COVID-19: Time to Double Down
Where We Stand
As insurrection gripped Washington, a grim Covid-19 milestone slipped by almost without notice: the country suffered more than 4,000 daily deaths from the novel coronavirus for the first time, with an average daily toll of almost 3000. Hospitalizations—the most telling measure of the disease’s--continue to hit all-time highs, as do the number of Americans in serious condition from Covid-19. Just ten months into the pandemic, SARS-Cov-2 has become one of the country’s leading causes of death, rivalling heart disease and cancer, having claimed almost 400,000 lives, one of every thousand Americans and rapidly rising.
In California, cases and fatalities are up fourfold since the summer surge. ICU capacity in Southern California is maxed out, sometimes leaving ambulances to circle for hours before finding a destination for their stricken patients. High rates of hospitalization are crowding out elective surgery in many locales. While the disease can afflict anyone, it is by far the deadliest in the very old. Yet thanks to the huge number of infections (more than 300,000 nationally in one recent, record-setting day, and more than 200,000 on average) and fatalities Covid-19 has probably become the deadliest killer of those in their mid-twenties through mid-fifties, who rarely die from natural causes. Some 20,000 Americans in this age group have succumbed to the coronavirus.
It will be many months before vaccinations truly reverse this trend, and even that depends on a smooth rollout. As Dr. Panagis Galiasatos of the Johns Hopkins School of Medicine puts it, “The vaccine is the first chapter in the endgame, but it is not itself the endgame.” Despite the unprecedented speed of finding and approving multiple vaccines, the opening weeks of the vaccination regime have been rocky. This is largely due to the lack of a coordinated federal plan--the same problem that plagued the initial failures of testing—and the consequent devolution of responsibility to states, hospitals, health care departments, and the private sector. States for the most part have insufficient funding and hospitals are simultaneously handling the daily burden of caring for sick and dying patients. The success of vaccines also depends on Americans continuing to engage in physical distancing, mask wearing, and other efforts at mitigation even after they receive the shots.
The onset of a new and more infectious mutation has added new urgency to getting the most people vaccinated in the shortest possible time, since the rapid growth of infections on top of the already staggering current rate would result in even greater disruption to the hospital sector and result in more casualties simply because of the now predictable case fatality rate relative to infections. Just as sobering is the fact that having more people infected makes the chance of further mutations more likely, along with the chance that one of these variations might make current immunity less durable or erode the vaccine’s effect altogether.
While the virus has tended to wax and wane in various regions of the US, the entire country is now experiencing, in effect, the third and largest surge of the first wave. Unlike other nations, the US never beat down the virus completely at any time, with the result that each successive surge built on the embers of the previous one.
Though circumstances differ slightly from state to state, the underlying causes of this most deadly recent surge are easy to identify. Winter is here: as cold weather drives people indoors the virus spreads more easily. The rollout of effective Covid-19 vaccines has encouraged some, sadly, to let down their guard even as the virus becomes more prevalent. Some confuse the existence of a vaccine with that of a cure; others misunderstand how long it will take them to be inoculated. Predictably, some who have been infected prior to being vaccinated will misinterpret the symptoms of the coronavirus with the side effects of the vaccine. Many others resist wearing masks or following public health advice regarding physical distancing. As some are taking fewer precautions, either because of fatigue or ideology, others are following the same patterns as before—however, in an environment with more infections this means spreading Covid-19 more widely.
A natural sense of pandemic fatigue (particularly in California, which has been on the frontline during all three surges and is now cracking) and the desire to downplay and deny the impact of the virus have been intensified by the example of the California governor and other public officials appearing not to play by the same rules that they have promulgated. This hypocrisy—even if in certain cases it was the spirit rather than the letter of the law being violated--has undercut their sense of moral authority that was already thin and fraying.
