Many serious challenges will face us once the curve has been flattened, and we work as a nation toward recovery in the war against COVID-19.
John J. Miller, MD
FROM THE EDITOR
First and foremost, we at Psychiatric Times send our thoughts, prayers, and best wishes to all. This is truly a global event that is impacting all of us in some meaningful way. As I write this on April 8th, in the US there are officially more than 400,000 cases of COVID-19, and there have been more than 14,000 deaths. COVID-19 is currently ravaging through all 50 states, with half of the documented cases in just 2: New York and New Jersey. The country continues to grapple with a significant shortage of personal protective equipment and ventilators, and the national stockpile is now depleted.
My flight home from Denver to Boston on March 13th feels like forever ago. Even then the airports were eerily quiet, and an occasional traveler was wearing a mask. Arriving in Boston, my home airport where I spend a great deal of time, a heaviness filled the air of the terminal as travelers scurried about, everyone preoccupied and subdued. I was naively unaware of the impending catastrophic health crisis that had already seeded our country and was about to blossom into a life changing pandemic, the likes of which I had previously only read about in medical textbooks.
Today I saw a photograph that was simultaneously surreal and anticipated: a refrigerated truck parked next to a hospital in NY with the back door wide open as a recently deceased person wrapped in white sheets was being carried inside. The truck was lined with a 2 X 4 framed scaffolding built along each inside wall, with sheets of plywood serving as shelves in a makeshift morgue, each shelve wide enough and long enough to hold one person. Sadly, every shelf held a recent victim of COVID-19, wrapped in white sheets, with no time frame in place to allow for the preparation of a farewell ceremony.
As disturbing as this photo was, I am more disturbed by the lack of a national integrated and aggressive response to this pandemic in our great country. I realize it is easy for me to play Monday morning quarterback, but as I learn more and more about the information available to us in December, January, and February, I am befuddled by the inaction, lack of preparedness, and the minimizing of our national vulnerability to this pandemic as COVID-19 established its deep roots prior to emerging to assault us. Remarkably, and against the strong recommendation of all of the experts in the fields of infectious disease, epidemiology, and public health, today there remains a handful of states whose governors have chosen not to implement a shelter at home policy-the only intervention that has been shown to be effective in slowing down the ferocity of this pandemic.
Interestingly and appropriately, the narrative has become one of the US being at war with COVID-19. Let me say that again: the UNITED STATES is at war. Despite this, our federal government has adopted a policy of surrendering the command and control center to fight this war to each individual state. Imagine if we were being attacked through our Northeast border by an aggressive and ubiquitous enemy that began an assault on the states of Maine, New Hampshire, Vermont, and New York, and the federal response was to provide back-up as needed to each state, which were instructed to ward off the attack with their own resources. In my opinion, this is a fair analogy as to how this COVID-19 pandemic has been approached by the federal government. Regardless of political persuasion, a time of war demands a response by the US, not by each individual state, as our strength, strategy, and success in times of crisis has always resulted from our united federal approach to any threat.
A related issue is the dissemination of information to the public. When our country is under attack, it is imperative to engage and deploy the various experts whose collective knowledge and experience can coordinate a response that is most likely to succeed with the least number of casualties. If you or a loved one were to be diagnosed with a malignant brain tumor, with whom would you consult for treatment options and recommendations? Personally, I would consult with several expert neurosurgeons and neuro-oncologists. I would ask these experts to communicate their recommendations to my family and their reasonings. As a psychiatrist, physician, and scientist, I have spent my life developing an evolving expertise in psychiatric disorders and their treatment options. However, please do not ask me to evaluate and treat a cardiac arrhythmia, renal failure, pulmonary fibrosis, or anemia-rather, please consult with an expert in the appropriate specialty. The contradictions, misinformation, false hopes, and radically different recommendations on how to proceed through this pandemic are greatly amplified by marginalizing the experts.
A glimmer of light has been the innovative ways that the scientific experts, who are in the best position to advise state and federal policy in this pandemic, have found vehicles to communicate their assessments and recommendations. The current national challenge is to convince the policy makers and political leadership to govern based on the science and evidence-based facts-from our own scientific experts as well as experts in the international community, many of whom have significant experience in fighting this COVID-19 pandemic. On April 7th, American Medical Association President Patrice A. Harris, MD, MA, addressed the National Press Club with the following message to maximize our national success in defeating COVID-19:
The AMA calls on all elected officials to affirm science, evidence, and fact in their words and actions. . . . We call on tech platforms to advance evidence-based information from credible sources and reduce the spread of misinformation.
COVID-19 has created massive collateral damage, the degree of which we cannot yet predict or fully understand. Sheltering in place, a necessary policy as we attempt to flatten the pandemic’s curve, has created an experience of isolation and disconnection at a time when we long for increased social contact and support. Hospitals, long-term care facilities, and other residential programs are banning visitors, which only serves to increase the anxiety and fear in us all. With this ban on visitors, families and friends are unable to be with their loved ones in their time of severe illness and approaching death.
It feels like our economy is also in the ICU, and financial vulnerability with the associated hard choices grow larger every day. Over the past 3 weeks, more than 16 million Americans have filed for unemployment, a staggering fact that was unimaginable just a month ago. As jobs are lost, many will also lose their health insurance benefits; access to necessary treatment and affordability of medications will become increasingly burdensome-likely leading to many unfilled prescriptions. It is not known what the long-term impact of our floundering economy will be once the pandemic subsides, or how quickly it can be rebuilt. We are likely in for a rough ride.
In psychiatric and medical practice, novel treatment delivery systems have emerged thanks to the commitment, innovation, compassion, and superhuman efforts of all members of the medical profession. As is the American way, citizens continue to rise to the challenges as they present themselves. By the time this editorial makes its way to print and into the hands of you, the reader, a lot more unknowable COVID-19 history will have been written.
As you read this, my sincere hope is that the pandemic will be loosening its choking grip. Many serious challenges will face us once the curve has been flattened, and we work as a nation toward recovery. Restoring our depleted medical resources, rejuvenating our overworked health care personnel, beginning to grieve the many losses that currently are necessarily on standby, establishing a safe return to work protocol, restoring jobs and income, and having the time to reflect on the personal and societal toll this pandemic has created will all happen in time.
There is still so much that is unknown: when will it be safe to resume social contact and gatherings; how do we deliver assistance to the financially depleted; will there be a second wave of the pandemic this fall or winter, and how do we best prepare for that; and how long will it take to restore our economy? Slowly, progress will be made toward developing medication treatments and vaccines, and our understanding of COVID-19’s biography will be published in the scientific journals. Ultimately, COVID-19 will write its own autobiography. As we move forward I hope that everyone whose lives have been affected by COVID-19 are able to begin to grieve the many, many losses in which we find ourselves submerged, and begin the long, slow process of recovery.
Dr Milleris Medical Director, Brain Health, Exeter, NH; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.