Tagged pandemic

…and then there are experiments

“We will allow gyms, fitness centers, bowling alleys, body art studios, barbers, cosmetologists, hair designers, nail care artists, aestheticians, their respective schools, and massage therapists to reopen their doors this Friday, April the 24th.” Gov. Brian Kemp (GA), 4/20

“If there’s a way that people can social distance, and do those things, then they can do those things. I don’t know how, but people are very creative.” Dr. Deborah Birx, White House Briefing, 4/21

“My daughters who are, you know, 13 and 14 and 11, I mean, right away they’re asking me, ‘How does that work, Daddy?’” Dr. Sanjay Gupta, CNN, 4/21

Dear Students,

Y’all remember what an experiment is, right? Like, you’re in a lab with a lot of mice genetically engineered to mimic Alzheimer’s. They build up clumps of amyloid in their brains, and they get even dumber than other mice. You find a molecule that binds to amyloid and say, “What if I could get it to attack the amyloid clumps?” You randomly assign mice to get or not get your cute molecule, and presto, the ones who get it clear the amyloid clumps from their brains. “Whoopee,” you think. You and some brain docs recruit a few brave volunteers with early Alzheimer’s to take Cute Molecule. (Hopefully they didn’t volunteer because they were already demented.) Did their amyloid clear? Equivocal, but then again you didn’t kill anybody. You move on to a larger trial, with a matched control group. You don’t know who got Cute Molecule in different doses or who got a vitamin pill, and neither do they. Double-blind. Results: still equivocal. Back to the drawing board. But wait. You analyze the results again and find that the highest dose of Cute Molecule helped some patients. “Whoopee!” More studies.

Those are experiments.

And then there are experiments. Like the one Doctor—oh, I meant Mayor—Carolyn Goodman of Las Vegas proposed. She told Anderson Cooper on CNN, “We offered to be a control group…and I was told by our statistician you can’t do that…and I said, Oh, that’s too bad because I know when you have a disease, you have a placebo that gets the water and the sugar and then you get those that actually get the shot. We would love to be that placebo side so you have something to measure against.” Her fascinating hypothesis: the parts of Nevada that stay locked down won’t have less COVID-19 disease than Vegas, which she encourages to reopen its casinos, bars, and restaurants.

Students, this is your chance to be one of those brave volunteers pioneering in Doctor—I mean Mayor—Goodman’s big experiment! Fly to Vegas and elbow in among those crowds of gamblers from everywhere in the reopened casinos. If you are serious about gambling, this is the experiment for you!

Or, come back to Georgia and get a massage, a tattoo, a haircut, a perm, or a manicure. Those are some of the businesses that Doctor—I mean Governor—Brian Kemp reopened in our state! Maybe you’ll be the experimental group and North Carolina, the adjacent state that’s staying locked down, will be the controls. Really, what’s the worst case scenario? You help prove that our neighbors to the north are right—AND you are going to look sooo good in your coffin!

Then there’s the experiment proposed by the Doctor-in-Chief or DiC. You can really help out here. Swallow, or better still, inject Lysol or another disinfectant. I think he meant, like, in your veins? Also, get some really bright (but maybe not too thick) flashlights, turn them on, and stick them in all the places where the sun doesn’t shine.

But I digress.

[See disclaimer here]

Good News

  1. New York, by far the worst-hit state, is definitely healing. As the governor says, 400+ deaths a day is nothing to celebrate, but it’s far down from the peak, and the pressure is beginning to ease a bit in the hardest hit hospitals. Intubations have been lower than extubations for days, and New York (as promised) is sending ventilators to states that have not yet reached their peak. What goes around comes around.
  2. The Starfish model that I wrote about last time is working for America. Most governors, including many Republicans, are leading their respective points of the star and ignoring the decayed head. This is making our country resilient enough to defeat the virus with an adaptive, headless network. Large majorities of Americans are keeping up social distancing and are worried about opening too soon.
  3. A different point of the headless star, the U.S. Congress, passed another near-$500 billion relief bill, to save more of America’s small businesses from the virus (especially minority-owned businesses—the most vigorous part of the category). Also, the bill will strengthen production of personal protective equipment (PPE), swabs and reagents vital for testing, and actually deploy real testing programs.
  4. NY and LA have instituted something I’ve been waiting for: random sampling of their populations for antibody testing. This gets a snapshot of the impact of the virus: where it has been, how many people had it without symptoms, how it spreads, who is most vulnerable, and what the real numbers are—total cases, which leads to believable case fatality rates.
  5. A retired farmer in Kansas wrote Gov. Cuomo that he had saved five never-used N-95 masks from his farming days. His wife has one lung and is diabetic so he is saving four masks for his family. But he sent the fifth one to Cuomo, asking him to give it to a nurse or doctor in New York. The man said he didn’t expect an answer, but the Governor read it and reread it on national television. There wasn’t a dry eye in the house. That farming couple and others like them are another point of the resilient American star.

