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
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• 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.
• Vaccine Terms
  • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
  • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
  • mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
  • mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
  • Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

A New Day for the Pandemic Begins

I am pleased to share that the United States of America, our country now has a national comprehensive plan to stop the dying.   It is not complicated, but it is detailed, practical, and can work.  And it’s easy to read.

Here it is:  https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf

It is an easy read and is long.  I am very grateful for both.  Stopping a virus takes actions that are simple to describe- basically they all boil down to one goal- stop the virus from spreading.   But this virus is rampant, and stopping it will take many steps in many directions, each of which is simple to describe but will take vast work to accomplish.

In a nutshell, the new plan, the new American plan, the plan for everyone of us launches our nation toward achieving a small number of rather big goals.  There are 7 goals, each easy to state:

1. Restore trust.
2. Get America vaccinated.
3. Slow the raging spread already happening.
4. Get emergency relief in place to all in emergency distress
5. Safely reopen America to work, school, and play
6. Make sure those at risk are protected, including communities of color, rural communities
7. Restore America’s powerful, effective, successful role as a leader in identifying and stopping plagues

Yesterday we saw this plan released and immediately begun to be put into action.  It is now the case that the people leading the charge against a virus that has killed 400,000 of us will be scientists who actually know how to stop the dying.  We saw that when Dr. Fauci was asked to speak openly about what we know.  I listened, I learned a lot, and will be sharing what I learned below.

But it’s not just one person.

Get to know Dr. Rochelle Walensky, the new chief at our CDC.  Dr. Walensky is profoundly experienced at fighting germs, and is very, very highly respected here and around the world.   She will be talking to us quite a bit, you can trust her.  Listen to her like we do Dr. Fauci.

Remember Dr. Vivek Murthy?  He was once Surgeon General and is again.  He is a great communicator.  Full disclosure, he is also a friend.  But that only means I know he has a calm, deeply informed voice.  He will be concentrating on helping to end the dying from this plague, he is important to listen to, a trusted voice.

Meet Mr. Xavier Beccera, the new head of the US Department of Health and Human Services.  Mr. Beccera brings the power of the law to promote to save our lives.  The former Attorney General of California, he will head an agency whose budget, if it were a nation, would be the 5th largest in the world.  He will bring the full power of this great agency to ensure the health care we need is delivered.  Watch how he helps our Dept of HHS help us.

Why a Fire?  Gasoline and Water.

So, help is on the way.   And if help is on the way why talk about fires?  Why mention gasoline, or water?

What do fire, gasoline and water have to do with COVID-19?

Readers of Real Answers will recognize that we have compared the raging pandemic to a fire burning out of control.  It is not just a visual statement, it contains profound realities.

Think of fire.  Aside from wartime, fires always start small.  A spark, a burst of flame.  So how does a fire get big?  Simple.  It heats up whatever is next to it until it catches fire.  A fire in Columbus cannot start a fire in Cleveland without starting fires in between.  Fires only get big by spreading to the thing right next to it.

And yet, though limited to spreading only step by step, fires can destroy whole cities, can kill thousands and thousands, can destroy vast domains across huge states.

And this is precisely how a virus works.  If I have COVID  while sitting in my living room, I cannot give it to someone in Oklahoma.   But if I get next to someone who does not have COVID, watch out, the spark can then spread.  Once it spreads, it will keep spreading as long as there is “fuel” for the “fire” to spread.  Fuel for a virus is someone who it can infect.  If everyone around an infected person is immune, then it cannot spread, there is no fuel nearby.  The spread fails to occur, and the fire of an epidemic sputters and stops, just as a fire ends once all the wood is burned down.

There are only three responses to a fire:

1. Let is spread without slowing it down or making it worse.
2. Make it spread like crazy, e.g.,  by pouring gasoline on it.
3. Put it out, e.g. by pouring water on it.

And so it is with epidemics and pandemics.

The Gasoline and Water of COVID-19

The gasoline for a pandemic is simple to state in one word: Gathering.

