Connecting Dots

(Photo from Jakarta, Indonesia by Arimacs Wilander at Scopio)

I missed something big.

With relentless either-or messages all around us, it’s hard to think about grey areas. COVID cases don’t always result in either death or full recovery. I understood that and warned about the growing impact of rising Long COVID cases as the grey area I thought was overlooked.

I recognized that even where survivors feel like they emerged okay, many have lasting damage that will manifest later. We don’t know yet what that will look like. Early hints include elevated incidence of cardiac problems, strokes and diabetes in the year after illness.

Reports of damage to T-cells and B-cells in the immune system made my skin crawl. It echoes one of the key aspects of HIV that leads to AIDS.

The dots still didn’t fully connect for me.

Too many children began to turn up with hepatitis, supposedly uncommon. Experts contorted themselves trying to blame anything other than COVID. It’s caused by an adenovirus that rarely does anything like this. It’s caused by dogs. It’s… a mystery.

Too many people are turning up with monkeypox, supposedly uncommon. Like the children with hepatitis, the monkeypox patients are in several countries, all at once.

The dots connect now. The picture they draw is ugly.

In Africa, AIDS was a wasting disease. People withered away. In developed countries of the Western world, that raised no eyebrows. Then developed countries began to see a weird surge in diseases among gay men that should occur seldom and only in the immunocompromised: Kaposi’s sarcoma, pneumocystis carinii…

The handful of scientists who joked months ago that COVID is airborne AIDS were closer to the mark than anyone wanted them to be.

The damage SARS-CoV-2 leaves in the immune system is not identical to the damage HIV does, but it’s in the same neighborhood, and it happens even in many mild or asymptomatic cases. It may be a key to the virus’ ability to hide somewhere deep within the body and persist, undetectable by ordinary tests unless the reservoir organ is biopsied.

Other diseases can take advantage of the immune system damage. Therefore, we should not be surprised by an outbreak of hepatitis that isn’t localized in one community, and an outbreak of monkeypox that isn’t localized, and… more illnesses that ought to hardly ever occur outside of limited circumstances but suddenly emerge.

We should have expected to need to grapple with outbreak after outbreak of who knows how many ailments in places and/or demographics where they shouldn’t be.

Implications

This has wide-ranging implications. Among the most obvious:

• Personally: Everyone who has had COVID will need to pay attention to anything that starts to feel wrong about their body, brain or nervous system. Letting a developing new health problem worsen before getting care generally makes it harder to treat and may reduce the chance of getting well from it. Finally, others in the household who have been through COVID can more easily catch something from an ailing member of the household.

• Health care: Although seeking medical help adds to the excessive burden on health care systems, it’s best when people seek help early. When they wait, their worsened condition increases the amount of care needed and therefore hits the health care system even harder.

• Productivity: Workforces already hindered by active COVID and Long COVID will take a further productivity hit from other illnesses that take advantage of open doors in the immune system.

• Insurance: In any country that treats health care access as a privilege rather than a societal necessity, most notably the USA as the largest such nation, health care will become closed to ordinary people for many illnesses. COVID is the ultimate pre-existing condition for excluding coverage for care. Care for a wide range of subsequent illnesses will be excludable on the grounds that they can be blamed on the immune system damage left by COVID. Need a liver transplant even though you’re a teetotaler and health food fanatic? Pay for it yourself.

• Vaccination: We can’t vaccinate our way out of this, at least not with what we have so far. Although smallpox vaccination is about 85% effective against monkeypox when it’s recently administered, people under about age 50 didn’t get that vaccine because we eradicated smallpox. We aren’t sure how effective the vaccine is after 60, 70 or 80 years. I’ve seen some mention of rolling out the smallpox vaccine again to combat monkeypox, but we can’t really do that. We don’t have stocks of it. It’s a live virus vaccine and we can’t be sure damaged immune systems will respond to it properly. Anyway, monkeypox is not the first or the last of the opportunistic pathogens we will face, so vaccinating against it wouldn’t stop the next disease that takes advantage of this opening.

Solutions?

Can we do anything about this? Of course we can.

• Personally: Try not to catch COVID. If you have stayed clear of it so far, keep on staying clear of it if you can. If you weren’t able to stay clear, try not to catch it again. Each bout adds to the cumulative damage. Each variant or subvariant is different, so it isn’t the same thing over again, and your immune system is weaker each time you catch it.

• Health care: Frontline workers are already screwed. The pressure on them is unrelenting. We can stop making them take unnecessary risks. They need the highest grade of personal protective equipment, e.g. N99/FFP3 face masks rather than surgical masks, plus good goggles or face shields, gloves and gowns. They need HEPA air filters that process all the air in their workspaces at least 6 times per hour. Where possible, they need UV units treating the air too. They also need to get to focus more on providing health care and less on jumping through bureaucratic hoops that aren’t part of protecting patient welfare. (Insurance companies and health care system bosses, I’m looking at you.) On top of which, they should be paid well for their work. We need them. We should treat them that way.

• Productivity: See above. No single mitigation measure does it all. If people can work from home, let them. If they’ve got to go elsewhere to work, they need good PPE, good ventilation and air filtration, adequate spacing and safe ways to take breaks for tea, coffee or lunch.

• Insurance: In countries like the USA, either regulate the heck out of it before the crisis reaches full scale, or convert to some form of national health care system. The latter is a huge step for the USA economy, even if it is done as Medicare For All. It would be quicker, simpler, less disruptive and highly effective to mend the intentional flaws that were inserted into the Affordable Care Act before it passed, and expand it to be the national system. It would look like the Swiss system (which provides perhaps the world’s best health care), where everyone has private health insurance with government help to pay for it if needed, and the insurers can’t cherry pick who or what they cover. Soon we’ll need to address appropriate regulation for life insurance, long term care insurance and long term disability coverage too.

• Vaccination: The key is to develop next-generation vaccines against SARS-CoV-x that are broad spectrum (hence the ‘x’), last longer, and most importantly protect against infection rather than only against death or severe acute illness.

• Treatment: For the most part, we aren’t making enough use of the treatments we have. Paxlovid seems to be as scarce as hens’ teeth for actual use, for example (at least in the UK where I live). We should be treating COVID without waiting to see who’s going to be sickest, because we need to minimize its damage. But we need to go beyond reducing severity of symptoms. Taking a step back, we have not figured out how to fully eradicate HIV from patients’ bodies. Although it has been done once or twice, we don’t have a therapy that can do it for large numbers of people. We’ve got to scale it up. We also have not figured out how to undo the damage HIV wreaks. Now we need to solve those puzzles, preferably for both virus families. If we solve this for HIV, where we have a head start, doing the same for COVID should be a comparatively small step, and vice versa. Do it, and we’ll close the door to these follow-on outbreaks.

• Transmission: As we should all notice, the same protective measures that can be layered to minimize transmission of SARS-CoV-2 also happen to work against other pathogens such as monkeypox. (It isn’t agreed how well the pox spreads through the air, but at the least, droplet transmission is widely acknowledged.) Mitigations aren’t purely about blocking COVID. They’re also about protecting ourselves more generally.

In Summary

By letting the pandemic run riot in much of the world, we set ourselves up for waves of follow-on health problems. We don’t have to let this run riot too. But wrestling it down is going to take some work. Let’s get to it.