The Pandemic Paradox

As we end this tumultuous year, 2020, which has been defined by the coronavirus, deaths in the U.S. from COVID-19 are approaching 330,000 from over 19 million confirmed cases. These numbers understate reality because not all cases and deaths have been diagnosed.

Why did it turn out so, the infections accelerating this fall as the weather turned colder and the U.S. responded with que será, será and a shrug?

The Paradox

The pandemic is a paradox which the country has not been able to solve.

Many who are infected with COVID-19 have no symptoms, many have mild symptoms, most recover — yet the virus is the third leading cause of death in the U.S., the cumulative death toll the same as the population of Salt Lake City or Birmingham, according to Scientific American.

The highly contagious disease spreads largely by close contact among people and, in some cases, transmission across longer distances. Limiting gatherings with others avoids exposure, by definition. When that is not possible, wearing a mask to reduce the probability of either inhaling the virus or expelling reduces the risk of infection. Yet government and business policies implementing these steps, either as regulations or simply recommendations, have been decried by some as unconstitutional infringements on personal liberty.

The life of an infection is relatively short — weeks — yet the U.S. has not been able to contain it after 11 months. It has consistently spread across the country, infecting all regions, even those knowing for months it was coming. December — not yet history — has been the worst month for deaths since the first peak in April.

Confirmed COVID-19 infections in the U.S. Source: Johns Hopkins University, 12/30/20.

Why is this pandemic such a paradox, when the U.S. has the medical expertise, the infrastructure, and financial resources to counter it? Why is it so difficult to manage, when other countries have demonstrated strategies that work?

I’ve concluded we lack government leadership, a coordinated and unified response, and both community and individual resolve. These interconnected deficits, amplified by a vocal minority of naysayers, have created a controversy about wearing masks and a false either/or choice between reducing infections or sustaining the economy.

What Can We Do?

Eleven months in, can we do anything to mitigate this tragedy or must we await the country being vaccinated, accepting the collateral infections and deaths while hoping they don’t affect us personally?

I think the following steps would yield measurable improvement, reducing infections and death until enough of us are vaccinated for the country to reach herd immunity. These steps must be implemented consistently across the nation, a “united we stand, divided we fall” strategy.

1. Stay in place for 14–21 days to minimize new infections.

The idea is for everyone to stay in place to let the current infections play out without causing new infections.

The incubation period for COVID-19 infection is 5–6 days average and up to 14 days, according to the World Health Organization. The BMJ reports data from culture studies indicates people can become infectious 1–2 days before feeling symptoms and will remain infectious for up to seven days. CDC guidance is a person with a mild case of COVID-19 remains infectious for “no longer” than 10 days after symptoms appear, while a person with a more severe or critical illness will “likely” be infectious for no more than 20 days.

The life of the infection defines the time we need to stay in place. While some exceptions will be required — seeking medical care, getting groceries — wearing masks and reducing the number of people in stores will reduce the probability of infection.

Everyone staying in place must be done nationally at the same time; otherwise the virus will cross borders and spread from areas with high infection to those with low infection — just as we’ve seen it cross the country this year.

2. Quarantine international travelers entering the U.S.

As other countries and some U.S. states have done, incoming travelers must quarantine for an appropriate time to minimize the risk of bringing in the virus and spreading infection.

A 14-day quarantine has been the norm, based on the incubation period for infection, although this time could be reduced if the quarantine is combined with testing.

Our near-empty hotels can provide the rooms, meals, and testing centers for travelers.

3. Implement a multi-layer testing strategy.

The foundation of a multi-layer testing strategy is in-home antigen tests with near real-time results, with a protocol of one or two tests per week per person following the national stay-in-place period. This policy would apply nationwide, for anyone going to public places (e.g., offices, stores, churches).

If a test is positive, the person quarantines while confirming the infection with either additional in-home antigen or local PCR tests.

Although the antigen tests may not be as accurate as PCR tests, they can be widely accessible, and the near real-time results will enable anyone infected — especially if they are asymptomatic — to protect others from becoming infected. See RapidTests.org.

Ideally, the test results would be reported to public health officials to provide community data on the positivity rate. To balance individual privacy with public health, the data — even from a positive test — could be reported anonymously (by zip code, perhaps). Someone with a positive test could be asked to contact local health officials. Anyone becoming seriously ill will presumably show up at a hospital.

4. Provide additional economic relief.

Given the economic impact of staying in place, adding to the year-long effects, it’s reasonable for the federal government to provide additional economic relief: unemployment, rent and mortgage assistance, and business support. Considering this national disaster, the “cost” to the federal deficit is an investment in the economy, particularly with interest rates so low.

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I believe if this strategy had been employed in the spring, when the coronavirus was first spreading in the U.S., the number of infections, deaths, and attendant economic devastation would be considerably less than what we’re living through. Had we been united around a nationwide response, the virus would not have been able to dance through our patchwork of local and state plans and political divisiveness.

While Operation Warp Speed’s development of vaccines is heartening and will, hopefully, enable us to return to a more normal life by the end of 2021, we have a long winter and spring to endure. A strategy built around these principles will alleviate the nation’s suffering near-term.

SARS-CoV-2 won’t be the last pandemic to threaten the globe. Developing such a strategy will help us better prepare for the next time.

Caveat: I claim no medical expertise. Nonetheless, I think the framework is a sound approach and should be appropriately tweaked to reflect the latest medical knowledge of the virus.