Bad News

  1. The fact that New York is sending ventilators to other states of course means that they have not passed their peaks of need but are still on the upswing (Utah, Mississippi) or in a plateau (Texas) of deaths. (Interactive graphs here.)
  2. Some states (Georgia, Florida, South Carolina, etc.), fortunately not many as yet, are as headless now as the nation is, and are pioneering ill-advised early opening. They can’t be effective points of the national starfish. But the mayors in most cities in those states—in Georgia, the mayors of Savannah, Augusta, Albany, Macon, Rome, and Atlanta—are the points of the now-headless state starfish. They will save the state, just as the wiser governors save the nation. The mayor of Savannah, for instance, has urged his citizens (in Georgia’s oldest city) to call their barbers and manicurists and pay for an appointment in the future, but not to go now.
  3. All the money from Congress so far does not begin to meet the need. It does not help the states to support first responders, provide adequate PPE, or deploy adequate testing and especially, contact tracing. Senate Majority Leader Mitch McConnell has advised states to declare bankruptcy, which is not legal, rather than use Federal funds to help hard-hit states. Much more is needed to rebuild crumbling infrastructure and finally build the health care delivery system we need. This would provide millions of needed jobs and leave our children with a more workable country.
  4. We are still woefully under-testing, and we need a ten-fold increase just to test for the virus itself. (The Rockefeller Foundation just issued a detailed plan for expanding testing and reopening the country). Crucial antibody (serological, you-had-the-disease) testing is far behind in numbers and most available tests are not accurate. A huge newly-trained force of people is needed to trace contacts.
  5. All experts agree that a second wave of the pandemic is highly likely in the fall and will intersect disastrously with the regular flu season, which it didn’t do this year. This includes the head of the CDC, the Surgeon General, Dr. Fauci, and Dr. Birx, who all risk being fired by openly contradicting their boss on this prediction. The best we can hope for is that we will have learned and that the next wave, even if it is worse, will not catch us flat-footed the way the first wave did. Watch the secondary waves already occurring in Asian countries.

Many experiments are under way and we will see how they turn out. That includes controlled experiments on treatments and vaccines, and uncontrolled experiments by politicians on volunteers who do not understand the risks they are taking by participating. The Mardi Gras experiment resulted in a large increase in Louisiana cases. The Wisconsin in-person primary election on April 7th is believed to have caused at least 19 cases, including at least one poll worker. Daily new cases in Wisconsin have seen an upturn (here, and graph below) in the two weeks since the primary. Live, in-person worship services, funerals, and other religious gatherings have resulted in many deaths, including an outbreak in Albany, Georgia after a funeral and the death of a pastor in Virginia who led live services. His wife also got the virus, and their daughter begs us to understand how serious the risks are. We will see what happens in Georgia barber shops and on Miami beaches.

Stay safe. Let me know if you’d like me to continue these updates beyond the end of the semester.

Dr. K

Do I Have It, Did I Have It, Am I Recovered, Am I Immune?

“A house divided against itself cannot stand.” Gov Andrew Cuomo, quoting Abraham Lincoln, quoting Matthew 12:25 and Mark 3:25

“The paranoia of stupidity is always the worst, since its fear of destruction by intelligence is reasonable.” American playwright Arthur Miller

“You can’t always get what you wa-ant. But if you try some time, you just might find, you get what you need.” The Rolling Stones, from home, yesterday

Dear Students,

A book called The Starfish and the Spider, published in 2006, was about the strength of decentralized organizations. The metaphor is not ideal, but if a spider loses its leg, it’s crippled, and if it loses its head, it’s done for. A starfish can regenerate its cut-off leg, and in some species the leg can regenerate the whole starfish. The authors argue for the strength of acephalous or headless organizations. Wikipedia and the Internet are examples. The Aztecs quickly fell to the Spanish conquerors, but the dispersed, leaderless Apache Indian tribe resisted them for centuries.

