Hope and Death

John Berman, interviewing Dr. Sanjay Gupta, December 3, 2020:

            “But there’s every reason to think that what’s going to happen over the next three weeks isn’t just awful but I’m talking historically catastrophic I’m talking 1918 levels of pain for the next month and a half or so until the vaccine comes into play.”

            “I have been tracking exactly what you said very closely John to sort of see where are we in this country as compared to what is widely considered as the worst public health disaster in the history of the world hundred years ago or at least the last few hundred years and … we have better hospitalizations, ICUs, therapeutics, and an ambulance system and despite that, if you look at the numbers, we are tracking just as badly as back then which speaks to the fact that no matter how good we get scientifically and all the wonderful things that medicine can do, despite all that, human behavior is still sabotaging us…”

            “I was looking at the models again last night and the projected peak keeps moving but sometime in January —the issue really is that we may stay there and just plateau at that unacceptably high-level for a long period of time…The exponential growth is too high…90% of hospitals now are at capacity around the country. Where do you go? …if the entire country is on fire what is the escape hatch? It is becoming increasingly hard to find one”

            “I don’t know where this peaks at this point I mean this is starting to defy the models even the aggressive ones in terms of how bad things could get…I don’t know if viewers have noticed but we hardly ever present those worst case models what we are presenting to you is sort of the middle of the road sort of model they could be better if we actually started to employ mask mandates and talk about those five locations restaurants, bars, cafés, hotels, houses of worship for example or it could be a lot worse as well and right now I’m not sure where we’re headed, but it’s very disheartening to hear that they’re still having this party at the White House, not just because of the White House but because then I get 100 emails from people saying hey how bad is it really? having a bunch of relatives over for the holidays will be OK right? That’s what I get all the time and I have to be the guy who says no it’s not and I hate to be the guy that says that, I enjoy a great holiday party as much as the next guy but this is not the year to do that.”

 

Dr. Michael Osterholm, leading epidemiologist, December 3, 2020:

            “Now the actual percentage of deaths as a number of people hospitalized is going to start going up because we can’t provide the same quality of care so you’ve got that factor at the same time you’ve also got the surging number of cases overall and that’s up to us that’s on us you know. We have a lot of power over this virus if we just stop swapping air with our friends, colleagues, and unknowns and if we don’t do that we’ll see the case numbers go up while the quality of medical care will actually go down because of the inability to provide adequately trained healthcare workers that’s the perfect storm and at that point I don’t know what this number could look like. It could obviously grow substantially.”

 

Dr. Robert Redfield, CDC Director, December 2, 2020:

            “December, January, and February are gonna be rough times. I actually believe they’re gonna be the most difficult time in the public health history of this nation, largely because of the stress that it’s gonna put on our health care system.”

 

Dear Students,

It’s been almost six weeks since I’ve written an update, and the reason is I haven’t known how to approach the disaster we’re in, or to really add to what’s on the news. I have never been so proud of medical science or so ashamed of my country.

Yes, it’s been a rolling disaster since March but now it’s a quickly swelling disaster and we have failed in every possible way to do the simplest things we’ve been advised to do all along. They didn’t originate with me of course but as those of you who studied “Disease and Human Behavior” with me last spring, I have been issuing warnings about the new coronavirus since January. I have said the same things over and over again, along with others who know much more than I do about this, and all advice has been ignored.

Why repeat it yet again? Well, if a fraction of people who hear the message heed it, that is a few cases prevented and a few lives saved.

Flu pandemic of 1919 vs COVID-19

If you were in that class, you saw a version of this graph before. It was an old-fashioned looking but perfectly respectable summary of the three waves of mortality in the flu pandemic of 1918-1919, which we studied. What I’ve done here is not an exact comparison, at all. These are mortality rates of major cities around the world. I’m superimposing points and projected points in the U.S. epidemic, which as you know I believe is most accurately drawn from hospitalizations, which you can see in the second chart. What is similar is that the 1918 pandemic started with a very serious wave, or two waves depending how you look at it, followed by the real killer wave, the worldwide tsunami. In the second chart you can see how our hospitalizations nationwide came in two waves, in different parts of the country.

