Tagged coronavirus

Bad Breath

“It’s kind of like people dying in a war after the peace treaty has been signed.” Dr. Sanjay Gupta, CNN, July 14, 2021

“This is like the moment in the horror movie when you think the horror is over and the credits are about to roll. And it all starts back up again.” Rep. Jamie Raskin (D, Maryland), July 22, 2021

“Folks are supposed to have common sense. But it’s time to start blaming the unvaccinated folks, not the regular folks. It’s the unvaccinated folks that are letting us down.” Alabama Gov. Kay Ivey, July 23, 2021

“Political division, disinformation and, frankly, stupidity are costing lives. It is not authoritarian to mandate vaccines in America.” Ian Bremmer, President, Eurasia Group, July 26, 2021

“Sometimes praying isn’t enough. I yell at Jesus if I need to.” Laurie Douglas, COVID-19 care nurse, CNN July 31, 2021

“I wish I could snap so many people out of their selfish stupor but I can’t, so I get to watch instead as people learn the hard way; with a tube down your throat. With a ‘code blue, code blue!’ and the crack of a sternum.” Kathryn Ivey, COVID ICU nurse, August 2, 2021

“We are seeing more and more pediatric patients coming in with COVID-19… I would love everyone to look within themselves and do what is right for their family, for our children, for our community… But if people aren’t going to use common sense, then unfortunately mandates may be important and necessary.”  Dr. Kelechi Iheagwara, Medical Director of the Pediatric ICU, Our Lady of the Lake Children’s Hospital, Baton Rouge, Louisiana, August 14, 2021

 

Dear Students,

I have not written an update since Juneteenth, by far the longest I have gone without writing. I have to say that I have been too discouraged. I realized that I could pretty much compose a new update with quotes from my updates over the whole tragic period since early 2020. I use the word “tragic” advisedly. What is tragedy after all but a catastrophe that was avoidable except for some profound human flaw? Why keep writing about it? Because some students and other readers tell me they trust the way I sift through vast amounts of bewildering information and say clearly what I think.

Since it’s my first update since Juneteenth, I want to start by showing you the chart on the right (from a recent article in Health Affairs; FPL means Federal Poverty Level), which shows more strongly than anything how we as a society have failed African-Americans. It really is astounding. It has been said that a civilized person can look at a page of numbers and weep. This chart should bring tears to your eyes. I wrote on Juneteenth, “2.9 is the odds ratio of blacks vs. whites being hospitalized with COVID-19, and 2.0” is their relative risk of dying.” This chart shows that no matter your insurance status, family income, or type of work, you were far more likely to die during this pandemic if you were black than if you were any other kind of person. This is systemic racism, an extension of slavery and Jim Crow, and it is our failure as a nation.

So what I am going to say about vaccine resistance (different from vaccine “hesitancy”), and opposition to masking pretty much exempts black people—let’s call it the Tuskegee exemption—although the chart  tragically shows they would benefit most from vaccination. (The Rand Corporation conducted a study of vaccine hesitancy in black communities last December.) Also exempt, of course, are the small number of people who have legitimate medical reasons for not being vaccinated.

I am talking about white people who carry placards lying about vaccines and masks. I am talking about white governors who repeat the lies or ban mask mandates. I am talking about TV personalities and social media “influencers” who are leaders in the lying. They are, all of them, not just liars but killers, spreading highly deadly disinformation.

I am tired of people who repeat self-serving lies, and I am tired of people who coddle them, who want to make nice-nice with them and help them come around to abandoning their lies. I don’t have time for such psychotherapy. If it’s someone you love, persuade them if you can. But don’t expect the rest of us to wait and see if your persuasion works.

Here is what I want to say to them:

You have bad breath. You have foul, diseased, deadly breath, both when you are spewing your lies and when you are breathing on me, and my children, and my grandchildren, who have done everything humanly possible to fight off this virus, while you have done everything possible to give aid to the enemy. You are traitors to the United States and to the human race. Soon you will be ostracized by widespread mandates, because coercion is all you understand. You will not be forced to accept a vaccine or wear a mask, you will simply be excluded from places where your obstinacy and stupidity can hurt people who have more common sense and more respect for others than you do.

I say to you: Breathe on each other, not on us. Spit on each other if you like, it amounts to the same thing. Keep your filthy, disgusting, sickening breath and other excretions to yourselves and others like you. Stay away from me and those I love.

Polls show that the great majority of all unvaccinated people state that they will not or probably will not get a vaccine. This is not lack of access, this is opposition. Every minute of every day we use laws, rules, mandates, and other forms of coercion to protect ourselves from human obstinacy and stupidity. We have to stop coddling the obstinate and stupid. We have used a lot of carrots, and they don’t work nearly well enough. We need sticks too.

Mandates (laws, punishment, coercion) have been an integral part of public health for centuries and have saved millions of lives.

This includes, but is not limited to, isolating people arriving in fourteenth-century Florence during the Black Death for 40 days (where our word “quarantine” comes from);  mandatory vaccination against smallpox in 1850s Britain, while some religious leaders inveighed against it as un-Godly; shutting off public water supplies carrying cholera (John Snow, 1854); outlawing spitting in public places in New York in the 1890s, when it was extremely widespread, to stop TB; forced quarantine of Typhoid Mary; mask mandates in the flu pandemic of 1918-20; mandatory childhood vaccinations for pertussis, diphtheria, measles, mumps, rubella, polio, etc. or you don’t go to school; mandatory meningitis vaccination or you don’t go to college; closing of bathhouses in the HIV epidemic; arresting and jailing people who deliberately spread HIV; severe restriction of smoking in public places and punitive taxation of tobacco products; infant car seats, seat belts, shoulder belts, and airbags; and cracking down hard on drunk driving.

All these coercions (“sticks”) and many more have stood up to legal, ethical, and historical scrutiny and have saved countless millions of lives. More and more institutions, governments, businesses, and schools will soon be mandating proof of vaccination and masking as the price of admission. You don’t want to do that, fine, you’re free to show me your back. And if you don’t, I’ll be free to call the police to keep you off my premises. And rest assured I will. In the end you will have to take your bad breath somewhere else.

On September 5, 2020, I wrote, “TETRIS [Testing, Tracing, and Isolation] is dead. So is the CDC. And the FDA. And 188,000 Americans.” (What a paltry number that seems now. If only we hadn’t insisted on more than tripling—and soon perhaps quadrupling—it.) I had high hopes for the new government in Washington. But a successful spring vaccination campaign had petered out by summer and, though daily jabs are rising again, they will not suffice.

On May 9th I wrote, “The country has fought the virus to a standstill on a hill some feared we couldn’t hold, and we fought it down the hill. If we can fight it down further off the high plateau, we might just win the war. As always of course, this involves not just vaccinations but other precautions, especially those against swapping air. But the situation in India is heart-breakingly bad and worsening by the day.”

Around that time, the CDC announced that vaccinated people could be unmasked indoors. They unraveled a year of education only to reverse themselves in July. While not as disastrous as last year’s CDC, this one is sending mixed messages that cost lives. If they had just looked at India and the U.K. in May, they would have known better than to ease up on masking.

But this is America. We don’t learn from other countries. So we now have the highest number of new cases in the world.

On the July 4th weekend, our new president took the opportunity to pretty much declare our independence from the virus. How very premature that was. As the second chart shows, we were just getting into the fourth, possibly worst wave.

As for the FDA, it’s also not dead, but some experts I trust say it’s moving far too slowly on full approval of vaccines that have been given to scores of millions of people with minimal safety concerns. The American Academy of Pediatrics has said the same about emergency use approval for children under 12.

If this is not an emergency, I don’t know what would be.

