Dispatch #8 | The Great Pause
Today is the 15th day back from my stint in a front line fever clinic, in the New York hot zone. No symptoms. Whew.
Let’s get to it.
I am not panicking. I am preparing — preparing for the slog ahead.
We now have a much better understanding of where we are, what we are dealing with and what we are up against. Now, it’s just a matter of which will prevail: pragmatism and science or politics.
So, what have we learned?
- We were not prepared.
- We have a neutered public health system.
- We have a long way to go.
And, as much as we have learned, it is clear that there is far more that we don’t know than we do know about the nature of the new, novel coronavirus with respect to its clinical manifestations, societal instantiations and economic contaminations.
Covid-19 is the teacher, we are the students. We are witnessing a biological object lesson on how fast things can spin out of control if we do not fight against it in a transparent, coordinated way. Biology operates very predictably, humans, and their attitudes, do not.
Our healthcare system is not a coherent ecosystem. It’s a freakosystem — a patchwork of not-for-profit and for-profit hospital and healthcare networks that all have different local, state and national incentives. Make no mistake about it, public health needs to be our collective priority and this is a policy decision. Our political neglect for public health in the spirit of just-in-time supply chains has been laid bare and it is causing real pain. I hope we take this opportunity to pause, reflect and imagine the world we believe is best for the public good and make it a primary issue.
Overall, I’m feeling better than I have felt since February. While the fog of “The Great Pause” lingers, it’s worth challenging ourselves to imagine a different existence — a better one. What did you not like about our pre-Covid society and what did you like? If I offered you a magic wand and gave you the ability to dream up a new world, what would it look like? Would you prefer unfettered modernity with its emphasis on accumulation and efficiency or would you prefer a slower, more meaningful life with an emphasis on contribution and quality? The world will change and you will be part of the change.
A QUICK REVIEW OF THE NUMBERS
In the US: 1,200,000 people have been infected and at least 71,000 have died as of May 5th. It’s the second leading cause of death in the U.S. and has sickened 3,600,000 and killed 256,000 people worldwide.
“TESTING. 1. 2. 3. TESTING.”
If it is not abundantly clear by now, we should be testing everyone with suspected infection by the nasal/oral swab, PCR, gold-standard technique. Antibody testing is getting better. I’m hopeful we will get high quality, accurate tests soon.
If you have a minute, it’s worth taking a look at The New York Department of Health’s most recent Covid-19 Advisory on Serology Testing. It highlights shitshow of low quality, initial antibody testing.
Why? The NY Times explains here.
The FDA is finally tightening the rules around testing and the companies that offer these tests. Test developers must now submit an EUA request with validation data within 10 days of an FDA notification, and these developers will follow a different submission template than the labs that are also developing antibody tests for authorization. “Flexibility never meant we would allow fraud,” the FDA said Monday. “We, unfortunately, see unscrupulous actors marketing fraudulent test kits and using the pandemic as an opportunity to take advantage of Americans’ anxiety.” It’s about time they realized how many bad actors were actually out there…ugh.
For context, there are four other, run-of-the-mill cold and flu beta-coronaviruses that annually travel the globe during normal flu season Some of these antibody tests pick up weak immunity to the “usual suspect” beta-coronaviruses . . .not this new novel one. That means you could get a test that says you have antibodies . . . and you do, yet not Covid-19 antibodies. This is a false positive. This means that the test says ‘positive’ but you do not have antibodies.
In my world if a test is positive, that usually means a bad thing and when a test is ‘negative’, it usually means a good thing. Odd, right?
You may ask, When will we have our collective testing “shit together’”
You will know when we have our collective “shit together” when we are testing 4,500,000 people per week in the US. Until then, we’re still flying blind.
Roche claims a highly reliable antibody test as does Abbott and Euroimmun.
Getting optimistic.
CONTACT TRACING | EXPOSURE NOTIFICATION
Not to beat this old horse, but a mainstay of public health is contact tracing. We did it for smallpox, Ebola and other infectious diseases. Now that we have computers in our pockets, it should be easier . . . but we still need trained humans and a degree of trust. San Francisco and New York have hired a small army of contact tracing people to help understand the prevalence of Covid-19 in specific communities.
Below is a graphic of one person in Korea and contact tracing. You can see that she visited the “C Club” on Jan 29 and had a car accident 7 days later and was admitted to the hospital on February 6. She drove home to get her clothes before returning to the hospital (do people do that?) and then attended church on February 9 before returning to the hospital where she then developed a fever. A few days later, while still being observed in the hospital, she left for a buffet lunch at a nearby hotel and then attended church again followed by a visit to a public clinic.
