“Whatever happens over the summer, this virus is going to be back with us in the fall. And so we have to prepare for the fall as well.” Dr. Ashish Jha, Harvard School of Public Health, 4-5-20
“What we are doing is working, and therefore we need to keep doing it.” Dr. Anthony Fauci, 4-9-20
“If we are not expecting a second wave, or a mutation of this virus, then we have learned nothing.” Gov. Andrew Cuomo, 4-10-20
“The worst thing that can happen is we make a misstep and we let our emotions get ahead of our logic and facts and we go through this again in any manner shape or form.” Gov. Cuomo, 4-11-20
“Well you know I did just finish a 24 hour shift overnight so forgive me if I’m a little brutally honest, but at some point we have to accept that we open up the economy and X amount of people are going to die and the question is what is that number and what are we willing to accept. You know as we flatten the curve, if we don’t time this right there may be another spike, and this won’t be flattening the curve, it will be flattening the roller coaster. So myself, the front line health providers, we don’t want to flatten this curve, we want to crush this curve.” Dr. Sudip Bose, Emergency Physician & Iraq War hero, 4-11-20

These quotes from experts and leaders over the past week, in order of when they were said, are more eloquent in their message than I could be. The so-called first law of medicine, If it’s working, keep doing it, is operating here. But so is the first law of life: Hope for the best, but prepare for the worst.

Good News

There is a lot of good news to celebrate this Easter Sunday, and it’s more than just hope.

1. New York, by far the worst hotspot in the U.S., has convincingly passed its peak of intubations, and that means the worst of the worst is over for New York. Daily death rates continue to be tragically high, but they are a lagging indicator and they too are plateauing. The overwhelming of hospitals has happened, but it may not get worse.
2. Christopher Murray’s model, often cited by the Federal government task force, from the University of Washington’s Institute for Health Metrics and Evaluation (IHME), is now projecting a total of 61,545 deaths for the U.S., down from 100,000 or more projected just a few weeks ago.
3. The West Coast states, notably Washington where the first U.S. cases were, but also Oregon and enormous California, have done an amazing job of keeping this in control from the beginning.
4. Clinical trials of convalescent plasma, antibodies from same, hydroxychloroquine, remdesivir (an antiviral), and other potential treatments are proceeding. Some are being prescribed under the principle of “compassionate drug use” approved by the Food and Drug Administration (FDA), although their effectiveness is a long way from proven. Many promising vaccine candidates are under study.
5. Testing is being gradually ramped up, with viral testing (to see if you have it) up to between 100,000 and 200,000 a day. Antibody testing (to see if you’ve had it) has begun in some areas.
6. Some top Washington officials say the country may go back to normal activity on May 1. Others see a carefully planned phase-in of normal activity over the subsequent weeks to months, guided by testing, testing, testing.

Bad News

1. Many parts of the country are behind New York on the curve. Some will succeed as the West Coast states have. Others, where social distancing has not been followed, may be disaster zones.
2. When you read the fine print on the IHME website, you find that they are only claiming to model “the first wave” of the pandemic. They have nothing to say about future waves. (Below I discuss a more realistic conceptual model that is speculative but helps me to think about what our longer-term future may look like.)
3. Very few states have done what the West Coast states have done from the outset, and some have done the opposite. If Los Angeles relaxes its controls too soon, it is projected to look like New York by late summer.
4. Early results from small clinical trials have concluded that it is ethical to continue them. This means two things: a) they are not doing obvious harm to volunteers; b) they are not so dramatically effective that the trials have to be stopped so that everyone gets the treatment and no one gets a sugar pill. They could still turn out to be useful, or have bad side effects, or both. If a vaccine is available in 12 to 18 months, it will be by far the fastest vaccine development time for any novel virus.
5. Testing remains woefully inadequate across the board, and claims to the contrary are demonstrably false. There are not enough viral tests for health workers at risk, much less for a suitable sample of Americans. If we do 200,000 tests a day, it will take half a year to test 10% of the country. Antibody tests, which if they work well enough can probably clear many people to go back to normal activity, have barely begun.
6. The IHME models, which are the ones quoted by and guiding Federal government officials, are premised on current strict levels of social distancing continuing through May. Earlier relaxation of vigilance is projected to increase deaths, as mentioned by Dr. Sudip Bose, the emergency physician and war hero quoted above.

The model in the graph below (or attached) is a conceptual rather than precisely mathematical model, and I have problems with it, but I think it broadly shows how we should be thinking. It comes from an odd place, namely Morgan Stanley investment research (thanks to Dr. Craig Hadley for alerting me to it; the head of the unit that produced the graph is Matthew Harrison). It has errors (it assumes that children can’t pass the virus on and it is too optimistic about the timetable for a vaccine). It may have been updated today, and I will let you know if I can access it. Meanwhile, it is conceptually valuable in showing us how to think about how this will unfold. You know I consider you leaders. Use your excellent brains to navigate uncertainty, especially when so much depends on how we steer.

Note: I made a mistake in an earlier announcement about the effect of the Great Recession on life expectancy. It actually increased life expectancy and reduced mortality at all ages. The improvement was due to decreased deaths from heart disease, auto accidents, and homicides, among other causes. There were increases in opioid related deaths and suicides but these did not offset the improvements. Improved life expectancy in the Great Recession has been shown in both the U.S. and Europe. A similar paradoxical effect has been clearly shown for the Great Depression of the 1930s and is probably true of other economic downturns. I did see one study claiming to show the opposite, and that’s what I expected, but the weight of evidence goes against my expectation. That’s science for you.

Stay safe, Dr. K