The Set-up

CoronaVirus aka SARS-CoV-2 aka Covid-19.  It has become everything.  It has consumed our daily lives.  The constant daily, nay hourly, haranguing of “breaking news.”  The media talks about nothing else.  As if life had stopped.  I want to give you a different view and projection.   A medical / epidemiologic / economic view.  A more global and comprehensive take.  The view from 10,000 feet as it were. This is going to be a longer blog.

This Virus is Striking High Density Cities

Is there a Middle Path?  We know the stories about China, Italy, and now the United States.  When in reality, statistical analysis tells a more sophisticated story.  It is never black-and-white.  In China 80% of all cases were in the city of Wuhan – Hubei Province.  Virtually no cases in Beijing or in Shanghai.  In Italy the vast majority of cases were confined to Lombardi.  And now the United States, the vast majority of cases are confined to New York City.  What is common to all of these?  High density populations.  In fact,  there is a paucity of cases and fatalities in the entire Southern Hemisphere.

Background Resources and Historical Perspective

I want to give you more specifics about this CoronaVirus with a list of resources and technical details. This is a variant of the CoronaVirus group which has been well studied since the 1960’s.  It is not new. The current mutation is the Novel CoronaVirus, SARS-CoV-2. The disease caused by this virus is Covid-19.  Do you remember the SARS and MERS epidemics?   Sudden Acute Respiratory Syndrome.

Let’s revisit my previous blog by putting this in proper historical perspective.  This pandemic is here.  It is worldwide.  It is real. It has been predicted. But we must see it in perspective.  Because you are being overwhelmed and I want you to see some daylight and hope.

This is not to ignore or in any way diminish the current suffering or stresses on our health delivery systems.  But the world has suffered from far greater pandemics and plagues in the past.  Watch this brief YouTube video from South Front – a necessary overview.  You can barely see Covid-19 in this graphic.  It’s like comparing Mercury to the Sun.  You will have a difficult time even finding Covid-19 in this graphic.

Now look at another fine series from The VisualCapitalist worth bookmarking.  It illustrates the same.  Just how massive previous pandemics and plagues have engulfed the world.

And here is an up-to-the-minute link for real-time stats from WorldOMeter.

Finally, another long video graphically detailing the apocalyptic Spanish flu of 1918, following the end of World War I.  It was a time of massive troop movements between America and Europe associated with widespread poverty and the devastation of war throughout Europe.

Why am I showing you all the videos links?  To give you a sense of how pervasive and absolutely devastating prior pandemics were.

So why are we so fearful?  How did we become so subordinated, freaked out and frantic over this current pandemic, as opposed to previous pandemics that were manifestly larger and more deadly?

Because we are overwhelmed with a sense of the unknown.  Heightened by a pervasive media and social amplification.  We are developing an entirely new lexicon.  Newspeak.  Social distancing.  Shelter-in-place.  We want zero risk in our daily lives.

The Bottom line: this is still a minor pandemic compared to the Black Death Plague of 1348, or the Spanish Flu Pandemic of 1918, and even more recent epidemics such as the cumulative deaths worldwide from HIV/AIDS.

What Exactly is this CoronaVirus – SARS-CoV-2?

SARS-CoV-2 originates from an animal vector – bats.  We suspect it travels to Pangolins whose scales are prized in Traditional Chinese Medicine.  Then humans are infected.  That seems to be characteristic of so many modern flu-like and viral pandemics.  Jumping from an animal reservoir to humans.  Like swine flu, bird flu, SARS (civet cats), MERS (camels) and now Covid-19.

We know that this virus spreads rapidly.  Scientifically and epidemiologically we look at R₀ values, how many people are infected by a single person.  In other words, its multiplication factor.  The ideal is R₀ = 1.  That flattens the curve. The current R₀ is assumed to be about 2.5.   But these numbers are estimates, subject to complex differential mathematical models.  We do not know how accurate these models are.

80% of all cases are considered mild cases.  That is the source of herd immunity.  Let me return to this concept later.

This may be a sidebar but highly recommended.  If you really want to know the science beyond the headlines here is the best lecture series I have seen.  He explains and shows you all aspects of this viral origin and pandemic spread.  It is produced by Ninja Nerds, an unlikely face of academic knowledge.  But if you watch this Ninja Nerds series on Covid-19 you will learn everything you need to know about the epidemiology and the pathology of this virus. You will be well schooled after finishing this series.

Controversies in Containment Strategies

I always look at the outliers.  Why are there so few cases in India, Australia, Africa, South America, and Scandinavia?  And why the differences in approach?  We are told the approach in China and in Korea was draconian.  Cell phones were being monitored.  And yet look at this recent story showing Korea did not shut down their entire economy like we have.

from NPR news:

How South Korea Reined In The Outbreak Without Shutting Everything Down

“We’ve seen examples in places like Singapore and [South] Korea, where governments haven’t had to shut everything down,” said Mike Ryan, head of the World Health Organization’s Health Emergencies Programme. “They’ve been able to make tactical decisions regarding schools, tactical decisions regarding movements, and been able to move forward without some of the draconian measures.”