Good News

  1. The resilience of the United States as a headless organization is being tested as never before, at least since the American Revolution. How many times have we now heard, “It’s up to the governors”? Well, guess what? The governors have gotten the message! They are fighting the would-be COVID conqueror with the resilience of a headless organization. This includes Republican Governors Larry Hogan (Maryland), Mike DeWine (Ohio), and Charlie Baker (Massachusetts), and Democratic Governors Andrew Cuomo (New York), Gretchen Whitmer (Michigan), and Gavin Newsome (California). They keep asking for Federal help, and people are dying for lack of it, but they no longer expect it from the executive branch, and they are getting the job done.
  2. The Congress is another leg of the starfish. It is drafting legislation to provide funds for millions of free tests a week, both for the virus (you have the disease) and for the antibodies (you had it). New York State, which accounts for almost half the U.S. cases and deaths so far, is pretty clearly over the worst. Following Germany and other countries that understand science, New York will implement massive random antibody testing to get a snapshot of how the virus spread through its population, calculate real mortality rates, and begin finding out who may be immune.
  3. As for treatment, hydroxychloroquine has not yet worked but is still under study, as is the antiviral remdesevir, which looks much more promising. The use of convalescent plasma (from recovered patients) is also being aggressively studied. All three are in short supply, but doctors can request any of them for individual patients outside of controlled trials. Vaccines are in development in labs throughout the world.
  4. Stay-at-home measures, social distancing, obsessive handwashing, masks, and other preventive strategies have dampened the curve in many states and in the U.S. as a whole, although they have not crushed the curve anywhere. Some states will begin returning to normal life in stages recommended this week by the Coronavirus Task Force, starting as early as the first week of May. Every person who voluntarily stayed at home has been part of the headless organization defeating the virus and saving literally countless lives.
  5. Recessions and even depression do not costs lives, but contrary to intuition they save lives. This has been shown for the Great Depression, the Great Recession and other downturns. Deaths from auto and other accidents, heart disease, lung disease, and infant mortality all go down. Deaths from suicide and addiction probably go up, but overall deaths decline. Obviously if a recession coincides with a pandemic, a lot of people are going to die from the pandemic, but the idea that recession itself will cost lives in the aggregate is false.
  6. Lady Gaga and Global Citizen yesterday presented One World: Together at Home, a two-hour concert from the homes of an astounding array of huge celebrities (see highlights here). As of today they have raised $128 million for WHO, the UN, and other headless organizations fighting the virus, some abandoned by the United States.

Bad News

  1. However successful the states are on the headless starfish model, the absence of Federal funds, especially for testing, will hamper their response and cost lives. Some states are opening up too much too soon and are ignoring the fact that unknown numbers of their citizens are infected and spreading the virus without having symptoms. New research shows that sneeze droplets travel much farther than 6 feet.
  2. There is another, negative aspect to headless organization emerging: large, angry protest movements both denigrating and flaunting public health measures. This has been framed in terms of “freedom” and “liberation” and encouraged from what is left of our country’s head, but the result is massive dense crowds of people with no protection against each other. This will have an effect similar to that of Mardi Gras in Louisiana.
  3. Hydroxychloroquine trials have been disappointing so far, both because of lack of positive effect and cardiac side effects. Compassionate use of remdesivir has been more promising but it also has side effects and controlled trials must be completed before it is widely used. Ditto for convalescent plasma. Many vaccine experts doubt the timetable we have been encouraged to think about, which is 12 to 18 months.
  4. Twenty public health experts interviewed for a long article in today’s New York Times have urged us to prepare for return of the virus after the first wave, and to see this as a process that may take years. Scientists have criticized the main model that the Federal government is relying on for its normalization plan, while others have provided more plausible models that see the virus returning in multiple waves.
  5. Congress is at this writing deadlocked on major measures to provide funds for serious testing and alleviate economic suffering. Some health measures improve in recessions, but mental health measures are probably not among them, despite stress reduction for some people.
  6. The impacts of poverty, racial oppression, age, and gender are clear in this pandemic as in so many diseases. Poor people, African-Americans, and the elderly are prime targets due to preexisting untreated conditions. Women are the majority in front-line occupations, although men are more like to get sick and die. Nothing will change in the long run without changes in our society and our health care system.

“Do I have it, Did I have it, Am I recovered, Am I Immune?” These are the critical questions that we cannot yet answer. Washington says there are plenty of test kits, but the governors (both parties) say there are no swabs to do the tests and no reagents for the labs to do the analysis. Imagine that you can sit for the SAT or the MCAT, but you don’t get a pencil. Or imagine that you get a pencil and fill in the bubble sheet, but it can’t be graded.

We can’t end social distancing except as guided by widespread testing which is not yet available.

Below or attached, two graphs of the influenza pandemic of 1918-20, which we studied early in our course. The first shows overall mortality in various cities. Notice that the bumps in mortality came in three waves, the first being the smallest. The second shows the difference between the curves in Philadelphia, which had a parade of 200,000 people on Sept. 28, 1918, and waited two weeks after the first case to implement social distancing, and St. Louis, which instituted social distancing two days after the first case.

Please, be a part of the worldwide headless organization that will defeat this virus.

I know you are disappointed to be losing months of your youth, months of normal college, and for many of you the ceremonies of graduation. I am truly sorry. But I want you to have the rest of your youth and the rest of your life, and that of your parents and grandparents. We will figure out a way to make it up to you about commencement.