There are many efforts afoot. Learn more about the Data Rights for Exposure Notification and where real cryptographers believe these efforts fall short of academic and industry proposals.
GET LOCAL | HERD IMMUNITY
Every city, county and state has variable rates of infection, immunity and transmission.
In order to crush the curve nationally, we need to crush it locally — hyperlocal.
The city of Santa Clara in the heart of Silicon Valley believes they have 3–4% immunity. New York, below, has up to 21.2%. Herd immunity requires at least 70% of the population to be exposed. Here’s a great primer on herd immunity by Johns Hopkins — and what the proponents of natural herd immunity are not saying.
When entire communities are tested, effective policy can be crafted to address the realities of the number already infected and the number that are infected. This will take leadership at the local and state level, working hand in hand with scientists, preferably in a public forum. As my friend Rajiv Bhatia writes in The Hill:
Near where I live is the small northern California hamlet of Bolinas. They tested every person, all 1800, and zero percent tested positive for antibodies.
VACCINES
Lots of talk, lots of hope. In order to prove a vaccine is effective, we need to observe its effect over time . . . lots of time. We have to make sure there are no detrimental effects that outweigh the benefits.
Folks at the Jenner Institute at Oxford in England have injected the first human subject of their test and are optimistic. The entire world is following this closely.
The only way to theoretically speed up vaccine development is the concept of a human challenge trial. Human challenge trials deliberately expose participants to infection, in order to study diseases and test vaccines or treatments. They have been used for influenza, malaria, typhoid, dengue fever, and cholera. Researchers are exploring whether human challenge trials could speed up the development of a vaccine for Covid-19, saving thousands or even millions of lives.
1 Day Sooner, is a pop-up, worldwide organization curating volunteers for vaccine trials; they already have over 10,000 volunteers in over 53 countries. Sign up!
Side Effects
An ironic side effect of waiting for a Covid-19 vaccine is that everyone else is skipping out on their routine vaccines. Many parents are postponing their children’s checkups, including shots, putting millions of children at risk of exposure to known, preventable deadly diseases. Ugh.
TREATMENTS
As of today, there are 687 Covid clinical trials going on worldwide. As you can see below there are a number of interventions.
Remdesivir is back in the news. Gilead, the maker of this drug, put out this press release showing that there is hope in severe disease. (RCT = Randomized Clinical Trial. This is very important. If a study was done not using this RCT method, it lacks true scientific validity).
The hydroxychloroquine story is unfolding vis-a-vis its clinical effectiveness. The FDA just published a strong advisory against people not taking it outside of the hospital setting due to heart arrhythmias.
Plasma infusions are working in small trials around the country; however, we need larger, more comprehensive trials. Johns Hopkins will conduct a randomized, placebo-controlled trial — smaller in scope than the Mayo Clinic trial — but it has not yet begun admitting patients.
Monoclonal antibodies are being developed to treat as well. Israel and the Netherlands are making progress.
Here is how Stanford is approaching treatment in a world of rapid learning. They are being prudent with interventions in ICU patients rather than using interventions ad-lib.
MIT has identified proteins that may halt the severe cytokine storms seen in Covid-19 patients. This is how most people die.
My good friend, David Ewing Duncan, wrote a nice report on the search for genetic clues in Vanity Fair in which leading geneticists suggest they may have a clue mid- to late summer.
All this to say, progress is happening and the scientific community appear more hopeful.
For the supergeeks, you can download the entire SARS-CoV2 protein interaction map which reveals targets for drug repurposing.
TRANSMISSION
Whoa, not sure I believe this! A Dutch study analyzing the results of Covid-19 contact tracing shows that kids with Covid-19 rarely infect each other or adults. They claim adults infect adults, and adults can infect kids, but kids rarely infect others. Furthermore, kids have particularly mild symptoms. This could be a game changer with respect to reopening schools….unless it’s not true. This is counterbalanced with a NY Times article that cites a study done in China that states that we may not want to open schools so fast because kids do transmit to other kids. Ugh.
The New England Journal of Medicine study concludes that ten days after testing is safe for individuals to interact with others. The CDC is going back to a time based strategy vs. testing based strategy to release patients from isolation. The smart money is going with a testing based strategy.
A study published May 4 in JAMA from Taiwan showed high transmissibility of Covid-19 before and immediately after symptom onset. This suggests that finding and isolating symptomatic patients alone may not suffice to interrupt transmission, we will likely need to test asymptomatic people, too.
New research in Science reveals that SARS-CoV-2 can infect and replicate in cells that line the human intestine, helping to explain why some Covid-19 patients experience gastrointestinal symptoms.
