TO YOUR HEALTH: 'I am so tired of Covid ... when will it all end?'
I have heard this from so many of my friends, my family, and my patients. Most likely you have that way as well. So, how does a pandemic end? I'll talk about three different ways, and three different experiences: New Zealand, Israel, and 1918.
I've written about New Zealand previously. They took the “hard lock-down + quarantine” approach, followed by the “secure the borders and constant surveillance contract tracing” approach. Israel took a different approach. They actually struggled mightily with the virus, but took the rapid vaccination approach to control and long-term prevention. In 1918, there really wasn't any approach. No vaccine, the world at war (World War I), no treatments -other than Tylenol and aspirin, no ventilators. Each of these situations is not quite what we currently have in the US, but might be instructive in seeing into the future.
New Zealand began their hard lock-down before the first case of Covid ever materialized in the country. Everything closed except for food markets, and you were not allowed to even leave your neighborhood (to prevent wider spread). Testing was done frequently if there were any symptoms, and aggressive contact tracing if a case was discovered. All people returning to the country (only New Zealanders could come into the country), were mandated to a two-week, government enforced quarantine in a hotel. The result? 2,595 total cases, and 26 deaths. The country is completely open, including all businesses, and no one wears a mask. The last death was in mid-February, and before that the last death was in late September. three-quarters of the deaths occurred in April, 2020. Comparing NZ vs U.S. numbers as the number of deaths and cases:
USA: 1,715 deaths per 1,000,000 people; 95,161 cases per 1,000,000.
New Zealand: 5.2 deaths per 1,000,000; 519 cases per 1,000,000.
Clearly, New Zealand has done much better (more than 100 times better!)
Admittedly, New Zealand is different than the U.S. It is smaller, it is an island nation, so it is much easier to close its borders, and its closest major neighbor (Australia) is about 2,500 miles away. They also have a single-payer healthcare system, or NHI (National Health Insurance), so everyone has insurance. Even people who live “off the beaten track” are not that far away, compared with U.S. Finally, New Zealanders trust their government and expect it to solve the nation's problems. Americans do not.
The Covid pandemic did not begin well for Israel. As of mid-April, they lost 6,331 people in a population of 9 million. Their death rate per million population is 703 (US=1,715), and the case rate per million is 92,455 (US=95,151). The combination of a younger and more fit population, and an excellent health system where everyone is insured and so can easily access care, probably kept the death rate lower than in the U.S. To control the pandemic and end it, Israel decided to aggressively vaccinate. They bought lots of vaccines early on, and tasked hospitals to vaccinate medical people, the national emergency services organization to vaccinate nursing home residents, and the health insurance companies (only four of them, all non-profit) with vaccinating everyone 60 and older.
Everyone knew who they would get their vaccine from. No getting up at 3 a.m. to check all the state sites, county sites, and pharmacy sites to see if there was any vaccine appointments available. They also had excellent electronic records to know who qualified and who to reach out to for an appointment. Finally, there was a single set of rules nationwide, as opposed to the U.S., where each state, and in many cases, each county had separate and sometime opposing rules. The result? Israeli citizens age 70-79 are 91% fully vaccinated. As a country, (in mid-March), 50% of Israelis were fully vaccinated, 60% had at least 1 dose. The U.S. in mid-March had 12% fully vaccinated and 21% had at least 1 dose.
Israel is a much smaller country than the U.S. geographically, and because they have been in a war-like situation pretty much since the country came into being, the whole population understands how to deal with emergencies. But, they are also a very divided country (sound familiar?), and haven't had a stable government, with 4 elections in the past 2 years. The fact that they could pull this off under these circumstances is impressive. They also have a health system that is more like a single payer system, where there is more governmental control. Finally, just about everyone has served in the Army, so there is a certain amount of understanding of the need for command and control. I'm not sure I'd say Israelis trust the government, but they understand they need the government in order to exist as a nation, so they are more likely to comply with the government's edicts. As a result, they may soon reach herd immunity.
The “Spanish Flu” (which actually started in Kansas, and spread worldwide due to World War I) was a bit like the “Wild West” in the area of public health. Localities (think cities) made the rules (and suffered the consequences). Baltimore had a mask mandate, and did relatively well. Philadelphia did not, and as a result had a higher death rate. Locally, Penn Yan, Dresden, and Rushville were hit hard. Things were further complicated in that doctors and nurses were serving overseas in large numbers due to the war. The Yates County Health Commissioner closed schools, churches, theaters, and banned public funerals. County organizations canceled all meetings (there was no Zoom in those days). The doctor who issued the Yates County order in mid-October 1918 died from the disease he was trying to fight two weeks later. Other doctors in town took sick and had to stop seeing patients. Sick people were basically on their own, some dying within 48 hours of their first symptoms, and many of them were between 20 and 40 years old (older people did better than younger ones in the 1918 pandemic). One positive outcome was that all this disease and suffering provided the impetus to raise the funds and build Soldiers and Sailors Memorial Hospital. The hospital opened in 1924, 6 years after the beginning of the pandemic. (Many thanks for a great article by Rich MacAlpine for the local info).
Doctors really didn't have much to offer in 1918. Treatment was mostly aspirin and acetaminophen (Tylenol), and bed-rest. Lock downs (quarantine), were probably the best solution for the times. Much like Covid, the Spanish flu started in March and hit particularly hard that fall and winter. In the US, 675,000 people died (the current Covid death toll is: 566,000—we are not that far off). Worldwide, 50 million died in the 1918 pandemic (some estimate as many as 100 million died). It is estimated that there were 500 million (=1/2 BILLION) cases world wide or one in three of the world's population at that time. It came in four waves (surges), much like Covid has.
Essentially, that is the reason it finally ended. We attained a very painful and costly herd immunity. People developed immunity to the virus when they caught the disease and (if) they survived it. It took a little more than two years for this to occur.
So, those are three ways to end the pandemic. It's too late to control it as New Zealand did. There's just no stomach for a complete lock-down (though that could change if we see a scary variant). We can definitely do what Israel is doing, if everyone will pitch in and help out by getting vaccinated. We really don't want to go the way of the 1918 flu. We probably won't reach the 1918 numbers because we do have some treatments, and because we have the vaccine, but it could still be a long and painful process if we go that route. Vaccination is far preferable, and safer (yes, it really is much safer). So, do your part, take your shot!
I'll discuss the J&J vs Pfizer/Moderna vaccine in my next column. Here's to your health!
Dr. Wayne Strouse is a family physician practicing in Penn Yan.