The Path Forward

My wife has a good sense of direction. She loves to look at maps and help us figure out the best way to get places. When we travel, she usually navigates, and I drive. 

We were driving to stay at an inn. As we got close I began asking, “Is this the place? Is that the place? What drive do I turn into? Is it this drive? Is it the next one?” Because she is navigating for some reason I expect her to know exactly what everything will look like.

She answered (like she has many times in the past), “Honestly – I don’t know. Neither of us have ever been here before!”

I am now asking myself and being asked by others what I think during the current COVID 19 crisis. What is really going to happen?  How many are going to die? What is this going to look like in West Michigan? Is it really going to get bad here? I find myself saying the same thing, “Honestly – I don’t know. Neither of us have ever been here before!”

We are moving through stages. I know where we have been. I have a good idea of where we are now. But to be honest – I don’t know – nor does anyone really know exactly where we are going. We are relying on our navigators, but even they have never been here before:

• Stage 1: Denial – It was just going to be another one of those China things.
• Stage 2: Wishing – Well, maybe it will be contained and just be sort of a west coast thing.
• Stage 3: Unsettled – Crisis decision making, dramatic changes in life and schedules, constant meetings trying to figure out new things, odd quiet settling over the hospital and day by day things being taken away from my life.
• Stage 4: Preparing for battle – Taking on new challenges. Setting up an improvised home office. Doing my first days of “seeing” patients via video visits and telephone visits. Constant Microsoft Teams meetings. Zoom get togethers to counter the isolation. “Surge” or as I would think about them “doomsday” planning meetings. Hearing horror stories from New York and then Detroit. Bracing myself for the sudden impact of a COVID 19 surge. It was supposed to be here in a week or maybe two or was it three?
• Stage 4 (now): The “Turtle’s Back” – Someone used this analogy and I think it is interesting. Social distancing has worked in West Michigan. The curve has flattened and continues to flatten even more. The modeling still says that we will get a “surge” but now it is getting pushed further out. When it hits it is supposed to be of lower intensity and longer duration. It is no longer a big spike and then drop. Rather than a tidal wave, it may be more of a very large swell that goes over our heads and stays there. We will be treading water and may have to do so for longer than we like. But hopefully we are now strong enough and prepared enough to keep our heads above water until the swell goes away.

It is now like the shape of a turtle’s shell (viewed from the side). We will have an increase and then a sustained high level of cases and then eventually a decline. They are still predicting that it will exceed all standard healthcare capacity. Fortunately, we have had time to prepare and with the flattened curve it will be more manageable. This is wonderful news. And this is terrible news.

It is wonderful that we should be better able to manage it. But the flat curve keeps extending further and further out. This means that this whole thing is going to go on a lot longer than people understand. I am afraid to even write about how long this may go on. But trust me – it is longer than you want.

What does this all mean? 

Two weeks ago, I was in an electronic meeting. I looked at the updated projections for West Michigan. I saw my Michigan summer slipping away. I came downstairs from my home office and sat in the living room with Sarah and felt incredible anxiety inside. I started to doubt if our society really could – or would – sustain this degree of social distancing for as long as we need them to.

The word that came to my mind was “sustainability.” 

We have all been running a sprint. It looks like we need to shift to running a marathon. 

We did this at work. When this started, in the hospital and our medical practice, we rapidly were cancelling things – patient appointments, procedures, etc… Slash, slash, slash. We were putting things off for a few weeks – then maybe 6-8 weeks. That seemed right at the time. It isn’t anymore.

In our lives we were doing the same thing. We locked ourselves inside and hunkered down like we would have for a couple of snow days. Now that it has been a few weeks – that strategy is feeling bankrupt.

Sustainability.  

How can we sustain social distancing for the long hall?

As a society? As an economy? As a business? As a family? As a human being?

We need to start asking strategic and hard questions. 

There are a lot of people that want to jump to either stage 1 (denial) or stage 2 (wishing that this is just a Detroit thing) again.  

The fact that they haven’t seen the horror of COVID 19 themselves makes them want to go back to my stage 1 or my stage 2. They want to say that it isn’t as bad as we were told. There are plenty of posts about embracing “herd immunity.” Just get it over and done with. Can’t we just pass through this like we do with influenza every year?  Can’t we just take our lumps and be done? Aren’t we doing equally as much harm with the economic and social destruction of social distancing? 

It is only rational and normal to ask these questions. I see people getting angry and divided over this. We have to ask all these types of questions if we are going to figure our way through this.

I don’t think abandoning social distancing and embracing herd immunity is the right strategy. Let me explain why.

