My COVID Journey, First Installment

I am an anesthesiologist. I am a pastor’s wife. I dabble in journalism. People often ask my what my COVID journey has been like. Throughout the crisis, I’ve tried to share my perspective through writing. I’ve got quite a diary of submissions, largely unpublished, despite attempts to the contrary. This was the first. I started writing it on April 25, 2020. I submit it largely unedited, as the retrospection is instructive both for me and others.

What If We Got It Wrong?

A Christian Physician’s Perspective

Kimberly D. Milhoan, MD

May 1, 2020

While they are saying, “Peace and safety!” then destruction will come upon them suddenly like labor pains upon a woman with child, and they will not escape (1 Thessalonians 5:3).

The year 2020 brought rumblings of a new respiratory virus in China. According to the U.S. Centers for Disease Control (CDC), Chinese health officials reported on December 31 a cluster of cases of acute respiratory illness in people associated with a seafood and animal market in Wuhan. By January 7, Chinese health officials confirmed a novel coronavirus (2019-nCoV), different than those that cause Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), was responsible for this cluster and the CDC established an Incident Management Structure. China posted the genome sequence for the virus on January 10. The CDC developed a diagnostic test within one week and posted a public assay protocol by January 24. Screening of travelers from Wuhan started at some U.S. airports on January 17. By January 20, China acknowledged the virus could spread between humans and claimed it had killed 3 people and infected more than 200. On January 21, the first person in the U.S. was diagnosed, in Washington state after travel to Wuhan, and the CDC activated its Emergency Operations Center. China began domestic travel bans in and out of Wuhan on January 24. On January 30, the World Health Organization (WHO) declared the outbreak a Public Health Emergency of International Concern. On January 31, the U.S. Department of Health and Human Services (HHS) declared a public health emergency, President Trump limited travelers from mainland China to U.S. citizens and lawful permanent residents and their families, and the CDC published a health advisory for clinicians and public health practitioners. By February 4, 20,741 cases had been confirmed in China, 13.6% with severe illness, and 425 deaths. Cases had also been reported in 26 locations outside mainland China, with one death. Eleven cases had been reported in the U.S. Nine had traveled from Wuhan and two were household contacts of these travelers.

Initial clinical guidance for this new virus, eventually named COVID-19 by WHO, was based on established management and prevention guidance for known respiratory illnesses such as influenza, MERS, and SARS. The public was advised to practice  what should be habitual actions known to prevent the spread of respiratory illness such as hand washing, covering coughs and sneezes, and staying home when ill. The elderly, those with co-morbid conditions, and those with compromised immune systems seemed most vulnerable.

By the last week in February, the WHO advised the virus had “pandemic potential” as it spread from country-to-country; there were widespread media reports of increasing cases and deaths in South Korea, Italy, and Iran; and the Diamond Princess cruise ship had docked in Yokohama, Japan. Fifty-three cases of COVID-19 had been reported in the U.S. Twelve were associated with travel to China, two were household contacts of these travelers, and 39 were from the Diamond Princess. When COVID-19 infection was reported in a passenger from Hong Kong who had been on the ship from January 21 through January 25, the ship returned to port but the passengers and crew were quarantined onboard from February 5 through February 20, when most were air-evacuated to their respective countries for further quarantine. By then, 619 of 3000 (17%) had tested positive, the largest cluster of infections in the world outside China. Six had died by the end of February, all of whom were over 70. Cruise ships provide a unique laboratory for the study of human-to-human infection transmission. This was the first clinical data I examined related to COVID-19.

My husband, Kirk, is a pediatric cardiologist and I am an anesthesiologist. We have participated in short-term international medical missions for over twenty years, with numerous trips per year to places such as Bolivia, Honduras, Iraq, Kenya, Kosovo, Kurdistan, Liberia, Malawi, Mexico, Mongolia, Nepal, Papua New Guinea, Sudan, Tibet, Uzbekistan, and Zambia. During the height of the SARS epidemic, Kirk accompanied a child with heart disease from Toronto to Mongolia via Vancouver and Beijing. Despite three-fourths of those locations having a high disease burden, neither he nor his team members contracted the disease. He was in Liberia during the Ebola crisis, without contracting the disease. The two of us traveled to Iraq during the MERS crisis, without contracting the disease. He deployed as a flight surgeon to Iraq in 2005 and 2007. One of his duties was to oversee public health officers at Balad AFB, responsible for the health of approximately 30,000 people.

