In these days of low-trust, fake news, conspiracy theories, social media rants and high confusion, I decided to turn to two doctors I trust. They are not putting up podcasts and they are not advising the government. They have not put themselves forward as Coronavirus experts. And they are not seeking a Facebook or Twitter following. They are doctors who have treated me and upon whose knowledge and experience I rely. Dr. Rennert has been my family doctor for over three decades and Dr. Lavi has been my haemo-oncologist for a year and a-half. I have been through stressful medical situations and both have proven to be professional and responsive to my needs, and to advise me respectfully, in clear language and factually.
I asked both of them for interviews to help me understand at least some of the issues relevant to us as we deal with COVID-19. I do not take it for granted that they took time from their busy schedules to talk with me as a budding journalist and not as a patient.
It is interesting to get the perspectives of doctors with two very different patient populations — one cancer patients and the other a general family practice. I reflect on the interviews at the end of this post and draw some personal conclusions.
Both doctors agree that the original lockdown in March 2020 successfully interrupted the chain of infections and that we came out of the lockdown too quickly and without an exit strategy that would have ensured we maintain the gains achieved. I remember how, after the first lockdown was declared over, I sighed in relief and felt that we had got through the epidemic without too much damage, that it was behind us here in Israel. I balked at using the face mask and scoffed at the regulations that made me join a line on the sidewalk outside stores I wanted to purchase merchandise from.
But then, by summer, it was clear that all was not well. Had we all just followed the guidelines, both doctors agree, we would not have reached the point at which the second lockdown was necessary. Dr Lavi described what she sees among her own patients:
In this recent second wave, including during the lockdown itself, similar to the rest of the Israeli population, some of my haemotology patients (who are among those vulnerable to complications from the virus) are not completely compliant with the guidelines. Many people take the guidelines lightly and, in accordance with their own personal beliefs, they bend the rules. Therefore, most of the infections are from other family members.
In order not to endanger those who are in a higher risk category, all members of the household need to take the greatest care; if everyone follows the guidelines for social distancing and wearing masks when they are outside home, their chances of getting infected are very low and then they will not bring the virus back to those at risk. As soon as compliance is only partial, there are infections.
I have a few friends who asked me to enquire about this situation: older couples (aged 70+) whose children cannot work because they do not have childcare want to move in with their parents so the grandparents can look after the kids. The parents and children are compliant with the lockdown and have been good about maintaining social distancing and masking. None have ever been infected. Is it safe for them to live together now? Both Drs Lavi and Rennert weighed in on this in similar fashion. Dr Lavi replied:
As long as there is a lockdown, the answer is simple: it is not a problem as long as everyone complies with the guidelines. When the children return to school or daycare, however, infections are likely to increase and then it will be imperative to take care. In my opinion, at least for the first while when there will still be a high number of infections it is best if children who are in daycare and school avoid being with their grandparents at home. As far as we know today, there is not a higher chance for high-risk people to become infected, but if infected, there is a higher chance that they will experience more serious complications.
I asked Dr. Lavi if there is a difference in treatment offered to cancer patients today as opposed to before the Coronavirus pandemic:
Because the virus is not going to disappear soon, we are not putting off cancer treatments. At the height of the first and second waves, we did not do Stem Cell Transplants (SCT) unless they were urgent and each case is judged on its own merits, but aside from those specific periods of time, we have been conducting transplants. Patients continue to receive their ongoing cancer treatments but for those meds that are not directly related to the cancer itself (such as infusions for strengthening the bones) we may reduce frequency from monthly to every three months based on clinical considerations. If the patient has been infected with the Coronavirus or is in isolation, treatments are temporarily withheld.
I am also interested in the psychological impact of the lockdown. I remember when I underwent an SCT and was kept in isolation in a hospital room for almost two weeks. It was important for my mental balance to have someone visit me each morning, even for just 20 minutes; the whole day alone was easily tolerable after that. I am not sure if ZOOM “visits” would have be enough for me. I asked Dr. Lavi how it is for her patients who have to deal simultaneously with both cancer (and other conditions) and social isolation. She replied:
The social distancing is difficult for all of us, but my patients, perhaps more than others, understand that now it is essential and there is no choice in the matter. I see them dealing with it quite well over all. There are many positive sides, such as mutual help that people can provide each other, and projects run by NGOs such as Halil Ha’or, and Amen (drives patients to treatment centers. for example). Given today’s technology, there is much communication among family and friends even without being able to meet in person so that the cancer patient is not more isolated than the rest of the population.
