Me, uncensored.

The background to my writing this post goes like this:

1) Spend a sleepless night vacillating between feeling angry, overwhelmed and distraught.

2) Post above picture and pen a vitriolic post condemning people's ignorance and selfishness

3) Realise I'm also ignorant and selfish and delete entire blog

4) Go for a run and spend the entire run in tears despairing over the human race. Luckily it was a short run.

5) Look at Facebook while eating breakfast and get angry all over again

6) Pluck up the courage to sit down and rewrite this blog.

There is a lot that I want to cover, so bear with me. I'm going to take the approach that one would take to eating an elephant (although, poor metaphor, because, dear Lord, please let us not be eating any animals right now...not sure what kind of pandemic an elephant virus would cause): that of one bite at a time. I have tried to be objective and dispassionate and stick to the facts- well, those few that I do have- but I beg your forgiveness for the odd rant or slipped expletive.

Every morning I spend 45 - 60 minutes catching up on medical advances relating to COVID. This is separate from the time that I waste watching pseudo-scientific crap on social media that I am required to watch because I know that theories are going to spurt forth from them and I will be asked by patients about their validity. Daily, I try to read any new international studies that have come out and I catch up on the latest local protocols and recommendations. This is by no means exhaustive: I'm only touching the tip of the knowledge iceberg, but it keeps me up to date with any important advances and helps me to set protocols in place for our practice. So I like to think that most of what I advise is based on sound scientific evidence.

First bite:

The numbers. Yes, I do not go to sleep at night until our Minister of Health has Tweeted the day's figures. Yes, I know this is ridiculous. It's kind of like a bizarre security blanket. The reason that it's a bit ridiculous is that the numbers don't really mean that much. They do give a trend, but because we are only testing under very specific circumstances, this is a very poor reflection of the extent of infection. Currently testing is reserved for a very small group of people so the number of positive cases that we know of are really only very sick people or people who are at risk of spreading the virus to others e.g. healthcare workers. There is also a massive backlog in testing so what we are seeing are historical figures to some degree. Then there is the fact that the testing is fairly inaccurate in that there is a high likelihood of you testing negative despite being positive (more on that in another bite). And of course, there are those specimens that get ditched on the side of the road, but that's a whole other blog that I'm not sure I can tackle. The bottom line is that the real numbers are actually much higher than the reported numbers. Even looking at the number of positive cases per cases tested is not foolproof because of the before-mentioned false negatives. Great news, I hear your saying, if the actual number of cases is way higher than the reported, aren't we on our way to herd immunity more quickly and doesn't that imply a much lower mortality rate? Well, unfortunately it's not that simple, as I'll explain later. At best, the numbers can give us a trend.

Bite 2:

The death certificate issue.

This is quite topical at the moment. What does it mean when we say that 128 people have died of COVID-related illnesses? Once again, there is really no simple answer here. Let me paint a couple of scenarios:

1) Mr A has underlying cancer. He is relatively unwell and probably only has a few more months to live. He contracts COVID and within 48 hours he has developed multi-organ failure and dies. Has the COVID killed him? Yes, of course. the mechanism of death was organ failure. The contributing co-morbidity was his cancer.

2) Mrs B has recently tested positive for COVID, but is otherwise well. She dies in a car accident. Did the COVID kill her? Because she tested positive prior to her accident, it may be listed on her death certificate. There is the small possibility that the COVID could have caused a stroke which caused the car accident, but that's unlikely. So in this case data might be skewed, but it's not exactly a common scenario. (Also, what were you doing driving around when you should be isolating, Mrs B?)

3) Mr C has hypertension and diabetes but is quite well and active. He gets sick on the weekend (with COVID, but he does not know that it's that and hasn't been tested) but is unable to get to hospital because he a)doesn't have transport or b)doesn't realise how sick he actually is or c)the hospitals are all full or d)can't afford to get to hospital. He is dead by Monday but dies without COVID on his death certificate because he was never tested.

These examples are purely to show how complex the situation is and how pointless it is trying to extrapolate answers from limited data. What we should rather look at are the practical, hard realities that are not dependent on what classifies as cause of death. In many places in the country, our hospitals are full, our ICU beds are full and we are running out of ventilators. We are running out of space in morgues and bodies are having to be stored in cold storage facilities because people are dying faster than they can be buried. Doctors working in hospitals are seeing the reality of what's happening. In places, people are having to dig mass graves. Sometimes it's better to look at what's really happening than argue about numbers. I was chatting to my son about the numbers and he put it into perspective more than any politician or statistician I've heard on Facebook. When I told him that we had had 128 deaths he didn't ask whether they were caused by corona virus or not. He didn't need to know what was written on the death certificate. He looked me in the eyes, with too much sadness for a twelve-year old, and said 'that's 128 families that have lost someone that they love.' 128 grieving, heartbroken families. Let's not get caught up in using numbers or pseudo-political agendas to justify or excuse our behaviour.

