Covid Follies

 

(Gentle reader:  This piece is a bit out of sequence…it should have come just after my arrival the Pole but, to be honest, I forgot I wrote this while cooped up in quarantine.  Kind of like how you forget bad relationships or time in a Turkish prison.  “Have you ever been in a Turkish prison, Bobby?” - Captain Clarence Over.)  

During my forays into public health, I came to understand that an epidemic within a closed population is a double-edged sword.  On one hand, one wants to prevent illness and death wherever it’s possible to do so.  On the other, if you have a captive audience you can prevent disease spread to the rest of the population through aggressive measures, even though it increases the risk to already infected persons.  An easy way to think about this is to recall that the island of Molokai in Hawaii was originally a leper colony.  The idea was that by sending lepers to an isolated island, they might eventually die from their affliction, but at least they would not infect others.  You may have heard of the priest Father Damien, honored by the State of Hawaii in Statuary Hall of the United States Capital Building for living within this leper colony and working to ameliorate their suffering.

Quarantine and isolation are time-honored measures to control communicable disease, but I think of them as “Princess Bride” words, as they may not mean what you think they mean.  Quarantine prevents the movement of suspected cases of illness or disease to prevent the infection of others.  The term comes from the Venetian word “quarantena” (forty days), which was the period of time that ships had to stay offshore before passengers and crew could disembark during the Black Death, the theory being that if the plague was onboard, everyone infected would die off during that time.  If there were no cases of plague seen, the ship was then free to unload.  Quarantine measures apply to those who are suspected to carry disease but not confirmed to do so, and are applied for a period of time during which the disease is expected to show itself or the person can be cleared. 

By way of contrast, isolation is the restriction of those with confirmed cases of disease.  It’s a measure taken against those already known to be infected or ill. Depending upon the agent involved, isolation techniques can be as simple as asking the infected person to wear a mask, to complex housing arrangements in rooms ventilation systems designed to prevent disease transmission. In most cases, isolation is generally much less restrictive than quarantine.  When we talk about a person who has tested Covid positive being asked to stay home and avoid contact with others, or to wear a mask in public, we’re employing an isolation technique.  When we ask the same of people who may be exposed to Covid but whose cases are not yet confirmed, it’s really a liberal form of quarantine, but we use the term isolation (as in “socially isolate”) because it doesn’t invoke the same kind of squeamish reaction that the word “quarantine” does.

The South Pole is a perfect example of a closed population that is at once both vulnerable to the rapid spread of disease but also where public health intervention can have maximal impacts.  There’s only one way in or out, and that faucet (the aircraft that leap into the air or drift safely down to earth on Skiway 02-20), can be closed at any time.  So one way to insure that Covid doesn’t reach the pole is to make sure all who come here are Covid negative before they arrive.

The way to do that is through the proper use of testing. The two means to detect Covid in general circulation are Rapid Antigen Testing (RAT) and Polymerase Chain reaction (PCR) tests.  Like isolation and quarantine, they look at different things.  RAT tests look for the presence of specific proteins, called antigens, found on the outer coat of the Covid virus.  PCR processes replicate the virus’s own RNA as  DNA, which is then detected by the test itself.  No one single test is perfect, of course…clinical and laboratory professionals use terms such as sensitivity and specificity to describe the risks of false positives and false negatives…but a strategy using measures of quarantine and both RAT and PCR tests in a targeted manner can effectively prevent Covid transmission as people enter and leave a closed population

As I write this, the current advice from the CDC is that for those who are symptomatic from possible Covid infection, you should test immediately.  For those without symptoms, but who are at risk from recent exposure to a confirmed case of Covid, the advice is to socially isolate for five days and then do three RAT test, each 48 hours apart.  If all are negative, one can consider themselves Covid-free and go back into the community, taking appropriate precautions to prevent catching the infection in the future.

