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Things are not looking good in regard to the COVID-19 virus. Infection rates are totally out of control (see Figure 1a). Testing rate is up since summer but positivity rates are way up and funding issues mean that some states are only testing when there are definite symptoms. This is not how one should test!

Figure describing COVID-19 infection rates and testing rates April 1 through November 18 2020 in the USA

COVID-19 infection rates and testing rates April 1 through November 18 2020 in the USA

I am not surprised by any of this data. Estimates are that about 40% of the population has either bought into nonsensical, non-scientific beliefs or doesn’t have a moral compass when it comes to the safety of their friends and neighbors. Those folks are going to infect people in large numbers. Infections will likely peak at the end of November or early December, but this depends on whether the additional public health measures taken in the hardest hit areas actually make a difference.

Hospitalization and mortality rates are also rising fast again.

COVID-19 Hospitalization and mortality rates April 1 through November 18 2020 in the USA

COVID-19 Hospitalization and mortality rates April 1 through November 18 2020 in the USA

Hospitalizations will peak about 2 weeks later (about late December) and deaths about 2 weeks after that (perhaps early January). There are, however, two mitigating factors that will help keep the mortality rate down in relation to number of cases. First, our treatment protocols are much more efficient than they were in spring—we have learned a lot over the past 6 months in keeping patients alive. Even with an uptick in hospitalizations, there’s a downward trend in daily deaths. As an example of that, look at the data from three hospitals in New York City, where the adjusted mortality ratio improved over 3-fold.

Second, the mean age of hospitalized patients is still much lower than it was in the spring, similar to the peak in the summer. Younger patients generally have a much lower mortality rate than older patients. That said, the virus will still exact a nasty butcher’s bill.

The Butcher’s Bill
I have seen a wide variety of estimates but think the realistic range by the time this pandemic is over will be 450,000 to 650,000 deaths directly attributable to the virus. That does not include collateral damage, meaning, patients who die because they are not getting the treatments they should because of the pandemic. Through October 3 of this year, the CDC estimated that some 100,000 patients died this way. That means an additional 150,000 to 200,000 individuals will die because they are too scared to go for the treatment of their medical conditions or cannot access treatment through their over-burdened healthcare system.

I understand why many people who have lost or are going to lose their livelihood because of public health measures are resisting those measures. I’m talking here about mask-wearing, social distancing, and measures designed to stop transmission of the virus in close quarters and to minimize super-spreader events. However, the truth is that the faster we get this pandemic under control, the faster we will all get back to some semblance of economic “normality.” In my opinion, resisting basic public health measures is actually counter-productive to the very people who rail against them and their behavior may have deadly consequences for all of us as well. I do think that massive lockdowns will be more harmful than helpful. If you are going to lockdown, it should be done very selectively, as was successfully done in Melbourne, in Australia.

The Herd Mentality and the Great Barrington Debate
Surveys have shown that some 30-50% of individuals are either strongly against or will decline the vaccine when it’s available. That will make it hard to reach the required “herd immunity” level of 70-80% needed to end the pandemic, and which will cause the virus to disappear into oblivion or at worst become a seasonal problem. But, some scientists have advocated for reaching herd immunity a different way rather than wait for mass vaccination.

Back in October 4th a group of health experts from Harvard, Oxford, and Stanford Universities signed a declaration in Great Barrington, Massachusetts, proclaiming that the virus should be allowed to spread freely among younger and healthier people while taking measures to protect the most vulnerable of our community. Ten days later the rebuttal to the “Great Barrington Debate” (GBD) was published in The Lancet. It was called the “John Snow Memorandum,” a reference to our first modern English epidemiologist who established principles of epidemiology over 170 years ago.

Here is the crux of the debate: One group believes that we should accept deaths and comorbidities until mass vaccination occurs as the price of preventing economic catastrophe. They are also concerned that prolonged and repeated lockdowns cause other deaths and comorbidities related to the lockdown. The other group believes that the economic catastrophe of lockdowns is worth the price to save lives because healthcare facilities are not overwhelmed with COVID-19 patients.

The fact that it would be challenging to reach herd immunity for an entire population by just getting its younger members naturally immunized, is only just one of its flaws. The debate is discussed in detail in The Economist for those of you who want to take a much deeper dive into the subject. The irony is the United States is now entering a GBD “experiment” of sorts whether it likes it or not because of the behavior of a large proportion of its population.

While the pandemic did not cause the national divides we face, it did crystallize them in such a way as to make them plainly obvious. Such divisions are one reason why we are effectively unable to handle the pandemic.