Pandemic Uncertainties and Next Steps

A contagion is clearly a complex phenomenon.  The way that the COVID-19 pandemic has affected different nations and the unique nature of the virus and its effects on the human body make for a very puzzling problem.  Added to this complexity is the fact that we are attempting to analyze and understand the contagion in real time with only limited historical data.

COVID-19 is clearly a dangerous contagion.  The virus, SAR-CoV-2, is much more contagious than the average flu and also appears to be about ten times as lethal. 

The fact that SARS-CoV-2 can create rampant outbreaks and huge challenges for healthcare systems with large numbers of resultant fatalities has been made clear in Wuhan, Italy, Spain, France, the UK and the U.S.  However, the pandemic has not yet had the devastating effect on developing nations that was expected, thankfully, and has been contained in some countries with relative ease – Sweden for example.

As we look forward to approaching summer in the U.S., there are several factors that seem to be critical in determining how things will develop from here:

Seasonality – Viruses are often seasonal.  The flu virus, which is also a coronavirus, has a distinct increase in its spread in winter and then more or less disappears in summer.  We do not know yet whether a virus as contagious as SARS-CoV-2 will be ‘seasonal’, but the fact that the contagion has seemed less dramatic in southern hemisphere countries may indicate that it is.  As far as I can tell, no one is quite certain why viruses are seasonal.  There may be many factors at play – the virus may be less viable at warmer temperatures, the way people interact changes, the air and atmosphere change, etc.  It is possible that summer will accelerate the decline of the contagion, which would certainly be welcome news.  But if that happens, then we would definitely have to be wary of a fall and winter resurgence.

Social Distancing Effect on Reproduction Number – Much of the U.S. avoided skyrocketing contagion by putting in place very restrictive social distancing measures, including the closing of restaurants, bars, businesses, stores, schools and most events.  Additionally, many people are now wearing masks.  Even with these measures, the reproduction number is just under 1.0 in most states.  The big question is whether relaxing many of these restrictions will cause the number to jump up (it has been estimated to be as high as 5.7 in some situations).  What is the ideal balance of social distancing and ‘open for business’?  We will probably have to experiment to discover the right mix, and hopefully we will not thrust ourselves right back into a catastrophic situation.

Antibody Effects and Immunity – People who have had COVID-19 have antibodies in their system.  Do these antibodies provide immunity to re-infection?  If so, for how long?  Will the immunity vary from person to person?  When a disease is rampaging in real-time these are the types of questions that are so difficult to answer.  Large amounts of data need to be gathered and analyzed to make any pronouncements.  The goal of herd immunity, where enough of the population has immunity to stop the spread of the disease (whether by vaccination or having had the disease) is highly desirable but not easily attained.

Health Risks of COVID-19 – The SARS-CoV-2 virus is very dangerous to the elderly and those with serious health problems such as obesity, diabetes, cardiovascular disease, high blood pressure, cancer and lung disease.  But it also occasionally strikes young, healthy individuals with dramatic effect, putting them in ICU’s on ventilators and sometimes killing them.  Yet, the virus can also be totally asymptomatic or have very minor symptoms, especially in the very young.  It takes time to understand all of the health impacts that a virus can have, and we will not understand all of the risks associated with allowing this virus to work its way through the world population for months if not years.  Another strange thing about this virus is that the very young rarely show significant symptoms and there are very few deaths in that age group, yet they are still a vector for transmission of the disease.

Testing and Tracking – The general trend of thinking in research groups and epidemiologists is that our only wise recourse in the interim period before a vaccine is available is to lower the number of active cases dramatically by continuing the strong restrictions that most countries have put in place.  Once the number of active cases is low, then a policy of aggressive testing, tracking and quarantine must be initiated to keep the contagion from re-surging.  If such a system is in place, then a reasonable level of ‘business as usual’ can be allowed.

The Social Compact

Human beings are social animals.  But our sociability to others, outside of our family group, is based more on creating a pleasurable association than on creating any sort of social obligation or support structure.  We love to have friends and acquaintances with which to share experiences, but when there is a call for help, we quickly start to put limits in place and rationalize the boundaries.

The current pandemic, COVID-19, is a fascinating, high octane study in the dynamics of our social compact.  But it also brings into sharper focus a general question that we have been nibbling around the edge of for years.  What is our obligation to other human beings? 

Americans think of themselves as being very generous.  And it is true that there is a lot of charitable giving in the U.S.   We are also quick to help out when there are disasters such as tornados, hurricanes, tsunamis, wildfires, famine and other short-lived times of need.

But Americans are reluctant to support longer term sacrifices for the general good, or to share their good fortune over the long haul.  The rugged individualism that has characterized much of the U.S. since its founding is profoundly suspicious and wary of any ongoing commitments to general social welfare.

