Watching A Wave Come In, Part 2
It's good to review what protections work and ask why so many state and local governments are focused on rejecting longstanding health guidance
If you’re interested in what a difference a year makes, go read “Part 1” of this post, published in late October last year. By the summer of 2020, we had discovered that wastewater monitoring was the best way to give us an early sign of what is happening with COVID.
With that knowledge, I would like to take a little rabbit trail and make a small complaint. I really wish more municipalities had started tracking COVID wastewater. It’s such a valuable early-warning sign about what is happening with infections, and yet I know few sources outside of Boston that do this. I’m incredibly impressed with them for knowing what metrics they should be tracking and having the capacity and competence to actually track them and publish the results in a public-facing website.
Back to the point: this was the best early-warning sign for a big COVID wave in the northeast last year. I see no reason to believe that this warning sign is less effective this year. It is giving us a pretty heavy signal that there is a COVID surge on its way through the northeast.
It’s important to note that this is not a track of COVID cases where we might be seeing a lot of very mild cases. This is tracking RNA concentration by volume. This means either a *lot* more people have mild COVID or people are still coming down with cases that will manifest as a more severe disease. This is not an encouraging sign.
This last week I’ve been ignoring COVID data as hard as I possibly can because, due to the holiday-induced lack of reporting which is inevitably followed by a surge of reporting when people get back into the office. The week after Thanksgiving is a terrible time to look at COVID data. The only worse time is the week of Christmas, when people actively avoid going to the doctor AND state health departments stop updating their data for a week.
The result is that we’re heading into a 6-8 week period of data confusion. That makes my job of trying to sort things out and inform people incredibly hard. Here is what I think is happening:
A serious COVID surge is happening in the Northeast and probably also the Midwest.
I’m holding out hope that high vaccination rates will dampen severe disease and death numbers. However, Florida had good vaccine coverage this summer and still got slammed with high rates of hospitalization and death. That makes me very nervous.
Southern states that had a rough summer are still at fairly low levels of COVID. If this year is similar to the last, they will see COVID numbers reach a nadir before surging up again in Jan or Feb (though likely at lower rates than the northern states will experience this winter).
The question now is “what can be done?” and I’m afraid the answer is “not that much”. We are now spectators to the natural spread of the virus. Our best option is to protect ourselves and pray for the best for others.
How Can I Protect Myself?
The most reliable form of protection that we’ve seen is vaccination. Every study I’ve seen indicates that vaccines reliably reduce disease severity. One shot provides initial protection, the second shot provides robust, long-term protection.
If you’re at abnormally high risk, the third shot should bolster that protection. Speaking plainly, you should consider yourself “high risk” if you are elderly (65 or above), immunocompromised, or obese. I haven’t really talked about obesity and COVID much but, outside of age, obesity is the most common factor for high COVID risk. It’s simply too big a risk to ignore.
Natural immunity (recovering from catching COVID) continues to provide robust protection. Hybrid immunity (infection then vaccination or vaccination then mild infection) is probably the best protection we’ve seen.
There is still a lot of debate about masks, but my very quick summary is that cloth masks decrease the chance of catching COVID only marginally. N95 masks reduce the chance of infection more, but not nearly enough that they could be considered a substitute for vaccination.
In theory, social distancing should help but, in practice, it doesn’t seem to really do very much, as we can see from the school policies. Schools are the place where we still see huge differences between how districts are trying to fight COVID. Some have returned to normal. Others have not.
Schools that have been obsessed with masking students and keeping them separated from one another by making children eat lunch in the cold are seeing exactly what schools with zero masking and distancing policies see: COVID rates among children in school are reflective of the COVID rates among adults in the larger population, regardless of school policies.
My recommendation (and the path that I’ve chosen in my personal life) is vaccination and then not worrying about any of this. Even during the big summer surge in my home state, I never stopped going to the gym or church. I never stopped socializing with friends and family. I never wore a mask unless it was out of respect for a venue’s requirement. This seems like the obvious choice and I love it.
How Can Government Protect Me?
This is, to me, a bigger question than the question of personal protection. We can all make our own decisions about personal protection from COVID. The joy of that is that we only have to make that decision one time. Once we’ve made it, we can push this disease out of our minds and get on with our lives.
In contrast, government mitigations often require ongoing positive actions. Mitigations from government entities involve travel bans, quarantines, and mandates (both mask and vaccine). Every mandate deputizes private businesses (often against their will) to police their staff and customers since the government does not have the capacity to do so.
In summer 2020, I noted that there is an absolutely prescient paper written in 2006 on how governments should mitigate a pandemic of influenza. It is the gold standard for this discussion not only because it is practical, but because one of the authors was D. A. Henderson, who led the WHO effort to eradicate smallpox. If anyone knew how to respond to a pandemic disease and which mitigations are practical and effective, this is the guy who knows it.
In the section on “Epidemiologic Expectations,” he proposes a disease profile that looks almost exactly like the COVID disease profile: it spreads rapidly within 2-4 days of exposure, patients shed virus before becoming symptomatic, and many individuals may be entirely asymptomatic.
He makes a particular point that mitigations will be needed for the duration of the pandemic (which could be 8 weeks or 8 months), that the feasibility of a given mitigation is the “central consideration”, and that we must give careful thought to the unintended adverse consequences. This paper is filled with warnings about what does and does not work and I want to summarize these here:
List of Do’s:
Vaccination - This is his number one method of protection.