As the news of COVID-19 broke, it was relevant to us on many fronts. My husband is the senior pastor of a church in Maui. We still travel for international medical missions. I practice as an anesthesiologist in Maui. We both serve one week each month in short-term physician contracts in hospitals in Texas and Arkansas. Kirk’s 80-year-old mother with heart disease lives with us. Kirk and I conducted a medical mission trip to Iraq in January. We also traveled to New York City and Las Vegas in late January and early February. Kirk was in San Antonio, TX when the first COVID-19 cases were reported there. I was in Little Rock, AR, with my 79-year old mother and her same age friend, when the first COVID-19 case was reported in Arkansas. We had continued our travels, not ignoring the rumblings of COVID-19, but employing our standard precautions of hand and respiratory hygiene and advising those with us to do the same.

My admonition in explaining hand hygiene is assume everything you touch is contaminated. In order to protect yourself, if you are going to touch your face or anything that you put in your mouth after touching anything contaminated, wash your hands first, preferably with soap and water or with a minimum 60% alcohol hand sanitizer. COVID-19 has rightly caused us to put more thought into protecting others. My contention is that we have been doing this poorly with rhinoviruses and influenza all along. According to the CDC, in the first 17 weeks of 2014-2020, we lost an average of 78,245 people in the U.S. to influenza and pneumonia. 2018 was the worst year with 87,123 deaths. COVID-19 is now being counted among these deaths for 2020 and we have lost 86,044 people in the U.S. so far. In order to protect others, if you touch your face, or sneeze or cough on your hands, or wipe or blow your nose, wash or sanitize them before you touch anything anybody else is going to touch, including someone else’s hand. Respiratory hygiene refers to covering your coughs or sneezes with your shirt or elbow.

Physicians are well-versed in infection transmission prevention. We are obligated to protect our patients from ourselves and from each other, and of course we are interested in protecting ourselves and our families. Terms like airborne infection, isolation room, standard precautions, contact precautions, airborne precautions, and eye protection are familiar to us. We wear masks when conducting sterile procedures, when we are sick (in the pre-COVID era, we often worked when we had a common cold because clinical demands often do not offer a choice), or when we are employing airborne precautions in caring for someone with a respiratory illness. Kirk did not wear a mask when traveling with the SARS epidemic, as he was asymptomatic. Kirk and I felt confident we could protect ourselves and our loved ones employing these precautions that were in line with CDC recommendations. I submit that we just haven’t done this well in the U.S., even in our hospitals or nursing homes, because we never perceived the cost of carelessness to be high enough. The mounting evidence of the number of COVID-19 cases that spread throughout our country while we were unaware lends support to this theory. COVID-19 has exposed the cost and therefore the necessity to understand and employ hand and respiratory hygiene precautions well.

On February 28, a case of COVID-19 was identified in a resident of a long-term care skilled nursing facility in King County, WA. By March 9, 81 of the residents of the facility, 34 staff members, and 14 visitors had tested positive for the virus; 23 persons died, including the initial patient. After the first U.S. death was reported, Seattle-area schools were closed, out of an “abundance of caution,” and Washington governor Inslee encouraged avoidance of mass gatherings. Also on March 9, due to increasing patients and deaths, Italy declared a limited travel ban that they extended to the whole nation the following day. School closings and cancellations of mass gatherings of all types started to occur across the U.S. The virus had spread to at least 45 countries and WHO declared it a pandemic on March 11, the same day the first case was reported in Arkansas. On March 12, President Trump declared a travel ban from Europe and I sent my mother and her friend home to North Carolina from Arkansas, admonishing them to consider every surface contaminated on the way home. As they were in a high-risk group, I knew it would be easier to keep them healthy in their homes than in a hotel should further travel bans be declared. The next day, March 13, I flew home to Hawaii, where only two travel-related cases of COVID-19 had been diagnosed on Oahu, following my own prescription for hand and respiratory hygiene. On March 15, the first case was diagnosed in a visitor to my island home of Maui and I began to observe what I considered a rising panic amongst even medical providers.

