Why does COVID19 mean we need a “new normal?”

Change is hard.

The commonest end point of a significant pivot in the way we do things is for us to return to our original behaviour over time.

Look at every new year’s resolution, every idea you bring back from a conference, even the range of medications you prescribe.

We don’t like change.

We lose focus on change that must happen over time, we don’t review and embed change.

We need others to help us, and we often rely on people who don’t really understand what needs to happen.

We lack commitment ourselves to see change through, we fail to inspire others to commit to change.

We lose energy and find it hard to maintain the effort required to embed change.

So why is the change caused by COVID19 going to be different?

SARS-Cov2 is not a short-lived phenomenon.

It emerged only in December 2019, NZ’s first case was in February, just 2 months ago. The graphs usually show an exaggerated bell curve, with a rapid fall in cases after a peak.

The rhetoric describes this as a fight. Wars are fought, battles are won and lost but eventually we will defeat this. We will “get through.”

The reality is that the only infectious disease that the world has managed to eradicate is smallpox.

Discussed from 1945, completed in 1979 this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and quarantine.

It is unlikely this illness will “burn itself out” as appears to have happened to SARS-Cov-1, this virus is much more infectious, and unlike SARS-Cov-1 does not appear to be limited in who it can affect.

“Herd immunity” (if achievable) is not a cure, it is an acceptance of prevalence.

Societal attitudes have changed.

Doctor’s waiting rooms have long been seen as a source of infection.

I am certain that every GP has had a patient in the past express that they don’t like sitting in the waiting room because it’s full of sick people.

This was usually dismissed with a shrug of the shoulders, a smile, a “What can you do, eh?”

Some of us would have apologised for keeping the patient waiting, assuming that was the underlying reason for stating of the blinking obvious.

There was an acceptance that risk was low enough, that consequences were minor, hidden or infrequent enough for us to dismiss.

We are now facing a “Semmelweis Moment.”

In 1847 Semmelweis recognised that handwashing reduced maternal mortality [1]. We have recognised that separating out infectious from non-infectious patients reduces transmission of COVID19 disease.

This isn’t new science.

What is new is our understanding of the need to change and we now need to act.

Semmelweis found it hard to ensure that cleaning hands between patients became the new normal, perhaps because change was imposed rather than developed through collaboration and engaging the hearts and minds of colleagues.

We are less likely to repeat that mistake because the general public will not let us.

More people across the world are contemplating routinely wearing face coverings, people are interested in the difference between aerosols and droplets, and the distance and speed at which viruses spread after a cough or a sneeze, they are asking questions about the length of time infectious particles can survive on plastic, metal, wood and paper.

It is never going to be acceptable again to sit in a place where lots of sick people have gathered and not to be provided with assurance that everything is being done to reduce transmission of disease between people.

It is unlikely there will ever be a cure.

History tells us that viruses and bacteria develop resistance to any “cure” we have created in the past, SARS-Cov2 is not going to be any different.

There may be medications that mitigate the impact of the disease, remdesivir and antiretroviral agents may interfere with viral replication, hydroxychloroquine and chloroquine may reduce the ability of the virus to enter cells, “convalescent plasma” containing antibodies generated by a person who has survived the disease may “boost” the immune system.

There is no doubt that we will develop better ways of intervening that will improve outcomes for people needing hospital care.

But it is very unlikely that we are going to be able to “cure” people of this illness with medication.

It is unknown if we develop or can induce long lasting immunity.

We hope that when we reach “herd immunity” either through a vaccine or natural immunity of 80% of the population, we will have reduced the risks to an acceptable level.

The fact is that immunity, whether vaccine induced or naturally gained is an unknown quantity.

If this coronavirus is like the others that cause 2o% of common colds, immunity may last 2-4 weeks, if it has similar properties to SARS-Cov-1 immunity it may last 2-3 years.

We don’t think the virus mutates as frequently as the influenza virus.

We don’t know if a safe vaccine will be found, or how long-lasting a vaccine will be.

What is clear is that vaccine development is not going to be quick.

The public response

Each year in New Zealand we accept that around 10 people will die from HIV, 20 people die from TB, we may not like it, but we accept that 2-3% of deaths in this country are due to lower respiratory tract infections.

COVID19 will become another blip in the numbers eventually, and its impact on healthcare will become part of the way we do things ‘round here.

People at high risk of other viral illnesses with no cure and no immunity, like Herpes and HIV, have changed behaviour to reduce the risk of catching and transmitting the virus.

This illness is going to gradually settle in the mind of the public into one of the risks that we take when we interact with others, but its global impact is not going to quickly go away in the mind of the public.

Although we rationalise the numbers of people who die each day from poverty, malaria, road traffic accidents, and medical errors the personal impact of seeing mass graves being dug in New York, the dying in hospital corridors in Italy, bodies in the street in Turkey that feels like this will stick.

The case load of SARs-Cov2 is following the same pattern of other respiratory infectious diseases.

We have seen a surge of known cases settle into a background incidence as a result of public health measures. It seems likely that this level of disease will flare and settle over time, both in the public consciousness and in the pressure, it causes on the health system.

How well we cope as a system will depend on the ability, we must keep that case load within the limits of the what the health system can cope with.

We may drift back to an acceptance of the risk when gathering to watch sports, concerts and theatre, to party and carnival, but the acceptance of risk is not going to extend to health care services.

Nor should it.

Dr Jo Scott-Jones FRNZCGP MMSc DipClinED DipSports DipObs DipGerMed

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Why does COVID19 mean we need a “new normal?”

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