May 8th Coronavirus Update from Crystal Run Healthcare

Dear Patients of Crystal Run Healthcare,

I’m writing once again to update you about the COVID-19 pandemic, to provide my perspective on “reopening” the country and the state, and what we, as New Yorkers and Americans, may expect going forward. My goal is not to scare you, but, as always, to be as honest with you as possible.

At least in New York, the number of new cases, hospitalizations and deaths continues to decrease—good news, to say the least. Yet New Yorkers continue to become infected, and as of yesterday, over 200 lives continue to be lost each day, in New York alone. In the rest of the country, the numbers are actually increasing.

Possibly the “hottest” question, currently, is when and how elected officials should “reopen” our economy. This is not a choice that they, alone, can make. Officials can set the outer limits of acceptable behavior, but only data—the facts on the ground—will dictate how people actually behave. Smart people will not start going out to restaurants, to the theatre and to sports arenas if their friends are becoming ill and dying. Of course, such rational behavior assumes everyone is paying attention and staying informed by reading or watching objective news reports.

Everyone hopes there will be an effective vaccine or treatment soon. No doubt there are some very smart people working on vaccines and antivirals—but judging by our level of preparedness for the pandemic itself, and our difficulty making even basic testing widely available, we should be reserved in our expectations. In addition, chance, as well as the characteristics of the virus itself and the human body’s response to it, all play a role in successful vaccine and therapeutic development—consider that we still have no vaccine or cure for HIV, 40 years after its emergence. 

Another concern as we consider “reopening” is our lack of understanding of the epidemiology of the novel coronavirus. Due to the lack of widely available testing, we are only beginning to understand where and when the virus may have first arrived in the US, where it came from, how prevalent it is in different parts of the US, and how many asymptomatic infections may have occurred. The most recent serologic (blood antibody testing) data suggests that many, many more people have been asymptomatically infected by the novel Coronavirus than have developed symptoms. 

So what would it take for New Yorkers and Americans in general to feel safe about resuming normal activity? In a perfect world, we would regularly test everyone, or at least those at high risk, for infection with the virus (particularly important since there appear to be so many asymptomatic infections), with a test whose results are nearly immediately available and whose false negative rate is nearly zero. And we would have technology-enabled contact tracing (i.e., a smart phone application) that immediately identifies all individuals with whom an infected individual has been in contact during the past several days (for example, while purchasing groceries), alerts those exposed individuals to quarantine and be retested immediately, and which notifies public health authorities. (If you believe wide scale public health measures like testing are impractical, remember that we routinely test high risk individuals for TB, Hepatitis C, and sexually transmitted diseases, and that we recommend vaccination for 100% of children for common childhood diseases.  Certainly, universal testing is more practical, rational, and cost effective than setting up new hospitals, deploying hundreds of thousands of ventilators, and dealing with the economic and societal fallout of failing to stop a pandemic.

What we actually have in the United States is a system that has only tested a few percent of Americans—it is still hard for health care providers to obtain adequate supplies for testing, and elected officials have asked that tests be reserved for symptomatic people and essential workers. It still feels a lot like the early days of the pandemic, when we were told we could only test individuals who had been to Wuhan, or who had been exposed to individuals who had been in Wuhan, even when we were highly suspicious that many patients lacking such exposure were infected—and even though we have since learned that most of the virus on the east coast, at least, came most directly from Europe, not China. Further, the turnaround for lab results from national labs is often still a matter of days, and the false negative rate of our tests is probably in the range of 30%, although the exact rate is not known. And our contact-tracing infrastructure? It is a holdover from the 20th century at best, and most recently and prominently has been used to identify the intimate contacts of those with sexually transmitted infections (STIs) so they can be treated. In terms of numbers alone, such an infrastructure cannot handle the COVID-19 pandemic. Further, in contrast to STIs, COVID-19 does not require intimate contact for transmissibility and individuals are unlikely to know the identity of the individuals with whom they have been physically close enough to spread COVID-19—making the need for robust contact tracing all the more important. 

Perfect is the enemy of good, and we do need to move forward.  Nonetheless, our ability to return to some semblance of normal requires testing, even if not perfect, to be more readily available and the establishment of effective, large scale and technology-enabled contact tracing. The sooner we do these things, the sooner we will further reduce the spread and incidence of COVID-19—and the more likely that rational people will reopen the economy, without any prodding from officials.

So what do I think the next few months will look like? Absent a vaccine or effective therapeutic (which could happen), I expect a long tail to the pandemic, particularly if we do not deploy aggressive testing and contact tracing. I expect there to be continued cases reported, with a “saw-tooth” pattern in the number of cases as physical distancing is alternately relaxed and again encouraged as individuals and municipalities test the limits of safe behavior. And I have particular concerns as the fall and winter flu season approaches—every person with “flu-like illness”—and there will be many as there always are— will be treated as if he or she has COVID-19 until proven otherwise, again heightening anxiety. At a minimum, this means that every one of you should make sure you receive the flu vaccine, as early as possible, this fall.  

Why am I telling you all of this? Am I trying to depress you? No. I am trying to set realistic expectations—and to help you understand, based on the science I know, that there are things we and government can do to get the pandemic under control, and our lives back to a more normal state, even absent a vaccine or effective treatment. I think I’ll call that “hopeful realism.” Meanwhile, we are here to serve your medical needs, whether COVID-19 related or not, and to do so in the safest manner possible. 

Thanks again for your trust in Crystal Run.

 Dr T

Hal Teitelbaum, MD, JD, MBA

Managing Partner & CEO