1. There is no denying that this is a bad virus and a bad disease.  We have read the stories. People get really sick.  Even those who do not get hospitalized can go through being scary kind of sick. A lot do get hospitalized. While not everyone gets that sick, a lot of people do. In healthcare we see a lot of different illnesses. This is different. It is not business as usual. It is real. It is scary.
2. There is no question that this can spread so quickly that it can exceed healthcare resources. We have heard about “Ro” and exponential growth. These are not just theoretical concepts. Italy, New York, and Detroit are just 3 strong validations of what can happen with rapid spread. We may not have seen it in West Michigan, but experts really think it is because we were 2 weeks ahead of Detroit in our social distancing. They got hit by a tidal wave with their back turned. We looked and locked down and didn’t get hit.

This disease is bad. It is not speculation. It is not hype. It has happened, with devastating consequences not once but in multiple locations. When healthcare resources are exceeded, then the case fatality rate starts to climb dramatically. 

Will it happen in West Michigan? I don’t know. I hope it doesn’t.

But, I for one expect to have medical care if I need it. 

I have thought about what I will do if I get COVID 19. I will try to tough it out at home. Sarah and I have talked about how we will distance from each other but closely monitor each other if one of us gets ill. And if I get ill – really ill – I expect that there will be a hospital bed, oxygen, someone to monitor me and someone to “prone me”. If I really need it – I expect that there would be a ventilator for me. I would consider it unacceptable if the numbers are so great that I will just be left to fend for myself.

That is why we have done all of this. 

We have done it so that we don’t have to have an eye doctor or an inexperienced medical student trying to run my ventilator. We have done it so we won’t get put on a makeshift cot in the hospital cafeteria or in a convention center hoping for the best. We have done it so that there is a state of the art ventilator available for me if or when I need it. 

But what we are doing right now is not the answer either.  

We need to shift and figure out how to make this sustainable. What things can we do to protect those who do need to work? Frankly I am bothered about the safety of the workers who have to stock the shelves for me. I am bothered by the people who cannot work electronically from home who now have no income. I am bothered by the growing wave of unrest as people struggle to adhere to strict stay at home rules. What can we do to allow more people to work? What parts of our society can we get moving again? Can we learn – and change – and do things smarter – better – safer?  Can we do them for the long haul? How can we survive all of this?

We need to have asked the question: “How can we maximally socially distance and do it in a way that we can sustain it for 4 months or longer?” 

There are two competing messages at the moment. One message is that we must keep it all up and do it even more tightly. Our governor surprised a lot of people when she tightened rather than loosened the restrictions in the state of Michigan. She is hearing the reports from Detroit. She is hearing the cries of healthcare institutions and workers begging for relief. She is hearing of violations of social distancing and experts begging for her to fix it. 

But there is another very valid message.  Let me lay that one out below:

1. Thank you! So many of you have done an amazing job. I have seen the empty roads. I have seen the empty stores and people standing 6 feet apart. I have seen people volunteering to make masks and asking what they can donate. I have seen churches close their doors and remake themselves in new and creative ways that they never dreamed of. I have seen grandparents wave out the window with arms that ache to hold their little grandbabies but staying apart anyhow. I have seen high school seniors give up those most important final few months of their high school life.  Thank you!
2. You have made a huge difference! Our case rates for COVID 19 have remarkably flattened and remained low. Your behavior has changed what was thought to be inevitable. 
3. I am sorry for your losses. The trauma of this has been more than just illness and deaths. The lost jobs and lost income and economic losses are not just about comfort. These are real and meaningful and painful. I know it. I am sorry.
4. Six months is different than six weeks. We need a long-term strategy. We cannot just shut down the world and do nothing. We cannot expect everyone to just stay locked in their homes. We need businesses to manufacture and people to work. We need to think about how to create a “new normal” where we can prevent the spread, keep the curve flat and yet not destroy our society.

There are very strong opinions about the protest in Lansing this week. I am not here to defend or criticize that. I am only here to say that what drove that protest is a cry for help. It is a cry for answers about how we can go forward if COVID 19 is truly going to be a problem for many months. It was anger that we did not hear about the 4 points described above.

What is the path forward?

What is really going to happen?

Honestly – I don’t know. Neither of us have ever been here before. 

But we are going to need to do the best we can to figure this out. We need open dialogue and smart people to re-engineer society. We cannot just judge or yell at each other. We are on the same team and fighting the same enemy. From what I can see now, this is:

• Real. There are people getting really sick and places where healthcare resources are overwhelmed.
• Not going to be over as quickly as you or I would like.

We have some more work to do.  

Yesterday 6 Midwest states (Michigan, Wisconsin, Indiana, Kentucky, Minnesota, and Ohio) announced their plans to work together to figure out how to safely reopen parts of our society. I have seen incredible ingenuity, energy and creativity over the past several weeks. Things that were in the past not possible have become possible. The people in our health system have been amazing. Many of you have been amazing. Can we as a society figure this all out together – responsibly – practically? 

I know we can. We must. We will.