The “paranoia of stupidity” that Arthur Miller refers to is driving some people into the streets and into the arms of the virus. Yours is the intelligence that can subdue that paranoia.

You can’t always get what you want, but if you try some time, you just might find, you get what you need.

Stay safe, Dr. K

   

The Virus Has a Vote: Update to Students April 12, 2020

“Whatever happens over the summer, this virus is going to be back with us in the fall. And so we have to prepare for the fall as well.” Dr. Ashish Jha, Harvard School of Public Health, 4-5-20
“What we are doing is working, and therefore we need to keep doing it.” Dr. Anthony Fauci, 4-9-20
“If we are not expecting a second wave, or a mutation of this virus, then we have learned nothing.” Gov. Andrew Cuomo, 4-10-20
“The worst thing that can happen is we make a misstep and we let our emotions get ahead of our logic and facts and we go through this again in any manner shape or form.” Gov. Cuomo, 4-11-20
“Well you know I did just finish a 24 hour shift overnight so forgive me if I’m a little brutally honest, but at some point we have to accept that we open up the economy and X amount of people are going to die and the question is what is that number and what are we willing to accept. You know as we flatten the curve, if we don’t time this right there may be another spike, and this won’t be flattening the curve, it will be flattening the roller coaster. So myself, the front line health providers, we don’t want to flatten this curve, we want to crush this curve.” Dr. Sudip Bose, Emergency Physician & Iraq War hero, 4-11-20

These quotes from experts and leaders over the past week, in order of when they were said, are more eloquent in their message than I could be. The so-called first law of medicine, If it’s working, keep doing it, is operating here. But so is the first law of life: Hope for the best, but prepare for the worst.

Good News

There is a lot of good news to celebrate this Easter Sunday, and it’s more than just hope.

  1. New York, by far the worst hotspot in the U.S., has convincingly passed its peak of intubations, and that means the worst of the worst is over for New York. Daily death rates continue to be tragically high, but they are a lagging indicator and they too are plateauing. The overwhelming of hospitals has happened, but it may not get worse.
  2. Christopher Murray’s model, often cited by the Federal government task force, from the University of Washington’s Institute for Health Metrics and Evaluation (IHME), is now projecting a total of 61,545 deaths for the U.S., down from 100,000 or more projected just a few weeks ago.
  3. The West Coast states, notably Washington where the first U.S. cases were, but also Oregon and enormous California, have done an amazing job of keeping this in control from the beginning.
  4. Clinical trials of convalescent plasma, antibodies from same, hydroxychloroquine, remdesivir (an antiviral), and other potential treatments are proceeding. Some are being prescribed under the principle of “compassionate drug use” approved by the Food and Drug Administration (FDA), although their effectiveness is a long way from proven. Many promising vaccine candidates are under study.
  5. Testing is being gradually ramped up, with viral testing (to see if you have it) up to between 100,000 and 200,000 a day. Antibody testing (to see if you’ve had it) has begun in some areas.
  6. Some top Washington officials say the country may go back to normal activity on May 1. Others see a carefully planned phase-in of normal activity over the subsequent weeks to months, guided by testing, testing, testing.

Bad News

  1. Many parts of the country are behind New York on the curve. Some will succeed as the West Coast states have. Others, where social distancing has not been followed, may be disaster zones.
  2. When you read the fine print on the IHME website, you find that they are only claiming to model “the first wave” of the pandemic. They have nothing to say about future waves. (Below I discuss a more realistic conceptual model that is speculative but helps me to think about what our longer-term future may look like.)
  3. Very few states have done what the West Coast states have done from the outset, and some have done the opposite. If Los Angeles relaxes its controls too soon, it is projected to look like New York by late summer.
  4. Early results from small clinical trials have concluded that it is ethical to continue them. This means two things: a) they are not doing obvious harm to volunteers; b) they are not so dramatically effective that the trials have to be stopped so that everyone gets the treatment and no one gets a sugar pill. They could still turn out to be useful, or have bad side effects, or both. If a vaccine is available in 12 to 18 months, it will be by far the fastest vaccine development time for any novel virus.
  5. Testing remains woefully inadequate across the board, and claims to the contrary are demonstrably false. There are not enough viral tests for health workers at risk, much less for a suitable sample of Americans. If we do 200,000 tests a day, it will take half a year to test 10% of the country. Antibody tests, which if they work well enough can probably clear many people to go back to normal activity, have barely begun.
  6. The IHME models, which are the ones quoted by and guiding Federal government officials, are premised on current strict levels of social distancing continuing through May. Earlier relaxation of vigilance is projected to increase deaths, as mentioned by Dr. Sudip Bose, the emergency physician and war hero quoted above.