While contact tracing is basically overwhelmed when disease spread is this rampant, there is considerable evidence that the biggest factor fueling the spread is at family social gatherings, not by businesses remaining open, other than bars, restaurants, gyms, and indoor arenas. Studies have begun to pinpoint the occupancy rates (20 to 40 percent) at which ordinary businesses can stay open, at least with the current version of the virus in play. Most businesses are complying and working hard to accommodate pandemic rules but their workers are catching Covid-19 in the community and bringing it to their workplaces. The extent to which local economies are impacted depends greatly on individual behavior as well.
The spread of Covid-19 in the U.S. has been accelerated by the backloading in the calendar of American holidays and festivals, which are clustered in the last two months of the year and thus coincide with lower temperatures and more inside gatherings. Since Memorial Day, this spacing seems almost to have been designed to produce a new surge of infections just as the medical system had come to grips with the previous wave. The relative dearth of holidays for the next five months should help in containing the disease.
In addition to the misinformation and disinformation that is rife about the coronavirus, much of it spread for ideological reasons, certain common features of the American character make an effective response to the pandemic challenging. Some are psychological, others structural.
Countries that have contained or crushed the virus have higher degrees of social trust. They also tend to place a higher value on protecting the elderly from harm, judging from international comparative survey data. Many Americans simply fail to understand how infectious diseases work, and in particular the concept of exponential spread. While some dismiss science altogether, others don’t recognize how scientific recommendations (as for mask wearing) can reasonably evolve when a disease is encountered for the very first time and is being studied on the fly.
Moreover, for a nation whose people are, comparatively speaking, suspicious both of government and science, many of its citizens are surprisingly literal about CDC and other government agency guidelines (six feet is not enough distance, often enough, if the airflow is moving in your direction!) and wrongly think that if a business is open it must be safe, rather than treating each situation or encounter as an exercise in relative risk. The triumph of consumer litigation in creating risk reduction of products, I suspect, is ironically the root cause of this paradox.
The slow-motion spread of Covid-19, with its slow onset and typically long time between infection and death, is more like a tide rather than a tsunami. This is at odds with the typical portrayal of pandemics in movies and popular culture in which people keel over rapidly and in real time. Deaths are largely invisible (thanks substantially to an interpretation of HIPAA, the medical privacy regulation) which cuts against this received image of a plague. Absent villains (save China, though the public health response doesn’t reflect where a virus originally came from) or agents it is hard to rally any population against a pandemic, let alone such a divided and heterogeneous and individualistic population as Americans.
Key parts of the response in places that have truly crushed the virus, mostly in Asia, are simply not part of the American toolbox. Countries that have crushed the virus—mostly in Southern Asia and the Pacific, enforced curbs on mobility, did testing and contact tracing earlier, and conducted aggressive and selective interventions without fears of stigmatizing particular groups, whether religious, ethnic, or impoverished. Though early deployment of standard public health techniques would have saved many lives, many if not most Americans—not only those that are protesting current restriction--would be leery of granting the state these kinds of power even in the context of a pandemic.
By contrast, other than early on in Seattle and New Rochelle and parts of New York City, the U.S. has not conducted “lockdowns” in any real sense but has chosen to enact largely unenforced or lightly enforced shelter-in-place provisions with both business and school closures. There is growing evidence that this strategy failed significantly to stem the spread of the virus while keeping children in poor learning environments and at the same time pushing many small businesses over the brink.
Nevertheless, given the decision by President Trump to devolve pandemic decision-making and the response to individual states, it is unsurprising over time that regardless of ideology practical circumstances meant that local and regional economies had to reopen substantially regardless of the severe loss of life that was correctly predicted to occur by most public health officials. With most states dependent on a tax base heavily skewed toward sales taxes and consumption, with aid to the states blocked by the Republican majority in Congress, and without industry-specific compensation for restaurants and other businesses the hardest hit (as in other countries), state convergence toward the mean-- partial reopening regardless of the public health consequences—was largely inevitable. (Except for states, like Hawaii and Vermont, that were isolated or small and distinct enough to take a different route.)
