ST. JOSEPH — In March 2020, there were only enough masks for the nurses at Spectrum Health Lakeland.
Dr. Lowell Hamel, Lakeland’s chief operating officer, had been visiting rooms and preparing for a new disease that at that point was thought to be spread by droplets, not by airborne transmission.
Weeks later, he was on a ventilator, fighting against the virus he had been working to protect patients from. The experience isn’t far away.
“I regularly take treats to the intensive care unit on Saturday. Walking down the hall and hearing the ventilator alarm go off, in an instant it took me back to a feeling of resignation,” Hamel said. “I wouldn’t say hopelessness, but really powerlessness: there isn’t anything I can do.”
Roughly two years after the onset of the COVID-19 pandemic and Hamel’s bout with the virus, health officials are beginning to say the coronavirus is shifting to an endemic disease.
What marks the boundary between pandemic and endemic – between powerlessness and control – has a lot to do with knowledge and experience.
“There’s physical testing, there’s treatment options and we know how to control it,” said Dr. Rex Cabaltica, the Berrien County Health Department medical director, of an endemic disease.
Effective vaccines and therapeutics, which can mitigate the worst of the disease, are now readily available.
Additionally, the U.S. Centers for Disease and Prevention estimates roughly 90 percent of Americans have been vaccinated against or have been infected with COVID-19, said Guy Miller, interim health director of the BCHD.
This is a different reality from March 2020.
“We had no vaccine. We had no therapy. We were still discovering what might be more effective or less effective,” Hamel said.
Pandemic versus endemic
A pandemic is an epidemic gone global: when a rapidly spreading disease in one region or country then spreads to a larger area, or, in the most recent case, all over the world.
An endemic disease describes one prevalent and reoccurring in a certain region, said Cabaltica. He drew the comparison to influenza, which has speedy testing and accessible treatment options.
With COVID-19, PCR tests, rapid antigen testing and surveillance sewage testing can provide both an individual and community picture of the state of the disease. Vaccines are incredibly effective at preventing severe illness and disease. Those infected now also have access to antiviral pills like Paxlovid and molnupiravir, as well as monoclonal antibody treatments.
“The virus will still be here, and it will continue to be here, but it will no longer have that same dreadful impact,” Hamel said.
Herd effect or herd immunity was a major talking point early in the pandemic, Hamel said, although it was then understood to prevent reinfection completely. After it became clear that neither vaccination nor infection prevented contracting COVID-19, the topic was dropped.
There is still a herd effect, Hamel said. It’s just that those vaccinated or having prior infection are very unlikely to face severe illness or death.
“The herd effect is not that you’re disease-free. It’s that you’re not on a ventilator, and you’re not dying,” he said.
This means more of the population has a prepared immune system when the virus rears its head again, Miller said. Among its older and more vulnerable residents, Berrien County has a high rate of vaccination.
Upwards of 73 percent of those age 75 and older have completed their vaccine series, he said, while 85 percent have initiated it. About 80 percent of those who are 60 to 74 years old have completed their vaccination.
On a micro-level, Cabaltica witnessed this herd effect at a skilled nursing facility. When COVID-19 first appeared, Cabaltica said roughly 75 of 120 total residents contracted the disease. Of the 75, 24 then died.
In the last wave, only 12 people at the facility got sick from COVID-19, and only one then died as a result of the infection.
“It’s fairly survivable now,” Cabaltica said.
He likened the growing knowledge to a Polaroid picture.
“When you look at the pandemic, it’s kind of like that. You shot the picture, you take a look at it and, it’s all white or greenish white. And you start seeing shadows. ... It becomes clearer and clearer,” he said. “In an age though, where you’ve got digital SLR with incredible, incredible resolution, we all want the digital SLR that tells me what’s right, tells me what’s true (immediately) and medical science is not like that.”
Each surge presented different challenges, Hamel said.
The patients of the first surge were comparatively less sick than those of latter surges, and there were far fewer patients. However, Lakeland didn’t have adequate personal or protective equipment.
The patients in the most recent January surge were the sickest they had been during the pandemic, and staff were exhausted and stretched thin while dealing with it, Hamel and Cabaltica said.
“Many ... had had monoclonal antibody therapy and outpatient steroids and still were getting worse,” Hamel said.
Additionally, patients who were admitted during latter waves were more likely to have multiple preexisting conditions, requiring multiple medications, Cabaltica said. As a result, some doctors were reluctant to prescribe Paxlovid and other newly available therapeutics because they were afraid of or didn’t know how the medications would interact with each other.
As Lakeland looks forward to future COVID-19 spikes, Hamel is optimistic past preparation will be sufficient, as the illness becomes less severe.
There is a possibility the virus will mutate into a more deadly form. However, the odds are in favor of future mutations being less virulent, and more of the population having antibodies against it.
New CDC metrics account for hospital occupancy when describing the COVID-19 threat, Miller said.
“It much more protects the high-risk individuals than try to prevent this from spreading through the community,” he said.
Burnout and misinformation
In 2020, Hamel’s recovery took about two to three weeks.
“Every day is significant for me, and I think for many who have been in a near-death experience,” Hamel said. “Every day I feel thankful, and every day is a blessing.”
What adds to this gratitude is the parallel recovery of the county, as cases and transmission rates drop, Hamel said.
But for these three health professionals, this optimism is accompanied by uncertainty. The pandemic both created and exposed vulnerabilities.
Nearly a million people have died from COVID-19 in the United States. Nurses were caring for dying patients without the help of their families, again and again, Hamel said, calling these experience “battle wounds.”
Lakeland plans to offer assistance for staff who are dealing with the emotional fallout of caring for COVID-19 patients.
Misinformation is a major challenge for coming public health crises, Cabaltica said. Public health professionals need to communicate with more humility, he said, and convey that medical insight is much more like a Polaroid camera than a DSLR.
However, Cabaltica and Miller were happy with the partnerships the health department built with local primary care providers and community organizations throughout the pandemic.