any doctor taking care of a sick, unstable patient. The situation may change hourly as test results return and new bits of a patient’s history are uncovered; yet decisions must be made immediately despite uncertainty. This means that some of the decisions will be wrong.
This weighs heavily on any doctor. But despite the emotions around an error, doctors and public health experts have to wake up the next day and make more decisions, most of them also relying on incomplete information. And today’s decisions must not be colored by yesterday’s mistakes. Learning from a mistake is crucial but over-reacting to a mistake can be paralyzing. Knowing how to balance the two opposing forces is the largest challenge of all.
This dynamic is the biggest risk to Covid-19 pandemic control as we head into year two. The “miniscule worry” and the “don’t wear a mask” mistakes and the failed “20 million vaccine doses given by December” promise can cause further problems if they over-influence the countless complex decisions that lie ahead.
The looming issues — vaccine availability and safety, variant strains of the virus, waning immunity, when to loosen public measures after a critical mass of vaccinations — are fraught with uncertainty, incomplete information and enormous consequences.
But decisions must be made. Inevitably they will be imperfect and will draw criticism. Adjustments made as more evidence becomes available will be viewed as waffling; a change in course will be called incompetence; the need to reimpose restrictions would be labeled a colossal failure. But everyone must come to work the next day and make the best decisions they can. The buck must no longer be passed to states and counties and hospitals.
The Biden team surely is aware of what lies ahead. We can only hope that its decisions will rely on evidence, sound judgment and, most of all, the lonely humility of a doctor caring for a critically ill patient.
We made a lot of mistakes, a doctor writes on Covid’s first year The British Journal Editors and Wire Services/ CNN.