Dr. Rennert, on the other hand, told me that about 70% of his time is spent these days dealing with the emotional and psychological fall-out from the Coronavirus pandemic. He spends most of his time reassuring his patients who have high levels of anxiety given the uncertainty caused by this novel virus and confusion in the messages we receive from the leadership and the media. “There is tremendous fear,” he told me, and went on:
Fear of the virus has reached unbearable levels; some patients call me each morning to ask how many sick and infected were reported the previous day if they missed the news. And there is the stress from isolation because of needing to maintain social distancing, loss of income and now with the lockdown even deeper loneliness. I get calls from patients who need help maintaining family and marital relations under these trying conditions. Suicidal thoughts arise and one 60-year-old patient had to be hospitalized for attempted suicide. She was totally alone and had lost her job. A young man of 30 has not left his house for six months and he does not let his wife and children near him because they do go out.
Dr. Rennert suggests that this is partly due to the confusion engendered by media reports.
It seems that the media relates to the lockdown as a social-economic step rather than a medical step.
It is true that there are serious social and economic repercussions from the lockdown and these need to be discussed without sensationalizing them. But asking the media not to sensationalize an issue would be like asking it to cut off its own oxygen supply.
Fifty of Dr. Renert’s approximately 4000 patients got sick from COVID-19. Forty have recovered, three died. He says that about 30% of those who recovered are left with lingering headaches and respiratory and cardiac conditions. Dr. Lavi said this phenomenon is referred to as “Long COVID” and it includes more complications and seems more prevalent in COVID-19 than the longterm complications experienced by patients with other viral diseases, such as the flu.
I also wondered if there have there been fewer hospitalizations this year from flu and pneumonia because of social distancing and mask wearing to protect from the Coronavirus. Dr. Rennert found that to be true among his patient population. Dr. Lavi expanded on this:
According to what we see happening in the southern hemisphere where there has been a significant reduction in flu incidence, it certainly appears that this winter we will see fewer cases of flu because of mask wearing and social distancing. However, there is the fear that some people may become infected simultaneously with both the flu and Corona, causing a much more difficult disease scenario and making diagnosis much more challenging. Therefore, it is recommended that people, especially the immunodeficient, not neglect to be vaccinated against the flu.
I have heard that even those who have had the virus are not immune to being reinfected and sick again. I asked Dr. Rennert if he had such cases among his own patients and he said he did not. Dr. Lavi said:
We know that within the first three months it is not likely that there will be reinfection given that during that time the level of antibodies remains high. There have been case reports of reinfection after this time period and it appears to be because of genetic changes in the virus just as we know happens with other infections diseases. While the immune system cannot always prevent reinfection, the immune system memory can result in reinfection being milder the second time. We do not know if those who are reinfected and asymptomatic are also contagious. For that reason, it is advised that even those who recover from COVID-19 follow the guidelines as well.
One question I asked was: are Zinc, Vit C and Vit D protective — if infected would they help have a less serious case of illness, or do they protect against getting infected even? Dr. Rennert replied that Vit D may be protective in case of deficiency. Dr. Lavi expanded on this:
In general, these nutrients can strengthen the immune system but there is no clear evidence that taking these nutrients as supplements will either prevent or reduce the complications of infection. There is much interest in the possibility that taking them may do either or both of these. Many studies on Vit D and COVID-19 show that a healthy level of Vit D prevents infection and disease severity. There is also research on Zinc and Vit C but these are not sufficiently validated to use as a basis for medical recommendations. The studies to date have been observational and what we need are randomized control experiments in which some patients receive the vitamin and some do not. So far, one study has been published but the number of patients is too small to be definitive and more patients are being recruited for the research.
It may be reasonable at the present time for people to check the level of Vit D in their blood so that if it is found to be low, they can take supplements. However, it is important to know that Vit D levels can be too high. I have already seen patients who have read about Vit D and Coronavirus and doubled the dose I gave them, reaching toxic levels. The Health Ministry recommends going out into the sun with arms uncovered for about 20 minutes daily sometime between 11:00 and 16:00 or taking 800-1000 units of Vit D.
She also shared her own personal experience:
I can tell you that this period of Corona has affected me personally. I considered what I can do in order to protect myself and I decided to move to a healthier plant-based diet (lots of fruits and vegetables) and to engage in physical activities in order to lose weight and lower the sugar levels in my blood. This reduces my risk of complications from the virus. Regarding Vit D, I ensure that I spend time in the sun. I believe that it is most important to maintain a healthy lifestyle and to make sure my body has access to zinc and vitamins C and D by natural means and not by taking supplements.
Dr. Lavi added a final comment:
It is important for me to emphasize that we know that by maintaining social distancing, by wearing a mask and by washing our hands we can prevent infection. These are quite simple to do. Remember that every time we violate these guidelines we endanger someone. This is a serious disease with high morbidity and higher death rates than a simple flu. Each time we go without a mask or gather in large groups, we risk infecting someone even if we are asymptomatic.