The country was relatively receptive to a short-term sacrifice to tame the surge of the coronavirus.  But as weeks turned to months a large number of Americans began to question why they should sacrifice to save the lives of the elderly or infirm.  They framed their opposition as a call to liberty from government interference and tyranny, but the unavoidable fact is that most Americans have a limited willingness to accept any curtailment of their good fortune for the benefit of others.

This wariness of social sharing also manifests itself in a general distaste for government safety nets, universal healthcare and higher taxation on the wealthy.  Many Americans blame the poor for their plight and feel that any so-called ‘entitlement’ programs only encourage slothful and opportunistic exploitation of government handouts and further bad behavior.

Americans justify their distrust of social policies by labeling them ‘socialist’ or ‘communist’ and point to the classic failures of communist nations such as the former USSR, Cuba and Venezuela.  Their disdain for government is at the center of their political thought, along with an unbridled faith in the free market’s ability to solve every problem.

Compare this to the ‘social democracy’ that is prevalent in European countries.  People in these countries are willing to pay higher taxes and accept greater government involvement in social and financial policy to ensure that there is social harmony and a reasonable level of economic equality.  These are capitalist nations that celebrate entrepreneurship and hard work just as much as the U.S. does, but do not see social obligation and government refereeing as contradictory or at odds with economic progress.

The pandemic puts our social compact in stark terms, though there are certainly nuances in the way that each nation will attempt to return to normalcy.  If indeed a full return to business-as-usual will overwhelm health systems and cause many needless deaths, are Americans so selfish that they will rebel against a longer-term cautionary approach?  We have already seen that the U.S. has suffered a harsher penalty than most nations because of its slow response and narcissistic leadership.

America will soon have to confront its conflicted relationship to the social compact.  It is ironic that the self-proclaimed most-Christian-nation is probably the least Christian in its response to the need for sacrificial behavior.  Will this pandemic ultimately bring out the best in America, or will it demonstrate to the whole world how bankrupt our values really are?

When Ignorance and Idiocy Become Dangerous

The recent right-wing protests against COVID-19 social-distancing and shelter in home orders are a dangerous and foolhardy expression of deep ignorance regarding the pandemic.

There is, of course, a healthy dialogue to be had about how we should proceed with relaxing some restrictions as we move past the peak of the first outbreak.  We have now had social distancing orders in place for 4-6 weeks, depending on location.  Yet we are still experiencing a stubborn rate of 30k new infections daily and close to 2k deaths each day.  One can hardly describe this situation as being ‘under control’.  The best we can say is that hopefully the worst is behind us.  But the wrong next steps could make that statement false as well.

What we know is that the SARS-CoV-2 (the virus itself – the disease is COVID-19) is extremely contagious, much more so than the yearly flu.  We see clearly in several cases – Wuhan, Italy, Spain, NYC, London – how devastating an outbreak can become under normal circumstances.  There is absolutely no reason to believe that totally relaxing restrictions would not send us right back into a disastrous situation that would once again overwhelm our healthcare resources.  This would be the very height of idiocy.

Any arguments that a certain level of deaths must be accepted to save the economy ignore the fact that the full raging outbreaks go well beyond any contagion that we have experienced before and lead to many unnecessary deaths because of the breakdown of healthcare systems.  Furthermore, it is not just the elderly and the weak that are succumbing.  Many young and fit people are falling prey to this strange disease, much like the influenza epidemic of 1918-19. 

Whether restrictions can be relaxed somewhat in rural areas and areas that have less population density without impacting the overall contagion spread is unknown.  No doubt some states will be probing this question over the coming weeks.  Larger urban areas will also attempt some decrease of restrictions, but clearly this must be done very slowly and methodically, in concert with large scale testing and follow-up tracing and quarantine.

In Germany, Angela Merkel has explained these facts and the science behind them to the country, and they are beginning to experiment very cautiously.  The Germans support her caution because they understand what is at stake and why the situation is so precarious.  They have been much more successful than any other country in performing adequate testing and thereby reducing the number of fatalities.  The U.S. should look to this as a model for moving forward.  Unfortunately, we have Donald Trump instead of Angela Merkel.

Peaceful protest is a right guaranteed by our constitution and I do not question whether the current wave of protests is lawful.  And I understand that the economic effects have been painful and that people are frustrated.   But protesters need to be wary of stoking the fires of partisan divide and making this pandemic a political discussion rather than a scientific and public health one.  That can only lead to further challenges in confronting the contagion and may have the very opposite effect of further delaying what the protesters claim to represent - a return to normalcy.

Idiotic protestors, some with AR-15 rifles in provocative poses, are so completely ignorant of the details of this crisis that they would be laughable if they weren’t also a danger to our civic stability and our ability to confront the contagion.  The fact that Trump is egging on this cretinous mob is not surprising, but it is one more indication of the lack of any leadership qualities in the man who somehow has become our President. 

