A has long been a metaphor for a simple, seemingly magical, solution to a difficult problem. The metaphor appears to be derived from folklore legends that bullets cast from silver were the only viable weapon against werewolves, witches, vampires, and other demons.
In medicine, the term "silver bullet" was particularly that ravaged mankind in epidemic proportions. Paul Ehrlich popularized the term when he pioneered a combination of silver and arsenic for the treatment of syphilis.
in wound dressings and as a coating on medical devices to reduce the likelihood of infections. The term "silver bullet" was subsequently applied to dramatic breakthroughs in infectious diseases, even when the treatment did not involve silver. For example, in the 1940s, that allowed doctors to treat and successfully cure many life-threatening infections.
We are all desperately seeking a silver bullet for the current COVID-19 pandemic. The concept of a "silver bullet" has such emotional appeal that some have unethically capitalized on the opportunity. In May, the FDA sought and was granted an injunction against Xephyr LLC, doing business as N-Ergetics, as a treatment for COVID-19.
No one should be taking colloidal silver to treat any disease, including COVID-19.
What is the "silver bullet" for COVID-19?
Many are placing heavy bets on a vaccine. But the possibilities for a successful vaccine are not high. Vaccines are designed to stimulate a protective immune response to the coronavirus. But those who have been afflicted with COVID-19 manifest only a weak antibody response, which appears to persist for . So if vaccines simply replicate the antibody response to a natural infection, to reliably prevent infection with SARS-CoV-2 for a meaningful length of time. No one should be terribly surprised by this. Medicine has never developed a successful durable vaccine .
Our best approach is to develop a combination of antiviral and anti-inflammatory agents that will effectively prevent morbidity and mortality from COVID-19. The early use of antivirals and the later judicious use of anti-inflammatory agents could conceivably convert COVID-19 into a tolerable disease for nearly everyone. We already have data that early use of remdesivir and the later use of dexamethasone can help many patients, as indicated and . Trials with more powerful antivirals and more selective (and potentially more effective) anti-inflammatory drugs are in progress. But the results of ongoing trials and the general availability of these treatments (if proven effective) will not be available for at least 4 to 6 months.
What do we do in the meantime?
Some people are not taking any precautions. Presumably, they are hopeful that, when infected with SARS-CoV-2, they will not experience symptoms. Or alternatively, if they become symptomatic, their clinical course will be benign and short-lived. They pray that they will only experience fever and cough for a few days and rapidly recover without sequelae.
But many will not be so fortunate. A distressingly high proportion of people will suffer a prolonged illness lasting for many months. An unknown number will develop permanent organ injury, affecting the lungs, heart, and brain. And some will develop progressive hypoxemia, myocardial injury, thromboembolic events, and death.
How many will suffer permanent injury and/or death? We simply do not know. The risks of a serious adverse outcome are very meaningful, not only in the elderly, but also in younger people. Is the risk of serious outcome 10%, 5%, 1%, 0.5%, or 0.05%? Depending on the population at risk, all of these estimates may be correct.
Is 1% acceptable? Is 10% too high? If you think that the risk of disability and death is an acceptable consequence of a preventable infection, then you must be afflicted with a strange affinity to play Russian roulette with a revolver that has an unknown number of chambers and bullets. No rational person should be willing to play such a game.
Since the effects of infection in any individual cannot be predicted with confidence, our only rational course at the present time is to take all reasonable steps not to get infected in the first place. And we need to make sure that -- if we become infected -- that we do not transmit the disease to others.
What should we do? We need to wear a mask when we are physically close to others whose infection status is unknown, especially if we are indoors.
What do masks do? It depends on the mask. Some masks for medical use prevent transmission of aerosols and droplets from infected people to the wearer of the mask and also from the wearer of the mask to others. But most nonmedical cloth masks probably act primarily to minimize the transmission of the virus from the asymptomatic or presymptomatic wearer to others. Under these circumstances, mask wearing represents a personal commitment that the mask-wearer cares about the well-being of other people. Additionally, it represents a visually obvious personal statement that the mask-wearer is concerned about the pandemic and he/she wants others to respect their personal space.
How effective is mask-wearing? It may be more effective than anyone has ever imagined. In Missouri, two hair stylists who had COVID-19 but who wore masks (and required their clients to wear masks) , even though they could not possibly maintain a 6-foot distance when cutting someone's hair.
A recent state-level analysis in the reported an inverse relationship between states with more stringent mask policies and the number of new infections. In a , the duration of masking wearing was inversely proportional to the risk of death from COVID-19. In Japan (where mask-wearing is nearly universal), the risk of infection and the number of COVID-19-related deaths .
Mask wearing is a no-brainer, but sadly, in our deeply divided country, . Some claim that mask wearing is a form of political protest, when in truth, it is a sign that the wearer cares about social responsibility and consciousness. To those who might care more about the economy than about public health, universal mask wearing allows for businesses to reopen. Compared with millions of people out of work and suffering in social isolation, masks are really inexpensive. Opposing the universal use of masks means that a person cares more about their ability to make a foolish choice than he/she cares about the health and economic welfare of their friends, neighbors, and community. Is there a better example of crass selfishness?
I want to be clear. I am not suggesting .
Our masks are symbols of our current state of isolation and despair, and no one should celebrate the need to wear one. But throughout human history, the survival of individuals and of society has required us to take actions that we do not relish. The personal sacrifice of wearing a mask is miniscule, when compared with its potential benefits.
Many falsely claim that our cultural norms abhor mask wearing. But nothing is further from the truth. Many of our most enduring and popular cultural icons of justice wore masks. Think of . These examples may sound ridiculously cheesy, but imagined heroes (embodied in our art and literature) reflect the values, hopes, and dreams of our society more faithfully than the invariably imperfect celebrities who exist in real life.
Arguably, the hero most famous for wearing a mask was . For those growing up in the 1950s, his presence on television inspired millions to champion the virtues of justice. The Lone Ranger was guided by the motto that "men should live by the rule of what is best for the greatest number." This principle seems perfectly appropriate during the current pandemic.
At the end of each televised episode, having prevailed against evil, the Lone Ranger would ride away accompanied by Tonto, leaving the townspeople mystified as to the identity of the men who had magically arrived to solve an impossible problem. The two conveniently departed the scene just before anyone had the opportunity to thank them for everything they had done. Bewildered by such humility, one bystander would typically ask: "Who was that masked man?" And with the refrains of the finale of Rossini's William (Guillaume) Tell Overture soaring in the background, another would invariably answer:
Until we have antivirals and anti-inflammatory drugs that dramatically mitigate the consequences of COVID-19, we need a silver bullet. And legend tells us that it was provided by a .
Disclosures
Packer has recently consulted for Amarin, AstraZeneca, Boehringer Ingelheim, Novartis, and Relypsa on issues unrelated to COVID-19. Novartis is one of several companies that manufactures hydroxychloroquine, and is conducting clinical trials with the drug for COVID-19. Packer has no financial relationship with Gilead Sciences, which is developing remdesivir for COVID-19.