For the fire of an epidemic to rage, the virus needs plenty of fuel to burn, and its fuel is people.  One person all alone is nowhere near any viral fuel, no epidemic.  Gather people together and you are piling up fuel for the virus to burn.  Gathering is exactly like pouring gasoline on a little fire.  It always leads to bigger fires.

Anyone who doubts that can look around our nation, where gasoline is drenching our communities.  The result is there for all to see, all our gathering has led to 400,000 of us dying, and there is no way to stop the fire in time to keep it from going to losing 500,000 of those we know and love.  All because we have been pouring gasoline on the raging fire.

The water for a pandemic comes in many forms:  Wearing a Mask, Staying Apart, Vaccinating.

For the fire of an epidemic to be put out we can take two main actions- make it harder for the virus to spread, or turn everyone into someone the fire cannot burn.

We know how to make it harder for the virus to spread:

• Do not gather
• Do not travel
• Wear a mask
• Stay 6 feet apart

Taking actions such as these keeps the virus away for new people to infect, it pours a lot of water on the fires of epidemic.  It does not put the fire out, but it keeps it from raging.  The state of Vermont simply did these measures, really did them.  They put water on the fire of the pandemic.  And as of today, they have 7 times fewer deaths per capita than heavily infected states.  If the nation had done what Vermont did, 250,000 of us now dead, would be alive today.  Water works on fire.  The right steps are like water on the fire of a deadly pandemic.

The most powerful water is vaccination.  We have seen vaccination end the fire of epidemics many, many times. Utterly put the fire out, completely.  Do you know anyone today who is infected with polio, or smallpox?  These epidemics devastated communities for most of history, but not now, only because of immunizations.  The COVID-19 vaccine if used soon enough across the world to enough people, before mutations escape its grip, could put out this fire all together.  We urge everyone to get the COVID-19 vaccine ASAP.

Fire, Water, Gasoline

So where are we now that the fire is raging, the gasoline is pouring, and the water is in our hands?

We stand in a strange, precarious, and promising position.

The strangeness comes from the combination of situations and possibilities of this moment.

The precarious should be obvious.  We are all in very real danger.  If the pandemic is a fire, we stand very, very deeply in the midst of a wildfire burning with little in its way, covering our whole nation, and much of the world.  We know that over 400,000 have been lost.  About 24 million are known to have been infected.  To guage the danger, consider that about 16 million Americans fought in World War II and now more than the 409,000 who died there have died here from COVID.  I think most of us would agree that being one of the soldiers fighting in the battles of World War II, Guadalcanal, Iwo Jima, Salerno, the Bulge (where my uncle fought), would be not only dangerous, but harrowing.  Well this fire is as hot as World War II and even if we pour all our water on it today, it will get much hotter.

A wildfire burning across our nation is precarious enough, but we continue to insist on pouring gasoline on the fire.  Readers of Real Answers may tire of hearing about the gasoline.  Every post for some months has contained clear messages about how the virus is only egged on to spread into hotter conflagrations by gathering.  But it’s true.  And we know from talking to friends, families, and talking with families across the practice, that we are pouring gasoline with great fury right now on this out of control fire.   We insist on traveling, on gathering, on seeing friends, on shopping, during a very dire emergency.

And when anyone pours gasoline on a fire, it has to spread, and this fire spreads.  This is why every expert agrees that no matter how many vaccines are given in the next few weeks, we will lose another 100,000 lives in the coming weeks.  A wildfire with gasoline cannot do otherwise.

Yet.

We also have water in our hands.  Right now, today, each of us can pour water on the fiery epidemic right in our neighborhoods, in our circle of family and friends, by not gathering, by wearing masks, by staying far apart, by not traveling.

And, we have the greatest fire hose history has ever given a people suffering from the harm of a raging virus- the immunization.

Together these buckets of water will put this fire out.  The more water we pour on this, the sooner the nightmare will end.

When will the fire go out?

