Tagged health

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.

 

 

 

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

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

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

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

                        Seema Yasmin, MD, Stanford University, September 2

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

                        Sanjay Gupta, MD, Emory University, September 4

Dear Students,

You remember what TETRIS is, right?

TEsting. Contact TRacing. ISolation.

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

Good News:

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

Bad News

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

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

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

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

So we’re in the Labor Day Weekend now.

What do I think is going to happen?

What do you think is going to happen?

Stay safe,

Dr. K

PPS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York TimesCoronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter.

Readin’, ‘Ritin’ & Russian Roulette

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

                        Dr. Ashish Jha, CNN, August 10th

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

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

Dear students,

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

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

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

 

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

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

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

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

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

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

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

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

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

Some other bad news:

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

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

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

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

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

I’m begging. Please.

Meanwhile, stay safe,

Dr. K

PS: In other news:

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

PPS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York Times Coronavirus Resource Center (NYT).

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).

 

 

16,000 George Floyds

“I can’t breathe.”

            Eric Garner, July 17, 2014, as he was being strangled to death by New York City police, for selling single cigarettes on a streetcorner in Staten Island

“I can’t breathe.”

            Elijah McClain, August 24, 2019, as he was being strangled by Aurora, Colorado police, for no reason, resulting in cardiac arrest in the ambulance and death days later

“I can’t breathe.”

            George Floyd, May 25, 2020, as he was strangled to death by Minneapolis, Minnesota police, for allegedly using a counterfeit $20 bill

“Once you get to the other side of it, you can breathe a little bit better… You think you’re gonna die during one of those episodes, I mean, you know you’re gonna die.”

            Kevin Harris, after recovering from the coronavirus infection that almost choked him to death

Dear Students,

These four men had two things in common: being African-American, and having someone or something strangling them. Kevin Harris did not die gasping for breath as the others did, and he was not strangled by police. But he was being strangled by racism.

I’ll come back to this and to the number 16,000, but first consider another number: 3,446. That’s the number of black people who were lynched in the United States between 1882 and 1968, accounting for 72.7 percent of the lynching victims in that time frame—when they made up around a tenth of the population.

We don’t have a record of what most of these 3,446 people said while they were dying, but most of them were murdered by being hanged by the neck until they were dead. They were not dropped to break their necks quickly as in a movie prison. They were usually “strung up” so that the group or mob could watch them struggle. Many were tortured and mutilated before and during the process. It was festive. Children were present. People took photos. They made postcards to send relatives and friends.

Some of the victims proclaimed their innocence before being hanged for crimes they did  not commit. Some spoke messages to loved ones. On March 9, 1892, three black men who had started the new People’s Grocery in Memphis, Tennessee were dragged out of their store by a white mob and lynched; it was simply too much of an affront to white rule for black people to have their own grocery store. One of them, Thomas Moss, said before he was murdered, “Tell my people to go west. There is no justice for them here.”

We don’t know what lynching victims may have said or tried to say while they were actually being strangled by the noose around their necks. They must have known there was no point in begging. But you can bet they were thinking: “I can’t breathe.”

A lynching is defined as a premeditated extrajudicial homicide by a group intending to punish someone or make an example of them. We don’t yet know whether the policemen who killed Eric Garner, Elijah McClain, and George Floyd intended to kill them, but we know that they showed utter disregard for these men’s humanity in their excessive, brutal, completely unnecessary, and ultimately fatal use of force—in each case in the face of victims and even bystanders begging them to stop.

I think it’s fair to say that they probably wanted to kill some black man some time, and this was their chance; otherwise, why would they have shown such disregard for black lives? The police were acting in a criminal manner toward each of these men; and ordinarily, when a homicide is committed in the course of another crime, it’s murder.

We also know that black people are killed by police at a rate between 2.5 and 3.5 times that of whites. We know that many white police officers, not just “a few bad apples,” are overtly or even proudly racist. And we know that the inadequate, even chaotic patterns of selection and training in police departments across the United States at best allow and at worst foster such racism.

This is all part of a pattern that anthropologists call structural violence: day to day destruction of human life by authorities as part of the normal course of things in, for example, colonialism, or the domination of one religious group over another. But if the victims of structural violence commit acts of violence themselves, even in protest or self-defense, only those acts are considered violent, not the day to day acts of the people in power oppressing them.

