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May 1, 2020  

Dear Patients,  

Many of you have expressed significant concerns and fears surrounding the COVID-19 pandemic. From our discussions, clearly much of this is based on the tremendous amount of misinformation, disinformation, and misunderstanding of the science being reported on COVID-19. Thus, I thought it would be helpful to put the facts, science, and medicine as we currently know them to help allay your worries and give you a better perspective on things.  

The Key Guiding Question to All COVID-19 Decision Making  

The key guiding question to all COVID-19 decision making is: Twelve months from now, will the number of infected, the number with any residual viral complications, and the number of dead as a direct result of the SARS-CoV-2 (coronavirus) infection be any different from any particular action or actions absent a curative treatment, highly effective vaccine, or the virus self-extinguishing?  

Quarantines/Lockdowns/Physical Distancing  

So, let’s apply the key guiding question to the quarantines/lockdowns/physical distancing strategies. Twelve months from now, will the number of infected, the number with any residual viral complications, and the number of dead as a direct result of the SARS-CoV-2 (coronavirus) infection be any different from the quarantines/lockdowns/physical distancing strategies absent a curative treatment, highly effective vaccine, or the virus self-extinguishing?  

The answer is an unequivocal no. They won’t change the outcome. They stretch out the process and only delay the inevitable. The virus solely determines the outcome.  

The quarantines/lockdowns/physical distancing strategies cannot improve the eventual outcome. Indeed the CDC physical distancing strategies were never designed for that. They were designed to slow the spread. Not stop the spread. The CDC has been fully aware that nothing we do will change the outcome. It is the virus and the fact that the world’s human population has not seen it that determines the outcome.  

The original purpose of slowing the spread through physical distancing was that we simply did not know how hard the virus would impact the population. Out of an abundance of caution to not overwhelm the capacity of our healthcare system, it was initially prudent to try and slow things down. At no time was it stated or implied by the CDC that it would save lives.  

However, poorly informed and overzealous officials took such guidance to infer that shutdowns of business and commercial activity along with stay-at-home quarantines would be even better than just physical distancing. And at the same time, these officials along with a complicit media morphed the message from “slow the spread” and “flatten the curve” to say that shutdowns and lockdowns keep you “safe” and will “save” lives. This is false.  

The claim that distancing, quarantines, and lockdowns alone will save lives is simply false.  

They can’t absent a curative virus treatment. The claim implies the number of infections and deaths will be mitigated by distancing/lockdown strategies. However, it doesn’t matter what we do with distancing, slowing, quarantines, and lockdowns. Ultimately the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative virus treatment, slow, fast, or anything in between. It is baked into the fact we are an immune naïve population for this coronavirus and the virus will attack until herd immunity levels are reached no matter what, absent a curative treatment, highly effective vaccine, or the virus self-extinguishing. (Herd immunity occurs when enough people have become immune by virtue of infection or a vaccine such that those left who are still at risk of infection are in fact protected by the others. For COVID-19, the most recent data suggests herd immunity might begin to develop with a population infection rate of only 30-50%. This is similar to influenza.)The virus solely determines the outcome no matter how much we run or hide. It will wait us out absent a curative treatment, highly effective vaccine, or the virus self-extinguishing.  

Indeed, after a little more than 6 weeks of lockdown in California new cases continue and deaths are ongoing. The virus solely determines the outcome in the end.  

Social distancing strategies like quarantines/lockdowns/physical distancing serve only one purpose. To slow rapidly rising rates of COVID-19 infection over a longer period of time. This doesn’t save lives from the virus. But it helps to avoid overloading the capacity of hospitals and the healthcare system to be able to adequately handle COVID-19 cases requiring hospitalization and thereby ensure ready access to medical resources.  

Certainly, when initially introduced in areas hard hit with rapidly rising numbers of cases from a virus we truly knew nothing about might have made sense. However, the law of unintended consequences reveals the outcomes of ongoing overzealous and prolonged quarantines/lockdowns/physical distancing.  

First, the most ominous consequence is that it is almost assuredly contributing and intensifying the clustering of large localized outbreaks that are the pattern of this virus as noted above. This is particularly true for the massive and tragic outbreaks that sweep the heavily locked down elder care facilities like nursing homes, long-term care facilities, and assisted living centers. Based on data reported by the CDC, about 18% of all COVID-19 deaths occurred inside such facilities.  

