Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

Spreadability and Severity

Today marks a truly catastrophic moment in US history.   The virus, SARS-CoV-2, causing an illness, COVID-19, invaded our nation, and the combination of this illness, and our response to it, has cost 100,000 of our lives in just 87 days.

This clearly establishes COVID-19 as a major cause of death, one of the deadliest in modern US history.  We say modern because prior to the invention of antibiotics which ended the threat of illnesses such as the plague and cholera, and of vaccines which ended the threat of illnesses such as polio, smallpox, and measles, infections killed far more than this number of people in the US.   But not since World War II.

Since the use of antibiotics and immunizations, there has been no infection that has killed so many of us this quickly, as COVID-19.   Not the flu, not pneumonia, not AIDS, nothing.

And so today, we pause and mark the loss of so many of us, and ask, what can we do now to avoid losing another 100,000 Americans to this virus?

Some Basics

As noted in earlier posts in Real Answers, COVID-19 is an illness caused by a virus, which means this disease shares many features with other viruses.  Its impact is directly related to how many people catch it and how sick they get from it.

When the virus first appeared, we knew so little about it that we wondered, could it spread from person-to-person?  Could it spread easily or not?  What sort of illnesses could it cause?  Could people with no symptoms spread it.

The first case known to occur in the United States happened in late January.  The first death known to be caused by COVID-19 in America took place on March 1, 2020, a little less than 3 months ago.

During this time, many basic questions were answered:

1. The SARS-CoV-2 virus is contagious, and when allowed to spread, is highly contagious.
2. It is good news that at least 50% of those infected will have no symptoms, but it is bad news that they are still very contagious.  A virus that can cause death that can also spread from people with no symptoms is a recipe for disaster,
3. Even though at least half of people who get infected have no troubles, the other half do.  And, this virus has certainly proven that if allowed to, it will kill many people, every adult is at risk for such a terrible outcome.
4. There are patterns to harm.  The majority of the 100,000 we have lost were over 60 years old, and had a problem, in particular hypertension.  Males are more likely than females to get very ill.  Other risk factors include obesity, heart disease, diabetes, and emphysema (more than asthma).
5. But of the 100,000 who have died, many were young adults in perfect health.
6. Hydroxychloroquine does not work for most people, and can lead to death if used.

During these first two months of loss of life, many questions remain unanswered, for example:

1. How much longer will this virus hover over all of the world, putting all of us at risk?
2. Over time, will the illness get more or less dangerous and deadly, or stay about the same?
3. When will a medication be available to protect us?
4. When will a vaccine be available to protect us?

Why Has Our Nation Suffered More Deaths than Any Other?

By absolute count, not per capita, the US has suffered a total number of deaths far, far greater than any country in the world.  The next closest countries are 5 nations with total deaths of 25-38,000, far fewer than us.  Aside from this handful of nations, no other nation in the world has suffered more than 10,000 deaths.

If we look at loss of life per capita, the US rate if death is 30 deaths per 100,000 Americans.  That places us in the top tier of nations around the world.   A small number of nations have per capita losses of life beyond our 30/100k, but not many, and all the rest of the nations’ rates are far smaller. https://coronavirus.jhu.edu/data/mortality

By any measure, we have not done well, and so the question must be, why?

The answer will emerge over time, but three possibilities come to mind-

First, we are an international travel hub, Second our fundamental strategy was deeply flawed, and Third, gaps in that strategy allowed the virus to rampage without limit in certain settings.

TRAVEL HUB

There is no doubt that many people travel from everywhere to and from the United States.  We are the richest nation in the world, so it is no surprise many Americans travel around the world, and the world travels to the United States.

One analysis of  where the SARS-CoV-2 virus flared found a very tight association with travel patterns.  Draw a line for every flight that went from one airport to another, around the world, for a month, last year, long before COVID, and you will of course see a very dense web of lines concentrating on just a handful of mega-hubs.

This turns out to be where this virus had its largest outbreaks.

NYC is one of the world’s great hubs for air travel, and we know the tragedy of lives lost there derived from heavy air traffic from Europe.

Curiously, 1/3 of American COVID-19 is traceable to one man who came from Wuhan back home in January.  He had close to 70 contacts traced, but the effort missed one person he did infect, who went on to cause 1/3 of America’s cases!  And so the fact NYC is an international hub is the origin story for a lot of American COVID, but not a lot of other, national flares of COVID-19.

THE FLAWED WESTERN STRATEGY

Readers of Real Answers have read many times of the difference in strategies in response to an outbreak in their nation.  This day, when we mark the loss of 100,000 Americans, it is worthwhile and urgent to review this problem, as it underlies the real reason that our exposures in NYC and from Wuhan in the West turned into 100,000 deaths through today, instead of several hundred or even a few thousand.

The strategy adopted by the United States was to isolate everyone.  We never decided to find as close to everyone infected as possible and isolate them.   When the COVID-19 cases began exploding in many states, the nation decided instead to have everyone who could to stay at home.

This strategy worked in some ways, and failed in others.  It clearly worked to slow the spread of the virus.  With no such effort, deaths would have continued to double every few days, and the loss of life could have been 500,000, or even a million by today.   And so this is a success.