Complying with the guidelines will also help heal Israel’s economy [as we will be able to avoid another lockdown]. We must show social responsibility. Overcoming the pandemic, and the difficult effects it has on us depends on all of us. I am still surprised to see that many people, even those in the high risk categories, violate these simple guidelines. Please, take care.
We are about to emerge from our second so-called lockdown. I say “so-called” because, in comparison with the over two-month lockdown in Wuhan what we have had is not a lockdown at all, just more stringent social distancing guidelines than we are generally expected to observe, together with the closing down of businesses in a way that defies logic. When weighing the need to stop the chain of infection versus the socioeconomic needs of the population, governments around the world are in a “damned if you do and damned if you don’t” situation and I do not envy those who have the responsibility for the decisions that may feel something like walking between the raindrops without getting wet. More about that in a separate article.
We, the regular citizens, can do nothing to affect the policymakers and those who are charged with deciding how best to conquer the pandemic. Success, paradoxically, means not seeing the numbers of deaths that would convince people that this is something to be taken seriously, just like taking birth control pills prevents pregnancy — years ago, I worked with young teenage girls who saw that they were not getting pregnant while on the pill and concluded that they had no need for the pill at all (until they did get pregnant). Adolescents are still cognitively immature but when adults use the lower than expected death rate to “prove” that there is no need for lockdown or masks, I wonder about their cognitive sophistication.
One thing I take away from my interviews with the two medical doctors I most respect and trust is that this is, indeed, a viral infection to fear getting; however, there is no need for hysteria. The hysteria created around COVID-19 by the media and the fanning of the flames by those on social media making all kinds of conspiracy claims make the situation intolerable for some.
It is interesting that Dr. Lavi’s cancer patients seem to be handling the stressful situation with greater resilience than many of those in Dr. Rennert’s family practice. If 70% of his time is spent reassuring his patients and helping shore up their emotional resources, that does not bode well for the general population as a whole. Perhaps the difference between Dr. Lavi’s and Dr. Renert’s patients points to a protective element of familiarity with dealing with ongoing stress of chronic illness; her cancer patients face their mortality each day with ongoing treatments and the uncertainly of not knowing when a tamed cancer will emerge from hibernation and become active once more. I wonder if this is true for others with any of a variety of chronic illnesses that kill.
Given that some of Dr. Lavi’s patients violate the simple guidelines that can keep them from becoming infected, even knowing how their cancer makes them particularly vulnerable to serious complications, leads me to consider the element of psychological denial. It is a mechanism that protects people from facing stressful truths. However, denial in this case can keep people from complying with the guidelines meant to protect them from infection. Many questions arise for me here: How much of the population that are not emotionally stressed are, in fact, in denial? Are those who rant against government restrictions of freedom in denial and is this their way of protecting themselves from becoming infected with media-promoted hysteria? Or are they showing a healthy scepticism that raises legitimate questions that the public should be asking? How can one tell the difference? A most interesting group are those who rant and rave against what they consider barbarous government edicts at the same time as they follow the guidelines to a T.
We can be sure that future research will examine the psychological impact of the pandemic on society and individuals. While the economic impact may have been as severe during the Spanish Flu pandemic, it is almost certain that the psychological impact is greater in today’s world of social media. We need to know what helps promote resilience under this degree of overwhelming uncertainty. We need to be able to tell the difference between healthy resilience and potentially dangerous denial. We need to be able to tell the difference between ongoing stress reactions and trauma, as some people are claiming that the current situation is traumatic. More about these issues in a separate upcoming article.
Personally? I feel like I have a healthy respect for a dangerous virus about which we still do not know enough. I am not hysterical, but I think I operate from a position of concern for my own welfare and that of those I love. I admit that I was in a state of denial until the summer and I even said so to a friend who asked me to put on the mask I hated. It was almost a proud declaration of refusal to be pulled into what felt like a strong undertow that would cause me to lose control. It took me some time to reach my current balance.
I appreciate those who raise red flags and ask us to examine what is going on and not to simply trust what the government is telling us via the overly sensationalized media. Without them, I would not have written this article and others that are in the works. Without them I would know less than I know today. And less than I will know tomorrow and the next day, etc.
So, argue all you want, social media friends and real-life friends! But please keep your masks on and avoid large gatherings and keep yourselves safe. Better to think this is all a hoax or that the government is taking advantage of a virus in order to control us than to take the chance of proving it is neither and finding ourselves in a third and fourth lockdown. No?