An article in Science:

Mathematics of life and death: How disease models shape national shutdowns and other pandemic policies

“Long lockdowns to slow a disease can also have catastrophic economic impacts that may themselves affect public health. “It’s a three-way tussle,” Leung says, “between protecting health, protecting the economy, and protecting people’s well-being and emotional health.”

“I’m not really sure whether the theoretical models will play out in real life.” And it’s dangerous for politicians to trust models that claim to show how a little-studied virus can be kept in check, says Harvard University epidemiologist William Hanage. “It’s like, you’ve decided you’ve got to ride a tiger,” he says, “except you don’t know where the tiger is, how big it is, or how many tigers there actually are.”

And more from the New York Times.  Dr. Katz is president of True Health Initiative and the founding director of the Yale-Griffin Prevention Research Center.

Is Our Fight Against CoronaVirus Worse Than the Disease?

“So long as we were protecting the truly vulnerable, a sense of calm could be restored to society. Just as important, society as a whole could develop natural herd immunity to the virus. The vast majority of people would develop mild CoronaVirus infections, while medical resources could focus on those who fell critically ill…

A pivot right now from trying to protect all people to focusing on the most vulnerable remains entirely plausible. With each passing day, however, it becomes more difficult. The path we are on may well lead to un-contained viral contagion and monumental collateral damage to our society and economy. A more surgical approach is what we need.”

If you are still with me, you will find this YouTube with Dr. Jay Bhattacharya, professor of medicine at Stanford University most enlightening.  Subsequent to his editorial in the Wall Street Journal.  He is asking the right questions.  Is our draconian approach based on faulty assumptions? 

Sweden and Holland have taken a different approach.  What I call the middle path.  Isolate and quarantine known cases.  That is what is traditionally done.  That is how you treat infected patients in a hospital.  Isolate and contain.

Adverse Consequences of Flattening the Curve

What has been missing in the United States is the mobilization of a centralized strategic plan.  It was all in place.  Now we have a patchwork of federalized responses.  These are tactics, with states scrambling for limited resources. This is not a strategic plan, which flows from a designated and recognized incident commander.  What we used to call a Czar. One who directs and executes the strategic plan.

Dr. Anthony Fauci is a vaunted virologist and epidemiologist.  Epidemiologists are not policymakers.  He should not be the face of this pandemic.

There are some very sophisticated models of viral spread based on R₀ values.  This is illustrated below, with an animated graphic. Here is the link the more interactive dynamic graphic model.  Please take the time to play with the interactive graph for a few minutes.

If you look at this model of increasing isolation (shelter in place) 3 critical questions arise.  What is the goal?

1. Reduce all cases – incidence?
2. Reduce and mitigate hospitalizations and stress on our entire EMS system?
3. Reduce and mitigate fatalities — mortality rate?

The answer to each of these questions might lead to entirely different strategic plans.

The incidence decreases the most.  Then you see a decrease in hospitalizations.  But the mortality rate decreases the least.

Our Ultimate Goal in Increasing Herd Immunity

As counter-intuitive as this may appear, decreasing the case incident rate may have negative consequences.  Our goal with natural wild type immunity antibody production vs. acquired immunity through vaccination programs is to increase “herd immunity.”  That is, increase the greatest number of people who have been exposed to a virus and are now immune.  They can no longer spread the disease to other people.  It is a firebreak. The current policy of “dampening the curve” actually diminishes herd immunity.  In the long run, that is the real goal.  That is what prevents the spread – enhancing herd immunity.

Dampening the curve will lower the incidence of new cases, lower hospitalizations, and slightly lower fatalities.   But lengthening this curve is at the expense of prolonging  economic and financial distress.  That is the key concept.   That is why you are seeing Congress hurriedly passing historic and unimaginable emergency legislation.  Remember Andrew Yang’s promise to give us each $1000?  How ridiculous that sounded?  Here we are.

What is missing from these epidemiologic models is a balance between containing the viral spread and prolonging economic dislocation and total financial/economic collapse.

The Economic Fallout will Dwarf the Medical Tragedies

We will see a rise in unemployment to historic levels.  Look at this graphic representation of the most precipitous DJIA slide in the stock market in history.  Even if you have no interest in the stock market or have nothing invested, it is an indicator of financial distress and a prediction of economic calamity.

The more important statistic is the VIX indicator.  The VIX is a measure of volatility — of panic.  And this level is equal to or greater than 2008.  It is a perfect storm with other indicators that I will leave to later.