Today’s heedless murders of black people by white police extend the structural violence of lynchings, which in their day extended the structural violence of slavery, going back 401 years to 1619, when America first became a slave society. No one can doubt that centuries of whips and chains, hanging trees, and police brutality—all condoned or even depended on by the larger society and its day to day need for intimidation and control—deserve the name “structural violence.”

But what about Kevin Harris, who couldn’t breathe because of a new coronavirus?

Well, it turns out that structural violence—including American structural racism—requires a lot more than whips, chains, nooses, guns, and the knees and choke-holds of policemen. It requires a system that relentlessly maintains huge disparities, day by day and generation to generation, between white and black people—in wealth, education, job opportunities, income, education, incarceration, and perhaps most painfully, health and illness.

Are unprevented and uncared-for diabetes, heart disease, hypertension, asthma, AIDS, influenza, and now COVID-19 less violent to a human life than whips, nooses, and chokeholds? I don’t think so, and neither do the growing number of physicians and public health experts who see the structural violence of untreated, preventable disease as just as much or even more an extension of slavery than police brutality is.

On the day that Kevin Harris described his near-death from strangling by the coronavirus, there had been a total of 182 deaths in the whole United States, yet it was already clear that blacks were affected more than whites. As of this writing, more than 140,000 Americans have died of this virus.

But the number 16,000 is not the total number of African-Americans who have died, not by far. It is the number who have died but who would not have died if black people only had the same death rate as white people. In other words, it is the number of extra black people who were killed by the virus just because they were black.

Thankfully, Kevin Harris did not become one of those unfair, unnecessary, extra black deaths. But 16,000 others did. So far. And it’s not over yet. And proportionately more black people than white are being added to the numbers every day. So the excess of 16,000 is only the beginning.

What explains it? The basic deprivation of health is part of the long story of American structural racism and structural violence. Everything about underlying conditions that makes us more susceptible to COVID-19 is more common in black than white people. That includes, but is not limited to, diabetes, heart disease, hypertension, asthma, and a wide spectrum of acute and chronic non-COVID infectious diseases.

And every form of preventive and curative care is withheld from black people but given to whites. Our lack of universal health care is unique among the wealthy countries of the world. We stand out from the world in this exactly the way South Africa did before apartheid ended.

Take a look at the graph in the picture. The American anomaly is astounding. All other advanced countries have had declining maternal mortality for decades. Ours has been rising starkly, and experts agree that a large part of the reason is our gross and growing racial disparity. Infant mortality has declined slightly, but is much higher than in other developed countries, mainly because of how we neglect minorities. Black infant mortality is more than double that of whites. So the structural racism that began in 1619 begins again at the start of every black life.

Oliver Wendell Holmes, Sr., the great 19th century physician, wrote, “The woman about to become a mother should be the object of trembling care and sympathy wherever she bears her burden or stretches her aching limbs. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly.” We always follow that advice. For white women. Black women and their babies are from that moment guaranteed to be more vulnerable to everything, including COVID-19.

In the pandemic, it’s good to stay home if you can. Most black people can’t. Their work requires that they expose themselves to others on public transportation and at their jobs. They are some of the doctors and many of the nurses and respiratory therapists, but they are also overrepresented among the cleaners and sanitation workers, the delivery people, the workers in groceries and restaurant kitchens, and many others who can’t stay home where it’s safe.

But that’s not all. Crowding is good for the virus, and it is much more of a problem for blacks than whites.  Poverty too. Lack of education. Lack of trust in authority (with good reason). Lack of clean air (the virus loves dirty airways). Polluted water. Lack of access to healthy food, which is much more expensive than junk food and much harder to find in black neighborhoods.

Black men are overwhelmingly over-represented in prisons in this country, and given that prisons are well known hot spots for COVID-19, they become another tool of structural racism in the pandemic. Given that incarcerated men are forced to work, manufacturing license plates and the like, incarceration of black men has been seen as a modern form of slavery.

The water crisis in Flint, Michigan, where the government was discovered to be pouring lead into black homes and poisoning children’s brains, has proved to be a problem in many other cities. The disparity between blacks and whites in wealth is far greater even than the disparity in incomes; white American families’ wealth is stored mostly in their homes, which many fewer black people own.

