New Sheriff, New Bad Guys

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      “We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never surrender.” Prime Minister Winston Churchill, House of Commons, June 4, 1940

     “C’mon man, gimme a break!” President Joe Biden, January 21, 2021, answering a reporter who asked if a million vaccinations a day was enough

Dear Students,

Don’t get me wrong. I love Joe Biden. I supported him when most of my family and friends supported Elizabeth Warren—who by the way was the smartest person running for president, and had policy views most similar to mine—or Bernie, or others. Also, I didn’t think anyone as old as me should be president again. Yet I supported Biden because I was fairly sure that he had the best chance of winning, and because I was completely sure that he is an exceptionally good man. Although I did not say this to many people, I thought that he might be a great president.

Also, he is off to a good start. The new sheriff is laying down the law—on racism, LGBTQ rights, economic rescue, environmental protection, masking, social distancing, and vaccinations. But as far as the virus goes, he does not get a break from me, and no, it is not nearly enough.

Dr. Peter Hotez, a distinguished physician-virologist who is probably the most knowledgeable person about the pandemic after Dr. Fauci—but who can speak more freely than Fauci even now—wrote an op-ed piece in the Washington Post on January 26th in which he described the new variants of the virus as a “looming catastrophe” that will bring us to 600,000 deaths by May. We need to deliver 500 million doses of vaccines—into Americans’ arms—to end community transmission. Do we want to wait 500 days? By that time the new variants will have run all over us. We need to do it by summer. Which is why Dr. Hotez is calling for 3 million vaccinations a day.

This means that we need more than two vaccines; a vast and rapid (warp-speed?) expansion of vaccination centers beyond those already planned; unprecedented invocation of the Defense Production Act; imaginative use of the armed forces, even beyond the National Guard; and innovative use of syringes and other equipment to minimize vaccine waste. A good account of the current vaccine development situation in terms of science is here, but we need more than science, we need wartime logistics.

We also need a new level of seriousness about masks, social distancing, and handwashing. If we don’t ramp up our use of these measures, we will surely face more lockdowns, with all the associated economic, social, family, educational, and psychological pain.

If you have studied with me, you recognize that we are in an evolutionary arms race with this virus. All infectious agents adapt and evolve. They evade our defenses—both vaccines and treatments. That’s why after almost four decades we don’t have a vaccine against HIV, which evolves even within one person. That’s why we need a new flu vaccine every year. That’s why every year, thousands die of TB and malaria because they are infected by strains that resist all known treatments.

If we don’t (culturally) adapt and evolve in the face of this new virus—or should I say these new viruses?—we will lose, and as always, black, brown, and Native American people will lose most. We will not win this arms race, this by far most deadly of all our wars, by asking for “a break.” We will only win by fighting the virus every hour of every day, in every place, in every way.

Good News

  1. The new sheriff is really, really different from the old one. His deputies can shoot straight and they know how to round up bad guys—bad viruses. The heads of the CDC, FDA, HHS and many other agencies responsible for fighting disease are superb people, not third-raters and sycophants like their predecessors; they are already speaking directly and frequently to the American people, without fear of censorship for delivering scientific truth. For the first time there is a national plan, and it is a fairly good plan. With it, we are building a shield against the virus that we never had before.
  2. There has been a significant decline in the past couple of weeks in the number of US cases and hospitalizations but not yet deaths, probably related to the end of the big holiday surge.
  3. The Pfizer and Moderna mRNA vaccines are working safely, and pretty soon a few million Americans will have approximately 95 percent protection (two weeks or so after their second dose). Preliminary data suggest that protection levels could be even higher in the community than they were in clinical trials.
  4. The Janssen/Johnson & Johnson (J&J) vaccine will likely be approved (like the first two) for emergency use in the U.S., within a couple of weeks. Despite being less protective than its predecessors, it is more effective than the seasonal flu vaccine and easily passes the threshold of 50 percent protection set by health authorities. It hides the DNA—the gene—of a SARS-CoV-2 spike protein inside the Trojan horse of a cold virus disabled from reproducing. It has tremendous advantages: first, it only requires one shot; second, it does not require any specialized freezing or cooling equipment (DNA being much more stable than mRNA). These advantages will make it literally a lifesaver in rural America and in the developing world.
  5. The Oxford/AstraZeneca vaccine, despite some stumbles in the Phase III trials, is being used in the UK and was just approved by the European Union. It requires two doses but no special freezers, and will probably be added to the US vaccine arsenal in April. It is similar in principle to the J&J but uses a non-reproducing chimp adenovirus (instead of a human one) as the Trojan horse. The DNA is stable at higher temperatures, but it is still being worked out what the ideal doses would be.
  6. A monoclonal antibody drug (bamlanivimab, Eli Lilly) has shown 80 percent effectiveness in preventing infection in a randomized controlled trial in nursing home patients, and even greater effectiveness against deaths. This would have been tremendously important a few months ago, before we had vaccines, but now that we do, it’s not clear how the antibodies will be used—especially since they may interfere with vaccine effects.

Bad News

  1. The big bad news, and it is really bad, is that the virus has evolved new variants—new bad guys that will make the new sheriff’s job much harder. Of course, it has been evolving all along. A new paper, “Emergence of a Highly Fit SARS-CoV-2 Variant,” traces the first big leap the virus took last spring. As you know, “highly fit” in this context means spreading faster for more reproductive success. That first mutation was a single base change known as D614G that emerged in Southern Europe and by June was the dominant strain in the world.
  2. Viral evolution continued. In December a new “variant of concern” (B.1.1.7) was found in Southern England that contained multiple mutations and was determined to spread much faster and cause more severe disease. The mutations make it easier for a spike protein on the virus to combine with ACE2 receptors on human cells to gain entry. Hospitalizations doubled in the UK as the new variant became dominant there. More replication, more fitness, more dominance. It has been found in several US states and is predicted to be the dominant strain here by March. Fortunately, it does not evade already existing vaccines.
  3. A new South African variant (B.1.351) with different mutations of the spike protein—one of the mutations is on the presenting tip of the spike protein—is spreading rapidly and may soon threaten my old friends in Botswana. Two cases were found in South Carolina. Dr. Brannon Traxler, Interim Public Health director for the state, announced that they are independent of each other and have no travel history. She added cogently, “We know that viruses mutate to live and live to mutate.” Another independent case was found in Maryland. Given that we only sequence half of one percent of the virus samples taken in this country, it may already be everywhere. Like the English variant, it is more contagious and produces more severe cases, but unlike the English one, it also appears to be less responsive to existing vaccines.
  4. A new Brazilian variant (P.1) is worrying scientists. It is spreading explosively there and has been found in Minnesota. It may infect people who have had the disease before. It may or may not turn out to be implicated in the newly announced tragic COVID-19 deaths of nine children in the remote Amazonian villages of the indigenous Yanomami.
  5. There is no chance that one million vaccinations a day in the United States will stay ahead of the coming invasion of these new viral variants. The best, if not the only chance, is a great intensification of other preventive measures, the same that have been recommended all along. Unfortunately the behavioral trends seem to be going in the opposite direction.

On “Meet the Press” yesterday, top epidemiologist Michael Osterholm said, “The surge that is likely to occur with this new variant from England, is going to happen in the next 6 to 14 weeks. And if we see that happen—which my 45 years in the trenches tell us we will—we are going to see something like we have not seen yet in this country… Imagine where we are, Chuck, right now. You and I are sitting on this beach where it’s seventy degrees, perfectly blue skies, gentle breeze, but I see that hurricane, Category 5 or higher, 450 miles offshore. And telling people to evacuate on that nice blue-sky day is going to be hard. But I can also tell you that hurricane’s coming.”

Dr. Nahib Bhadelia of Boston University’s School of Medicine, asked to comment on Osterholm’s metaphor, said we are in  “the eye of the storm,” not sitting on the beach with the storm hundreds of miles out. She means that the worst part of the storm so far—December and January—is deceptively slacking off. As the hurricane moves over us, the lull of the eye passes, and we get slammed with another monstrous storm surge in March and April.

Dr. Osterholm went on to say that we need “an audible”—American-footballese for a last-minute yell on the field that changes the plan. He thinks we need to get as many people as possible vaccinated once right now, and forget about the second dose until later. There is controversy about this, but Osterholm is really smart.

Recall what Dr. Traxler, South Carolina surgeon-turned-health official, said when she became the first American to announce the South African strain: “We know that viruses mutate to live and live to mutate.” She continued, ““That’s why it’s critical that we all continue to do our part by taking small actions that make a big difference. These include wearing our masks, staying at least six feet apart from others, avoiding large crowds, washing our hands, getting tested often, and when we can, getting vaccinated. These are the best tools for preventing the spread of the virus, no matter the strain.”

On December 15th, when I posted “Double Down or Double Deaths,” we had just crossed 300,000, but we were having the first vaccinations and hope was in the air. I said we could go to 600,000 if we don’t change our behavior. The IHME model now projects 582 thousand by May , 600 thousand taking the new variants into account. That’s the doubling. Considering we’re at 440,000 today, it’s not a stretch.  Depending on what we do and what the variants do, we could be anywhere between 600 and 2,400 daily deaths in May. The difference would be the equivalent of two 9-11’s every two days. And of course May will not be the end.