Most rural Western states still have lower death rates per capita than average because of their low population density, isolation from global travel, and because they were largely spared from the first wave that hit primarily the East and the Pacific Northwest, both travel hubs.
One striking exception was South Dakota, whose governor Kristi Noem initially wrote off the disease as not worse than the flu and has flirted with the notion of natural herd immunity even before the rollout of an effective vaccine. Many Republican state governors and many residents of rural Western states share this skepticism to some degree, but Noem actively fanned the infection flames by allowing South Dakota to host “super-spreader” events like the Sturgis Motorcycle Festival which drew 250,000 participants with little or no mitigation. Though estimates of its impact differ, follow-up studies agree that this event was a key contributor to spreading Covid-19 throughout the Upper Midwest. Although the state now records some of the worst per-capita death rates both among U.S. states and worldwide, Governor Noem not only defends her record but is taking an unwarranted victory lap.
What We Need to Do
Embrace Personal Responsibility and the “Swiss Cheese” Model
Even though it appears that cases and deaths are now plateauing--at a stunningly high level--this is the most dangerous phase of the pandemic. There is far more virus now in circulation than at the outset of the pandemic and during the summer surge. The more infectious mutation that has been driving up case rates in Great Britain has been identified in multiple states. Strains on the health care system are real and intensifying, with zero ICU spaces left in Los Angeles and much of Southern California and Arizona. The federal Covid-19 Task Force recently called for “aggressive mitigation… to match a much more aggressive virus.”
Even as the vaccination rate improves, this means that personal responsibility and a full range of collective mitigation measures, especially physical distancing and proper mask wearing, will need to continue and in fact to be intensified. All the approved Covid-19 vaccines give full protection slowly. We don’t know if the efficacy of the vaccines in practice will match the results from their trials, whether mutations may render some vaccines less effective, and whether those who are vaccinated may still be contagious and for how long.
The US, with a very few exceptions, like Seattle, New Rochelle, and parts of New York City early on, has instituted a largely symbolic shelter-in-place regime that works mostly on the honor system. This approach can suppress the spread of the virus even in the absence of vaccines—Japan, in particular, has achieved a very high level of disease suppression (fewer than 2 percent of deaths per capita relative to the United States) despite a relative lack of early testing compared to its Asian neighbors and without strict regulations on mobility. Other Asian and Pacific countries that have put more emphasis on mobility restrictions and early and massive testing have achieved even lower relative rates of infections and deaths.
Because mitigation measures can work and because none of them is a “silver bullet,” short of attaining a vaccine-driven herd immunity, following what the philosopher James Reason and the social theorist Nicholas Christakis have termed a “swiss cheese” approach—in which multiple layers of defense (any of which might be sufficient under ideal circumstances, such as a fully effective vaccine or universal masking done properly) cover up the holes in any single strategy. Both the outgoing and incoming CDC directors have endorsed this approach. Dr. Robert Redfield stated in testimony to Congress that “These face masks are the most important, powerful public health tool we have,” adding “if I don’t get an immune response, the vaccine is not going to protect me. This face mask will.” Dr. Rochelle Walensky noted that "Over time we will be able to maybe one day not be in our masks anymore, but I have told my family I anticipate they'll be wearing a mask for the better part of '21.”
Most transmission takes place in the home, at bars and indoor restaurants, in churches, hotels, and during travel—basically any place where crowds gather or people live in close quarters and talk a lot. Speaking softly and seldom is helpful. Ventilation and air flow matter a lot, with the virus capable of infecting people at a considerable distance under some conditions. One of the largest sources of infections appear to be household gatherings both within families and especially across multiple families. If people in a household work outside the home, it makes sense to wear a mask around family, as both the CDC and the Country of Los Angeles, among others, have suggested.