I am aware of the stigma of comparing COVID-19 to influenza. However, physicians are very aware of the high seasonal disease burden and deaths due to influenza, pneumonia, and other respiratory viruses. Nothing I had learned prior to the WHO’s pandemic proclamation on March 11 had persuaded me to think differently about how this virus was transmitted and who was vulnerable. I had every desire to protect my mother, her friend, my mother-in-law, and my patients, so had increased my hygiene vigilance in all situations, not just the hospital, and advised anyone who asked me to do the same. The CDC’s initial report, published online on February 5, declared “2019-nCoV symptoms are similar to those of influenza (e.g., fever, cough, or sore throat), and the outbreak is occurring during a time of year when respiratory illnesses from influenza, respiratory syncytial virus, and other respiratory viruses are highly prevalent.” In medicine, we talk about “bad flu” years and 2020 was already proving to be one. In hindsight, it is likely because COVID-19 was unrecognized at the time. We do not always test for the underlying virus when someone presents with a respiratory illness. That is why the CDC looks at pneumonia deaths in conjunction with influenza deaths in order to get some sense of influenza activity.

Making sure I was not ignoring appropriate warning signs, I found an analysis of the Diamond Princess on March 4 which was reassuring. Case fatality rates from WHO for COVID-19 were estimated to be as high as 3.4%, but, as the CDC asserted in their 2017 guidelines for community mitigation of respiratory pandemics, “attack rates and case-fatality ratios can be difficult to measure early in a pandemic because of variations in care-seeking behavior and testing practices; not everyone seeks care for their illness, and not everyone is tested and receives a diagnosis….As a result, severe cases might be more likely to be reported, resulting in an overestimate of the case-hospitalization or case-fatality ratio.” A cruise ship is a perfect laboratory because it is a closed population where likely everyone is exposed and everyone is tested. Thoughtful analysis from this closed population showed the case fatality rate for COVID-19 could actually be between 0.05 and 1% and confirmed elderly adults were at risk for severe disease or death. On March 5, I found an analysis of temperature, humidity, and latitude that demonstrated significant community spread of COVID-19 had occurred in an east and west pattern in a 30-50 degrees north corridor in areas with 5-11 degrees Celsius average temperature and low specific and absolute humidity that I shared in a Facebook group for Maui medical providers. This analysis, which has held up as of an April 6 revision, seemed particularly good news for my island home and, if it continues to hold up, should be good news for a lot of places in the world, supporting the idea that we do not need a one-size-fits-all response the world over.

On March 21, as calls for travel quarantines and stay-at-home orders in Hawaii grew, I read and naively shared with that same Facebook group a now infamous article summarizing available data analysis by lay author Aaron Ginn called “Evidence over Hysteria—COVID-19” on medium.com that was taken down within hours. I found the analysis compelling and compatible with the cruise ship and latitude/temperature/humidity data I had explored earlier. Local providers commented that the analysis was “excellent”, “thorough”, “thoughtful”, and even “reassuring”, but they were concerned it would cause us to be complacent and slow down our preparation for the worst-case scenario. I also shared the article in a group text conversation soliciting my signature for a shelter-in-place petition, despite only five cases on Maui at the time and none in the hospital. One person commented on the author’s political affiliation and negative social media comments on the article before having read it. After he did read it, he criticized the article for not being peer-reviewed and for the author not being a physician or epidemiologist. Another commented that my subsequent defense of the data analysis was “logical”, but that he would sign the petition, even if it seemed overzealous because he’d rather be safe than sorry.

