Shut it down, start over, do it right

[Scooter]

Shut it down, start over, do it right
An open letter to America’s decision makers, on behalf of health professionals across the country.

Dear decision makers,

Hit the reset button.

Of all the nations in the world, we’ve had the most deaths from COVID-19. At the same time, we’re in the midst of “reopening our economy,” exposing more and more people to coronavirus and watching numbers of cases -- and deaths -- skyrocket.

In March, people went home and stayed there for weeks, to keep themselves and their neighbors safe. You didn’t use the time to set us up to defeat the virus. And then you started to reopen anyway, and too quickly.

Right now we are on a path to lose more than 200,000 American lives by November 1st. Yet, in many states people can drink in bars, get a haircut, eat inside a restaurant, get a tattoo, get a massage, and do myriad other normal, pleasant, but non-essential activities.

Get our priorities straight.

More than 117,000 Americans had died of COVID-19 by mid-June. If our response had been as effective as Germany’s, estimates show that we would have had only 36,000 COVID-19 deaths in that period in the United States. If our response had been as effective as South Korea, Australia, or Singapore’s, fewer than 2,000 Americans would have died. We could have prevented 99% of those COVID-19 deaths. But we didn’t.

The best thing for the nation is not to reopen as quickly as possible, it’s to save as many lives as possible. And reopening before suppressing the virus isn’t going to help the economy. Economists have gone on record saying that the only way to “restore the economy is to address the pandemic itself,” pointing out that until we find a way to boost testing and develop and distribute a vaccine, open or not, people will not be in the mood to participate.

Listen to the experts.

Public health professionals have made clear that even after we’ve contained the virus by staying at home, in order to reopen American cities and towns safely, we will need:

-- Enough daily testing capacity to test everyone with flu-like symptoms plus anyone they have been in close contact with over the last 2 weeks (at least 10 additional tests per symptomatic person). We currently have only 35% of the testing capacity we need to meet that threshold. The more people get sick, the more testing is required.

-- A workforce of contact tracers large enough to trace all current cases. That’s 210,000 more contact tracers than we had in April, but the number keeps going up as infections rise. Most states are far short of the number of contact tracers they need.

In addition, we need more personal protective equipment (PPE) to keep essential workers like health professionals, emergency responders, and grocery store clerks safe.

Shut it down now, and start over.

Non-essential businesses should be closed. Restaurant service should be limited to take-out. People should stay home, going out only to get food and medicine or to exercise and get fresh air. Masks should be mandatory in all situations, indoors and outdoors, where we interact with others.

We need that protocol in place until case numbers recede to a level at which we have the capacity to effectively test and trace. Then, and only then, we can try a little more opening, one small step at a time.

You should bar non-essential interstate travel. When people travel freely between states, the good numbers in one state can go bad quickly.

If you don’t take these actions, the consequences will be measured in widespread suffering and death.

We need you to lead.

Tell the American people the truth about the virus, even when it’s hard. Take bold action to save lives -- even when it means shutting down again.

Unleash the resources needed to contain the virus: massively ramping up testing, building the necessary infrastructure for effective contact tracing, and providing a safety net for those who need it.

Many of the actions of our government thus far have fallen short of what the moment demands. Mr. Trump, federal administration, honorable governors: we remind you that history has its eyes on you.

Sincerely,

Matthew Wellington
Public Health Campaigns Director, U.S. PIRG

Ezekiel J. Emanuel, M.D., Ph.D.
Vice Provost of Global Initiatives
Chair, Department of Medical Ethics and Health Policy
Levy University Professor
Co-Director, Healthcare Transformation Institute
Perelman School of Medicine and The Wharton School
University of Pennsylvania

David Sherman, PhD
University of Washington

William Hanage, PhD
Harvard T. H. Chan School of Public Health

Richard H. Ebright, Ph.D.
Rutgers University

Karen Walter
University of Washington

Karen Thickman, PhD
University of Washington, Department of Microbiology

Seth Trueger, MD, MPH
Northwestern University

Sanjat Kanjilal MD, MPH
Harvard Medical School, Brigham & Women's Hospital

Valerie Bengal, MD, FAAFP former UCSF Associate Clinical Professor
UC Santa Cruz and Capacitar International

Mariposa Mccall, MD

Reshma Ramachandran, MD, MPP
National Clinician Scholars Program, Yale School of Medicine