(A quick note for those who say that different recommendations over the past three years mean that nobody know what’s going with coronoavirus, and therefore all medical advice is to be mistrusted.  That’s a fundamental misunderstanding of how science works.  When an epidemic is first identified, you hit it hard.  You use every tool in your public health arsenal, including disease tracking, public education, and legal means in a full-court press to control to  control the outbreak. As you learn more and develop testing strategies, preventive techniques, and therapeutic measures your strategy adapts and changes.  If it doesn’t, you’re doomed to fail.  It’s like building a Victorian-era battle plan, expecting it to work in early 21^st century mechanized warfare, and changing nothing when it begins to fail.  That was World War One.

Viral behavior plays a role here as well.  If I’m a virus, my goal is to infect as many people as possible.  If I kill everyone I come in contact with, then I can’t sire zillions of little baby viruses to go off and incubate in the a multitude of new nasal passages of potential hosts.  So when my genetic material is duplicated with each new virus formed, some of the material gets reshuffled and mutations arise.  Most of the mutated viruses have no particular distinguishing features, but some variants become less virulent.  Because they are less likely to kill their host, they hang around longer and have more opportunities to infect the unprotected.  This constant churn is why the target of our vaccines for seasonal illnesses such as influenza change every year, and why we’re now in the third version of coronavirus vaccine in a little less than two years.  It’s not that we don’t know ow what we’re doing; it’s that the virus moves faster than we do, and it’s always a game of tag.

Public health clearly got a black eye during the Covid wars, and I think it was because we not only failed to explain how science works, but we also ignored people’s true hopes and fears.  The dragnet approach…”Just the facts, ma’am”…doesn’t provide comfort for emotionally volatile animals who don’t hesitate to throw poop at their adversaries when feeling threatened.  I am, of course, referring to chimpanzees.

But nobody wants to hear that, right?  Much easier to just assume that the government is out to control you, Bill Gates is putting a microchip in the vaccine, and it’s okay to let the elderly and infirm die because it’s nature’s way of thinning the herd so only the immune…which is hopefully only “our kind” of people…will be left.  Do you need any more proof than noting that when President Trump praised his own Operation Warp Speed vaccine development program and encouraged everyone to get the jab, he was booed by his own audience?

Wait a sec…my tinfoil hat just fell over my eyes.  Pushed it back up.  That’s better.   To continue…)

Antarctica had been fortunate that Covid had not reached the chilly southern shores until December 2020, nearly a year after the start of the pandemic.  I suspect that much of this had to do with the actions of the government of New Zealand in restricting travel in and out of the country in the first year of the scourge.  Once travel opened up in a limited fashion, it’s my understanding that the United States Antarctic Program.  Those going to the ice spent time in  designated quarantine hotels in gateway cities, eating their meals in their rooms and being taken out for an hour each day in buses to outdoor venues roped off for their use before flying south.  In addition, outside sources of infection such as deliveries by cargo ship were halted.  Skeleton crews on the continent kept stations running, but the usual summer science and construction activities were halted to minimize the inflow of personnel.  It was a draconian approach but perfectly understandable at the time, motivated by the virility of the virus, the knowledge of the time, the lack of high-intensity care on the continent, and good old-fashioned fear.  But it worked.  In 2022 the isolation policy loosened up, and as a result the USAP saw its’ first clusters of Covid both at McMurdo and at the Pole. 

As I write this, the current version of the USAP Continental Infection Control Plan is fairly comprehensive.  It covers what to do with those who test positive for Covid anywhere on the continent.  The plan covers testing, masking, isolation policies and procedures for those who are positive for coronavirus, and when the Covid case can be released back into the community.  What it doesn’t cover is what happens prior to arrival in Antarctica, what measures apply to those who are asymptomatic, or people who when initially tested are negative for Covid.