Bad News

  1. The Delta variant—which is so different that I’m inclined to call it “The Delta Virus,” although that’s technically wrong—now accounts for well over 90% of US cases. It is much more contagious than earlier strains (each infected person infects 5-10 others, as opposed to 1-2), makes people sicker, is easily contracted by vaccinated people (although it rarely sends them to the hospital or kills them), and affects young people, including children, more than earlier strains did. It will result in millions of cases of long COVID, which will burden our nation’s health for years, maybe decades, to come. As of today, Delta is the story.
  2. In states with low vaccination rates (and some have killer governors), Delta is overwhelming hospital systems. Georgia is one of the worst states. Children’s wards are filling up fast, and many children are very sick. Nurses are quitting, citing “compassion fatigue.” Don’t have a heart attack, an auto accident, or appendicitis in these states right now. There’s a likelihood that no one will be there for you. On January 5th, when there were a mere 350,000 American COVID deaths, I wrote about overwhelmed health care workers, “We will kick them until they are dead.” This seemed hyperbolic, but we did kill many, some by their own hand. We are about to do it again.
  3. No children are vaccinated, and children are getting COVID-19 in unprecedented numbers, around 100,000 in the past week (that we know of). Of these, roughly 1-2,000 will be hospitalized, and some 300 will die. An unknown number, somewhere between 2,000 and 20,000, will experience long COVID. As Dr. Daniel Griffin said in his latest podcast, if no adults got the virus we would consider this an extremely serious childhood illness. But many people still think it doesn’t affect children all that much because it affects adults more. Schools are opening across the land. CDC Director Wilensky keeps saying, “We know how to protect our children.” Sure, and if you gave each school a couple of million dollars they could implement the protections. Unless of course your governor forbids you to do that. Closures for quarantine are already occurring. And yes, I do get that children need to be in school; but I also get that their health needs protecting.
  4. This virus is evolving. Delta is not the last new variant we will see. Read my “interviews” with the virus (here and here) to learn more about “Sarsie’s” ongoing quest to follow the steps laid out by his Uncle Charlie Darwin, in order to advance his species in its struggle against ours. And heed the warning of Dr. Andrew Pekosz of Johns Hopkins University, which I quoted last time: by have a large unvaccinated population side by side with the vaccinated, we allow the virus to go back and forth and evolve new strains to overcome vaccine protection. It’s essentially the same way Pekosz creates—evolves—new strains of viruses in his laboratory. And of course, the world at large is mostly unvaccinated. We have imported new, increasingly contagious and/or virulent strains of SARS-CoV2 from several other countries, and we will continue to do so until we vaccinate the world.

Good News

  1. Daily vaccination rates are going up again, although they are still a small fraction of the numbers we saw in April and May. Still, we are slowly chipping away at the numbers of unvaccinated people, at least the minority of them who had access problems or who were persuadable. Slightly more than half of Americans are now fully vaccinated. The FDA says it may give full approval (as opposed to Emergency Use Approval) to some vaccines in September.
  2. There are plenty of vaccine supplies for our country, so in the not too distant future a third booster dose will be available. We already approved the third dose for immunocompromised people (around 3% of Americans), and Israel, Germany, and some other countries are already offering it to all older people. This will protect us as vaccine immunity inevitably wanes, on an unknown timetable.
  3. Monoclonal antibodies save many lives if administered to outpatients in the first ten days or so of an infection, although they are much less effective in hospitalized patients. They have kept many thousands of people out of the hospital. If you or a loved one has been exposed and is showing symptoms of COVID-19, get a test, and if you test positive, call your doctor or go to an emergency room to inquire about this treatment right away.
  4. Here is the best news of all, but be wary of it because it is a speculative projection. The Delta wave could go away as fast as it surged. This has happened in India and the UK, two extremely different countries in everything from vaccination to sanitation. Nobody knows why, but it is just possible that the same will happen here. Right now, though, we are very much in the rising portion of the surge, and that means rising cases, hospitalizations, and deaths, including children. Don’t become a statistic, or turn your loved ones into statistics, while we are waiting and hoping for the surge to peak. And remember Uncle Charlie Darwin; the virus has more tricks to play on us after the Delta surge is over.

We have vaccines. Many people refuse them, and masks as well. They have a deadly movement. They are not just ignorant, they combine ignorance with arrogance. They deny they have COVID while they are in the ICU dying of it, and while endangering the people taking care of them. After a year and a half, if some of those brilliant, brave caregivers walk off the wards and don’t come back, you won’t see them getting blame from me.

As for anti-vaxxers and anti-maskers: Keep your foul breath to yourself in your own dirty places. Blow it on your friends and relatives if they will stand for it. But keep away from decent Americans who care about our country and each other.

As  for the rest of us, rewind last year’s horror movie. We are watching it—no, we are in it—again.

Stay safe, and keep your loved ones safe. I will see some of you soon.

Dr. K

Juneteenth. 605,000. 2.9x. 2.0x.

            “All we have to do is look at the situation in India and Nepal…and in the United Kingdom, where variants of COVID-19 have become the dominant virus in those populations—in the UK despite a somewhat successful vaccination campaign. And those variants have different properties that increase the ability of this virus to spread and…eventually cause disease in the population. Anytime we give the virus a chance to get to know its host better, to get to see immunity against it, the natural selection principles laid out by Charles Darwin suggest that variants that are more fit will emerge. And, particularly in the US, we can’t look past that, because we really have sort of a dual population, we have the unvaccinated and the vaccinated, in many places the unvaccinated are larger than the vaccinated populations, and that just sets up a situation where the virus can see immunity, can go into people who don’t have immunity, and that back and forth is essentially how my laboratory selects variants when we’re studying them. So we’re setting up that scenario within the population, and that’s not a good thing for us to be doing.”

Dr. Andrew Pekosz, Johns Hopkins Bloomberg School of Public Health, June 11, 2021

 

Dear Students,

Being in a meditative mood, I want to reflect back as well as forward on this particular day, but being who I am my reflections start with numbers. It is said that a civilized person is one who can look at a page of numbers and weep. I don’t know how civilized I am, but these four numbers become a little blurry when I dwell on them.

Juneteenth, of course, is short for June 19th, the day in 1865 when the last black slaves in Texas were told of their freedom. Today is the 156th commemoration of that day, but the first 155 were unofficial. Now Juneteenth is a national holiday.

The holiday was declared by President Biden just a few days ago, perhaps on the same day that the total number of deaths in our country crossed the milestone of 600,000. It’s hardly something I wanted to be right about, but on December 15th I wrote an update called “Double Down or Double Deaths.” We had just crossed 300,000, and vaccinations had begun, but masks and social distancing were as important as ever, and the vaccine syringe was a shiny object I feared would distract us from these vital preventive measures, which we should have been doubling down on. We did not double down, so we doubled deaths.

George Floyd statue unveiled in Newark, NJ

2.9x is the odds ratio of blacks vs. whites being hospitalized with COVID-19, and 2.0x is their relative risk of dying. Some 89,000 African-Americans have died of it, and it’s a good bet that every one of them said, or if they couldn’t speak, thought, “I can’t breathe,” while dying—just as George Floyd did when he was being murdered by a policeman on a Minneapolis street.

So Juneteenth is well worth commemorating today and on all future June 19ths, but I am not sure how much celebration is in order. Those slaves in Galveston heard about their freedom, but the senses in which they were freed were limited. They were delivered into poverty, landlessness, wage slavery, fake and reversible “Reconstruction,” a century of Jim Crow with its countless lynchings, then a limited process of integration, reversible Voting Rights and Civil Rights laws, police brutality, and essentially permanent gaps in wealth, income, housing, education, imprisonment, and of course health—meaning life.

The same state of Texas they were supposedly freed into in 1865 is taking away their freedom—their voting rights—actively and aggressively, on this first official Juneteenth holiday. The same US Congress that passed the Voting Rights and Civil Rights Acts of the 1960s is, today, aggressively blocking legislation that would protect those laws from being dismantled by Texas and dozens of other states.

So as we celebrate this first Juneteenth National Holiday, white power elites are taking freedom away from blacks—to the cheers of their poor white dupes of course—as they have always done. They are preventing schools from teaching the truth as it actually happened, exactly in the spirit of Holocaust Denial, and with similar consequences. They are building and protecting the New Jim Crow, with state legislators, governors, police, and prison wardens taking the place of the Ku Klux Klan. They are redrawing red lines in housing, jobs, education, and health care delivery that generations have struggled to erase.

Do we think that a federal court system stuffed with young conservative appointees, crowned with a 6-3 hard-right Supreme Court like a rancid cherry on top is going to prevent these nationwide trends? Please. Do we think that with all these new forms of voter suppression the Democrats will keep their paper-thin margin in the Congress a year-and-a-half from now, and the White House two years later? I will let that question hang, and turn to more urgent matters that I personally know more about.

We are about to see the Southeastern Region, including my own state of Georgia, become the new experimental cauldron of differential death. The disparity between the races is much greater down here, in everything, even while the percentage of African-Americans is much higher. Oh, and the vaccination rates? The lowest in the country. The situation is ripe for a new variant of concern to cause a new surge, and as always a new chance for blacks to be sickened and killed more than whites.

Is there such a variant? Yes.

The variants now have Greek letter names to avoid stigmatizing countries or forcing us to memorize long strings of numbers. The original variant first seen in Wuhan (FSI-W) is the baseline. The first evolved variant of concern (FSI-UK) is now called Alpha, which because of greater transmissability caused grave problems in Britain in the winter. Beta (FSI-South Africa) is able to overcome a number of vaccines to a concerning extent. Gamma (FSI-Brazil) spread very fast there, has unexplained properties, and has been seen in many US states.