When the vaccine was proven safe and effective and released for distribution, the first dose was given on December 2.  It was clear if the roll out had been well implemented, we could look forward to 200 million doses, that is 100 million Americans immunized by April 30.  If, if, if, we had all joined hands and slowed the fire of COVID by not gathering, and 100 million had been immunized, we would need to only immunize another 190 million Americans to hit 90% immunized, a level that would very very likely end the pandemic here.  And given that at least 25 million, likely as much as 100 million of us have had COVID, perhaps fewer than 190 million would need to be immunized to hit the 290 million immune mark.   So on December 2, I had reasonable hopes we would see the end of this nightmare in late May or sometime in June.

But instead we did not pour water from December 2 to today, we gathered, and in Europe and America we actually partied.   And we did not implement the vaccine roll out well, so as of today we have 17 million immunized with 20 million doses on the shelf.

The good news is the new Administration has the plan noted above, and is working 24/7 on very specific, very clear steps to make sure the number of doses is ramped up, and that if a dose is available, you can get it.  It will take even the most heroic team a few weeks to implement this plan across the nation. I have no doubt they will.

This is why the target for April 30 is now 100 million doses given, or 50 million American immunized.  I actually think we will surpass this goal.    But the fact that from December 2 to January 20 no efforts were made to put together the complex work needed to implement immunization will cost us time today.  Those weeks of implementation and our continued frenzy to gather push the time it will take to end the pandemic well past May and June.

Dr. Fauci has stated as recently as 2 days ago that he believes this raging fire will be reduced to a much smaller fire that will allow some degree of safety and therefore normalcy to return to our lives sometime in August or September.

And in a few weeks, it is anticipated that the Johnson &  Johnson vaccine will be available, a one dose process, the US has purchased 100 million doses, so we could be adding 100 million more Americans immunized to our projections, moving the end of the fire sooner than August.

One more point here, if vaccine supplies remain limited, setting priorities, most endangered people first makes sense.  But should the vaccine become abundant the plan is to eliminate the priorities and allow everyone access at the same time.

We are living in a moment of national emergency, the fire surrounds each of us.  Let us hope we take a look around and see the danger, the devastation, and get serious.  Let us stop pouring gasoline on fire.  Let us take hold of the water in our hands and put this fire out.

Update on Viral Mutations:  We are in the Race for Our Lives- Mutation v. Vaccine

In the last Real Answers, we discussed the concept of viral mutations in some detail.  Today we offer some updates.

As you will recall, mutations are nothing more complicated than change.  The word means simply that.  And all life changes.  I just learned from my dentist that in the last 25 years they have noticed people’s wisdom teeth are getting smaller and many people are now born without any to develop, a change driven by not needing them.  But the point is that if you live, you change.

Viruses are no different.  Every time viruses like SARS-CoV-2 infect a person, they make zillions of copies and for sure, many are different than the original.  So far, none of the changes have been so big the vaccine won’t work anymore.  But here’s the problem.   If only one person gets COVID a year, it would be essentially impossible for a mutation to occur so big the vaccine would no longer work.  But what if we give COVID, through our actions and choices, to 100 million people, at a rate now of 750,000 new cases a day (current world figures)?   Well, that really ramps up the number of mutations being created, daily.

What does that mean?  Remember, every vaccine ever created, including the new COVID vaccines, has only one mechanism to offer- present the body with a protein, have the body make an antibody to that protein.  If you pick the right protein, the antibody to it will wipe out the virus if it enters your body.  That’s it.   Now, we have figured out a protein on the SARS-CoV-2 virus that if attached to a protein will render the virus unable to infect.

But that antibody all the COVID vaccines gets us to make only can attach to that one very, very specific protein.  If the virus changes that protein enough, the antibody will not stick and the virus is free to kill.

This week, Dr. Fauci gave an excellent review of our current state of mutations.  Almost all remain meaningless, changing the virus so little that no one gets sicker, and the vaccine still works great.  With two exceptions, the UK and the South Africa mutations.

The UK mutation was discussed in the last Real Answers, but we now have better information that it is stopped by the vaccine.  Still, it is clearly much more contagious.   Remember the jump of 70% more contagious means one person spreading COVID-19 will infect 3 million rather than 9,000 people if not quarantine or mask is employed.  And we have seen dramatic surges in the UK.  That virus is here, certainly around the nation.  I dread its impact.  We have not decided to take this epidemic seriously, we gather, we travel, our kids play sports, as said, we are pouring gasoline on a raging fire.  Add in a dramatically more contagious virus, and I fear.

