The annual review is an opportunity to prepare for the second year by reviewing the mistakes and successes of the previous twelve months. I will focus only on the medical decisions and dilemmas of the first year, leaving others to evaluate the most disastrous policy decisions made – although I will note without comment that the first anniversary of laboratory confirmation of the first case at the US Centers for Disease Control and Prevention falls on the same day as the end of President Trump’s presidency and the beginning of the Biden administration.
For me personally, it’s been an extremely humbling year. We infectious disease specialists are often misled – a predictable single event problem, but still. We have long been accustomed to talking about the devastating pandemic of SARS, the flu, the Ebola virus, smallpox and many others. To stay calm and move forward, we decided, not so fast, to wait for the tone that better suited the gentlemen doctors who populated Victorian novels than the globalists of the 21st century. Century.
And our sound for years has been that of Mr. Rogers, right on cue. But not this time. In late January/early February 2020, perhaps due to misleading information from China, we downplayed the threat. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, called the risk to most Americans negligible and said he was more worried about seasonal flu than the new coronavirus. He advised people to wash their hands and stay away from crowded areas, but not to bother wearing a mask.
Like many others, I repeated this advice based on the well-documented medical literature on influenza, which ultimately proved to be incorrect. It is unclear whether the order for everyone to wear a mask would have affected the behavior of many people at this early stage of the pandemic, given the small number of cases in the United States, but it was and still is a blatant misunderstanding.
That wasn’t the only mistake. Since mid-February, scientists have had the idea of developing and offering a reliable and widely available diagnostic test. And then there was the political backlash and it was decided that the states should compete with each other for the supply of EVPs and fans.
Even when hydroxychloroquine is excluded, no adequate therapy exists to treat patients with covid19 : We have a bad and very expensive drug, Remdesivir, which attacks the virus itself. It must be administered intravenously. The uncertain efficacy led to the drug being removed from the World Health Organization’s treatment guidelines. Another category of therapies to improve the immune response to infection are the expensive antibody infusions administered to the President and his cronies. Full and definitive studies have yet to be conducted, but this approach could certainly play a role for patients at risk of serious illness.
Fortunately, the old, cheap reserve dexamethasone, a steroid commonly used to treat inflammation and a handful of diseases, has lowered mortality in almost every study to date. Moreover, medical care in general reduced the mortality rate of those affected.
These challenges remind us how difficult it is to make decisions when incomplete information leads to an incomplete understanding of an actively changing situation.
On a much smaller scale, however, it is a challenge for any physician caring for a sick and unstable patient. The situation may change from hour to hour as test results come back and new parts of the patient’s history are discovered; despite the uncertainty, decisions must be made immediately. This means that some decisions will be wrong.
It’s hard for any doctor. But despite their sense of error, doctors and health professionals have to wake up the next day and make more decisions, most of which are also based on incomplete information. And today’s decisions should not be colored by yesterday’s mistakes. It’s important to learn from a mistake, but overreacting to one can be debilitating. Balancing two opposing forces is the greatest challenge of all.
This dynamic represents the greatest risk in the fight against the Covid 19 pandemic as we enter its second year. The lack of concern and mask, as well as the 20 million doses of vaccine pledged for December, could cause further problems if they unduly influence the myriad of difficult decisions that must be made.
The challenges – availability and safety of vaccines, different strains of virus, weakening of immunity, timing of government action after a critical mass of vaccination – are surrounded by uncertainty, incomplete information and huge implications.
But decisions have to be made. They will inevitably be imperfect and provoke criticism. Adjustments made as evidence becomes available are seen as faltering; the change of direction is described as incompetence; the need to change restrictions is described as a colossal failure. But everyone has to come to work the next day and make the best decision. No more money should be given to states, counties and hospitals.
Biden’s team is certainly aware of what lies ahead. We can only hope that his decisions will be based on evidence, common sense and, above all, the solitary humility of the physician treating a seriously ill patient.