The new shield we got on January 20th is not nearly big enough or thick enough. And the new variants teach us that unless we think about protecting the developing world, protecting the whole world, which is the virus’s continuous playground, our shield will be full of holes.

Are you tired of the precautions? I am too. I want to hug my children and grandchildren so bad it hurts (and I don’t care that it’s ungrammatical). I want to see live theater. I want to eat out with my wife in any sort of restaurant, even McDonalds. I want to smile at people and see them smile back. I am tired of restricting myself for the benefit of myself, my community, and my country. I am, to use an  expression my mother might use, bone-tired. But I am not yet dead-tired. I will be dead-tired if and when the virus kills me.

And oh, by the way. In case you get to whisper in President Biden’s ear, give him this message from me: Mr. President, Sir, with all due respect, the next time a reporter asks you if a million vaccines a day is enough, do what you always said you would do: Level with us. Don’t say, ‘Gimme a break man.’ Say, ‘No, it’s not enough. We need three million a day at least, and  I promise you I will not rest until we have that. We are at war. We will fight this virus in the clinics and in the stadiums, we will fight in the pharmacies and supermarkets, we will fight on street corners and parking lots, we will fight in convention centers and on fair grounds, we will fight in the poor dense cities and in the bucolic countryside, we will fight with syringes and tests and masks and distancing; we will never surrender.’

Stay safe,

Dr. K

Superspreader Insurrection

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     “The vaccine is the weapon that will end the war, but it won’t hit critical mass until June, September or even December. If we float along relying solely on the vaccine, the way many states are, we are looking at months of shutdowns and the economic, mental, and spiritual hardship they bring.…We can’t do that. We just can’t let that happen. We can’t float along, watching the pain, the hardship and the inequality grow around us. That’s not what we do in New York. We must take control of our destiny.” Gov. Andrew Cuomo, State of the State Address, January 12, 2021

     “If quick action isn’t taken, then the highly infectious B.1.1.7 variant of COVID-19 will become the main variant in the United States by March, further burdening our already overburdened health care system.” Frank Diamond, Infection Control Today, reporting on Centers for Disease Control warning, January 18, 2021

Dear Students,

My wife Ann and I got our first dose of the Pfizer vaccine on Friday, and while we’re not changing our precautions at all yet, it’s a huge relief to have gotten started. We’re both over 65, which puts us in priority Group 1A in Georgia, but there was a lovely personal touch as one of my former students who is in practice in Atlanta reached out to us and said her office had vaccine. She was sitting right where you are around 15 or 20 years ago. Slightly sore arms were the only side effect.

Since today is the holiday honoring the Rev. Dr. Martin Luther King, Jr.’s great legacy, it behooves us to remember that of the 400,000 Americans killed by the virus so far, a greatly disproportionate number are black. African Americans have also borne a disproportionate share of the economic devastation. I have written about this before, but I am emphasizing it again today. In 1963, two days before my 17th birthday, I was present in Washington for Dr. King’s “I Have a Dream” speech. We have come a long way since then, but we still have a long way to go.

Case in point: the insurrection that took place in the same city on January 6th was overwhelmingly white, and many among them were avowed white supremacists. Nobody thinks that if the rioters had been black they would have been allowed to get as far as they did in taking over our government.

Two days from now the same huge mall that I stood on with two hundred thousand others on that day in 1963 will be decidedly empty, despite the fact that President Biden will be inaugurated.

One reason it will be empty is the virus of course, which Biden has so much more knowledge of, and so much more appropriate caution about, than his predecessor. But the twenty thousand National Guard troops deployed to D.C. this week are not there to defend against the virus. They are there to defend against another right-wing insurrection.

The attempted coup on January 6th at the Capitol, designed to prevent the transfer of power to a duly elected new president, was also a superspreader event. Very few of the rioting revolutionists were wearing masks, and they certainly weren’t observing any kind of social distancing.

More surprising perhaps, some members of Congress who were hiding from them also did not wear masks, despite being crowded into rooms where they were sheltering from violence. Some of them mocked their colleagues and their official physician who were wearing and distributing masks. These members of Congress were Republicans.

Since the pandemic began, 62 members of Congress have contracted COVID-19, 44 Republicans and 18 Democrats. At least 7 have tested positive since the insurrection, most likely because of mask refusal by Republicans. Looking at the course of the American epidemic, blue states were affected first but controlled the spread better, and red states have had a much worse fall and winter surge, especially after controlling for rural and urban populations.

I try not to get too political in these updates, but these are the facts.

Some students have asked me what will be different after President Biden is inaugurated at noon on Wednesday. My answer is: a lot. First, we have to get there, and the possibility of further disruption by Trump supporters both before and after Wednesday is real.

But here is the good news:

  1. Biden has already appointed the most competent and experienced physicians and scientists to deal with the pandemic. There is a world of difference between them and the people they are replacing. This includes the heads of the CDC, FDA, HHS, the Coronavirus Task Force, and many other positions, starting with Dr. Anthony Fauci, who will finally have the ear of the president and the ability to speak directly to the American people.
  2. Biden has a detailed national plan for rectifying the dismal failure of the vaccine rollout, with an attainable goal of having 100 million doses delivered in the first 100 days of his presidency. Far from abandoning the states to their own floundering, he will work closely with the states and their governors to properly organize distribution and injection.
  3. Similar national plans for huge expansion of testing will be implemented, giving America its first detailed knowledge of who has and who is spreading COVID-19. Ditto (see #2 above) on working with the states.
  4. Public health education for preventive measures against the virus (masking, social distancing, etc.) at a national level will be hugely improved, along with increased mandates where possible, and the standards and models set by people in national government will be positive instead of negative.
  5. President Biden will invoke the Defense Production Act much more extensively than his predecessor, giving manufacturers well-compensated mandates to produce more vaccine, vials, syringes, freezers, protective personal equipment, and many other sorely needed products to fight the war we are in, as has happened in previous wars, but so far very inadequately in this great war against the pandemic.
  6. While the Senate is only narrowly controlled by Democrats, Biden, like Lyndon Johnson before him, is a ‘man of the Senate.’ He spent most of his life there, knows the institution and its ways, and is friends with many sitting senators. He may not get 100 percent of the funding he wants to fight the virus, but he will know how to compromise and he will get a lot.

The bad news is:

  1. Political opposition to all of the above will continue. That includes resistance to public health measures, vaccine refusal, and pretty much everything else the new administration wants to do. The same people who brought you 400,000 deaths will do all they can to bring you at least a couple of hundred thousand more. Continuing insurrection will make all this worse.
  2. New variants of the virus, especially the B.1.1.7 strain first identified in England, are spreading fast in the United States. This is partly because they spread at least 50 percent more efficiently, and partly because our precautionary measures have been so inadequate and the vaccine rollout such a failure. Continuing insurrection will make this worse too.
  3. 100 million doses of vaccine in the first 100 days (i.e. by the end of April) will get us nowhere near the herd immunity that all vaccination campaigns aim for. Even with the (probably) soon-to-be-approved one-dose vaccine from Johnson & Johnson added to our current options, we will still have protected only a fraction of Americans.
  4. And probably the worst news of all is that we could easily have a late spring and summer surge in the new variants, given the laxity of proper precautionary measures, and the slowness of even a greatly improved vaccine rollout. The dual graph comes from the new CDC paper on this. On the left is a reasonable model of what will happen with vaccination but without strict precautionary measures. On the right, a likely result of vaccination with masking, social distancing, and so on.

So, due entirely to our own failures, the overall pandemic will likely be with us through the summer and possibly into the fall of this new year and beyond. But it won’t be as bad as it is now, it just won’t yet be normal. Of course, we could change all that if we did the right thing.

Stay safe,

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 Times Coronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. I also recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning. For an antidote to my gloom, check out the updates of Dr. Lucy McBride, who doesn’t see different facts but accentuates the positive. For an up-to-date account of the clinical facts by the marvelous front-line doc Daniel Griffin, listen to TWiV episode 701, a marvelously clear step-by-step from exposure to recovery in 39 minutes.

