Join us in welcoming Grice Connect guest columnist Mark Murphy, M.D. Mark is a Savannah physician and accomplished writer.
I have long been a fan of Mark. We got to know each other years ago when he saved the life of an employee of ours. It is a truly remarkable story of a young man that should have died (and almost did) and a doctor who would not give up the fight. Mark is intelligent, compassionate and well researched. When you read a piece of his work, you know it will be balanced and based on science, fact and common sense. This is no exception. It is a bit of a long read, but you will agree, well worth it. You can follow Mark on a blog he created entitled Journal of the Plague Year which offers a unique insight to from a local physician on the front lines of the COVID-19 fight.
How We Failed: The mechanism of the COVID 19 resurgence, and what can be done to turn it back
I woke up surrounded by an apocalyptic dust storm this morning. The massive cloud, large enough to see in satellite images, had blown up from the distant African Sahara, billowing across the vast seething Atlantic until it finally arrived in America. The cloud transformed distant landscapes into hazy uncertainty, made the horizon blurry and indistinct.
“How fitting,” I thought.
For in this pandemic season, the future is as indistinct as the horizon I saw when I gazed out of my kitchen window this morning.
I’ll cut right to the chase here: The U.S. response to the COVID 19 pandemic has been, without question, the most egregious public health failure in our nation’s history, costing nearly 130,000 Americans their lives in the span of 6 months and leading to financial ruin for many. It’s been an mitigated disaster, and it’s not over yet—not by a long shot.
The University of Washington’s IHME database projects that there will be over 179,000 U.S. deaths from COVID 19 by October 1. That total might even be worse if current social distancing requirements are eased further (https://covid19.healthdata.org/united-states-of-america). To put that in perspective, a total of ~58,000 U.S. servicemen died during the entire Vietnam War, most of these spread out over a 10-year span (1963-1973).
So how did this happen? How did the world’s wealthiest and most powerful nation fail to adequately contain a pandemic it saw coming despite all of the vast resources at its disposal?
One can glean some insight into this by comparing how we addressed the pandemic to how some other nations addressed it. Places like New Zealand, Australia, Thailand, South Korea, Iceland and even various nations in previously hard-hit Europe have utilized strategies which we had at our disposal and either failed to use—or declined to.
Initial Failures
The COVID 19 pandemic in the U.S. started small. Although the outbreak in Wuhan, China had been present since early December, the Chinese government did not alert the World Health Organization about the outbreak until December 31.
Human-to-human transmission of the disease was confirmed by mid-January, and the Chinese government closed down Wuhan on January 23. During the previous three weeks, however, 7 million people had traveled from Wuhan, including thousands of infected travelers, seeding outbreaks in Beijing, Shanghai, Bangkok and other cities. Germany’s first case was diagnosed on January 27—spread to a German businessman living in Munich by an asymptomatic Chinese colleague. It was the first hint that the SARS CoV-2 virus could be spread even by those who were infected and asymptomatic—an ominous and unsettling finding (https://www.nytimes.com/2020/06/27/world/europe/coronavirus-spread-asymptomatic.html). Nevertheless, the World Health Organization did not declare the Wuhan outbreak a “public health emergency of international concern” until January 30. By that time, COVID 19 cases had been detected in 30 cities across 26 countries.
Alex Azar, the U.S. Secretary of Health and Health and Human Services, had begun warning President Trump about the possibility of a pandemic which might impact the U.S. in late January. Trump enacted a travel ban from China on February 2. This was significant, as there are typically 23,000 visitors to the U.S. from China every day. Still, by mid-February 2020, there were only 15 known cases of COVID 19 in the U.S., all of which had direct links to China.
But this was only the tip of the iceberg.
It has been estimated that there were already over 2000 active cases in our country in mid-February—and more were pouring in by the day, from Europe and elsewhere. The CDC insisted on using its own SARS Cov-2 test, as opposed to the already available WHO test—and the initial CDC tests did not work consistently, delaying disease detection for weeks and allowing further undetected spread.
Hidden Circulation
By late February, federal health officials had concluded that the SARS CoV-2 virus was likely to spread widely in the U.S., and recommendations shifted toward mitigation strategies, such as restrictions on domestic travel and social distancing measures. But the Trump administration, fearing damage to the economy, did not initially support such measures—and travel throughout the U.S. was widespread during the next month. By the last days of February, researchers with the Seattle flu study uncovered a local COVID 19 case with no travel history—a definite sign that community spread of the disease was ongoing in the U.S. Over the following two weeks (March 1-14), over 4.3 million people made trips across the rest of the United States from the Seattle area. Genetic samples linked to the Seattle outbreak later appeared in over 14 states.
