Tagged health habits

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.

 

Hope and Death

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

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

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

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

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

 

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

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

 

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

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

 

Dear Students,

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

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

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

Flu pandemic of 1919 vs COVID-19

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

COVID hospitalizations as of 12-4-20

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

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

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

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

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

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

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

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

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

The Good News

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

The Bad News

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

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

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

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

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

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

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

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

Dr. K

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

 

Lightning, Thunder, Flash Floods…Drownings

“Obviously if you do more testing you’re gonna see more cases but the increases that we’re seeing are real increasing in cases, as also reflected by increasing in hospitalization and increasing in deaths.”

           Dr. Anthony Fauci, Congressional Hearing, July 31

“It’s very frustrating as an epidemiologist to see these cases at numbers continuing to rise without a national strategy, without adequate testing, without contact tracing as we need it—all of the things we’ve been talking about for months and months and these numbers are going to continue to go up until we do have these things in place.”

           Dr. Ann Remoin, UCLA, August 2

“What we are seeing today is different from March and April. It’s extraordinarily widespread.”

           Dr. Deborah Birx, White House task force, August 2

“It’s like a policy of mass human sacrifice.”

           Rep. Jamie Raskin, D-Maryland, Congressional Hearing, July 31

Dear Students,

At this writing, a tropical storm is progressing from the Caribbean up the east coast of Florida and will proceed north from there, affecting to some extent even the northeastern U.S. This is below hurricane status but still has hurricane-speed winds and has badly flooded some Caribbean islands. Storm surges will follow after the wind and rain die down. There have been drownings. They will be very sad and perhaps to some extent avoidable.

But as you know if you’ve been following my updates, the drownings in the title above are metaphoric—the deaths are all too real, but they do not involve storm waters. Americans are drowning and dying in the flash floods of viruses, being killed partly by the accumulation of fluid in their lungs as part of the crash of lung and heart function under viral attack. And the numbers of dead are hundreds to thousands of times higher than will be caused storm drownings.

So: our metaphor likens the features of a storm in weather to the features of the resurgent viral pandemic. You know I am not impressed by a surge in cases alone, if only because our mendacious political leaders falsely claim that more testing leads to more cases. For the record, once again: it is a lie that we do more testing than any other country, and it is a lie that 99 percent of the cases detected are benign. There are simple ways to use case records to refute these lies, such as rising or falling ratios of positive tests to total tests, but I decided not to get into an argument with unscrupulous men who have the most powerful megaphones in the world. I decided to wait for a measure that has no relation at all to the amount of testing: hospitalizations.

I suggested we think of the case surges as lightning and the hospitalizations following as thunder. As we began to see a month ago, the lightning strikes across the southern half of the nation were followed a few weeks later by rolling thunder. Hospitalizations surged, hospitals overflowed, health care workers were overwhelmed, and in general the southern states that had been feeling superior to New York followed exactly in New York’s path, in a way that was as predictable as it was completely unnecessary, since New York had blazed the path—both on the way up and on the way down.

I said at that time that I was not sure that deaths would follow hospitalizations, because the average age of victims was younger, and the treatments for advanced cases were better. I said that if the cases were lightning and the hospitalizations were thunder, the next stage could, but hopefully would not be, flash floods (overwhelmed lungs and hearts) and drownings (COVID-19 deaths).

This hope was dashed, and the surge in deaths is here. That is why Dr. Fauci told Congress on Thursday that the increase in cases is real, “as also reflected by increasing in hospitalization and increasing in deaths,” contradicting the lies of his boss and the leaders of several southern states.

 

Bad News

  1. The huge surge in America’s cases in June, which did not occur in any “advanced” country (or even in countries like Georgia, Rwanda, and Uruguay) was not a second wave, it was a devastating extension of the first wave. All advanced countries and some developing ones completed their first wave by reducing cases to tens or hundreds per day. The lowest we ever got was 20,000 a day, and now we have 67,000, more than double the mid-April maximum of around 31,000. Every day.
  2. Rep. James Clyburn, House Majority Whip, chairing Thursday’s congressional hearing on the coronavirus, showing the surge

    These cases are not caused by increased testing, and the U.S. does not have a good testing program. Our per capita testing is behind a number of other countries, who are testing more and finding fewer cases. Also, we are doing the wrong kind of testing, taking an average of four days and often much longer to get results. These results are useless for contact tracing. As Bill Gates said months ago, what are you supposed to do, send apology notes to the people you infected before you knew your own result?