A recent study of a hospital in Wuhan showed that in well-ventilated rooms, the amount of coronavirus in the air was minimal. This bodes well for opening up more of society knowing that it really spreads quickly in crowded, poorly ventilated areas. Of note, this study did show that it was found in higher concentrations in public bathrooms.
Takeaway: As we move to open up society, go to the bathroom before you leave home and avoid public restrooms if you can.
New York City Subways Won’t Run 24 Hours a Day During Pandemic. They are shutting down from 1 a.m to 5 a.m. to allow for deep cleaning.
LOWER YOUR RISK
Vitamin D: An April 30 analysis revealed that older and male cases with pre-existing conditions and below normal Vitamin D levels were associated with increasing odds of death. What’s interesting is that beyond anti-inflammatory and pro-immunity effects, Vitamin D has a specific mechanism for modulating ACE2.
Wear a mask or face cover as much as you can. As much as we are beginning to “open up” and “relax” our physical and social distancing measures, you should envision a world of face coverings for a long time. Each decision you make is an individual decision; yet you cannot avoid the impact of those decisions on your community (and vice versa). Masks are a great example: respiratory droplets are an important mode of Covid-19 transmission, but it remains unclear to what extent virus can remain in the air and be transmitted through aerosolized particles. Wearing a cloth face mask when you are out and about probably doesn’t add significant protection for the wearer. But in communities where masks are commonly worn, there is an assumption that they contribute to better infection control by shielding others from the wearer’s respiratory droplets. So even as restrictions on individuals are lifted, we can continue to protect ourselves by making and modeling choices that protect others.
Households need to clarify their collective approaches to reducing risk or even determine if lower risk family members are better off living independently. Commitments to mask-wearing, handwashing, staying home when we are sick, testing, quarantine, isolation, tracking and tracing will all be burdens shared by each of us that benefit all of us.
Here is a quick 4 minute video and visualization about the importance of masks by De Kai. Bottom line: Masking protects your community, not just you.
SYMPTOMS
Not a bunch of new stuff here, other than we do have a better understanding of the neurological symptoms. In severe disease, 36% of patients were found to have neurological manifestations in the form of headache, dizziness and impaired consciousness.
The New England Journal published this graph to show who is more at risk
- Fever | 44–94% ( greater than 38 degrees celsius or 100.4 degrees Fahrenheit)
- Cough | 68–83%
- Loss of smell or taste | ~70%
- Sore throat, runny nose, nasal or sinus congestion | 5–61%
- Shortness of breath | 11–40%
- Fatigue | 23–38%
- Muscle aches | 11–15%
- Headache | 8–14%
- Confusion | 9%
- Nausea, vomiting, diarrhea | 3–17%
Hospitalization vs ICU
20% of all those hospitalized died.
A JAMA study of 1,151 patients who required mechanical ventilators, 320 for whom final outcomes are known (either death or discharge), 88% died. That compares with about 80% of patients who died on ventilators before the pandemic, according to previous studies — and with the death rate of about 50% that some critical-care doctors had optimistically hoped for when the first cases were diagnosed. (WaPo.)
ON SWEDEN
Everyone seems to think Sweden has it all figured out. Let’s take a look at the numbers to understand the difficulty in making blanket statements.
Sweden’s coronavirus death toll is worse than America’s but better than New York City’s. Let’s look at population density. New York City has more than 38,000 people per square kilometer,
London, at the other end, is very low and spread out with 18,769 people per square kilometer.
Sweden has just 25 people per square kilometer —meaning that they are already mostly all socially distanced by default. See below.
Even within the small nordic countries, Sweden is not faring well compared to its neighbors; yet they are keeping things open.
ON MODELS
A model is an exercise in taking what we think we know, what we don’t know, and what we have no idea about to create a probabilistic set of outcomes. Models change as new data comes in. Anyone who defaults to “Models Were Wrong” does not understand what a model is. It is not a report sent back from the future!
A sobering report from the Center for Infectious Disease Research and Policy paints three different scenarios based on a history of pandemics.
The report attached to the above graph concludes:
“Whichever scenario the pandemic follows (assuming at least some level of ongoing mitigation measures), we must be prepared for at least another 18 to 24 months of significant COVID-19 activity, with hot spots popping up periodically in diverse geographic areas. As the pandemic wanes, it is likely that SARS-CoV-2 will continue to circulate in the human population and will synchronize to a seasonal pattern with diminished severity over time, as with other less pathogenic coronaviruses, such as the betacoronaviruses . . . and past pandemic influenza viruses have done.”
We cannot escape basic epidemic math.
“In the absence of a vaccine, stopping the spread of the virus requires about two-thirds of the population to have been infected. And some experts have argued that before what is known as herd immunity kicks in, the number of people infected nationwide could reach a staggering 90 percent if social distancing is relaxed and transmission rates climb.” Read more about hotspots.
