Everyone is asking the same question: Why have we not been overwhelmed, coast to coast, by this novel coronavirus? It is a legitimate question. Some say it is because the virus is an underachiever. That the lockdowns, isolation and closure of everything was an overreaction. Much ado about nothing.
That is not an accurate depiction of what has happened, however. Here's what really happened: Due to our swift and thorough actions, we have the virus in a COVID-19 Mexican Standoff. And the virus has us in the same position.
There are several reasons why the COVID-19 Mexican Standoff has occurred. First was the rapid sequencing of the coronavirus’ genome. In January of this year, it took Chinese researchers less than a month to sequence the genome of that we now call SARS-CoV-2, the virus that produces COVID-19 illness. Compare that to the original SARS virus in 2002-03, when it took some twenty weeks to sequence. The dizzying speed with which this new SARS-CoV-2 virus’ sequence was then digitally transmitted to PCR testing machines all over the world was a marvel of collaboration and a testament of just how far we have come with medical technology in seventeen years. Testing began at a rate never before seen globally.
At the same time, the Internet -- light years ahead of where it was in 2003 -- became an information (and disinformation) hub. People were able to obtain all kinds of information rapidly. The 24-hour news cycle pumped the images of suffering and death from all over the world, onto televisions and devices across America. Social media became the filter for commentary for a lot of this information. China -- no, Italy! -- became the focus of the world's attention.
Then the cases started in the United States. Seattle, with its world-class public health infrastructure, endured what we thought were the first cases. Then our attention turned to New York City. Then Boston. Then back again to the West Coast, and San Francisco.
Based on this deluge of information, and armed with the historical accounts of what the nation and their communities went through in 1918, political leaders listened to the health care professionals advising them. They almost universally reacted en masse, and the same way. They closed their cities and states. They closed America. But even before the political leaders started formulating policy and making decisions, the American people did their own calculus and decided the risks of traveling and venturing outside of their homes was too great. Nowhere was this more apparent than in sunny Florida, the third largest state in the Union, a state with the highest population of the elderly, numerically and per capita. A state that, by all rights, should have been decimated by the virus.
Except it wasn't. Or, more accurately, hasn't been decimated yet. The Tampa Bay Times story I have linked to is a commendable narrative on just how quickly Floridians made their independent decisions to stay home and not go outside. Of course, Florida still has been hit, but not nearly as bad as the Northeast.
What was the effect of all this? The interventions government implemented – social distancing, closing schools and business and government and shopping and dining and exercising and congregating – all those interventions wound up actually beating the virus to Main Street. The effort was hugely successful! The virus did eventually arrive, but largely found fewer human hosts than expected, based on this universal adoption of these inventions. This lowered the dreaded R-naught (R0) to a figure so low, the virus had great difficulty spreading.
If you read the interviews with the architects of Social Distancing as national pandemic policy during the George W. Bush Administration, whey will all tell you they never thought it would work to the degree it did. As Dr. Howard Markel, author of “When Germs Travel” and one of the architects of the “W” Social Distancing policy, recently told the New York Times:
Dr. Markel called it “very gratifying to see our work used to help save lives.” But, he added, “it is also horrifying.”
“We always knew this would be applied in worst-case scenarios,” he said. “Even when you are working on dystopian concepts, you always hope it will never be used.”
The exceptions to this narrative are painful. New York City. Boston. Dougherty County (Albany), Georgia. Nursing homes everywhere. Meat packing and processing houses nationwide. Situations as strange and varied as the virus is unpredictable. But for most of America, the virus has not yet been allowed to gain a foothold. And nowhere has the virus been allowed to reach fully into the country. Not yet. My friend and mentor Dr. Michael Osterholm told USA Today this week:
"This damn virus is going to keep going until it infects everybody it possibly can," Osterholm said Monday during a meeting with the USA TODAY Editorial Board. "It surely won’t slow down until it hits 60 to 70%" of the population, the number that would create herd immunity and halt the spread of the virus.
"It’s the big peak that’s really going to do us in," he said. "As much pain, suffering, death and economic disruption we’ve had, there’s been 5 to 20% of the people infected, ... That’s a long ways to get to 60 to 70%."
Osterholm acknowledges that the nation "can't lock down for 18 months" and said political and business leaders need to find a way to resume activities while adapting to a virus that won't soon disappear. He doesn't believe there has been enough of a frank assessment on the economic harm the virus will cause over coming months and its disruption to international supply chains.
"We all have to confront the fact there’s not a magic bullet, short of a vaccine, that’s going to make this go away," he said. "We’re going to be living with it. And we’re not having that discussion at all."
So let’s have that discussion. In order to have it, we need to accept that as we outraced the virus, we also sailed into Uncharted Waters. In other words, we have never been here before. This is the first pandemic in history where the response outpaced the spread of the virus - hence our Mexican Standoff.
