Lessons to prepare, grieve, console, help, learn, teach, and unite

COVID-19 hit some cities like a raging storm, and we hope that it will spare others through preventative measures and warmer weather ahead. Most of us have not experienced epidemics of this magnitude in the USA and can only look at history books to appreciate the disasters of the 1918 flu epidemic, among others. The crisis of HIV seems more remote now, thanks to better understanding of its biology and therapies compared to when I started my medical education and saw helplessly countless victims dwindle and die.  

Like any storm, the need to prepare is clear.  Inferring from the 1918 epidemic, cities that implemented measures earlier and longer fared better.  So how should we prepare? In Asia, it is common to see the use of masks among the general population during the flu season.  In America it is rare. But rather than learning from our Asian countries, the overwhelming response seems to have been of skepticism bordering on arrogance.  I believe that community leaders and those in public service should be exemplary in wearing masks as a reminder to people of local recommendations to do so—and I applaud those who have.  

The efficacy of various masks, such as cloth, hospital, and N95, in preventing such small virus particles (about 70-90nm, or about 3-millionth of an inch) is much contested. However, their use is largely advocated by the medical community. That said, our population is generally poorly educated on their proper use, and particularly on how to put on or carefully take off these masks.  I noted, on my latest trip to the grocery store, a large number of folks not consistently wearing their mask, not covering their nose, wearing some masks upside down, not pulling the mask under their chin, etc. Similarly, regarding improper use of gloves, a colleague sent me a picture of a person holding on to their protective glove in their mouth to text while in the line of another grocery store.  Of note, COVID-19 is largely a respiratory virus like the flu and mainly infects us from contaminated hands to touching the mouth, nose, and eyes. This is perhaps the major reason why wearing a mask or even a scarf over the nose and mouth when leaving the house makes sense. It diminishes our propensity to touch our face. It is also why washing hands frequently is of great import. For those in close contact with infected individuals, many of whom are without overt symptoms, inhaling the virus particles is a clear threat. Viruses carried on aerosolized particles during conversation or cough may have a greater chance of getting caught in the fibers of a mask, but may pose greater risk of infection to the unprotected individual.  This is again why social distancing makes sense, as well as avoiding the potentially higher concentration of gatherings such as in airplanes, buses, trains …and yes even elevators. The carnage at the bottom of a mudslide is evident, but what we do earlier at the top can make a big difference.

Presently, this virus will continue to take its toll, and we all hope that these preventative measures will spare other cities from its devastation.  For others less fortunate, it is truly a time to grieve and console. However, I am alarmed by the equally rampant spread of conspiracy theories. I have seen COVID-19 referred to as the Chinese virus or even as an intentional Chinese WWIII bioweapon. Some profess that different strains were intentionally created and “targeted” to different countries.  These speculators stand on the pulpit of misinformation and vagaries, and have little appreciation of the scientific facts, such as COVID-19’s higher rate of mutation as an RNA virus compared to DNA viruses and the marked human immune responses to a new virus creating even higher selective pressure for the viral mutation. Some further profess how the Chinese appear to be “spared” of the illness, just as the Jews were “spared” of the bubonic plague.  I recall cringing at the judgemental moralization during the onset of the AIDS epidemic, and cringe now at the callous bigotry and irresponsible portrayal of this illness. I believe that such wild conjectures, politicizing, and conspiracy theories divide us, spread unwarranted fears, deprecate fellow human beings, and breed hatred and mistrust when true understanding and compassion are much needed.. 

It is clear that this pandemic and the well-thought means of hindering its spread will have a broad social and economic impact on our society. Countless services have been curtailed, businesses are suffering, and layoffs continue to climb. I note many are pointing fingers at policy makers, resenting infringement on personal rights, blaming many for personal losses, or even claiming that this epidemic is an outright hoax. Denial and anger are natural human responses in coping. While I can empathize with the heated emotions, I emphatically urge that we all try to move forward and to focus on helping those around us less fortunate in meeting their daily living, transportation, emotional, and economic needs. This begins with each and every one of us making calls to loved ones, neighbors, and long-neglected friends to inquire about their well-being. Publicly, I propose that upcoming policies should be focused on the healing of a nation, rather than on politicizing or making decisions contingent on personal gains in finance or popularity. As the clouds lift from this storm, I hope the sunshine will be from the goodness of all people by supporting local businesses and helping others, even one person at a time.

So what can we learn and teach from this COVID-19?  It is a wakeup call for being better prepared for future epidemics.  This virus is here to stay—much like the “common cold” is today—and it is likely that most of us will eventually become infected or immune in the years to come.  From what we can learn from the 1918 epidemic and from the recent resurgence in parts of Asia, after its initial wave we can expect “aftershocks,” hopefully much diminished, as we relax preventative measures. Thus, practices of seasonally wearing masks and social distancing will need to become better accepted for the weeks, if not for the many years ahead. There is much to be learned scientifically, as carefully constructed controlled studies are underway to replace the mountain of anecdotal reports for the dozens of potential candidate treatments.  This will be the only way to sort the snake oils from the true medicines for this disease. There will also be much to be learned about the biology not only of this virus, but also of unrelated viruses, bacteria, fungi and parasites that loom as potential causes of future epidemics. We will need to set ways to share accurate and unbiased information openly, rapidly and internationally. Notwithstanding the uncertainty of COVID-19 origin, most epidemics have indeed been traced to mammals and birds because these warm-blooded animals share a similar biological environment as humans for germs to propagate. Thus, it may also be an opportunity to rethink the way we grow, handle and prepare our foods. Besides the obvious humanistic concerns, closely-quartered, caged, and antibiotic-fed animals, for example, may have huge implications in the spread of disease and resistance to treatments. While the US remains one of the top countries for per capita meat-consumption and food wastage, it is also my hope that reducing such consumption will possibly decrease the demand on such higher resource-consuming production of foods, lessen the origin of epidemics, and even curtail the far greater epidemic of obesity presently affecting a third of the US population.

But in specific appreciation of the need for better hygiene and daily habits, we also need to teach our children to embrace these concepts, not only by way of reminders but by our own examples: washing hands frequently, being careful during food preparation, covering the mouth when sneezing, staying home when ill, not leaving dirty dishes in the sink, removing clothes off the floor where germs settle, and closing the toilet seat before flushing to decrease aerosolization, for instance. These sensible practices are now as clearly relevant as ever.  As COVID-19 infections can be more severe in people with underlying conditions such as diabetes, obesity, and heart or lung illnesses, we all have a choice to improve health by exercising, eating healthier, avoiding substances that may cause harm, and being more mindful of our blood pressure, blood sugar, cholesterol, and weight.

The rallying cry is, “We are all in this together.”  COVID-19 infects people regardless of sex, race, religion or political ideology. We each must do our part immediately in containing the disease, and then in helping those less fortunate from the broad social and economic impact of this disease. We need to allow essential services to continue and not demonize those who are ill. I believe in the human spirit to emerge united not only as a nation, but globally, in overcoming this pandemic. Wishing you all health, safety and peace.

Hiroshi Mashimo is a physician and scientist at the VA Boston Healthcare System and Harvard Medical School.