On the East Coast, things were just beginning to heat up. Although New York City had a single known case of COVID 19 by March 1, it is estimated that 10,000 infected persons were circulating undetected at that time. Over 5000 contagious travelers left New York during the first two weeks in March. Genetic analysis later revealed that the New York outbreak was fueled largely by persons traveling from Europe—and the New York-derived strains later eclipsed the Seattle-derived strains (which had come largely from China) as the source for most of the U.S. outbreak.
Travelers from New York in early February spread the virus to New Orleans—just in time for the annual Mardi Gras celebration, which culminated on February 25. The first documented COVID 19 case in Louisiana was subsequently confirmed on March 9—and Mardi Gras-related outbreaks were later discovered in Arkansas, Texas and Tennessee (https://www.nytimes.com/2020/04/13/us/coronavirus-new-orleans-mardi-gras.html). New Orleans became one of the early epicenters of disease in the Southeastern U.S. Still, the U.S. authorities consistently downplayed the risk. Jerome Adams, the U.S. Surgeon General, stated on March 9 that “the risk is low to the average American.” Cell phone data provided by the mobility data analysis platform Cuebiq showed that the American people were unimpeded in their normal travel and movements on March 10.
Pandemic Official
On March 11, the WHO formally declared COVID 19 a pandemic. By that time, thousands of cases had already been reported in Italy, Iran and South Korea.
Georgia’s first COVID 19 death occurred on March 12. That individual, a man from Atlanta, had recently returned home from attending two funerals in Albany, Georgia. Within weeks, the Albany outbreak became one of the nation’s worst on a per-capita basis (https://www.businessinsider.com/coronavirus-hotspot-albany-georgia-funderals-covid-19-cases-per-capita-2020-4). To date, there have been nearly 2000 COVID 19 cases in Albany, a town with a population of just under 90,000.
The president banned travel to the U.S. from Europe on March 13—but by that time, the travel restrictions were largely pointless, as the virus had already been circulating throughout the United States for months.
By March 16, President Trump asked Americans to limit travel, avoid groups and stay home if they felt sick—advice that public health officials had been suggesting for weeks. U.S. citizens’ mobility declined substantially after that point. Georgia Governor Brian Kemp issued a shelter-in-place order effective at 6 PM on April 3. Georgians’ mobility declined substantially after that, reaching a low mark on April 9, according to Cuebiq (https://www.cuebiq.com/visitation-insights-mobility-index/).
China, meanwhile, had used an aggressive lockdown strategy, extensive testing and contact tracing techniques and had managed to corral the virus. New cases had slowed dramatically. Similar efforts in Thailand (the source of the first COVID 19 case outside of China), South Korea, Iceland and New Zealand (https://www.npr.org/sections/coronavirus-live-updates/2020/06/08/871822321/with-no-current-cases-new-zealand-lifts-remaining-covid-19-restrictions) have thwarted COVID 19 in those countries. The similarities between those countries’ efforts? Again, extensive testing, aggressive contact tracing, isolation and quarantine of all exposed individuals were at the epicenter of all of their efforts.
The American people began getting antsy early on after the economic lockdowns were imposed, and Georgia was no exception. As virus cases declined, there was an increasing clamor to reopen the state’s economy, which had been devastated by the economic shutdown. On April 24, Governor Kemp issued a formal order of reopening, with some restrictions—making Georgia the first state in the union to do so. Data provided by Cubiq showed that people in Georgia had almost returned to normal mobility levels as soon as May 10.
Numerous other states rapidly followed Georgia’s example. Shelter-in-place orders were lifted across the country. COVID 19 concerns soon took a back seat to street protests over ongoing conflicts between the police and members of the African American community. People flocked to beaches, began going to bars and restaurants, and President Trump even held an election rally in Tulsa. Debates, often politically-motived, erupted on social media which pitted advocates of universal mask-wearing against those who declared that being asked to wear a mask was an infringement on their civil rights. Vice President Pence even penned an opinion piece in the Wall Street Journal crowing that “There isn’t a coronavirus ‘second wave,’” citing declines in the nationwide volume of new cases to 20,000 per day (https://www.wsj.com/articles/there-isnt-a-coronavirus-second-wave-11592327890). In Georgia, the seven-day moving average of cases bottomed out on May 9, at 516 cases per day.
But the holiday was soon over.