I was bewildered to observe physicians acting contrary to our training. We are trained to examine data and evidence and practice accordingly. “Journal Club” is a regular feature of medical training and practice where we analyze studies and articles in the medical literature, determining if their conclusions warrant a change in practice. Criticizing an article before reading it based on others’ critiques or the author’s background or politics is really unheard of. Information was coming so fast and furious with COVID-19 that there has been little time for peer review, let alone time for busy medical professionals to digest all of the data. I was pleased that someone with analytical skill like Ginn had taken the time to summarize what data there were. Trying to honor their desire for opinions from public health and medical professionals, I sought, found, and ultimately did not share a March 17 article by a Stanford physician and epidemiologist, Dr. John Ioannidis, warning against prepare-for-the-worst measures of extreme social distancing and lockdowns in the absence of good data regarding disease prevalence and the adequacy of such measures. His article referenced a comprehensive review of the research on community mitigation strategies and included another encouraging analysis of the Diamond Princess cluster of infections. Like Ginn’s article, I found this one well-reasoned, compelling, and supported by data. This time, however, I read all the criticisms of it online and realized for the first time the polarization of views, even in the medical community, regarding COVID-19. I find it ironic, long after the fact, that a March 19 article by a lay person other than Ginn survived on medium.com and has been translated and shared the world over.

I was not abandoning caution and concern or even advocating complacency regarding COVID-19. I simply didn’t think the evidence warranted our employing measures we had not employed or studied. The U.S. was relatively unscathed during the SARS epidemic in 2003 and the MERS epidemic in 2012, but we had endured the H1N1 influenza pandemic that began in 2009. Data analysis from the H1N1 pandemic motivated the CDC in 2017 to update their 2007 community guidelines for mitigation or prevention of pandemic influenza or other respiratory viruses that I referred to earlier. CDC-recommended categories of non-pharmaceutical intervention (NPI), based on evidence supporting their effectiveness, include “personal protective measures for everyday use (e.g., voluntary home isolation of ill persons, respiratory etiquette, and hand hygiene); personal protective measures reserved for influenza pandemics (e.g., voluntary home quarantine of exposed household members and use of face masks in community settings when ill); community measures aimed at increasing social distancing (e.g., school closures and dismissals, social distancing in workplaces, and postponing or cancelling mass gatherings); and environmental measures (e.g., routine cleaning of frequently touched surfaces).” Notice the absence of consideration of shelter-in-place or stay-at-home orders, as well as this caution: “When a pandemic emerges, public health authorities should assess its projected impact and recommend rapid action to reduce virus transmission, protect populations at high risk for complications, and minimize societal disruption.”

An article in Health Psychology noting public health consequences of media exposure offers a good explanation of how we came to employ unprecedented mitigation strategies, such as stay-at-home orders, in the absence of data or experience supporting their effectiveness. Pictures out of China and Italy with individuals in Ebola-type personal protective gear, accompanied by incessant reports of rising patient and death rates and overwhelmed hospitals, induced a panic motivating us to lock down our country as they had. An additional factor was the risk to health care workers (HCW). We are either vaccinated, in the case of influenza or Hepatitis B, or know how to protect ourselves against HIV, Hepatitis C, methicillin-resistant staphylococcus aureus (MRSA), and even tuberculosis. Stories of nurses and doctors dying from this illness for which we did not have a vaccination and the population did not have herd immunity got our attention. The physician-initiated petition for a stay-at-home order on Maui cited the need to protect medical workers. An article in the Washington Post on March 25 that I found chilling reported that hospitals were considering universal do-not-resuscitate orders for coronavirus patients in order to protect doctors and nurses.

A planned, but cancelled, three-week medical mission trip followed by a week in Arkansas meant I was not scheduled to work at the hospital in Maui for four weeks. While declining to sign the stay-at-home order petition, I decided to respect my colleagues’ concerns and cease any further argument, since I was not going to be at personal risk on the front line. This allowed a rare opportunity to turn my undivided attention to our church community.

