An elastic band to a gun fight: why Covid-19 isn’t going anywhere
Around July 2019, barely a year ago, I found myself grappling with a set of problems. In my particular field of medical practice I was immersed with a threat that had been 80 years in the making.
Drug-resistant bacteria (superbugs) were the bane of every hospital and particularly their intensive care units. In front of me were boxes of patient data and laboratory reports that I was to collate and analyse for a study on carbapenem resistant enterobacteriaceae in private-hospital ICUs.
This problem had been well described the world over since the advent of the antibiotic era in 1928 when Alexander Fleming first suggested that penicillium mould secreted an antibiotic substance.
Within a few short years Chain and Abraham reported the first observations of resistance to penicillin. What followed was the golden age of antibiotics, when just over half the antibiotics we use today were discovered. Concurrently, as each new class was discovered and used in patients, drug resistance was observed.
Fast forward to 2012 and we had widespread reports of pan-drug-resistant bacteria plaguing ICUs, claiming lives and rendering all forms of medical and surgical therapy redundant. This was, by and large, driven by inappropriate antibiotic use in the healthcare setting and in the farming of livestock and crops.
Antimicrobial stewardship is the systematic effort to educate prescribers and consumers of antibiotics to follow evidence-based guidelines and best practice with an intention to slow the spread of resistance. In September 2014, US President Barack Obama issued an executive order and developed a task force to combat antibiotic resistance. Drug-resistant bacteria claimed 35,000 lives in the US in 2017, according to the Centers for Disease Control and Prevention (CDC). In 2020 we are no closer to solving the problem than we were in 2012. There were no new antibiotics available, just repurposed old ones. The combined might of the world’s best scientists backed by first-world governments, pharma and organisations such as the World Health Organisation and the CDC have gained little ground in the fight against primitive organisms.
The basics tenets of hand hygiene and appropriate drug use ironically still remain the best tools. We aren’t as smart as we think we are, and certainly not as advanced as the lay public would like to believe.
For the first time since the 1918 Spanish flu pandemic, each member of society can contribute every day to the health of those around you and to those we have not even met
December 2019 had medical journals buzzing with an entirely new topic, a novel strain of coronavirus. Respiratory viral pathogens are a challenge for any doctor. The standard treatment is supportive as there is very little direct antiviral treatment. Influenza and varicella pneumonia can be treated with specific antiviral agents but for the most part nothing specific exists.
This virus was different though, as it represented a crossing of species from pangolins and bats to humans. Lessons learnt from SARS, MERS, and influenza H1N1 (swine flu) reminded the infectious disease and epidemiology community that this could be deadly on a global scale. All eyes and ears were focused on this very real threat.
To many, including doctors, SARS-CoV2 and the infection it causes (Covid-19) should burn itself out (suggested by US President Donald Trump) just like those other feared viruses with a modest casualty rate. Except it isn’t. It has stopped the world in its tracks and the global community finds itself in a war against an invisible enemy that we have had a few short months to study. By contrast to my assertions on complex organisms like bacteria, which we have struggled for 80 years to best, we have had mere months to understand SARS-COV2.
Thousands of scientific papers have been published. Many offer not much more than an account of disease evolution in communities across the world and warnings of poor outcomes in specific populations like the elderly, those with hypertension, diabetes and other co-existing conditions.
Very little has come about from effective therapy. No specific antiviral exists for treatment. Old drugs like chloroquine and steroids are repurposed monthly as our understanding of their effectiveness is either supported or refuted. What is left really for the sick, hypoxic patients is vitamins, paracetamol and supportive oxygen. And I write this with a sick feeling in the pit of my stomach because it is akin to bringing an elastic band to a gun fight.
SARS-CoV2 is unlikely to “burn itself out” either. There are several reasons for this. From a pathogenesis perspective, this virus is different to other coronaviruses (SARS/MERS) because it is a much greater affinity for the receptor in the respiratory epithelium (lining of the airway tract) and therefore it is easier to get infected and also to spread infection. This translates to a high reproductive rate, meaning each infected individual will infect at least three others, which mathematically implies it isn’t going away in our global community for a long time to come.
Our coordinated response as a society thus relies on us working together. For the first time since the 1918 Spanish flu pandemic, each member of society can contribute every day to the health of those around you and to those we have not even met. Wear masks properly, limit all close interactions and conduct them with the proper precautions. Lend your expertise and resources to the fight, and never commit the ultimate crime of exploiting the vulnerable.
Our racial, socio-economic and political differences make little difference to our success against this pandemic as we are inextricably linked
President Cyril Ramaphosa was resolute in March when he and health minister Zweli Mkhize recognised the serious problem we faced and in my view took decisive and timeous action. The lockdown was initiated and we sat for the most part at home, while the healthcare infrastructure in both the public and private sectors grappled to understand Covid-19 and the sort of casualty scenario we would face. Various national, provincial and private-sector task teams were established.