New COVID 19 cases set records across the country this past week, spiking past 40,000 cases per day nationally (https://www.npr.org/sections/coronavirus-live-updates/2020/06/26/883799638/u-s-sets-daily-record-for-new-covid-19-cases). The Sun Belt states, places like Florida, Georgia, Texas, Arizona and California, were particularly hard-hit. Hospitals in Houston, Texas are nearing capacity (https://www.theguardian.com/us-news/2020/jun/24/texas-coronavirus-cases-infections-houston-hospitals). The health care system in Arizona is in danger of being overwhelmed (https://www.fox10phoenix.com/news/what-went-wrong-in-arizona-for-covid-19-cases-to-sky-rocket-experts-weigh-in).
In Georgia, the 7-day moving average of cases jumped to 1228 per day on June 20. Chatham County, which has had one of the lowest per capita caseloads of COVID 19 in the state, has also seen its numbers of cases jump substantially over the past couple of weeks, moving from a rolling 7-day average of ~13 new cases per day on June 9 to nearly 100 per day on June 27 (https://covid19.gachd.org/daily-average-of-new-cases/). Some of this may be due to more testing taking place, but the percentage of positive tests has also risen—a factor which means that increased testing cannot be the only explanation. Indeed, cases of COVID 19 are increasing in 30 states across the U.S. As hospitalization numbers balloon upward nationwide, it is increasingly obvious that the U.S. efforts at viral mitigation are failing (https://www.healthline.com/health-news/covid19-cases-rising-states-reopened).
What Can Be Done Now?
So here is the predicament we find ourselves in at this moment: The United States has by far the most COVID 19 cases in the world, by far (2.6 million) and the most COVID 19 deaths (approaching 130,000). Texas, which had only 1511 hospitalized COVID 19 patients on Memorial Day, set a record on June 26 for the 16th consecutive day, with 5523 COVID 19 patients currently being treated in the state’s hospitals. Paradoxically, Americans are now banned from travelling to the EU, due to the uncontrolled level of viral proliferation in this country. The EU is averaging 16 new cases per 100,000 population per day over the last 14 days. The U.S. is currently averaging 107 (https://www.nytimes.com/2020/06/23/world/europe/coronavirus-EU-American-travel-ban.html).
Each successive day, the U.S. is now setting records for new cases. This isn’t the dreaded “second peak” we all were worried about. This is, in fact, the second wave of the first peak—a rolling cataclysm of rampant pandemic infection, brought about by our own disorganization, hubris and willful ignorance.
There is a tiny bright spot in all of this
States in the northeast, which bore the brunt of the pandemic early on, have learned what it takes to deal with SARS CoV-2. As a result, their numbers of cases are falling. The same can be said for European countries, which are all beginning to successfully reopen their economies now—without the spikes in COVID 19 caseloads that we are currently seeing in the United States.
So how do we right a sinking ship in the rest of the country?
First and foremost, we need consistent and effective leadership from government officials—leadership which makes its decisions based solely upon the available scientific data
Politics should have nothing to do with it. Elections should have nothing to do with it. Decisions about public health issues should be based upon coherent information provided by medical and scientific experts.
We can readily see what happens when politics and self-interest intrude upon the public health decision-making process. President Trump’s initial pronouncements about the pandemic were incredibly sanguine, significantly downplaying the risk. His reluctance to address the pandemic led to a decentralized, patchwork federal response, guided by political priorities and seasoned with a heavy dose of false reassurance. This, in turn, left it up to individual states and municipalities to decide what pandemic control measures were appropriate. The inconsistencies which have resulted from the lack of a coordinated federal anti-COVID 19 strategy has led to mass confusion over what mitigation measures are appropriate. The American public has been getting mixed messages all along—and we are now reaping the whirlwind of that chaotic maelstrom of misinformation.
Will we see a change in the federal response going forward? It isn’t likely.
The federal government has been taking its cues from President Trump. Unfortunately, the president has consistently shown a profound disdain for scientific data, choosing instead to maintain his focus on his own prospects for re-election–as evidenced by his recent diatribe against additional COVID 19 testing at an ill-advised campaign rally in Tulsa. This lack of any consistent evidence-based federal direction thrusts the onus of pandemic control squarely on the shoulders of state and local officials, leaving it up to them to make and enforce decisions which will directly impact the health of their citizens. The reason we are seeing a crazy quilt of COVID 19 approaches is because of this fragmented, state-by-state methodology.
So far, the patchwork regulatory method isn’t working. The U.S. failures have been legion and nonpartisan, as cities and states led by both Republicans and Democrats have struggled to come up with any sort of coherent virus-containment strategy. At some point, however, common sense and human decency will win out over political expediency as case numbers skyrocket and hospitals reach capacity.
It should not have to get to that level.
