Throughout the COVID-19 epidemic and the unprecedented response to it, I have tried to express a number of concerns about the response that I think have to a large extent proven to be valid, despite the death toll in the US due to COVID-19 being much larger than I expected it to be. Today, with the benefit of hindsight and a growing number of scholarly articles, as the epidemic begins to wane in the face of precautions and vaccines, it is time to re-assess the positions taken.
Put the COVID-19 Risk in Context
I argued that responsible leadership is responsible for putting emergent risks in context. Though I understand that Dr. Fauci may have felt the need to be an alarmist given the misinformation and outright lies propagated by the Trump administration, I still believe strongly that responsible leadership should have put the COVID-19 in context. That >500,000 have died due to this infection in the US, is indeed tragic. However, it would have been of great value to put the number infected and the number of deaths in context. For example, consider annual deaths to routine variants of flu. Because we take the annual flu for granted, it is hard to get estimates of annual deaths with the CDC suggesting perhaps 18-60,000 deaths while other estimates are larger (CDC Report). In fact, despite rapid effective diagnoses and anti-infective treatments, >48,000 die annually due to anti-infective resistant bacterial and fungal infections. (CDC press release, 11/13 2019)
The other important context is the death toll in the US vs other countries. Today, the >500,000 deaths in the US account for 20% of the COVID-19 deaths in the world while the US has a bit more than 4% of the world’s population. (CDC Press release, 3/3/2021) Thus if COVID-19 deaths in the U.S. were proportional to the population, deaths would be perhaps as much as 100,000. (Though the percentage may decline a bit as more less developed countries are infected and the impact of uneven distribution of the vaccines is accumulated.) The U.S. has contributed 20% of the COVID-19-related deaths in the world is highly relevant and several studies suggest that the high death toll in the U.S. was the direct result of poor management of the epidemic in the U.S.1. It is long past the time to stop trying to hide the death toll in the U.S. and begin to learn from the encyclopedia of mistakes and missteps of the Trump administration’s handling of the epidemic.
Define the Risk Reduction Goal
In no endeavor does the 80/20 rule apply more forcefully than in efforts to reduce specific types of risks. For example, vehicular deaths peaked in the 1960s at about 60,000 deaths and that number has been reduced to less than 40,000 by the concerted efforts to make cars and highways safer and to require seat belts and airbags (National Highway Traffic Safety Association PR Oct 2020) The investment has been sizeable but proportional to the risk and is sustainable. Had the investment in auto safety not been coincident with an increase in drug and alcohol use, the impact of the investment in safety may have larger, but most of us accept the current level of risk as acceptable and drive every day. Every day we make a decision to rise and go about our daily activities or stay in bed. We make these decisions knowing that if stay in bed, our risk of embolic events that could end our lives rises, but our risk of household accidents declines. Many of us still smoke and no one can deny that they are not informed of the profound risks of smoking. If we never enter a motor vehicle, our risk of an accident on highway is nearly zero, yet most of us in on the streets and highways many times a day. The obvious point is that every decision we make every day is a risk/benefit calculation of some sort and we live with enormous risks. The risks that we live with today are vastly different from the risks of humans at the beginning of the 20th century and most would say that we like the risk profile today better than that of 1921. In 1921, it was still common to have children die from infections and other health problems. Some of us grew up with measles, mumps, polio, etc. Compared to those risks that were fully accepted as part of life, COVID-19 pales. Remarkably many of the common risks that killed have been reduced to near zero and almost all of the “zeroed-out” risks were solved via enhanced sanitation and/or vaccines and anti-infectives. However, in general, to take any risk to zero is associated with enormous cost and a decision to try to “zero-out” a risk needs to be made cautiously and the approach to resolving the risk carefully considered and implemented as was the case with the great successes of vaccines for a variety of infectious diseases.
At the minimum, the stated goal should have been that the death rate in the U.S. be proportional to our population. If authorities had set any reasonable goal, then it should have been fairly straightforward to decide on the types of interventions that could meet the stated goal with the least disruption in economic and social life.
