March 13, 2020
I am so appreciative of the positive feedback from many people. I am a relatively private person and not naturally drawn to social media. However, it is an enormous pleasure for me to share the fascinating stuff that we talk about every day at work with a broader palate of people. I wish it were under slightly better circumstances.
Again, feel free to broadcast my post to interested people in your lives. If anyone has a tech-y solution for reposting / sharing without the links getting screwed up, please let me know. I am thinking about collecting these posts into a webpage at some point. It is really annoying that facebook won’t allow positing of pdf files. I also am going to probably join twitter this weekend which definitely means the apocalypse is upon us.
I grew up in a suburb in an east coast city. We drove everywhere and did most of our shopping at strip malls. Pretty standard American living. A pretty good life.
At some point in early adulthood, Chihana and I developed a sense that a missing piece was a connection with “nature”. We moved to Seattle and the great outdoors was part of the reason. Think of some REI-inspired vision of a family (handsomely adorned in $400 Arteryx jackets) standing outside of their tent somewhere in the North Cascades as the sun lowered. We fell for this idea and that is fine. I still love being in the mountains and the ocean and we have those opportunities here.
However, my working definition of nature at the time was pretty naive. Nature is not only physical beauty and it is not just the wilderness. Nature is also the ICU where a patient may or not recover from critical illness. It is our schools and our offices. It dictates our emotional response to crises. It is with us every second of every day no matter where we live. Nature captures the ambiguity of what will happen next. It signifies our lack of control, and our lack of understanding, of most things. In this sense, nature is an even more beautiful concept, provided we are humble enough to accept its uncertainty.
I am going to go for maximum drama here, but the story I am telling is some approximation of what actually happened. Sometime in November, a wild animal, perhaps a member of a critically endangered pangolin species, was shedding SARS-CoV-2 in a market in Wuhan. This is probably not that unusual. I bet the animal was not even sick, though the fact that it was in that market in the first place does not bode well for its current condition. Some viruses made it into a person’s airway and entered some cells. It also could have easily started with just one virus entering just one cell. (I happily concede that at the start, one animal might have infected many people, or many animals could have infected many people. I doubt that we will ever be able to completely deconstruct that first critical week of the pandemic.) In any case, the virus wanted to do then, what it wants to do now, in Snohomish county and everywhere else, which is to find a cell with the right receptor, enter the cell, make copies of itself and access new cells. If this single initial, random event goes down even slightly differently, then none of this happens and there is no such thing as COVID-19.
Instead, we are humbled by nature. In many parts of North America, Europe and Asia, we have made the collective decision to all but eliminate what my son’s soccer coach eloquently referred to as “the most important unimportant things” from our lives, maybe for weeks, but possibly for much longer. Two great civilizations are on their knees with more to come I am afraid. An incredibly high number of world leaders have had credible exposures to the virus. And in my city, we are looking into the abyss, knowing that we will come out of it unruined, but wondering exactly when.
It is now evident that China and Korea have effectively curtailed their local epidemics in dramatic fashion:
I can’t find as much on Japan. There are reports that policy decisions being made there are worrisome and reflect some of the same early errors made in the US (lack of broad testing of symptomatic people with known sick contacts). However, the numbers still seem relatively low. I am praying that they dodge a major epidemic:
Overall, this suggests that in much of East Asia the level of circulating infection is amazingly low. If you travelled to any of these countries today and tried to get infected, you would probably fail (I am NOT suggesting this). Recall that just 2 months ago, Wuhan was in chaos. East Asia is not out of the woods given that there are still many cases and re-emergence could happen rapidly. But still, what an incredible ray of hope for North America and Europe for what is possible if we act now.
I am fixated on how extremely crowded countries in Asia are pulling this off. Great stuff from Taiwan:
Masks. One theme in Taiwan’s plan to combat local spread is widespread availability and use of masks. It is the same with many other countries throughout Asia. These recommendations are coming from well-respected Asian academics and public health agencies, in countries that have successfully contained the epidemic. In the US, masks are somewhat frowned upon by policy makers and academics alike. If I am being honest, I think the tone of these critiques can be dismissive and even condescending at times.
So why the disconnect and which side is right? I thought this article in Time magazine was really excellent in describing the issue on a personal and scientific level. The bottom line (in my opinion) is that we do not know. So perhaps more modesty, and a bit less religiosity, is in order with our recommendations.
I may ruffle feathers here but many of the anti-mask proclamations I hear from US and local experts are bromides. For example, “The virus can still easily get around the sides” or “The masks become less effective when they get moist” or “They just prevent people from touching their own faces”. This is not data. And the scientists in this article argue that there is very little data. I definitely am not an expert in this sphere and there could be great papers out there. However, if there are not, then this would be a great collaborative project for a bioengineer and an epidemiologist that would address an urgent unmet medical need. At present, I am telling my patients not to buy or use masks because they are needed more in the hospital. However, when I am asked if masks are effective in preventing infection in public, particularly if worn properly, I have to answer honestly and say that I simply do not know:
Mortality in young patients. Powerful reporting from the NY times about 2 young HCWs in China who became extremely ill and one who unfortunately died. These personal stories are heartbreaking and essential to making the numbers seem meaningful:
That being said, the recent numbers from Korea continue to suggest a very low death rate among those <50 which is fantastic news.
Politics. Tony Fauci is in an impossible position. He is world class and showing great courage:
Vaccine development. To those outside the field, this may seem like a hum drum story. However, it is really an extraordinary step to bypass animal testing and go right to human trials. I trust that these trials will be done with appropriate oversight and care. Vaccines are an enormous challenge to design, manufacture and fund. It would be a really cool silver lining to our current situation if the general public gained a better appreciation of this process and a greater respect for vaccines in general:
What is next for Washington state? Here is a lovely explanation for why we needed to act quickly. Exponential growth is what it is:
So will our intervention of moderate social distancing work? Here are projections. The bottom panel in Figure 1 is the money figure (new infections). The problem is that % reduction in contacts is a very abstract idea. Who knows how to translate this # into real life? The graph is helpful because it gives a date ~3/22 when we will really be able to look at the data for a response. It is still probably too early now because new cases popping up now were last week’s transmissions:
Some small, beautiful things from Seattle and in Italy: