CDC | UnsplashCOVID-19: Facing Facts, Working to Prepare, Trusting in God March 4, 2020 Features Dr. Lisa Gilbert, MD, FAAFP, CTropMed, has been closely monitoring research on the COVID-19 coronavirus since very early in the outbreak. She is a board-certified family medicine physician with additional training and certification in tropical medicine and infectious diseases, and has volunteered in several African countries — including in Liberia during the Ebola crisis. She serves day-to-day as a core faculty member at Ascension Via Christi Family Medicine Residency in Wichita, Kansas, and has won awards for international outreach and service to the community. What brought her to TLC’s attention is how she has also added theological acumen and Christian reflection to her medical career. A member of the Ukrainian Catholic Church, she studied for a year mid-career at Augustine College in Ottawa and is currently pursuing a master’s in Catholic Clinical Ethics through Georgetown University and Catholic University of America. She was interviewed March 2 by Abigail Woolley Cutter. The interview has been lightly edited. AWC: Dr. Gilbert, it was not until Feb. 25 that the CDC issued a warning that Americans need to prepare for the novel coronavirus and a serious disruption to our lives. You, however, have been saying this for many weeks longer. What caused you to take the situation seriously so early? Lisa Gilbert LG: My international experience has framed how I’ve seen this outbreak. Apart from direct work with the Ebola outbreak, I participated in some epidemiological work in Liberia in the wake of Ebola, where vaccine rates plummeted — because obviously nobody wants to take their child to a doctor for their routine vaccinations because they don’t want to be around the healthcare system. It’s reasonable. The problem is [this population] is always bordering on the lower levels of herd immunity, so we started to see measles, and there was a pertussis [whooping cough] outbreak — which is really serious for infants. So, we were trying to identify that, respond with vaccinations, and figure out how to get antibiotics to areas that were really remote. Throughout this experience, it became clear that, while the news is not useless, it doesn’t report what you — particularly healthcare workers — need to know in a real-time fashion. I started following public health workers, virologists, and epidemiologists on Twitter. Following the actual public health workers on the ground in these particular countries really allowed me to have a different perspective on what’s happening in the world as it relates to infectious diseases, to know how to interpret data that’s coming out of various places. Because of all that, and also because infectious disease is a particular passion of mine, I definitely tuned into this situation a lot earlier than anyone else I knew. It’s also because, when we hear “coronavirus” in the healthcare world — particularly those of us who are trained in tropical disease or infectious disease — we pay attention, because we know that coronavirus or influenza are the pandemics that are likely going to circulate worldwide and have the greatest impact. As I see it, Ebola was a bit of an outlier in terms of what we were expecting. It can still happen that a disease like Ebola spreads rapidly and it certainly has a high fatality rate, but overall, it’s not as high as a risk in general. See, we in the West are not very likely to spread Ebola, since culturally, we are not as likely to spread bodily fluids — we have different plumbing systems, we don’t prepare the bodies of our own who have died, etc. AWC: So that’s why a coronavirus is more likely than Ebola to spread globally. LG: Yes, coronaviruses and influenza: because it’s respiratory. And none of us are good at keeping our respiratory germs to ourselves. Think of common colds, many of which are caused by coronaviruses. It’s almost unstoppable. But then we had SARS and MERS, which are also coronaviruses. They really startled the world, because they had a particularly high mortality rate, especially for a respiratory virus — roughly 10%. That’s very severe, with lots of patients needing hospitalization and intubation. It did spread, and it infected a lot of healthcare workers, who were the ones who were intubating people or putting them on nebulizers. About 11 million people in the United States would need ventilators, but we have about 200,000 ventilators. But what makes COVID-19 different from SARS or MERS is that it has much more mild symptoms in the first week — and just in general, for most people, it is mild. That sounds like a great thing. And it is, except that you continue to go to work and do whatever you do. And maybe you even feel miserable, but it doesn’t knock you out, so a lot of people go on with their daily business. And it seems that, from case reports, people who are asymptomatic or have incredibly mild symptoms are able to spread it, just like anyone else. They certainly have the same viral load. For instance, there were reports of a nine-year-old who was asymptomatic or had almost no symptoms, but he spread it to his entire family, and a number of them died. You just can’t contain a disease with mild symptoms that mimics a common cold and is so easily spread. So even from the beginning, I was thinking, ‘I don’t understand why the WHO [World Health Organization] keeps saying this is containable, because it’s not.’ It’s no more containable than influenza is every year, or the common cold, especially with the majority experiencing only mild symptoms. AWC: You’ve spoken elsewhere about the challenges that medical professionals are going to face. What kinds of demands are you expecting to see? What can we do? LG: It seems likely that 40% to 70% of the world is going to be infected with this, according to Harvard epidemiologist Dr. Mark Lipsitch. And I think that’s a very reasonable prediction without a vaccine. And we know from current data that about 20% are going to be severe or critical, according to WHO classification. This means that they will need hospital care in order to do well, perhaps in order to survive. To date, about a third of those who are severe and half of those who are critical go on to die. So presumably, without interventions, we would see a much higher death rate, in the portions that are severe or critical, since they’re not likely to survive outside of hospital care. Now, when I do the math, it’s going to be 26 to 45 million people [in the U.S.] who are going to