乌鸦传媒

I have not written a blog post since October 2019. For the last 6 months, life had become too busy, and I had no time to write anything of quality. If I did not have the time to say something of value, it was good to remain quiet.

The world of October 2019 no longer exists. Our lives have been transformed in ways that we could not possibly have imagined. Many already thought that the world was an irrational, unkind, and dysfunctional place in October of last year. Now, they refer to that period -- a mere 6 months ago -- as a time of "normality."

Normality? Is that the right word? Many people think that the word that refers to a state of being normal is "normalcy." But "normalcy" did not assume its current meaning until Warren Harding used it (incorrectly) in a speech during his 1920 presidential election campaign. His slogan was "Return to Normalcy," a plea to return to the way things were before World War I.

From 1914 until 1919, the world suffered through a Great War and a horrific multiyear pandemic. People yearned for a "normal" world, i.e., one that resembled that before the war, and that is what Harding promised. Harding won the 1920 election with >60% of the popular vote and with 404 electoral votes. At the time, it was the most lopsided victory since the advent of the two-party system.

Harding's appeal was not surprising. The 1918-1920 pandemic infected as many as 20 to 100 million people, including 600,000 to 800,000 Americans. There were substantial adverse global economic effects. Social distancing was strongly recommended and highly effective, but often ignored. Physicians were baffled by the disease, which was unlike any they had seen before. Many patients died of cytokine storm.

In their efforts to treat influenza, physicians became irrationally enamored of the benefits of an old familiar drug -- aspirin. Bayer lost its patent on aspirin in February 1917, which allowed many manufacturers' entry into the market, providing the drug at cheap prices. Official recommendations called for the use of high doses. There is substantial evidence that aspirin contributed to a large .

Does this sound eerily familiar now?

COVID-19 is a vicious disease, whose pathogenesis appears to be unlike anything that most physicians have ever seen before. The virus can trigger a , which explains the extreme hypoxemia, the thrombogenic state, and the dysfunction that progressively leads to death. contributes to a large number of fatalities. Social distancing is widely recommended, but variably practiced. The disease has had a profound deleterious impact on economic activity. Furthermore, physicians are learning that many of their established therapeutic algorithms do not work in patients with COVID-19, and they may make things worse. Two old familiar drugs -- chloroquine and hydroxychloroquine -- have been recommended, and when used in high doses, have led to death, presumably related to their well-known proarrhythmic effects.

We may enter a seasonal lull, and the temporary abatement would buy us valuable time. Time to develop new effective antivirals or new ways of therapeutically mitigating the lethal consequences of cytokine storm. Time to make meaningful progress on a vaccine. Time to understand how hypoxemia should be managed. Time to greatly expand our testing capabilities. Time to reorient and refocus our resources to make our societal and medical response more effective.

But any lull is likely to be brief. The lulls in the 1918 pandemic lasted only a month or two. There were three pandemic waves in 1918-1919, and the later waves were more devastating than the first. If the second wave of COVID-19 strikes, it may return with a vengeance, and it will not necessarily wait until the fall or winter months.

Anyone who thinks that the solution to the pandemic is "herd immunity" is likely to be disappointed. It is not clear whether patients with antibodies to SARS-CoV-2 are immune to reinfection, and there is no good evidence that human beings developed natural herd immunity during the 1918-1920 influenza pandemic. The , and not because humans were able to launch an effective community-based immune response.

Do you still think we will be going back to "normal" soon?

If you are dreaming of a "return to normalcy," you may have forgotten that, 6 months ago, we lived in a horribly dysfunctional world. As I described in nearly 100 essays that I posted to this column over a period of 3 years, the world of medicine was illogical, ineffective, outrageously expensive, exceptionally self-serving, and often mean-spirited. Perverse incentives dominated the landscape, and the administrative burdens were horrific. Healthcare providers were at their breaking point. Medical blogs were filled with vivid descriptions of psychic pain.

Anyone who wishes to return to our pre-COVID-19 lives forgets how much they were complaining a mere 6 months ago.

But we are not going back. COVID-19 has unleashed forces that will not be readily reversed. Here are a few of my predictions; none are particularly original.

1. COVID-19 will dramatically accelerate societal recognition of healthcare as a right. Currently, the federal government has declared that financial resources should not play any role in whether patients with COVID-19 receive medical care, since it is with the disease. Whether you agree or not, the principle of receiving medical care as a right is no longer in dispute.

2. COVID-19 will trigger major changes in the medical insurance industry. Right now, the insurance industry has maintained its revenues, but dramatically reduced its expenditures, since there has been a striking decrease in elective procedures and non-COVID-19-related medical care. The windfall profits for insurance carriers will be immense and morally and politically unacceptable. And what good is employment-based insurance if >20 million people are newly unemployed?

3. COVID-19 provides an exceptional opportunity for medicine and science to regain the public trust. The public now celebrates those who are on the frontlines of patient care. Furthermore, if the pharmaceutical industry develops a truly life-saving antiviral within the next 6-12 months or an effective vaccine within the next 12-18 months, their currently tarnished public image will be greatly improved.

4. COVID-19 is dramatically changing the way that physicians access and share medical information. Telemedicine will become a dominant theme. (Why come to an office if the physician never examines you?) Telecommunication will also dominate physician-to-physician exchanges. During the past 2 months and for the foreseeable future, nearly all face-to-face medical conferences and meetings have been cancelled, and many have been replaced by virtual presentations. No one has traveled by plane, checked into a hotel room, or sat in a hall to listen to speakers. When COVID-19 subsides, will the medical congresses and conferences return? Many were already in serious decline before the pandemic.

Journals have been rushing to publish any and all new information about COVID-19, but in truth, much of the research that has appeared in journals has been of lower quality than editors would have previously accepted. Are these papers being read? Readership of journals has been plummeting for years before COVID-19, and it is not clear that physicians have regained any interest in reading journal articles. Most physicians have been communicating with each other online, and information is being , bypassing the peer-review process entirely.

You can dream all you want. But the world that existed 6 months ago is not coming back. Only a crisis ignites , and crises accelerate the adoption of ideas that are already in play.

I know that you do not want to believe me. Most readers are yearning for a "normal" world. Warren Harding promised a "return to normalcy," and he was elected in a landslide.

So what happened during the brief Harding presidency?

Harding appointed Andrew Mellon, one of the richest men in the country, as Secretary of the Treasury. Mellon spearheaded an exuberant pro-business economic agenda that included massive tax cuts and interest rate cuts by the Federal Reserve. The U.S. public embraced an overzealous culture of consumerism that was fed by vast amounts of thinly collateralized credit. At the same time, the U.S. government encouraged substantial economic inequalities, supported a brutal anti-immigration program, and promulgated a strong campaign against science. Does any of this sound familiar?

Mellon's agenda fueled wildly speculative excesses that led to the stock market crash of 1929, and the collapse of credit triggered the Great Depression.

There is no going back. You need to work with the world that you have now. If you were distressed by the dysfunctional pre-COVID-19 state of affairs, our current crisis provides an unparalleled opportunity to make things right. If we do not take the lead, others will do so for us.

Comment