The model in the graph below (or attached) is a conceptual rather than precisely mathematical model, and I have problems with it, but I think it broadly shows how we should be thinking. It comes from an odd place, namely Morgan Stanley investment research (thanks to Dr. Craig Hadley for alerting me to it; the head of the unit that produced the graph is Matthew Harrison). It has errors (it assumes that children can’t pass the virus on and it is too optimistic about the timetable for a vaccine). It may have been updated today, and I will let you know if I can access it. Meanwhile, it is conceptually valuable in showing us how to think about how this will unfold. You know I consider you leaders. Use your excellent brains to navigate uncertainty, especially when so much depends on how we steer.

Note: I made a mistake in an earlier announcement about the effect of the Great Recession on life expectancy. It actually increased life expectancy and reduced mortality at all ages. The improvement was due to decreased deaths from heart disease, auto accidents, and homicides, among other causes. There were increases in opioid related deaths and suicides but these did not offset the improvements. Improved life expectancy in the Great Recession has been shown in both the U.S. and Europe. A similar paradoxical effect has been clearly shown for the Great Depression of the 1930s and is probably true of other economic downturns. I did see one study claiming to show the opposite, and that’s what I expected, but the weight of evidence goes against my expectation. That’s science for you.

Stay safe, Dr. K

 

 

Letter to my students on COVID-19, April 5, 2020

“I skate to where the puck is going to be, not where it has been.”

Wayne Gretzky, widely viewed as the greatest hockey player of all time

Volunteers
Volunteer Georgia health professionals on their way to New York

Dear Students,

This is my outlook on the COVID-19 pandemic as of Sunday, April 5, 2020. I pay close attention to many sources of information and sift or curate them as best I can. This is a constantly changing situation and you should not rely too much on me. As I’ve told you before, you are the future leaders of our country and our world and you must ultimately lead, not follow. Please let me know if you have information that is different or if you think I’ve made a mistake.

In my favor, I have been talking to you about this virus since our class began in January and I updated you every Tuesday and Thursday until Emory closed. Since then, I’ve been updating you every few days to a week. I try hard to get this right and not to scare you too much. I did try to scare you when we talked about Ebola, polio, and the flu pandemic of 1918-19, and I always said the next pandemic was a matter of when, not if. I did not know that this was it when I first mentioned it in January, but now everyone knows.

Good News

  1. The CDC has found that homemade masks or bandanas covering your mouth and nose when you leave your house will help to slow the spread. First Lady Melania Trump endorsed this, as have many other opinion influencers. It is not a substitute for social distancing, hand washing, and other measures, and it would be disastrous if people thought it was. It is an added measure on top of all those things. It is designed mainly to protect others, not you. When you breathe, talk, laugh, cough, or sneeze into the mask, the cloth will capture half or more of the moisture, and that means half the viruses if you are infected but don’t have symptoms. (You can experiment by spraying water into a glass through a cloth; only some moisture gets through.) If you do have symptoms, you must assume you have COVID-19, and self-quarantine completely until you are symptom free for three days. Call your health professional for specific instructions, and don’t dial 911 unless you are short of breath. Do not try to buy medical-grade masks; you will be taking them away from medical professionals and you may cause some of them to become sick and die. An example of how to make a mask is here.
  2. Rapid tests for the virus itself are slowly becoming more available, and antibody tests for whether you have already had the virus but recovered will become available more slowly. Widespread testing will be a game changer for control of the American epidemic, as it has been in China, South Korea, and other places.
  3. We have real leaders in this country who are regularly speaking out: Gov. Andrew Cuomo of New York, (Republican) Gov. Larry Hogan of Maryland, Speaker Nancy Pelosi, Dr. Anthony Fauci, and others. They speak honestly and to the best of their ability accurately about how to beat the virus and mitigate its economic effects. They don’t just call it a war, they act like it’s a war. Governors of many states are bypassing a mostly passive Federal government and attempting to help each other.
  4. Fortunately not all states are experiencing this wave of the pandemic simultaneously, so people and equipment are beginning to move where they are most needed. New York has by far worst crisis, so it is calling loudly for help. The state of Oregon sent 140 ventilators* to New York; this is a small fraction of what will be needed but it is a very important symbol. Twenty-two thousand health professionals from other states have gone to New York to volunteer. New York is worst now, but it will be better first, probably within a few weeks. It will then have excess ventilators and professional volunteers to send to other states as the crest of the wave moves around the country.
  5. Studies of treatments are proceeding, including convalescent plasma donated by people who have recovered from COVID-19; antibodies derived from that blood fraction; hydroxychloroquine, which has antiviral action in lab studies (and which I took for years to prevent malaria when I was in Africa, and then again for years for a skin condition); azithromycin, an antibiotic with possible antiviral actions; and specific newer antiviral drugs. I am hopeful that one or more of these will prove effective within weeks to months, much sooner than we have a vaccine. However, it is immoral to take hydroxychloroquine for prevention or self-medication at this time; it is not proven to work, and it is in short supply for people with lupus and other autoimmune diseases, who desperately need it.