COVID hospitalizations as of 12-4-20

The second chart ends with an exponential rise that has swept past the peaks in the first two waves and is going straight up. (The chart, shown on CNN December 4th, comes from The Covid Tracking Project and is almost identical to the chart shown on the same day in the machine-learning-based model of models that integrates many sources.)

As you know if you’ve read these updates before, I like to present good news and bad news. One part of the problem right now is that the bad news is worse than ever. How do I word things when I’ve given so many warnings before? It’s not that I’ve “cried wolf”—quite the opposite, every warning I’ve issued has tragically proved true.

No, it’s that as a writer I can’t figure out how progress from bad to terrible to horrible to disastrous to catastrophic without sounding like a repetitive jerk. And how am I supposed to find words to say that the next two months will be by far the worst we have had? And that the reason will be the same as it has been all along, or at least since we went from bad to worse back in March: Not the virus, but behavior—which viruses don’t have—human behavior.

Okay, nothing new. Yes, denial has gotten worse. Heroic nurses have described people dying of COVID-19 whose last words were that COVID-19 is a hoax. Trump rallies were held throughout the summer and early fall with near-zero precautions and each one was followed by a sharp spike in cases, roughly a doubling, in the communities where they were held, with hospitalizations and deaths close behind. Failure to follow guidelines caused predictable spikes after the Memorial Day weekend, the July Fourth weekend, the Labor Day weekend, and Halloween.

Oh, did I leave out Thanksgiving? No. We don’t have the data yet. It will come soon, and it will add a big surge of cases to what is already—let’s see, are we at catastrophic yet, or only disastrous? Hmm.

I know, we’re not the only ones. Canada had its Thanksgiving on October 12th, and since Canadians also didn’t follow guidelines, they are in their Thanksgiving surge now. But they never got, and will never get, to the levels we have been brought to by American Exceptionalism. We are the worst in the world. Japan is worried right now, but they have had fewer cases in the whole pandemic than we had yesterday!

What about the good news? I’ll get to it soon, but first I have to explain why good news is bad news. The good news is mainly about vaccines, and in my opinion they are going to be wonderful. Some of you have asked me what I think of them, and my answer is that collectively they represent one of the greatest achievements in the history of science. So how can they be bad news?

They can be bad news if they add to the denial of the pandemic—if they make people think it’s basically over, right when we’re starting the worst months of it—months during which the vaccine will do little or nothing to stop it. If you are reading this, it is overwhelmingly likely that you will not be able to get a vaccine until April, May, or later.

Depending on the models, we are talking about adding between two and three hundred thousand American deaths before that time, perhaps as much as doubling the total we have today. And that doesn’t take into account an unknown but undoubtedly large minority who will refuse the vaccines, or the potential for halting vaccinations in the unlikely event of a vaccine safety disaster. By the way, if any of the three vaccines I describe below were offered to me today, I would take it.

The Good News

  1. On November 9th the Pfizer-BioNTech collaboration on an mRNA vaccine announced completion of their Phase III trials and reported an astounding 95 percent efficacy. The FDA will make a decision on December 10th about approving it, and if they say yes, it will be deployed to the highest-priority populations starting December 15th. (An mRNA vaccine consists of messenger RNA injected with the hope that it will enter cells that read the message, assembling a spike protein of the virus, which provokes your specific immune response.) This vaccine is already approved for use in the UK.
  2. On November 16th Moderna announced that its vaccine (also mRNA) completed Phase III trials with an efficacy of 94.5 percent. The FDA will decide on December 17th whether to approve it, and if the answer is yes it will start shipping on December 22nd.
  3. On November 23rd, the Astrazeneca-Oxford University collaboration completed Phase III trials and announced that its vaccine had on average 70 percent efficacy, easily crossing the threshold for FDA approval (50 percent) despite falling short of the two prior announcements. However, they made a mistake in one arm of their study and only gave half the usual first dose, giving a full dose for the second injection. This arm of the study had an efficacy of 90 percent. More important, their vaccine, unlike the first two, can be stored for 30 days at ordinary refrigerator temperatures. (Their vaccine uses an adenovirus vector genetically engineered to carry the message for a coronavirus spike protein and to be unable to reproduce itself; one possible explanation for the happy dosage mistake is that some people develop immunity to the adenovirus and therefore the booster shot doesn’t work as well—unless your first shot was a half-dose. Needless to say, this is under study.)