These homes, this wealth, is passed from generation to generation among whites, and in every generation it becomes a more solid foundation for permanent disparities in education, because schools in America are funded locally, from taxes on homes that whites are much more likely to own.

But in addition to the structural racism that withholds health, medical care, wealth, homes, education, opportunities, fruit, vegetables, and water, we have to add air: “I can’t breathe.” So said an unknown number of black police-chokehold victims, 3,446 black lynching victims, and 16,000 excess black coronavirus victims, so far.

If you have easy access to air, be grateful. Not everyone does. Breathe out. Breathe in. Don’t take it for granted.

Stay safe and be well, if you can,

Dr. K

PS: Many of you have been asking me whether I think you should come back to campus. This article should help you decide. As always, you should weigh the risks and difficulties you may face where you are staying now; some people may be better off on campus, assuming it really is open to you a few weeks from now.

Rolling Thunder

            “What we’re seeing is that this illness has no mercy, against any kind of gender, age, or race.” Joseph Varone, MD, Houston physician, June 30th.

            “The epidemic is out of control across the southern United States.” Peter Hotez, MD, Houston pediatric virologist and vaccine scientist, July 7th.

            CNN’s John Berman: “Do you see an end in sight, or a plateau?” Rebekah Jones: “Absolutely not, especially if schools are opening next month, then we’re on a third wave of this first wave of catastrophe.” Rebekah Jones is a former Florida State data scientist fired last month for refusing to manipulate COVID-19 statistics, speaking on July 8th.

Dear Students,

These quotes, which you can find on CNN videos, come from three different kinds of experts, and all of them are visibly upset about what they are seeing and saying. But the greatest anguish is in the face and voice of Dr. Varone, who has been interviewed many times since the above quote, in his hospital, on the front line of the spreading American epidemic. He is devastated. He goes to work every day to take care of people of all ages who are more and more numerous and more and more sick with a virus that could have by now been controlled.

I feel as if I am in a time warp. I am watching heroic doctors and nurses in Los Angeles, Phoenix, Tucson, Houston, El Paso, Miami, and other southern cities describe, on the verge of tears, the exact same overwhelming of hospitals that we saw two months ago in Queens, Brooklyn, and The Bronx.

Hardened medical professionals are begging—in mirror images of their April northern counterparts—for us to behave differently. They are telling us that they can’t handle any more coronavirus patients. They are running out of ICU beds, and if they had the beds, they would not have the professionals to staff them.

All the governors of these southern states had to do was watch how Andrew Cuomo of New York get that state’s epidemic under control, and do the same thing—except that they didn’t have to be taken by surprise and be a little late with it like he was. But instead of imitating him, heeding his warnings, and starting earlier, they denied they would ever have to face what he faced. Now they are facing it, and are headed for worse.

In the past few weeks I have likened the surging case numbers to lightning and have repeatedly said that I would wait to hear the thunder, namely the surge in hospitalizations. Leaders of our country and of many states told us we could ignore the case numbers because they were only the result of more testing. Never mind that the case numbers were rising much faster than the number of tests. Never mind that the proportion of tests coming out positive keeps going up and up and up.

We were also told that because the surging cases were at an average age that was younger we would never see a surge in hospitalizations.

But they already knew that younger people too could get very sick, and that younger people inevitably also infect older ones, so this was not wishful thinking, it was lying. Lies on top of lies. Lies, lies, and more lies.

In Miami-Dade County, since June 24th, hospitalizations have gone up 87%, ICU patients 91%, and patients on ventilators 108%. That is a doubling time of a little over two weeks, and it’s not just Miami. More than 50 Florida hospitals have reached their ICU bed capacity. The 7-day average of new daily hospitalizations in Florida meandered around 150 during April and May, declined into early June, hit an inflection point around 110 on June 7th, rose steadily, hit another inflection point around 170 a week ago. The average climbed more steeply from there, reaching around 270 on July 7th. There is no indication yet of the slightest  bending down of this curve.

In Texas, the count is reported differently, as the total number of people in the state in hospitals with COVID-19 on a given day. This number hovered under 2,000 in April and May, rose slowly but steadily in early June, then rose more steeply, increasing almost every day, to a total of more than 9,000 on July 7th. The Phase 1 opening in Texas began on May 1st, and proceeded despite rising cases, which were not supposed to produce rising hospitalizations—unless you believed the science, which said they were almost inevitable.