Our elected officials should have the intestinal fortitude to do what is right based on the scientific data without being painted into a corner by a fulminant medical crisis. Governor Greg Abbott of Texas was recently forced to shut down bars across his state only weeks after opening them and expressed regret at having initially reopened them too early (https://www.texastribune.org/2020/06/26/greg-abbott-texas-bars-regret/).
“The bar setting, in reality, just doesn’t work with a pandemic,” Abbott said, noting that people “go to bars to get close and to drink and to socialize, and that’s the kind of thing that stokes the spread of the coronavirus.”
It would have been ideal if he had listened to his experts and not opened bars as early as he did. Then, perhaps, the incipient disaster currently unfolding in Houston could have been avoided.
Second, we must consistently utilize evidence-based strategies to decide how to further reopen our local economies
One thing is clear at this point: Going back to full lockdown is not likely to happen. The prospect of further damage to the economy, and to the relatively fragile financial status of many Americans, would almost certainly pre-empt such considerations. But we can slow the planned re-opening phases, enact additional social distancing measures and take the common welfare into consideration in order to mitigate the deleterious effects of the virus as the economy is reopened.
We now have a much better idea about things we can do to slow the spread of COVID 19. Some of the measures are quite simple, but the public must be convinced to undertake them for the benefit of all of us (https://www.wsj.com/articles/how-exactly-do-you-catch-covid-19-there-is-a-growing-consensus-11592317650).
Despite politically-driven reluctance and a misguided application of the concept on individual liberties taking precedence over public health concerns, the scientific data are relatively clear: Universal mask-wearing in public has been shown be researchers to decrease COVID 19 transmission and can be an effective strategy in lowering the transmission rate (R0) of COVID 19 below 1.0 (https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31142-9.pdf), thereby reducing viral spread (https://www.cnn.com/2020/06/25/health/face-mask-guidance-covid-19/index.html).
The previously-cited IHME database estimates that universal mask-wearing alone from this point forward could save about 33,000 U.S. lives. Currently, there are 14 states which require that face masks be worn in all public places (https://www.cnn.com/2020/06/19/us/states-face-mask-coronavirus-trnd/index.html). Georgia, unfortunately, is not one of them.
The WHO has recommended a consistent positive testing rate of less than 5%, sustained for 14 days, before relaxing social distancing measures
This is a metric that has been used by many countries with subsiding outbreaks (https://coronavirus.jhu.edu/testing/international-comparison). Georgia’s positive test rate is currently at ~8.8%, suggesting that further relaxation of social distancing requirements is not reasonable. By contrast, New York’s rate of positive testing is currently about 1%.
Closing bars and limiting indoor gatherings clearly could have an impact, since crowded indoor venues are much more likely than outside venues to allow the spread of COVID 19 (https://www.bloomberg.com/opinion/articles/2020-05-15/will-i-get-coronavirus-at-the-grocery-store-unlikely).
The third, and most important, thing? Making people take the pandemic seriously.
I actually saw a Facebook post last week that stated emphatically “The COVID 19 hoax is over,” as though 130,000 U.S. deaths somehow did not happen. I’ve seen conspiracy theories that hospitals have fabricated COVID 19 infection data simply to drive up reimbursements (not true), or that death totals are being driven artificially higher for reasons of political gain (also untrue). And I’ve seen people egregiously flaunting any efforts at social distancing, packing into bars, restaurants and stores without facemasks, as though being willfully resistant to public health efforts put in place to combat a potentially lethal illness were some sort of badge of honor.
News flash, folks: It’s not.
It is, instead, selfish and irresponsible behavior, “like driving drunk,” as one professional colleague recently said. People should not be so blinded by ideology and self-interest that they lose all capacity for reason—and yet that is exactly what has crippled our nation during this pandemic.
I have taken care of a multitude of very ill COVID 19 patients. A COVID-19-infected friend in Atlanta was intubated in the ICU for week and racked up a whopping $900,000 hospital bill to show for it. He’s 55, with no “underlying health conditions,” and is alive today through the Herculean efforts of his doctors and nurses and the sheer grace of God. The COVID 19 patients I have seen range from twenty-somethings to ninety-year-olds. The disease can, and does, infect everyone. We are all at risk. The sooner we recognize that, the sooner we can take the steps we need to defeat it.
We can beat COVID 19
We can get on with our lives and return to some sense of normalcy. But we cannot simply click our heels three times and wish it away. Medical science does not work like that. It’s time we stopped crowing about our “rights” and started thinking about our responsibilities—to ourselves, our loved ones and to each other. Because adopting that mindset, ladies and gentlemen, is the only way that this pandemic is going to go away any time soon.
