You don’t want to control epidemics, you want to eradicate them.
In the United States, it will be difficult even to control COVID. We have been left with a poisoned well, where a large part of the public does not believe that the centuries-old weapons to destroy epidemics: track and trace, isolate and vaccinate, matter or work. The recent war on evidence-based reality will afflict our public health for a long time.
It must be blissful to disregard the truth of the world: climate change does not exist. COVID is little worse than the common cold. Recent deaths from it are, as Donald Trump Jr. said, “almost nothing.” If you get it, you quickly get over it.
These are some of the messages nearly half the electorate has given us in the past few days.
Aided by anti-reality social media, people can now happily live in universes with “alternate facts.” There are scientists and doctors and many other slick pitchmen who tell you today’s crises are “way overblown.” Then there is the national administration, which has assured Americans that masks are silly or useless: witness the President’s “Zorro” move as he dramatically takes off his mask after his “rescue” by Marine One from the hospital. “It’s nothing folks,” he tells us.
There’s nothing to fear. And you don’t have to fear going to the restaurant, or the cinema, or the stadium.
The end result is a population focused on a false belief that everything will be “fine.” They don’t have to do anything. Life will magically “return to normal.”
This winter will put paid to that lie. But hundreds of thousands of people will pay a terrible price.
For the health of the country – its physical, mental, social, and spiritual well-being – have taken a terrible battering the last few years. The idea that health is a cooperative venture, where we protect each other, has undergone vigorous and sustained attack. Often it is replaced with an ideology of health as “individual decision,” as if people choose to get Covid, sarcoma, or lung cancer. Many patients tell me “I will not live in fear,” that they need not take any precautions, because “I will take all the consequences myself.” The idea that people live in communities, that humans are social animals who cooperate to survive and thrive, is missing from their rhetoric.
The majority of COVID infections will spread from people who have no idea at the time they are infected: you could be Typhoid Mary, kills dozens, and never know you were the agent.
Vaccination and Herd Immunity
Lots of stuff gets written about herd immunity, but what does it mean? To control COVID enough that the health care system is not overloaded, you may need 60-70% of the population to be “effectively” vaccinated. (After reaching “ideal” herd immunity you still get serious disease and plenty of people die.)
What’s “effective?” Depends on your endpoint. Does the vaccine prevent death? ICU admissions? Hospitalization? Cold symptoms? Infectiousness?
We will certainly get different vaccines with different endpoint effectiveness, varying for different populations. But let’s say we get lucky – a vaccine that prevents 75% of national hospitalizations. To get that version of herd immunity you will need 80% of the population vaccinated.
Not happening. Many folks are now convinced COVID is a hoax, or unimportant. They also don’t trust vaccine makers. Then there is the issue of distribution, and how long vaccination-based immunity lasts.
Does 10% of the population already have immunity? We know coronaviruses mutate quickly and generally come back in different forms each year. We have also seen COVID reinfections.
Mark Meadows, the president’s chief of staff, admitted there was no national program to “control the virus.” We will long pay for that decision in blood.
What To Do
Many countries got this right. Taiwan has had 7 total deaths from COVID. Their economy is doing well.
Ours? Most of the world, though apparently not our leadership, knows economies will not truly come back until COVID is potently controlled.
The pandemic plans were in place. We knew what was needed, how to do it. Yet in the past year, we just didn’t bother. The Taiwanese, and the South Koreans, and the Vietnamese, trace and track actively. They know a healthy economy requires a healthy population. Despite multiple epidemics, South Korea has had one eightieth the number of deaths per million we’ve had.
To start, the U.S. needs a nationwide system of standardized data collection. That we don’t is both scandal and disaster. Until recently Texas had 254 counties all with different ways of measuring and reporting COVID.
If you don’t know what’s happening and where, how do you confront it?
We also need a national program of trace and track. That includes money for isolation. Throw people back into their families under quarantine and you infect their families, and perhaps triple infection and death rates.
In many countries, public health officials got up every night on television and told people what COVID was doing to them, and what they needed to do. It worked well.
The US should have done that from the beginning. It’s part of every standard pandemic defense – communicate, communicate, communicate. In this country much of national communication was false –often knowingly (https://www.nejm.org/doi/full/10.1056/NEJMe2029812.)
Every two and a half days COVID kills as many as 9/11. By the middle of winter, we might approach that ghastly number every day.
Right now, public health is the economy. We will now have to introduce the pandemic playbook much too late. Many will not bother to listen.
But better late than never.