But the most concerning so far is Delta (FSI-India), far more transmissible than Alpha, which was far more transmissible than the baseline virus. It already predominates in the UK and is spreading fast in the US, especially among children and other unvaccinated people. Vaccine experts seem confident that they will be able to come up with solutions to present and future variants, sooner or later—for the vaccinated, currently a fraction of the world.

Good News

  1. New York, California, and many other states are opening up, pretty much completely. Air travel is huge again, and restaurants are humming. Some states and countries have vaccination rates that justify these comebacks.
  2. Continental Europe’s vaccination program has finally gotten traction and looks like it will continue to accelerate for a while. Israel led the world in vaccination success, the UK was not far behind, and Canada has caught up to them.
  3. India, while still very burdened, has seen a decline in cases in recent weeks that suggests that strict lockdowns in April and May worked (the full vaccination rate is 4%).
  4. Monoclonal antibody studies have continued to bring very good news. If you are offered them after testing positive, with or without symptoms, do not say no.
  5. Novovax has added a new vaccine to our armamentarium. It is based on a more conventional technology than mRNA, tried-and-true for several others, and it seems to have fewer unpleasant effects even after the second dose.

Bad News

  1. The relatively high vaccination rate in the US hides marked regional variation. The Southeastern and some other traditionally Republican states have low vaccination rates and are accordingly vulnerable. The politicization of our national response to the virus has been and will be absurd and deadly.
  2. Biden’s vaccination program accelerated from 1 to 3.5 million a day in his first 100 days, but then plummeted to less than a million and is now almost sure to fall short of his target of getting 70% of Americans vaccinated by the Fourth of July.
  3. India is projected to have a third surge in a few months time, and there is little sign that vaccination rates will go up enough to prevent this.
  4. Japan has decided to proceed with the Summer Olympics, already postponed from last year. The vaccination rate is about 5 percent and not likely to increase to adequate levels by the time of the games. Preventive measures will be used, but the majority of the country does not want the games to go on.
  5. The UK was slated to open up completely on June 21st, but the Delta variant is spreading so fast there that Prime Minister Johnson has postponed opening until July 19th, a decision met by widespread protests.

My friend, poet Marilyn Mohr, shared a poem with me recently that captures the message and the anguish of the virus. It reads in part:

Carried on the moisture of our breath,

it contains us in loneliness, cages us in fear.

We cannot sing or touch, even our smiles are masked.

Of course we want to reopen, reconnect, celebrate. We are starting to be able to do that. But we for now we need to keep looking over our shoulders. Please take to heart the exquisite clarity of Dr. Andrew Pekosz’s explanation of our situation and how the disease works. Please remember that the virus is always changing, and that some of us are more vulnerable than others.

Now that Juneteenth is a national holiday, it would be nice to have a period of national reflection between it and July 4th. In a sense July 4th is meaningless without Juneteenth, which was one halting step (among many, with many more needed) toward realizing the promise of our Declaration of Independence.

Jews have a period of self-examination and penitence for ten days from the New Year to the Day of Atonement. Juneteenth to July 4th could be a more celebratory period, but the self-examination could be equally useful.

See you in the fall I hope. Stay safe,

Dr. K

PS: Please don’t just rely on me. Dr. Michael Osterholm’s now biweekly podcast from CIDRAP, the Center for Infectious Disease Research and Policy of the University of Minnesota drops on alternate Thursdays. He combines realistic assessments and warnings with uplifting stories about how people are finding light and small victories in the pandemic. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Covid Digest, now weekly. More generally, I recommend the following: This 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, including Dr. Daniel Griffin’s superb clinical updates from the front lines. 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.  

Oasis in a Burning World

            “This virus is telling us, loud and clear, it is not done with us. It is not done with us.” Dr. Michael Osterholm, CIDRAP podcast, May 6, 2021

            “The spring wave has not really materialized. I’ve been describing it as this spring plateau, if you look at numbers across the country… We’re actually looking at a really good July ahead of us… So this is the time for masks, distancing, outdoors versus indoors, limiting group sizes, all these non-pharmaceutical interventions as we call them, and vaccination…” Dr. Daniel Griffin, “This Week in Virology” podcast, May 6, 2021

The United States is following Israel and the UK in winning the vaccination vs. variants battle, with evidence that nationwide and even in states like Michigan, where signs were ominous, the number of cases, hospitalizations, and deaths is slowly declining. The feared fourth surge has not materialized. The faster-spreading variants have not proved resistant to the vaccines or to natural post-infection immunity so far.

New York Times, May 9

We plateaued at too high a level after the winter surge plummeted, and a few weeks ago we began to rise from that too-high plateau. But vaccinations had doubled from one to two million per day and then doubled again to four million. This stopped the fourth surge and the slow decline began. We are still not yet below the high March plateau, but with a continued slow decline we could be in a better place soon.

Vaccinations have dropped back to between two and three million a day and may drop further until they are deployed to children. Vaccine stupidity, euphemistically known as vaccine hesitancy, explains this.

Still, the country has fought the virus to a standstill on a hill some feared we couldn’t hold, and we fought it down the hill. If we can fight it down further off the high plateau, we might just win the war. As always of course, this involves not just vaccinations but other precautions, especially those against swapping air.

But the situation in India is heart-breakingly bad and worsening by the day. Latin America is also going in the wrong direction. It is still reasonable to fear that these epidemiologically chaotic and tragic situations will allow the virus to evolve new variants over time that can come back to haunt us.

For this reason it is not just a humanitarian imperative but a self-protective one to help these suffering overseas populations in every way we can. The US may be steadily improving, but how we keep safe in the long run in a world in danger is a question we have not yet answered.

Good News

  1. The one-dose Johnson & Johnson vaccine that probably caused an extremely small number of blood clots has been reapproved by the FDA and the CDC and redeployed for emergency use alongside the two two-dose mRNA vaccines, along with instructions for monitoring and treating the rare clots. It may not be needed in most US situations but it is very important for the world.
  2. The CDC has expanded its list of what fully vaccinated people can safely do. It does not represent a complete return to normality, but it certainly adds many freedoms and reinforces the desirability of getting vaccinated.
  3. All US adults are now eligible for vaccinations regardless of age or other conditions contributing to vulnerability. There is plenty of vaccine for everyone.
  4. Pfizer has applied for full rather than emergency use approval for its vaccine. This will take time but adds to the correct perception that the vaccines are safe.
  5. Pfizer is expected to be authorized this week to vaccinate adolescents 12 to 15 years of age, a group where the vaccine has proved extremely effective and safe. This has great implications for school openings and is essential if we are ever to achieve “herd immunity.”
  6. Both Moderna and Pfizer are conducting clinical trials in children under 12. Completion and approval will take some time, but the positive implications are very similar.

Bad News

  1. Vaccine “hesitancy” and refusal—largely associated with political views—are causing a serious slowdown in vaccinations and will surely prevent the US from developing “herd immunity” to the extent that that is even possible. Many parents are expected to refuse vaccination for their children.
  2. Two days ago the CDC, following the lead of the WHO one week earlier, finally acknowledged that SARS-CoV-2 the virus that causes COVID-19, is transmitted in aerosolized form. It is airborne. This means that all enclosed indoor spaces can spread the virus in forms that float in the air for a long time, farther than a distance of six feet. I don’t understand what took them so long, as the signs of airborne transmission (not just droplets that gravity pulls to the ground in short order) have been fairly clear since the beginning.
  3. School reopenings remain challenging and controversial. Schools were involved in the Michigan surge, although frequently the virus was brought into the schools from the community rather than the other way around. The CDC’s latest guidelines for school reopenings are confusing and too expensive and difficult for many, perhaps most schools, to implement. Everyone agrees that the cost of keeping schools closed is great. We need more clarity about the risks and costs of opening.
  4. India is in by far the worst phase of its epidemic so far, and has the worst statistics in the world. Hospitals have been overwhelmed for weeks. Since there is no way to take care of or even evaluate all the country’s cases, nor any room in hospitals for people with life-threatening cases, all these terrible statistics are gross underestimates. Expert calls for a national lockdown go unheeded. Vaccines are scarce. Spread to Pakistan, Nepal, and other neighboring countries is happening fast. Thailand and Laos are also experiencing surges.
  5. Latin American virus statistics are also ominous. Brazil’s statistics, among the worst in the world for many months, has experienced some improvement, but remains in crisis. Uruguay, Argentina, Costa Rica, and Colombia are four of the ten worst-off countries in the world for COVID-19.
  6. SARS-CoV-2 continues to evolve new variants of concern, and each one presents potentially serious new challenges. The international situation now and over the next months will provide many new evolutionary opportunities for the virus.

There is a myth that the virus does not affect children. Children make up a large and increasing minority of US cases today. Thousands of children have been killed by the virus in Brazil. Why? New variant? Careless failure to protect them? We don’t know.

