As those of you who have read my commentary on COVID-19 over the past month are aware, I have been more optimistic than most on its health impact in Ohio, and in the USA. I never bought into the “Best Models” and their predictions of millions and later hundreds of thousands of deaths. Yes, this pandemic, like all pandemics and epidemics has brought sadness and death to many Americans. Every life is cherished, and I wish that every death could be eliminated in pandemics. Unfortunately, that is not Nature, and that is not possible.
I’d like to share my unfiltered thoughts on what has happened up to now, and where we go from here. These are just my opinions as a recently retired physician and involved citizen, with an academic interest in infectious disease and a desire to help. I base my opinions on existing literature and the consumption of all information that I have found during this ongoing COVID-19 pandemic.

To set the table, here are 10 of my observations, beliefs, and assumptions, and then I’ll move forward:

1. COVID-19 emerged in humans in China no later than November 2019. COVID-19 has likely been in the US since December on the West Coast, and then a little later, through Europe, on the East Coast.

2. The U.S. has been unprepared for an infectious respiratory pandemic “forever”, and this has been a bipartisan faux pas for many decades, even more so over the past 15 years when recent “new” viral outbreaks should have sounded the alarms. All levels of government and governmental public health agencies in the US are to blame.

3. The CDC has been unprepared, unprofessional, and poorly managed for a long time. Their failed response to the January challenge to develop a functional, uncontaminated COVID-19 test is a national embarrassment. Like all of America, the CDC and the FDA have grown fat and overconfident with prosperity. They should have asked for help from private industry early on.

4. The WHO is not who they claim to be. Yes, they do a lot of good throughout the world, but they are corrupt and let money and politics cloud their vision and taint their mission. Their utter failure to protect the Earth’s people outside of China, hand in hand with China, is reprehensible and indefensible.

5. I’ll assume that trying to pick a date that the U.S. borders should have been shut down would be retrospective back seat driving and any discussion of that would be degraded by a distracting horde of opinions by political party loyalists, so I’ll refuse to go there. I’ll just say an insincere “Thanks a lot” to the WHO and domestic political partisans and leave it at that.

6. The COVID-19 models were flawed from the start, tainted by poor input data including assumptions of static transmission rates and the inability to predict the efficacy of adaptive human behavior…humans want to live and will adapt to survive without governmental orders/shutdowns. These flawed models set off panic by “leaders”, led to draconian interventions in many places, and even led to hoarding of materials by both individuals and hospitals. Instead of these models being questioned, they were lauded by State and Federal “experts”. Those smaller players who questioned them were marginalized by the “experts” and the press.

7. COVID-19 is a serious threat to a small minority of our population. It can result in death of the elderly, the chronically ill, the immunocompromised of any age, and the obese with diabetes. The vulnerable need to be isolated and protected from COVID-19. That said, most of our nation’s population is not at high risk of a dangerous COVID infection. The “true case fatality rate” is no where close to what is currently reported, as only the “sick” with COVID-19 have been tested thus far.

8. The COVID-19 Virus has already infected a much larger percentage of the US population than the “positive case” numbers suggest, and a large number are already “immune” with COVID-19 antibodies. This is critical to understand for policy makers, so I will elaborate for a minute:

If this brand new, very highly contagious virus entered the U.S. in December/January, and it has a currently reported mortality rate of 5-6%, why haven’t more people died from it? We have proof that it is easily transmissible. That is not a question, as we have seen that in nursing homes, Ohio prisons, and in densely populated urban zones like NYC. We know that from the Diamond Princess cruise ship and the Theodore Roosevelt aircraft carrier experiences through COVID-19 testing. So why don’t we have more deaths? It’s because 25-50% of all COVID-19 infections are likely asymptomatic, and a huge number are minimally symptomatic, not requiring a doctor’s visit, let alone a hospitalization. They just haven’t been tested yet in the US.

Do we have additional evidence that there is a significant “recovered and previously untested” asymptomatic infection rate? Yes, that’s been confirmed in a couple communities in the US and in Italy through serological antibody testing where random, citywide testing demonstrated that up to 15-20% of their populations had already recovered from COVID-19 infections and had developed antibodies, hopefully giving them immunity. An important caveat is that serological testing is not perfect and could exaggerate these results. That said, more and more local community studies are producing similar results, including the LA County Study which suggests that while they only “knew” of 8000 positive COVID cases, antibody testing found that 4% in the. county had already been infected and had recovered, which suggests that there should be at least 200,000 LA County residents who have already been infected/recovered, and may now have COVID-19 immunity. Likewise, a study of the sewage water (fecal material) of a Massachusetts community suggested that COVID-19 had infected a much larger percentage of their population than their number of “confirmed cases”.