What is the point?  It is a plea for a middle path.  What is the least amount of time of widespread quarantining vs. a disastrous total shutdown of local commerce, business and economic vitality?  This cannot go on much longer.  So many small businesses will fail as unemployment figures skyrocket.

This will exceed our experience of 2008. The economic consequences will eventually dwarf the medical consequences.

Prevention, Treatment, and Therapeutics

This is what all my patients are asking.  What can I do for prevention?  What can I do if I become sick?

The most important set of preventatives is concentrating on your optimal health and immune support.  7 to 8 hours of sleep daily.  Some degree of day exercise.  Healthy eating.  Decreasing carbohydrate intake.  Increase in your protein intake.  A good nutritional supplement program.  This includes adequate a quality multivitamin, Vitamin D, Vitamin K, extra selenium, extra zinc, and a good probiotic at the very least.  All my patients are taking much more. as part of a robust daily routine.

Good hormonal balance, which includes optimal thyroid balance.  Thyroid is the seat of your immunity.

I am not convinced that wearing masks are effective.  The most effective N95 masks are in short supply and should be saved for medical workers.  Washing hands and possibly wearing surgical gloves may be beneficial.   I have always been wary of ATM pin pads and handle bars on shopping carts.  These are simple precautions that are easy and beneficial.   Avoiding all possible contaminated surfaces.

I now recommend stop watching the news!  It is no longer healthy, educational or informative.  You will see your stress levels fall immediately.  Watch all your old favorite movies or all those new ones you have not seen yet.   Read more.   Take the time to do those things you have been putting off for years.

There is no definitive drug treatment for this virus except for pulmonary support, fluid resuscitation, and some possible advanced therapies directed to the loss of alveolar surfactant and accumulation of alveolar consolidation.

Many of you have asked me about the combination of Chloroquine and Azithromycin.  There have been very limited studies that show some promise.  But these are more anecdotal.  Although I personally favor empirical approaches to medical problem solving, I do not support the use of these drugs for casual and unsupervised use.  This combination should be limited for very sick hospitalized patients.

There are a number of problems with Chloroquine.  Hydroxychloroquine (Plaquenil) is less toxic than Chloroquine.  And in the mad rush to sequester and hoard Chloroquine or Hydroxychloroquine you are stealing vital medications from patients with advanced rheumatoid arthritis, lupus, scleroderma, or CREST syndrome who rely on these drugs for their significant disease modifying benefit.

And by the way, behind the scenes, there are conflicting policy decrees.  The CDC is trying to approve “off label” use of Chloroquine and Azithromycin for life-threatening disease.  On the other hand, the Medical Board of California has issued warnings that physicians using these drugs off label are being warned.  We do not know whether that includes sanctions or some other bureaucratic intervention.  It all muddies the waters further.

It is very interesting that in the medical profession, we have been chided for the last 20-30 years not to use antibiotics for viral syndromes.  The standard dogma is “antibiotics do not treat viruses.”  And yet the addition of Azithromycin is now being advocated as an adjunct.  There are some theoretical aspects of Azithromycin and Chloroquine enhancing zinc absorption which enhances antiviral activity.

There is also a theoretical discussion in medical journals regarding the potentially harmful effect of ACE inhibitors and ACE blockers.  This would include Lisinopril, Vasotec, Cozaar (Losartan), and Valsartan (Diovan) to name a few.  It is postulated that the CoronaVirus attaches to ACE2 receptors facilitating viral penetration and cellular infection.  This ultimate effect of this mechanism is an unknown at this time.  But you may hear various discussions regarding this mode of activity.  Do not stop these anti-hypertensives.

I fall back on my anti-viral routine which has been successful in the past.  At the very first sign of any viral infection.  I highly recommend:

• Vitamin D 50,000 units for five days.
• Astragalus 1000 mg daily for five days.
• Thymic protein A (Pro boost) 2 packets 3 times daily for 5 days

Now having made that recommendation, I am seeing major backorders for virtually all nutritional supplements and most especially, zinc, Astragalus and Pro boost.  My recommendations still stands as soon as they are available.

In Summary:

It did not have to be this draconian.  So many missteps and failures of leadership.  But here we are.

One more quote from Max Brooks, son of the great Mel Brooks and Author of World War Z :

I think right now we have to be so careful about who we listen to, because panic can spread much faster than a virus. And I think in addition to social distancing, we have to practice good fact hygiene.

Take care of your own health. Don’t watch the news any longer.  Watch great movies.  Be with your family.  Read my past blogs on nutritional routines.  Support clear thinkers.  You will be OK.

Send me a list of your favorite movies or books.   Every one will have their own.  If enough people respond I will publish later.

For sure another CoronaVirus blog will follow soon.

Philip Lee Miller, MD
Carmel, CA
April 2020