The Key Issue for the U.S. was and is the Delivery of Health Care
I have argued that the core issue was the need to marshal and coordinate the delivery of health care in the U.S. during the epidemic. I argued that there were a number of obvious steps that should have been taken including the mobilization of the Public Health Service, the military and the Veterans Administration health care staffs, the creation of centers of excellence in each area to which patients could be referred, the mobilization and manufacturing of needed equipment and tools, e.g. masks, the establishment of mobile units to be dispatched to hard hit areas, the rapid institution of diagnostic tests that could have been as simple and immediate as temperature checks and then include diagnostic tests as they became available.
In fact, the response of the Trump administration was far worse than inept. It delayed, denied and obfuscated the risk while Dr Fauci was taking the other extreme position. Worse still, rather than recognizing that every person infected increased the risk of all being infected, and if for no other reason than self-preservation, and providing support to hard hit areas, the Trump administration actually withheld aid to “get even with perceived political enemies” and bragged about it. There can be no doubt the excess deaths in the U.S. are due to the abject failure of the Trump administration to initiate a common-sense response. Then to make matters worse, when responses were implemented state by state, they included a quarantine the healthy approach that exacerbated the manufacture and supply of needed materials (as well as stapled and this led to hoarding). Then in a final act of abject incompetence, knowing that vaccines were being developed, the administration failed to define and implement a plan to deliver the vaccines.
Politicians must learn from this experience that emerging infectious disease risks are potentially dangerous events to which we should implement well planned proportional responses. In the U.S., we seem prone to announcing “wars” on all sort of perceived issues. Certainly, an emerging infectious disease risk merits a “war on” response and the excess deaths in the U.S. are explicable by the lack of effective response at the national level, an astonishing failure in basic governance and leadership.
PROVIDE DIGESTIBLE THOUGHTFUL AND FREQUENT EDUCATION TO THE GENERAL POPULATION
I am sure that I am joined by many who found the lack of understanding about viruses, epidemics, infections in general and potential mitigations truly shocking. Nor can I be alone in the astonishment I feel about how little seems to be understood about the perceptions of risks, how to think about emergent risks, risk management and risk/benefit decisions that we all make many hundreds to thousands of times a day. When one considers the lack of basic knowledge about all this and the astonishing mis-information provided by our elected leaders, for example “drink Clorox or expose everyone to UV rays”, it is no wonder that confusion reigned and still does. That the most thoughtful communication about these complex scientific issues to the populace came from newspapers is both terrifying and a searing indictment of the failure of medical and scientific leadership to communicate as effectively as needed. Nor did scientists need permission from the Trump administration to do the job we all should have done.
For example, simple explanations of what a virus is and how aerosol viruses are transmitted would have helped more people understand why masks make sense and are not simply “an intrusion on our freedom”. More simple scientific discussions might have helped people to understand how the immune system works and could easily have helped predict what is obvious today that immunological status and immune response are key determinants in the response to viral infections. Explaining why being older increases risks from infections might have helped those who are healthy elders to worry less. Certainly, if people had been told clearly and frequently that if you smoke, have COPD, other lung infections, asthma, are immunocompromised or have had bad clinical courses with other viral infections might have helped focus on the populations at risk.
Now as the epidemic is waning and the vaccines are increasingly available, once again there is no forum via which knowledgeable scientists can clearly and directly communicate with concerned citizens. Rather, we continue to depend on the press and politicians. For example, simple explanations that the help people understand what a meaningful difference in vaccine performance is could allay anxieties and dispel nonsensical concerns like “nanobots”. We are learning more every day about measures that worked and those that added little value or were exorbitantly costly. Such information would be easy to convey in very simple terms. We are also learning a great deal about the immunological factors that contributed most to severe clinical courses. These learnings could be conveyed simply. Also, of great value would be simple explanations about co-variate analyses and why examining a single variable and drawing conclusions is usually wrong. We live in a period in which mass communication is fully democratized and used effectively to deceive, misinform, spread destructive rumors, ruin reputations and disseminate terrorist plans. Surely the scientific establishment could provide useful digestible information via any or all of these vehicles, yet there is no obvious place for the lay person to turn, so they go to Fox non-news or worse.
Before implementing a draconian response to COVID-19 that has highly predictable catastrophic effects, with no evidence of benefits that outweigh the negative impacts, consider other less draconian approaches that have been shown to work.
