Dear Fellow Citizens:

With the recent illness of our president with COVID-19, our community and our country has been thrown into a new wave of fear and uncertainty. There are many questions. What exactly is this new coronavirus? Who gets it? How is it transmitted? Why do some people get sick from it while others have no symptoms at all? What is the best way to protect myself? How can I still make a living and yet stay safe?

I’m writing this letter for two reasons. The first is that, as a physician who treats COVID-19, I’m concerned by what is now a dangerous lack of clarity in the media surrounding the disease. Furthermore, as someone who works and lives in our corner of rural America, some of you already know and trust me. The second reason is that for me this is now personal. I’m part of a small team of medical providers that treats every COVID-19 patient admitted within the St. Lawrence Health System. Our team has treated close to forty COVID-19 patients to date. We have and continue to gain experience, and in a time when much of what we hear about COVID-19 comes from people with no direct experience in treating the disease, I wanted to share some of what I’ve learned.

I will not try here to answer all of the questions above. Instead, I’d like to provide a brief summary of some things we now know about the coronavirus.

It is not a hoax.

This fact comes from my own experience in treating COVID-19. If I were to describe the coronavirus in a sentence, I would say it is one of the most unpredictable and the most consistently dangerous virus I’ve seen in my career. I tell you that it is not a hoax because of the simple fact of my experience. As I mentioned, some of you already know me. I can tell you that this is real and that I’ve seen it. Please take me on my word.

It is both variable and consistent.

COVID-19 is variable in its presentation. It can kill, it can cause no symptoms and it can do almost everything in between. But for those COVID-19 patients sick enough to be admitted to the hospital, it is now a disease that I can usually recognize even before I confirm it with a test. The symptoms, the lab findings, the findings on a chest CT scan are all straightforward to recognize in most cases. And what is it we see? For the sickest patients, it’s often a disease that has two phases. In the beginning, there is often fever and a cough, then shortness of breath, then a variety of other symptoms that can come and go. The coronavirus is tricky in this way. It can wax and wane. It can give you the sense that it’s going away and then come back to strike you even harder than before. I call the first phase of the illness the infectious phase. The virus is dividing in the body, and the goal at this stage is to kill it. At this stage of illness, the medicines we use to fight COVID-19 are called antivirals. A good example of this today is a drug called Remdesivir.

The second phase of illness is what affects many of the sickest patients with COVID-19. It is also the phase in which many people die. This is the autoimmune phase of the illness. In this phase, the biggest problem isn’t that the immune system is busy fighting the coronavirus. It’s that the immune system is fighting the coronavirus too hard. The result is what is called a cytokine storm. In an infection, cytokines are messengers in our bodies that tell our bodies to either start fighting the infection or, if the fight is already underway, to fight the infection even harder. In cytokine storm, a barrage of these messengers is unleashed. The result is that, like a fighter who keeps punching his opponent long after his opponent has been knocked out, the immune system now starts fighting an infection inappropriately (in other words, it fights too hard). Tremendous damage can be done in this phase of the illness, including everything from failing organs to extremely high fevers to heart attacks and strokes. The goal in this phase of the illness is to slow the immune system down, and the medicines we use in this phase are immunosuppressive (immune system lowering) medications. A good example of this today is a drug called Dexamethasone.

There are a number of ways in which a physician treating COVID-19 will try to fight the disease. These include:

Remdesivir - This prevents the virus from dividing. It is typically given to COVID-19 patients sick enough to be admitted to a hospital. Studies show that it can shorten the time to recovery for some patients.

Dexamethasone – This lowers the immune system. It is typically given to COVID-19 patients who are not only sick enough to be admitted to a hospital but who are also requiring some form of additional oxygen. One well publicized study (the RECOVERY trial) showed that, in COVID-19 patients who require oxygen, taking dexamethasone can lower the risk of mortality. On the other hand, this same trial also showed that patients who are not sick enough to be on additional oxygen may have a higher risk of mortality if they receive dexamethasone.

Blood thinners – COVID-19 is notorious for causing blood clots. It can cause heart attacks and strokes, sometimes in young and previously healthy people. We use blood thinners in different strengths and doses for most COVID-19 patients who are in a hospital.

Convalescent plasma – This is an infusion of antibodies against the coronavirus. It comes from people who have already been infected with the virus and who, in turn, have developed antibodies against it. We are still learning how and when to use convalescent plasma. Like all experimental medications, it has risks that we don’t yet know about. This is typically given to sicker patients with COVID-19.

The easiest way to stay safe is to observe social distancing guidelines and to wear a mask.

I hesitate even to include this statement in this letter. We have all heard this advice, and the issue of mask wearing has become divisive enough that it brings me some fear just to bring it up. But just as nothing fights fear like the truth, so I believe that this must be stated once again. For those of you who may be wondering if politics may have influenced this part of my letter to you, I can assure you that they have not. I give this advice only because there are is now very good evidence that when two people both wear a mask, the likelihood of one of those people passing the coronavirus to the other is significantly reduced. I also give this advice because it’s what I do myself. I’ve seen enough of this virus to tell you that it frightens me. I wear a mask to protect myself and those around me. I’ve gotten used to wearing a mask over time, and while I don’t like it I like the alternative (i.e., possible infection with the coronavirus) even less.

I will conclude this letter by talking a little about rural America. Some of you may have the sense that, because we in St. Lawrence County often have the benefit of open space, we are all to some extent already social distancing. Unfortunately, this is both true and false. As rural Americans, we do often have more physical space than those in urban areas, but we also have more poverty, more people and families living in crowded homes and more infection hotspots such as nursing homes and prisons. We also have fewer medical resources. Everyone in our region who is reading this letter knows that rural America has a shortage of medical professionals. We have fewer doctors in general and, in all but a few parts of rural America (ours is a fortunate exception), we have almost no subspecialists. We also have almost no representation in clinical trials (again, we in St. Lawrence County are a fortunate exception here) and, in my opinion, we are rarely truly seen by elites anywhere, be they in government or corporate America or the American medical community. I believe that, with time and a lot of effort, this can change. But for now, our greatest resource remains ourselves. Rural Americans must bond and fight this virus together, just as we must bond and fight all of our challenges together.

There’s too much we still don’t know about COVID-19. And yet, there’s also much that we have learned. There are more than 70,000 journal articles on the coronavirus to date and the number is growing quickly. In my own case, I am like any other physician fighting the virus. I am learning as I go along, and I feel it’s my responsibility to let you know what I have and haven’t seen. The truth is a light above all else. I hope we can use our growing knowledge and the strength we have as a community to fight this virus together both now and in the months to come.

Eyal Kedar, MD

St. Lawrence Health System COVID Team Member