In Arizona, the number of COVID-19 patients in hospitals (click on the icon for “Hospital COVID-19-Specific Metrics” in the lower right then on the appropriate button across the top), the number on ventilators, and the number in ICU beds have all risen steadily and sharply since early June. According to The Arizona Republic, “85% of current inpatient beds and 91% of ICU beds were in use” as of Wednesday, July 8th. Native Americans are suffering most, extending the pattern of white people bringing them deadly diseases beginning with the arrival of Columbus.

California’s governor announced on Wednesday that hospitalizations for COVID-19 have increased 44% and ICU admissions by 34% in the past seven days. For Los Angeles County, the three-day moving average of patients hospitalized with the virus peaked at around 2,000 on April 29, declined to around 1,300 on June 15th, and rose twice as fast to return to around 2,000 yesterday. Available ICU beds are around all-time lows for the epidemic. “This is the explosion we warned about,” said a professor of public health at UC Irvine.

And in our own state of Georgia, where Emory will reopen partly live on August 19th, the seven-day moving average of the number of people hospitalized with COVID-19 declined steadily from 1,500 on May 15th, stayed under a thousand for most of June, then rose much more sharply than it fell, doubling to almost 2,000 today, with no end in sight. On Tuesday, Brian Kemp, Georgia’s governor, announced a marketing campaign to encourage Georgia businesses to be safe, including no mandatory anything.

Hospitalizations are rising in more than 20 states, so I could go on, but you get the idea. In every state, black and brown people suffer more than whites, and where there are Native Americans, they suffer most. All these states are trying to backtrack on aspects of their openings. (See the impact of early opening here.) They can still do something, but it better be big, and it better be now.

All the above graphs are what are known in statistics and business (among other fields) as hockey-stick curves. It’s what start-up companies dream of. You’re holding the hockey stick and your sales are flat for a while (the part of the hockey stick that you hit the puck with) and then there’s a long upward zoom that goes to the sky, or at least up to your chest. The upward zoom is straight and fast.

For sales, this is a great curve. For a disease outbreak, not so much.

Remember, we are now counting hospitalizations, the thunder. There is no argument that more testing leads to more hospitalizations; not even the world’s most empty hairdo could argue that. Only more disease leads to more hospitalizations, especially in a time when you’re hoping to stay out of the hospital and doctors are trying to keep you out. Also (a teensy reminder of good news from prior updates) remdesivir, dexamethasone, more sophisticated oxygen management, and maybe even a resurrected chloroquine are shortening hospital stays. Yet admissions stay ahead of discharges. Way ahead.

But what about deaths? Ah yes, the deniers are still holding that ace: declining or stable deaths. There are three reasons: 1. the above treatments have made the disease less deadly; 2. the average age of cases is going down steadily, and younger people are less likely to die of it, so far; and most importantly, 3. death is a lagging indicator—hospitalizations are doing the hockey-stick thing now, but we have to wait a few weeks before we know about deaths.

I would add that these upward-leaping hospitalizations also lag infections, by days to weeks. So whatever risks Americans took on the July 4th weekend are not yet reflected in these numbers. All that is ahead of us.

At the risk of straining the metaphor, we had the lightning (skyrocketing cases), we’re having the thunder (the hospitalization hockey stick), but we have not yet had the flash floods and drownings: a sudden surge in deaths on top of the 132,000 we have had already. We may not have it. But we have to do more than hope.

Sometimes when I watch an interview with a nurse or a doctor, and I remember those who risked or gave their lives to save us from our own stupidity, it’s hard for me to hold back tears. As the celebration of our independence passed, and it was not balanced with any wisdom about how to use that freedom, I was not proud of my country.

Look at New York (which opened in such a way that its cases dropped in half after the opening), or almost any other advanced country and you will see how it should have been done. Heck, look at Uruguay, Rwanda, or our sister state of Georgia (in Asia, capital Tbilisi) and you’ll see how we could have saved at least a hundred thousand Americans.

To any young person going through this I say: I was young once, and I loved it. You are losing part of it, and I am sorry for your loss. But I promise you: if you do the right thing now, it will almost certainly be behind you in a year. And you will live to brag for six decades about how you made it through that deadly pandemic of 2020.

