Note: This thread is related to #Coronavirus #COVID19

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Bob Wachter
+ Your AuthorsArchive @Bob_Wachter Chair, UCSF Dept of Medicine. Career: What happens when a poli sci major becomes an academic physician. Latest book: The Digital Doctor: Hope, Hype & Harm... Jun. 27, 2020 6 min read

1/ Covid (@UCSF) Chronicles, Day 101

This week, it felt like we entered a new phase of Covid. In March & April, we had panic, lockdowns, and surges… in certain places. The next phase (May-early June) saw cases & deaths plateau, we began opening up…and the seeds of complacency.

2/ And now we’ve entered another phase, with major surges in places that were spared the first time around. Given all we’ve learned in the past few months, it’s all very predictable, and it was at least partly preventable – which makes it especially sad.

3/ Predictable, because the best evidence says that the virus’s essential characteristics – its ease of transmission and virulence – are unchanged. And, unless you’re living in New York (where 15-20% of people have antibodies), the virus's targets – namely, us – are the same too.

4/ In mid-March, @tomaspueyo introduced a powerful metaphor to help guide our response to the threat of Covid: The Hammer & the Dance  https://bit.ly/34Ryhsk . The required initial response to the coronavirus was analogous to a hammer: an unyielding, no-nonsense lockdown.

5/ Why? Because the alternative was apocalyptic: massive numbers of sick people overwhelming their healthcare systems – which lacked PPE, testing, ICUs, ventilators, treatments, staff, and experience. The result would have been deaths on a scale not seen since the 1918 pandemic.

6/ The Hammer mostly worked. Some unlucky places, like NYC, locked down late & suffered terribly – because the virus had been spreading, unnoticed, for weeks before anyone learned of its presence. They only became aware of it when critically ill patients swamped their ERs & ICUs.

7/ This magnificent @nytimes visualization illustrates how SARS-Co-V-2 spread in those crucial first days  https://nyti.ms/2YC3gqN . San Francisco locked down early and kept its curve flat; NY, Boston, Detroit, New Orleans weren’t as fortunate, or as well led, and were brutalized.

8/ Some states, mostly red ones w/ libertarian leanings, called the virus’s bluff & got away with it. But they were more lucky than smart – escaping NY’s horrors by being less crowded, warmer in springtime (thus more folks outside), & less apt to have visitors from China & Italy.

9/ If you were in these states (eg, TX, FL, & AZ), you may have seen Covid as a blue state-only problem – yet the disruptions to your economy & life felt very real. Moreover, neither federal nor state leaders spoke truthfully re: Covid’s risks or the need to distance and mask.

10/ So, when Covid waned in NYC, it was easy – logical even – to think that the U.S. had survived the worst. With summer afoot, thoughts turned to opening up, getting out, saving the economy – and another crisis: the Floyd murder & the racial justice issues it painfully exposed.

11/ In fact, we WERE in a better place – we've made enormous progress since March; I’ve listed some of it below. With strong leadership and citizens that believed the science on masking and distancing, we might have entered The Dance poised for success.

12/ If we had gone to The Dance in the right way, we could have returned to quasi-normal version of life (eating outdoors, outdoor shopping, seeing friends) with a small rise in cases – and each case associated with lower mortality since we're much better prepared.

13/ But that Dance would have included wearing masks & distancing. Unfortunately, too many people didn't follow this part of the playbook.

The result was massive surges, mostly in states that dodged the first bullet, where people and leaders saw The Dance as a chance to party.

14/ This time around, lots of cases in young people (Fig: CA data) due to riskier behavior by them (and, one hopes, less risky behavior by high-risk elders). Young folks are less likely to get very sick and die, which partly accounts for fewer deaths than we'd expect... for now.

15/ But young folks with Covid are still a problem. First, a fair # will get very sick. More importantly, as Fauci said today  https://bit.ly/2Vko2co , “you will infect someone else… and ultimately infect someone who is vulnerable… on chemotherapy, or a child who has leukemia…”

16/ Another difference this time: places that got slammed in March are doing OK now – because their citizens know to be careful, leaders have learned the fatal risk of BS’ing, and, in some cases, their most vulnerable people have been infected and are immune (or, sadly, died).

17/ But the overall U.S. picture is grim and getting grimmer. One key component of The Dance is iteration: close monitoring of the situation (testing, contact tracing, tracking ICU/hospital capacity) & a willingness to tighten things up – even to return to The Hammer if needed.

18/ That's starting to happen. Today, @GavinNewsom urged surging Imperial County to return to shelter-in-place  https://bit.ly/2COozxb  If other regions surge, I don't doubt they'll also be forced into SIP – in CA, & other states with leaders like @NYGovCuomo and @GovMikeDeWine.

19/ Bay Area not too worrisome yet, but troubling trends. @UCSFHospitals: 14 pts, 4 on vents, both double two weeks ago (Fig L). In SF, case counts trending up, as are hospitalizations (Fig R) – latter mostly via transfers from other counties, including from San Quentin prison.

20/ In California more generally, the numbers are worse than in SF – not as bad as AZ, TX, FL, but bad –particularly (but not exclusively) in SoCal. Overall state figures: uptick in the effective transmission rate, % positive tests, and hospitalizations (Figs below).

21/ With huge surges in TX, FL, and AZ, the question is: will @GregAbbott_TX, DeSantis, & Ducey – who have been both complacent & complicit – now make hard choices? Hard to know. Nice to see Abbott now supports masks and a pause in reopening  https://bit.ly/3i8aw5q  Better late…

22/ In Bay Area, leaders are closely watching series of indicators (Fig). I have no doubt that if we enter the red zone, they'll scale back our opening or return to SIP, accepting the blow to morale and the economy. It won’t be easy, but neither was the initial shutdown in March.

23/ Masking & distancing – combo is remarkably effective (Fig from  https://bit.ly/2VosEOZ ). If there was clear and consistent messaging & widespread adherence, cases, hospitalizations & deaths would fall, we’d buy more time for better therapies & a vaccine. Then we'd be Dancing!

24/ America is good at many things. But handling a pandemic – at least in our current political atmosphere – isn't one of them. In fact, we suck. We’re too individualistic, too spoiled, too vain, too partisan, and too willing to believe misinformation, conspiracies, or craziness.

25/ Many people have died, & many more will die...but we still have the power to save tens of thousands of lives if we – both leaders and citizens – make better choices. We can no longer claim we didn’t know. At this point, many Americans will die because not enough people cared.


You can follow @Bob_Wachter.



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