Some thoughts on how we're handling COVID in the United States

Influenza has been around for a long time.

During that time, humanity has developed a certain degree of resistance to it. To be sure, thousands die of it every year. And every year, the virus mutates to not be identical to the previous year's version. Sometimes, as in 1918 or 1957 or 2009, a version emerges which is sufficiently different from what we're used to that a whole lot more people get sick from it than usual, and a whole lot more people die.

We have flu shots which to some degree protect us even though a given year's virus might not be identical to what we've seen recently, or even at all.  The 2009 virus and the 1918 virus were both H1N1, having a genetic similarity to one another. But the 2009 outbreak was by no means as serious, probably to a large extent because of technology and improved health care. And as we continue to be exposed to more and more genetic variants, we as a species become resistant to, if not necessarily immune from, more and more variations on a theme.

We have a "flu season" every year. Some years are worse than others, both in how many people get sick and how many people die. But we've built up enough resistance to influenza in general and are sufficiently prepared in terms of a vaccine which, while it might not be entirely problem-free, protects most of those who get it that there is no need to resort to the kind of extreme measures we took during the 1918 outbreak and are taking now.

Contrary to what some sources (ahemTheFederalistahem) seem to think, and despite the comparisons the President and others have made, COVID-19 is not influenza of any kind. It is, at least at one level, superficially similar to the flu in that it's another respiratory virus. However, it's one that seems to attack pretty much every organ system in the body and causes tiny blood clots to develop which sometimes end up killing comparatively healthy young and middle-aged people, often at a point when they seem to be recovering from the illness. And while it's still rare, it has become clear that PIMS (Pediatric Inflammatory Multisystem Syndrome), a serious and often lethal condition caused when babies are infected by the SARS CoV-2 virus, makes COVID a threat to the very young as well as to the very old. No, this is really nothing like the flu.

On the other hand, neither is SARS CoV-2 an entirely new critter. Coronaviruses are, after all, a whole family of viruses, including one that is among the many which cause the common cold. We've had outbreaks of another coronavirus causing severe acute respiratory syndrome (SARS) before. Still, our species doesn't have nearly the experience with COVID-19 and its relatives that we do with influenza. And even though one of the viruses that cause the common cold is a coronavirus, we don't have a vaccine for it;  different viruses grant different amounts of immunity to those who recover from them, lasting different lengths of time. We still don't know very much about how much immunity COVID-19 bestows, or how long it lasts. Obviously, this impacts not only how useful a theoretical vaccine might be, but how useful the very concept of "herd immunity" is when talking about COVID-19.*

As I noted yesterday,  despite statements which seem to imply otherwise from Swedish public health officials, the Swedish ambassador to the United States denies that Sweden's more laissez-faire approach to the pandemic which has resulted in vastly larger percentages of its population both contracting the virus and dying from it is based on an attempt to establish "herd immunity" among Swedes, a situation which normally occurs when around 60% of the population as antibodies in its bloodstream (Sweden, which is far ahead of the United States in the percentage of its population that has been tested, seems to have achieved something short of half of that despite its unusually large number of infections). Instead, she paints it as a pragmatic attempt by the Swedish government to make use of a culturally high level of mutual trust and community spirit to rely on voluntary rather than mandated restrictions on behavior likely to spread the virus. The policy is controversial even in Sweden, and the ambassador emphasized that there really is no "Swedish model" of approaching the pandemic for other countries to emulate.

But the concept of "herd immunity" continues to be discussed. The Federalist even ran an article by a dermatologist suggesting that we use voluntary infections by young, healthy Americans to artificially create it here (Twitter decided that the article was irresponsible and removed a tweet from The Federalist linking to it). It should be noted that the article did cite a credible study suggesting that "herd immunity" might be conferred by the immunization of as little as a third of the population, though that was a minimum number which Sweden seems not to have been helped much by approaching.

The number 60% isn't arbitrary. Several projections have suggested that it's inevitable that before COVID-19 can be put behind us between 20% and 60% of the world's population will have become infected. Obviously, that number would drop drastically if a vaccine is developed and widespread immunization takes place before we reach it. One thing seems clear, though: relying on "herd immunity" would be a solution that wouldn't be effective for quite a while, and in the meantime, the butcher's bill would be horrendous.

Complicating matters is the fact that the majority of the people who contract COVID have few symptoms, or even none and all, and that comparatively few become seriously sick. Only that small minority are ever reported. This would tend to drive the actual mortality rate for the disease far below the reported numbers. But recent evidence suggests, on the other hand, that the number of people who have died of COVID may be drastically underreported because so many were never actually diagnosed, and a surprisingly large percentage are people- including young and middle-aged people in good health) who seem only mildly affected or seem to be well on the way to recovery when they suddenly die of stroke due to the now-recognized tendency of the virus to produce small blood clots.

