The COVID Three Step: Can We Please Just Do The Dance?

It’s time we learned to live with this virus.

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ith August barely in her grave, the aspen trees in Calgary took their first trembling steps into autumn, exchanging pleasant greenery for royal hues of gold and red. Fall was still officially three weeks in the future, but there was no time to waste — in this neck of the woods fall is but a colourful hiccup between the end of summer and the start of endless winter.

In lockstep with the quivering aspens, trembling parents — scared witless by the pandemic — sent their children back to school. Sixteen percent of Calgary parents were frightened away entirely, opting instead to enroll their kids in online learning.

To school or not to school? That was the burning question as August expired, an agonizing conundrum that produced heated debates and sleepless nights but no satisfactory answers.

And no wonder. Every day the apostles of the apocalypse and the disciples of denial (Team A and Team D, if you will — there can be no other team, it seems) scream incessantly at each other, their claims and quarrels amplified deliriously by media of all stripes and sources. It’s tough to maintain one’s sanity amidst the bedlam, let alone chart a sensible course forward.

Within days of schools re-opening, the inevitable “first case” cropped up at a high school in northwest Calgary. Dozens of “close contact” students were sent home to quarantine.

The school’s principal promptly took to social media to berate Alberta Premier Jason Kenney and Education Minister Adriana LaGrange:

“I’m exhausted, devastated, furious, frustrated, scared, anxious, sad, and so many, many more things all at once.

While this case was brought into our school from an outside source, I know people will now be afraid — the exact opposite of what schools should be for kids and school staff.

I feel a very heavy load and I’ve never been more angry. This could have been avoided with the support of the government. We followed all the AHS guidelines. This is not my fault. This is your fault, Jason. This is your fault, Adriana.”

Not quite the voice of calm and reason and steady leadership parents needed to steady their nerves, I daresay. The agitated principal would have been well advised to heed Rudyard Kipling’s sage admonishment to “to keep your head when all about you are losing theirs”. Yet who can blame her for losing her head (I mean no disrespect whatsoever), given the incessant catastrophizing by Team Apocalypse?

Lost amongst the all the clamour, unfortunately, is the genuine good news around this pandemic. And there’s plenty of it.

Consider, for instance, the plummeting death rate from COVID-19. If you get sick from the virus today, your chance of dying is a mere fraction of what it was in March.

As Colby Cosh summarized in the National Post a couple of weeks ago, the case fatality rate (CFR) has plummeted. (The case fatality rate is the number who die, divided by the number who test positive for the virus — not to be confused with the infection fatality rate (IFR), which is the number who die, divided by everyone infected, regardless of whether they are tested or not. The latter denominator is far greater than the first.)

Cosh:

“The observed case-fatality rate (CFR) in April was about eight percent for patients in their 60s; 22 per cent for patients in their 70s; 31 percent for those in their 80s; and 40 percent for those in their 90s.”

For August… only 1.2 percent of patients in their 60s died. The number for the 70s age bracket, remarkably, is also 1.2 percent. In the version of the data set I downloaded late Monday, only one person in their (his) 70s developed a fatal case of COVID-19 in all of Ontario in August. This makes this number somewhat unreliable, as astonishing as it is, and suggests that the June-July CFR of five percent may be a better estimate going forward.

The news is good for the even older, too: the August CFR for patients in their 80s was just 4.8 percent. The 90-pluses had a bad month, recording a 37.5 percent CFR, but their death rates are in obvious decline, too: the figures for June and July had been 19 percent. At the beginning of the pandemic it seemed as if the CFR for the extremely elderly would be more like 40 percent almost as a matter of natural law.”

We know far more now than we did in March. We understand the disease better, and so we are better at treating patients. We know now that COVID-19 is not primarily a lung disease; that the virus causes vasculitis in those who get sick, an inflammation of blood vessels that in some patients rages like wildfire. We no longer slam patients hastily on to ventilators. Instead we flip oxygen-starved COVID patients like burgers on a griddle to maximize their ability to breathe on their own. We’ve learned that dexamethasone, cheap and plentiful, works wonders to douse the fires of inflammation.