An unprecedented collaborative effort was under way to radically reshape our healthcare facilities in a matter of weeks. Debates and arguments to every proposal on virtual meeting platforms were waged well into the night. What is consistent to Covid-19 is change. We have to be able to adapt, and quickly.
Epidemiology projections by our local scientists and in collaboration with international teams predict our disease burden to be many times over than what we could ever cope with even if we had another year to prepare. There is perhaps little difference between first and third world health systems in this respect. Hospital capacity is exceeded before the peak of the first Covid wave is reached, no matter how well our infrastructure is prepared. Doctors, nurses, PPE, ventilators, drugs and even oxygen delivery are already under constraint.
We must not be misled. Covid affects all of us. Whether young or old, Covid-19 infected or not, your access to healthcare for you or your loved ones is already affected by the shortage of beds, theatre equipment and protocols set in place to protect the patient and healthcare workers alike.
SA, beset with challenges from our recent (and distant) past, was poised in 2019 to enter the new decade with a fresh look, a new leader and the semblance of an economic growth plan. Corruption is a sin again, with education and a universal healthcare model the new virtues of government. Unbeknown to us, a gauntlet was thrown down by Covid-19, and it’s here to test our leaders’ mettle.
Ramaphosa shone in the conduct of his office since March, speaking calmly but with clear instruction of our nation’s plan, supported by SA’s experts like Prof Salim Abdool Karim, who are doyens on a world stage. We duly followed and secured ourselves in lockdown. Come mid-April and we hear of very few cases, but more of an economy nosediving into recession, yet our president orders us into an extended lockdown. To many it made no sense. To the healthcare workers about to enter possibly the greatest challenge in our lives, time was running out. A lockdown will not stop Covid-19. It was instituted to buy us time to prepare for the public disease burden. A lockdown flattens the curve and may just have bought us enough time that we now could save many more lives had we not instituted it.
Our president, with his cabinet and Covid-19 command council now grapple with an economic meltdown, and trying to govern a country with soaring unemployment and an industrial sector treading vigorously to keep itself above water.
What is required is a simple set of rules and regulations and business reform that speaks to longevity before profit
It is abundantly clear that we cannot survive without the economy, and each of us is bound inextricably to it. It is incumbent upon the president now to be decisive as a leader, to pronounce a clear and rational plan to manage the economy amid a crippling pandemic. The news and social media abound with embarrassing failures from his counterparts around the globe. “Fact-denying populism”, the contemporary equivalent of the 19th-century Flat Earth Society, which promotes pseudoscience and conspiracy to the lay public, only serves to undermine and complicate our president’s challenge to curb the Covid-19 infection rate and launch a genuine economic stimulus package. One certainty exists, Covid-19 is no political football. Our racial, socio-economic and political differences make little difference to our success against this pandemic as we are inextricably linked.
Beyond any doubt, 2020 is a year for survival in any definition. Those fortunate to find opportunity amid the pandemic will soon realise that sustainability in any venture is even more rare. It is incumbent upon any business, its management and employees to understand the facts of Covid-19, because that is key to their survival, and in fact to our country’s future. Business must open but with purpose and compliance to regulations that will ensure they remain a going concern. The National Institute For Communicable Diseases of SA has access to information but all too often it is still difficult for doctors to decode. What is required is a simple set of rules and regulations and business reform that speaks to longevity before profit.
The vaccine for SARS-COV2 is perhaps the most eagerly anticipated. I have no doubt one will be developed and perhaps even several given time and to meet the antigenic drift of the virus. But it will not be soon enough. Vaccines to viral infections take several years to develop, and even if expedited to clinical trial and spurred on by billions of dollars’ investment it will likely be at least a year before a successful candidate reaches the public. More than 150 vaccine candidates are in various stages of development across the globe and even on our shores.
My opening paragraphs serve to demonstrate that the time to solve the conundrum of a deadly infectious disease is very slow and tedious, even if the demand is very real. The reproductive rate of SARS-CoV2 is approximately three days. This translates to hundreds of thousands of infections within 12 months and tens of thousands of deaths and with them an economic collapse. In short, we cannot base our strategy on either a vaccine or cure as neither exist at present.
It is not too late to adapt. As South Africans we are experienced with hardship. To survive Covid-19 we must each do something fundamentally different – to always consider and protect the person next to you and they in turn must act to protect you.
• Dr Ryan Ramdass is one of the country’s leading specialist physicians with interests in diabetes and antimicrobial stewardship. He is a resident specialist physician at the Lenmed Ethekwini Hospital and Heart Centre, heads up the centre’s Physician Advisory Board and KZN Antimicrobial Stewardship, and is one of the founding members of its Covid-19 Task Team Committee.
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