A clear pattern seems to have developed in an extraordinary number of "excess deaths" (i.e., deaths over and above the usual annual number for a given period) during peak COVID outbreak periods all over the world. Worldwide, they seem to amount to at least 74,000 over two months;  there seem to have been at least 24,172 in New York City alone.

Not all of these, of course, were clinically attributable to COVID. Lockdowns tend to increase the prevalence of depression and suicide, as well as domestic violence, to use two obvious additional causes of death likely to have been higher than usual. But the fact only illustrates the impossibility of getting an accurate idea of the actual death rate. The unknown number of unreported COVID cases combines with this to make it virtually impossible for us to actually know either the death rate or the number of people who have contracted the virus and recovered,

Current tests aren't all that reliable, though they're better than nothing. In any case, the United States lags far behind other nations with the largest populations in the percentage of the population that has been tested despite having conducted a larger number of tests than anyone else. Even if the more reliable antibody tests were conducted, the United States is nowhere near being in a position to even measure how close or far away "herd immunity" actually might be.

Besides, in the absence of a contact-tracing program such as those being used elsewhere in the world, meaningful attempts to keep track of and even meaningfully confine the spread of COVID especially as precautions are relaxed and states begin to open up are futile. Even poor countries are carrying on such a program and doing so effectively. But such a program would by its very nature have to be coordinated among the various states to ensure statistical reliability and the urgency of the need raises serious questions about whether the Federal government doesn't need to step in and get the ball rolling rather than relying on fifty separate state governments with fifty separate sets of local circumstances and pressures to take the initiative.

Dr. Anthony Fauci was quite frank in warning Congress of the risks states would take by precipitously opening up their economies.  Predictably, President Trump, in his ongoing and thoroughly reckless attempts to open things up as quickly as they can be opened up even if they don't meet the criteria established by his own task force and whether or not the experts consider it safe, has sharply criticized Dr. Fauci for his remarks.  I strongly suspect that Dr. Fauci is walking a tightrope narrow enough that I suspect that his firing is inevitable. His integrity in reporting the facts and giving his best expert opinion is working at cross purposes with the administration's determination to ignore the experts and the established facts and barge in where angels fear to tread.

Simply relying on the development of "herd immunity" as a solution to the pandemic while recklessly ignoring the advice of those who actually know what they're talking about is a prescription for a holocaust.  "Mitigation" rather than "suppression" was the strategy employed through most of the 1918-1919 pandemic, and the result was horrendous. With a potential "second wave" likely headed our way this fall and winter, we lack not so much the resources or even the will to be ready as the leadership.

Just as Mr. Trump stubbornly ignored the warnings of the experts and of the intelligence community about the approaching crisis and only acknowledged that it was a serious problem a matter of weeks ago, he seems determined also to ignore the advice of the experts and hurry along the process of reopening the country far before we are ready. A crash program of testing is already underway. This needs to be accelerated and a clear idea of where we need to be developed before we are anywhere near being in a position to take the steps the President wants to take. Yet in this as in so much else, he barges ahead blindly, trusting his own intuition more than the facts and refusing to take the advice of people who know more than he does.

This is going to end in a disaster beyond the imagination of Mr. Trump and his supporters if state and local officials don't resist the pressure from the White House to hurry things along unless the Executive Branch gets its case together, puts together a reasonably accurate picture of the lay of the land where the pandemic is concerned and starts providing some leadership in taking concrete steps to address the crisis instead of continuing an irresponsible and politically motivated crusade to take action that can only make things worse.

I'm confident that a new and more competent administration will be in charge come next January 20. But that might be too late to prevent a holocaust.

* ADDENDUM: While Swedish public health officials continue to maintain that because it takes time for antibodies to appear in people who have been infected by the virus something like 20% of the population should have been infected and developed antibodies,  a new study of the population of Stockholm done by the Swedish public health service shows that only 7.3% of the residents of the city had developed antibodies as of April. Predictably, the percentage of the population outside of Stockholm was even smaller.

The most prominent proponent of the Swedish strategy of relying on voluntary restraint rather than government-mandated lockdowns to control the spread of COVID, Dr. Anders Tegnell, says that the number is "a little lower" than expected, "but not remarkably lower." He still maintains that due to the time lag by now the true number is closer to 20%.

To be sure, new infections are trending downward, as they are through most of the world. But with the second wave of COVID anticipated during the fall and winter, the fact that after all the suffering and death Sweden has seen in the last couple of months it has managed to achieve at most only a quarter of the number of recovered patients necessary to reach the classic threshold for "herd immunity" raises the question of how many deaths will be necessary to go the rest of the way. It's hard to reach any other conclusion than that the Swedish strategy has failed and that "herd immunity" is simply not a viable option for dealing with the pandemic unless one is willing to accept a death toll that would affect a country even more deeply than the current recession is likely to affect it. And then, there's the question of the burden that knowing that many of those deaths could have been prevented would place upon a nation's conscience.