 

 

 

350,000

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“The vaccine rollout has been embarrassingly slow. I’m having patients call daily, anxious, fearful that they won’t get vaccinated, and as you know we’re losing thousands of lives a day. I think what needs to happen is a better communication between the federal government and our states; we need coordination of delivery; and we need more funding to get the shots out of the refrigerator and into people’s arms.” Dr. Lucy McBride, internal medicine physician, on Bloomberg TV, January 4, 2020

“The challenge we have right now should’ve been expected. I’ve been talking about the last mile and the last inch for the better part of several months. What we did is we invested a great deal of money in the basic research and development, the licensing and approval, the actual manufacture of the vaccines, but we we forgot about what will it take to actually get this vaccine in to peoples arms… Long-term care facilities are being handled by a private pharmaceutical or pharmacy company and they were not really ready to go. Healthcare workers have been slow in getting the vaccine to because they’re also in the middle of a crisis, and so to try to do both vaccination and care for all these patients has been a challenge.” Dr. Michael Osterholm, epidemiologist, on Bloomberg TV, January 5, 2021

“Come back and look with me. I have no beds. I have nowhere to put you.” Jenna Rasnic, Methodist Medical Center Emergency Room Nurse, USA Today video, January 4, 2021

 

Dear Students,

Happy New Year, sort of. If you’ve been following the news at all you know that we are in the worst phase of the American pandemic, getting worse every day. Hospitals are overwhelmed (in California, Mississippi, Georgia, etc., etc.) and the Christmas week (not to mention New Year’s Eve) surges have not even darkened their doors yet. Patients are being cared for in chapels and gift shops. Triage committees have been implemented in many hospitals so that patients can be turned away because others have a better chance of recovery. Naval hospital ships are being begged for in some cities. National guard troops have been mobilized to store the cascade of bodies needing refrigeration after death.

I won’t tell you in my own chosen words how the vaccine rollout is going, but it rhymes with “duster truck.” Also, with “muster luck.” Luck is something we have only really mustered in one domain since this time last year: the beautiful science of the vaccines. And that wasn’t luck anyway, it was earned by brilliant scientists. Apart from heroic clinical care, it’s the only thing we have done right.

If you want to understand why there are tens of millions of lifesaving vaccine doses sitting in freezers right now, why the government’s predicted number of actual vaccinations—20 million by the end of 2020—turned out to be a pathetic 2 or 3 million, all you have to do is remember the year that was: how carefully we handled containment in the early weeks, how strongly and promptly we stepped up production of personal protective equipment, how well we did testing and contact tracing throughout, how responsibly we followed the simplest public health measures, how effectively we communicated the dangers, and how cleverly we avoided and flattened the predicted and avoidable monstrosity of the fall and winter surge.

Oh wait, I forgot. We didn’t do any of those things.

Bad luck, you could say, I suppose, except it wasn’t. It was failure. Failure after failure after failure. Abject, shameful, humiliating, lazy, reckless, titanic failure. Failure on a scale and in a manner unprecedented in our nation’s history. Failure of thought. Failure of planning. Failure of ethics. Failure of patriotism. Failure of equality. Failure of caring. Failure of love.

For a while you could say we were lucky in one other way. We had a corps of nurses, doctors, and others on the front lines in ERs and ICUs who never flagged or shirked their duty even when they were crying in their cars on the way to and from work, terrified of infecting themselves and their families yet going back and back for more. They even worked out a few inventive ways of lowering our chances of death once we enter the hospital.

And how do we reward them for conspicuous bravery, compassion, brilliance, and patriotism under fire?

We reward them by grabbing them by their hospital gowns, slamming them against the ICU wall, and punching them until they fall down. We reward them by slobbering and spitting more and more virus in their beaten faces. We reward them by kicking their wounded bodies when they’re down. Those of you aiming for clinical careers take note.

And now, with the new holiday surges about to come, we will give them their ultimate reward: we will kill them with our virus. We will kick them until they are dead. And then the National Guard can come and store their bodies alongside ours in the overflow refrigerator trailers. Maybe trailer parks can double as makeshift cemeteries.

Some of you have thought that I wrote angrily before. I guess I have reached a new level of frustration, anger, and grief. To trash the beautiful hopes raised by the vaccines by having no plan to distribute them, to leave them to spoil on shelves while the hospitalizations and deaths mount and mount, is not only a last straw, not only an insult to the genius of those scientists who invented, developed, and tested them in record time and with near-perfect precision, it is an insult to humanity. Yours. Mine. Everyone’s.

Someone said that the mark of a civilized person is to be able to look at a page of numbers and weep. We are learning, more every day, to look at a graph and weep—and yet I don’t believe for one minute that we are civilized.

The Year of Colossal Failure will now be extended, not for weeks but for months. September is now an optimistic view of when we are done with this. Welcome to 2021.

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 Times Coronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. I also recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning. For an antidote to my gloom, check out the updates of Dr. Lucy McBride, who doesn’t see different facts but accentuates the positive. For an up-to-date account of the clinical facts by the marvelous front-line doc Daniel Griffin, listen to TWiV episode 701, a marvelously clear step-by-step from exposure to recovery in 39 minutes.

 

Shiny Object

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            “I think the bottom line here is that the interventions that are needed to prevent the spread, regardless of which variant it is, are the same, and I think that’s key and that’s where we should be focusing. While scientists are still doing the lab experiments to figure out what are the implications of this new variant—Does it really enhance transmissability as has been suggested? Does it really prevent antibodies from binding to the virus? Will it have any implications for vaccine efficacy?—these are still questions that scientists are hopefully going to answer in the coming days and weeks.” Dr. Soumya Swaminathan, MD, World Health Organization Chief Scientist, on Bloomberg Television, December 21, 2020

            “I think it’s pretty likely that social distancing and wearing masks will be helpful for this period. I mean, [the new strain] doesn’t have magical powers. If people aren’t near each other, it can’t spread. So this is a moment when you have to really realize that it’s both the vaccine and what we do that drives the population rate down, and as that comes down, we get to do more things in our lives. So, it’s, you know, a real sign that it’s not enough just to wait for the vaccine.” Dr. Joshua Sharfstein, MD, Johns Hopkins Vice Dean for Public Health Practice, on Bloomberg Television, December 21, 2020.

            “We’ve learned a lot in the last year about how to treat patients. We have therapies, modalities such as steroids, which reduce the risk of mortality 20, 30 percent. So we don’t have any game changers or homeruns on the forefront of therapeutics at this point. And so we’re gonna have to rely on public health, you know, sound public health prevention to get over this period. It’s gonna be a difficult next several months during these winter months as this surge is occurring, not only in the United States but in many parts of the world.” Dr Albert Ko, Professor of Epidemiology and Medicine and Chief of Medicine, Yale Medical School, on Bloomberg Television, December 24, 2020

Credit: Andrzej Wojcicki

Dear Students,

I’m going to keep this short, because of the holidays—the quotes above say it all—but also because of the holidays, I can’t not do it. There is too much danger around us right now.

A new type of SARS-CoV2 has been found in southern England. It is referred to by the British scientists as a VUI—Variant Under Investigation. There is limited evidence that it may be more transmissable, possibly 70 percent more, than previously identified variants. It has 23 mutations that have been seen in other variants, but not together. Some experts are skeptical that higher transmissibility has been proved.

Sealing the UK off from the rest of the world seems simply too late to do effectively now. The most likely reason it was found in the UK is that the UK does more viral genetic sequencing than any other country, far more than we do. Especially if it is indeed more transmissable, it is probably already in many other countries, including ours.

What can you do about it? What I hope you have been doing all along: masking, social distancing, handwashing, and avoiding social gatherings, including small ones that include people from two or three households. If you have been slacking off, stop slacking off and double down on all precautions. For our country, this is the worst time so far, by far.

The photo shows a shiny object that is distracting many people. Forget about those who are fool enough to reject the vaccine. I’m talking about those who feel complacent because they think the vaccine has already saved us. Not even close. That’s the point of the hourglass in the syringe. For each one of us who gets a first dose, the jab comes with a four to five week delay until protection.

For the country as a whole, it comes with a delay of six to eight months. That means we will not only not have protection as a nation, we will actually be in worse shape for the next two to three months than we have ever been before, or for that matter worse than any nation in the world has ever been before.

Because you see, although the vaccine’s scientific development has been Operation Warp Speed, the distribution will be Operation Snail’s Pace. I heard someone on TV brag today that we’ve vaccinated a million people already! In just ten days!

Good luck getting back to normal at that rate. Of course, it will increase. There will be millions by New Year’s Eve. But we need scores of millions right now, not millions, and we will need hundreds of millions to get back to normal—July 1st, if everything goes according to the non-plan. If it doesn’t…

Yes, the non-plan. There never was a plan for distribution, and there isn’t one now, not a national plan. This past week the White House finally got an order in for a decent number of vaccine doses. Manufacturing will start on that order, and…and…

If there had been a plan, especially if the Defense Production Act had been invoked to start producing the number needed, as could have happened long before approval—it was just a matter of money to make and store them—then we would be deploying scores of millions of doses now.

But there was no plan and the DPA was not invoked. So we face the worst now, for two to three months, and a pandemic that lingers, worsening until spring, then tapering slowly until summer.

Don’t get me wrong, the vaccines are great. They are very safe and highly effective. I would take either of the mRNA vaccines (Pfizer and Moderna) already deployed right now, today, if I could. In fact I would take my chances with either of the adenovirus vaccines (Astrazeneca and Johnson & Johnson) that haven’t even finished clinical trials.

The science behind them did not begin this year, it began with SARS-1 in the early 2000s. It’s being finished this year. What’s not going to be finished until the middle of 2021 at best is delivering this great science into the arms of the American people, and making our lives whole and normal again.