Kirk starting speaking consistently from the pulpit on COVID-19 on March 1. He advocated hand and respiratory hygiene and staying home if ill, part of or living with someone in a high-risk category, or simply concerned. Since each of our services average around 100 people, still within local guidelines at that time, I think we were one of the last churches on Maui to have an official service, on March 22. We cleaned all potentially contaminated surfaces. We made hand sanitizer available at the door. We did not serve our usual donuts and coffee. We had congregants pick up their own single-service communion cups. We did not have our usual greeting time. That day Maui Mayor Victorino announced a stay-at-home order effective March 25. A 14-day quarantine of travelers arriving in Hawaii started on March 26. These two orders effectively shuttered Maui’s tourism industry. Estimates are that unemployment rates ranged from 25 to 50 percent. We immediately elected to extend our church food pantry hours from three to seven days per week, receiving clarification from the mayor’s office that our services were deemed “essential” and being transparent we would conduct regular meetings that would include teaching and worship. When we found out that Alcoholics Anonymous meetings were not considered “essential,” our federally recognized mobile medical clinic allowed Kirk to medically supervise a daily 6 a.m. meeting that was possibly the only one available on our island.

Conservatively, we had well over 50 people participate in our daily 9 a.m. to 2 p.m. endeavor over 5 weeks, picking up food from donors, stocking shelves, cleaning and sanitizing, greeting and ministering to guests in our sanctuary, staffing the pantry itself, providing security, providing lunch for volunteers, delivering food to those who could not or would not come to our facility, praying, and even attending twice weekly meetings. As guidelines changed, we changed with them. Volunteers wore masks and gloves. Visitors were greeted at the door with hand sanitizer and a touchless thermometer. We enforced social distancing guidelines. We’re served over 1100 people per week compared to our previous 125. Those of us who served, including many of retirement age, Kirk’s 80-year-old mother among them, were grateful for meaningful service and fellowship during this time. If any volunteer had any concerning symptoms, they were required to stay home. No volunteers tested positive for COVID-19 during that initial time period.

Over those four weeks that I didn’t work at the hospital, I followed medical center e-mails, group text and WhatsApp conversations, and health department data. As I prepared to go back to work, I reviewed personal protective equipment (PPE) protocols and evidence supporting them. A March 12 article from Taiwan reported that during their SARS experience (and South Korea’s MERS experience), hospital workers (HCW) contracted the virus, despite never having contact with an infected patient, via fomites, meaning by touching contaminated surfaces. They developed a system of patient triage, transportation, and isolation, as well as HCW PPE use and environmental cleaning and disinfection, to reduce both fomite and respiratory spread. In the 18 hospitals that implemented the protocol, no HCWs and two patients were infected, while 115 HCWs and 203 patients were infected in 33 control hospitals that did not implement the protocol. An April 4 article from Hong Kong described prolonged exposure to a patient on oxygen in an open ward with ten other patients before they were transferred for intubation for their subsequent COVID-19 diagnosis (the need for oxygen and eventually a ventilator indicates severity of illness). None of 120 patient or staff contacts with this patient developed COVID-19, which they attributed to hand and environmental hygiene and the wearing of surgical masks. An April 17 article from the CDC described 143 HCWs coming in contact with an undiagnosed COVID-19 patient in a Solano County, CA hospital in February, many for procedures believed to be high risk for viral transmission because they generate respiratory droplets or aerosols. Since there was low suspicion for COVID-19 infection at that time, HCWS may or may not have worn gloves or surgical masks. They definitely did not wear gowns, N95 respirators, or eye protection. Only three HCWs developed positive test results for COVID-19. A Swiss study from April 20 particularly commented on 21 HCWs, who did practice hand hygiene but did not wear face masks, coming into contact with a COVID-19 patient, some with prolonged exposure for patient care activity. None tested positive for COVID-19, while the patient’s closest family member did.

