Greg Ganske: Where we've been and where we're going with COVID-19

As a physician and former U.S. congressman whose committee had oversight of the Centers for Disease Control and Prevention and the National Institutes of Health, I have been asked questions about COVID-19 public policy. I am not an infectious disease specialist or epidemiologist. However, I have studied this pandemic closely.

It is a tragedy. To date it has worldwide caused 25 million known cases and about 1 million deaths, of which about 180,000 are U.S. deaths. Had this pandemic been contained by earlier isolation steps in China and had knowledge of human-to-human transmission been shared by the World Health Organization, there is no question there would have been fewer deaths.

It is small comfort that the Spanish flu of 1918-19 was magnitudes worse or that we baby boomers remember the childhood polio epidemics that arrived each summer. Polio peaked in 1952 with 60,000 cases. One day you had a headache, the next you were paralyzed. It wasn’t until three years later that the Salk vaccine conquered this highly infectious disease — which didn’t just kill but left so many who with lifelong disabilities.

In 2009, the H1N1 swine flu (a subset of the influenza A virus, like the 1918 flu) was very infectious. It would have been even worse than COVID-19 if it had the later virus's lethality, killing several million Americans. We dodged a bullet.

We are fortunate to have had influenza vaccines since 1945. The trivalent vaccines for influenza A (H1N1, H3N2 and one influenza B virus) have prolonged the lives of the elderly by preventing fatal pneumonias. COVID-19, however, is a different type of virus for which scientists have tried unsuccessfully to develop an effective vaccine for decades. The elderly, especially nursing home patients, are particularly vulnerable because their immune systems are weaker than younger people's and because they are more likely to have underlying diseases.

Underlying conditions make recovery from the virus less likely. The CDC’s report of Aug 26 on data from Feb. 1 through Aug. 22 says that only 6% of deaths were due to COVID-19 alone. All other U.S. COVID-19 deaths had an average of 2.6 additional conditions such as Alzheimer's, cardiac arrest, diabetes, sepsis, among others. Some recorded COVID deaths are those who died of other causes but merely tested positive, as openly reported in some states.

Fauci excels with singular focus

I respect Dr. Anthony Fauci, who in the past testified before my congressional committee. As a medical researcher, scientist and the administrator of the National Institute of Allergy and Infectious Diseases, he approaches this epidemic in a careful way, knowing that anything he says has great import. A typical statement would be that he is “cautiously optimistic” about the development of an effective vaccine. He gives advice from the perspective of what is best to achieve the lowest sickness and death from the virus, period. He knows it is not his job to handle all the other public policy considerations, such as the national economy.

The randomized, controlled scientific study is his holy grail.

On April 13, Dr. Fauci stated that President Trump listened to his advice when he recommended that mitigation efforts be taken to stop the spread of the virus. In testimony before Congress on July 31, he confirmed that he was involved in the president’s decisions in the early stages of the pandemic to restrict travel, and that it saved lives.

But elected officials must weigh more

While Dr. Fauci’s job is to consider health as it relates to a patient and the virus per se, President Trump and the nations’ governors — by contrast — have to consider broader health and economic questions; in other words: What is the cost/benefit calculation across the economy and society to governments’ responses to this pandemic?

They make those decisions without the benefit of scientific precision.

There is a question common to all public policy decisions, especially involving health care: What is the cost? I am not just talking about monetary cost, but also other aspects of public health. As a hypothetical example: Let us speculate a new drug comes along that can prolong a cancer patient’s life by three to six months but would cost Medicare $10 million per patient. Could Medicare afford to put so much resource into a small group of patients, which would affect the availability of care for many others?

Often when I was in Congress, a constituent would want me to support some good idea. In a world with limited resources, many ideas sound good but can’t be afforded without taking from other important programs. This is what political leaders around the world are struggling with now in dealing with the pandemic. Do we lock down the economy and “save every last life” regardless of the chances of a successful outcome while devastating the economy and small businesses?

In addition to hundreds of thousands of struggling businesses and massive unemployment, there are significant health care costs from isolation, such as alcohol and drug abuse, which result in family discord and abuse. There is the long-term cost of children not going to school.

The people hurt the most by the business lockdowns are the people who can afford it the least. Many have only enough savings to last two weeks without a paycheck. The COVID-19 scourge has divided the American workforce. Professionals, wealthy entertainers, professors, managers, people who can work online and are in the technology sector are doing significantly better than those in the service economy, such as secretaries, cashiers, janitors, restaurant workers, and those in retail and the travel industries.

Even more troubling is that the economic groups being hurt the most by business shutdowns are disproportionately women and minorities, those who have already fallen behind in the race to a technology culture. They are wondering not only if they can afford rent and food, but also if they will even have a job when the pandemic subsides. Making this even more heartbreaking is that, before COVID-19, many had seen significant economic improvement and higher wages because of the booming economy when unemployment was at record lows.