So it’s still up to you. Protect yourself and your loved ones. Protect neighbors and strangers too. Don’t be distracted by the shiny object in the photo. It won’t bring normality any time soon. It won’t even bring safety. Only you can do that.

Have a safe and happy holiday season by not trying to have a normal one. Live, and help others live, to celebrate normally next year and for many years after.

Be wise and stay safe,

Dr. K

 

Double Down or Double Deaths

2

            “I feel great. I feel hopeful today, relieved — I hope this marks the beginning to the end of a very painful time in our history.”

            —Sandra Lindsay, Director of Critical Care Nursing at Long Island Jewish Medical Center, after becoming the first person in New York, possibly in the U.S., to be vaccinated against COVID-19, December 14, 2020

             “It was truly, truly a humbling moment to be able to do that… So, this is the light at the end of the tunnel, and we truly have to be patient in order to make this work we have to make sure that we continue on to follow the guidelines —socially distancing, wearing our mask, washing our hands, and not having large gatherings—following those guidelines along with the vaccine, we can defeat this. This is something that is giving us that huge light at the end of the tunnel. It’s still a long tunnel but again, it’s up to us to do our part to assist in stopping this pandemic. So with those things in place along with the vaccine, it’s a good prognosis for the future… Let science speak for itself.”

       —Dr. Michelle Chester, DNP, director of employee health services at Northwell Health, who injected Ms. Lindsay with the vaccine, interviewed on CNN December 15, 2020

            “This disease is real, it is serious and it is deadly. Wear the mask, socially distance, if not for yourself then for others who may lose a loved one to the disease.”

—Kim Miller of Carbondale, Illinois, in the obituary she wrote for her husband Scott

Dear Students,

Two milestones for our country yesterday: the first people outside of research trials to get a COVID-19 vaccine were inoculated; and we crossed the threshhold of 300,000 deaths from the virus, by far the most of any country in the world. The vaccine will eventually be everywhere, but that death toll is only in America.

The first photo shows Sandra Lindsay (quoted above) being vaccinated by Dr. Michelle Chester (also quoted above) and the second shows Ms. Lindsay applauding as she gets her bandaid. She was one of the very first and possibly the first person in the U.S. to receive any COVID-19 vaccine outside a research trial.

People are understandably excited about the vaccine. For a few days it seemed that all I saw when I turned on the news was freezer trucks leaving Pfizer vaccine factories and distribution centers. You would think they were carrying the secret of life, and in a way they were, for those few who will be vaccinated soon. By next week at this time, trucks will be rolling out with a second very effective mRNA vaccine, from Moderna.

But I couldn’t help think of a different kind of refrigerator truck, the portable morgues that are being brought in to hospitals and coroners’ offices all over the country—and not for the first time—to store the overflow of bodies of people killed by COVID-19. Hundreds of hospitals are at full capacity for those still alive, and a third of U.S. hospitals are almost out of ICU space.

Doctors agree that death rates will go up as health care workers are overwhelmed—they, not ICU beds, are the ultimate bottleneck of care—over the next two to three months. Remember that the small number of front-line heroes being vaccinated this week will not have full immunity until the third week of January. Even according to the Trump administration, always bragging about solving the problem, projects 20 million people will be vaccinated in December, and another 20-25 million in January. That’s the first dose; 3-4 weeks later, the second dose, and then a week more for full immunity.

There are 350 million people in the U.S. We add roughly 200,000 cases and more than 2000 deaths a day, with deaths lagging by about 3 weeks. You do the math. Vaccines will have no impact on the next 60 days’ deaths (adding 120,000) and little impact in the next 60 after that. Community spread will continue up to and beyond April 1st, when deaths are projected to pass 500,000, or 600,000 with relaxation of mandates.

But you know of course what can slow the spread right now, today? Masking, social distancing, avoiding gatherings, and proper hand washing. What are the chances that enough Americans will take these simple measures during the holiday season? Close to zero, even though they would save scores of thousands.

In the past nine months, Americans have chosen the worst kind of “social Darwinism” which is contrary to Darwin’s own beliefs. We have chosen to allow the virus to kill off certain groups of people we evidently consider expendable: the old, the sick, the obese, and people whose skin is not white. And now we are cheering and celebrating the deployment of vaccines that will not make a significant dent in community spread for months, and will not stop the U.S. epidemic until we have doubled the number of deaths.

The choice is clear, as it has been all along, except now we have the worst two months of the pandemic right in front of us. We can either double down on precautions or double down on deaths. Remember that young people will be among those killed. And a much larger number of people young today will live out their lives getting reminded every day of the permanent damage the virus did to their bodies.

Celebrate the vaccines, sure, but bear in mind that they will not make a real dent for a long time. Other preventive measures will make a great difference now.

Enjoy the holidays safely, so we can truly have a blowout celebration next year. I’ll see you in January, unfortunately still on Zoom.

Stay safe,

Dr. K

 

Hope and Death

3

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.

 

Sick Man, Sick Land

2

           “All of the information medical professionals want to know, all the things that are happening, vital signs, what his clinical exam looks like, what does he look like as a patient, are we treating the actual patient or are we treating a political ideology or a title or an office, and without that information at your disposal it’s hard to think about what are the processes going forward, how are we keeping this evidence based, how are we keeping this patient centered, are we doing the best we can to manage this actual human, this actual person‘s disease and if we are, we need to be transparent with it.” Dr. Myron Rolle, former NFL player, now a Neurosurgery Resident playing defense on the front lines of COVID-19, Massachusetts General Hospital, discussing the White House handling of Donald Trump’s case

            “Do you think these rallies like the White House event a few weeks ago are likely to become superspreader events?” Jake Tapper, CNN

            “Yes, I really do, and the virus is the constant here, it is very contagious. You put people together for long periods of time, longer than 15 minutes, closely clustered, maskless, those are the ingredients for a superspreader event. The challenge has been there are so many newly infected people every day in this country, contact tracing has basically become a futile task. How do you contact trace 50,000 people every day? It would be an entire sector of our society dedicated to doing that. But what we did and we have some reporting on this, we were able to go back to these cities, Tulsa you mentioned, Phoenix, and then Oshkosh, Wisconsin, in the beginning of August. you know after people are exposed to the time they get hospitalized is typically a few weeks, right?… It’s hard to actually contact trace back to the event, but hospitalizations is a truer measure. In Tulsa as you mentioned Herman Cain [former presidential candidate and Trump supporter] may have been exposed at that event and subsequently died. But we know hospitalizations went up three-fold a few weeks after Tulsa. We know in Phoenix hospitalizations were about 2000 per day at the time of that rally and went to 3000… Oshkosh—hospitalizations went up 20 percent within that time period after the rally so, again, cause and effect is always gonna be challenging to draw but look what happened in all the cities a few weeks after. People got sick. Hospitalizations went up. Was it directly related to the rallies? We may never know. But in places where the virus is already spreading like this? It’s really challenging.” Dr. Sanjay Gupta, CNN

            “The next 6 to 12 weeks are going to be the darkest of the entire pandemic.” Dr. Michael Osterholm, leading epidemiologist, Meet the Press, Sunday, 10/18

            “Its not like it’s a mystery anymore of how to beat this thing, it’s just a matter of implementing what we know.” Dr. Ashish Jha, leading epidemiologist, 10/19

 

Dear Students,

I am writing in a different mood from my usual fact-based, hyperlinked style. My mood, I have to say, has become more meditative, and even sad. I have not avoided politics completely in past updates, but now I have come to a point where it is impossible to discuss the health of Americans in this dangerous moment in history without taking a political stand. The behavior of our current president is severely damaging to the public’s health, more so every day.

Because of his arrogance and negligence, he himself was colonized by SARS-CoV2, as were his wife, his teenage son, and many of his closest associates. He invited the virus into his body in late September, either at the superspreader event celebrating his Supreme Court Justice pick on the 26th, or in the next few days of intensive, close, maskless debate practice.

His young aide Hope Hicks became ill on Thursday, October 1st, and was confirmed to have the virus too late to protect many, including the president. Whether she gave it to him or got it from him is impossible to say, because of consistent lying about the president’s frequency of testing, not to mention refusal to reveal the results. In the small hours as Thursday turned to Friday, it was announced that both he and the First Lady had tested positive.

Friday afternoon he was ‘coptered to Walter Reed Army Hospital and admitted. After a number of days of concealment and lying by his doctors—both of which are still going on—we learned that he had had a significant fever, that his blood oxygen had been below normal on at least two tests, although no numbers were offered except that it was below 94 and above the low 80s. Since he had serious lung symptoms and signs, it is inconceivable that he did not get a chest X-ray, a chest CT, and possibly other lung studies; however, the results of those studies were not shared with us.

Similarly, we were never told the reason for his impromptu visit to Walter Reed Hospital a year ago. Lies were told first about it being an early start to his annual physical, then about it being a follow-up. He and his doctor officially denied that he had been evaluated for transient ischemic attacks (temporary strokes), but he bragged about his performance on a cognitive test with a very low ceiling, meaning it was only intended to rule out big brain problems such as stroke and dementia.