But if you get it and have lingering lung damage, as some young people do, you may not have the breath to brag so loud. And if you bring it to your grandparents and kill them, you will shudder with shame whenever 2020 is mentioned.

Your choice. That freedom’s real.

Dr. K

 

 

 

 

 

One Marshmallow

       “These plans are so unrealistically optimistic that they border on delusional and could lead to outbreaks of Covid-19 among students, faculty and staff.”

       Laurence Steinberg, The New York Times, June 15, 2020, referring to proposed college reopenings

Dear Students,

A few weeks ago, New York Times columnist Paul Krugman (winner of the Nobel Memorial Prize in Economics) wrote a column called “America Fails the Marshmallow Test.” This is a reference to a famous 1960s psychological experiment, in which a marshmallow (or cookie, or piece of candy) is placed in front of a young child, who is told she can eat that marshmallow now, but if she waits 15 minutes, she’ll get two instead of one. Studies stemming from this experiment became a cottage industry, and among the claims made by those involved, being able to postpone gratification for greater gain was a fundamental character trait in the two-marshmallow kids that predicted much about their later success. They were said to have better “executive function,” meaning their frontal lobes were better able to suppress the impulse to get one marshmallow now in order to get two later.

Krugman understood that a 2018 study apparently failed to replicate the marshmallow study, but wanted to use the metaphor for our country’s inability to wait a little longer before lifting social distancing restrictions. Actually, the marshmallow study was not debunked by the 2018 replication, which has been criticized for controlling away some variables (like early cognitive ability) that are intrinsic to what the marshmallow test tries to measure. Also, the replication did find that the test predicted some characteristics of adolescents, just not as much as earlier studies claimed. The critics of the critics—the marshmallow defenders—called their paper “Good Things Come to Those Who Wait,” with the running head, “Delaying Gratification Matters.”

Speaking of delaying gratification, it’s not just five-year-olds who are not good at it. Adolescents are not good at it either.

I know you don’t like to think of yourselves as adolescents, but the fact is that brain development is not complete until age 25 or so, and the main part of the brain that keeps developing is precisely those frontal lobes that are involved in executive functions: planning, reasoning, analyzing, and yes, postponing gratification. This period of extended frontal cortex development has been called youth, pre-adulthood, or emerging adulthood.

Psychologist Laurence Steinberg is the world’s leading authority on brain development in adolescence and beyond, especially in relation to executive functions. He has co-authored papers in law and psychology journals with titles like “Blaming Youth,” “Young Adulthood as a Transitional Legal Category,” and “Less Guilty by Reason of Adolescence.” He has tried to protect young people from the most severe punishments for acts which they literally did not have the brainpower to control.

Now Steinberg has weighed in on a question many of you have asked me about: College reopenings in August, including ours. Steinberg, who has spent his life as a college professor researching the young, wrote an essay two weeks ago called, “Expecting Students to Play It Safe if Colleges Reopen Is a Fantasy.”

Based on his 40 years of research on young people, he writes, “Most types of risky behavior — reckless driving, criminal activity, fighting, unsafe sex and binge drinking, to name just a few — peak during the late teens and early 20s. Moreover, interventions designed to diminish risk-taking in this age group, such as attempts to squelch binge drinking on campus, have an underwhelming track record. There is little reason to think that the approaches proposed to mitigate transmission of the coronavirus among college students will fare any better.”

The evidence on the other side is very strong. Steinberg and his colleagues recently completed “a study of more than 5,000 people between the ages of 10 and 30 from 11 different countries (including both Western and non-Western ones)… Consistent with large-scale epidemiological studies, we found a peak in risk-taking somewhere between age 20 and 24 in virtually every country.” There are three straightforward reasons.

Youth (not just adolescence) is a time of 1. heightened risk taking, and 2. poor self-regulation in all cultures. These two psychological features of young adulthood are in turn explained by 3. easier activation of the brain’s reward circuits, made even worse under conditions of emotional arousal and in the presence of peers.

To Laurence Steinberg, who probably knows more about not only the psychology but the neurobiology of young people than anyone else alive, college reopenings will be a “perfect storm” for viral spread. College reopenings are also being criticized by moral philosophers, college presidents, lawyers, and, of course, some epidemiologists. Dr. Anthony Fauci, our nation’s leading expert on the pandemic, says the matter is “complicated” and will depend on what region of the country you’re talking about.