Second, by excessively slowing and delaying the natural progression of the disease, virtually all but a few hard hit hospitals have seen very few, if any, COVID-19 cases and are running at substantially less than capacity and fairly empty in some places. In essence, we are as prepared as we will ever be to hospitalize and treat COVID-19 patients with massive investments into pandemic infrastructure but the quarantines/lockdowns/physical distancing have reduced the volume of potential patients so much in most places that hospitals are languishing. Worse, because hospitals have been banned from their normal activities they are getting into increasing financial peril and many have had to layoff vital healthcare workers in the face of the ongoing quarantines/lockdowns/physical distancing.  

Third, hospitals cannot survive on the high level of COVID-19 preparedness that they are currently at indefinitely. They will have to return to normal operations or go broke. Thus, as the phasing out of the quarantines/lockdowns/physical distancing mandates is increasingly delayed, hospitals will be increasingly less prepared to handle the expected uptick in the number of COVID-19 infections once the phasing out occurs. This will simply create more of the healthcare chaos and costs that we have already worked through.    

Some food for thought about public officials with respect to their quarantines/lockdowns/physical distancing mandates: Some have mandated that incarcerated criminals be released from their close, confined quarters in a closed down jail settings to protect them from getting infected with COVID-19 while at the same time mandating that our elderly residents of nursing homes, long-term care facilities, and assisted living centers be locked up in close, confined quarters in a quarantined facility in confinement, sometimes solitary confinement, with no outside contact in order to protect them from getting infected with COVID-19. To date, there have been no major COVID-19 outbreaks in the jail setting but there have been massive outbreaks with expected significant mortality amongst the elderly in their facilities.  

Twelve months from now, will the number of infected, the number with any residual viral complications, and the number of dead as a direct result of the SARS-CoV-2 (coronavirus) infection in that elderly population be any different from the very rigid and aggressive quarantines absent a curative treatment, highly effective vaccine, or the virus self-extinguishing?  So far we have seen the virus penetrate the cracks of these quarantines with devastating results as we would expect in a closed facility with prolonged exposure to the virus. Despite the best efforts to intensively quarantine, the virus finds a way in and uses the quarantine as a tool to spread explosively in these nursing homes, long-term care facilities, and assisted living centers.  

How Easy Is It to Catch COVID-19?  

The most likely source of transmission of the SARS-CoV-2 virus is from respiratory droplets expelled by a sufficiently infected person. This occurs when a sufficiently infected person coughs or sneezes secretions from their respiratory tract into the air. It has been theorized that talking may also do this but there are no reported cases of COVID-19 infection actually occurring from talking without coughing. In general, droplets can travel no more than 6 feet before dropping to the ground and this is where the 6 feet distancing recommendations came from.  

How easy is it then for a person to get sick from such an exposure? In large part, most of these secondary infections have occurred in clusters affecting larger groups of people. The infections are not random or evenly distributed. Virtually all the cases that have occurred have come out of prolonged group exposures in close-contact closed spaces. The sources of these infections are closed-down households, hospitals and healthcare facilities treating COVID-19 patients, long-term care facilities, congregate gatherings, ships, and other prolonged exposures in public transit.  

So basically you need a prolonged and repeated exposure to a sufficiently infected person in a close-contact closed space in order for you to possibly catch the virus and get sick from it. The risk of catching the virus and getting sick from it is all about sufficient dose and duration regarding exposure.  

So then, what is the likelihood of catching COVID-19 and getting sick by casually passing by an infected individual outdoors or while shopping? While there is no definite data on this yet, based on all we know the risk appears to be very low, if at all, for casual passing.  

And what about the risk of catching COVID-19 and getting sick by handling items an infected person has touched in passing such as in a market or restaurant? While there is no definite data on this yet, based on all we know the risk appears to be very low, if at all, for this as well.  

What about the risk of catching COVID-19 and getting sick by handling items an infected person has touched such as handing you a package? While there is no definite data on this yet, based on all we know the risk for such objects appears to be very low, if at all, for this as well. In addition, there is no data supporting the need to disinfect the surfaces on items like these.  

But what about surfaces heavily contaminated by a significantly infected and sick person in a healthcare setting or sick room at home? The risk of this is unknown but it is prudent to assume a much more significant possibility of risk of disease transmission because of the dose and duration issues we discussed above. In these circumstances, appropriate environmental disinfection should be done.  