Sometimes it was difficult to know what the policy really was, especially before we arrived on ice.  In Christchurch we were initially told that it was okay to be outside, and if we were indoors we should wear a mask around others and to avoid crowded places; if you went out for a meal, sit outdoors or in a quiet corner away from others.  However, the day before getting our Extreme Cold Weather (ECW) gear we were told that masks were required on USAP property, which lead to the comical rush to don a face mask as the shuttle bus arrived to take you from your hotel to the ECW fitting, and then just as hurried an effort to take them off once back at the hotel.  We were PCR tested at 48 hours prior to the ice flight (to McMurdo) and then RAT tested just before boarding.  There was the same rush to mask while going onboard under the watchful eye of the USAP staff; in fight, the aircrew didn’t wear masks so ours came off, but as we touched down and were once again in the spotlight the face covers went back on.  Those who tested positive in Christchurch preflight were left behind to isolate in their hotel rooms for an additional 10-14 days depending on test results and flight schedules.

So far, so good.  Things are a bit irregular and sometimes contradictory depending on whom you ask, but we’re dealing with humans in the later stages of a pandemic; and humans are, after all, not the most consistent of mammals.  But when we arrived at McMurdo, we were RAT tested, instructed on the use of masks in indoor public spaces, and berthed at the McMurdo Mountain Inn (MMI).  I’ve already mentioned in a prior post that I was none too thrilled with the lodgings.  But the MMI was also the berthing designated for those more severely ill patients who tested positive for Covid.  Not knowing for certain what was going on with other lodgers, we didn’t know if we were being put at risk or not.  This was especially troublesome when, in trying to follow directions to stay away from others, we would see clusters of the Great Unmasked in common areas and restrooms.

The medical staff at McMurdo had their own interpretation of the masking requirements.  They considered that the medical clinic was a safe space, as everyone who was working there had been cleared of Covid, and if anyone was seeing patients from outside our circle we would most certainly be masked.  Since we had been instructed that, masked or not, we could not go into public areas such as the galley except to pick up food to go (and the two bars on-site were certainly off-limits), the small break room at the Medical Clinic became our Social Center, where we would drink coffee in the morning, eat all our meals, imbibe some wine in the evening, and fling misaimed darts at the wall and try not to poke out someone’s eye, which would brought our Antarctic adventure to an early end.

We were RAT tested again the day before our flight to the Pole, and tested again on arrival.  We were then placed in five more days of stricter isolation, able to walk outdoors without a mask but otherwise confined to our rooms with a fifteen minute window before each meal to get food and take it back to the room, and the need to knock on the door and make sure the communal bathroom is clear before entering and moving a slider on the door that says “Hey! There’s a Maybe Covid Guy in Here!” which of course is not stigmatizing n the slightest.  (If the bathroom is occupied, you wind up doing a 60-year old version of the “Pee Dance,” which in toddlers is kind of adorable but in me is just sad).  After five days of this, it’ll be another five days of wearing a mask indoors at all times, only being allowed to unmask in the galley to eat and drink in the corner labeled “FOR COVID USE ONLY”  Again, no shaming here. 

Some of this process makes sense.  Some is pure theater.  But it will catch Covid if it arrives.  As much as I hate my isolation, the public health guy in me gets it and knows this works.  Besides, I’ve got 300 more days on-site.  I won’t miss anything.

But as I write this, with the exception of a couple of walkabouts I’ve been cooped up in my room in a false quarantine (as yes, it does mean what I think it means) at the South Pole for 72 hours, with two more days to go.  After that I can run loose, but only with a mask.  To be fair, it’s actually a pretty nice room, private with a twin bed over a six-drawer storage unit, desk and shelf space, a wardrobe, some empty floor space for my fold-up laundry hamper, and a window with a perpetual sunlit view of the Geographic South Pole.  Nonetheless, I’m going stir crazy.  I go to the cafeteria on schedule, take a tray back to my room, and eat it at the desk.   I can’t talk to anyone in the hall on my way back and forth despite wearing my mask and staying six feet sway, lest the schoolmarm catch me and make me write sentences.  It also means that over the course of today my room has smelled like biscuits and gravy and taco salad, and in the morning I’ll be greeted by the cheery aroma of desiccated barbecue ribs because I’m not allowed to return my used plates until the next scheduled feeding.  To say this is a prison is a metaphor too far…I know when my sentence ends, if I stay up late enough I can catch the satellite pass between one and five AM and still buy stuff from Amazon, and while I consider myself pretty cute I have no particular fears of the shower.  But wouldn’t it make more sense, given the official recommendations of our official government, for our official Antarctic program to let us go about the station in a liberal quarantine (again, used properly) for the next few days with masks on, taking them off only to eat in a designated area, testing appropriately until cleared, but being productive, learning new systems, taking stock of our supplies, and getting familiar with the clinic environment in the few days before our predecessors leave and we are truly on our own?  Still, it’s the price we pay for being here, and the view outside the cellblock is pretty great.  But if I don’t get out on probation soon, I may carve my last Milky Way brought from home into scrumptious chocolatey shiv.