Of equal — perhaps greater — importance is that we’ve been doing the COVID Three Step: Wash your hands, Keep your distance, Wear your mask — 1, 2, 3. Some of us dance better than others, and some aren’t dancing at all (I’m looking at you, Team D), but collectively we’re doing pretty well. And it’s making a difference.

Drs. Monica Gandhi and George Rutherford recently observed in a New England Journal of Medicine editorial:

“As SARS-CoV-2 continues its global spread, it’s possible that one of the pillars of Covid-19 pandemic control — universal facial masking — might help reduce the severity of disease and ensure that a greater proportion of new infections are asymptomatic. If this hypothesis is borne out, universal masking could become a form of “variolation” that would generate immunity and thereby slow the spread of the virus in the United States and elsewhere, as we await a vaccine.”

For most of recorded history, smallpox was a scourge upon humanity, killing 30 percent of its victims during outbreaks and leaving survivors horribly disfigured, many of them blind. But as early as the fifteenth century the Chinese discovered that grinding up dried-up scabs from smallpox patients and blowing the powder up the noses of healthy people provided significant protection. It wasn’t without risk: most people thus inoculated developed only mild illness with few sequelae, but one percent died. But weighed against a 30 percent risk of dying from natural exposure to smallpox, many people took the bet.

That process — variolation, as it came to be known — was adopted around the world, mostly via the less intrusive method of rubbing powdered smallpox scabs into scratches on the skin. Why it worked was the subject of conjecture at the time — the discovery of viruses lay far in the future. We know now why it worked: exposure to smaller doses of virus induced an immune response that proved life-saving when blasted with a far higher inoculum of smallpox virus during natural exposure.

Variolation was eventually and thankfully replaced with the far safer process of vaccination, thanks to the brilliance of Edward Jenner and others. But the principle stands, and it underpins why the COVID Three Step has had such an impact.

Washing your hands, keeping your distance, wearing your mask: none of these measures are perfect. But taken together they result in smaller inocula of virus if you are exposed. Which means you stand a far greater chance of beating the virus back. That means more asymptomatic infections; and if you do get sick, less severe illness — less chance that the immune response to the virus will develop into the raging inferno that has carried so many to early graves and left many others (the so-called “long-haulers”) with significant disability.

If we collectively and responsibly continue to dance the COVID Three Step we can go back to living, schooling, and doing business, sensibly controlling the spread of virus and allowing the steady acquisition of population immunity as we await a vaccine that may never come. There’s lots of promise on the vaccine front, but nothing proven — and rushing that process is fraught with peril. (One wonders what the future holds for New Zealand, having developed no natural immunity to COVID by dint of staying — for the most part — free of the virus: in the absence of an effective vaccine or cure it will truly be an island unto itself, wholly isolated from trade and tourism).

e’ve come a long way since March (can it be only six months ago?) when we shut down the schools and sent all students home to hunker down in place. At the time we stood transfixed (amidst bales of hoarded toilet paper), appalled by video footage of Chinese citizens being welded into apartment buildings, aghast at overflowing morgues and hospitals in Italy, frightened by the growing carnage in New York City.

The hellish viral beast was headed our way, we realized. It was only a matter of time. And it was eminently reasonable, when we couldn’t properly grasp the scale of what we were facing, to hammer down, close the schools, and make preparations as best we could.

But that was then. This is now. We know now this isn’t the Black Death. This isn’t smallpox. Nor is it the Spanish flu. We’re not stacking bodies in the streets. Nor is that likely to happen.

I know it’s early in this pandemic. I know that dismissing its dangers prematurely is rather like reading the first 50 pages of Tolstoy’s 1215-page War and Peace classic and declaring you’ve grasped the entire epic. I’m aware that it was the second wave of the 1918 flu that claimed most of that grim pandemic’s casualties. (I’m not the only person, I’m sure, bemused by all the talk of a “second wave” in Alberta when the first was barely a ripple.)