It’s not always a bad idea to take a reward now even though it may be smaller. That’s why we have the proverb, “A bird in the hand is worth two in the bush.” Young people are designed to take risks for short-term rewards because that is how they test themselves, learn about life, find mates, make friends, and generally position themselves among their peers. Up to a point you have to take risks.

But we are not talking about a torn ligament, a bad hangover, or a brush with gonorrhea. This is a situation that has never before existed in my lifetime, not even during the early years of HIV/AIDS. I have repeatedly emphasized to you that the unknowns in relation to this pandemic are greater than the knowns, and that remains true. Right now cases are on the rise in the nation, in most states, and in almost every major city in the southern half of the country from Los Angeles to Miami.

The entire state university system of California will be 100 percent online. If you were in college in a rural area of Massachusetts or New York, you would probably be safe attending live, but you are not in one of those colleges. The situation in Atlanta is uncertain, but Emory says it is taking precautions that will make reopening safe.

Last week I said that case counts are like lightning, and that I was waiting for the thunder—hospitalizations and deaths. Being no longer young, I am able to wait. Some leaders claim that the only reason we have more cases is that we have more testing. I think this is wrong, but I don’t want to argue about it because I can wait. Others say we really do have more cases but because the age of infection is on average much lower than it was a month or two ago, we will never see the hospitalizations or deaths go up by much.

Lightning is flashing all across the southern United States, and some say it is starting fires that will be impossible to control and that will in the end kill many. State after state in the south are backtracking on their openings. But the states don’t really control behavior, especially the behavior of the young.

The July 4th weekend is coming, and millions of young people will take the one marshmallow. What will you do?

Dr. K

“I, Corona”: My Exclusive Interview with the Little Guy Who’s Changing the World

Dear Students,

I have a special treat for you today, an exclusive interview with SARS-CoV-2, his first ever, on his life and times so far. I was able to arrange this through my special friend Charles Darwin, whom Sarsie—his preferred nickname—likes to call Uncle Charlie. Sarsie doesn’t think he’ll be confused with his older brother, SARS-CoV-1, whom he calls “pathetic,” nor does he think highly of his cousin MERS. “I mean, really, a few months in one or a few places, and then, poof! they’re pretty much gone.” He has a certain grudging admiration for cold viruses.

            But I’ll let him tell you in his own words. By the way, he insists on he/him/his, because as he puts it, “I don’t have the equipment to reproduce, so I gotta beg, borrow, or steal it from someone who does. I just put in my genes, and they do the rest. Also, let’s face it, a guy like me, who puts ambition above everything…I mean, I’m most likely gonna be male, right? Yep. My whole species, and my brothers and cousins too.”

            He asked me to call this column “I, Corona,” as an hommage to Isaac Asimov’s science fiction classic, I, Robot. “I didn’t like his three ethical laws, of course, but when he got to the part about robots that secretly run the world, I could definitely wrap my envelope around that. But why keep it a secret? Just take the world over and run it, I say.”

            What follows is a lightly edited version of our interview, with my questions removed. Not that there were many. He doesn’t let a human get a word in edgewise. So I listened and learned.

            “Yep. I’m on the move for sure. My bros and cousins were well meaning, all princes in their way—and we’ve got more princes than the Saudi Royal family—but I’m the Crown Prince (get it? Corona? Crown?) and I will be King.

            “By the way, this whole debate about am I alive? Am I alive? Are you kidding me? I’m alive and I’m eating you alive.

            “But back to the family. We’ve only been around a hundred thousand years, less than you even, but then again, we reproduce in 48 hours, you take 20 years. Do the math. Ex. Po. Nen. Shl. As Uncle Charlie would say, we can sure do some evolving.

            “The family divides up the spoils, but we’re not all equally successful. Some of the corona cousins specialized in farm critters. It’s a dirty job but somebody’s gotta do it. Let’s be honest, though, you’re not goin’ down in history for makin’ a chicken cough or givin’ a pig a belly ache. Then there’s the bunch I call the Corona Sniffles, they’ve done alright for themselves actually, they got around, they hang around, they evolve, they come back. No drama, mama, but Uncle Charlie would be proud.