What about asymptomatic people? Can a person who is infected with the coronavirus but has no COVID-19 symptoms cause another person to get infected and become sick? There is no definite data on this other than anecdotal reporting. However, given that the virus is transmitted by expelled droplets from an infected person, it would require that infected person to be coughing, sneezing, or blowing out respiratory secretions containing the virus. Of course, this then begs the question of whether a person is asymptomatic if they are coughing or sneezing from their infection. I would say you are not asymptomatic in that situation. Thus, the same discussion about risks of transmission applies in this circumstance as above for anyone sufficiently infected with the coronavirus to have symptoms.  

Wearing Masks or Face Coverings by the Public-at-Large  

There appears to be a great deal of misunderstanding about the wearing of masks and face coverings in public settings.  

First and foremost, there is absolutely no evidence that wearing a mask or face covering in public will lower your risk or protect you at all from becoming infected with COVID-19. Period.  

The community mask/face covering recommendation by the CDC was made based on the understanding that a mask or face covering would reduce the possibility of a sufficiently infected person who has no symptoms or is in the early stages of developing illness from spreading their infection to another person and causing them to get sick. According to the CDC, the recommendation is an “additional, voluntary public health measure” in addition to physical distancing. Once again, it is necessary to point out that if you are infected with the coronavirus and you are coughing or sneezing then you really are not asymptomatic. And again, based on all we know the risk appears to be very low, if at all, for casual passing when not wearing any face covering.  

Some states and many localities have wrongly extended the CDC guidelines and adopted mandatory and enforced rules requiring the wearing of masks/face coverings in public spaces and inside businesses. Therefore, let us apply the key guiding question here. Twelve months from now, will the number of infected, the number with any residual viral complications, and the number of dead as a direct result of the SARS-CoV-2 (coronavirus) infection be any different from the mandatory wearing of masks/face coverings by the public at large in public settings absent a curative treatment, highly effective vaccine, or the virus self-extinguishing? The answer is no. There is simply no evidence that such a mandate could or will protect anyone the virus intends on infecting. This mandated wearing of masks/facial coverings in public settings will not save a life. The virus determines who it will infect. It will find you one way or another over time absent a curative treatment, highly effective vaccine, or the virus self-extinguishing.  

Importantly though, if you are coughing or sneezing respiratory secretions then you should assume you have COVID-19 until you know different and manage that accordingly.  

The Confusion of Case Fatality Rates and Death Rates  

It is quite frightening to hear and see the tally of deaths from COVID-19 on a daily basis. Even worse is to hear and see are data reported as “death rates”. These numbers are terribly characterized and misreported however. From my perspective, it seems like they are reported without context or explanation in order to sound as very frightening.  

So just what do these numbers mean?  

What is being reported mostly is a death rate based on the number of deaths attributed in any way to COVID-19 divided by the number of diagnosed cases.  This number has no scientific or medical value whatsoever. It tells us nothing.  

Why?  

The most significant flaw in these death rates is that they imply that the number of diagnosed cases represent all the cases of COVID-19 infection. It is a highly distorted attempt to describe the scientifically important number what known as case fatality rate. The case fatality rate is the number of people who have died of COVID-19 divided by the number of people actually infected by the SARS-Cov-2 virus. And therein lies the fallacy of the reporting. We do not know the real number of people actually infected by the SARS-Cov-2 virus. The true case fatality rate is actually unknown at this time and cannot be calculated.  

But we do know that with viral illnesses like COVID-19 there are many people with mild or no symptoms who do not see doctors and are therefore not counted in the numbers of infected people. Getting that denominator number right is very important to understand your true risk of succumbing to the disease.  

At present, the “death rate” (not the true case fatality rate) in the United State is reported at about 6%. In California it is reported at about 4%. This implies that that about 6 out 100 people in the United States infected with the coronavirus dies. This is false. A surveillance study in Santa Clara, California suggests that the prevalence of all those who been infected with coronavirus may be 50 to 85 times higher than the number of reported cases. Another study in New York state suggests the prevalence of all those infected to be about 10 times higher than the number of reported cases. It clearly appears that there are a large number of people who have mild, insignificant, or no symptoms from a COVID-19 infection and recover without consequence. So, if the number of infected people is at least 10 times greater than what the media reports, then the true case fatality rate in the United States drops to at most 0.6% and in California 0.4%.  