But it is a failed strategy when compared to other strategies that could have prevented a very large number of the 100,000 people lives lost through today.   We know this because of the very real world experience of 48 nations around the world, in yes Asia, but also Europe, Africa, South America, every continent the virus is present except North America.  In these 48 nations, they have adopted strategies that have brought the number of people dying in their nation each day down to close to zero.  (www.endcoronavirus.org)

For most of these nations, their ability to end the spread, and end the dying from this virus was based on the strategy of finding as many infected citizens as possible, and have them stay out of circulation, outside the home, until no longer contagious.  It works.  It has saved lives.

And so our strategy may be a success in that we could be worse off, but it is a failure for many, many thousands of our fellow Americans who did not have to die.   The approaches taken by 48 countries around the world could have kept us from this day of 100,000 dead here in the US for a very long time, perhaps never.

GAPS IN THE AMERICAN STRATEGY

Perhaps the American strategy of relying on everyone isolating would have prevented us from losing 100,000 lives if it did not have so many gaps in it.

What is meant by a gap in this strategy?  Any reality that forced people not to isolate.

The easiest illustration of such a gap is work.  Although many adults stayed home, most have not.  About 75% of America still has to go to work outside the home.  This includes laborers at grocery stores, Amazon, many factories, delivery services, hospitals and medical offices.   Going to work keeps the American population from being truly isolated and allows the virus to continue to spread, even with so many indeed isolating at home.

Then there are realities of American life, really life everywhere, that make it impossible to truly isolate everyone.

These include:

• Nursing homes
• Prisons
• Homeless shelters
• Assisted Living neighborhoods

We know that in each of these places, the virus even today is running rampant.   People living in places where they are bound to be in sustained contact with others erupt in COVID-19 cases.

Many nursing homes and prisons have reached nearly 100% of people in them infected, and those infections then spread to the surrounding communities because of that first gap- not everyone is isolated even at home due to over half of Americans still working.

And then there is the monumental gap, the one involving communities of color and neighborhoods of poverty, which overlap, but are not the same.  Since the first American death by COVID-19 in March, a pattern of death by color and wealth has emerged.   The observation is very real, and although such observations are not always fully understood we do know these facts:

• Hypertension, a condition more associated with death by COVID-19 than almost any other, is far more common in American communities of color and neighborhoods of poverty.
• Americans who work the jobs that force them to be out of their homes, in contact with many people, are more likely to be part of communities of color and neighborhoods of poverty, than not.
• Neighborhoods of poverty are more densely populated, at least in urban centers, and therefore, allow any virus, including the SARS-CoV-2 virus, to spread more readily.

Today is the Day We Lost 100,000 Lives, What About Tomorrow?

One would hope that any country that lost this much life, knowing that so many other nations have found a path to stop so many people from dying, would change course, and adopt that path.

Let us hope we do.  It would take more than testing.  It would take these steps:

• Screening- doing quick tests on as close to everyone as possible looking for some clue that someone might be infected:  fever checks, rapid lung CT (truly, can take 5 min, finds people with the infection who are well), questionnaires for symptoms.
• Testing two groups- everyone with a positive screen, and everyone with a direct contact (see below)
• Tracing- say you find 10 people who test positive after a positive screen.  Well, each of these 10 fine folks have been within 6 feet of some people, these are direct contacts, and should be tested as noted.  You cannot find all those direct contacts without a trained tracer interviewing every positive tested person.
• Isolate- now, it does not good to have all those found to be infected, positive on the swab, going home, where the virus can still spread.  All the infecteds need to be isolated outside the home.

Should the United States choose not to change our strategy, then we will almost certainly see cases, and therefore, more deaths, rise as more gaps are opened in our choice to rely on isolating everyone, rather than just those infected.  Note that the strategy dropping the new deaths close to zero is not based on testing alone, but testing as part of a system that identifies those infected and isolating them as outlined above.

For our communities of color and neighborhoods of poverty there are steps that could be taken that take into account the risks noted above, should the US adopt the strategy of finding the infected as just outlined.  Such steps might include:

• Screening everyone over a certain age for blood pressure, along with more typical screens already mentioned (temperature, symptoms)
• Screen members of at risk communities with special testing sampling, to determine which neighborhoods are experiencing outbreaks
• Focus testing on all those engaged in work that demands frequent contact with others.

BOTTOM LINES

1. The first death from COVID-19 in America happened on March 1, the 100,000 death happened today, May 26.   These terrible losses could not happen without the SARS-CoV-2 virus, but just as truly, did not have to happen with the virus.
2. On this day that we now record 100,000 of us passing from COVID-19, it is urgent that we pause to reflect, why did 100,000 die in America, nowhere else have even 40,000 people died yet?  How have 48 nations on every infected continent but North America tamed the virus so that deaths are brought down to nearly zero every day, but not here.
3. The answer has to do with choices made here and elsewhere.  Here we continue to pin all hopes on everyone avoiding the virus.  In nations that have tamed the virus, they pin hopes on finding who is infected and isolating them.
4. We cannot change choices made from March 1 to May 26, but we can going forward.  Let us hope we do, or to many more will die who do not have to.

This is a somber day in our American history, my condolences to all who have lost someone they knew, loved, cared for.   We continue to work to keep this virus from doing more harm.

To your health,
Dr. Arthur Lavin