Misunderstanding the Mask “Mandate”
While federal guidance about wearing masks has been weak and haphazard, there is considerable evidence that wearing masks properly saves lives. In early January 2021 the Institute for Health Metrics and Evaluation (IMHE) at the University of Washington, a frequently-referenced barometer, projected that some 170,000 American lives could be saved by April 2021 if mask wearing were universal and properly conducted.
Despite the understandable furor over those who refuse to wear masks and who sometimes flaunt their antisocial behavior, the prevalence of mask wearing has been better than many would predict. Mask wearing represents a totally new behavior for most Americans. Compared to the time that it took for other efforts at managing individual behavior on behalf of the common good, either voluntarily or legally--proscribing drunk driving, enforcing seat belt laws, ending indoor cigarette smoking—mask wearing has taken root much more quickly.
Skepticism about the overreach of state power is often well intended, but those who oppose wearing masks to fight a communicable disease misunderstand why mandates are enacted. These intend to reinforce a wide commitment to individual responsibility while acknowledging the reality that some people will not do the right thing, precisely in order to make more draconian action by the state (like true lockdowns) unnecessary. It is about giving a nudge to good behavior rather than bringing down the heavy hand of the state.
Some Republican governors of Western states, for instance, like Utah and North Dakota, instituted mandates, while others did not. But most of them recognized that relying solely on individual responsibility alone was insufficient. As Wyoming governor Mark Gordon, referring to those who flouted public health measures as “knuckleheads,” recently fumed: ““We’ve relied on people to be responsible, and they’re being irresponsible. They think somehow this is all nonsense.”
The debate over Covid-19 and mask wearing echoes the prior debate over the “individual mandate” to purchase health insurance coverage in the Affordable Care Act. In both cases, “young invincibles” are unlikely to suffer serious harm from either the virus or lack of insurance coverage though in each case the slight chance of catastrophic personal harm exists.
However, if too few of the young people sign up or eschew masks, it results in greater risk to the older and more vulnerable and may upend the health care system as a whole. The alternative to such personal or individual responsibility is a far greater degree of government intervention, either full-fledged lockdowns (in the case of the virus) or a single-payer system (in the case of uninsurance).
Critics of the individual mandate in health insurance coverage wonder why penalties are so modest, arguing that even if enforced they will not deter or motivate individual behavior.
But, as with Covid-19 “mask mandates,” these critics miss the point. The idea of a mandate is to promote a culture of individual and personal responsibility, the terms that backers prefer. This requirement is primarily a reminder of civic responsibility, not an effort to bring the full force of the state to bear (nor, in related though opposite fashion, to use large positive incentives for compliance, such as offering large insurance subsidies—dangling carrots rather than sticks) While “nudging” people to do the right thing may prove not to be psychologically or practically effective, depending on circumstance, the intent of a mandate is to exert the minimum degree of government intervention, not the maximum amount.
Rebuilding Public Health Will Need Both Funding and Respect
In ordinary times, public health funding tends to be relatively easy to cut because the threats that health officials combat tend to be invisible. Sadly, during the most high-profile public health event in history, public health officers at every level were threatened and denounced both by legislators and protesters. Much of this opprobrium was driven from the top down, as President Trump, for example, referred to Anthony Fauci and his colleagues as “idiots” and tweeted “Liberate” to Michigan and other states that had stricter public health protocols in place. High-level HHS political appointees literally called for the execution of public health officials, and protesting mobs menaced them at many public events and at their homes. Already under siege from anti-vaccination protests, public health officers took a further hit from Covid-19 denialism and backlash.
According to an investigation by the Associated Press and Kaiser Health News, at least 181 state and local public health leaders had resigned, retired, or been fired during the pandemic, an astoundingly high number in a group already short of full strength before the coronavirus struck. This exodus took place despite the fact that the public health community has been generally accurate in its pessimism toward the spread of the coronavirus, warning that from a health perspective states were opening too soon and accurately predicting that the winter surge of Covid-19 would surpass the damage of the initial phase. Moreover, with few exceptions, public health officers bent over backwards to work with businesses in most states and were continually undermined by businesses that didn’t follow the most modest reporting requirements for the virus.