Train the Models
We can better our models by understanding sewage. Wastewater offers a promising way to track the virus. The EPA, which regulates wastewater treatment plants, said it is coordinating with the CDC to kick off scientifically sound monitoring in areas hit hard by the virus. Australia is leading the way in these efforts.
Let’s hope we get a vaccine or treatment sooner than later.
ON THE ECONOMY AND WORK
We all want to get back to some semblance of normalcy . . . according to pandemic testing, here is their four phase plan. So say we will not go back to work, rather we will go forward to work — whatever that means. The world is slowly lurching towards opening up and there are many implications both pro and con. We will see many real-time experiments played out. Spain, for example, is closing their borders until October.
Harvard Business Review does not believe we are headed for a new Great Depression.
Greece is starting to open up — and they have a very rational, transparent plan. We should all aspire to this level of critical, responsible action.
Below is a roadmap as well as some indices of which business are critical to a functioning society in metro and rural areas.
DR. ZOOM
Many physicians and patients have quickly adopted the concept of the video-visit. For that past 10 years, we have wondered if this would ever be adopted. The technology has been there, but the medical incentives and patient preferences haven’t. A new study at the VA shows that we are entering a whole new world.
The longer term impact if this remains “a thing” is the entire business model of hospital networks and their voracious appetite for real estate. Historically, a doctor would get paid $100 for an in-person visit and $50 for a video visit. From a pure convenience factor, the in-person visits means the patient needs to drive or take a bus, walk, wait in a waiting room, wait again to be seen and after the visit they need to reverse that sequence to get home. Now, many visits can be done from their home and the need for hospital and clinic real estate will decrease — especially now that many doctors are loving video visits and they are getting paid the same rate as an in person visit. Big changes afoot here.
To put a fine point on this issue, there are some visits that just do not work via video and an in-person visit is the gold standard. The adoption of telemedicine is the string that will pull the thread that will expose the flaws in our incentive models.
YCMTSU | You Can’t Make This Shit Up
Insurance companies, the despised, arch-rivals of doctors, are creating loan programs for doctors who are unable to open their practices. This is equivalent to cranky landlords loaning their tenants money. Blue Shield is giving doctors loans. Wow. Just wow.
Injecting disinfectants: Two men in Georgia and one man in Kansas drank liquid cleaning products “to ward off Covid-19” after Trump suggested injecting disinfectant into the lungs to combat the virus. Kentucky Poison Control Center reports a spike in calls related to sanitizer exposure and ingestion.
FINAL THOUGHTS
It is May. We have over 250,000 deaths in the past two months. We have a lot more to learn. Edward Schoedinger eloquently stated, “In an honest search for knowledge, you quite often have to abide by ignorance for an indefinite period.” It’s okay not to know. Even Socrates said, “I know one thing: that I know nothing.”
The Great Pause has a lot to teach us about ourselves, each other, and the broader community which we inhabit. What do you want your world to look like? Less cars on the road or more? Less plastic in the ocean or more? Less inane FOMO and cyberbullying or more? Few quality conversations with your children or more? More social media or more human interaction?
If the internet age has taught us anything, it’s that we can get pretty much anything we want with the click of a button in less than 24 hours. This pandemic is forcing us to revisit the forgotten art of patience and prudence. It’s time to remember how to go slow, be methodical and parse objective truth from intersubjective fictions that make us feel better without actually making us better.
Will Covid-19 and this pause call into question the religion that we call modernity. I would ask Yuval Harari.
My daughter asked me a riddle this weekend: “What is always in front of you and you cannot see it?” Hmmmm.
Uncertainty often causes anxiety and anxiety causes us to make decisions that may not be wholly rational. Let’s be crystal clear, Covid-19 is very methodical and biologically rational. It is imperative that we temper our anxiety by slowly and systematically experimenting with this new world of uncertainty. We must not be afraid, just cautious.
The economic fallout, the impending mental health crisis combined with the number of people not getting regular medical care portend a perilous future. Hope and speed should not obscure the baby steps required to get out of this mess. Until a silver bullet is discovered, in the form of a treatment or vaccine, we are confronted with the dynamic, twin issues of national, macro decisions and the personal decisions we make as individuals.
Sometimes when we open a window to brighten a room, the dark from outside makes the room less bright.
If you’ve made it this far, I implore you to watch this video of a father reading a bedtime story to his daughter about 2020 — it’s four minutes and it will make you smile.
The answer to my daughter’s riddle of “What’s in front of you that cannot see?”: The future.
“The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man & woman.” — George Bernard Shaw
Until next time,
Jordan
PS.
FLATTENING THE TRUTH — A great read by Dave Eggers.