The negative impacts on human beings of the “quarantine the healthy” approach have been so extraordinary as to defy fully grasping the damage done. In fact, the effects of a “lockdown” were so obvious, so predictable, so catastrophic, it seems almost redundant to recite a few of the more compelling. Millions of Americans who once were the “working poor” have slipped into poverty. Millions of businesses have closed. Suicides, domestic abuse and other manifestations of isolation have increased. An entire school year has been lost to poorly prepared online and home schooling. In fact, it is estimated that 1.6 billion students were affected worldwide and there were significant increases in early marriages and pregnancies among students with many students failing to return to school at all (Global Fund For Children, press release Feb 1, 2021).The economic fabric of the world has been severely damaged requiring trillions of dollars of stimulus packages that increase the national debts of many countries and there is no guarantee that they will work long term. Health care and the health care providing industry have experienced disastrous effects that are not fully understood and highly unlikely to be fully recoverable. Because of the lack of access to normal care and the loss health insurance and funds used to pay for care, many hundreds of thousands of excess deaths due to poorly treated chronic diseases, cancer and other disorders have ensued. Sadly, the consequences on the very populations thought to be at greatest risk from COVID-19, the most vulnerable groups, the aged, the impoverished, the neglected young have, as was easily predicted, suffered the most2. Mental health has also been greatly adversely affected by the isolation. Additionally, the U.S. healthcare industry itself has been damaged with many organizations taking on debt as the only means of managing the crisis3. At some point all of this debt and additional costs must be passed on to the health care consumer adding true insult to injury. Finally, the impact the of deferral of preventative medicine, prenatal care, diagnosis and treatment of chronic diseases is yet to be encountered and will be enormous.
The lack of national leadership led to an” every state for itself mentality that exacerbated the fragmentation of the people of the U.S. that is already at an unprecedented and dangerous level. Recall that one of the main stimuli for the creation of the U.S. constitution, was that states were acting independently and establishing tariffs imposed on goods from other states. It is not hard to imagine that states that acted independently to restrict activities and travel could have imposed limited access to U.S. citizens from “problem states” like New York or California. All of this was, for me at least, unimaginable a year ago. Today, I could imagine the next steps that could easily have led to true tests of the strengths of our constitutions and will to remain “united”.
On the international level, in the absence of American leadership, the world descended even further to nationalism and in every nation for itself mentality. This is particularly saddening because an epidemic is, by definition, a problem for humanity that could and should have brought nations closer together and strengthened international cooperation. And it could have been much worse. Historically, profound disruptions in the world economy whether they derived from natural disasters like climate change or from man-made events such as the great depression, have led to war. In fact, it is remarkable that so far, no wars have been initiated, but it is certainly true that cohesion among nations has suffered and will require strenuous efforts to repair or even more negative consequences may ensue.
Tragically, plans to deal with COVID-19 type risks existed and could have been implemented. In fact, there are literally scores of plans that range in scope from worldwide to local. Not a single plan that I reviewed recommended a total quarantine and several strongly recommended against such an approach. Every major plan that I found argued strongly that the impact on the world economy be considered and that each step be carefully considered and represent a balance in reduction of the risk of infection versus other risks4, 5, 6, 7. Even more tragically, proven methods existed and could have been implemented. These included the use of masks which has been common in Asia for decades, social distancing, quarantining the sick and protecting the at risk. At the minimum, I argued for a “controlled trial” of quarantining the healthy vs other less draconian approaches. Today, studies are being published that conclude that such things as masks and social distancing were of high value while quarantining the healthy added little2. It added little good, but no study has tried to estimate the damage of this approach, but I am confident that when such studies are done, they will show that the “quarantine the healthy” approach did infinitely greater harm than good and should not be repeated.
Conclusions
All of us recognize that we have experienced a tragedy in the past year. It is not an “American” or “Californian” or “World” tragedy, it is a HUMAN tragedy that has been caused by a relatively simple virus, but exacerbated to an enormous extreme by catastrophically incompetent and misanthropic political leadership in the U.S. and the failure of medical and scientific establishments to step in and cohesively and thoughtfully fill the leadership vacuum. If we do not learn from this tragic comedy of errors, lies and liars, then we will have experienced only loss. We will gain nothing. It is time to learn and for thoughtful people to express their concerns forthrightly in a human -not a U.S. or worldwide-debate.