The first medical information we got about him was a letter from his personal physician saying he would be the healthiest man ever to become president. Obviously that physician could not have made the comparison, and he admitted that Trump had dictated the letter to him. Later we found out that he had a cholesterol in the 260s, since brought down. He is also reported to have a common cardiac problem, which based on his cholesterol levels in the past and on his obesity, would most likely be coronary artery calcification.

That’s about all we know of his underlying conditions (other than age and body mass index) relevant to his recent case of COVID-19. Based on the medications he was given, it is widely agreed that his doctors at Walter Reed—some of the best in the world—were very concerned. The main medications were:

  1. An experimental antibody medication that the president refers to as Regeneron—the name of the company that makes it, since the drug does not yet have a name;
  2. Remdesivir, an antiviral medication that many (including me) have thought was very promising but which a new WHO study (published since Mr. Trump got it) has cast doubt on;
  3. Dexamethasone, a standard steroid treatment for inflammation in many diseases, proven to save lives in advanced COVID-19.

Mr. Trump got all three treatments within the first day or two of his symptomatic illness, very unusual for dexamethasone. His doctors were either extremely worried from the outset or they were giving him VIP treatment, not always beneficial to the VIP.

He was also given supplemental oxygen, only instituted because of low blood oxygen and/or difficulty breathing, and fever-lowering medications, including dexamethasone. We never heard anyone on his medical team mention those medications when they repeatedly announced that he was fever-free.

He was released from the hospital Monday evening. He did not speak spontaneously but he had made a few brief videos for public consumption. After climbing the White House steps he removed his mask, appeared to have difficulty breathing, and did not speak.

If his course of dexamethasone was usual, it would have lasted ten to fourteen days. We have not been told if or when his dexamethasone was tapered to zero. If he was indeed tapered and has not been taking it for the past week or so, then it is quite possible he had a mild case, less serious than most who are hospitalized.

Because so little is known about the monoclonal antibodies he took, we can’t be sure when his own antibody response would be expected to kick in, but 21-25 days is a reasonable expectation after the Regeneron antibodies clear. We do not know if or when he stopped taking dexamethasone.

These questions are important for two reasons: 1. Is he immune or even partly immune to reinfection? 2. Is he still potentially subject to self-attack by his own immune system, which happens in so many COVID-19 patients—including, probably, his wife, who yesterday dropped out of her first campaign event in months, reporting a persistent cough.

COVID-19 is a two- or three- phase disease in the serious cases. First, the virus does its nasty work on your lungs, but it usually remains in the cells lining the lungs and bronchi. In most cases it does not enter the bloodstream or affect other organs on its own. It tends to stay where you breathed it in. It can kill you in this phase, but often doesn’t.

Phase 2 is your immune system response. This produces an attack on the walls of blood vessels everywhere in your body. This, your own body’s response, is usually what damages your heart, kidneys, brain, blood vessels, and other organs. This is very often the cause of death, including in children. By the way, the same was true of the influenza of 1918-19, although most deaths were in young adults, who are relatively protected from COVID-19 death.

Phase 3, which we are learning occurs in more people than we thought, is what has been called the “long haul.” Long haulers have symptoms, probably due to the lasting effects of inflammation, for months after recovering from the main part of the illness. The virus is too new for us to know whether these months may turn into years.

When Former Governor Chris Christie, whose COVID-19 was almost certainly contracted while coaching the president for the debate, left the hospital after a more serious case than Mr. Trump’s, he said loudly and clearly that he had been wrong, that he had let his guard down, that he had underestimated the virus. He also said that everyone should take the virus very very seriously.

Mr. Trump said the opposite. He told us not to be afraid of the virus, that he had beaten it and we could too; we should refuse to let it dominate our lives. He said that he had been cured by “Regeneron,” a completely experimental treatment no ordinary patient can get. There is no cure for COVID-19 as yet. In the days that followed his discharge, Mr. Trump showed what are very widely recognized mental symptoms caused by dexamethasone: strangely elevated mood, disorganized thought processes, and hypomania.

He soon returned to his most intense level of campaigning, making long speeches without difficulty breathing. The most likely explanation for this recovery is that he simply dodged the bullet—he had a mild, short case irrespective of his medications. The second is that he really was greatly helped by the trio of medicines he was given: the cocktail of two antibodies given to very few people in the world; the Remdesivir; and the dexamethasone started exceptionally early in his illness. As far as we know, no one has ever been given this combination of drugs with this timing.

A third, and I think distant, possibility, is that he is not yet over it. It is only 19 days since he entered the hospital. His treatment may have postponed his Phase 2, the autoimmune attack, rather than putting it permanently aside.

Mr. Trump’s public remarks about the virus since he had it are something like a worst case scenario for almost every public health expert and every family mourning a COVID death. He has stepped up his rhetoric minimizing the virus and he has held two to three likely super-spreader events per day for the last week, many in states that have rapidly rising case loads and hospitalizations. He continues to violate and ridicule the only preventive measures we have, or will have, between now and when we can be widely vaccinated, and he continues to lie relentlessly about when such vaccination is likely. He has caused, and will continue to cause, many thousands of needless deaths, and the suffering of hundreds of thousands of survivors of the virus and of the loss of loved ones.

Which brings me to the question of the other kind of illness he may have.

For years now psychiatrists have been arguing over whether it is possible to give Mr. Trump a diagnosis from a distance. The American Psychiatric Association defends the Goldwater rule, which rejects such diagnoses of political or other public figures without examining them. This organization preemptively threatened sanctions against member psychiatrists who attempted to diagnose Mr. Trump without examining him personally.

Others, including a group led by Bandy Lee, a psychiatrist and ethicist at Yale Law School, have concluded that the well-established Duty to Warn applies to Mr. Trump. This duty holds that patient confidentiality may or must be violated when the doctor concludes that the patient poses a clear and present danger to others, based on what the doctor has learned.

Few psychiatrists would claim that they can glean more information in a face to face two-hour diagnostic interview with a new patient than they already have about Donald Trump in the public record, which, importantly, goes back through his adolescence and childhood. I have an MD but do not practice medicine and am not licensed to do so. I have a lifelong interest in psychiatry and neurology but I am not qualified in either, but neither do I have anything to fear from APA sanctions.

So I will not give you a diagnosis, but I will tell you the criteria for the diagnoses that are most frequently discussed as mental disorders Mr. Trump may have.

Narcissistic Personality Disorder (NPD, DSM-5 301.81):

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

Antisocial Personality Disorder (ASPD, DSM-5 301.7)

  1. A pervasive pattern of disregard for and violation of the rights of others, since age 15 years, as indicated by three (or more) of the following:
    1. Failure to conform to social norms concerning lawful behaviors, such as performing acts that are grounds for arrest.
    2. Deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit.
    3. Impulsivity or failure to plan.
    4. Irritability and aggressiveness, often with physical fights or assaults.
    5. Reckless disregard for the safety of self or others.
    6. Consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligations.
    7. Lack of remorse, being indifferent to or rationalizing having hurt, mistreated, or stolen from another person.
  2. The individual is at least age 18 years.
  3. Evidence of conduct disorder typically with onset before age 15 years.
  4. The occurrence of antisocial behavior is not exclusively during schizophrenia or bipolar disorder.

Not surprisingly, both of these disorders are far more common in men than in women. When a person meets the criteria for both disorders, the term malignant narcissism is sometimes applied, although it is not an official DSM-5 (Diagnostic and Statistical Manual of the APA, 5th edition) diagnosis. In neuropsychiatric terms, it seem reasonable to hypothesize that someone who meets the criteria for both disorders has a lower than average inhibitory capacity of the prefrontal cortex in relation to the impulses stemming from the amygdala.

When a man (and it would likely be a man) who meets even some of these criteria is in charge of the “land of the free,” he puts millions of people at risk. Objectively, his personal behavior resulted in his family, aides, staff, associates, and their families becoming infected with SARS-CoV2. Whether they mostly got it from him (quite possible) or got it from each other under conditions he created and insisted on, he caused them to be ill. His wife is still coughing, too sick to campaign with him. His friend and debate coach Chris Christie spent a week in the hospital with a much more severe case than Mr. Trump had, and after his release he publicly announced that he was wrong and publicly advised Americans to do the opposite of what their president is encouraging them to do.

The result has been, and will continue to be, what Dr. Sanjay Gupta explains above in his answer to Jake Tapper’s question. Yes, the President of the United States is continuing to hold one superspreader event after another, and yes, the President of the United States has caused and will cause at least scores of thousands of unnecessary deaths, which are the tip of the iceberg of American suffering.

A few hours ago, an analysis published by the Columbia University School of Public Health estimated that between 130,000 and 210,000 of the 223,000 people who have died of COVID-19 in the US to date had preventable deaths. Suppose we take the lower number and cut it in half to get to a rock-bottom minimum. That would leave 65,000 needless deaths so far, approximately the number of Americans killed in the Vietnam War.