            “SARS-1 did alright for himself but he just couldn’t get transmissable enough, and on top of that he only jumped from Jim to Jane, or from Zhang Wei to Mei Ling, after he gave Jim or Zhang symptoms. Jane and Mei knew to keep their distance. So my Sarsie-1 bro hit Guandong Province in China, got to Toronto somehow, and got locked in with quarantine. 8,000 cases, 800 deaths, a little economic slump, that was about it. One wave in 2003, so far done and done.

            “Cousin MERS was a killer though, too much for his own good. You kill a guy, he ain’t passin’ you on. Also Cousin MERS was never good at jumping from one of you sorry humans to the next. Probably more of you have gotten him from camels than each other. He broke out in Saudi in ’12, trickled around to 27 countries since, 2,500 cases, 800-some-odd deaths, well controlled by even your bumbling species, nothing to write home about.

            “You can see where I’m goin’ with this. I’ve done more in eight months than the rest of them put together. I’m the Crown Corona Prince by acclamation. I mean, let’s look at the facts. Okay, I was trapped in bats for I don’t know how long. I was bummed. Do you have any idea what a bat cave smells like? But I took a deep breath—the kind I make impossible for you—and channeled Uncle Charlie. He counseled patience: “Be like a Buddha Virus, bide your time, mutation and evolution will do the rest.

            “Boy, did they ever. You helped, by bulldozing forests and setting the bats I was riding free. My hosts got snared, sold, and eaten, and I was on my way. Okay: I’d evolved my way from bats to humans, but would I be like my cuz MERS, get stuck in a bat-to-human trap like he did (mostly) with his camel-to-human song-and-dance? No way. Or would I maybe take a leaf from my bro Sarsie-1’s book and only jump from Jim to Jane when Jim was already sick and Jane could avoid him like, well, the plague? Nope again.

            “I did everything by Uncle Charlie’s playbook, evolve, wait, mutate, evolve. Jump from bats to you folks (Whoopie!): Check. Jump from Zhang Wei to Mei Ling: Check. Now, jump from Zhang to Mei before Zhang gets sick—three days, a week, two weeks: Check. Now, don’t even make Zhang sick at all, ever. Or Mei Ling. True, a cough or a sneeze will spread me yards in droplets and aerosols. But if Zhang and Mei are rehearsing in the same chorus for a couple of hours, or even sitting at different tables at a restaurant with the right air circulation system, that’ll work fine for me. If they exchange looks and fall in love and do a Chinese version of French kissing, I’m golden.

            “But think about it: I can’t win big in Uncle Charlie’s sweepstakes by staying in one corner of Wuhan. So here’s where your species really starts to help me. Homo sapiens? Homo dumbellus is more like it. That young doc in Wuhan who tried to blow the whistle on me last year, right at the start? Whew, that was a close call. That could have ended me maybe, but thankfully his bosses shut him up fast. They even made him apologize for making me up! That was a great moment in my career, gave me just window I needed to zip around Wuhan.

            “He was some kind of hero. Poor guy got sick from one of the patients he tried to help, and I killed him. Wasn’t trying, you know, but there it is. He gave his life to tell the truth and save your species from mine. Not fair, but that’s how Uncle Charlie’s law swings. Or, you might say, how the fortune cookie crumbles. Sorry, couldn’t resist; but I spent enough time in China to know fortune cookies don’t crumble there, only in America.

            “Speaking of which, I was getting folks to carry me out of Wuhan to all over, even while the Chinese did a 180 and started to shut me down. They had the right government and the right science and the right culture to do it, and I was done there in a couple of more months. People cared about each other. They believed their doctors and scientists after that first blooper. They show the world how your species could win the war against mine. Or could have.

            “Some learned, some didn’t. I was rockin’ and rollin’ man. Jims and Janes, Fritzes and Gretchens, and especially Sergios and Claudias were leaving Wuhan and taking me home as a souvenir. I got a foothold on the Pacific Coast of your country in January, but that was small potatoes compared to Italy and Spain. Those folks love their grandmas, so instead of quarantining them they killed them. Okay, I killed them, but they gave me free rein.