The South African mutation according to Dr. Fauci has changed the very protein all our vaccines target enough to weaken their antibodies sticking to the virus somewhat, in the lab.  Time will tell if that actually leads to the vaccine not working as well in the real world, in us.  Dr. Fauci is hopeful that is not the case.

But the point is that as 750,000 people around the world endure an infection with this virus, it is having 750,000 chances a day to change, to mutate.  I have little doubt that given enough time, it will mutate to a form that does not get stopped so well by our current vaccines, perhaps not stopped at all.

At the same time, we have the answer in our hands.   We simply have to stay apart, not gather, not travel.  And the number of new cases will plummet, the creation of new mutations will sharply drop, and the oncoming vaccines we have in hand will work, and the pandemic will end.

We should mention that even if the worst happens and a new SARS-CoV-2 virus that our current vaccines will not stop emerges, the mRNA platform allows us to create a new vaccine to beat this mutation too, but it will take a few months.

A Surprise Thank You

As we turn the page on a catastrophic start to the American experience of COVID, let’s offer some gratitude to someone who is not that popular on the right or the left.

She is a famous physician, but not well known.  From 2005-2014 she led the US effort against effort to stop AIDS across the world, and was deeply admired for outstanding work.  Many African nations were seeing rates of infection beyond 40% (!), and she helped lead efforts to dramatically drop those raging rates through solid public health work, village by village, across nations.

She was asked to take this ability to stop deadly viruses to the US effort to stop COVID, and she became as famous as Dr. Fauci, but more identified with the Trumpian surrender to the plague.

What isn’t known is that in the last half of 2020 she joined a trusted public health long-time colleague, hopped in a car, and together drove through 43 states and across 23,000 miles.  She visited drug stores gas stations, met with governors and public health leaders.  Everywhere she went she did what she did in Africa, taught the power of basic steps to stop a virus from killing you.  Here it was wearing a mask, keeping distant.  States changed their policies and saw COVID numbers drop.  Villages and cities changed behavior.

Her work was heroic, and she deserves our thanks. So thank you Dr. Deborah Birx.

Bottom Lines

1. The United States of America, our nation, now has a national plan to stop the catastrophe, to return our lives fully to normal.  It is a good plan, and when fully implemented, will work.
2. The concept of fire, and how gasoline and water affect fire is crucial to understanding the pandemic and our current situation.
3. Right now, our nation is in a full out raging nationwide wildfire that threatens to burn everyone of us.
4. We have plenty of gasoline and water in our hands.
5. Right now, we have largely chosen to pour the gasoline in our hands on this fire.  We gather to rather astounding degrees, right in the face of the raging fire.   We see the effects in our office every day.  Babies and many loved ones infected.
6. The fire is so extremely hot that Dr. Osterholm, who we interviewed a few months ago for Real Answers, has stated that we should not be going in person to grocery shop right now, that March could still be quite severely bad.
7. That gasoline includes playing school sports, flying on airplanes, getting together with even just a few friends or family members, shopping, not wearing masks, coming close together.
8. Right now we also have vast quantities of water, the sort of water that puts fires like this out.  We can act like we are in the danger we are in, for just a few more months, not forever, and stay apart, for a few more months.
9. It will take longer because we haven’t taken these steps yet, but with vaccine roll out in time to beat the emerging mutations, we could see this pandemic begin to end by August or September, and with hard, hard work, and new quantities of new vaccine available, maybe sooner.
10. As Dr. Birx leaves the stage, we should pause to thank this hero of health.  Who saved countless lives across Africa, then drove across America and saved many more.  And we thank the new team on hand, from Dr. Fauci, Dr. Walensky, Dr. Murthy, Dr. Osterholm, and Mr. Becerra, and all who work them.

My Takeaway – In One Sentence:

A great and vast fire is hotly consuming our nation right now, we have the gasoline of gathering and the water of not gathering and getting vaccinated in our hands, let us choose water to live.

To your health,
Dr. Arthur Lavin