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Since I originally write the body of this piece, there have been a few more developments on the Covid front.  First, as we neared our winter close on February 15, there was a mandate to clear the Pole of any Covid risk as well as not send anyone out who had a current infection.  So for five days in a row, we did mass Covid testing of everyone on station (nearly 100 folks at that time).  People would come to breakfast a get some eggs, maybe juice and a pastry, and have two healthcare providers they’d never seen before shove a swab up their nose.  I noticed that over time, the Physician Assistant got more business than I did, meaning that he probably had a reputation as a gentle swabber while I was looking for the cotton tip to hit the brain, determined to eliminate those fond recalls of third grade.  We did close to 500 Covid tests during that time.  The testing scheme did not exactly fit the CDC recommendations of doing RAT tests in asymptomatic patients 48 hours apart, and if they’re both negative you’re done.  But I get that some people may not want to admit to symptoms, especially if ti means potentially being forced to leave early or spend more time stuck in isolation.  Given the ways humans (chimpanzees?...see above), I was oaky with the extended days of testing and reassurance.  A bit of theater, perhaps, but reasonable given the situation.

But nothing ever goes as planned, and late one night during our testing mania an Air National Guard crew drifted into the Station to look around and see if our little store was open for snacks and souvenirs.  Apparently they encountered only a random person or two, and those at a distance, before zooming off again into the wild blue yonder.  But their presence was enough to throw the entire Covid testing plan into a tizzy.  As the flight crew were up and gone, there was no way to test the suspect individuals nor isolate them, so how do we make certain that Covid had not been accidentally introduced into the station?  We were also running short of Covid tests, especially if more mass sampling was in order.  We were on tenterhooks as we awaited direction from the powers-that-be up north; fortunately, cooler heads prevailed and we were able to continue our program without disruption.  (For the record, I have no idea what a tenterhook is, nor a tizzy other than things can get thrown into one.)

The policy seems to somewhat fluid as well.  In the few weeks prior to closure,  we accepted folks into the community without further masking who had already done isolation at McMurdo after testing positive for Covid.  I don’t have a clinical issue with that, but the asymmetry between my experience and theirs made up by the fact that if I was going to be in isolation, much better here than there.   And when the folks from the South Pole Overland Traverse (basically a month-long, tractor-powered wagon train bring winter supplies) stopped by, we did an initial RAT test and then they were allowed to roam freely about with the rationale that as they all tested negative before the traverse and had only been amongst themselves for over a month, if still negative they were surely clear.  Again, I have no problem with this, as it makes clinical sense.  But one of our managers was let go from the program for allowing into the station an adventurer who had just set a record for a solo voyage to the Pole and had been alone for 34 days without other contacts, so there’s some asymmetry in the response (and possibly other agendas) in play as well. 

I have no idea what our practice is going to look like in October when the summer staff alights on the ice.  I have a feeling that more quarantine and mass testing is in order, and that I might as well anticipate the need to order more cases of tests.  Maybe the word will get out that I’m a “rough swabber,” which may at least decrease my workload.  What I do know for sure is that whenever I cough, I reflexively look up at whoever’s nearby and say, “Not Covid.”  Because I should know, right?