Promising news, but a long way to go

At first, in dealing with the unknown behavior of this virus, we worried about health systems being overwhelmed. This was the rationale for social distancing to the extent of shutting down portions of the economy. We were told to “flatten the curve.” What most people didn’t understand about “flattening the curve” was that (short of an effective vaccine, a miracle drug or herd immunity) a flatter curve is not necessarily a less deadly one.

There is a benefit to a federal system of states in dealing with this pandemic. This is a huge country, and one-size-fits-all prescriptions many times don’t fit specific locales. Public health has traditionally been the purview of state government, with federal advice from agencies like the CDC. New York City with its high-density population and 80% use of mass transit is different from Iowa and South Dakota. 

The COVID-19 case/death ratio trends in the U.S. and the world are somewhat promising — but there will be hot spots as economic distancing is relaxed. There will be resurgences in cases where businesses reopen. It is to be expected that there will be more cases, for instance, in college towns where large numbers of young students congregate. Fortunately, this virus is not like the Spanish flu, which hit young healthy people so severely. However, younger people can infect older citizens and they have responsibility to older citizens.

Sifting evidence on best use of masks

I wore a surgical mask in the operating room throughout my medical career. A surgical colleague recently commented to me that we wore the surgical masks more to protect our faces from sprayed body fluids than to prevent infections. However, in regards to COVID-19, medical-quality masks, protective gowns and gloves and proper technique do protect health personnel.

In the earlier days of mitigation, Dr. Fauci and the CDC recommended that the public not wear masks. Perhaps this was to preserve a supply for the health personnel. 

However, Dr. Fauci and colleagues were undoubtedly also aware of medical reviews of controlled, randomized studies between 1946 and 2018 that tested the efficacy of face masks for preventing laboratory-confirmed influenza that showed no significant reduction in influenza transmission. Other studies conducted in households showed no reduction of confirmed influenza with face masks. Some researchers concluded that “randomized controlled trials of face mask did not support a substantial effect on transmission of laboratory-confirmed influenza.”

A systematic review in 2007 showed the same thing, “with the exception of some evidence from SARS we did not find any published data that directly support the use of masks by the public.” A review in 2010 of face masks and influenza found some efficacy of masks if worn by those with respiratory symptoms but not if worn by asymptomatic individuals.

Dr. Fauci and others were also concerned that face masks could be deleterious if not worn properly by the public. In particular, they worried that people would touch their faces more often to adjust masks, not cover their noses, and contaminate their faces with hands carrying the virus. This is still a concern, as is people wearing masks but not socially distancing because of a false sense they are safe.

There is now more evidence for the benefit of wearing masks, albeit anecdotal. Indirect evidence is emerging, like a study from Hong Kong that shows wearing masks helps contain the pandemic when combined with social distancing but that wearing masks alone was not statistically significant.

My advice: Always wear a mask around other people if sick (and isolate), wear a mask in larger groups of people, and wear a mask if you can’t socially distance. It is easy to wear a mask in stores. Wear a mask in the grocery store or any establishment that requires it. But wear clean masks and cover your nose and mouth. Surgical masks are better than others; some cloth masks aren’t very good. If you are alone or with family, you don’t need to wear a mask. Wear a mask if around anyone immunosuppressed or with significant underlying conditions. Wash hands, wash hands, wash hands.

The precautionary principle is an approach to new things where extensive scientific knowledge is lacking. It emphasizes caution and review. Just because there aren’t controlled clinical trials or definitive epidemiological studies showing that masks in the general population make a difference, wearing a mask is not very cumbersome or harmful for the vast majority … and it may help!

Debate policies, but grant some grace

Fighting this virus will be a long haul, a marathon. With all the companies around the world seeking a vaccine, I, too, am cautiously hopeful we will have a readily available effective vaccine by the middle of 2021. However, coronaviruses haven’t yielded vaccines in the past, and COVID-19 will probably mutate. A vaccine is no sure thing. I suspect that COVID-19 is going to be with us like influenza is and we will be getting annual vaccines and learn to live with this new virus like we have with influenza.

Our political leaders are trying their best in dealing with this “novel” coronavirus. They have made mistakes, such as sending COVID patients back to nursing homes prematurely, as done in New York and Sweden, and it will be easy to criticize in hindsight. In the meantime, our elected officials have the tough job of continuing to make difficult decisions balancing many health and economic factors in dealing with a disease we don’t fully understand.

We should wish wisdom for all our government leaders in managing the balance between economic considerations and disease suppression. We should cut them a little slack; we may disagree with some of their choices and can debate the merits, but they are trying their best.

Dr. Greg Ganske is a retired plastic surgeon and was a congressman representing Iowa from 1995 to 2002.