Bad News

  1. We have inadequate leadership at the very top in Washington, giving out inconsistent messaging, with no national strategy for supply and logistics for COVID-19 care—ventilators, N-95 masks, shields, gowns, and other personal protective equipment (PPE), and consistent only in predicting unrealistic time frames for ending the pandemic and getting the country back to work. The government in Washington has declined to order a national lockdown for social distancing, to mobilize the armed forces to help the hospitals and the states, to order manufacturers to make desperately needed ventilators and PPE, or even to set an example for our people in things like social distancing and wearing of masks.
  2. The hospitals in New York, Detroit, and New Orleans are already overwhelmed, but the word overwhelmed will be given new meaning in those cities in the next week or two. Large numbers of health professionals, police officers, firefighters, EMTs, and other first responders are already sick and more will be. Many who are not sick are crying every day. Some, understandably, are quitting in fear of bringing this deadly virus home to their families. Similar effects will be felt in other cities throughout the country over the coming weeks. Hospitals built out in convention centers and mega-tents were ready but almost empty for days until they were allowed to take COVID-19 patients. U.S. Navy hospital ships are almost empty because they still will not take COVID-19 patients.
  3. Many people still do not take social distancing seriously. Gov. Kemp of Georgia reopened the beaches and parks in our state after closing them. In many states social distancing is not enforced and not likely to be until it is too late. According to current official government projections, the United States will see a minimum of 100,000 to 240,000 deaths if we strictly follow social distancing and other precautions. We are not yet doing that. The number of deaths in the U.S. passed 9,000 today and is doubling approximately every 3 days, which would put us over a hundred thousand in 10 days or so. If we act properly and lengthen the doubling time to 4, 5, or 6 days, it will take longer to get there. But bear in mind that the increase continues to be exponential at those longer doubling times.
  4. The Congress, especially the Senate, has offered too little too late to offset much of the disastrous economic effects of the pandemic, and as usual the poor and minorities will suffer most of the consequences, including worsening health, inadequate access to care, and premature and preventable death. Poor families have the greatest psychological vulnerability to the post-traumatic effects of this experience. Families at all socioeconomic levels have seen increases in domestic violence.
  5. Something that I have been reluctant to mention in these announcements, but which more and more authorities are considering, is the possibility that this is only the first wave. The flu pandemic of 1918-1919 had three waves. We must watch closely what happens in China, South Korea, and Japan as they declare the virus beaten and relax social restrictions. The virus is currently spreading in the Southern Hemisphere of the planet and may get worse in their winter, even as it may get better at the same time in our summer. I wish I could promise you that Emory will have live classes again in the fall.

We all need to adapt to situations that are psychologically abnormal. You can do it. Facetime or Skype with your friends and family. Have Zoom rituals, club meetings, and parties. Go outside with a homemade mask and run or walk while social distancing. Watch those movies you always wanted to see, binge-watch those hot TV series, even maybe read a book that’s not assigned for school.

Whether we have one wave or more, we will in time have treatments and a vaccine. Those who have had the virus and recovered will slowly begin normal life again. They will help restart the economy. This will end.

Your great-grandparents lived through World War I and the flu pandemic of 1918-1919. Your grandparents lived through the Great Depression and World War II. Your parents lived through the Vietnam War, 9/11, terror of terrorism, and the Great Recession. If any of your generations were in the developing world, they saw and lived through other terrible things. You can live through this. Just do what you’re supposed to do and help others as best you can. Do your homework and study. Come to class online. You are still a college student and you still have great dreams. You will live to see your dreams come true.

Dr. K

  • A note on terminology: I said in an earlier announcement that a ventilator is the same as a respirator. The Medline Plus dictionary of the U.S. National Library of Medicine says, “A ventilator is a machine that breathes for you or helps you breathe. It is also called a breathing machine or respirator.” However, other authorities use the word “respirator” to mean something entirely different, namely the top-flight hospital grade N-95 masks that screen out at least 95 percent of airborne particles not carried in oil. Because of the two meanings of “respirator,” I will avoid this word going forward. COVID-19 is the name of the disease caused by one of many coronaviruses; this coronavirus is designated SARS-COV-2. However, we all know that today “coronavirus” or even just “the virus” will pretty much get the message across.

