Issue: April 2020
Disclosures: Leonard Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB. Cassandra Calabrese reports no relevant financial disclosures.
April 28, 2020
6 min read
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Reflections on COVID-19 Across Generations

Issue: April 2020
Disclosures: Leonard Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB. Cassandra Calabrese reports no relevant financial disclosures.
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These are unparalleled times indeed. We believe over the next number of weeks and months, the events unfolding now will represent a defining time for our profession and our society. As we write this in March 2020, we are approaching the maelstrom of the epidemic and bracing for events that cannot be predicted with great accuracy.

We both, like you, are practitioners in the field of rheumatology and, in addition, we have our footing divided between the practice of rheumatology and the practice of infectious diseases. Who would have predicted that our interests and skills would place us here at this moment? Who would have thought that combined training in rheumatology and infectious diseases would ever be so timely?

Leonard H. Calabrese
Leonard H. Calabrese
Cassandra Calabrese
Cassandra Calabrese

We are privileged to be called upon to humbly render our opinions on COVID-19 to our colleagues, our institutions and other organizations as we add our pebbles to the pile. At times, it seems so ironic for us to have arrived at such a central place in this pandemic. As Rick said in Casa Blanca, “of all the gin joints in all the world, she walked into mine” and so did COVID-19 enter the world of rheumatology and infectious diseases. Although we are of two different generations, we bridge them as colleagues and family and are privileged to share with you a few reflections and admonitions, as we weather this storm.

Concerned Yet Grateful

Of course, we are concerned about the pace of the pandemic as well as where we are going and how fast. We look at the heroics of our areas’ hospitals racing to prepare and increase capacity for the unpredictable surge. We worry about our families and friends and colleagues and get messages daily of the good and bad. We are you.

We both have feelings of great pride for many things, as do you. Our own institution, as most of yours are as well, is in full battle mode and we are humbled by the bravery and dedication of our front-line workers but also our administrators of whom we are frequently so judgmental. We are grateful to so many, but especially the unheralded environmental service workers who clean and scrub selflessly. We are proud of our area hospitals and colleagues who are bridging institutional rivalries to work collaboratively. We are also proud of our state of Ohio and its Republican governor who is — in our opinion — best in class for leading the charge for social distancing in an effort to #flattenthecurve.

From a rheumatology perspective, who cannot be amazed with the rapidity of the global rheumatology community to come together to help track, investigate and inform us all on the COVID-19 epidemic. This critical work is thanks to the efforts of so many people, but a special shout out goes to Phil Robinson (@philipcrobinson) and Jinoos Yazdany (@JYazdanyMD) who sprang into action to spearhead the creation of the COVID-19 Global Rheumatology Alliance (https://rheum-covid.org/). The mission of the Alliance is to create a secure, de-identified, international case reporting registry and curate and disseminate the outputs from that registry.

The hope is that the information collected will help guide rheumatology clinicians in assessing and treating patients with rheumatologic disease and in evaluating the risk for infection in patients on immunosuppression. Each of you can tangibly contribute by entering rheumatic disease patients on the website in less than 5 minutes time! We know that each of you has your own story of colleagues, friends and institutions who infuse each of us with pride which is a driver of empathy.

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The Pace of Science

Whatever we write today will be outdated in the few-week turnaround of this editorial so let us reflect from a 30,000 foot level. First, who would have thought that in this first quarter of the epidemic, the world would be so focused on antimalarials and IL-6 targeted therapies? We also add that many more therapies of which the rheumatology community is so familiar with (anti-cytokine agents, kinase inhibitors and beyond) are under active consideration and or investigation.

As of March 30, ClinicalTrials.gov lists 172 trials just launching or about to in the battle against COVID-19. We have found ourselves, and we believe you will find yourself, valuable resources to our colleagues in the fields of infectious disease, critical care, hospital medicine, and beyond who are grappling with therapeutics with which they are not familiar. Lend your expertise now and it will be valuable and appreciated.

However, how can we possibly keep up with this? Although it is hard, this is an area where social media combined with critical appraisal of data can provide us with real-time information. We have each read so many articles that we would have never seen otherwise simply by following the feeds of some of the most respected critical thinkers in our field.

Other resources to keep an eye on include an up-and-coming patient-facing website (http://www.rheumcovid.com/) that will be geared toward rheumatology/autoimmune disease patients, spearheaded by Jeffrey R. Curtis, MD, MS, MPH. The aim of this website will be to pull from credible sources including non-rheumatology (such as the CDC) and rheumatology-specific (eg, ACR, EULAR, CreakyJoints) resources, as well as to cover up-to-date articles and stories on COVID-19, serving as a ‘one-stop shop’ for credible and current information. Healio Rheumatology will make every effort to serve as a clearing house for the highest level of evidence-backed information on COVID-19 as we move ahead.

Coping, Hope and Compassion

Dealing with uncertainty is by definition stressful, and we both are experiencing the same anxieties as you. While we don’t have any panaceas for this, we will share our collective approach. Interestingly, we both have similar personalities and tend to be the extreme optimists in our family. This does not mean that we have magical thinking and, in truth, our optimism is currently being challenged.

We both are informally stoics — in fact, Len actually keeps a medallion on his desk that says “Amore Fati” that literally means love your fate, as whatever is happening is going to happen and thus is necessary. We try to focus on things that we can control and the rest... well if you don’t mind, it doesn’t matter. One of Len’s favorite books is The Daily Stoic by Ryan Holiday and Stephen Hanselman — check it out.

Hope is key right now as it propels us through uncertainty. In tangible terms, as we come out the other end of this crisis, we will no doubt have learned much. We strongly believe that we will have developed therapies and preventive vaccine technologies that can be exploited to other arenas of health care that will be likely to help us all. Even more importantly, as a global community, this horrible pandemic will hopefully teach us all that we are frail and interconnected in ways we never imagined and that systems of collaboration, rather than nations first, are the only road to a better way of life.

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Finally, there is empathy and compassion. These terms define our ability to see and process the suffering of others and communicate our concerns back to them combined with a desire to help. Already we are seeing examples of empathy and compassion in ways that are inspiring, as along with extraordinary care we are seeing extraordinary caring. We must cultivate and grow these human attributes as they are the true wellspring of resiliency.

Are there generational differences in our perspectives regarding the COVID-19 pandemic? In reality, not really any important ones. Kurt Vonnegut, the great writer and humanist we both revere, reminded us that generational differences are really trivial, given the fact that we all have lived for such a brief time on our precious little planet. Accordingly, Vonnegut believed we should all treat each other as brothers and sisters, as family. We think this bit of wisdom is apt advice at this time.

We look forward to writing a follow up of this sometime in the future and truly hope and believe there will be a rich story to tell. The text of this remains to be written, so for now let’s be silent and reflect. Send us your take through Twitter at @LCalabreseDO or email me at calabrl@ccf.org.

Disclosures: Leonard Calabrese reports consulting relationships with AbbVie, Centecor Biopharmaceutical, Crescendo Bioscience, GlaxoSmithKline, Horizon Pharma, Janssen Pharmaceuticals, Pfizer, Regeneron Pharmaceuticals and UCB. Cassandra Calabrese reports no relevant financial disclosures.