need hospitalization. Normally we admit about 34 million [annually], so we may more than double our yearly hospitalization rate. And I suspect that a lot of these new infections will occur over a much shorter time than the course of a year. And the reason I suspect this is that this is about twice as contagious as influenza, so I expect we will see more cases blossom over a shorter period of time than the influenza season. If you do the calculations, about 11 million people would need ventilators, but we have about 200,000 ventilators by last estimates (maybe 300,000 by now). Regardless, we simply don’t have capacity for that, even if people only need a ventilator for a few weeks. I think we are headed toward some very “uncharted territory” — I think the WHO today [March 2] used that exact phrase. We are going to have some very difficult challenges ahead in the healthcare world because it’s simply a fact — we don’t have that number of beds; we don’t have that much oxygen… So, this is not to be alarmist, but because there is a very important reason that people need to practice measures to reduce spread, things like handwashing, social distancing, improved cleaning. We have to slow this down. We in the healthcare world can manage if we can slow it down, but if it all hits at once, because people are spreading it around, continuing to travel, shaking hands, etc., we simply don’t have the resources for that. What else can we do now? I do anticipate that we are heading toward a time in which a lot of our elders are going to pass away from this — even with these preventative interventions. And I think that having conversations now is important. I was talking to a colleague pediatrician, and she has already sat down with her grandparents to make sure their documents are in order. They live in a nursing home, and at some point, this will probably come through nursing homes. And as cruise ships have shown, even if everyone stays to their rooms, this will spread around. She said they are ready, both mentally and spiritually, for whatever comes. AWC: How have your medical and theological work come together, and how are they informing each other in this particular situation? LG: First and foremost, as a healthcare worker, I see myself as someone who is striving to be like Christ, who is the Great Physician. In the sense that that was one of his ministries, I relate to this ministry, the desire to see healing and restoration for people — as do many Christian healthcare workers. In this situation, what I hope to do is not to cause panic or fear, but to warn and prepare people. I think we are not being told enough about how serious this is and how this is going to affect our families and our lives. Whether we like it or not — whether we believe it or not — it is coming, and it is going to affect us. And it is out of charity for people: if they know what’s coming, even if it’s not good news, it allows people to prepare in their own way. You know, this is not a stage of grief, but there are some similarities in accepting any bad news: I think most people are in denial, some people are angry, some are bargaining… Whatever stage, I think it is helpful to begin recognizing that there is something big in the next three to six months that will have impacts on each and every one of us, unless there is some unexpected miracle. AWC: What do you hope for the Church in this time? LG: We certainly have a theology of suffering — of redemptive suffering — and an understanding that this life is not all there is. And yet at the same time, we have a theology that calls us to reach out, and to do everything we can to support others who are in need, and to warn others about danger. So we have both of these in tension: we are willing to lay down our lives, knowing that they’re not our own, and yet at the same time, to stand up and try to protect others. My biggest message is to encourage people to measure their response more in terms of the common good rather than merely whether the virus will be serious for them personally. You could think, “Well, I’m probably going to have mild symptoms, so I’m not going to worry.” I’d rather have people say, “How can I support the common good — of our church, of our community?” For instance, it’s the reason we vaccinate — to serve the common good. And in the Catholic Church, that’s why vaccination is promoted — your own child probably would do fine without a vaccine, but for the sake of the community, for the vulnerable people, we reduce the burden of disease in the community and protect those who need it most. I have also seen a lot of ageism and a lot of ableism, unintentionally, as people are trying to reassure themselves about COVID-19. Everyone, I think, knows that the [case fatality rate] so far seems to be about 2% — which is about 10 times higher than influenza — and the majority of those who die are older people. I continue to see in the news and other places, “Thankfully, most people — 80% of people — have mild or moderate symptoms, so there’s really nothing to worry about.” And I’m thinking to myself, “How does that sound to people who know they would be the other 20% if they got sick, since they know they have medical problems or are older?” And some of these problems are not serious problems — the ones the Chinese are reporting are things like high blood pressure, diabetes, heart disease, lung disease. Even if you don’t have these conditions, you certainly know someone who does. These are your normal chronic conditions that a lot of people live with. So, on a personal level, the reason I don’t want to get sick is not because I think I would die, I think I’d do fine. But it is for the sake of the common good. I want to be able to show up at the hospital when this really hits and we have a lot of patients there. I don’t want to unknowingly transmit it to one of my vulnerable patients, or to somebody at church or the store. That’s really the message I would like to see the Church embrace — understanding that we do all of these protective measures — social distancing, etc. — for the sake of the vulnerable. And it’s an act of charity, of love, for “the least of these.” AWC: “Social distancing,” as you mention, is one of the best preventions of contagion. But it sounds so contrary to our practices and who we are as the church — whether it’s being there for each other in person, or participating physically in worship. LG: Yes. For those of us who are sacramental, there’s such an importance to that incarnational sacramentality, that