These studies demonstrate that supposedly high-risk exposures, some of which generated respiratory droplet and aerosols, with inadequate PPE, with patients symptomatic enough to be receiving medical care, did not result in a high level of disease transmission. My review of the medical literature found evidence for airborne or respiratory spread is largely theoretical and based on modeling. In fact, an April 20 article in Anaesthesia admits “the mechanisms and risk factors for [airborne] transmission are largely unconfirmed.” There is good evidence, however, for fomite spread of disease due to poor hand and respiratory hygiene, even and probably especially in hospitals and nursing homes. Analysis of COVID-19 transmission at two family gatherings in Chicago in February show evidence of touching common items, such as food serving utensils. Review of other so-called “superspreading” events support a similar hypothesis.

The focus on six-foot separation and the wearing of masks places the public’s, and the medical community’s, emphasis solely on airborne transmission of the virus, missing the opportunity to emphasize likely more important education on hand and respiratory hygiene. Masks may catch some respiratory droplets, but they likely decrease contamination of the environment resulting from touching one’s face. An April 9 article in The British Medical Journal conceded the “evidence base on the efficacy and acceptability of the different types of face mask in preventing respiratory infections during epidemics is sparse and contested,” but argued for the precautionary principle, “a strategy for approaching issues of potential harm when extensive scientific knowledge on the matter is lacking.” I submit the precautionary principle has overwhelmed our public health decisions in this crisis, while we’ve simultaneously ignored evidence that a lot of what we are doing is unnecessary, ineffective, or even harmful.

School closures were effective and protective with H1N1 because children were vulnerable to severe infection and death. A systemic review of the medical literature for COVID-19 demonstrates if children do become infected, which in itself is rare, they have a milder disease course than adults and deaths are extremely rare. Analysis of the Diamond Princess concluded isolation and quarantine prevented 2307 cases, but simply allowing the passengers to get off the ship on February 3 would have resulted in 76 versus 619 cases. The proportion of cases among passengers increased as cabin occupancy increased from two to four passengers. Stay-at-home orders send us home to live with others in close quarters, akin to quarantine on a cruise ship. The only way this is effective in decreasing spread of disease, if we haven’t learned to practice hand and respiratory hygiene, is if no one is infected at the beginning of the order and no one in the household interacts with the outside world. Knowing this is impossible, hand and respiratory hygiene again become imperative with every interaction outside the home, actually negating the need for stay-at-home orders. In a very thorough literature review of influenza transmission at mass gatherings, prolonged close contact (for example, over days, such as at a music festival) in dense settings seemed to demonstrate increased risk while transient contact (such as at a sporting event) did not, with some indication that being outdoors was beneficial. Restricting outdoor activity in any fashion during this crisis has made the least sense. Stay-at-home orders put individuals at risk of physical inactivity, weight gain, behavioral disorders, social isolation, and insufficient sunlight. Physical inactivity and insufficient sunlight can result in obesity and Vitamin D deficiency, which may play a role in the severity of COVID-19 infection. Because of my personal involvement with our church and food bank, I can attest to the actual not just theoretical concern for stay-at-home orders increasing domestic and sexual abuse, substance abuse, depression, and suicidal ideation.

There is no doubt the cost has been high, economically, socially, psychologically, and even medically. Since I’ve returned to work, patients’ conditions are more serious than usual for their underlying condition because they’ve stayed at home longer than they should have, fearing a trip to the hospital. My motivation in this entire synopsis is to free people from fear.

2 Timothy 1:7 says, “For God has not given us a spirit of fear, but of power and of love and of a sound mind.” You can be simultaneously rational, logical, and scientific, and not fearful. Based on my review of the evidence, the time course of this disease, and our reactions to it, I believe a number of things: 1) because of misinformation from China, this virus was circulating in this country long before we were aware of it; 2) the CDC was monitoring and employing strategies to educate and mitigate spread as soon as they were aware of it; 3) the national populace remained largely unconcerned until we saw evidence of community spread and death in our own nation in early March; 4) most of the subsequent personal and public health behavioral changes implemented, consistent with prior CDC pandemic mitigation guidelines and including the release of federal guidelines to “slow the spread” on March 16, were likely helpful and may have been sufficient; but 5) somewhere in that third week of March, we panicked and believed we needed to shut down the country. We can play the blame game from the benefit of hindsight all we want. People are unlikely to change their behavior if they don’t believe they are at risk. When the risk became real, our collective behavior changed. Analysis released by the CDC on April 17 demonstrates a decrease in population mobility as increasing community mitigation strategies were implemented. The 3-day percentage change in COVID-19 case counts were either going down or at their peak when stay-at-home orders were implemented in four U.S. cities, implying stay-at-home orders were late and traditional and more conservative measures were already working.