Why does it matter that I believe that a large number of Ohioans may already have some degree of COVID immunity? Because there are only 2 ways to really “defeat” a new virus. Effective vaccine development is the Holy Grail, but we are likely still 12 months away from that, at a minimum. “Natural Herd Immunity” is the other prize that we cherish in pandemics. If a population can achieve even 40% immunity, the pandemic becomes much more “manageable”. If we find that Ohio has high COVID-19 antibody prevalence, then we may be well on the way to “relative herd immunity”.

9. In Ohio, we have successfully mitigated any stress on our health care system caused by COVID-19. The curve has been flattened and is in a prolonged plateau at this moment. That was the only goal of the mitigation efforts and it was achieved. Eradication of the virus is not achievable through mitigation. Further mitigation with “stay at home” protocol for all will not decrease the number eventually infected. It will likely not decrease the “end death total”, it will only spread the cases and deaths out over a longer period of time, until a new cure or an effective vaccine is publicly available.

10. “Stay at home” mitigation and government ordered business closures in Ohio have led to severe economic repercussions. Depression, alcoholism, opioid addiction, domestic violence, child abuse, poverty, and suicide are all byproducts of the resultant economic depression and unemployment. Any decisions that Ohio makes to move forward must take into account the impact of the action on COVID-19 deaths, unemployment related mortality, and our citizens’ basic civil rights. Our societal well being is not simply reflected by a COVID-19 “growth rate graph” or “curve”.

Do I believe that we should have subjected Ohio citizens to a “stay at home order” from our government leaders?

I’m not going to back seat drive here, because all decisions were prospectively made off of the “best models” that turned out to be “bad models”. Based on those “bad model” projections, if our leaders believed them, I couldn’t fault them. That said, do I believe that our current successful mitigation results could have been matched without the “stay at home orders”? Yes, I do. Based on retrospective analysis of the growth rate curve, a negative growth trend was already achieved with the nationwide recommended social distancing protocols combined with Ohio’s closure of bars, restaurants, and schools. This improvement intoe COVID-19 trend occurred a few days before the “stay at home” order was actually given and many more “non-essential” businesses were closed. Live and learn, but yes, I believe that we would have still been well under our hospital “stress levels” and may have ended up in better economic shape. In addition, we may have been farther along in working toward Ohio’s “herd immunity.”

Enough with my assumptions and speculation. Let’s move forward now:

How do we move out of “stay at home” and get back to work?

To be clear, I believe that Ohio must meet the Federal Guidelines to “return to work” today safely. I believe that we have done so, from a disease control standpoint, if a recent spike in cases isolated to a couple prisons is dismissed as an outlier event, and it should be. Does Ohio meet the rest of the Federal Guidelines to enter Stage 1? Providers must have adequate PPE, and I believe that they do, though there has been no public verification of this by the Governor or ODH. Adequacy of both COVID and COVID antibody testing must be confirmed. Confirmation of adequate contact tracing capabilities is critical, and that includes a reported potential need of up to 500 personnel dedicated to successfully perform contact tracing of every newly COVID-19 positive individual in Ohio. Contacts of newly positive individuals need to be traced, contacted, and isolated in less than 48 hours. Repeated surveillance testing of high risk populations has to be adequately staffed. In addition, the ODH must have a system in place to be able to rapidly identify any signs of an impending surge in the state before it stresses the health care system. Other states have been actively recruiting and training contact tracers, including California. Has Ohio’s ODH put a trained team together?

Before I get into what I think is going to happen when Ohio reopens its economy, I want to address one last critical point: When one looks at the “science and data”, there is no proven formula for “when” to transition to a “containment stategy” and a return to work. This is new territory. There will be purely politically motivated groups that will be waiting to pounce as soon as there is a rough patch. That said, when looking through the prism of a balanced, “trinary (health, economic, civil rights) approach”, there is no choice but to reopen the American economy as soon as mitigation efforts “flatten the curve” and the “containment requirements” are in place. “Stay at Home Orders” have bought Ohio time to prepare safely, but the economic and civil rights costs that I’ve detailed earlier have reached a breaking point. There is no evidence that further prolongation of an already successful mitigation phase leads to “better health” or less death, but it will result in further unemployment and its poor health consequences. In my opinion, the time for Ohio to begin to reopen its businesses is now.
Assuming that Ohio’s DOH infrastructure is solidly in place, it appears that Governor DeWine plans a staged return to work beginning on May 1.

How will staged reopening look in Ohio? First of all, public space mask wearing will be in place, and in my opinion, it should be. Social distancing will be maintained, including at work. Workplace sterility will be stressed for all. The vulnerable populations will stay “isolated” at home for now, and those vulnerable who are employed will have to work from home for now, if they are to remain employed. Why the masks? Because we do not want to jeopardize our resuscitation of the economy by instantaneously having an uncontrolled spike in COVID-19 cases through asymptomatic carriers infecting large portions of the workplace immediately. We can’t afford an instantaneous surge, or our political leaders might panic and revert back to “stay at home” orders once again, which could lead to Economic Armageddon. Wear the masks and social distance when you go back to work, and don’t complain.