This post also published on Medium.

Milestones

On this day, Monday, December 14, I note several milestones worth remembering:

Joe Biden was officially elected president and Kamala Harris vice president with the vote of the Electoral College — actually 50 separate tallies, one in each state. The totals were 306 to 232, coincidentally the same split as in 2016, when Donald Trump was elected.

The first SARS-CoV-2 vaccinations, developed by Pfizer, were given across the U.S. after the FDA approved use of the vaccine late Friday. The U.S. has ordered some 100 million doses, enough to cover 50 million people, each requiring two shots 21 days apart. Vaccines being developed by several other companies are being tested, with Moderna’s version set to be reviewed by an independent panel of the FDA this Thursday.

That is a hopeful sign in the face of the grim milestones that more than 300,000 Americans have died of COVID-19, over 110,549 are now in the hospital, and 1,358 died so far today, according to data on The COVID Tracking Project website.

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Another positive milestone would have been President Trump conceding the election and graciously congratulating the new president and vice president. He didn’t. Even before the election, he was claiming voter fraud and a stolen election, offering no proof to support his wild claims. Is Donald Trump delusional or just a massively sore loser, intent on destroying as much of the government as he can on his way out of Washington?

Two Countries, Two Very Different Responses to SARS-CoV-2

SARS-CoV-19, the virus causing rampant COVID-19 infections around the globe, is the greatest scourge to the country’s health and economic well being as any threat during my lifetime. As disturbing and puzzling as how the virus attacks the body — its spike protein able to penetrate human cells to replicate — is the country’s psychological response to the pandemic.

Assuming no attempts to mitigate the virus, an infected person is estimated to spread the virus to 5.7 others (R₀ = 5.7), which makes it highly contagious, particularly since someone carrying the disease often shows no symptoms ¹. While most people do recover, the number of deaths from the virus in the U.S. has reached a staggering 250,000 since January 21, when the first U.S. case was reported.

That dichotomy — most recover yet many die — may help explain why our society is struggling to develop a national strategy and the will to carry it out. The failure to develop and deploy an effective strategy to address the pandemic falls on the president. When confronted by a national challenge, we look to our president to marshal the country’s response and secure citizen commitment, particularly if we are asked as individuals to sacrifice for the good of the nation.

Tragically, President Trump’s response has been confusing and contradictory. The accelerated campaign to develop a vaccine, known as Operation Warp Speed, is his best effort, as a vaccine will have the greatest long-term effect reducing infections and deaths. Unfortunately, as the pandemic arrived in the U.S., the administration was inconsistent and ineffective coordinating the manufacturing and distribution of an adequate supply of PPE, largely leaving the states to compete with each other for scarce supplies. He favored the states with Republican governors and criticized Democratic governors and mayors for their quarantines.

From the bully pulpit, the president downplayed the seriousness of the virus and the best steps to prevent infection, undermining the use of masks through his words and the actions of his administration. The lack of masks and social distancing at the White House ceremony nominating Amy Coney Barrett to the Supreme Court arguably led to the president’s own infection with COVID-19, as well as multiple people who attended the event.

His contradictory and bellicose messages have obfuscated the seriousness of the pandemic and amped a strain of American individualism and distrust of government, a “you’re not the boss of me” attitude. His tweets and campaign speeches calling for the “liberation” of states and cities imposing quarantine measures fuels this dangerous ideology.

The president has consistently claimed success fighting the pandemic. During last week’s presidential debate, he said, “We're rounding the corner, it’s going away.” Yet the data shows the falseness of his words. The ineffectiveness of the president’s hollow claims and his wanton disregard for scientific guidance is quite obvious comparing the COVID-19 infections in China and the U.S.

Does this data confirm the president’s claim that “it’s going away”? Source: 91-DIVOC and Johns Hopkins.

China was slow to respond to the initial outbreak in Wuhan. When it did, it imposed a severe lockdown across the country, from 23 January until 8 April in Wuhan (ending sooner in other parts of the country). While the accuracy of China’s official numbers is questionable, it’s hard to argue the country’s infections were as high or as prolonged as those in the U.S.

Although its authoritarian quarantine was draconian, China did a far better job containing the virus. The country’s economy has reopened and is recovering. We are still struggling to limit the spread as SARS-CoV-2 propagates across the country. Surely our democracy can do better than we’ve done.

Coda

Today, appearing on CNN’s State of the Union, White House Chief of Staff Mark Meadows said, “We’re not going to control the pandemic. We are gonna control the fact that we get vaccines, therapeutics and other mitigation areas.” He said the pandemic can’t be controlled “because it is a contagious virus, just like the flu.” ²

1. https://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome_coronavirus_2 ↩︎
2. https://www.politico.com/news/2020/10/25/white-house-chief-of-staff-controlpandemic-432236 ↩︎

Reflecting on the Coronavirus

From time to time — less often than I would like — I collect my thoughts in what I call an “audio postcard” that I send to my kids. It fulfills my desire to keep in touch and share something meaningful, meaning something that might be worth listening to in a decade.

As we’re in the midst of a global societal shutdown caused by a virus only 120 nm in diameter,¹ a crisis “forecast” yet not experienced since the 1918–1919 Spanish flu pandemic, I have been thinking about the SARS-CoV-2 virus and thought I would share my thoughts.

This was recorded on March 29. Tragically, the numbers of infections and deaths are far higher today.

1. https://en.wikipedia.org/wiki/Coronavirus ↩︎