I don’t sympathize with people who spit in subway stations, smoke in restaurants, refuse to use seatbelts, mock the use of masks, crowd together, or turn their backs on vaccines. They are a clear and present danger to themselves and all around them.

So is anyone who fails to see that this pandemic is global and that the virus will evolve globally, continuously, and unpredictably going forward.

Stay safe, enjoy the American spring.

Dr. K

PS: Please don’t just rely on me. Dr. Michael Osterholm’s weekly podcast from CIDRAP, the Center for Infectious Disease Research and Policy of the University of Minnesota drops on Thursdays. He combines realistic assessments and warnings with uplifting stories about how people are finding light and small victories in the pandemic. 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.  

Robin in the Coal Mine

            “‘Michigan is an outlier that’s profound,’ said Dr. Eric Topol, a professor of molecular medicine at Scripps Research in La Jolla, Calif. ‘This is a precedent in the country. It’s about plasticity, flexibility in responding, in being able to pivot.’ He added that tens of millions of doses were sitting unused across the country, and ‘in some states, you can’t even give them away…’ Vaccines could have been surged to Michigan weeks ago when signs of its new wave of infections were appearing, he said, like signs that are now showing up in other states, such as Minnesota. ‘We have this incredibly powerful tool, and we’re not using it…And it’s just an outright shame.’” The New York Times, April 13, 2021

            “Hi this is Michael Moore and this is an Emergency Podcast System episode… I appeal to my friends across this country and across this world: please stand for Michigan. Please come to our aid. The level of COVID cases has doubled, then it tripled, then it quadrupled…  We need to act immediately. This is a surge that’s out of control… Sadly the CDC has decided, the Biden administration has decided, not to give Michigan any more vaccines during this very sad turn of events. Now I think that’s wrong. And I think that we need to demand that the vaccine—the Pfizer vaccine that is made in Michigan, in Kalamazoo Michigan—that we get as many of these vaccines into as many arms as possible…to help put a stop to this UK variant. But if it gets ahead of the number of vaccinations…we may not catch up. And believe me there’s no Covid border around the state of Michigan. This…will happen where you live… So number one, the CDC needs to send more of the vaccine to Michigan, in hospitals, doctors, clinics, every pharmacy…This needs to happen in the next few days, not next week, not next month. The Governor of Michigan has to shut the state down…just for a little bit, this is not some long-term thing here this is just right now, immediately, to try and bring an end to this rapid, rapid epidemic in Michigan… Both are wrong; the CDC is wrong, the governor of Michigan is wrong. Let’s get this fixed right now. Please call your Congress people and your Senators at their switchboard on Capitol Hill 202-224-3121. Please contact the governors office…in Lansing, Michigan, and please go on WhiteHouse.gov and send a note to President Biden and ask him to please increase the amount of doses to the state of Michigan this week, right now, let’s not let this thing grow…it’s critical right now, this doesn’t need to happen… This just has to end. Everybody get your shot, everybody wear a mask, everybody keep your social distance and wash your hands. Be kind to each other. And politicians, the Governor, please, please…close it down just for a little bit. And the CDC: you’ve got to send us more vaccine…” Documentary filmmaker Michael Moore, Podcast #182, April 12, 2021

            “[Michigan] State Representative Steve Johnson, a Republican, said he doubted that many people would comply with a lockdown order. ‘For [Governor Whitmer] to try to continue those measures would have been political suicide,’ he said.” The New York Times, April 13, 2021

Dear Students,

The American Robin is the State Bird of Michigan, and it’s shown here singing its heart out on the graph of the new massive surge in the state. Michigan’s coal mines were tapped out decades ago, but there’s a saying about “the canary in the coal mine” that warns miners of toxic gas, not by singing but by dying.

Plenty of people in Michigan are doing that job for us in America, where we just keep digging ourselves deeper into a hole that the Michigan Robin is trying to warn us about. Of course, it’s just the Michigan population of the American Robin, just as the Michigan virus is part and parcel of good ol’ American SARS-CoV-2.

Michael Moore is right to say that Michigan’s Governor Gretchen Whitmer should ideally shut down the state again. But as that state legislator Steve Johnson points out, it would be political suicide.

If only that were the worst form of suicide it could be.

Last spring lockdowns led a Trumpist mob to stage an armed coup in the State Capitol building, a coup that actually succeeded in shutting down the legislature for several days. Obviously it was another robin in the coal mine, warning us of a similar coup attempt on our nation’s Capitol on January 6th. We have not seen the last of these.

But meanwhile, a group of deadly serious armed plotters were planning to kidnap Governor Whitmer, ending her administration, and some of them were planning to kill her. This planned assasination and coup was aborted by the FBI, but the next one may succeed. That doesn’t mean that she doesn’t have a duty to keep the people of Michigan safe, she still does.

But it’s pretty sickening when CDC Director Rochelle Walensky sits in the complete safety of her office in Washington and turns down a threatened and vulnerable Governor who is begging for vaccines. Walensky and President Biden have miserably failed the people of Michigan, and they will soon be failing much larger swaths of America, by insisting on a pigheaded policy of distributing vaccines exactly in proportion to a state’s population.

That means not only the Michigan surge but other state and regional surges to come will be ignored while millions of doses of vaccine sit unused. Biden and Walensky are already planning how to distribute internationally hundreds of millions of doses that will comprise a huge American surplus in a few weeks time.

Do I understand that vaccines take weeks to start working? Yes I do, and you know I do if you’ve been following what I’ve said all along about them. But that just means that Biden and Walensky failed Michigan weeks ago as well. Dr. Ashish Jha, one of the leading public health voices throughout the pandemic, tweeted on April 8, “This is very upsetting. Michigan is struggling. We need to be surging tests, vaccines to the state.” The idea that it is too late now is in my view absurd. Vaccines now could prevent millions of Michigan cases a few weeks down the road, even with one dose of a two-vaccine regimen.

What Walensky and others are saying to justify not doing this is a disgusting evasion. They are playing a political game. You can be that if this surge were in Texas or Florida they would not be withholding vaccine. Michigan is a blue state, like the color of the sky behind the robin. Biden’s people are afraid of seeming to favor Democrats, so they are letting Michigan and its Democratic Governor twist in the wind.

That’s the game—avoiding blame—instead of avoiding illness and death.

Walensky said, “The answer is not necessarily to give vaccine.” Not necessarily? What kind of mealy-mouthed answer is that? And, “The answer to that is to really close things down, to go back to our basics, to go back to where we were last spring, last summer, and to shut things down.”

So, Dr. Walensky, is your boss going to send troops to protect Governor Whitmer and her family? Are you going to stand beside her in Lansing when she faces another anti-lockdown mob that wants to kill her?

Michael Moore understands the value of “everybody wear a mask…keep your distance, and wash your hands.” He is also, like Governor Whitmer, begging, begging for a surge of vaccines for Michigan.

Dr. Eric Topol, whose twitter feed has been a vital source of information for me and thousands of others throughout the pandemic, thoroughly understands and promotes the tried-and-true precautionary measures, and knows, as I do, that they would be a faster response to the Michigan crisis than additional vaccines would.

He also said about extra vaccines for Michigan, “We have this incredibly powerful tool, and we’re not using it…And it’s just an outright shame.”

Where Dr. Walensky or anyone else gets the idea that vaccines and masks are substitutes for each other is beyond me. I do think however that we are watching a political game run by Biden in his Michigan vaccine-refusal gambit, just as we so often watched Trump play as President.

The irony is that Trump’s political game worked against blue states like New York and Biden’s political game is working against the blue state of Michigan.

Good News

  1. Biden’s performance in rolling out the vaccination program nationally, despite my grave reservations expressed above, has more than met expectations. I criticized him for thinking at first that a million shots in arms a day was an achievement, at a time when experts were saying 3 million a day were needed. Biden deserves credit for getting to that number as an average, with maximums up to 4.6 million. We will have 200 million jabs by the end of Biden’s first 100 days, double his original goal.
  2. Biden and his associates frequently wear masks in public and preserve social distance, setting desperately needed examples for the American people—examples which, very happily, are the opposite of what we had for the previous first year of the pandemic. Biden takes frequent opportunities to encourage these measures as well as thinking about ways to address the looming problem of vaccine hesitancy.
  3. Data continue to emerge confirming the safety and effectiveness of the two mRNA vaccines, which represent a completely novel kind of vaccine science and one of the greatest achievements in the history of medical science. In addition to safety and efficacy, the mRNA technology afforded an unprecedented platform for speed in development of the original vaccines without compromising safety, and it will continue to provide a platform for speed in the relentless arms race against new variants of the virus, allowing for the development of variant-specific new vaccines and boosters with unprecedented speed. (Read the moving story of Dr. Kati Kariko, the brilliant and heroically self-sacrificing lab-science gypsy who helped lay the mRNA groundwork.)
  4. Just in the last few weeks some uncertainty has been removed about whether fully vaccinated people can contract, carry, and pass on the virus asymptomatically. The answer increasingly appears to be, for the most part, no, even with the much more transmissable and more virulent UK variant. Also, current protection against hospitalization and death, at least with the UK variant and the main one preceding it, appears to approach 100 percent.
  5. Monoclonal antibodies (aka passive vaccinations) have continued to prove themselves as useful if not magical. They still require intravenous infusions but are increasingly doable in outpatient settings, and they prevent early cases from progressing to hospitalization. Increasingly too, they are being introduced for people who have no symptoms but positive tests for active virus and even for people who just have known exposure. Vaccines are not much use in these situations. Research on intramuscular injection of monoclonals is under way, and if successful would greatly enhance the deployment of this lifesaving technology.