Both the stimulus package passed in December and that proposed by President-elect Biden contain lots of vastly needed new funding to shore up the immediate need for vaccination support and contact tracing. While tracing was largely rendered moot by the millions of infections incurred by Americans in recent weeks and months, it will become more vital for returning to normal as caseloads drop; states and localities have hired just 70,000 of the 100 to 300,000 tracers that most experts think are needed.
But unless public health funding is held more steady and new personnel recruitment efforts—made much harder by the negative attitudes on display during this pandemic—take shape we are in danger of repeating the last boom-and-bust cycle, when the threat of bioterrorism in the wake of 9/11 and anthrax attacks brought about a one-time influx of funding that dissipated rapidly.
Step Up the Research and Development of Therapeutics
Despite much better knowledge of how to treat individual patients, the death rate in the U.S. from Covid-19 has been predictable from the underlying case rate ever since the initial surge abated. It has been basically steady for months. What this means, practically speaking, is that many people have gone to the hospital only when it is too late, that among younger patients especially it is hard to predict who will succumb to the virus, and that we still have a dearth of therapeutics and antivirals that can actually make a life- or- death difference rather than, for the most part, shortening hospital lengths of stay.
Despite considerable effort and much controversy, a vaccine for AIDS has never been developed. Though it affected far fewer people, fear of AIDS subsided largely when effective antiviral drugs became widely available, at least in the health care systems of rich countries.
Current antivirals for Covid-19, such as monoclonal antibodies like Regeneron, are relatively complicated to administer, time-intensive, in limited supply, and effective only in the early stages of the disease, when most patients don’t tend to seek them out or doctors to insist on the. This means that they are in short supply, costly, and underused simultaneously. Even existing antiviral drugs may be less effective against the more infectious British mutation which has been observed in the United States and which may become the dominant strain in circulation over time. This increases the urgency to find better or comparable substitutes.
Covid-19: Treat It as a Warning, Not as a “Black Swan”
Dozens of articles and commentaries, many of them in elite media and across party lines, continue to make the same, mistaken point: “Who could have seen the pandemic coming?” (Bret Stephens in the New York Times, Kathleen Parker in the Washington Post, and numerous Trump supporters) Though the exact timing was obviously uncertain, many commissions, task forces, epidemiologists, and scientists expected a zoonotic pandemic to occur in the near future, largely because of the encroachment of human beings on formerly wild habitat and the unsanitary conditions of much industrial-scale meat production . A novel coronavirus was widely pegged as a likely culprit. That is why the CDC had embedded an expert in China to look out for exactly this eventuality before she was pulled back, ostensibly for budgetary reasons. One well-informed author, Lawrence Wright, even published an uncannily accurate novel (The End of October) that foretold the pandemic on the eve of the actual Covid-19 outbreak. The inevitability of a serious pandemic was comparable to that of a major earthquake on the San Andreas Fault. It was not a “black swan” or a “once in a hundred century” event, and even less so if the measuring stick is gauged in terms of the future.
Prior to the Trump administration, an international body of epidemiologists and scientists rated the United States tops in the world in pandemic preparedness and capacity. Moving on from a pandemic requires a great deal of forgetting; dwelling on personal culpability and blame is probably not productive. But demanding a full review of the nation’s response is important, since by any measure the U.S. should have been, by any measure, one of the world’s leaders instead of its highest-profile laggard. One reason South Korea’s response stands out is because the country suffered through a recent bout with MERS, the cousin of SARS. The next virus may well be much more lethal on paper, but the experience of Covid-19, reflected in a rebuilt CDC and an improved public health preparedness regime, could and should make its impact on both the United States and the world far less damaging.