COVID19 UPDATE: When Should We Return to Normal?
The other night on one of the news programs, the newsreader announced yet another COVID-19 death occurring in a 91-year-old patient in a nursing home. This brought the total number of deaths in Australia to just under 80 in over three months. 10 of these deaths have come from two nursing homes in Sydney and 19 Australian deaths from the one cruise ship.
It is vital to remind all of us that the death of a loved one is always a tragedy, regardless of age, for the children and grandchildren and should never be underestimated. But, the vast majority of people who have succumbed to this virus were in high dependency nursing homes or had some other significant underlying illness, greatly already affecting their quality of life, and if COVID-19 wasn't the final cause of their demise, some other condition or infection would probably have occurred at some stage over the next few months.
It is also vitally important to state that our infection numbers & death rates are much lower per head of population than all other major, developed countries in the world which must be attributed to the superb work to date from the Government and health authorities but also the extraordinary cooperation from the public in abiding by the social distancing, home and self-isolation & all the other measures we are following.
I have mentioned in previous articles my position on why Australia has done so well compared with countries like the US, Italy, Spain, the UK and who knows what are the genuine figures from China. I will reinforce these points in my next article.
But last year, during a relatively weak flu season, Australia had 900 deaths in around four months. It was not announced on the news on a regular basis that yet another elderly person with clearly serious co-morbid conditions had died from influenza. The reality is that very sick, elderly people die and typically it is some type of infection that pushes them over the line. The COVID-19 pandemic has certainly precipitated the death of many people around the world but the reality is that the vast majority of people who have succumbed to this virus were already quite ill, the virus being the final factor that pushed them over the edge.
Every year in Australia alone, there are around 170,000 deaths. In the vast majority of cases, these people die from acute or chronic complications of cardiovascular disease or cancer. Conditions such as Alzheimer's disease, diabetes and osteoporosis are also significant underlying factors for many people. Infections, whether this be COVID-19, influenza, other forms of pneumonia or any viral, bacterial or other type of pathogen purely exacerbate the underlying condition, often leading to death.
The vast majority of all of our common killers has a strong genetic basis but as I often say, it is your genes that load the gun and your environment that pulls the trigger. Thus, to take the example of cardiovascular disease and, in particular, atherosclerosis (the progressive build-up of fat, inflammatory tissue and calcification within the walls of your arteries), 90% of atherosclerosis is due to either insulin resistance or lipoprotein(a) which are both genetic conditions. The remaining 10% due to less common genetic abnormalities.
Over decades the fat and other tissue substrates build-up in the walls of the arteries. If you imagine a doughnut, the hole is where the blood flows but the fat sits in the wall. This fat remains dormant until some precipitating factor makes the fat acutely rupture (somewhat like squeezing a pimple), the fatty plaque then ruptures into the channel, a clot forms and often this blocks the artery leading to a heart attack or stroke, depending on the site & size of the plaque.
So the big question is – What makes the plaque rupture? Or, in other words, what are the precipitating factors for a chronic, dormant condition becoming an acute illness, such as a heart attack or stroke.
There are five basic stressors that may do so:
1) Emotional stress – please show me someone who doesn't have this!
2) Mental stress – you're under the pump at work with enormous pressure and this is often the setting for an acute vascular event. A long-term trial performed in the UK known as the Whitehall study looked at 17,000 British civil servants over 20 years and showed those workers who suffered job strain (which is high demand, low control) i.e. the middle managers, not the bosses, were those most likely to suffer acute vascular disease.
3) Physical stress – regular exercise, in my view, is the second best drug on the planet after happiness. I suggest we perform 3 to 5 hours of moderate exercise on a weekly basis. But as physical stress, I’m referring to the fat guy who doesn’t exercise who has to run for the bus or people who perform exercise over and above their capacity are the ones at risk for the precipitation of an acute event. Those people who climb Mount Everest are not putting themselves at risk just because of the heavy climb but also because of the freezing cold temperatures and low oxygen levels. But, it may also be the physical stress of an operation or chronic pain which may also precipitate an acute vascular event.
4) Pharmacologic stress – legal or illegal stimulants may precipitate acute vascular problems.
5) Infective stress – any infections, as mentioned above, may precipitate an acute vascular problem. Thus, when a person dies from the complications of COVID-19, in the vast majority of cases, I would see this more as a precipitating event rather than the cause of their death. As mentioned above, any infective organism can deteriorate an underlying condition and it is clearly sick, elderly people with co-morbid conditions that are at much greater risk for serious complications and death from the COVID-19 Pandemic. But, should we really be calling this a COVID-19 death rather than blaming the underlying condition?
The world has been shut down temporarily because of this pandemic and no one can be really sure when our life will get back to normal. Australia has been the poster child for management of COVID-19 but now the infection rates are at, or close to, single figures, shouldn't we start “dipping our toe back in the water” to return to, at least, a semblance of some normality.
There is no doubt that the social distancing works and I believe this should continue definitely throughout winter but our civil liberties have been significantly affected and it is my own personal opinion that the current restrictions are far too punitive for the vast majority of society.
Unfortunately, we are asking our children and grandchildren to cope with the economic devastation caused by the shutdown as a consequence of this virus.
The reality is that the death rates from COVID-19 are probably just a bit above a bad dose of influenza, so why don't we have the same response to influenza every year? We have shown collectively as a nation that we have cooperated with the government’s demands but I believe now the time is right to slowly return to some degree of normality and we certainly need firm and solid guidelines as to how this can be achieved without seeing a major increase in infection rates.
Providing stress echocardiography heart health services for more than 25 years, Dr Walker is an expert in the field of preventative cardiology and has published seven best-selling books about the subject. Dr Walker is a member of the Miskawaan Health Group medical advisory board.