In addition, there is a great deal of controversy about the reporting of COVID-19 deaths. It has been suggested that deaths are being attributed to COVID-19 as opposed to other causes of death that normally take place. This type of over-reporting is not uncommon in medical crises. If the true number of deaths attributable to COVID-19 were even 20% lower then the case fatality rate in the United States reduces to about 0.5% and in California to about 0.3% based on our assumptions. Furthermore, if we consider the cluster outbreak in New York to be the outlier that it is and recalculate the number of deaths in the United States excluding New York, the based on our assumption the true case fatality rate for the rest of the United States drops to about 0.4%. Because of the highly clustered nature of COVID-19 outbreaks, the case fatality rates in many localities are substantially lower.  

Why does the case fatality rate matter?  

It informs us about how serious the disease is and the intensity of the public health measures needed to protect against illness and death. Obviously the worse the number, the more investment in resources and protective measures are indicated. Similarly, the better the number the less the concern. For some perspective, the case fatality rate for seasonal influenza is about 0.1% and for modern pandemic influenza up to about 0.2%.  

Another important number addressing the deaths from COVID-10 is what is known as the mortality rate or the death rate when the term is used correctly. This is the number of deaths per unit of population. This helps gauge the significance of deaths from one condition compared to other conditions. Based on the current number of deaths (bearing in mind the over-reporting we discussed earlier) in the United States in early May, 2020 the COVID-19 death rate is about 19/100,000 population. For comparison, pre-vaccination combined seasonal influenza and pneumonia death rates were substantially higher such as in 1990 when the death rate reported by the CDC was 36.8/100,000. In 2017, in our highly vaccinated society, the combined seasonal influenza and pneumonia death rate reported by the CDC was 14.3/100,000.  

What About Contact Tracing?  

Other than for voluntary research purposes, at this point in time there is no role for widespread contact tracing in the United States.  

Why?  

There are 2 major purposes for contact tracing and surveillance. The first is to contain and eradicate an infectious disease by containment measures. The second is to learn about infectivity and transmission characteristics of an infectious disease.  

For the SARS-CoV-2 virus, the time for containment and eradication was when it first appeared Wuhan, China. Once the virus was transported by infected individuals around the world, based on the characteristics we have learned about the virus, it could not be contained and could not be eradicated by containment measures. It’s here to stay until it infects everyone it intends to absent a highly effective vaccine or the virus self-extinguishing.  As discussed above, the quarantines/lockdowns/physical distancing strategies cannot improve the eventual outcome. It doesn’t matter what we do with distancing, slowing, quarantines, and lockdowns. Ultimately the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative treatment, highly effective vaccine, or the virus self-extinguishing.  

What we have learned from contact tracing is that even with non-casual passing (basically meeting with somebody), non-family contacts an infected person will be associated with a contact infection infrequently at a rate of about 4.5-5.5 out of 1000 contacts but secondary infections associated with an infected person amongst household members was about 15-20 times higher. The rate is even higher in a closed workspace setting. This data is consistent with our earlier discussion about the need for prolonged and repeated exposure to a sufficiently infected person in a closed space in order for you to possibly catch the virus and get sick from it. The risk of catching the virus and getting sick from it is all about sufficient dose and duration regarding exposure.  

Upticks in Cases and Deaths As Restrictions Are Lifted  

As the elimination of COVID-19 restrictions get underway it must be recognized and accepted that there will probably be an uptick from the pre-existing levels of COVID-19 and influenza-like symptoms as well as COVID-19 diagnoses and deaths at each level of restrictions that are lifted. The mobility of the virus and the rate at which infections occur varies with the mobility of people as we discussed above regarding quarantines/lockdowns/physical distancing. It doesn’t change the outcomes related to the virus, only the rate at which they occur. This concern may be partly mitigated by the undoing of quarantines and lockdowns that feed into the prolonged group exposures in close-contact closed spaces including closed-down households and long-term care facilities. However, all planning should expect an uptick as a natural course of events and set parameters for an acceptable uptick based on healthcare capacity. There should be no retreat as the restrictions are lifted in a timely way unless healthcare capacity or healthcare resources are imperiled. It cannot be emphasized enough that the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative treatment, highly effective vaccine, or the virus self-extinguishing. So we should not be surprised that it will do what we know it will do. We should prepare accordingly.  

Some Thoughts on Moving Forward  

We have 2 competing disasters on our hands. The first is the COVID-19 natural disaster that cannot be stopped and over which we have no control over the outcome now absent a curative treatment, highly effective vaccine, or the virus self-extinguishing. We can control the pace but not the outcome otherwise. The second is the occupational, economic, social, recreational, and spiritual disaster created in response to the first disaster. This one we have much more control over.  

Any mandate that has no scientific evidence or confirmable scientific rationale for its existence needs to be discontinued immediately.  

