In less than two months, medical schools across the nation will welcome a new first-year class. For the first time in modern history, the students will find themselves in a virtual world. They will rarely see one another or their professors. They will temporarily forgo the white coat ceremony. They will take exams in large rooms separated by barriers and empty desks and never "enjoy" their time in the study carrel or library. Most of all, theirs will be the first class not to study anatomy in person.
It is hard to know if the actions being implemented by educators across the nation are appropriate.
Although we know by observational and modeling data that school-age children are silent spreaders of infection and closing primary school during influenza pandemics may partially mitigate community spread, we have less information regarding the impact of closing colleges and universities. Certainly, many schools are closing "out of an abundance of caution" to protect the students and staff. Some closings may be due to concerns about legal liability. Undoubtedly, underpinning the decision-making is the widespread belief that SARS-CoV-2 is highly lethal.
Whether this is universally true, however, remains to be seen.
Although SARS-CoV-2 is hardly the first virus to infect humans, it is the first to create a pandemic in a socially interconnected world. It is the first time physicians and healthcare providers have come face to face with Marshall McLuhan's famous 1964 expression – "the medium is the message."
We know today that McLuhan was not simply suggesting that the platform by which content is delivered is more relevant than the content itself, but for the moment we shall not search for a deeper meaning. The medium in the case of COVID-19 is Twitter, Facebook, daily press conferences, and/or any means of instant communication, where information travels at the speed of light.
We are already familiar with the unintended consequences of spontaneous tweets or inappropriate Facebook posts. Now, however, we are becoming familiar consequences of instant, widespread dissemination of inaccurate and misleading information regarding the COVID-19 pandemic by individuals and self-ordained experts -- mass anxiety.
It would be irresponsible to suggest that the COVID-19 pandemic is of little concern and, in so doing, President Trump is clearly wrong. However, it would be equally irresponsible to blithely accept the contrarian and alarming statements by politicians and news reporters, without placing the pandemic in context.
Widespread epidemics are not new. In prior centuries, infections tracked trade routes, as was the case with the bubonic plague in the 1300s and 1600s. In the 20th century, however, the introduction of cruise travel followed thereafter by international air travel allowed regional epidemics to quickly become global pandemics. Such was the case with COVID-19.
To respond appropriately to COVID-19, one needs to understand prior 20th century pandemics.
The most well-known is the 1918 flu, in which 40% of the global population was infected in 18 months, resulting in approximately 20-50 million deaths. The case fatality rate has been estimated at 2% but varied greatly by region. In contrast to COVID-19, the 1918 flu was most virulent in the 20- to 40-year-old age group and affected the white community to a greater degree than the non-white community; most probably because a larger percentage of the white population lived in urban areas where spread was easier.
Although multiple retrospective studies have tried to clarify the impact of school closings on the spread of the 1918 flu, the data remain inconclusive.
Based upon projections by the Institute for Health Metrics and Evaluation, the pandemic likely to be most comparable to COVID-19 appears to be the influenza pandemic in 1957-58. Nearly 25% of Americans were infected and 116,000 succumbed with a calculated case fatality rate of 0.27% (albeit slightly higher elsewhere). If one assumes a similar percentage of the population becomes infected with COVID-19 and extrapolates based upon population growth, the number of American deaths will be about 223,000.
In 2008, a computer simulation model analyzed the impact of school closings in the United Kingdom during the 1957 pandemic and concluded that school closings resulted in a 12.5% to 14% reduction in epidemic size but the impact was less if the reproductive rate of the virus (R0) increased to >2.5. At present, it is believed the R0 of COVID is 2.6. Critically, the study focused on nursery schools and elementary schools and did not independently assess the impact of closing colleges and universities.
The 1968 influenza was less virulent than either of the above variants. Even so, it is estimated 100,000 Americans died in less than 12 months. As with COVID-19, the elderly were the primary victims of the disease. When adjusted for population growth, the figure today would be 165,000 deaths with an estimated case fatality rate of 0.1%.