The Bad News

  1. Both of the marvelously efficacious mRNA vaccines have to be stored at ultra-low temperatures—the Pfizer at -70°C, the Moderna at -20—until almost ready to go into arms. Now I took a canister of liquid nitrogen (-195) with me to the Kalahari Desert to store blood samples for a study, so the temperatures themselves didn’t faze me. But I had a small number of samples and we need to store 700 million vaccine doses just to cover the US. Nothing remotely resembling the network of special freezers we’ll need exists in our country today.
  2. Aside from the thousands of freezers, an unprecedented distribution system will have to be created almost from scratch. I heard someone from Pfizer say that 20 freezer trucks are ready now to carry the vaccine where it’s needed, but that the eventual number of truckloads would be 40,000. The vaccines have to be shipped in perfect condition, and there has to be someone at the end of each journey qualified to inject it safely.
  3. Remember how many times we heard President Trump say that anyone who wants a COVID-19 test can get one? It wasn’t true then and it isn’t true now, in fact testing capacity is declining when it should be many times what it is today. We will have a new president, one who takes science seriously, but science can only go so far against the formidable engineering, social, and political obstacles (much authority will devolve to the states) to doubly vaccinating 350 million Americans. You have to get the first dose, then come back three or four weeks later for the second, then wait a week for your immune system to really protect you. Varying estimates say 100 million Americans will be vaccinated by anywhere from February to July.
  4. Many, many Americans will refuse to be vaccinated, and it is uncertain whether we will ever have enough vaccine acceptance to achieve herd immunity.

Meanwhile, today is a day of milestones. There were 2,879 deaths yesterday, the highest number ever, expected to reach 3,000 a day soon. More than 100,000 people are currently hospitalized with COVID-19, and hospitals throughout the country are nearing full capacity. It isn’t the number of ICU beds or even any beds. It’s the heroes who stand next to them.

Remember when front-line health care workers left Georgia and other safe places for New York, and then later when New Yorkers returned the favor? Nobody is going to leave anywhere for anywhere because every state will need them—and many more like them—right where they are. Death rates in those hospitals will go up as they are overwhelmed.

Those of you who are pre-med or pre-nursing, remember what you see over the next two months, because it will be catastrophic, and this won’t be your last pandemic. Watch the doctors and nurses and respiratory therapists despairing, even crying every day until they collapse from exhaustion or get the virus themselves, knowing all along that this didn’t have to happen.

Because guess what: We have had since Day 1 measures as effective as many vaccines. Masking. Social distancing. Handwashing. These could have prevented most of the 277,000 deaths we’ve had so far, the untold suffering of the families of those people, and the many, many thousands who thought they had easy cases but will end up paying a physical price throughout their lives.

The same measures can save scores of thousands of lives not lost yet but standing in line for their own coffins as they go to bars, hold parties, and “celebrate” the holidays. This will be the most tragic holiday season in all of American history.

I have never been so proud of medical science or so ashamed of my country.

Mask. Social distance. Wash your hands. This is the vaccine you have had all along, and its efficacy is very very high.

Dr. K

PS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York TimesCoronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. With thanks to Prof. Craig Hadley, I also strongly recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning, which has outperformed most others in its projections.

 

One comment

  1. Sylvia Cerel-Suhl says:

    Unfortunately this is too true – And what most people don’t understand is that once hospitals are full and healthcare workers are stretched beyond their abilities ALL causes of death go up, ALL health problems don’t receive proper attention.
    The folks who didn’t or don’t believe in COVID-19, STILL have family, friends or themselves who need things like treatment for motor vehicle accidents, heart attacks, strokes, or cancer. People receiving care for even minor things like emergency visits for food poisoning and dehydration, kidney stones or injuries will all dramatically suffer with worse or no healthcare available.

    Surely these facts could help motivate the ? 30-40% still engaging in risky behaviors ( or in some states suing for the right for everyone to do so.) If only there was a medium they trusted to reach them with this message. But scientific literacy , and following the large scale cause and effect argument is clearly beyond a significant portion of our population. A population of the descendants of the independent thinkers who left every land to come here “ yearning to breathe free.”

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