Or, consider how news outlets and people throughout the world react to the crash of a single jumbo jet that kills 350 passengers and crew; billions of people react with pity and grief, and eventually may get angry, trying to find out why the plane crashed and who perhaps should be held responsible. My very-lowball estimate of 65,000 preventable deaths so far is the equivalent of 186 jumbo jet crashes, or around one crash every day since the first US case.

As you know, I’m not enthusiastic about predictions, but the consensus model (thanks again to Dr. Craig Hadley) has us at around 5,000 cases a week right now, rising to around 5,500 over the next month. If protective measures are relaxed, we could go to over 7,000, or if they are more strongly applied, half that. If we stay between 5,000 and 5,500, we will have added 50,000 to 55,000 deaths by New Year’s Eve. I consider that a low estimate, but we could easily reduce it to 30,000 or less, or if we are reckless enough, increase it to 70,000 or more.

Thus with this very conservative model of models, we could save at least 40,000 lives by enhancing rather than relaxing protective measures. Taking into account the advent of flu season, the effect of winter driving people inside, and the holiday season creating larger-than-usual family gatherings, the maximum number of deaths, and therefore the potential number of saved lives, could be much greater.

This is without considering the impact of Mr. Trump’s more than daily superspreader events around the country for the last three weeks leading up to November 3rd. Mr. Trump’s behavioral role in causing the new wave of the pandemic we are in would be explained if it were possible to find in him traits 4 and 7 in the NPD criteria above, and/or traits 5 and 7 in the ASPD criteria. Speaking as a lay person who has access to all public information about Mr. Trump, I think it is legitimate to state that he has those four traits. This is not a diagnosis, but it is tantamount to finding that he is an effective ally of the virus in its spread through our people.

The chart, based on Johns Hopkins University data (not projections) suggests that we are well into the third wave of the US pandemic, with a steep rise in daily cases rivalling the maximum achieved nationally in July, and still very much on the upward swing. Thirty-one states have more cases this week than last, and only one, Hawaii, has fewer.

Hospitalizations (second chart), a much better measure, are already following suit, and many states, particularly in the Midwest and Great Plains, are beginning to see overflow crises comparable to what we saw in New York in March and April and in the southern states in July. Deaths will duly surge, although not as much as in the past, since fortunately we are saving more of those hospitalized.

What caused the third wave? Many factors. Dismally prepared college openings caused youth outbreaks which caused community spread. People let their guard down in crowded bars and restaurants. The President of the United States made fun of mask wearing and encouraged people to relax other precautions. Premature school openings were often reversed because of spikes in cases, not usually harmful to children but gravely threatening to teachers, staff, and families. And spread continued in and from nursing homes, prisons, and meat packing plants.

Good News

  1. While two major vaccine trials (AstraZenica, Johnson & Johnson) were halted because of adverse effects, including a death, two other major trials (Pfizer, Moderna) are progressing well and could request emergency use authorization from the FDA by early December. The FDA vaccine group is meeting today to discuss guidelines for approval.
  2. Although Remdesivir has proved disappointing in the most recent research, it has been successful in other studies, and it just became the first treatment approved by the FDA specifically for COVID-19.
  3. Another antiviral, now called EIDD-2801 has been extremely successful in a mouse model that carries transplanted human lung tissue. Unlike Remdesevir, it is an oral medication, and could be used as an outpatient treatment very early in the disease, or even prophylactically for those with known exposure. Human trials are under way.
  4. Antibody cocktails such as Mr. Trump received (part of his VIP treatment) are under study and may prove their efficacy in time, in ongoing trials.
  5. Former New Jersey Governor Chris Christie, after an apparently near-death-experience with the virus—which he likely caught from or because of Mr. Trump—has become a strong advocate of taking the virus seriously and applying all known preventive measures.
  6. The best news is that we already have a hugely effective vaccination program: First Shot: Social Distancing; First Booster: Wear a Mask; Second Booster: Wash Your Hands; Follow-up Examination: TETRIS (Testing, Contact tracing, Isolation). This is the vaccination program that has utterly beaten the virus in quite a few other countries. Will we ever use it?

Do the right thing, be patient, this will pass, live to brag about how you didn’t get it and didn’t give it to anyone else, stay safe,

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.

Hope

10

Dear Students,

I’ve waited almost a month this time between updates, the reasons being (aside from having other responsibilities) that I saw no basic change in the situation, no real news that I felt a need to help explain, and my own general discouragement with the situation. Also, I always want to be able to offer hope, something we all badly need more of.

There is certainly news now. Hope is also the name of the former teenage model who rose to become the communications director of Fox News and then one of the closest aides to the President of the United States. Yesterday it was announced that she had tested positive for COVID-19, and that she had symptoms. Since she had been in constant close contact with President Trump, he and his wife, the First Lady, also a former model, were carefully tested and as of early this morning, both have the virus.

I mention the modeling because Mr. Trump has always tried to associate with beautiful women, and beauty carries with it a certain aura of superiority and invulnerability, but the virus doesn’t see it that way. Hope Hicks has symptomatic COVID-19, and Melania Trump is carrying, probably has infected others with, and may soon have symptoms also caused by SARS-CoV-2. They have joined the ranks of some seven million other Americans who could not avoid this infection.

The President also has thought himself invulnerable and has consistently acted as if he believed it. He has minimized the virus and failed to take or encourage needed precautions. Now the virus has proved him wrong. He has not only failed to protect the 208,000 Americans who have died from the virus and the millions more who have suffered in surviving it—some of whom will suffer for many years to come—but he has failed to protect his 31-year-old trusted and trusting aide, his wife, or himself.

There is a German word you may know, Schadenfreude, which English speakers appropriate for a certain emotion that English has no singular word for. It means literally something like damage-joy,* or taking pleasure in someone else’s suffering. It’s a natural human reaction, and if we are honest with ourselves, when we see others suffering we often have the fleeting thought, It’s not me.

Taking joy out of the suffering of people at the apex of American power is as wrong as it would be to celebrate the illness of anyone else, and as an MD I would be violating my oath if I felt that way. So I do all I can to suppress these unethical sentiments, and suppression starts with knowing myself, knowing that such feelings may be there.

But I have to say objectively that there is hope, the other kind of hope, in the fact that these people are now infected, and that others at the top are being tested, quarantined, and may become infected and even ill. There is poetic justice, surely—not the same as Schadenfreude—in the very powerful people who have failed to provide and even discouraged TETRIS (Testing, Contact Tracing, and Isolation) being put through this basic process themselves and, unless they are utterly stupid, being grateful for it.

But where is the hope here? It lies, quite simply and I think strongly, in the fact that the scores of millions of people who have believed the lies these people told them—the virus is no big deal, it only affects a few people, it will disappear like a miracle, we already have a cure in hydroxychloroquine, you can inject disinfectant, masking shows weakness, a vaccine is a few weeks away, we have turned the corner—these many millions of believers will now watch the leader who has lied to them, and those closest to him, directly face the consequences of his own mendacity, ineptitude, and forceful opposition to science.

I hope—I hope—that many lives will now saved by the example, this time unwilling, set by the most prominent man alive, the same man who has up to now set the wrong example and thereby caused scores of thousands of needless deaths. At a minimum, I hope that he will  not go to Wisconsin, the state with the worst reversal of fortune and the fastest rise in cases, and speak to crowded rallies of mainly unmasked people, as he had planned to do this weekend. Those cancellations alone will save lives.

I hope that, going forward, many of those who worship President Trump as a savior, almost a god, will now see that their idol has clay feet, that the virus is not overblown, and that they should start to listen to someone other than him if they want to protect their families and themselves, as he failed to do. This is not taking pleasure in the fact that he and those closest to him are infected. It is simply expressing the hope that lives will be saved by this new example—or more exactly, counterexample.

As the graph shows, we are turning a corner. We have probably entered the second wave, without ever as a country really leaving the first behind. With five percent of the world’s population we have a fifth of the world’s cases and a fifth of the world’s deaths, largely because Mr. Trump has been a never-ending superspreader of misinformation about the pandemic of COVID-19. Maybe now he will, against his will, become a source of truth.

Recall that the second wave of the pandemic of 1918-19 was much larger and more devastating than the first. That may or may not happen this time. To a large extent, it’s up to us. I hope that by this time next year we really will have turned the kind of corner that puts this behind us, but what happens between now and then depends on what we have learned and what we do.

Don’t be among the college students who have already played a large role in starting the second wave. Don’t go to parties or mix in crowds. Keep your distance even in small groups, even in pairs, unless you have quarantined together. Wear a mask wherever you may encounter other people. Wash your hands for a count of twenty frequently. Get a flu shot or risk getting and spreading both infections at once.

We will get through this, and as I have said before, if you do the right thing you will live to brag to your children and grandchildren about how you survived and how you protected others. Your stories will help them get ready for anything, because they will learn how you were ready for this.

