The Perfect Enemy | Opinion | The Checkup With Dr. Wen: We need an honest accounting of covid’s toll - The Washington Post
February 2, 2023

Opinion | The Checkup With Dr. Wen: We need an honest accounting of covid’s toll – The Washington Post

Opinion | The Checkup With Dr. Wen: We need an honest accounting of covid’s toll  The Washington PostView Full Coverage on Google News

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You’re reading The Checkup With Dr. Wen, a newsletter on how to navigate covid-19 and other public health challenges. Click here to get it in your inbox.

My column last week on how we are overcounting covid hospitalizations and deaths drew outrage from both sides. Right-wing commentators claimed that the admission came “two and a half years late.” Some on the left insisted that, based on excess mortality data, covid-19 deaths are being undercounted.

I agree with both sets of critics in one crucial respect: We must have honest accounting and transparent reporting. That requires acknowledging that data changed over time and that deaths due to the pandemic are not necessarily the same as deaths due to covid.

At the beginning of the pandemic, many people — including a lot of young and otherwise healthy individuals — became very ill from covid pneumonia. Testing was limited, and it’s likely many deaths weren’t attributed to covid that should have been.

This is almost certainly the case in other parts the world, such as Eastern Europe, where the official death counts from covid were probably much lower than the actual mortality from the disease. In the United States, there were probably quite a few missed covid cases early on, so even if some deaths were improperly attributed to covid, they were still likely undercounted in 2020 and much of 2021.

Things changed by 2022 with the spread of the milder omicron variant and as the vast majority of Americans acquired excellent protection against severe disease through vaccination or infection. My colleagues and I noticed a dramatic shift among patients with covid-19. Far fewer were being hospitalized with covid pneumonia and other direct impacts of the virus.

Now, most covid patients fall into two categories: The first is those who are admitted to a hospital for a non-covid health issue but who have to take a test because of hospital protocols. Many of these patients test positive incidentally, especially in communities with higher rates of covid.

Importantly, this kind of across-the-board testing isn’t being done for flu, RSV, adenoviruses or other coronaviruses. If it were, we would see a much higher rate of hospitalizations due to those viral infections, too.

The second category includes medically frail patients for whom covid might exacerbate an underlying condition. People with severe chronic lung disease, congestive heart failure or other serious underlying conditions are at risk of being “tipped over” with any respiratory infection. If they catch covid, they could become hospitalized. Unfortunately, some die.

Because there is incredible variability in how hospitals document covid, this translates directly into variability on death certificates, where it’s common practice to enter multiple causes. If covid-19 appears on a death certificate along with several other diagnoses, it’s unclear whether covid was the primary reason for death, a contributing cause or incidental.

This is why we need more rigorous research like what Shira Doron from Tufts Medical Center is spearheading. Hospitals and health departments should use a uniform set of criteria to classify covid hospitalizations and deaths. The accounting should also be retrospective so that we can put to bed the criticism that severe illness was overcounted all along.

Such analysis is more precise than the often-cited excess mortality data, which measures the number of deaths that surpass the expected number in a given period. It’s tempting to compare the current level of deaths to pre-pandemic mortality and attribute all additional deaths to covid. But this confuses correlation with causation.

That’s because the pandemic has caused vast disruptions to the health-care system. Hospitals have been so overwhelmed that patients with heart attacks and strokes couldn’t receive timely care. Waiting times continue to be astronomical, exacerbated by the shortage of nurses and other health-care workers.

In addition, primary care offices canceled in-person visits, and surgeons postponed procedures. Patients deferred cancer screenings and fell behind on blood pressure and diabetes management. In fact, a recent BMJ paper estimates that more than 30,000 excess deaths in Britain are due to worsened cardiovascular disease, which, as the top cause of death, was already exerting a heavy toll.

We’ve also had a terrible RSV and flu season, probably because of the immunity gap from covid mitigation measures. Other infections, such as sexually transmitted diseases, are on the rise, in part because community health resources have been diverted to address the coronavirus.

And let’s not forget that “diseases of despair” are escalating, with skyrocketing deaths from opioid overdose and alcoholism and increasing depression and mental health distress, including among youths.