Relatively little data exist on school closings during the 1968 pandemic.
The late June 2020 announcement by CDC Director Robert Redfield that community-based antibody testing suggests 10 times as many individuals (or more) have already been infected than initially estimated results in a COVID-19 case fatality rate of approximately 0.25% to 0.50%. By historical standards, COVID-19 is no more lethal than many of the more recent pandemic viral infections, particularly for individuals under the age of 50.
Perhaps of most importance is that in contrast to influenza, the transmissibility of COVID by children under the age of 17 years seems to be very low.
Despite articles, editorials, and graphics making these reassuring points, the medium has obscured this message and two critically important facts, at least from the perspective of educators. First, we do not know whether closing colleges and universities will alter the natural spread, and second, the case fatality rate in the college and medical school-age population based upon the original CDC estimates was <0.20%. This rate (which does not account for unrecognized infections) is indistinguishable from the case fatality rates during the 1957 and 1968 pandemics. Yet, during neither of those pandemics did the nation enter hibernation, shut down the economy, or indefinitely close the schools.
Much of what has happened over the past months reflects the medium becoming the message. In addition to his observation about the medium and the message, McLuhan made a second observation -- societies tend to miss subtle changes which occur as a result of an innovation. We know what a new technology or innovation is designed to do, but often fail to anticipate what it will do. In the case at hand, a thought to be positive innovation, social media, has nurtured a level of public anxiety and fear not seen in many years, particularly in the "worried well."
I am not suggesting there is no reason for concern, nor that some otherwise healthy individuals including young adults and truly selfless front-line health care providers have not died. There is, and they have. I am not insensitive to their sacrifices and have great sympathy for their family members and loved ones.
Rather, I am merely observing that infections will inevitably occur, they will spread despite our best efforts, and humans will succumb. We must acknowledge this reality. For our acknowledgment to be of value, however, it must be followed by objective analyses, an understanding of history, and a willingness to make policy decisions based upon science and data, rather than hope.
Unfortunately, to date, some of our nation's most visible politicians and leaders repeatedly disregard evidence-based data, including the importance of age-related risk (as described), choosing instead to engage in political diatribes of uncertain value and accuracy. They have made decisions, purportedly in the interest of public health and welfare, even when the facts do not fully support their recommendations.
To further complicate the picture, we have become a risk-averse society. Although corporations and educational institutions certainly seek recommendations from medical personnel to guide their decision-making, it is likely that in the final analysis many rely more upon recommendations from legal counsel due to concerns about potential liability in the event an employee or family member succumbs to COVID. This last observation may explain why institutions of higher education (including some of the most prestigious medical schools) have chosen to convert to an online format despite the absence of evidence that the short-term benefit meaningfully outweighs the long-term harm.
For incoming medical students, virtual education is a problem. It is hard to appreciate online the tactile difference between tendons and ligaments, learn to palpate the liver and spleen, or understand the "leg bone-knee bone" attachments.
It is also hard to rationalize why local school districts anticipate a return to in-person education in the fall (despite evidence, at least with respect to influenza, suggesting a benefit to school closings), but institutions of higher learning (where there is no evidence to suggest benefit) paradoxically do not.
The harm to our society, economy, and educational institutions/processes created by, inconsistent, alarming, and misleading public statements followed by poorly informed decisions by a cohort of political and corporate leaders is immeasurable and may take years to repair.
Is it appropriate for medical schools to replace classroom instruction with virtual education? I do not know. Let us hope, however, that when today's first-year medical school students graduate in 2024 they not only know to what the leg bone is connected, but also know that prior to engaging in public or online discourse, one needs to ensure that their facts are correct and their comments appropriate. Otherwise, none of us will have learned anything from this whole experience.
(And, incidentally, the leg bone is not connected to the knee bone – it is connected to the thigh bone!)
Mark Jay Zucker, MD, JD, is a transplant cardiologist in New Jersey and clinical professor of medicine at Rutgers University-New Jersey Medical School. He is also vice chair of the Cardiovascular Network of the American College of Chest Physicians.