Doctors' Observations about COVID-19 Used to Be Embraced
While rounding on an inpatient service, Dr. Anil Makam noticed positive news about COVID-19. Many of his online colleagues did not appreciate these upbeat observations
Today’s guest post is from Dr. Anil Makam. Dr. Makam is a hospitalist and assistant professor here at UCSF. He is a brilliant health services researcher, and has always been a nuanced, and critical reader of the literature. He reflects upon a tweet he made recently, which pointed out some upside in recent COVID-19 news, and the reaction he received. Some of his colleagues were simply not ready to acknowledge the facts.
Vinay Prasad MD MPH
By Anil Makam
-Never say never is an aphorism I try to abide by in medicine.
What follows are the lessons learned from a clumsily worded tweet about my recent experience caring for patients on the hospital wards this month at San Francisco General Hospital.
Severe COVID-19—defined as respiratory failure from a lung infection (pneumonia) caused by SARS-CoV-2—has all but disappeared from my experience. I didn’t care for a single patient with severe COVID-19, despite a high number of COVID19 cases in my community. I wrote the above Tweet because this is something I could hardly have imagined two years ago.
My misstep was insinuating that severe COVID-19 was eradicated. This is not true, and honestly, unlikely to ever be true. I’d be foolish to ask you to trust my four days of clinical experience in a city that is generalizable to just about nowhere.
I meant to celebrate a positive turn in the pandemic—the marked reduction in severe disease. This good news was built on my own experience, the experience of trusted colleagues on the front lines, and on published reports (here and here) over the past 9 months.
As a health services researcher and epidemiologist, I trust the scientific process, and try my best to follow it dispassionately. I’m not prone to panic but I rang the alarm bell in March 2020.
I am an ardent believer in the miracle of COVID-19 vaccines. I avoided the trappings of flawed scientific papers promoting dubious therapies. I embraced the emerging evidence of steroids for the treatment of severe COVID-19 before the study was formally peer-reviewed. And now, I firmly believe we have achieved our goal, which was set in in 2020: to prevent most severe COVID-19.
The disconnect between the hospitalization data and the experience of in-patient clinicians stems from our developed population immunity (from vaccines and acquired infections) combined with a less virulent but much more contagious variant.
Unlike in 2020 and 2021, over two-thirds of patients who now test positive for SARS-CoV-2 on screening tests upon admission are truly incidental or minimally symptomatic. The surge in hospitalizations “with” and not “for” COVID-19—once a dog whistle to downplay the pandemic—is now reality (see here and here).
You may now ask what explains the daily death tolls from COVID-19?
In the same way that hospitalization data does not sort out from vs with SARS-CoV-2 infection, I worry that death certificate data during the Omicron era is also misleading.
As a stark reminder, at the height of the pandemic we did not standup makeshift hospitals and morgues because people were succumbing to non-respiratory complications like fatal blockages in the brain (stroke) or blood clots in the lung (pulmonary embolism), or because frail patients were “tipping over” from milder illness that spared their lungs. It was because of severe COVID-19 damaging the lungs.
Ascribing the cause of death on a death certificate is a murky endeavor. Given the surge of patients testing positive, in situations where the cause of death is unclear, thoughtful doctors may list COVID-19 as an immediate or contributing cause.
We’re at an impasse. Formerly trustworthy metrics of hospitalizations and death continue to show doom and gloom, yet trusted clinicians and published reports show the opposite: that most severe COVID-19 is averted.
To move forward we need better, not bigger data. We need adjudication of outcomes just like we do for other illnesses that cannot be diagnosed by a test result.
Either way, we should celebrate the undeniable progress, which doesn’t erase the past or ongoing suffering.