COVID-19’s comparisons with “normal” mortality from seasonal flu is a misguided mental model. “Why” is well illustrated in this must-read Scientific American piece by a front line clinician, and is the most important article I’ve read on what makes COVID-19 the civilizational challenge of the century.

The doctor is right. In my nigh thirty years experience in emergency medicine, I have never seen anyone die of the flu itself. People die of pathologies secondary to the flu – they get pneumonias, they get blood-infected sepsis, they die of cardiovascular collapse from sepsis, they die from fluid loss. Managing all of these is utterly routine.

People “die of the flu” when the secondary evolutions are not treated in time, and the damage they’ve done cannot be undone. The CDC’s reported flu deaths are really a garbage can full of extrapolated factors that create shifts in a community’s morbidity. Often, the category “Influenza-Like Illness” checks the same vague, extrapolated-idea box. Most of these patients are older, and will not have an autopsy to pin down actual cause of death, the way you’d see on CSI.

COVID-19 itself, by itself, is a killer. The disease does not affect the mechanics of breathing the way a pneumonia would. It steals the oxygen from the patient at the gas exchange level. A badly affected body must mount a defense against the invading virus that is the equivalent of a mutually assured destruction nuclear war. With a routine virus, death is secondary, with COVID-19, it is a primary killer. Calling it a flu was a mistaken concept for our scientifically naive populace (not to mention our President).

I had an intern with me on the first day we were seeing lots of COVID cases, and at the end of the day I told him, “we are all rookies now.” All of our treatment modalities failed with COVID, all of our normal powers against pulmonary disease are diminished. We had to put away what we thought we knew about normal pulmonary disease and wing treatment for COVID (and it is very much an article of faith of mine that I will not have to explain “winging” in a lawsuit, two years from now, when everyone forgets the novel challenge called for the novel response).

The right model for thinking of COVID-19 is as a serious infection in the pre-antibiotic days, where any major infection might be deadly. We are back to the days where exposure to a pathogen starts a fight between the patient and the pathogen, and let the best organism win. The disease is highly infectious, the societal effects will be more like the plagues of, say, yellow fever, which historically brought cities to their knees. If you have a loved one who is elderly or in any way immunocompromised, resign yourself to the responsibility of not allowing your life to “return to normal” any time soon. I wear a mask around my wife.

It seems likely high-awareness campaigns to cope with “routine” flus, to prevent those “secondary pathologies that kill” masked the primary threat of the Corona virus, conceptually. Instead of flu, we should have another name for COVID, for the limited-attention span Twitter era, like “unique death in a micron that ends your being an apex organism.”

I have seen as many people die from COVID-19 in the worst six weeks of the outbreak as the number of people I’d see die of all causes in a third of a year, probably more.

No return to normal is possible outside a vaccine after wide distribution, and therapies for treatment.

Eugene Darden Nicholas

About Eugene Darden Nicholas

Eugene Darden (Ed) Nicholas is from Flushing Queens, where he grew up sheltered from the hard world, learning the true things after graduating college and becoming a paramedic in Harlem. School continues to inform and entertain in all its true, Shakespearean glory. It's a lot of fun, really. In that career, dozens of people walk the earth now who would not be otherwise. (The number depends on how literally or figuratively you choose to add). He added a beloved wife to his little family, which is healthy. He is also well blessed in friends and colleagues.


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