  3. But then again, we do not have serious contact tracing, certainly not where the epidemic is worst. I and many others said months ago we would need an army of contact tracers, and we barely have any. It may be that with the numbers of cases we have now (at least 4.5 million), contact tracing is no longer a possible strategy for controlling the disease. Imagine contacting all the 67,000 new cases each day, finding all their contacts, testing them, and isolating those who (a week later) turn up positive, and then contacting their contacts, and—you get the idea.
  4. Nationally, hospitalizations are clearly up again, the “rolling thunder” I wrote about on July 9th. This, as I showed you, was especially true in 20 states, and now it is true in more. Even averaging in the big declines in the northeast, weekly hospitalizations per hundred thousand were around 10 in mid-April, 4 in mid-June, and back up to 7 in mid-July. Multiply each of those numbers by 3,300 to get the approximate totals. Further increases are likely.
  5. Daily deaths in the U.S., the best indicator of the progression of the pandemic, peaked in mid-April at around 2,300. They bottomed in late June at around 550. As of today they have been over 1,000 for the last few days. The increase in July was steady, large, and real. Bear in mind that these national figures average in an ongoing decline in deaths in the northeastern states, so much of the rest of the country is at an all-time high. Deaths are a lagging indicator, so they could go higher. Black, Latinx, and Native American people are affected much worse than whites. Prison inmates, nursing home residents, and workers forced into dangerous conditions in meat packing and other workplaces are most at risk.
  6. All the above statistics were coordinated, analyzed and reported by the Centers for Disease Control, a collection of 1700 scientists ideally suited to this task. It was taken away from them two weeks ago and placed in the hands of the much less experienced and much more political Department of Health and Human Services. The only reason I can see for this change is that the people in power in Washington were not satisfied with their efforts to muzzle the CDC and distort its work, so they just admitted what they were doing and made the collation of statistics purely political.

 

Good News

  1. The first vaccine to enter Phase 3 clinical trials is the one being jointly developed by the biotech company Moderna and the National Institutes of Health. This is a real-world trial in which 15,000 people will get vaccine and the same number placebo, which gives it sufficient power to see whether the vaccine protects people from community spread, and whether it is safe. It allows representation of age, sex, and minority populations. It is an mRNA vaccine of a type not approved for human use before. (For more on different vaccine types, see my update of June 20th.)
  2. The University of Oxford/AstraZeneca vaccine, based on a chimpanzee adenovirus carrying coronavirus genetic information, is expected to start Phase 3 in August, and the Pfizer/BioNTech one, like Moderna’s an mRNA vaccine, in September. This website monitors vaccine progress. “Experts estimate that a fast-tracked vaccine development process could speed a successful candidate to market in approximately 12-18 months – if the process goes smoothly,” the website says. I think that means 12-18 months from when they started earlier this year. Roughly 150 vaccine projects are under way worldwide, the above three being among the five prioritized in Operation Warp Speed (stupidly named because it will increase anti-vaxxer rejection).
  3. Dr. Anthony Fauci, the nation’s top infectious disease expert, did an amazing job Thursday testifying to Congress for almost four hours (with a little, actually very little help from two other officials, and a lot of speechifying from Representatives of both parties) before the House Select Subcommittee on the Coronavirus Crisis. He managed to thread the needle of telling the truth without saying anything that might get him fired, something no other government scientist or physician can do. But if you want to hear the real Dr. Fauci in a real conversation with other scientists, being himself and saying what he thinks and knows without pausing for many seconds before carefully answering, listen to the July 17th episode of This Week in Virology (TwiV-641).
  4. Treatments are also being sought throughout the world. The ones working now are: Remdesivir, an antiviral developed for Ebola; dexamethasone, a tried and true general-purpose anti-inflammatory; and convalescent plasma (probably). On the near horizon are monoclonal antibodies derived from convalescent plasma, other anti-virals, and combinations of anti-virals. Remember that a triple antiviral therapy changed HIV/AIDS from a deadly to a chronic disease, and plays a vital role in limiting spread. (Contrary to my own hopes, since I safely took it for malaria prevention, hydroxychloroquine doesn’t work. Also, ingesting or injecting bleach or other cleaning products will kill you.)
  5. The new recommendation of face shields or goggles along with mask wearing, social distancing, handwashing, and reversal of some of the most ill-advised state openings (bars, indoor rallies, packed houses of worship, etc.) all show promise of bending the curve downward again—cases first, then hospitalizations, then deaths—across the southern United States. Midwestern and North Central states have yet to be walloped by the two-by-four of COVID-19, and they are not learning from watching the suffering of others, so they are clearly next.
  6. The most exciting new development that I have heard about recently is a revolution in testing proposed by Michael Mina, a virologist and clinical pathologist at the Harvard School of Public Health. Rapid, less accurate testing is the key. (Abbott’s ID Now test, which I told you about on May 12th, is only one example.) The gold standard, PCR, is very accurate, but if it takes a week or more to analyze it is almost useless. Strips of cardboard mass-printed with molecules that detect virus in swab samples have not been widely deployed yet because they are not considered accurate enough. However: They are accurate enough if used when a person has enough virus to be infectious. At $1 a day, they can be used often by everyone, with results in minutes.