Trump the Anti-Scientist

One of the most disturbing personality traits of Donald Trump (and they are legion) is his disregard for science and his reliance on his ‘instinct’ to deal with issues that should be informed by science.

We have seen this in Trump’s frequent absurd tweets regarding climate change.  Here is a sample:

• Ice storm rolls from Texas to Tennessee - I'm in Los Angeles and it's freezing. Global warming is a total, and very expensive, hoax! 
• The concept of global warming was created by and for the Chinese in order to make U.S. manufacturing non-competitive. 
• Any and all weather events are used by the GLOBAL WARMING HOAXSTERS to justify higher taxes to save our planet! They don't believe it $$$$!

Even among conservatives there is a growing consensus that climate change is real and is caused by human activity, not to mention the totality of scientific organizations and 97% of climate scientists that have been trying to warn the world for the last 20 years.

As in all things, it is difficult to know whether Trump actually believes the things he says, or whether they are just a necessary maneuver in his machinations to delight his followers.  Another example is Trump’s championing of the Obama Birther movement.  Did Trump actually believe that Obama was not born in Hawaii, or did the birther movement just happen to be the best way for him to cultivate a radical and fawning group of admirers to bolster his political chances?  It doesn’t really matter, the effect is the same.  One is not better than the other.

Trump’s primary purpose in everything he says or does is to focus attention on himself.  He is the ultimate narcissist.  Vanity is his sole motivation.  In concert with this love of self and desperately insecure need for attention is his love of drama, hyperbole and shock.  He refers to his gut and his instinct for two reasons: (1) Because gut and instinct reflect all decision-making and policy back to Trump and his all-powerful position.  He is the arbiter of all things, his ideas are the basis for all policy.  He doesn’t need other opinions, research or facts.  (2)  Gut and instinct can be voiced in provocative, sensational ways that contribute to his rabid followers’ allegiance and uncritical love.  There is nothing like a non-PC declaration of ‘gut’ to show that Trump is ‘sticking it to the elites and the left-wing scientists’.

Science is the exact opposite of all things Trumpian.  There is, of course, plenty of ego in science, as in all things human.  But science is generally expressed in sober, unsensational terms.  Because of its complexity, most science is not well-suited for aphoristic, melodramatic statements.  And sadly, it is not easily understood by the public, especially a public that has been poorly educated in science and raised on a diet of pseudo-science or outright anti-science pablum. Scientists and physicians, though highly motivated and eager for recognition in their fields, serve the higher goals of knowledge, truth and humanity.  They are polar opposites of Trump.

Scientists are by their nature detailed, deep thinkers who avoid the spotlight and prefer to develop their ideas fully before exposing them to their peers or the public.  True scientists abhor anecdotal data and theories, which are the majority of the public’s (and Trump’s) ideas about science.  The scientific method and evidence-based science are the only acceptable basis for theories and proclamations from a scientific point of view.

In the COVID-19 pandemic, Trump’s anti-science personality has had devastating effect and will probably continue to harm the country’s efforts to combat this plague.  His dismissal of the virus as no worse than the flu cost the country weeks of preparation time and a large number of deaths can certainly be directly attributed to this ‘gut’ decision-making.

Another potentially disastrous ‘instinct’ of Trump in this pandemic is his premature and probably mistaken cheerleading for hydroxychloroquine as a treatment.  Any normal leader would have left such decisions about treatment regimes to his medical advisors and the medical community at large.  By touting an unproven treatment, Trump has probably made the clinicians’ and the research scientists’ jobs much more difficult.  There are already reports of patients refusing to be enrolled in trials for other treatments (such as remdesivir, which may prove to be a much better option) because they ‘want the Trump drug’.

Trump’s endorsement of the malarial drug was clearly the typical Trump technique of aggressively associating himself with everything so that he can claim success if there is indeed success.  It is all about Trump, always:  Trump’s gut, his instinct, his likes, dislikes, his thin skin his shocking ignorance of science.  It is bad enough in the normal run of the government.  In a world-threatening pandemic, it is outright criminal. 

What Lies Ahead in the Pandemic?

The first great wave of the COVID-19 pandemic is either peaking or past its peak in China, parts of Asia, Europe and the U.S.  What lies ahead?

What does it mean when people say, ‘the worst is over’?  It means that the explosive growth of the pandemic in a particular city or nation is over, that the healthcare system is no longer stretched beyond capacity, that the number of new cases each day is not getting larger.

But it does not mean that the contagion has stopped spreading.  There may still be more new cases each day than cases that have been resolved.  New people will go into the hospital.  New people will need intubation.  New people will die.  There will still be large numbers of people who walk the streets in either a pre-symptomatic or asymptomatic state.

The only way to completely stop the spread of COVID-19 before a vaccine is available is to test universally and constantly, and track and quarantine all infections, efforts that very few countries will be willing or able to mount.