We could consider these deaths pandemic-related deaths, since many of them would not have happened if it were not for the last three years of covid. But these deaths need to be separated from those directly caused by the SARS-CoV-2 virus.

Reader Chris from Minnesota summarizes this well: “There are excess deaths occurring since covid started, but if we assign all of them to covid, then we are missing other ways that our health-care system is failing.”

Ask Dr. Wen

Newsletter subscribers are invited to submit questions to Dr. Wen. Not a subscriber yet? Click here to sign up.

“I have started going to the gym again. I am wondering how safe it is to use a sauna with other people in an 8-feet-by-8-feet room and the whirlpool with other people in the 8-feet-by-10-feet tub? Also shower stalls? Finally, how about a swimming pool that is very empty?”Fred from Maryland

I’d consider each on a case-by-case basis. A large swimming pool that’s pretty empty is very safe, even if it’s indoors. A shower stall, presumably that’s not shared with others, is low risk as well.

The whirlpool depends on the room and how many others are in it. If it’s a large, well-ventilated space, and there is only one other person, there is less risk than if there are five people and the jacuzzi is in a small space.

That leads me to the sauna. The hot, humid air reduces virus transmission, but a small sauna room could be risky if others are packed together. You could wait until you are there either alone or with one other person.

“My adult kids (one of whom is a junior high teacher) seem to have constant covid exposures from students, co-workers and others who didn’t know they were sick but who found out they had covid the next day. Our kids usually do not wear masks, like most people. What precautions should we, their parents, take when we find out they’ve had a recent covid exposure? We wear masks most places (we are 65 and have all the vaccines and boosters), but we have stopped wearing them to see our kids. Thoughts?” – Catherine from Illinois

If your adult children reported a covid exposure, and you want to be cautious, wait at least five days from the time of exposure, then have your kids take a coronavirus test before you see them indoors. If you want to be extra careful, you could wait the full 10 days as recommended by the Centers for Disease Control and Prevention, but that might be a bit onerous if they are constantly exposed.

The most practical solution is to have your kids test just before seeing you — and, of course, to postpone a visit if they are symptomatic.

“It appears to me there is a lot of confusion regarding the bivalent boosters and people thinking they are updated because they already had a ‘booster.’ Why not differentiate them and call the new one something like B. Booster (for bivalent) and let everyone know they received the B. Booster?” — Ellen from Maryland

Ellen, I agree with you. I think we need to change what it means to be fully vaccinated so that people no longer consider the number of vaccines they’ve received but rather whether they’ve received the most recent booster.

This is what we do with influenza. People don’t say, “I’ve received 31 flu vaccinations, and this year it’s my 32nd”; instead, they report whether they’ve received this season’s updated formulation. Thinking of the covid boosters as we do annual flu vaccines can clarify confusion and, I hope, increase booster uptake in the future.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

Throughout the pandemic, public health experts have referred to factors that make someone more susceptible to severe covid. But what about factors that make someone more protected? A remarkable study in the American Journal of Preventive Medicine addresses a key protective element: exercise. Americans who reported engaging in “some” physical activity had nearly twice the rate of death and 1.4 times the rate of hospitalization compared with those who describe themselves as “always active.” Those who worked out at least 30 minutes most days were about four times more likely to survive covid compared with those who were inactive. “Public health leaders should add physical activity to pandemic control strategies,” the authors wrote.

The journal Pediatrics published an excellent, though sobering, study looking at the rise in pediatric emergency department visits for mental health. While emergency-department visits overall increased by 1.5 percent annually between 2015 and 2020, mental health visits increased by 8 percent annually in the same period. Between 1 in 7 and 1 in 8 were return visits. These numbers underscore the huge unmet need for mental health services, including among children.

I appreciated this thoughtful opinion piece in the New York Times by David Wallace-Wells about the pandemic narratives we’ve gotten wrong and continue to perpetuate. For example, eventually we did what the authors of the Great Barrington Declaration advocated in 2020 by moving past interventions such as masks, but that doesn’t mean they were right at the time. Also, the problem with China’s vaccination campaign is not so much that its vaccines are less effective but that it did a poor job of vaccinating the elderly. Finally, the worst effects of covid-19 weren’t in the United States but probably in Eastern Europe.