Bad News

  1. The Johnson & Johnson (Janssen) vaccine has been halted because of a blood clotting problem affecting about one in a million vaccinated people (6 in the US; one died and one is gravely ill). This is a similar adverse effect to that suspected with the AstraZeneca vaccine. In both cases the nature of the clotting disorder is unusual, and so unlikely to be part of the background clotting problems expectable in such a large population. The J&J patients were women of reproductive age, suggesting an immune system problem. The halt, if it has to continue, removes a single-dose vaccine from the toolkit, a loss for the US but a much more important loss for the world.
  2. 200 million doses in American arms by the end of April (Biden’s 100 days) means 100 million people fully vaccinated, approximately 30 percent of the US population, or less than half of the level needed for herd immunity. Even adding the immunity of people who’ve had the virus doesn’t get us near herd immunity, which is at best months away—without taking the newest variants into account, with their potential for resistance against immunity and vaccines.
  3. Vaccine hesitancy, particularly common among Republican men, will play an increasingly large role as more of the country is vaccinated. Children will not even begin to be vaccinated until late summer at the earliest. Herd immunity is not a slam-dunk; it will be an increasingly uphill slog as long as vaccine acceptance is politicized.
  4. I have become increasingly convinced, thanks to Michael Osterholm who along with a few others has been arguing this for months, that we should be using our vaccine doses very differently. Namely, we should administer twice as many first doses of the two-dose vaccines rather than insisting that people get a second dose within a few weeks of the first. As Osterholm cogently argues, using two doses to give two people first doses results in 80 percent protection for both, while giving two to one person and none to the second person results in an average of 47.5 percent protection, since the two-dose person has 95 percent protection and the other has zero. Mathematical models easily show that Osterholm’s strategy gets to herd immunity faster.
  5. Last, and most important, the pandemic is not an American problem or a developed world problem but a global one, including a general threat of global instability. We have not even begun to fight the global war against the virus. Herd immunity for the world will take years to achieve. You don’t need to care about humanity, just the long-term repercussions for you. The virus loves the global stage, which is its evolutionary playground. We already have growing numbers in our country of the South Africa variant (B.1.351) and the Brazil variant (P.1). What new variants will evolve in the slowly vaccinated populations of poor countries and bounce back to us in ’22 or ’23? Stay tuned.

Michigan, the robin in the coal mine, represents what much more of America will be facing in the months ahead. If the Biden administration does not drop its political games and surge vaccine supplies to states and regions that have surging virus—whether blue or red—we will be wasting time and vaccine doses and causing preventable deaths. The time may come soon to tally up the deaths cause by the Biden administration’s sometimes willful errors, just as we have done with Trump. They won’t be as many, but they will be substantial. Biden doesn’t get a pass on a bad decision because it followed two good ones.

Also, we need to look at the evidence for Osterholm’s claim that vaccinating twice as many people once would save many thousands of lives. We only found out recently how much protection one dose of the two-dose vaccines gives us. As Dr. Topol said, “It’s about plasticity, flexibility in responding, in being able to pivot.” New knowledge brings new responsibility.

Old knowledge helps too. Mask up. Keep your distance. Avoid gatherings. Use caution until we see what the new variants can do. This is not over, not even close.

Stay safe,

Dr. K

PS: Please don’t just rely on me. The most important recent addition I have is Dr. Michael Osterholm’s weekly podcast from CIDRAP, the Center for Infectious Disease Research and Policy of the University of Minnesota; it drops on Thursdays. He combines realistic assessments and warnings with uplifting stories about how people are finding light and small victories in the pandemic. 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.  

 

 

 

 

 

 

Sarsie Rides Again

            “We are not driving this tiger, we are riding it… We are the one country in the world that’s opening up faster than ice melting in a sauna. It’s crazy… Vaccine’s coming. But it isn’t coming fast enough. It’s not. We’re not going to see a big expansion of vaccine availability for at least weeks yet. We will. Eventually we will. And I think this summer is going to be a really wonderful time that way. But we’re a ways off. B.1.1.7 is here, those numbers are beginning to rise, and I feel like it’s a déja-vu-all-over-again moment.” Michael Osterholm podcast, March 23, 2021  

            “When I first started at CDC about two months ago I made a promise to you: I would tell you the truth even if it was not the news we wanted to hear. Now is one of those times when I have to share the truth, and I have to hope and trust you will listen. I’m going to pause here, I’m going to lose the script, and I’m going to reflect on the recurring feeling I have of impending doom. We have so much to look forward to, so much promise and potential of where we are and so much reason for hope, but right now I’m scared.” Rochelle Walensky, CDC Director, March 29, 2021

            “I’m telling you right now…we are just beginning this surge, and denying it is not going to help us. We are walking into the mouth of this virus monster as if somehow we don’t know it’s here. And it is here. Now’s the time to do all the things we must do to slow down transmission, not open up, and we’ve got to get more vaccine out to more people.” Michael Osterholm on CNN, April 1, 2021

            “We’re not driving this tiger, remember, we’re riding it  … No other country in the world is loosening everything up—pretending the virus doesn’t exist any more. Nobody’s doing that… We are creating the perfect storm. We’ve got a bad, bad virus. We’ve got a lot of people yet who can still be infected despite the fact that vaccines are rising. And we’re opening up as if we’re done with the virus. It’s like dismissing gravity. ‘I don’t want to deal with gravity any more today. I’m done with it.’ It doesn’t work that way.” Michael Osterholm podcast, April 1, 2021

Dear Students,

Some of you may remember my exclusive interview with the SARS-CoV-2 virus (“Sarsie”), way back in early June. He talked a lot about his relationship with Uncle Charlie—who he said was advising him on how to evolve. I didn’t think Darwin would do that deliberately, but Sarsie clearly obeys the old man’s laws.

Actually, he wasn’t interested in being interviewed.

“Professor, shut up and press the record button. I don’t need your questions. I can talk to the students directly, and anyway they’re bored stiff with your doom and gloom. I’ll give it to them, like the new Prez says, straight from the shoulder. Okay, I don’t have a shoulder. Straight from the spike then.

“When I spoke to you back in June I was gearing up, had notched a few wins on the evolutionary scene, and was getting ready for my real triumphs. This column is the half-time show in my superspreader superbowl.

“What’s that? You don’t like the half-time show idea? How about top of the fifth inning? Okay, bottom of the fifth. The home team, your species, is scoring some runs with vaccines. In June they were barely a wisp of a hope. Nine months later, they’ve been born, quadruplets, and they’re starting to grow up.

“I know, you think it’s the seventh-inning stretch at least, or even the end-game. You think you’re about to start hitting them out of the park. Dream on. I’m looking at half the game ahead, not counting overtime. And I’m so confident, I’m about to give you my playbook. Only fair. Homo dumbellus needs a handicap.

“Let’s review the basics as Uncle Charlie set them out: Variation, adaptation, duplication, reproductive success. If you remember two words, make them the last two. You don’t even need the words, really, if you can’t spare the space in your Homo dumbellus brain. Just the letters.

      “RS.

      “It’s Darwin’s own version of Newton’s Law of Gravity. If Variant B reproduces faster than Variant A did, B rocks. If Variant C does even better, it’s Bye-Bye Baby B. And so on. Insanely simple. Not like the rocket science you need to escape gravity. Even a dumbellus can understand Uncle Charlie’s law. Heck, even a virus can.

      “In June I reviewed my early life. Years in the bat-cave spinning my wheels, then a variant that let me jump to you. Nice shot, but more of a bunt than a home run. Then a variant that let me jump from you to you, and I took off like, well, a bat out of Wuhan.

“Mutation, mutation, mutation. I love those little bloopers. Most do nothing. Some knock off the adventurous virus that blooped them. But every once in a while, and don’t forget I’m reproducing zillions of times a day—that’s an approximation—I get one of those happy typos that makes my day, week, month, or year.

“Mutation. Variation. Variants. Variants of Concern.