COVID-19 message to my students this evening

Hi all,

I thought that our session yesterday was quite good and loved the chat contributions in the first

Photo by CDC on Unsplash

part of the class. I have thought most though about this comment from Garrett:

00:28:15 Garrett Canterbury: “I think the issue that Trump and other officials, including state and local, are struggling with is that at what point is putting millions of people out of work worth saving X amount of lives. I think the goal should be to move to the South Korean model where there is loads of testing, the economy is mostly re-opened, and the sick and vulnerable are isolating while the healthy are back to work.”

This is to me a vital question. I heard people who should know better say on TV in the past day or two that to weigh the economic consequences of social distancing and lockdown against the lifesaving public health measures many are taking is irrelevant or unethical.

There are things that I think are unethical to debate. This is not one of them. Take a look at this short column a couple of days ago by Tom Friedman, a liberal and no supporter of Trump: https://www.nytimes.com/2020/03/22/opinion/coronavirus-economy.html (Links to an external site.)

What is happening to our economy now, what will happen soon, really really hurts people. It will kill people.

But Garrett is not suggesting we do nothing. He is suggesting the South Korea model, which means social distancing based on testing, with one eye on getting people back to work. Here’s what I have to say about the balance:

  1. We must get the economy going again as soon as we safely can.

  2. The projected one to two million American deaths without strong social distancing would also tank the economy and rip the hearts out of millions of families. The overwhelming of hospitals and deaths of health care workers would do the same.

  3. We have missed the boat on testing at the right stage of the epidemic the way South Korea did, and we have missed the boat on timely mask and ventilator manufacturing BUT…

  4. We are where we are and we have to look forward. We must social distance to flatten the curve or this will destroy our hospitals, killing nurses, doctors, and other first responders.

  5. We have to hugely ramp up the things we haven’t done and still aren’t doing nearly well enough. The first is testing. We need tens of millions of tests, not tens of thousands, to follow the South Korean model as Garrett rightly suggests. We need two kinds of tests: one to find and isolate the currently infected, aggressively testing those they have been in contact with; and another one to identify those (now perhaps in the millions) who have had the virus and have successfully recovered. Those people are almost certainly no danger to anyone and can go back to work, socialize, and help others.

  6. We need manufacturing that is on a war footing. In World War II we did not ask auto makers to please make tanks. We ordered them to make tanks—and planes and helmets and bullets and uniforms. And by the way that project put a lot of people to work and saved the economy, as well as winning the war.

  7. We do not have medicine for COVID-19, but we have medicine for the economy, and it is being applied. The Federal Reserve bank has reduced interest rates to near-zero and is pumping unprecedented trillions into the economy. Even the dithering Congress has agreed to pass a two trillion dollar stimulus package and will do more. We know how to treat the economy when it is sick. Yesterday the Dow had its biggest increase since 1933, and another increase today. People will get paychecks in the mail that will be too small, but will help. Companies will get too much, but will be somewhat rewarded at least for not firing people and giving them paid sick leave.

McKenzie and others yesterday in saying we have the wrong kind of health care system to handle all this right. We also have the wrong kind of economy and a shameful lack of preparation. (See the previously assigned 2005 Scientific American article, “Preparing for the Next Pandemic.”  We didn’t.) But we are where we are. Go to this website to see what will happen to hospitals in your state under varying degrees of social distancing. Click on your state and see the date on which, with inadequate social distancing, your hospitals will be overwhelmed: https://covidactnow.org/ (Links to an external site.)

And please please learn the meaning of the word several of you supplied yesterday: exponential. We have more deaths from auto accidents right now, but they are not increasing exponentially. We have more deaths from seasonal flu, and this is a bad season, but they are not increasing exponentially. Our hospitals take care of patients in danger of dying from those two things every day, every year. They cannot take care of an exponentially increasing number of victims of COVID-19.

Take care of yourselves and protect yourself and others. Flatten the curve.

Dr. K

PS: If you’re curious to see how long I’ve been fighting for a better health care system, go here: https://www.melvinkonner.com/new-york-times-op-ed-page-columns/

Summary I sent my students on Wednesday, with preface/update Saturday

Photo by CDC on Unsplash

Since Wednesday the number of identified cases in the US has gone from 3,500 to 20,000, partly because of increased testing. Testing remains woefully inadequate so the real number of cases must be much higher. The US deaths have passed 200. More young people are sick and dying. Mardi Gras (Feb. 26) made New Orleans a hot spot and Carnival encouraged transmission throughout Latin America. Spring Break on Miami Beach will have a similar effect. US hospitals are begging for supplies, personal protective equipment (PPE), and ventilators (respirators),  and the government in Washington is so far not demanding that factories repurpose to produce these items. Barring drastic action, hospitals will be overwhelmed in two or three weeks, heroic health professionals will be dying at higher rates, and remaining doctors will have to decide who lives and who dies. Don’t become one of those casualties. Protect them, yourself, and those around you.