But this is not 1918. A century later our grasp of virology is light years beyond what it was then. We’ve quickly learned how this virus triggers disease, and we’ve adapted treatments and strategies accordingly.

As of this writing almost 10,000 have died from COVID-19 in Canada — 80 percent of them long-term-care residents. Had we treated COVID victims from the beginning as we do now, and if we had adopted the COVID Three Step from the beginning, that number would be much smaller: 2,000, perhaps, or even less — approximately 400 of them outside of care homes.

Retrospect is all well and good, of course; but here’s my point: going forward, the misery inflicted by this disease is likely to be far less than it has been.

To be clear: I am not discounting the value of any person’s life. All lives are precious. Every premature death is a tragedy.

But it’s worth a reminder that we sustain roughly 2,000 traffic fatalities in Canada in an average year (the bulk of them individuals in the prime of life). Yet we don’t shut down traffic in the face of that grim statistic. We do take precautions to limit the carnage. Imagine the death toll if there were no rules of the road, no speed limits, no seat belt laws, no airbags, no vehicle manufacturing standards, no drunk driving laws.

Even with all those precautions there are still traffic accidents; people still die; and among those who don’t die are many who are injured and disabled, some permanently. Yet we don’t shut down traffic.

No should we shut down society again in the face of COVID-19. We should absolutely observe the rules of the COVID road to minimize our risk. Do the dance: wash your hands as much as possible, keep your distance where reasonable, wear masks in indoor public spaces. Recognize that even with all those precautions, some will die; some will be injured, and some will be permanently disabled. That’s reality. That’s life.

Continuing to strangle the proper functioning of society to avoid one risk among many will serve only to deepen our economic ruination (and especially that of our children and grandchildren) and ignores escalating rates of suicide and substance abuse. The enormous spike in fentanyl deaths alone (many of them young) during the pandemic has far outstripped deaths from COVID-19.

Children, happily, remain relatively unaffected by the virus. They carry the virus, but for the most part it doesn’t make them sick. Nor do they spread the virus easily, particularly in this era of washing and sanitizing their hands like never before in recorded history. Teachers are far more likely to get sick from each other or outside of school than from their students.

Yet a survey of teachers in my province released last week reported that 95 percent of teachers are experiencing high levels of stress.

Again, teachers should heed Mr. Kipling and “keep their heads”. I’d point out to them that since the pandemic arrived in these parts pediatric doctors like me have been dutifully going to work along with our nursing colleagues, attending to sick children day in and day out. There have been a handful of COVID-19 infections among health care workers, but most of them acquired outside of hospitals. Why? Because we’ve been doing the dance: we wash our hands, we wear a mask, and apart from examining and treating our patients, we distance as much as is reasonable. If we can do the COVID Three Step, my teacher friends, so can you.

To all of those still clamouring that we should keep the schools closed, I would point out that the health of our society rests as much — if not more — on the proper education of our children as it does on keeping our hospitals open.

And if we all engage in the COVID Three Step outside of schools and hospitals we stand a far better chance of keeping our schools open, and a far better chance of keeping our critical health care workers safe.

Those on Team D prattling on about their “rights” and refusing to wear masks remind me of petulant three-year olds, arms crossed defiantly, lower lips thrust out, chanting “You can’t make me!”. Look in the mirror: do you see yourselves? You obey the rules of the road, don’t you? You wear your seat-belts, don’t you? You obey speed limits, don’t you? You don’t blow through playground zones at 150 km/h, do you? Wear a bloody mask, already. Grow up.

On the other side of the spectrum we have Team A, typified by a fellow witnessed at a traffic stop the other day: alone in his car, N95 mask and face shield in place, his head fully encased as he sat with gloved hands on the steering wheel staring grimly ahead, presumably on the lookout for coronavirus particles that might make it past his windshield.

Sometimes I wonder if this pandemic has turned us all into head cases.

Let’s get a grip, people. Please. Just do the dance.

Pediatric Emergency Physician

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