“My first big VoC after my breakout from Wuhan was one you didn’t even know about at the time. It was the D614G. Let me clue you in how to read that gobbledygook. The spike protein is a string of amino acids (aa’s), and this means a change in the 614th one from aspartate to glycine. Just a blooper in duplication.

“Now that wasn’t so painful was it?

“The explanation wasn’t, but the reality was. It made me much more infectious. G614 outcompeted D614 by binding better to the ACE2 receptor that folds me into your cells. I had greater fitness; that is, greater RS.

“Remember Italy and Spain in early 2020? Wildfire there, then all Europe, then New York—the Big Apple. With D614G I gave my regards to Broadway, and after that the world. Wuhan was just a memory. By June, when I last spoke to you, my darling G614 had swept the globe.

“Big spring surge, then a rest, a bigger summer surge, and after a little vacation in early fall, you took a deep breath and I got set for my giant winter surge. It went well for me. How did it go for you? Oh yeah, I remember. Homo dumbellus. Thick skulls, stupid habits, stupid leaders.

“Wow, did I take off in January. The graph itself looked like a rocket ship.

“But I didn’t rest on my laurels. Uncle Charlie wouldn’t have liked that, and I always want him to be proud of me. Turns out there were plenty of dumbelluses in England, so I fixed my fitness lens on Trafalgar Square. You know. The UK variant. B.1.1.7.

“If I squinted, I could see old Charlie nodding in his photo. He must have also liked that you started naming strains according to their evolutionary history. Couldn’t very well have named it according to one mutation. It had 23! 23 differences from the Wuhan original.

“Eight were in the spike protein, and three of those are a big deal: N501Y, (a blooper changing asparagine to tyrosine), P681H (proline to histidine), and two aa deletions at positions 69-70. The tyrosine at 501 made my spikes even better at binding ACE2, my key to your cell’s locks. The other two changes probably helped me fold myself through your cell membranes.

“You can see why I thought I saw Charlie swell with pride. I was mixin’ & matchin’! I was upping my game several ways at the same time. God I love evolution. My UK variant soon proved up to 70 percent more infectious, and the Brits, who had gotten D614G from their Southern European cousins, returned the favor as a Christmas present, sending the new B.1.1.7 back to Europe and now the world.

“Let’s take a break from the gobbledygook and note that this variant is the one you dumbelluses need to worry about right now. It’s dominant in Europe and soon will be in the US and much of the world; the only thing that will contain it other than vaccines, which work but are not moving fast enough to beat it, will be other souped-up versions of me that hold it to a standoff.

“By the way, the B.1.1.7 is also more lethal. Don’t think for a minute that I like that. Billions of my bros go into a hole in the ground every time they kill one of you—if you were still infectious when you died. Heck, what happens as soon as one of you stops breathing? No breathing, no aerosols, no RS.

“That’s why I evolved to be less virulent—less lethal—than my cousins MERS and SARS-1. I out-evolved them to put it mildly. Dumb as your species is, it gives me no pleasure to kill you. I want infections with few or no symptoms, especially in young people, whose restlessness and appetites whisk me around the world.

“Speaking of which, the world is welcoming me in more variants than one. The South African one, B.1.351, also has the N501Y blooper, but in combination with other changes in my recipe—K417T (lysine to threonine) and E484K (glutamate to lysine)—that make me resistant to your vaccines, even if Africans can get them. Africa is to me a vast unconquered world, an evolutionary opening of collossal proportions.

“Then of course Brazil, where the so-called leaders are as bad as yours, and they’re welcoming me to a banquet. My P.1 variant has 17 unique bloopers, including three that affect our binding to your receptors: K417T, E484K, and N501Y. The P.1 came out of the Amazon—famous for its diverse life forms, including me—and swept the country. But you don’t think my boys are going to stop at the Brazilian border, do you?

“E484K, aka the “Eeek” mutant, may be my jiu-jitsu trick to duck your immune systems and even vaccines. You can bet I’m going to make good use of the Eeek in the future. I’ve already popped up with it in Oregon independently, meaning—Uncle Charlie rocks—parallel evolution. If I can evolve that one pretty much anywhere, and it does turn out to nix your vaccines, well, Katie bar the door.

“Meanwhile, there’s a new New York variant, the B.1.526, which affects young people more, and a new two-form California variant, the B.1.427/B.1.429, with three spike protein mutations, including the novel L452R (leucine to arginine), that make it more contagious.

“Understand: most of your species hasn’t seen any version of me yet. I’m just getting started with them. See what I mean about half time? Bottom of the fifth? I still have to get to the majority of the species, and I will keep spreading faster than vaccines. I will also keep evolving. So you Americans beat the versions you have with the vaccines you have. But wait, you already have the Eeek!

“And something else: Do you think the bottom half of the world won’t be sending evolved versions of me back to you next year? The year after?

“Eventually you’ll fight me to a standoff with evolving vaccines. The smartest strains of your dumbellus species—the scientists—move fast enough to do that. But eradicate me? Forget it. Boosters for waning immunity, annual shots like my bro the flu, we can make a deal.

“A guy like me has a career trajectory. I could evolve toward even less virulence, become more like the common cold than the flu. Just bubbling up, year after year, not much damage but spreading just fine, bubbling and bubbling forever.

“So now you have my playbook and my retirement plan. We’ll get along eventually—after the pandemic game, my species against yours, is over. Which it isn’t even close to being yet. Like the man said, don’t dismiss Newton’s Laws, or Darwin’s. If it’s the bottom of the fifth, you, the home team, are up. Are you going to continue to let me strike you out? Or do you finally hit one out of the park?”

Maybe I should ask Sarsie to say what he really thinks.

He claims he doesn’t like to kill us, but he’s killed 550,000 of us in a year. We’re losing over a thousand a day and that is not declining; cases and hospitalizations are rising, and deaths will rise too.

It’s a fierce evolutionary process that can do that for one, two, three, and soon four American surges. Some biologists say that viruses aren’t really alive. Sarsie said last time, rather annoyed, “I’m alive and I’m eating you alive.”

Either way, his biological evolution has been amazing; cultural evolution is supposed to be faster, but our cultural evolution in response to him continues to lag way behind.

Stay safe,

Dr. K

PS: Please don’t just rely on me. The most important addition I have since my last update is Dr. Michael Osterholm’s weekly podcast from CIDRAP, the Center for Infectious Disease Research and Policy of the University of Minnesota; it drops on Thursdays. He combines realistic assessments and warnings with uplifting stories about how people are finding light and small victories in the pandemic. 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.

 

 

Arms Race

      “Please hear me clearly: at this level of cases with variants spreading, we stand to completely lose the hard-earned ground we have gained. Now is not the time to relax.” Dr. Rochelle Walensky, CDC Director, CNN, March 2, 2021

      “Dr. Walensky is right, and the reason she’s right is while things are way better than they were about a month and a half ago the level of infection in the country right now is the same as at the peak of the summer surge, so we’re not in great shape. And we have variants, and variants are starting to take over, and if they become dominant and we relax restrictions I think we can absolutely see a huge spike that will really lead to a lot more suffering… We have a high level of infection, we’ve got states easing restrictions, which they should not be doing at this moment, and we’ve got the variants that are circulating that are a lot more infectious. Put all that together and I can’t help but worry about where we’re going to be for the next couple months.” Dr. Ashish Jha, epidemiologist, Dean of the School of Public Health, Brown University, CNN, March 2, 2021

      “I have to congratulate this administration for what they have done…with the vaccines… But we also have to tell the story of what is still ahead of us. And at 2.9 to 3 million doses of vaccine a day, over the next 6 to 14 weeks, when this surge is likely to happen, is not really likely to take care of the problem at all… We still have a lot of high-risk people out there, and when this surge comes, they’re going to be highly vulnerable… The other thing we see right now is that every governor wants to open schools… and as a grandfather of five children I get it. But the problem is that if you look at Europe, the challenge we’re seeing right now is a lot of transmission in schools with this new variant… So we’re going to have some tough days ahead in the older population and the younger population with this new variant virus.” Dr. Michael Osterholm, Director, Center for Infectious Disease Research and Policy, University of Minnesota, on Meet the Press, March 7, 2021

      “The pandemic still remains a very serious situation.” Dr. Rochelle Walensky, Monday, March 8, 2021, Politico.

Dear Students,

The US reportedly delivered 2.9 million vaccines into arms yesterday, far ahead of what Joe Biden initially promised and almost at the 3 million per day minimum that experts have recommended. However, the UK variant (B.1.1.1) is rapidly becoming the fastest spreading strain in the US, destined to account for at least 50 percent of new cases in Americans in the next few weeks. In Britain and Europe, this has been the threshold for new and very serious burdens on health care systems.

