Opening Gambits: Freedom Goes Viral

            “With your talents and industry, with science, and that stedfast honesty which eternally pursues right, regardless of consequences, you may promise yourself every thing—but health, without which there is no happiness. An attention to health then should take place of every other object.” 

                        Letter from Thomas Jefferson to Thomas Mann Randolph, Jr., July 6, 1787

Dear Students,

The letter that includes the above passage was written as part of a series to a young man of great promise. Randolph was 18 on the date above, which happened to be two days after the 11th anniversary of the Declaration of Independence. The Constitutional Convention was under way in Philadelphia, but Jefferson was still posted to Paris. (The federal government, still based in Philadelphia, was suspended several times during the 1790s yellow fever pandemic.) He began the letter by apologizing for his delay; he’d been traveling in southern France and northern Italy.

There is plenty of other advice in the letters, but young Thomas had been seriously ill a couple of years earlier, and the elder Thomas was concerned. The young man did take care of himself, and when the Jeffersons returned in 1789, he courted and married Jefferson’s eldest daughter Martha. They had 13 children together; 11 survived to adulthood. They eventually became estranged because his drinking interfered with his health and their life, although she was at his bedside when he died at age 59. But first he was a colonel in the War of 1812, served two terms in Congress, and became Governor of Virginia.

His future father-in-law’s advice kept him healthy for decades, and when he stopped following it he paid the price. I wonder what Thomas Jefferson, perhaps the greatest founder of early American freedoms, would have thought of the people risking their health and that of others to protest social distancing—while crowding together and refusing to wear masks—in the name of freedom.

All 50 states and many countries are easing or marching boldly out of their lockdown phases. It’s too soon to know the results; I predict they will be fine in some places and terrible in others. However, even “terrible” is in the eye of the beholder. Sweden has twice the population of Norway but around 16 times the number of COVID-19 deaths. Swedes regret that so many elderly and vulnerable people have died, but they defend their strategy of valuing individual autonomy and freedom; they think that other countries will have to follow their lead to the elusive goal of herd immunity.

Clearly a large minority of Americans agree. New York is opening slowly and carefully, but only after rigorous measures put its severe epidemic almost completely behind it. Texas and North Carolina are opening  boldly while cases continue to rise. The US as a whole gives a false impression of decreasing cases, but that is due to the huge decline in the worst-hit state, New York; most of the country is flat or rising.

The First Amendment to the Constitution, insisted on by Jefferson and drafted by James Madison, is now being used by leading legal authorities to justify anti-lockdown protests; they don’t mention the limits on my freedom to falsely yell “Fire!” in a crowded theater, or on my freedom to drive myself home from a party where I’ve been drinking. Protests are different as long as they’re non-violent. Apparently, wilfully spreading viruses more dangerous than bullets (bullets don’t keep jumping from person to person) is non-violent.

Good News

  1. The pharmaceutical company Moderna reports that of 45 patients who received their experimental vaccine, the 8 who got two specific doses (25 and 100mg), mustered antibodies to the virus more strongly than those found in people who have recovered from the disease. This vaccine uses messenger RNA (mRNA), which the viruses uses to make its proteins; this is a new approach that could be a game-changer for other viruses.
  2. Some states are opening slowly, carefully, and systematically. California is expanding its corps of contact-tracers from 1000 to 13,000. New York is deploying both viral and antibody testing, as well as contact tracing, and is poised to reimpose any restrictions it lifts if conditions warrant that. In Germany, this sequence from lockdown to partial opening, to small outbreaks, to selectively reimposed lockdown has already cycled through. When we have broadly available testing and contact tracing, as only a few places are approaching now, we can reopen more safely.
  3. Hospital systems are no longer overwhelmed in most of the U.S., and increasing numbers of elective procedures unrelated to COVID-19 are being done. Important exceptions are small community hospitals in areas surrounding meatpacking plants, prisons, and other hot spots, which may still be headed for disaster.
  4. Stay-at-home orders have worked. A multicity ongoing study conducted by the School of Public Health at Drexel University, estimates that the successful stay-at-home patterns prevented more than 2 million hospitalizations and 230,000 deaths. There is no vaccine and no treatment that has any prospect of making this much difference in the near future.
  5. We are understanding more and more about the course of illness (look at the excellent Medscape graph below; no, really look at it), modes of transmission (very numerous), and symptoms, especially those outside the lungs, also numerous.