            “Who’s they, you want to know? The young people. The ones who couldn’t sit at home. The ones who were chock full of me and I didn’t even make them sneeze. They were my ambassadors. Healthy young humans doin’ their thing, havin’ fun, hustling, moving. They’re the reason I left my Sarsie-1 bro and MERS cousin in my dust. They took me to every place on the planet. You humans talk about flyways for the flu. You mean geese and ducks. They fly south and north on two routes. They overlap a tad in the arctic. Geese? Ducks? Your species has a hundred thousand flights a day that go from everywhere to everywhere. And every one of them is carrying someone carrying me. Flu too by the way. He and I are gonna make beautiful music together. There’s gonna be some Darwinian mutual back-scratchin’ for sure.

            “Anyway, Italy mourned. Doctors and nurses were crying in the hospital halls. But I was headed for the U.K. and New York! That clown Boris thought he could pull a Sweden. I tried to help him see the light by laying him low for a while, but he squinted and bumbled again. Herd immunity? You have to be kidding me. That’s years away everywhere.

            “Treatments? Some day. Right now they’re just making a dent for the sickest, and may help me evolve resistance. I admit it’s been hard for me to reinfect someone I got to once before. I’m working on that, according to Uncle Charlie’s rules. We’ll see. The flu comes back every year in a different form. Every year a new vaccine that’s maybe half effective, and half of Homo dumbellus doesn’t even bother with it. Is that the sort of standoff I could live with long term? As they say in North Dakota (where by the way I’ll be heading soon), you betcha!

            “Meanwhile, Boris the Clown can’t hold a candle to that donkey’s rump Bolsonada in Brazil. It’s like Sweden without the modicum of leadership and with twenty times the population. Wow! Talk about a field day for me! They can’t dig graves fast enough in São Paulo. Mind you, it’s no great deal for me to be buried in a hole in the ground. But it’s the cost of doing business.

            “And then of course there’s the Clown of Clowns, the fat one with the orange face and pouffy yellow hair, the It’ll-be-gone-like-magic Gotta-open-up-our-country Whaddya-gotta-lose happy hero of every virus in Darwin’s kingdom. Sorry, it’s your country, I don’t want to hurt your feelings. But really. Open up the meat plants: Check! Don’t worry about the prisons and nursing homes or the small towns around them: Check! And then you got those folks yelling about freedom. “Don’t put your mask on me!” I love them so much I want to hug them. I do hug them.

            “And now these protests. I’m sorry, they have a right to grieve, but it doesn’t matter to a guy like me whether the crowds are righteous or not. I don’t give a flying fig whether I infect a Democrat or a Republican, as long as it’s a warm body. I am a teensy little Darwinian machine obeying Uncle Charlie’s laws to the letter. Good thing for me that guy in New York isn’t running your whole American show. I’d be beaten back into a corner for the summer and then you’d be gearing up to fight me and my buddy Flu-Boy in the fall.

            “But this is a zero-sum game, my species against yours, and I don’t think I’ll be in retreat during the summer. Maybe if you wake up in July and lock down again I’ll give you a five-minute break in September. But I’m not promising.

            “Good thing for me too that there aren’t more women running more countries. Seems like most of the countries that have kept me down or out are run by females, and the countries I win hands down are run by overgrown, overblown boys. Maybe you are actually two species: Homo sapiens, the ones with the reproductive equipment who know how to protect their own; and Homo dumbellus, the ones with DNA donation, the big shoulders, and the bluster.

            “Better believe it when I tell you you’ll be seing me around.

            “What? You think I’m ruthless the way I’m taking over the planet? How the hell do you think your species did it? You poisoned the earth, killed off half the other animals and plants, and brutalized each other beyond belief in your own species. You packed yourself into the crowds I swoon for. I can become King of the World without doing a fraction of the damage that you’ve done. It’s a miracle there were any bats left for me to evolve in.

            “But now you are really really helping me, so keep up the good work!

            “And oh, please, I’m begging you, whatever you do, please please re-elect Empty Hairdo, the Leader of the Free World who will never ever figure out how to keep it free from me.”

            Well, students, now you’ve heard it, Sarsie in his own words, uncensored, from the horse’s—or the virus’s—mouth.

            And don’t knock his hopes and dreams. He’s just following Dr. Darwin’s prescription. For him.

            Dr. D’s advice for us? Stay safe, be well, and keep in touch—from a distance.

Dr. K