It’s not up to me, but I assume that medical and dental outpatient practices will be immediately reopened. Patients with other diseases are suffering, and there is no reason that this has not already happened. Hospital based “non-emergent surgery” will also be reinstitute immediately, in my opinion. The other businesses that were deemed “non-essential” will also begin to reopen on May 1. Of those, restaurants will have to incorporate social distancing and may find it difficult to stay viable, unless their takeout orders remain high now that people have gotten more comfortable with takeout over the last month. In terms of the “staging”, in my opinion, there is no reason to “stage” the openings of different types of businesses, except for the bars and mass gathering entertainment industry. These will likely stay closed in May. A staged return of the “workforce” to the office will also occur with those who can effectively work from home continuing to do so, in order to maximize social distancing in the workplace.

What do we do with the kids? We’ve already heard that Ohio’s public schools are going to remain closed through this school year. I think that is wise, but only because there is only a month left in this school year, and all public school students have lost significant education momentum. That said, let the kids return to “group play” soon, though not immediately on May 1, with as much distancing as can be achieved in “play”. The children are actually a COVID-19 low risk group and are invaluable in obtaining more rapid “herd immunity”. Continue to keep them away from the still isolating vulnerable population. If you are in a “vulnerable family”, then restrict your children’s interactions as you see fit.

What about the “lack of testing”? I hate to even address this, because it is what it is, and we have to move forward regardless of the facts and opinions. The “lack of testing” is real. There are COVID-19 “swab test kits” (“fast” and “slow”), and there are enough to get back to work and test newly positive individuals and their contacts. That said, we cannot test the mass numbers that many desire to test. Why? It is because we didn’t have the reagents, media, and swabs that we need to use the test kits. Why? It is because our dependency on outsourcing production to China and Europe for the last 30 years has come back to bite us. We can’t run the tests because we are relying on China and Europe to help us, and that is not going to happen in large scale in the midst of a pandemic. I’m not going to get political here, but this has to end now, and if you want to blame anyone, blame ourselves for allowing our “leaders” to cripple us in the name of “globalization” and false “free trade”. The good news is this: America has rallied once again, and we will have enough “swab tests” to move forward in conjunction with other testing today.

Reopening the Ohio economy is not going to be smooth sailing. We are going to see COVID-19 surges, and there will continue to be spikes in the vulnerable high density areas. The Department of Health will have to use their repeated surveillance testing in nursing homes, prisons, and urban clinics to keep those spikes under control through rapid recognition and containment isolation. If we maintain our social distancing protocols and mask wearing, I believe that we can minimize the inevitable surges and stay below our hospital and ICU bed “stress thresholds”. In my opinion, we cannot panic and overreact to each new surge. Repeated reinstitution of “stay at home orders” should be avoided at all costs, and instead we should simply tighten up our distancing and mask wearing. This pattern of surges and recessions, or a persistent “higher plateau”, will continue well into the summer. In my opinion, within 3 months of “back to work”, we may achieve sufficient levels of “partial herd immunity”. If so, Ohio may enter Federal Guideline Phase 3 with a return to “normal life” by early August.

By then, we will have learned a lot more about this virus, and about the anti-COVID treatments that have been studied around the world. I doubt that we will have found a “cure”, but I think that we will find that some treatment approaches were truly effective in diminishing COVID-19’s impact and in saving some lives. While a successful vaccine will likely come in 2021, we must remember that we also have “successful” flu vaccines, yet we still lose 50,000-70,000 American lives to influenza in a “bad flu” year. COVID-19 will not disappear, and we will add it to the long list of potentially viral infections that we have to watch out for year in and year out. It may return this winter, but if we have truly achieved “herd immunity” by the Fall, we should be able to deal with COVID-19 Part 2 much better, until a vaccine is developed and released.

In summary, it is important for all of us to realize that while this experience has been painful in terms of lives lost and unemployment, we will recover, and we must remain thankful that early predictions of widespread death were wrong.

We have learned a lot from this experience, and we must apply what we have learned moving forward:

We must be better prepared for future pandemics. We should never again accept epidemiological models as gospel. We should always practice good hygeine, and now we really know how to do that. We must establish “health independence” by re-establishing pharmaceutical and medical device manufacturing and supply chain at home. We are at our best in the US with public-private partnerships in problem solving. We work well together when we set politics aside. “One size solutions” do not fit all, even when the problem is global or national. Physical and Economic Health are inseparable.

We will be better from this experience. As we move back to work in May, let’s do it with the same cohesive approach that we “mitigated with” for the first couple of weeks of “stay at home”. Let’s refuse to blame or whine, but let’s keep our politicians on their toes if we see any of Health, Employment, or Civil Rights being neglected. Let’s stay positive and continue to protect ourselves, our families, and our vulnerable through the healthy habits that we’ve learned and practiced.