Stay safe,

Dr. K

*I had mistakenly translated schadenfreude as “shadow-joy.” I mistook schaden (damage) for schatten (shadows). Thanks to Shebardigan and Misha Pless for correcting me.

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.

TETRIS Is Dead. So Is the CDC. And the FDA. And 188,000 Americans.

2

            “We are not anywhere near done with this and I think we have more days ahead of us than we have behind us.”

            Ashish Jha, MD, Harvard School of Public Health, August 28

            “The problem here is the credibility of the FDA is crumbling before our eyes. This is an agency that so many of us in the scientific world have looked up to, trusted it, we know that they have these really rigorous scientific protocols, but that’s all changed this year.”

                        Seema Yasmin, MD, Stanford University, September 2

            “Obviously there are places around the world that have been able to control this. What I’m starting to feel is the existential threat is the human behavior. I’m discouraged and frustrated… Other countries are essentially vaccinated right now, not because they have a vaccine, but because they did these things, they are back to normal. They reduced their death rates into the dozens or hundreds, not the hundreds of thousands.”

                        Sanjay Gupta, MD, Emory University, September 4

Dear Students,

You remember what TETRIS is, right?

TEsting. Contact TRacing. ISolation.

Those are the “these things” Dr. Gupta is referring to above, along with mask wearing and social distancing, that have enabled other advanced countries with large populations to have hundreds of deaths from COVID-19, while we have hundreds of thousands of deaths.

Good News:

  1. Many other countries have got this under control, and they are immediately using TETRIS to bring any new breakouts under control. Per capita hospitalizations and deaths are a tiny fraction of what they are here now, and that gap will only widen as they prevent and control their second wave—which we won’t have because never controlled the first wave, only smushed it down and smeared it, and that only a little. Our second wave will come on top of an enduring first wave.
  2. Cases per week have gone steadily down in the U.S. for at least a month, and that is good news if real. As you know I was skeptical of case rates when they were going up because politicians were saying daily that the rise was only because of more testing. Now when we know testing is going down, because it was badmouthed by politicians and the CDC recommended doing less of it. You don’t hear politicians saying one reason for the decline in case rates is less testing. Deaths, being a lagging indicator, have gone down only slightly. Also, the southern states are doing somewhat better while the midwest is having its big first wave, and the northeast is rising but from very low levels.
  3. Vaccine development is proceeding around the world. Phase III testing is going slowly and will be difficult to interpret because of marked underrecruitment of minority people, who are way overrepresented among the cases, hospitalizations, and illnesses.
  4. Finally, the sum total of well-designed research has shown that steroid treatment (like dexamethasone) reduces deaths in patients severely ill with the virus. Death rate for 1,700 people across 12 countries was 32% with steroid treatment and 40% with placebo. That amounts to saving 1 in 5 very sick COVID-19 patients who would otherwise have died.
  5. There is a lot of talk about, and even some progress in, cheap rapid testing, but the deployment of these tests has been slow due to manufacturing bottlenecks and general badmouthing of testing by politicians. Nevertheless as these tests become more available, we should make progress against our U.S. pandemic (near the world’s worst), but that would require a revival of TETRIS and a modification of behavior based on test results.
  6. The CDC has issued a mandate against evictions until January 1, as a public health measure. But the CDC does not have a police department and it will leave enforcement to local authorities. There are many exceptions that would still allow people to be evicted, and after January 1 all those protected will owe all back rent. Perhaps there will be another Congressional stimulus package by then to soften that blow.

Bad News

  1. The latest models from IHME and Johns Hopkins agree on where we are now, and the graph shows three projections as to where we are going, depending on one of threee assumptions. The most likely scenario (dark blue line) shows where we will be on January 1 if we keep on doing what we’re doing: 300,000 deaths total, and adding about 3,000 deaths a day. If we had universal mask use, that total would be around 230,000 and the daily deaths would stay under a thousand for a while in the fall before doubling or tripling again with the cold weather (more time indoors) and the flu season giving many both viruses. If we continue to have easing of social distancing mandates, we are expected to have 600,000 total deaths and almost 12,000 cases a day by years end. You will hear some politicians say that these projections have been wrong throughout in overestimating the future damage. This is a lie. Except for the very beginning when nobody knew anything, the IHME reference scenario has been too optimistic. Testing is going down or staying at low levels in most states, contact tracing is beyond inadequate, and isolation is accordingly moot.
  2. We’ve learned that infected people are most likely to infect others during the first week or ten days of significant viral load, which is why superspreader events attended by healthy people are the major U.S. source of viral spread right now. These are most likely to be indoor, largely unmasked, crowded events. Viruses linger in the air for hours in many such spaces. These superspreader events have included Mardi Gras, church services in Arkansas and elsewhere, funerals in Georgia and Ohio, and a Boston meeting of executives at Biogen, a large molecular technology company, among many others. The Sturgis motorcycle rally in South Dakota in early August has resulted in at least 70 cases so far (it’s difficult of course to track folks from an event like that). These are in addition to the well known virus petri dishes known as cruise ships, prisons, nursing homes, meatpacking plants, choir practices, and now colleges and universities. Luck matters, since one person can be a key superspreader, and neither you nor they know which one in the crowd they may be.
  3. In the past month or two there has been a wave of oh-so-careful openings of colleges and universities, and now there is a national wave of even faster closings. (See my update predicting this and explaining why it was inevitable.) Despite evidence of universities acting to cover up coronavirus cases, we know that there have been outbreaks at many, and they are rapidly spreading the virus to the local communities. As of September 3, “More than 100 colleges have reported at least 100 cases over the course of the pandemic, including dozens that have seen spikes in recent weeks as dorms have reopened and classes have started. Many of the metro areas with the most cases per capita in recent days — including Auburn, Ala.; Ames, Iowa; and Statesboro, Ga. — have hundreds of cases at universities.” Thousands upon thousands of students are now being sent home, where they will bring virus to their communities. (See my update on “Bye-Bye Grannie.”)
  4. “Sloppy coronavirus immunity” is a term that has been used to describe the handful of documented cases of people getting the virus twice (it also applies to other coronaviruses, like the common cold). At least one of the reinfected patients caught a different strain, so as you know viral evolution will play a role. It should also apply to the question of how effective any immunity from a future vaccine will be, and how long it will last. Vaccine refusal in the U.S. has been at high levels for decades, and this vaccine will be no exception, unless the rushing of it and the prior erosion of public trust swells the ranks of anti-vaxxers to unprecedented levels (especially if, as is likely, it requires two shots). Imagine a COVID-19 vaccine that gives us about the same level of protection as the seasonal flu vaccine (~50%), lasts about as long (<1 year), and is accepted by 50% of the population. So we’d have seasonal protection for a quarter of the population, have to repeat the shots every year, and we’d still have to have over a hundred million more cases and hundreds of thousands more deaths to get to herd immunity.
  5. Harold Varmus, a Nobel Laureate and former National Institutes of Health head, and Rajiv Shah, president of the Rockefeller Foundation, published an article on August 31 called, “It Has Come to This: Ignore the CDC.” Their statement is based on the latest of a series of false, incompetent, and frankly craven pronouncements of “advice” issued or changed by the political appointee at the top of that organization, obviously in response to pressure from those who appointed him, non-doctors and non-scientists all. When Stanford’s Dr. Seema Yasmin said (above), “the credibility of the FDA is crumbling before our eyes,” she was likewise referring to the latest of multiple instances of knuckling under by the political appointee directing that organization. This would be (together with the CDC) following orders from non-doctors and non-scientists in the White House to order states to prepare for widespread distribution of a vaccine by November 1 or sooner. These non-experts say that it is purely coincidental that this is two days before our national election on November 3. The vaccine will be deployed with great fanfare on the basis of far-from-complete Phase III trials, it will put minority people at greatest risk, and there will no time to find out what damage is done by this half-baked but highly touted vaccine before people vote.
  6. The principal advisor on the pandemic in the White House is now Scott Atlas, MD, a neuroradiologist and health policy wonk at Stanford’s right-wing Hoover Institution. Dr. Atlas has no qualifications in infectious disease, epidemiology, or virology, but he is happy to parrot the long-standing White House views playing down the virus. He has denied reports by several reliable sources that he argues openly in Task Force meetings with Dr. Fauci and Dr. Birx (the real experts) and he has more than hinted that he favors “herd immunity” as a strategy, which would entail far more American deaths than the huge numbers projected above. Like an overpopulated herd of deer, we would be culled.

I must say it surprised me to see the expression on Dr. Gupta’s face and hear him say he is “discouraged and frustrated.” I am too, and that’s why it’s been so long since my last update. Frankly, I expected more from him. He’s one of my greatest heros—a top-flight brain surgeon and medical school professor, the most inspired and gifted medical broadcast journalist who ever lived, and, I’m proud to say, our colleague at Emory.