But there is no doubt that human beings will attempt to return to a more normal life and be willing to take on a certain level of risk to ensure that total economic collapse and all of its attendant consequences do not occur.

So, what will life be like in this interim period, before vaccination but after total shutdown orders have been lifted?  Knowing that there are still significant numbers of infected people in public, will people be willing to fly on airplanes?  Will they go to bars and restaurants?  Will they attend sporting events, concerts, plays or theater?

This will partly depend on the level of contagion in any specific area.  And that level will probably ebb and flow much like the tides and any other cyclical phenomena.  COVID-19 is highly contagious, so if the social distancing measures are completely abandoned it will return with a vengeance. 

Will a more relaxed social distancing policy, with people generally wearing masks in public and trying to keep their distance from others, be enough to keep the virus at bay?  Will the mortality rate be lower if we keep the contagion at a lower level and allow our healthcare providers to work in an optimal manner?

The unpredictable nature of the COVID-19 sickness may have a sobering effect.  Even young, healthy adults can end up on a ventilator and ultimately die.  Will this fact cause much more conservative behavior, or will people be willing to take that relatively small risk and resume their normal lives?

Clearly, elderly people and those with pre-existing health problems will be very reluctant to risk exposure as long as there is a significant level of contagion present.  This is a growing portion of our population and a group that contributes heavily to our economy.  Their isolation and sheltering will certainly be a brake on any real recovery until there is a vaccination available.

One possible short-term aid would be the development of a treatment that stops or significantly reduces the so-called ‘cytokine storm’, the medical event that seems to herald the rapid demise of patients and is responsible for the death of young and healthy victims.

It is impossible at this point to accurately predict the future of this contagion.  But I believe there is enough evidence to support the argument that any true return to normalcy is many months away.  There may be an improvement in economic activity once the strictest shelter-in-place restrictions are lifted, but it is likely we will endure many months of a seesaw response.  We will simply have to do our best to adapt to each new situation and, most importantly, avoid desperate moves that pit state against state, country against country, rich against poor.  Our humanity is being tested; we must all do our part to meet the challenge.

Why Was COVID-19 A Partisan Issue?

It is not hyperbole to postulate that partisanship and distrust of science in the U.S. is responsible for thousands of unnecessary deaths in the COVID-19 pandemic.  It is a lesson that we have paid heavily for in the last month, but hopefully it will have beneficial long-term effects that could save lives and suffering in the future.

When the spread of COVID-19 first became obvious to the world outside of Wuhan, scientists and physicians were nearly unanimous in warning of the potential for a pandemic.  There was sufficient data from Wuhan to make it clear that COVID-19 had a much higher reproduction factor and mortality rate than influenza.

The Trump administration was cavalier about the danger from the start.  The primary reason for their reluctance to acknowledge any risk was the possible impact on the stock market and the economy, which Trump saw as the key to winning a 2^nd term in November.  This led the administration to interpret any pressure from politicians or the science and health communities as attempts to create a panic situation and bring down the ‘Trump stock market’.  Trump and various right-wing pundits and news shows even went so far as to deride these warnings as hoaxes.

By constantly comparing COVID-19 to the annual seasonal influenza, Trump and his allies showed both an astonishing level of ignorance and a cynical willingness to gamble the health of Americans on the hope that somehow the virus would indeed be relatively harmless.  This hope was not based on any science or data, but on the ‘instinct’ and so-called ‘common sense’ that seem to be the only basis for Trump’s decisions on every issue.

Because of this incomprehensibly stubborn refusal to listen to reason, Trump wasted weeks of time when the nation could have been preparing for the onslaught of the virus.  Testing could have been accelerated, a large-scale national effort to make personal protection equipment and extend hospital facilities could have been initiated. 

The time lost during Trump’s selfish attempt to save his own fragile economic legacy has had devastating effect.  Thousands more will die than would have died had he acted aggressively in the nation’s best interest rather than his own.  Compare his administration’s response to that of Germany and you will see the difference between the leadership of a vain, petty demagogue and a true selfless, determined humanist.

Trump’s disdain for science and data has set us on a course for disaster, and not just in this pandemic.  There is an even more catastrophic highly probable natural disaster awaiting us in the near future with climate change.  We can only hope that all of humankind, and particularly the science-ignorant public in the U.S., will draw a lesson from this pandemic and understand that science informs us about the dangers ahead, but politicians must take action.

We are learning through this pandemic that the earth is a single, fragile organism in many respects.  There have been numerous noble gestures and empathetic responses across the globe.  The sacrifice and dedication of health care professionals worldwide stand in stark contrast to the woeful actions of our President.  We must unite in our determination to defeat this current pandemic, heal the economic wounds, and then use that unity to face the certain challenges that lie ahead.