Right now, we Americans are feeling good. The holiday surge is over, and cases, hospitalizations, and deaths have come down an astounding 70 percent since their winter peaks. However, this is primarily the result of the mess we made by our behavior on the holidays. When we’ve been banging our head against the wall harder and harder, there is only so much credit we can take for feeling better when we stop.

But now cases and hospitalizations are plateauing at levels higher than the summer peak when the virus swept the south and west and the national surges scared the living daylights out of us. We are stabilizing at that way-high level—a convenient platform for the virus to take off in a new surge—and, right on cue, we are starting to bang our heads against the wall again, with premature openings and ending mask mandates in some states and lazy complacency in many others.

These foolhardy blunders can easily take us from the high plateau we are on into a fourth wave that will once again cause scores of thousands of needless deaths.

As the photo suggests, we are in an arms race between evolutionary changes in the spike protein—the virus’s arm for prying open our cells—and the human arms getting jabbed in the vaccination campaign. The virus is flooring its Darwinian gas pedal with new variants of concern (VoCs) in South Africa and Brazil, yes, but also New York and Oregon.

Our university is among those that have seen surges in student cases—in Emory’s case an unprecedented outbreak after a year of safe performance—due to Superbowl parties, fraternity and sorority pledging, and other activities the virus loves. So many opportunities to evolve! Now spring break is coming for many colleges, and—well, here we go again.

Good news

  1. The Johnson & Johnson single-dose vaccine was given its expected Emergency Use Authorization, putting it on a par legally with the mRNA vaccines. The J&J is an adenovirus carrying viral DNA and is stable for weeks at refrigerator temperatures, a tremendous boon for rollout—as is the fact that you only need one jab. It is substantially less effective than the mRNAs at preventing cases (72 vs. ~95 percent), but, like them, close to 100 percent effective at preventing severe cases and death. Initial rollout has been slow but will ramp up fast.
  2. Not vaccines, but other preventive measures (masks, social distancing, handwashing), along with the pass-through of the holiday surge, have brought cases and hospitalizations down more than 70 percent. Nursing homes, where the most vulnerable have lived and died of COVID all along, have declined even more—in their case largely due to priority vaccinations.
  3. Total vaccinations, mainly with mRNA vaccines, have been deployed more and more effectively, with 450 vaccination centers and thousands of volunteers across the country. We are almost at 3 million a day, and if we can keep that up or, preferably, increase it, we have a chance of flattening the curve of the fourth wave. If we keep up masking and other preventive measures, we have a chance to avoid it altogether and by the end of the year bend the current high plateau way down—if the vaccines provide long-term immunity and the new variants can’t evade them.
  4. Herd immunity through widespread vaccination—up to 85 percent is needed—can be achieved and life can return to something close to normal, with tremendous positive implications for the treatment of non-COVID illnesses, education, jobs, and mental health. Healing from this dreadful national trauma will be under way.
  5. Dr. Peter Hotez has lauded the vaccine rollout in India as having the potential to save the world from the virus—even while reminding us that the US will never be safe from it until it is controlled (not necessarily eliminated) worldwide.
  6. The CDC finally came out with guidelines for people who have been fully vaccinated. They can be indoors with small numbers of fully vaccinated people without masks, or with well-known low-risk people from one other household. They should not go to gatherings, eat indoors at restaurants, and the like.

Bad News

  1. Variants of Concern now include the UK/B.1.1.7 (mutation N501Y), which spreads 50 percent faster and is sweeping the US but is susceptible to existing vaccines; the South Africa/B.1.351(N501Y+K417N+E484K), which spreads faster and is less susceptible to vaccines; the Brazil/P.1 (N501Y+K417T+E484K), same; the new New York variant/B.1.526 (S477N+E484K), same; and the Oregon variant/B.1.1.7 (N501Y+E484K), same.
  2. Lets put this bad news in English. For each of these codes, the number in the middle represents the consecutuve position of the relevant mutation on the viral spike protein. The before and after capital letters represent the one-letter code for amino acids. Thus N501Y means the amino acid in position 501 has changed from arginine to tyrosine due to an underlying mutation (replication error) in the RNA triplet that specifies 501. Since 501 is in the binding domain of the spike protein, the mutation can and does make it easier for the virus to bind with and enter cells—thus increased transmissibility.
  3. The two mutations at position 417 (K→N →or K→T) as well as the change at 477 (S→N) also affect the spike binding domain. All can enhance transmissibility and all are popping up independently in different places. Also, these Variants of Concern involve amino acid substitutions that change the shape of the folded spike protein at least a little, and are therefore able to enter our cells or resist our antibodies more easily.
  4. Most concerning to scientists appears to be the E484K mutant, (glutamic acid → lysine at position 484). This mutant, present in 5 of the 6 new strains named above, makes it easier for the virus to evade our antibodies, thus undermining both natural and vaccinated immunity. Its nickname is the “Eek” mutation, and yes, it is that scary.
  5. Mutations occur constantly, and some of them are adaptive, so the virus evolves. To paraphrase an old song, it’s a mighty restless bug in a mighty restless land. Scientists have a huge deal of trouble figuring out which of the many mutations are silent, and which, like the ones above, matter for humans. On top of that, the mutations operate synergistically, for better or worse, when they appear in the same strain.
  6. Since we still do a woefully low amount of viral sequencing, and overall testing and tracing are low and/or declining, we are fighting the new variants in the dark without a flashlight. Our friends in vaccine manufacture and development start scrambling to invent booster shots for new variants as soon as they appear, but it’s a race against time, vaccine development vs. viral evolution.
  7. There have been disappointments on the clinical side this past week. Convalescent plasma in a metaanalysis was shown to have no benefit on any standard outcome measures. Fortunately, it is being replaced with monoclonal antibodies that work better if introduced early in the illness. Dexamethasone (a steroid) increases mortality if given early in the illness but remains confirmed as effective in advanced stages. The IL-6 inhibitor tocilicumab helps if given after dexamesthasone but is harmful if given without dexamethasone. Something similar is true of other IL-6 inhibitors.
  8. Standard views about children being less likely to be infected than adults may be due to testing bias, so they may be equally vulnerable. It still seems true that they don’t get as sick, but a new study finds that as high as 13 percent of children who are infected will suffer from long COVID. Dr. Daniel Griffin, who gives the clinical updates on the This Week in Virology podcast, calls this “a disaster.” Long COVID goes up by age to peak in the age period 35-49; overall it affects at least one in five people who get infected with COVID-19.

States are opening prematurely. Governor Abbott of Texas, still reeling from accusations that his negligence caused scores of death in the recent snowstorm, has decided to cause thousands more excess deaths from COVID by boldly opening Texas “100 percent.” The governors of Mississippi, Arizona, and other states are doing the same.

This failure of leadership is a step by step repeat of the mistakes that led to last summer’s and then this winter’s surge, needlessly killing hundreds of thousands of Americans, and it will have similar consequences.

Such stupidity in leadership acts synergistically, like the evolving viral mutations, with the stupidity of ordinary Americans. If you have missed it, take a look at the photo on the left. It shows the good citizens of Boise, Idaho, ceremoniously burning masks outside the state Capitol. As with all ceremonies, this one expresses deeply held beliefs, and the adults are passing their beliefs on to their children with the ceremony.

As playwright Arthur Miller said, “The paranoia of stupidity is always the worst, since its fear of destruction by intelligence is reasonable.” These neighbors of ours have bad ideas, which they probably sense cannot hold up in the face of better ones, and since they are attached to their bad ideas, the possible loss of them makes them afraid.

Yet what can we do in the face of such stupidity except continue to meet it with the best intelligence we have? Meanwhile, as always, the stupidity of our fellow citizens, including leaders, puts us all at risk. Eek.

Stay safe. It won’t be too much longer, provided we aren’t stupid enough stretch it out again.

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.

 

 

 

“Baby, There’s COVID Outside”

            “Dr Chris Murray from the IHME told Anderson this earlier tonight, they’re expecting over 100,000 additional deaths between now and June … they don’t think that the US will reach herd immunity before next winter. I mean that’s a pretty scary proposition—what do you think?” 

