America Struggles with the Pandemic
By Nayyer Ali MD
Three months after widespread shutdowns affected states on the East and West coast, America has utterly failed to contain the COVID-19 pandemic. Other nations were much harder hit in March and April, particularly Italy and Spain and also Britain, France, and Belgium. However, they have all brought the pandemic under control. Even Britain, the worst affected in April, just lifted most of its social distancing restrictions.
In the US, states in the northeast, particularly New York, New Jersey, and Massachusetts, were devastated by the pandemic in April and into May. In New York, the health care system was close to being overwhelmed, and volunteer staff and equipment had to be sent into New York City to help cope. But since then, that part of the country has brought the disease under good control. Meanwhile, other states that were initially spared are seeing dramatic surges in both cases and hospitalizations. This is most noticeable in Arizona, Texas, and Florida. California, which did very well, compared to New York in April and May, is seeing increasing cases of infection detected in the last three weeks, with daily new cases going over 6,000, compared with 2,000 last month.
This dramatic failure to bring COVID under control is astonishing. America is the richest, most powerful country in the world with massive technological, medical, and industrial resources at its disposal, and has failed to get a handle on this tiny little virus. Why has America failed? The answer is simple.
There has been a total failure of leadership at the national level. We have 50 different responses, and in some Republican-led states like Arizona and Texas and Florida, the response has been to pretend that nothing needs to be done. The natural consequence of this failure is now visible. The US has lost over 125,000 people to this so far, and if we include the likely undercount, the death toll is probably closer to 150 or 175,000. Within the next three months we could see the total go well over 200,000, even if we ignore the undercount of people who die at home or without a formal diagnosis.
What should have been done? It is not that hard to figure out. The most important thing was to get national leadership and a national policy to control this pandemic, otherwise the hard work done by one state would be undone by the failures of another. The governor of New York is now so concerned about this he is considering requiring quarantine of anyone entering New York from Florida. The single most useful policy response would have been requiring everyone to wear a mask in public. Even masks made from simple cloth are extremely effective in keeping an infected person from passing the virus to others. If everyone wore masks, transmission would drop 90%, and the disease would fade away. This is what happened in East Asian countries and in European countries that adopted masking early.
Secondly, the federal government should have dramatically increased testing and paid for it for anyone who wanted to be tested. America is doing about 400,000 tests daily, which is an impressive number, but we need to be doing 2-3 million tests daily. It is only with widespread testing that we can find who is carrying the virus, and quarantine them so they cannot spread it to others. Widespread testing has worked very well in other nations, and it is unfathomable why this has not been pursued in the US. Testing is currently being driven by the states, and is not being done with enough frequency to get ahead of this.
Finally, we needed to hire and train an army of contact tracers. These people would follow up with everyone who tested positive and track down every person they spent more than 15 minutes with in the previous several days. Those would be potential new infections, and they would need to be isolated to break the link in the transmission chain.
While the number of cases is surging, so far the death toll has not. In California, for example, the seven-day average death toll has actually been declining a bit for the last few weeks, and is down from April. Even in Arizona, the death toll has not risen sharply yet. This may simply be because we have not waited long enough to see these new infections turn lethal. It takes about a week for a patient to go from being infected to being put in the hospital, and another week before they worsen enough to die.
There is however another possibility. It may be that we are getting much better at taking care of COVID-19 pneumonia. We now have an antiviral drug, remdesevir, that is effective against the virus. We also have clear data that giving steroids reduces death rates. In addition, we are using blood thinners more regularly, as blood clotting appears to be a common and sometimes deadly complication of this disease. Perhaps with these specific elements, and the general benefit of more experience treating this severe illness, we are saving more lives and lowering the death rate. Another potential treatment is on the horizon. The company Regeneron is testing a cocktail of two antibodies produced through genetic engineering that appear to neutralize the virus. As they are lab-produced, in theory we could manufacture enough to treat everyone. These have great promise but must be shown to work clinically in actual patients, and that will take another few months to demonstrate.
The real answer is still a vaccine. Over 100 groups are working on candidate vaccines. The three leading candidates include a Chinese group using killed virus, a group out of Oxford University using viral antigens inserted into a benign virus, and the American company Moderna, which is trying an RNA vaccine in which RNA genetic material that codes for viral proteins is injected directly into the patient’s own muscle. All three groups are going to start Phase Three (final phase) trials this summer, and we may have one or more effective vaccines by end of the year or early next year. Dr Anthony Fauci just testified to Congress that this aggressive timeline could be met, but of course in medicine there are no guarantees.