It cannot be emphasized enough that the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative treatment, highly effective vaccine, or the virus self-extinguishing. Twelve months from now, will the number of infected, the number with any residual viral complications, and the number of dead as a direct result of the SARS-CoV-2 (coronavirus) infection be any different from the quarantines/lockdowns/physical distancing strategies absent a curative treatment, highly effective vaccine, or the virus self-extinguishing? The answer is an unequivocal no. They won’t change the outcome. They stretch out the process and only delay the inevitable. The virus solely determines the outcome.  

Given that the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative treatment, highly effective vaccine, or the virus self-extinguishing, then the single guiding principle to opening things up must be the ability of the healthcare capacity and healthcare resources to safely and effectively treat incoming COVID-19 patients.  The best way to see this is to think about the process as a pressure cooker. The natural medical disaster of COVID-19 and the manmade disaster in response to it have created a tremendous amount of pressure on our society and culture. If not handled right, it will explode in our faces with unimaginable consequences. We have no choice but to aggressively and expeditiously release the most pressure we can. Based on all we discussed that means we must ease up on the quarantines/lockdowns/physical distancing strategies as quickly as possible, the limits of which should be solely guided by the capacity of the healthcare system to manage any concomitant increase in COVID-19 cases. This is the only control we have on things for the foreseeable future.  

The approach taken by Sweden took into account the fact that the virus will infect the same number of people and will harm and kill the same number of people no matter what we do absent a curative treatment, highly effective vaccine, or the virus self-extinguishing. They avoided significant quarantines and lockdowns but did limit the size of public gatherings and trusted their citizens in mostly voluntary social distancing measures. The mortality rate from COVID-19 in Sweden based on their reporting is about 27/100,000 at this time. This is higher than we are at now but our mortality rate is artificially reduced by virtue of our rigid quarantines/lockdowns/physical distancing strategies. For comparison, pre-vaccination combined seasonal influenza and pneumonia death rates were substantially higher in the United States such as in 1990 when the death rate reported by the CDC was 36.8/100,000.Our numbers will rise however as restrictions are eased. In the end, our mortality statistics will be not be significantly better than Sweden’s but the occupational, economic, social, recreational, and spiritual price we paid  may turn out to be ruinous unless we accept the reality of things and move forward as Sweden wisely has.  

The limitations to accessing healthcare services for non-COVID-19 health issues will have serious health ramifications in the near future. The costs of this in terms of health, well-being, and dollars are yet to be tallied but will be painful. Healthcare delayed is healthcare denied.  

Similarly, the medical harms of joblessness and poverty are profound. As these result directly from the rigid quarantines/lockdowns/physical distancing strategies these consequences must be factored the decision-making for opening things up quickly.  

It seems to me that we have been using a mass casualty approach to utilizing hospital services in large clustered outbreaks. While time is if the essence in in large trauma casualty events and getting to the nearest medical care is critical, in large part, this does not apply to COVID-19. In these large clustered outbreaks of COVID-19 it appears that a limited number of hospitals were seriously overburdened by patients beyond their capacities solely because of their geographic location while many nearby hospitals had readily available capacity and capability. However, most COVID-19 patients requiring hospitalization are not in an immediate live-or-die situation. Therefore, it would make much more sense that any hospital at or near capacity stop accepting more patients and have patients move to the next available facility that has resources and availability. We should not have to experience mass casualty overloads for COVID-19 patients.  

There must be liability protection for all employers and businesses against being sued for failing to protect anyone against the coronavirus. It’s a virus. It does what it wants. It now can’t be stopped absent an effective vaccine or attaining herd immunity. Any liability for this virus rests solely those who failed to contain it when it first presented itself in Wuhan, China.  

COVID-19 infections are highly clustered and come out of prolonged group exposures in close-contact closed spaces. The risk of catching the virus and getting sick from it is all about sufficient dose and duration regarding exposure. We also know the sunshine and UV light are great disinfectants including against SARS-CoV-2. Therefore, one the easiest low-tech things that could help mitigate the virus is aggressive ventilation by moving in fresh air cleansed by sunlight and blowing out the inside air in homes and buildings.    

I hope this helps answer many of the concerns you have expressed.  

Best of health to you all.  

Jeff Sarkozi, MD, FRCPC, FACR    

Jeff Sarkozi, MD, FRCPC, FACR
Fibromyalgia Polypain Arthritis Center
801 North Tustin Avenue Suite 503
Santa Ana, California  92705

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