Covid, the sequel

It’s been a quiet week at Lake Wobegon. Too bad we can’t say the same at Westside Family Medicine.

Omicron is here, and after a few months of relative normalcy we are again being hit by a tidal wave of Covid.

Reports abound of family, friends, or coworkers who tested positive, not to mention acquaintances who happened to be sitting nearby. Cases are so rampant that contact tracing feels almost pointless.

Worse, we are seeing a significant discrepancy between rapid antigen and pcr results, even in patients with symptoms. Also, symptomatic patients with exposures who initially test negative, and then turn positive several days later.

A negative rapid does not mean you don’t have covid.

Omicron doesn’t care if you are vaccinated, boosted and have natural immunity to boot. The barbarians have broken through the ramparts.

And through it all, peoples’ reactions seem schizophrenic.

A sense of doom pervades as the case rate increases exponentially; yet no one seems to be cancelling anything. Never mind a lockdown, football stadiums are at capacity, family vacations are still on, restaurants and bars are full.

It all feels a little like dancing in Pompeii while Vesuvius smokes in the background (melodramatic, I know, but doesn’t it?).

And yet, could it be that this behavior makes a kind of sense?

After all, for vaccinated patients most Omicron infections are mild, ranging from a bad cold to a flu. Some are even asymptomatic. Would it be so terrible to get sick for a few days and then go back to the dance?

But what about the unvaccinated, the immunocompromised, and the elderly? They are still at high risk. For them, little has changed except that they are even more likely to get Covid now than last year, and still likely to be the ones who die from it.

Perhaps we need to be pragmatic, and approach these populations differently.

Back in the late 1980’s and early 1990’s, at the height of the AIDS epidemic, a new philosophy of treating substance abuse took shape. It was called Harm Reduction.

At the time, the prevailing model was Alcoholics Anonymous, where abstinence was the goal and anything less was seen as a treatment failure. The medical attitude was all-or-nothing.

Harm Reduction advocates viewed this attitude as misguided and ineffective.

Instead, they argued for an incremental approach, where small, stepwise interventions would, over time and in the aggregate, have a greater health impact, while also respecting the agency of the drug user.

Examples included needle exchange, supervised consumption sites, and a safe supply of heroin and cocaine.

Which is the better medical approach for Covid? All-or-nothing like AA, or little steps like HR?

It all depends.

For the vaccinated, low risk population (including young children), HR seems like the right approach . For the unvaccinated and the high risk, AA seems like the better fit.

HR for Covid means masking indoors, and outdoors in crowds; social distancing when possible; testing when exposed; and isolating when infected. Also, using common sense – contrary to popular belief, Covid does not take a break during lunch!

AA for Covid means sheltering in place. Harsh, I know, but in this population, if it ever made sense, it makes sense now. I know that’s easier said than done: it’s been a long pandemic, and people have had it.

My kids were supposed to visit my ninety-one year old mother in Florida over Christmas break. There were exposures, and now they may not go. She is not happy. What if you die of Covid? we said. What if I die of loneliness? she replied.

I totally get it, and in cases like this, AA and HR have to overlap like a Venn diagram – with daily testing added to masking, distancing, and meeting outdoors. Lockdown Lite.

Complicating the picture is the hospitalization rate, the real wild card. That’s the metric that I’m checking every day. If the total caseload gets high enough, the spike in admissions, along with a staffing crisis, could overwhelm an already stressed and demoralized medical system to the point of collapse.

On the brighter side, some epidemiologists believe that the Omicron variant will burn out fast, as seems to be the case in South Africa. Does that mean that we’ll be able to forget about Covid, as my daughter, Georgia, pleaded the other day?

It sure does, I said. You bet. Now pull up your mask.

Dr. Bertie Bregman
Dr. Bertie Bregman
Full Stack Family Medicine is a newsletter about what it’s really like to practice medicine and run a medical practice in New York City.
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