physicalness, whether that’s receiving communion, dipping your fingers in holy water, kissing an icon, shaking hands or hugging, singing, simply being with other people. We can recognize that those things are very, very good, but at the same time, they’re not God himself. We will continue to worship through this season, but maybe in different ways than we have before. And hopefully it’s only temporary. It’s not like this is going to become the state of the church — as if we are always going to be distant from each other and not touching each other. We’re still going to mourn with those who mourn and weep with those who weep. And then later, we will resume those ways of worship that are good for our souls and bodies. So social distancing, as contrary as it seems, would still be my recommendation in that regard. AWC: What spiritual resources are you drawing on, or do you think that the rest of us ought to be drawing on, given that — even if we’re not in hospitals — this seems likely to be pretty disruptive? LG: We can obviously turn to the Psalms and some of the old hymns of the Church. The stories of the heroic Christians who lived before us. Ultimately, we must remember where our hope is — it is found in Christ. While there are a lot of challenges for many people here in America, particularly those who are vulnerable, a lot of us don’t experience immense challenges on a daily basis. We’re going to have to draw deep again from the Church and from her wisdom. For example, John Paul II wrote On the Christian Meaning of Human Suffering, which I think speaks beautifully to this. Others, like Stanley Hauerwas and Timothy Keller, have written on the same theme. I think we’re all going to need to wrap our minds around these questions again, but in a new way. Where is my true hope found, and the hope of my loved ones? How can I remember that we are called to resurrection and life eternal? This is where our hope is found, and no matter what happens here, that is the hope of the Christian: the resurrection of the dead and the life of the world to come. And when things are hard, we can draw on the Psalms. If we are alone in quarantine, we are always with Christ. When I was in quarantine for 21 days after I returned from Liberia, I remember this strange sense of understanding (just a little bit) the solitude of Christ. It is in this sacred solitude, especially fitting during this season of Lent, that we can encounter him. Also, we can respond by focusing on those who are vulnerable. A lot of us are probably going to do just fine, but there are a lot of people who aren’t. And how can we support them, and how can we advocate for them ahead of time? How can we love them? AWC: What are ways we can serve people if they are quarantined or if we are avoiding going out to limit spread? LG: Go back to the casserole! Bring them food. Maybe send little notes or letters. The church can make care packages in advance with scripture verses and words of encouragement. It’s the same things you would normally do for people who are sick, it’s just that you can’t be there with them. You can still give it to them, drop it off on the porch, share a smile at the door. And thankfully, for all its minuses, we do have social media; we have ways of connecting with people more than before. We want to make sure people don’t feel isolated and alone. AWC: Should we be running FaceTime tutorials now for folks who don’t already use video chat technology? LG: Yes, good idea! If you have grandparents who don’t use FaceTime, maybe teach them! Because there’s not going to be enough protective equipment for visitors to come to their home, hospital room, or nursing home. You may not be able to visit them, so show them how to use these things. AWC: Many of us are accustomed to living in a world in which disasters are staved off by governments or some other authority. What attitude should Christians assume if it seems that no one is in control? LG: Well, obviously God is in control, and he knew this was going to happen. People have different theologies about plagues, where they come from, and whether we are in the “end times.” I won’t speculate on that. I don’t know God’s plan and his purposes, but I do know that he has allowed this and foreknew this. And he loves us. But I do think that Americans are often accustomed to having terrible things happen elsewhere, and it may lead us to question our faith in God’s providence. Now, while I think we are not being given enough information to prepare for the sake of the healthcare system, I want to give credit where some credit may be due. In addition to the healthcare impact, which is what I’ve studied, there’s also economics and general functioning of society. While I don’t fully understand it, I do know that panic causes crazy things to happen on the stock market, and ultimately there is a downstream effect on vulnerable people. While I suspect the economy is being prioritized far and away above the healthcare system, there may be a sense of wanting to reduce panic for legitimate reasons: looting and anarchy are not helpful. And there is value in economic stability. AWC: You’re suggesting that the goal of economic stability may be one reason we’re hearing very gentle messaging from officials. Why else might be people be hesitant to face the full extent of what could be in store? LG: Yes, I still hear even physicians downplaying it. They don’t understand the numbers and also have been told that this is just another influenza season, which it’s not. This is at least 10-fold worse. Also, there’s this problem of “the boy that cried wolf.” We’ve been in a state of “the sky is falling” for years now in the media, no matter which political side you’re on. It’s almost like people’s emergency receptors are saturated. We can’t fathom that a real wolf will come to the village. So even among healthcare workers, there’s a tendency to want this to be another influenza, but the numbers just don’t show that. But I think we have to remember that God is good, he loves us and he is faithful. We can cast all our cares and worries on him, because he cares for us. No matter what the future holds, whether this disease ends up causing a lot of destruction, or somehow a cure or vaccine are found quickly — as Christians, our hope and trust is in him. Abigail Woolley Cutter is a frequent contributor to Covenant, TLC’s weblog. She lives in Dallas, Texas, where she is pursuing a PhD in Christian ethics at Southern Methodist University. She attends St. Christopher’s Episcopal Church.