Isolating the sick - Hospital isolation is recommended but, if there is a surge beyond what a hospital can accommodate, they will need to communicate across multiple hospital systems.
Providing effective home care - He recommends home isolation of the sick whenever possible, but this is paired with a plan for delivering home care in the form of medical and food supplies as well as a short-term increase in paid sick leave.
List of Don’ts:
Large scale quarantines - “A World Health Organization (WHO) Writing Group, after reviewing the literature and considering contemporary international experience, concluded that ‘forced isolation and quarantine are ineffective and impractical.’”
Home quarantine for the asymptomatic - “This sounds logical, but this measure raises significant practical and ethical issues.” Henderson shows great reticence for extended home quarantine for mild cases, as he worries this will be overly disruptive for communities. He notes that sick leave is best saved for people who are sick and that sick leave wouldn’t help hourly workers and the self-employed.
Travel restrictions - “screening and quarantining entering travelers at international borders did not substantially delay virus introduction in past pandemics . . . and will likely be even less effective in the modern era.
(S)creening individuals on domestic interstate flights for symptoms of flu…would not be effective and would have serious adverse consequences.”Prohibition of social gatherings - “Implementing such measures would have seriously disruptive consequences for a community if extended through the 8-week period of an epidemic in a municipal area, let alone if it were to be extended through the nation’s experience with a pandemic (perhaps 8 months).”
School closures - He accepts the practical necessity of closing schools for a week or 2 due to high absentee rates among students or teachers, but rejects any longer-term plans or pre-emptive school closures.
Mandated social distancing - Good in theory, disruptive as a government recommendation.
Mandated masking - Also good in theory, but “studies have shown that the ordinary surgical mask does little to prevent inhalation of small droplets bearing influenza virus”.
The overriding principle of this paper is “communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning of the community is least disrupted.”
This is all the guy whose life work was eradicating smallpox, a disease much more devastating than COVID. (And, of course, his co-authors whom I have unfairly ignored. To be fair it would also be tough if you had to co-author a paper on moon exploration with Buzz Aldrin and Neal Armstrong.) His number one concern is to treat the sick while reducing anxiety and allowing the communities to operate in the least disruptive ways possible.
In my view, the majority of government mitigations in the US have failed at this goal. Indeed, it seems that many regions have actually prioritized heavy-handed and ineffective mitigations exactly because they are visible indicators and constant reminders that the people in charge are “doing something”. Many places have taken the list of “don’ts” and implemented the majority of them.
I don’t know where Dr Henderson would land on the question of mandatory vaccination for COVID, but I suspect that it would run afoul his guiding principle of “community should be least disrupted”. Firing people for not getting a vaccine is a pretty disruptive event. Indeed, in his book Smallpox: The Death of a Disease, he only mentions one event in which a smallpox vaccine mandate was implemented and he described it as a policy of last resort for a nomadic religious sect that posed a danger of smallpox resurgence across multiple countries.
These ongoing rolling mitigations seem unreal to me because they fly in the face of the formal recommendations from the most experienced pandemic experts in the world. There seem to be public health officials with a preference for disruptive and ineffective policies when that is exactly what they should be advising against. This is a bias in favor of disruptive action because that action can be identified as “doing something” when they should instead submit to the greater calming wisdom of simply letting people live their lives.
Disney Shorts: Mickey’s Garden (1935)
Man, this short is wild. Mickey’s garden is overrun with insects and he concocts a terrible bug poison to handle the problem. All this should just be an easy setup, but the animation team decided to go all out in animating the bug infestation given that each insect had to be hand-animated, the complexity of these early setup scenes is overwhelming.
Mickey ends up getting a taste of his own bug poison, which sends him into a dream state where he and Pluto shrink to the size of insects and have to fend for themselves as tiny interlopers in their own garden, fighting off an increasingly threatening set of insect opponents. This is a superb example of the kind of fantasy work that only animation could bring to life at that time.
The only downside is that the short doesn’t really come to a compelling conclusion. Mickey fades out of his bug poison sickness and he and Pluto are ok, but his house and garden are still overrun. We’re just supposed to be happy it was all just a dream, I guess, except that it was always clear to the audience that it was just a dream.
Still, the elaborate and colorful animation dominate in this short and there are plenty of good insect-related gags to keep things interesting.
Yes, this is marginally related but I’m processing and need to rant *somewhere*. I’m a resident physician in NM, where a booster mandate was just announced for hospital/long term care/detention center employees. Yes, *boosters*. Get one by Jan 17 or be unemployed.
It was mandated on the back of the CDC recommendation for boosters for all adults 18+, which itself came with a disappointing amount of supporting data.
At this point, the mandates are (by my view) about finding a scapegoat to point the finger at for the pandemic not being over. We ran out of unvaccinated people to shout at, so now it’s those measly two-shotters. No data, just social pressure and panic.
-- This is a a bias in favor of disruptive action because that action can be identified as “doing something” when they should instead submit to the greater calming wisdom of simply letting people live their lives. --
This, for me, calls into question the importance or level of respect that should be provided to public health officials in some way. Any politician or college freshman in PoliSci101 can demand that we "do something," but what our experts should be able to do is advise us on the hard decisions informed by data or point us in the right direction when it goes against base instincts.