Experts in epidemiology and public health discuss how medicine is changing in response to the pandemic — and what to expect in months ahead.
(CN) — First, Luis Barache had a sore throat.
The 67-year-old New Jersey resident had experienced similar irritation over the years, so the symptom was not unusual. But in mid-March of 2020, it was enough to prompt Barache to make a doctor’s appointment.
At the time, many Americans were talking about the novel coronavirus that causes Covid-19 as if it were a faraway problem, Barache remembers now. “I’d heard about Covid,” he said, “but we were told, ‘it’s not going to be in the United States, that’s in China … don’t pay any attention.’”
Barache’s appointment was the last of the day, he recalls, around 6 p.m. Restaurants and bars were still open, and after visiting the doctor, he caught a movie: “The Irishman.”
Over the next two or three days, even with the medicine prescribed by his doctor, Barache’s symptoms got worse. He developed a fever. His appetite disappeared; his longtime partner, Edgar, had to force him to eat. Chills got so bad that Barache remembers asking the friend who eventually drove him to the emergency room to grab a blanket from the car, to warm himself while sitting in the socially distanced waiting room.
After eight hours of treatment, which included being put on an IV and taking a Covid-19 test, Barache was sent home. His fever was down, and a doctor told him it was too dangerous to stay any longer. “It’s getting crazy here,” Barache remembers the doctor warning.
He returned home, under doctor’s orders to self-isolate, since a Covid-19 diagnosis seemed likely. His partner took over the duties of cooking and caring for Barache’s 84-year-old mother, María de Zubiria, who lived with the couple.
Barache’s mother got sick anyway. Already under treatment for Parkinson’s disease, she quickly developed a sore throat and lost her appetite, mirroring Barache’s symptoms. Breathing became difficult, sleep did not come, and, when emergency medics arrived at the house a few days later to take her to the hospital, they told Barache to prepare for the worst.
A conversation with a medic stands out in Barache’s memory: “’Be prepared,’ he told me. ‘It can be a miracle, but she’s in bad, bad shape.’”
Unable to accompany his mom to the hospital, Barache got updates from doctors by phone. His mother was on a respirator, still fighting. Then, she couldn’t fight anymore. She died after three days in the hospital.
Two or three days after that, Barache got the test results affirming he had Covid-19. His partner Edgar, 56, tested positive, too, though he never got especially sick.
Now, Barache has mostly physically recovered. For a few months, his full head of hair would shed in handfuls when he showered, and for now, lingering blurry vision still prevents him from driving at night. But losing his mom made the pandemic’s toll permanent for Barache and his family.
Their story mirrors many who lost a loved one to a disease that nobody knew about just a year ago. Half a million Americans have now died of Covid-19, and while the disease thrust most of the planet into the unknown last year, its steadily growing death tally underscored the inevitability of the somber milestone the nation crosses today.
Looking back to the early days of the pandemic gives a sense of how far we’ve come. Hospitals have tweaked their methods of care to better serve patients, and continue to do so. Public health officials have wrangled messaging to address misinformation.
Ahead, we could soon see more vaccine candidates in the mix. But progress could be tempered by the emerging new virus strains, setting up a race to vaccinate people before even more mutations can arise and take hold.
Medicine Adapting to Covid-19
When Luis Barache’s mom died, the system was so overloaded that he didn’t receive her cremated remains for two months.
“At that time, it was crazy,” Barache says: There were “people dying every minute.”
On the phone, Barache’s voice breaks up as he describes the months of waiting, not knowing where his mother was, after having been unable to stay with her before she passed away.
Back then, hospitals, morgues and funeral homes were all unable to keep up with the pace of deaths from the virus; bodies filled up facilities and even refrigerated trucks when space ran out.
In fighting the pandemic, the goal is to make sure we don’t reach that level of public health emergency again, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
Ultimately, vaccination campaigns will bring an end to the pandemic. But hospitals have also adapted as they have learned more about the coronavirus to improve the outcome for patients.
“The virus still is a deadly virus — that can be very challenging to treat, but we’ve gotten much better at doing it,” Adalja said in a phone interview. “It’s much better to be in the hospital now, in the ICU, in February of 2021, than it would have been to be in March of 2020.”
Quicker diagnosis, thanks to better testing available now, is one reason for the improvement, Adalja said. Earlier confirmation that someone has Covid-19 means they can begin treatment sooner.
Methods of treatment have improved, too.
Hospitals have started using drugs like dexamethasone, a steroid used for inflammation from allergies and arthritis, to treat Covid-19 patients. The medication has been shown to reduce deaths in hospitals. Remdesivir, a widely used antiviral drug, seems to help people get better faster, Adalja said.
Health care workers have also developed better strategies for helping patients who have trouble breathing after getting sick. “We have much better strategies with delivering oxygen, where we’re not reflexively putting people on mechanical ventilators,” Adalja said. Other methods include using BiPap and CPAP machines, and high-flow nasal cannula.
Learning about common complications from Covid-19 has also informed treatment. Patients can be prone to developing blood clots, for instance, which can be prevented with medication.
“When a complication occurs,” Adalja said, “we’re much more able to recognize it and treat it than we were a year ago.”
He explained that progress doesn’t mean ending the coronavirus altogether, but managing it to reduce deaths and strain on hospitals.