I want to say something about school and college openings, which are starting now. This is a mass experiment, with the lives of students, teachers, parents, and grandparents being put at risk, with conflicting guidelines about how to do it, and with low likelihood of compliance with guidelines anyway.

Major League Baseball is failing at safe reopening, even with their vast wealth and tight organization. More than 6,600 cases have been identified on college campuses that have mostly not yet opened for the fall semester. Young children (usually) do not become very sick from this virus, but they are quite effective transmitters of it to each other and to adults. Middle and high school kids are more effective spreaders. What has happened at summer camps and in the first school openings is not reassuring.

Rebekah Jones, a scientist fired by the governor of Florida for refusing to fudge the state’s statistics the way he wanted her to, said on July 8th, “If schools are opening next month, then we’re on a third wave of this first wave of catastrophe.”

Black leaders were in the news this week. Former President Barack Obama spoke brilliantly at the funeral of civil rights giant and “Conscience of Congress” John Lewis, whose last live appearance was at a Black Lives Matter protest. He died of pancreatic cancer. Rep. James Clyburn, Democrat of South Carolina and House Majority Whip, chaired the hearing of the Subcommittee on the Coronavirus Crisis, where he and Dr. Fauci told the truth. Herman Cain, a leading black Republican and former presidential candidate, died of COVID-19, which he probably caught while proudly attending a crowded Trump rally in Tulsa, Oklahoma, on June 20th.

Stay safe, you know how.

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).

 

 

Opening Gambits: Freedom Goes Viral

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

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

Dear Students,

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

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

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

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

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

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

Good News

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

Bad News

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

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

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

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

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

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

“Dr. K”

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

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

Epidemic Obesity: Adaptation Gone Wild

Obesity is unnatural, but it’s natural to try for it.

titian_venus_mirrorThis morning I sat on a panel for medical students; the subject was obesity. Nationally, as anyone who hasn’t been hiding under a rock knows, the picture is not pretty-in fact it’s pretty ugly. By the standard definition, obesity means a Body Mass Index (BMI; weight in kilos over height in meters squared) above 30, and in about 15 years starting in 1990 we went from 22 percent to 33 percent obese.

Now, I don’t care what you call it or Read more

Obesity

Is obesity an epidemic? Is it even a disease? Semantics aside, it’s huge and growing burden.

boys eatingI’m writing this in an airport, and a couple of hours ago as a line of passengers filed past me in the airplane aisle, I noticed, as I often do, that some of them were not just overweight—many are that—but obese. I remembered from yesterday’s news that some airlines are considering charging such people for two seats. It seems unfair, and yet… Read more

Eat Like a Hunter-Gatherer

An excellent new study once again takes us back to the future.

Last week’s issue of The New England Journal of Medicine carried another powerful vindication of The Paleolithic Prescription, a book co-authored by Boyd Eaton, Marjorie Shostak and me just twenty years ago. Boyd and I fired the first salvo in the same journal in 1985, with an article called “Paleolithic Nutrition.”
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In Sickness and In Wealth

"Maladaptive" habits help the poor cope with their stressful lives, and the best healers don't blame them.

I recently had the privilege of "shadowing" one of the best docs I know as she made hospital rounds at Grady. Grady is one of those places-like Los Angeles County Hospital, Cook County Hospital in Chicago, and Kings County in Brooklyn where I volunteered as a high school kid-
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