Three Doctors Put Forth Provocative Facts, Opinions & Questions on Coronavirus
The following is a piece written by Sheryl Wulkan, M.D., John Stiller, M.D., who you probably don't know…and Margaret Goodman, M.D., who you may well, because she runs the Voluntary Anti-Doping Association (VADA).
Here is some informed material on coronavirus, compliments of: Wulkan, who is an internist, and does work with the NY State Athletic Commission; Stiller, a Washington, DC area neurologist; and Goodman, a boxing lifer who heads up the nation's most highly regarded agency for PED testing, after a solid stint with the Nevada athletic commission. Much of the focus of this content has to do with MMA, specifically UFC.
Dana White adheres to the President Trump line of thinking, that getting back to business is job one. His UFC 249 had a tough time finding a home, but eventually, after going “state shopping,” the UFC crew found kindred spirits in Florida. UFC 249 unfolded in Fla. Saturday, but caused ripples of worry when a fighter and two of his crew showed up, got tested, and tested positive for the virus.
Bottom line: it will be up to media, and to physicians who are truly embracing of the “first, do no harm” adage to call out situations where perhaps protocol could be handled more dexterously.
Emotional decision making cannot be the driving force behind health care policy. Decisions guiding the future of the nation/world must be data driven and should include a coordinated effort of specialists with diverse expertise, including, but not limited to research scientists, physicians, molecular biologists, epidemiologists, social and behavioral psychologists and business professionals.
There is no place or time for political rhetoric, no place for spin, no place for “overly positive talk”‘ like the kind adults use with children when difficult discussions must take place. There is no time for blame. At least not now. It takes too much energy and distracts from the realities of what must be accomplished, what we might face in the future if we as a nation, don't get our collective heads out of the sand and start dealing – dealing with facts, dealing with the harsh realities of what is, so that we can mitigate worse case future scenarios.
We will make mistakes. Some might be costly, both in terms of lives, and the U.S. and world economy. But we can only navigate a reasonable course with effective, well-coordinated and well implemented emergency action plans that rely on expert advice and use innovative ways to troubleshoot various problems that arise (e.g., supply chain dilemmas).
We need to learn from, but also let go of the pursuit of missed opportunities, stick to a rationale timeline, and implement objective assessment tools to navigate future decision-making processes. In other words, we can't do the same old thing, hoping we'll dodge the proverbial bullet: we can't move forward living in the past.
Facts about the Coronavirus – The minimum information ringside physicians should know and should share with their Commissions
1.The Coronavirus is so named because the spikes on its surface look like a crown. There are many different types of Coronaviruses, one of which causes the common cold. What does COVID 19 mean? COV stands for Coronavirus, ID for infectious disease, and 19, the year the virus was identified.
2. The Coronavirus is a zoonotic virus- that means that its natural host is an animal. Sometimes viruses mutate or change in ways that allow the virus to infect a new host, such as humans, if /when the appropriate opportunity arises. People have no immune response to a novel virus, since by definition, the human immune system has never before been exposed to this organism.
3. All viruses need a host for replication – that's why social distancing is so important until we can develop a medication to treat the infection or develop a vaccine. What makes this virus so different? It is easily spread, it is infectious 2-3 or more days before infected persons demonstrate symptoms, and the majority of people don't die, so it doesn't “burn itself out”. Remember, the virus cannot live outside a host.
4. If the majority don't die, what's the big deal? We don't yet fully understand the mechanism by which damage is done to those infected, or whether long-term problems can result as a consequence of this disease. It was originally believed that younger individuals didn't become as sick as older individuals, but the majority of hospitalized patients are in the young adult category, and we are now seeing adults (20-40s) who test positive for antibodies but who do not recall being ill, developing strokes. Children, who were once thought to be immured from this disease are now being hospitalized with rare inflammatory conditions.
5. The virus has to get inside a host cell to replicate. For each virus that enters a cell, many new virus particles are released into the host.
6. Scientists are looking at many different sites in the virus replication cycle for ways to stop infectivity or to prevent replication.
7. Researchers need to make sure medications developed to treat the infection are not only effective, but are unlikely to cause viral mutation with resultant resistance to the treatment. Time is required to develop medications that can ideally interrupt more than one site in the replication cycle, or to develop multiple medications that interrupt the virus' life cycle at different points.
8. A vaccine takes time to develop, but also requires rigorous testing to make sure it is safe. It would be unethical to inoculate otherwise healthy individuals with a vaccine whose side effects were equal to, or worse than the disease.
9. Genome tracing (genetic viral tracing) has become a reality. The German government has graciously shared its site GISAID, and information can be uploaded by researchers to nextstrain.org. in order to determine/track which viral strains are present in different areas of the world.
10. Epidemiologic models will not be perfect, because we are dealing with the unknown. Epidemiologists use as baseline, knowledge gained from the study of other infectious diseases (1918 flu pandemic, equine influenza North American outbreak 1800s, SARS COV-1, MERS, Ebola). Now that the natural history of the virus is better understood, we can estimate how many people are likely to be infected by a single carrier, and models can be built to determine whether interventions undertaken to contain infectivity are working (harbor in place, masks, social distancing).
11. A minimum of 70-80% of the population needs to be immune for herd immunity to occur. The current estimate is that 10-15% of the US population has thus far contracted the virus.