Bite 3:

The herd immunity issue. And social distancing. Let's just lump it together in one bite. As a prologue to discussing this, I'm going to go full disclosure and admit that I have become slack with social distancing. It's happened surreptitiously, without me even really acknowledging or recognising it. As things have started opening up, I've started running with one or two friends. I've seen my sister and my children have seen their cousins. My kids have even had a playdate with a friend. I've kidded myself that it's ok: it's only one friend, we need to see family, just once isn't going to cause any harm. This weekend I got very irritated and angry when I saw some photos (definitely no social distancing going on in the photos) on social media of a group of friends who were definitely not adhering to any form of social distancing. It took me about an hour to realise that I had no right to be angry because I had essentially (if not as obviously) done the same thing. It is easy to forget how important social distancing is when one comes from a position of privilege- health, medical aid and resources. But here is why it is so important to adhere to social distancing, even though it's lonely, it's tough and it's difficult to see tangible consequences:

1) There is more and more evidence to suggest that we will not develop herd immunity to COVID without a vaccine. You can catch it again. Yes, you understood that correctly. Just because you have had COVID does not mean that you will not get it again. In one recent study 20-30% of people did not develop antibodies to SARS-CoV-2 after having it (antibodies, very simplified, are what provide immunity), but more worryingly, when researchers looked at levels of neutralising antibodies i.e. levels required to stop viral replication, 79% of subjects tested had no or only partial immunity to reinfection. Even more worrying to those of us who keep saying 'it's ok, most people don't even get symptoms' was the fact that the more symptomatic that the subjects were, the better their chances of subsequent immunity. Simply put, if you have COVID and have minimal or no symptoms, you're far more likely to get it again. So sorry, COVID parties (the concept, like chicken-pox parties, will be familiar to people who lived 300 years ago or those who don't believe in vaccination) are not going to help here. More importantly, those of you who are walking around thinking it's fine to socialise because you're going to get it anyway so might as well get it now and be over with it, yes you are probably going to get it. Possibly multiple times. You will also spread it multiple times, which brings me to my next point.

2) Making the decision not to social distance is socially irresponsible. Sorry, I can't put this in gentler terms. Insisting on having that party because it really is an important milestone: sorry, but you are being socially irresponsible. You think it's fine to go to that braai with 20 other people because you really do need some normality in your life and you've been feeling really crap lately? Suck it up buttercup, we've all been feeling really crap lately. Your going to that braai could kill someone. Again, no really kind way to say that. I understand that it's difficult to visualise the potential ramifications of your actions. It's not easy to understand that at that braai, where you are all feeling fine and having a great time, one asymptomatic person (yes, asymptomatic and pre-symptomatic people can transmit the virus) can spread the infection and cause a whole cascade of events. Let me make it more real by creating a scenario (note that the names are no reference to real people!). John goes to the braai and feels fine but he has contracted COVID unknowingly from a colleague in his office. He stands around the fire with his friends, innocently chatting away and someone makes a joke. He laughs at the joke because it was really funny. Laughing, we know, is one of the most effective ways to spread the virus. Sorry for Brad and Jen standing next to him. He puts his arms around Angie and Nick for a photo and spreads it to Angie and then tastes a really good wine from Celeste's glass, transmitting it to her. All the guests leave the braai in a great mood, having had a wonderful evening. The following day, John still has no symptoms. In 5 day's time, Angie starts feeling a little unwell (she's asthmatic) and 2 days later she is in hospital on oxygen (she was lucky, this was before the hospitals were full). Brad takes his son to the beach a couple of days after the braai and his son slips and cuts his foot on a rock, which requires stitches, so Brad and his son visit their GP and infect their GP, who is then unable to work for two weeks, and an old lady who happens to be in the waiting room. She dies a week later. Celeste never displays signs of COVID (despite contracting it), but she does develop a tooth abscess which is incredibly painful and so visits her dentist who works on her mouth for half an hour doing root canal. Of course, she transmits the virus to him and he ends up unwell and, after testing positive, unable to work for 2 weeks. Nick hosted the braai and although he feels fine and never displays symptoms, his domestic worker, who has hypertension and diabetes, and who cleans up after the braai, ends up in hospital seriously ill. Because I'm being realistic here, she has to go to a government hospital because she has no medical aid and there are no ventilators available for her when she needs ventilation and she dies. I know that your natural inclination on reading this will most likely be to dismiss it as an exaggeration, but trust me, it's not. I have had to learn to dissociate my personal likes, dislikes, beliefs and guilt from the facts: not an easy or comfortable thing to do. The far more comfortable reaction is to get angry with what I'm writing or disregard it as nonsense. It takes immense courage to look into one's heart and admit when one has made a mistake.

3) We are still on social distancing here...I did warn you this would be a long post. Lets talk about jobs and the importance social distancing. We all know that the government had to lift the lockdown to open up the economy. It's no use saving people from COVID but letting them starve to death instead. The economy must function and people must be able to work and earn a living, which implies an inevitable, unavoidable measure of social interaction. This makes elective 'social' social distancing even more important. If there is going to be social interaction, let it be while people are working and earning a living. Don't waste the exposure!

4) We are most likely all going to get it, maybe more than once, but by social distancing we contain the spread giving clever scientists more time to develop a vaccine, try to find cures and learn more about the disease to optimise management. Your chances of dying of COVID now are much less than what they were a couple months ago because we now know more.

I still have a whole lot more to say, but I think that I will make a part two, bites 4&5, to this post, partly because you probably have brain overload by now, but mostly because I have children and patients who need my attention. My intention with this post has not been to vilify or blame anyone; it was not meant to sound condescending ( a little irritated maybe, but not condescending); and it was not meant as a comprehensive discourse on statistics and social distancing. The purpose of this post was more to try to make people aware of certain confusing aspects to data reporting around COVID and also to remind everyone, myself included, of the importance of social distancing. As humans, we are social beings. We crave touch, we thrive on interaction, we live and function best in communities, but as humans we also have a responsibility for the well-being of other humans: we have to act with integrity and humanity, and if that means temporary discomfort for a greater good, we need to find within ourselves the strength to rise to that challenge.