“We’re not eradicating this virus,” Adalja said. “What we’re trying to do is to have this virus cease to be a public health emergency.”
Central to that goal is treating, and vaccinating, people who are hardest hit by Covid-19.
What Makes a Virus Deadly
In her mid-80s, and with her health weakened already by Parkinson’s, María de Zubiria had the odds stacked against her when she got sick last March. Age and underlying health conditions are the main factors determining how likely someone is to die from Covid-19.
Among most significant underlying conditions are lung, heart, and cardiovascular disease; hypertension; obesity; cancer; and diabetes. Multiple states have begun or announced plans to vaccinate people with those conditions, regardless of their age, to help protect the most vulnerable populations.
Living conditions also play an important role. In places where people live communally — nursing homes, homeless shelters, jails and prisons — social distancing can be impossible.
The American Medical Association and former U.S. attorneys general Loretta Lynch and Alberto Gonzales have called for incarcerated people, along with police and correctional officers, to be prioritized for vaccines, but few states have explicitly declared priority for detainees. In Oregon, the decision came only after a court order.
Offering vaccines in prison would make a “tremendous difference” in mortality rates, given the impossibility of mitigating factors through masks — which are often unavailable — and physical distancing, said Dr. José Ramón Fernández-Peña, president of the American Public Health Association.
“Have you ever been inside a jail? Social distance? Really?” Fernández-Peña asked, rhetorically, during a phone interview.
A person’s likelihood of being killed by Covid-19 is tied to more than just living conditions or health risks, Fernández-Peña pointed out. He and other public health officials are focused on how the burden of diseases like Covid-19 falls to different communities and populations.
“We see in this case, like we see in so many others, that the distribution is quite uneven,” Fernández-Peña said. “People of color are carrying the heavier burden of this disease.”
Black, Latino and Indigenous Americans are more likely to die from Covid-19 than white and non-Hispanic Americans, data from the Centers for Disease Control and Prevention show.
Black Americans, for example, are nearly twice as likely to die from the virus, and nearly three times more likely to be hospitalized.
Mortality trends of the virus have also contributed to deeper — though not necessarily permanent — divides in life expectancy. In the first half of 2020, the U.S. lost a year on its expected average lifespan, a decline not seen since World War II.
The effect was even worse for Black Americans, for whom the CDC observed a three-year decrease, and Hispanic Americans, who saw a two-year drop. This created the widest gap in life expectancy between Black and white Americans since 1998 — a difference of six years in expected lifetime length.
Covid-19, like previous pandemics, has revealed and amplified underlying health care disparities behind those rates, Fernández-Peña said.
“There’s nothing in a Black person that makes them more vulnerable to Covid,” Fernández-Peña said. Factors like where someone lives or works, which do play a role, are “larger indicators of structural inequities.”
Looking Ahead in 2021
One year into the pandemic, expectations of the future — and the vision of an “end” to Covid-19 — have shifted dramatically.
The CDC continues to update its guidance on things like mask use and managing risks in schools. Support from the federal government has made a difference in forming a cohesive message from the federal government. (It was at the end of April, weeks after the CDC recommended everyone wear a mask, that then-Vice President Mike Pence showed up to tour the Mayo Clinic without one.)
“At least now we’re talking more with one voice about what this means,” Fernández-Peña said. “The messaging is more consistent now, so I hope that people are listening better, because we’re trying to be more intentional with that kind of message.
“The flip side of that,” he continued, “is we’ve been at it for 10 months, or 11 months, and we’re all sick and tired of the message.”
Restlessness from pandemic restrictions could play a role in the spread of disease, Fernández-Peña said. “People continue to engage in behaviors that we know are not safe at this point in time.”
Particularly given the risks of new coronavirus variants that are more highly transmissible, a January analysis warns that becoming lax about precautions could lead to a spike in deaths.
The CDC has already warned that rapidly spreading strains from the United Kingdom and South Africa can make more people sick at once, potentially overwhelming hospital systems.
In trying to predict what the months ahead will look like, Fernández-Peña said there has been “a lot of wishful thinking,” especially with regard to the unknown factors like spread happening outside of the U.S.
Access to rural and poorer areas is already complicating vaccine rollout, both in the U.S. and abroad, and health experts stress that vaccine efforts cannot only be focused on high-income countries.
Optimistically, Fernández-Peña said, he wants to believe that by Thanksgiving, he’ll be able to visit his in-laws in Washington state. But, he acknowledges, “I don’t have a lab or a crystal ball.”
Also looking toward the future is Luis Barache, whose story is a reminder that behind each set of death statistics is a life lost, a family scarred, and the real weight of what we’re collectively up against.
After his mother died, Barache and his partner moved out of their old home. There were too many memories that now felt painful, and it was time for a fresh start.
“Life is too short,” Barache told his partner. “Let’s move from here.”
The couple found a beautiful apartment with a view of Manhattan. They still can’t travel as they used to enjoy doing, but Barache is hopeful that the opportunity will return soon.
At a virtual memorial last year, about 60 people gathered to honor Barache’s mother. Family members joined from her native Colombia, as well as Florida, California and Spain.
But Barache still wants, and plans, to give his mom a proper, in-person sendoff. It will be in her hometown of Barranquilla, where she can be surrounded by family.