I confess I succumbed to fear on March 21. My fear was not of the virus, but of my fellow man. I did not believe, based on scientific evidence, that we needed a stay-at-home order in Hawaii. I was not excited about the restriction on travel to Hawaii, but once I knew that was inevitable, I doubted we would have much community spread of disease. Our confirmed cases by date of exposure peaked in Hawaii over a week before the travel quarantine started, on or about March 18, and most were travel-related, but in residents not visitors to Hawaii. Since February, throughout the state, we’ve had 70 cases requiring hospitalization and 16 deaths. In Maui, we’ve had 14 hospitalizations and 5 deaths. Unfortunately, our biggest evidence of community spread of disease in Maui has been in our hospital, with a cluster of positive tests in health care workers, none of whom had to be hospitalized. I attribute those positive results to two reasons: 1) health care workers were the only population tested even if asymptomatic so we found them as opposed to other asymptomatic disease carriers; and 2) distraction in emphasis on PPE and potential respiratory spread, missing the importance of fomite spread due to poor hand and respiratory hygiene. Failure to explain this well has made the public afraid of the hospital and victim to likely more serious health consequences.

My concern on March 21 was the travel quarantine and stay-at-home orders were unnecessary and would devastate our local economy. That fear has been realized. I don’t know when or if we will recover. I did not continue to defend that position locally, however, because discounting someone because of their political and religious beliefs is a powerful deterrent. I’m a Christian conservative who voted for President Trump and I realized that would be emphasized were I wrong. I was also afraid of attracting unnecessary attention to our church and compromising our ability to serve Maui through our food pantry. I am grateful I had four weeks where I did not have to mix my medical and church worlds.

I think for most of us who are not at risk of serious illness or death due to COVID-19, our biggest fear is unknowingly spreading it to someone who is. We’ve focused on social distancing and staying home and wearing masks, and we are quick to accuse the non-compliant. In the Christian world in this era, loving your neighbor means staying home. We carry the weight of the reputation of our church in specific and Christians in general should we be uncovered as any source of infection. I know Kirk, his assistant pastor, his elders, and all of us in leadership in our church have felt this weight.

In my role as an anesthesiologist, my everyday decisions can result in devastating consequences, including death, for my patients. Not every day or every case is dramatic, but many are. Someone else’s life is dependent on my training, my education, my knowledge of evidence, and the often in-the-moment courage of my convictions. This situation with COVID-19 was not unlike that. Kirk and I staked the reputation of our church and the health and lives of our church members on our understanding of the evidence regarding COVID-19. This was not a faith test in terms of “if you just believe, you won’t get sick” nor was it a demand for our rights to convene and worship. As soon as required by the county, we stopped official worship services. We stopped home group meetings. We stopped Bible studies. We stopped all gatherings unless they were related to serving the food pantry. We made it clear as soon as March 1 that there was no pressure to be involved at church in any way and if we could serve those at home through prayer, shopping, delivery of food, or any other service, we would. We educated our members on our understanding of their risk and many chose to be involved. We have enjoyed the freedom to fellowship and serve others as we believe Jesus has called us to. I long to bestow that freedom on others.