My expectations for him were totally unfair. Unlike me, he has rubbed his nose in this stinking situation all day every day for eight months. Also unlike me, he probably has not had a dark view of human nature lasting a lifetime, based on a different branch of science—behavioral biology. So yes, he has a right to see the “existential threat” in “human behavior,” and he has more right than me to feel discouraged and frustrated, having worked his heart out 24/7 to prevent things from getting anywhere near this bad. Which it wouldn’t have if people had listened to him. It will still save many lives if people start listening now.

Mardi Gras: outbreaks. Memorial Day Weekend: big outbreaks. July 4th weekend: ditto.

So we’re in the Labor Day Weekend now.

What do I think is going to happen?

What do you think is going to happen?

Stay safe,

Dr. K

PPS: 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.

Readin’, ‘Ritin’ & Russian Roulette

5

            “We can’t become immune to this level of suffering…Georgia is in no shape to open its public schools in most of the state, the virus levels are too high.”

                        Dr. Ashish Jha, CNN, August 10th

            “I don’t know how long we’re gonna keep playing Russian Roulette with our children, Andrea. It’s not safe to do.”

                        Dr. Lipi Roy, Andrea Mitchell show, August 13th

Dear students,

My grandson proudly started third grade this week. Virtually. The teacher and the school are in Georgia, but he and his family are in upper New York state, which thanks to the leadership of Gov. Andrew Cuomo and the discipline of New Yorkers, is practically virus free. His sister will also be taking full advantage of the beauty and safety of upstate New York, as she attends a Georgia kindergarten virtually.

On the other hand, thanks to the “leadership” of Gov. Brian Kemp of Georgia—along with the lack of discipline of its citizens—hospitalizations and deaths in our state have climbed relentlessly. My newest grandchild and his two moms were hiding out in our house in Atlanta from early March until his six-month birthday in late June. That was because Atlanta was much safer than their home city, Brooklyn. But by June Atlanta and Brooklyn had changed places, and they are much safer in their home than they would be in ours

Dr. Sanjay Gupta, who lives in Georgia, weighed all the facts, including his three daughters’ need for education and a normal life, and he and his wife decided they would start school virtually. They did this after examining the school carefully and concluding it was taking all recommended precautions.

 

Photo by the very brave 15-year-old Hannah Waters of the unsafe opening of her school

Georgia is famous now for the chaos and recklessness of its school openings. The photo of the school hallway, which you’ve seen if you haven’t been hiding under a rock, was taken by 15-year-old Hannah Waters, during a class change at her Dallas, Georgia high school. She was suspended for her pains, until an outcry forced school authorities to reinstate her. Meanwhile they threatened other students who might also be considering blowing a whistle on this deadly situation.

Hannah Waters is famous now too, because her photo immediately went, um, viral. She’d been planning to return to school, but students and faculty there began testing positive. There are at least 35 cases and counting, so Hannah will be learning virtually.

Let’s be clear though: the word “suffering” used by Dr. Jha above, and the word “deadly” in my last paragraph, do not apply to Hannah’s fellow students. They are very unlikely to suffer much and extremely unlikely to die. But this is not true of the teachers, cafeteria workers, and janitors. And it is not true of the parents and grandparents of the students. And it is not true of the others in the community they will infect.

Hannah’s fellow students will bring suffering and death to others, as they have throughout the pandemic, without suffering and dying themselves. This, we know, is the virus’s evolutionary strategy, and it is working like a charm. The virus can pervade the crowd of kids in that hallway like an invisible toxic gas or radioactive rays, except that unlike the gas or the rays, the kids can take the virus anywhere.

The chaotic process of Georgia schools and school districts opening, finding infected children, and closing down again has been so widespread and bewildering it’s frankly impossible for me to follow, and it’s happening in much of the rest of the country as well. Cherokee County, an Atlanta suburb, opened on August 3rd by unanimous decision of the school board, and reported that 1,193 cases of COVID-19 were quarantined by August 12th.

Some districts and counties around the state will have live options. The Atlanta City Schools will be all virtual, and of the nearest counties, Dekalb, Cobb, Fulton, plus the suburban cities of Decatur and Marietta, 100 percent will be 100 percent virtual. Go a little farther away from Atlanta and you’ll still be eligible to choose to put your kids at risk. Except that these rules are changing day to day.

Very confusing. Easy to follow though is the relentless Presidential drumbeat of Have-to-open-Have-to-open-Have-to-open-schools. The nation is marching to a different drummer. 35 of the 50 largest school districts in the U.S. will open online only, and others, like New York City, are reconsidering their plans for a safe hybrid open.

Let’s consider what little we know about COVID-19 and children. First, the good news, which won’t take long to relate: very few children have gotten very sick or died from the virus since the beginning. That’s good news for the virus too, since these kids can mobilize it like crazy.

Some other bad news:

  1. Kids between 10 and 19—Hannah’s classmates—can transmit the virus just as well as adults. A new, large, careful South Korean study of 59,000 people who had been in contact with one of 5700 infected cases showed that kids 10-19 years old are very effective at infecting others. This study was done during a period of school closure.
  2. Kids under 10 can also transmit the virus, and have been important vectors bringing it home to their families. The South Korean study above found that kids under ten were less likely than older kids and adults to transmit the virus to others, but they can and do transmit it. A new study published in JAMA Pediatrics showed that younger children carry more SARS-CoV2 viruses in their nose and throat than older children or adults. As Dr. Gupta notes, the jury is still out on how infectious they will be when schools are open.
  3. The impact of #2 has been limited so far, since young children have mostly stayed home. Now that millions are going back to school, we will find out just how big a deal this sort of family transmission can be.
  4. Some kids do get sick and die with COVID-19. For unknown reasons, a small percentage go through the same process as adults. A nine-year-old African-American girl became the fifth child in Florida to die of it; this was in July, and there have been many more since. Her family took her to the hospital, they sent her home, and she collapsed due to heart failure. SARS-CoV2 attacks the heart as well as the lungs, in children as in adults. Her name was Kimmie, she loved unicorns and making TikToks and YouTube videos. She had a contagious goofy laugh and she had no underlying conditions.
  5. And there are also strange tragic accidents; the youngest victim in Georgia was a 7-year-old African-American boy who drowned in his bath when a sudden fever gave him a seizure; seizures are very common in children with COVID-19 fevers. It was only after his death that anyone knew he had the virus, and he had no underlying conditions.
  6. Some children develop a rare but deadly post-viral disease known as multisystem inflammatory syndrome in children—MIS-C. Four children have died of it very recently in Louisiana alone. There have been at least 570 cases nationwide. It is not the virus itself, it is a process nobody understands that is triggered by the virus. It attacks widely throughout a child’s body. A 12-year-old girl named Juliet suffered cardiac arrest and was “about as close to death as you can get” according to her doctor. Jack, age 14, woke up in agony and with heart failure and was hospitalized for ten days and sent home with residual damage. It’s a horrible disease and in the worst cases it’s a truly horrible death.
  7. And in a crowning irony, an 8-year-old named Hermione escaped on an evacuation flight from Wuhan Province in China where the epidemic first raged, only to contract COVID-19 six months later at home in America, after China had long since conquered the virus. Hermione’s father and grandparents also have the virus.

It’s worth noting that when we shut down schools in March, there were around 5,000 cases of COVID-19 in the U.S. Now as we reopen them, there are more than 5,000,000.

I know, there are places where schools can reopen safely, but many places where kids are being pushed back into school are not in that category. I know, there are ways to make schools safer, but they are not being consistently implemented and even where they are children are still getting the virus. I know, virtual learning is much less effective than live learning. Trust me, I know. I taught more than 150 students that way starting in March and will be teaching another 250 starting next week.

But somebody help me out here. Apple, Microsoft, Google, Facebook, Netflix, and Zoom (among others) have seen their shares go through the roof since the pandemic started. (Full disclosure: I like millions of others have participated, if only through retirement plans.) Is there nobody at these companies who can figure out a way to make virtual learning work better? To make it fun for kids of all ages? To get computers and tablets and broadband too into the hands of all who need them?

Our kids love screens. We fight constant battles with them to get them off screens. Now their lives depend on learning through screens. Is there no one among all the brilliant nerds and geeks in the United States of America who can design virtual learning that will engage children and really really teach them? Is there no one in the colleges of education that can ally themselves with the nerds and geeks?

I’m begging. Please.

Meanwhile, stay safe,

Dr. K

PS: In other news:

  • The United States notched its largest number of deaths in a day for the summer so far: 1500. Most recent days have seen more than a thousand deaths each. Testing remains completely inadequate in our country, and contact tracing is almost nonexistent.
  • The Russians are deploying a vaccine that is not ready for prime time—it has not been studied in anything like a proper way. Let’s hope that the people in Russia who are being used as guinea pigs get lucky. Bad vaccines don’t just fail to work, they can kill people.
  • Georgia’s governor, whom my friend Kathy calls Deathcount Kemp, has dropped his lawsuit against Mayor Keisha Lance Bottoms to stop her from mandating masks in her (our) city. Like they say down here, she whipped his butt, scared him silly, and he crawled off with his tail between his legs, where a different anatomical organ was supposed to be.

PPS: 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 Times Coronavirus Resource Center (NYT).