            “I think that Dr. Murray and his colleagues are probably right… It’s going to take us quite some time to get…enough supply. Hopefully we’ll reach that by by mid-summer but…we really need the vast majority of adult Americans to take the vaccine, and I’m afraid that because of the pandemic of disinformation, it’s going to be really difficult to do that, and so I’m hopeful that we can do this by winter and have a normal Christmas and New Year’s, but it’s going to take a lot of hard work for us to get there, and the variants can really throw a wrench into the works… I really do worry about the variants, because if you have something that’s a lot more transmissible then it’s not just a matter of linear spread; so something that’s 50% more transmissible, you’re not going to get 50% more infections, you’ll get many many many times more infections… I also worry about variants that potentially could be less effective with the vaccines that we have and we may always be happy to play catch-up so we vaccinate everyone, but then there are variants, and then we have to get boosters to target those variants. So we could always be trying to play catch-up here, and that is a big problem.” Dr Leana Wen, with Don Lemon, CNN, 2-19-21

            “The virus and the pandemic as we know it is not the virus and the pandemic that we face right now… This virus is changing and it is changing rapidly. There about 4000 different variants… To find a variant you have to genetically sequence, it requires skill, immense computing power, and frankly not many countries are doing that… Those three main strains [UK, South Africa, Brazil/Japan] are out there and they are improvements from the original virus, because that’s the way evolution works. When there is even a tiny advantage that advantage is pushed along through natural selection at an enormously rapid rate because evolution in viruses happens very very quickly… I’ve been following the story of one particular intensive care nurse who was quite optimistic because she had gotten her vaccine and then her COVID ward suddenly changed when these mutant strains arrived:”

            “We’ve seen patients now with absolutely no past medical history, not overweight, runners, people who go to the gym, people in their 40s, and these patients are dying.”

            “What would you say to Americans who might not have woken up yet to the fact that this is coming?” 

            “If you love your family, if you love the people you know, wear a mask, stay indoors, wash your hands, be careful, just realize that this will kill.” Richard Engel with a UK intensive care nurse, MSNBC, 2-21-21

Dear Students:

This is much my favorite of several parodies of the old song, “Baby It’s Cold Outside,” making the cloud rounds since Christmas. I know, it’s cold outside too. Colder than it has ever been in, for instance, Texas, where due to the incompetence of state leadership, at least 32 people have died from the winter storm—of at least 69 nationally—as of yesterday.

My heart goes out to the victims, their families, and the millions of others who suffered from no heat in freezing cold—some made fires from their furniture—and no water due to ice-burst pipes. But consider.

The 7-day moving average of daily deaths in Texas from COVID-19 was 119 on Saturday. So, despite the lowest death rates since November, during the week of the storm the virus killed over 800 people, or around 25 times as many as the cold did. But the storm news thoroughly dominated the air waves all week, with virus stories and analyses relegated to short segments late in the hour.

Nationwide we are under 2,000 deaths a day, down from 4,000 in mid-January (see the chart). This is terrifically good news. But we are still far above the summer peak and only around the immensely disturbing first peak of last spring. That’s with all the advances in treatment and two months of vaccine roll-outs.

Hospitalizations have dropped similarly, a tremendous boon to our frontline healthcare heroes, and cases have dropped even more. But all are still at or above previous peaks. We just crossed the nauseating milestone of half a million deaths.

Baby, it’s COVID outside.

Good News

  1. New cases in the US have dropped 70 percent from the winter peak, hospitalizations and deaths have been halved. This is most likely due overwhelmingly to the pass-through of the holiday-period recklessness and the resulting unprecedented surge. Improved behavior, partial immunity due to prior infection and (to a very small extent) vaccination have probably helped.
  2. The vaccine roll-out continues with great fanfare but at a slow pace. We have reached over 60 million vaccinations, mostly first dose, and that is increasing at 1.6 million a day. So far this is overwhelmingly the Pfizer and Moderna mRNA vaccines, but the Johnson & Johnson single-dose one is on the verge of Emergency Use Approval, with more to come.
  3. A study in Israel, where vaccination rates beat the world, shows that a first dose of Pfizer vaccine affords 85 percent protection between 15 and 28 days out. This is far better than anyone expected. Another Israeli study showed that a double dose prevents transmission as well as disease, at a rate of 89 percent; this was a big question mark until now.
  4. Treatment advances continue, including monoclonal antibodies for early-stage patients to keep them out of the hospital, and late stage tocilizumab, an interleukin-6 (IL-6) inhibitor, given after or with the steroid dexamethasone. Immune system interventions like these, science fiction a few decades ago, are working. Early anticoagulant (blood thinner) treatments and vitamin D supplements also make a difference.
  5. The new administration in Washington has set a new tone. Masks are cool and people from the top down are modeling their use. Social distancing, handwashing, and other preventive measures are mentioned frequently. The stupid culture wars over prevention are not done, but the federal government is on the side of science.

Bad News

  1. SARS-CoV-2 is evolving fast. The 4,000 variants mentioned above are of uncertain importance, but some could change the game, and not enough people in government or news outlets are talking about them. The UK variant spread like wildfire there and doubled hospitalizations almost overnight. Cases of it are doubling every 10 days here and it will be the dominant US strain by March. Cases of the South African and Brazil/Japan strains are here. The first is resistant to some vaccines and the second is implicated in a new epidemic that engulfed Manaus, an Amazonian city of 2 million.
  2. Dr. Peter Hotez, probably the nation’s leading expert on vaccine development, says we need 3 million doses in arms per day, almost twice what we have now, and there are no plans announced to get to that number. Dr. Michael Osterholm gave up his own second dose because he believes triage requires that we (like the UK) choose to vaccinate twice as many people once before we give second doses (see #3 above).
  3. President Biden has promised to “level” with us, and, like FDR, to give it to us “straight from the shoulder.” But if he did that, he would not talk about 600 million doses by mid-summer as if it were adequate. He would apologize and pledge more. And he would certainly not, as I have heard him, blame his predecessor, which is uncomfortably reminiscent of what his predecessor did.
  4. Israel, the UK, and even the United Arab Emirates show that vaccinations can move much faster than they are moving here now. The UK has been on lockdown for many weeks and will reopen only slowly as conditions allow in March. Bhutan, Rwanda, and Senegal have done far better than we have in controlling this pandemic. Are we still too proud to learn the lessons all those countries and more have to teach us?
  5. The issue of school reopenings has been handled by the new CDC Director, Dr. Rochelle Walensky, almost as bumblingly as by her predecessor. On Sunday the 14th CNN’s Jake Tapper asked her to defend her new guidelines. She tripped all over herself. She said (for example) that community transmission has to be controlled where the school is. Tapper pointed out that 99 percent of US schoolkids live in red zones. No answer. This was without noting that thousands of schools would go bankrupt if they met the guidelines for cleaning, ventilation, and so on. Biden’s White House did not back her up. Of course kids need school, but the new CDC is still being disingenuous. Vaccinate the teachers, janitors, and food workers.

Speaking of kids, I reached the two-week anniversary of my second Pfizer dose on Friday, and on Saturday I snuggled with my grandkids while reading to them for the first time in almost a year. We were outside and I was still masked, but it was a great feeling. One of the new studies mentioned above told me I would be unlikely to carry it asymptomatically to them

As I said to some of you yesterday, I wish I could tell you to party. You have as much right to party as I have to hug my grandchildren. But if you do it now, you will join the ranks of the foolish who infect themselves and others.

This is not over. Not all 4,000 viral mutants are “variants of concern,” most are biologically silent, but some make the disease more likely to transmit, more deadly, or more resistant to vaccines and our own immunity. I was happy to hear cable news talk about natural selection, but I am not happy with the results of that selection. And we are underestimating it because we do so pathetically little viral genome sequencing.

Dr. Michael Osterholm said Friday on PBS that we are in the calm before the storm, and that a new surge caused by the UK variant (B.1.1.7, which current vaccines do prevent) is inevitable. Based on the UK’s own experience, we could see 195,000 hospitalizations a day, compared to the 130,000 a day that overwhelmed our hospitals in January—the surge that among other things required a fleet of refrigerated trucks to store the bodies.

Dr. Fauci said yesterday we may still be wearing masks in 2022—some degree of normality by the end of ’21, but not without masks and other precautions between now and then. Today he said, “This is a common enemy. We’ve all got to pitch in. We’re in some good shape now with the vaccines, but it’s going to be a race against the infections that keep coming.”

Dr. Tom Gillespie, of Emory’s Environmental Sciences Department, was quoted in yesterday’s New York Times (“And Then the Gorillas Started Coughing”), commenting on two San Diego Zoo gorillas that contracted SARS-CoV-2—which they could only have gotten from humans—warning that apes and other infectable species could become a reservoir that preserves the virus after the pandemic and circulates it back to us. Viruses of many kinds are a long-term threat.

Mohamed El-Arian, financial advisor and president of Queen’s College, Cambridge, said today we were in a two-horse race, vaccines against the virus, but that now it’s a three-horse race, with the third horse being the new variants, and if that horse comes up fast, we could be in bad trouble again. We only beat the third horse with the precautionary measures we have been advised to take all along.

As you know, Emory itself, which has done very well all along, has had an unprecedented burst of cases among students in just the past week, for unknown reasons.

Parts of the country are in the deep freeze, but baby it’s covid outside. 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.

New Sheriff, New Bad Guys

      “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

     “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

“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.