Use this source for daily future updates, interactive maps, and reliable information in days to come: https://www.nytimes.com

COVID -19 UPDATES

WEDNESDAY March 18, 2020, 8am

Here is what has changed in the past week:

  1. The WHO declared a worldwide pandemic last Wednesday
  2. Italy is probably the worst hit, with hospitals completely overwhelmed; Iran may be worse, but we have no reliable information from there.
  3. France announced a nationwide lockdown two days ago, noting a rise in severe cases in young people around the country.
  4. The U.S. President announced a national emergency & discouraged gatherings of more than 10 people.
  5. Testing became more widespread, but still lags far behind that in other countries.
  6. Testing proved that the virus is being spread by people who have no symptoms, mainly the young; the young may not know it, but they are killing the old.
  7. Stock markets crashed & economies shut down in many countries and U.S. states.

Here is where we are this morning:

  1. Many leading U.S. hospitals are seeing a dramatic rise in cases and expect to be overwhelmed soon.
  2. Many governors are calling for U.S. army and other national aid that isn’t there yet.
  3. Approximately 3,500 cases are identified in the U.S.; experts say there are 10 unidentified cases for every identified one, so the real number is around 35,000.
  4. Despite lockdown in many areas & the closing of restaurants, bars, gyms, theaters, sports events, etc. by law, experts agree social distancing is far less than needed.
  5. Hospitals are running out of supplies needed to protect health care workers.
  6. Ventilators (respirators; breathing machines) cannot be manufactured fast enough to keep up with the need; doctors will have to decide who will get treatment & who will be let go of, just like in a war zone.
  7. Doctors and nurses are getting the virus from their patients and going home; they cannot be replaced, even if machines and supplies can.
  8. The Secretary of the Treasury now warns that U.S. unemployment can go from 3 to 20 percent.
  9. Economists widely agree that we are in or are “sliding into” a recession which cannot be avoided, and which could be worse than the Great Recession of 2008.
  10. No one can tell us how long this will last or how bad it will get.
  11. Epidemics in warm countries seem to disconfirm the hypothesis that summer weather reduces the number of cases.

My advice to you right now:

  1. Stay home and urge anyone in your family who is not performing a vital service (hospital work, food and medicine deliveries, grocery stores, pharmacies) to stay home too.
  2. Maintain contact with friends and family by phone, Skype, etc.
  3. If you must leave your home, stay six feet away from any other person.
  4. If you have traveled anywhere by air, train, or bus, stay away from your grandparents & all older people for at least 14 days. Stay in touch with older people by phone & have food and medicine delivered to them if you can.
  5. Develop, & urge everyone you know to develop, skills for working, preventing isolation & sadness, & being entertained at home. If you must get out, walk in the woods or in a park where you can avoid getting within 6 feet of another person. If you have to walk the dog, use the same precautions.
  6. If you are coughing & sneezing without a fever, stay home & call your doctor. Do not just show up at a medical office or emergency room. Get a test if you can find one.
  7. If you develop a fever and feel very weak, call 911.
  8. If you are in the U.S., check the CDC web page every day:

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html (Links to an external site.)

  1. Wherever you are, check your national, state or provincial, and city or local health department websites every day.
  2. Wash your hands for 20 seconds many times a day; avoid touching your face as much as possible; frequently wipe down all surfaces from cell phones to kitchen counters with alcohol wipes; gloves & masks are in short supply, so use them wisely.

(Note: the photo above shows viruses in the coronavirus family, not SARS-COV-2, the causal agent of COVID-19, currently pandemic.)

Swine, Flu and Us: 3

Could it be in the end we will thank this virus for bringing us together?

The H1N1 epidemic is not much in the news anymore, but of course it’s percolating along. WHO now calls it “sneaky” because human-to-human spread is rapid and because the virus has the potential to mutate into a more virulent form. As of May 25 the number of countries affected (46) has doubled Read more

Swine, Flu and Us: 2

How can we be sure how serious the threat is? We can’t.

According to the World Health Organization, which is carefully tracking the new H1N1 virus and reporting daily, as of 4 PM today (Wednesday, May 6), 23 countries have reported 1,893 official cases (822 in Mexico) and a total of 30 deaths (29 in Mexico). Since I wrote on this last week,  Read more

Swine, Flu and Us

It’s always wrong to panic, but it’s never wrong to be prepared.

There is an ancient relationship between humanity on the one side, and parasites, microbes, and viruses on the other. It has been rightly called an evolutionary arms race—or more exactly, a series of them—and I will return to that idea in a moment.

But the writer in me prefers another metaphor, used by the virologist Richard Krause as the title of a book: The Restless Tide. As the subtitle explains, Read more