So to move forward, the Mexican Standoff must end. It ends by us making some decisions. We need to make the decision to move forward, selectively reopening America, and looking to see what the virus’s next move is. We must be patient but we also must not divert from this strategy. Until we have an effective vaccine that the virus cannot mutate itself around, we must carefully maneuver toward at least partial herd immunity via exposure. But we need to be careful and not be reckless.
So what decisions are to be made, exactly? Because we have never been here before in human history, we can say that there are no bad decisions, until we start generating data from all these reopenings and see what worked and what may have put Americans under unacceptable risk. As Mike Osterholm said, we cannot stay closed for 18 months. In my opinion, probably not even 18 more weeks. We cannot keep schools, colleges and universities closed indefinitely. Our way of life is at risk.
Many point to Sweden as the global best practice for forcing Herd Immunity upon its citizens. We can look at Sweden, but we should also be looking closely at Georgia, and Florida, and every other state which is trying to navigate those Uncharted Waters. The jury is still out on Sweden. Their strategy is not a done deal. They cannot declare success just yet.
We know that as we reopen, case numbers are going to go up. That is inevitable. Maybe the summer heat and humidity will work on the virus. We simply so not know if summer will make the virus wilt or not. We need to be prepared for this scenario not to happen. But if it does, then summer heat and humidity become our allies and we need to be ready to exploit them.
We need to redouble our efforts to identify and protect those with comorbidities and protect the vulnerable among us. Identify those most at risk from the virus and have a strong plan to keep them out of harm’s way. Keep these groups working from home if necessary. Do our part as neighbors and minimize their trips to the market. Toward this, government data is perhaps the most important commodity. Is VISTA still around?
Despite the CDC’s recent reversals, we still need to continue to clean solid surfaces. Routinely and maniacally. At work, at home, at businesses, at the grocery store, at theatres and concert venues. Do this for morale if nothing else. I am still betting solid surfaces transmit COVID.
Open the schools. Kids for the most part are not getting seriously ill, and if we are going to reopen the nation, parents need to be able to send their kids to school. You will not have a substantive economic rebound unless and until schools reopen. What is the best way to achieve social distancing in schools? Here's an idea: When I was at Pompano Beach Junior High School, I had to endure the Hell of Double Sessions. And I lived to tell the tale! Split the sessions. Separate the students. Pay the teachers for the extra work, or hire some additional staff, or have classes in the cafeteria, or the auditorium, or the gym, and spread the kids out and combine classes. But you've got to get the kids back in the classrooms if you want economic recovery. And by the way, make sure the football players are in the early schedule. We need football!
Kids and teachers can wear masks. Kids will wear them so they do not infect their teachers. And vice versa. Kids might not hear their teacher well through the mask, so here’s a novel concept: Listen closely!
We need to completely rethink our testing strategy. As Mike Osterholm said yesterday, "It's a mess out there." The CIDRAP report on testing was released yesterday and it bears analysis. It does push for national standards and involvement, but it also makes the point I am making here: We need a reliable supply chain for these tests, as the virus returns in the fall and as the virus continues to pop up during the summer. I have proposed stockpiling tests – including antibody tests – for the anticipated Second Wave of the virus, sometime in the fall. However, we equally need to test now to confirm when we see the spikes coming from reopening. We have got to ensure we have enough tests for the second wave, and a stable supply chain to provide them. Couple this with some world-class contact tracing, for which we need to be doing our building and training now for the fall. If we stockpile enough tests now, we should have more than enough to fully engage in the Second Wave. Plus, we should have remdesivir, hopefully in enough quantities to administer it to the highest-risk groups and first responders early in their infections, when it will decidedly do the most good.
If we see a spike in cases, and if we are blocking and tackling as well as we should be, then we should be able to respond to the spike and bring it down without having to resort to the same harsh blanket responses as we used in the beginning of this pandemic.
And we need to wear masks in public. The purpose of wearing masks is not to avoid getting sick. It is about keeping your germs to yourself. Wearing a mask greatly reduces the chance you will infect someone else. Refusing to wear masks to make a political point is not the time to be making a political point. Wearing masks is not a Constitutional issue, and thus, refusing to wear masks is not a God-given right, according to Alan Dershowitz. He cites the Tenth Amendment. Anyone here want to debate him on Constitutional grounds? Are we really serious about wrestling this virus into submission? You want everything open? Wear a mask. Please.
If you are watching Sweden (3,832 fatalities as of this blog) and (loudly) pointing to their herd immunity program, then to be fair, you must also point to Japan (768 fatalities nationwide) and trumpet Japan’s ability to keep their fatalities well under Sweden’s, simply by wearing masks. Combining Sweden’s herd immunity strategy with Japan’s mask adoption will see us through this crisis, until we have either a vaccine, or inhalable remdesivir, or both.
NOTE: This blog was edited following the release of the CIDRAP testing guidance.
]]>
(Photo Credit Boston Globe)