The virus COVID-19 is now a reality in our lives, like rhinovirus, influenza, or any other infectious pathogen we spread from human-to-human. Medical providers practice universal precautions for bloodborne illnesses like HIV, which means we assume everyone has one and we protect ourselves accordingly. Now we know COVID-19 is in our communities and we should act accordingly with universal precautions of hand and respiratory hygiene, not only to protect ourselves, but, more importantly, to protect others. I haven’t changed my mind on masks in the community. I’ll obviously still wear them when required and I do think there is Biblical support for wearing one if it comforts someone more fearful. In our community of servants, we have stayed home when sick, but otherwise, when patrons aren’t present, we haven’t worn masks or kept six feet away from those we know. We even hug each other with permission, and we hug pantry patrons when they ask for it. This has moved many to tears. We just wash our hands. A lot. There is hand sanitizer all over our church facility. We also clean all surfaces regularly. When I can, I’ll go to a restaurant, get on a plane, go to a theater, and do any number of things, rationally, without fear, continuing to employ the same precautions. We’ll also open the doors of our church to worship.

As we release restrictions, we are going to continue to be bombarded with increasing counts of positive test results. That will be predictable as we expand our testing to include the asymptomatic and it will largely be academic. We cannot solely allow positive results to be the enemy and gauge of our behavior. We need to track what I would call clinically significant disease resulting in hospitalization, ICU admission, ventilator support, and death in order to support any tightening of restrictions.

With COVID-19, we’ve pulled back the curtain on the reality of disease and death. The media and public have never been so obsessed with a particular diagnosis being cared for in our hospitals. Our obsession and our actions were the result of a lot of unknowns. We know more now. The great majority of those infected with COVID-19 are asymptomatic or have mild disease. Risk of hospitalization and death increases markedly over age 65 and in the presence of co-morbid conditions, such as obesity, hypertension, diabetes, and heart and lung disease. Social media allows us to focus on individual cases and anecdotal exceptions. While we have had over 900,000 deaths from all causes in the U.S. in the first 17 weeks months of the year in 2015-2020, we’ve focused on this cause. If we posted on social media every death from cancer, heart disease, influenza, and trauma, we might take up those causes as well, never leave our homes, or collapse under the psychological weight of it all. We see this phenomenon on our pediatric cardiac mission trips. New team members will understandably focus on and advocate for a particular patient, not taking into account the hundreds, even thousands, who have been screened and all the decision criteria determining which patients receive a particular intervention. Despite the fact that we make cost-effectiveness decisions in public health and medical care all the time, mentioning the economic cost of this crisis and how we’ve handled it inspires accusations of valuing money over human lives.

I long to explain this well. I value every human life. I mourn every lost life. I do not deny the loss of human life to this virus is horrific. My occupation gives me a front row seat on tragedy every single day. It helps me to realize every day is precious and not guaranteed. It makes me thankful for the health I do possess. It motivates me to travel the world to help children with heart disease who don’t have the same access to medical care that we do in the United States. I will do everything in my power to protect my patients and those I love. We have just gotten tunnel vision on COVID-19 at the expense of a lot of other concerns.

Life is inherently risky. As a medical community, we’ve traditionally allowed people to take whatever risks they want. Individuals can smoke, abuse alcohol and other drugs, be obese, forego exercise, drive a car, or participate in any number of risky behaviors, and we have pledged to take care of them. With COVID-19, we’ve allowed an unprecedented amount of time to acquire PPE, ventilators, and other supplies; develop clinical protocols; and begin researching treatment. We know how to protect ourselves. Our hospital systems are not overwhelmed. We are obligated to educate and protect the public, but we need to pledge to take care of COVID-19 on top of everything else we take care of. Ultimately, each individual person will decide whether to go out of their house, whether to wear a mask, and whether they are careful to wash their hands in case they’ve touched a contaminated surface.

We may do everything “right” and still contract or pass on this disease. We pray, we seek the Lord, we act responsibly, and, in this as in all things, entrust our souls to a faithful Creator in doing what is right (1 Peter 4:19). Our hope, after all, is not in this world, but in eternity because of our faith in the sufficient sacrifice of Jesus Christ on the cross for our sins. That is the message we need to be freed from fear to share.

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