12. The purpose of “flattening the curve” is to prevent the overwhelming of public health care/medical resources, and to mitigate worse case scenarios. Those who are being hospitalized with the infection have longer hospital stays than required for most other illnesses, and many require round the clock intensive care. Flattening the curve does not mean we are over the worst of the pandemic. It just means we are moving into the next phase. And the next phase needs to be handled with careful consideration.
13. We are beginning to realize that the virus attacks multiple organ systems, not just the lungs. The virus often presents differently in different age groups and in people with multiple medical problems.
Individuals may compensate well for several days, and then take a rapid turn for the worse, sometime between days 5-9. Patients who become severely ill usually have underlying conditions, such as high blood pressure, diabetes, obesity, cardiovascular disease, or are immunocompromised. Until proven otherwise, athletes with any of the above conditions should be considered higher risk.
14. Hospitals in some regions of the country have been overwhelmed or nearly overwhelmed by the pandemic. There is useful information available from areas that have already been severely affected by COVID-19 and this should be used by ringside physicians when deciding when combat sports events are safe to resume in their localities. For example, if your state or tribal jurisdiction is witnessing a rise or leveling off, but not a drop in hospitalized cases, one should consider whether it is safe to send injured athletes to the local Emergency department, and whether it is reasonable to further burden an overly taxed system for the sake of sport (by using resources such asprotective equipment, as an example.)
Scientists, physicians, those in the creative arts and with entrepreneurial mentalities are more likely to deal comfortably with unknowns, as they are accustomed to stepping into areas not previously explored. That's why the UFC took the risk it did. We all want to get back to some type of normalcy. It was up to Florida's experts to determine the real relative risk of the production.
Perhaps it is unfair to ask the majority of people in our nation, people who have been raised in a culture of self-centricity as opposed to the “collective good”, and who have unwittingly been conditioned through confirmation bias and repetitive endorphin release from chose conventional news media sources and internet services that reinforce individual ideation, to be prepared to deal with the sacrifices required of this challenge, just as it is unfair to expect young adults to have all the coping skills needed to act independently if they've grown up with helicopter parenting. How do we get beyond the confusion?
By obtaining solid information from those who have supported transparency, those who have supplied facts that objectively relay the pros, cons and caveats to the best of our current understanding. This is where the Florida Commission might have taken pause to consider whether they had enough supporting evidence to allow the event to occur. Dana White and the UFC followed the safety guidelines established by the Commission. It was Governor DeSantis' responsibility and the responsibility of the Athletic Commission to say it's just not the right time.
Federal guidelines recommend a two-week downward trend in new Coronavirus cases prior to reopening the state. Florida's Coronavirus cases have reached a steady state. So, while the athletes and their camps were tested, it is unclear why the Commission did not include in its action plan a statement that required competitors to arrive 14 days prior to the event, or that limited the extent to which athletes and their camps were exposed to friends, family and outside training partners within the same time period.
The Commission will argue that testing was successful, citing the removal of Mr. Ronaldo Souza from the card once he and his camp tested positive. But Souza and his camp underwent two prior tests that were negative.
Were the first two tests performed accurately or was the viral load as yet undetectable?
Were the athletes, television crew, other ancillary personnel and Commission staff aware that positive tests are meaningful, but negative tests mean little?
Did negative results cause a false sense of security among staff and athletes causing a more lax attitude toward PPE guidelines?
Did the Commission contact trace with whom the competitors came in contact in the hotel or during their travels to and from the state/venue?
Could social distancing have been more strictly enforced during the weigh in?
Could inspectors have respectfully reminded cornermen that some of them were using protective equipment less than effectively?
What was done to mitigate risk when sending injured athletes to an emergency room likely dealing with COV SARS-2patients?
And perhaps most importantly, what contact tracing, if any, will be done by the Commission after the event to determine whether their procedures endorsed adequate protection?
What if any, was the responsibility of the Commission to other hotel guests when a participant or ancillary staff tested positive?
If athletes must sign, as part of their contract, a waiver regarding Non-disclosure of concerns surrounding COVID 19 safety protocols, it will be difficult to gather data necessary for epidemiologists, ringside physicians, lawmakers and Commissions to improve their event planning for all contact sports and make them safer in the future.
New York Governor Cuomo has been an excellent leadership role model in this time of crisis. He has gathered information from experts in multiple fields, and, whether you agree or disagree with him, has made decisions based on facts, not emotions. He has been fluid in his thinking. He has coordinated efforts with neighboring states, and shared resources, data and intellectual capabilities for the betterment of the collective.
Members of the ABC and ARP should perhaps have done the same: developed and implemented a national, coordinated plan, based on facts, adaptable to emerging data, and free from political, economic or personal agenda.
DISCLAIMER: The opinions/statements in this article reflect those of the authors and are in no way representative of the official positions of the organizations/regulatory bodies with which we are affiliated.
EDITOR NOTE: Wulkan is a NYSAC ring physician, a sports medicine expert, former Association of Boxing Commissions committee chair who was instrumental in establishing ringside MMA protocols. Stiller is a long-standing chief Maryland ring physician and former Association of Ringside Physicians board member. Goodman is the current president of CADA and former chief ringside physician for the Nevada State Athletic Commission.