Bad News

  1. Just as one swallow doesn’t make a summer, 8 people responding doesn’t make a vaccine. The Moderna study is a very early Phase 1 trial. Phase 2 will involve hundreds of people, Phase 3 thousands. About a hundred other vaccine candidates are under study. I wouldn’t want to be a premature adopter of any of them. Remember that uselessness in preventing the disease is certainly not the worst possible vaccine outcome.
  2. I believe that bad blunders are being made in some reopenings. Time will tell, and it will take time because some states and localities are doing it right, some are not, and people in many places are taking more or fewer risks than their governments advise. I get that everyone is tired of being locked down. Imagine how tired we will be of death if the second wave (almost certain to come in the fall, complicated by flu season) has, like the second wave of the 1918-19 flu, far more cases and deaths than the first wave. All the carpenters in America working full tilt could not make enough coffins.
  3. The small rural hospitals that may soon be overwhelmed are far less resilient, flexible, and resourceful than the big urban hospitals that expanded their ICU, ventilator, and to a lesser extent PPE capacity, in a matter of days to weeks in April. Community hospitals, even if they could somehow get the beds, ventilators, and other equipment, do not have the expertise to use them. Perhaps an army of doctors, nurses, respiratory therapists, and others from major medical centers will fan out to the rural hotspots overnight, but those people are literally sick and tired. How much damn heroism can we expect?
  4. Lockdowns have worked, but they are ending in haphazard ways, with hopelessly inadequate testing and tracing. We just have to see what happens, and continue building up (high-quality) viral testing, antibody testing, and contact tracing. Experts keep hammering away at this advice for a very simple reason: We are not there yet. Here’s your mnemonic: TETRIS: TEsting, TRacing, and ISolation.
  5. There is so much more about COVID-19 and SARS-CoV-2 that we don’t know. First, it was “Children don’t get it,” then, “They might be carriers,” then, “They’re definitely carriers but they don’t get sick,” to “Hundreds of children are showing up with a devastating post-viral hyperinflammatory syndrome and some of them have died horrible deaths.” The number with this, Multisystem Inflammatory Syndrome in Children may or may not remain small. Also, loss of smell and taste went from “Maybe in some cases” to “Maybe in a lot of cases” to “Often the only symptom.”

Your fellow student Caroline Yoon sent me a marvelous question the other day in a message called “Your take on positive retests?” She was concerned about the apparent reinfections in South Korea and on the aircraft carrier U.S.S. Theodore Roosevelt, and asked whether there might be reactivation of a long hidden infection as with HIV. It could be reinfection or reactivation or lousy tests, no one knows. But here’s my answer:

“The evidence of possible reinfection is very concerning in the two places you mention. The South Korea cases may be attributable to testing difficulties; the negative tests they had may have missed continuing infection (false negatives; there is a lot of evidence that this can linger for weeks to months). Or, the positive retests may be due to what some call “virus litter”—fragments hanging around after the infection is over (a type of false positive). The interpretation is complicated by post-infection symptoms due to viral damage during infection that takes a long time to heal, or to overactive and prolonged immune responses. The dreadful syndrome that has been hospitalizing and in some cases killing children (fortunately still a small number) is thought to be a post-viral hyper-inflammatory syndrome, perhaps a kind of autoimmune overreaction.

“The possible reinfection cases on the Roosevelt are more concerning to me than the South Korean ones, because conditions have been so controlled. The now 13 sailors who have retested positive did so after 14 days of quarantine and two consecutive negative tests. We haven’t been told whether any of the 13 have shown symptoms. Today it was announced that the Roosevelt will leave Guam and go back to sea—presumably, one hopes, without those 13. This will be an informative, I hope not dangerous, experiment, as the ship had over 1000 cases at one time not too long ago.

“I wish I had more definitive answers. Sometimes the best we can do is admit our ignorance, while pushing science forward to alleviate it.

“Stay safe, best wishes, and thanks again for your questions, Caroline.”

“Dr. K”

Eric A. Meyerowitz, MD; Aaron G. Richterman, MD, MPH,

A Quick Summary of the COVID-19 Literature So Far – Medscape – May 18, 2020.

Leave a Reply