The fog of war

Here in California, Gov. Gavin Newsom (D) recently ordered universal mask use in public. It is possible that mask use is more effective than previously thought, so use them. He and other governors also rolled back some reopening plans.

However, after seeing about 10 cases early on (all survived) in our three geriatrician practices, we have not seen a COVID-19 case in over six weeks. Our local hospital is far from overwhelmed. There are about 20 hospitalized now. Two months ago there were 50 and it was not overwhelming then either. We have also learned how to provide better care.

Independent reporting also found situations as in the state of New York - consistent with that of ours. We have all the protective equipment and supplies needed. Medical offices are up and running full time, with infection control procedures.

Seniors can be confident it is safe to see the doctor or receive hospital care, after all, the "curve" seems to have flattened. Despite having an expected uptick in cases across the nation, deaths are down.

Will things ever get back to a semblance of normal?

Of those who get sick and are tested, the case fatality rate (CFR) is 5 to 6 percent. Still, most infections are asymptomatic and unrecognized. As such, the overall infection fatality rate (IFR) as judged by serology testing among all ages - which actually counts those asymptomatic people - may be closer to 0.25 percent or at worst 0.5 percent-or about one in 200400. For those under 70 years old, it's 0.05 percent, or one in 2,000. It is far less - statistically zero - for those under 20 years old.

The old and ill are at greater risk and must be offered protection. The IFR in people over 90 years old and living with comorbid conditions may be about one in 10. That's bad and those seniors might be better off choosing a "safer at home" approach by quarantining until a vaccine is developed and made available to the public, or until natural herd immunity is established. However, quarantining doesn't guarantee safety and wellbeing; some seniors who were locked in their rooms in retirement centers during social distancing protocols became depressed, terrified and deathly ill as a result. Some skipped critical cancer therapy.

Early on we pulled kids out of school and brought them home to prevent what many feared would cause child-to-child school transmission. It turns out children get it from adults at home much more often, they have fewer symptoms and get less infected than others. In retrospect, we should have left them in school. It's the grandparents that need protection. The American Academy of Pediatrics has just strongly recommended that all children go back to school full time, with or without social distancing and masks, because failure to do this would be worse for all.

The lockdowns resulted in 45 million jobs lost, some forever. Education stopped or was badly compromised. This happened to young and healthy people who are very unlikely to get sick. It makes sense to send them back to work.

Nursing homes are a huge problem. Before COVID-19 the median life expectancy of a nursing home resident was sadly only five months. Only 1.4 million out of 330 million Americans live in nursing homes, but 40-70 percent of COVID-19-related deaths struck these facilities.

Let that sink in - if you don't live in a nursing home your risk is much lower. If you do, your risk is horrible, as it always was.

A lot depends on how well you are now. Those who are not obese, not diabetic, have no heart disease or lung disease at any age have lower risk. Their infection fatality rate is far less than one in 2,000. Vitamin D deficiency seems to be a risk factor, so we are asking all our patients to check vitamin D levels and supplement it with 2,000 international units per day.

Sunshine makes Vitamin D in our skin. But early on the beaches were closed and people were told to stay home, which effectively meant staying out of the sun. That too was a mistake. Social distancing, hand washing, better hygiene, limited contact with strangers and mask use certainly saves lives. Quarantining the vulnerable elderly saves the most lives. Let's do all that better.

However, it is not clear that lockdown added much. Clearly some of the things we did made things worse. The number of deaths with and without lockdown might have been similar, but far less collateral damage would have been done.

At some point we probably have to step back and admit this is an ongoing natural disaster that will become part of the background risks we all live with day in and day out. Life will go on.