Janet Perlman, MD, MPH
UCSF

David Rosen, MD, PhD
Washington University School of Medicine

Farheen Qurashi, MD, FACS

Jamie Burke
Colorado State University

Anthony Orvedahl, MD, PhD

Drew Schwartz, MD, PhD
Washington University School of Medicine

Howard Forman, MD, MBA
Yale University

Krysia Lindan, MD, MS
University of California, San Francisco

Margaret Handley, PhD, MPH
University of California San Francisco, Department of Epidemiology and Medicine

Thomas Lietman, MD
UCSF

Travis Porco, PhD, MPH
University of California, San Francisco

Veronica Miller, PhD
UC Berkeley School of Public Health

Kenneth Rosenberg, MD, MPH
PHSU-PSU School of Public Health

Jason Newland, MD
Washington University

Cathie Currie, PhD

Elizabeth Jacobs, PhD
Department of Epidemiology and Biostatistics, University of Arizona

Saskia Popescu, PhD, MPH, MA, CIC
University of Arizona

Pamela Koehler, JD, MPH

Fern P. Nelson, M.D.
Veterans Administration Hospital

James Gaudino, MD, MS, MPH, FACPM
OHSU-PSU School of Public Health & Gaudino Consulting

Joan Casey, PhD
Columbia University Mailman School of Public Health

Daisy Sherry, PhD, ACNP-BC

Joyce Garrison, PhD

Bruce Agins, MD, MPH
UCSF

Kay Mattson MSW, MPH
Independent international Public Health Consultant

Susan Walker, MS

Patricia Harper, MA
San Bernardino Balley College

Bonnica Zuckerman, MPH
UVM


Paul Song, MD
PNHP

Katherine Villers, MUA
Community Catalyst

Angela Rasmussen, PhD
Columbia Mailman School of Public Health

Megan Ranney, MD, MPH
Brown University & GetUsPPE


Jeffrey Cohn, MD, MHCM



Bethany Letiecq, PhD

George Mason University


Jared Rubenstein, MD


Vineet Arora, MD, MAPP

University of Chicago and IMPACT4HC


Marian Betz, MD, MPH


Ann Batista, MD


Pete DeBalli, MD

UCF School of Medicine


Morgan Eutermoser, MD


Carrie Beckman, PharmD

UC Health


Marc Futernick, MD


Linda Girgis, MD


Megan Whitman, MD


Iris Riggs, PhD


Krys Johnson, PhD, MPH
Temple University


Catherine Cowley-Cooper, RN

Michael Core, MD

Theo Allen, BS

Ryan Marino, MD
Case Western Reserve University

Eric Goralnick, MD, MS
Brigham and Women’s Hospital/Harvard Medical School

Jason Ayres, MD

Michael Kelly, PhD, MSW
Loyola University Chicago School of Social Work

Craig Norquist, MD

Wade Berrettini, MD, PhD
University of Pennsylvania Perelman School of Medicine

Aalim Weljie, Ph.D.
University of Pennsylvania

Kevin Foskett, PhD
University of Pennsylvania

John Hansen-Flaschen, MD
University of Pennsylvania

Garret FitzGerald, MD
University of Pennsylvania

Vasilis Pozios MD

Amy Humrichouser, MD
University of Michigan

Aurora Horstkamp, MD
Washington State University

Timothy Ellender, MD
Indiana University

Michael Becker, DO, MS

Alan Peterson, MD

Christine Brewer, MSW, MSN, RN
Villanova University

Kay Vandenberg, MD, FACOG

Melissa Freeman, MD

Pamela Norton, PhD
Drexel University College of Medicine

Diane McKay, Psy.D.
LECOM

Dominique Ruggieri, PhD
School of Medicine and Center for Public Health Initiatives, University of Pennsylvania

Eve Bloomgarden, MD
Northwestern University and IMPACT4HC

Nicole Theodoropoulos, MD
UMass Memorial Medical Center

Robin Aronow, MA

Catherine Marsh, B.A.
EndCoronavirus.org


Jessica Garfield-Blake, MEd
Knox Trail Middle School Teacher

Jerry Soucy, RN, CHPN
Death Nurse, LLC

Syra Madad, DHSc, MSc, MCP

Jonathan Moreno, PhD
University of Pennsylvania

Reid Masters, MD

Keelin Garvey, MD

Laurence Carroll, MD

Lana Fishkin, MD
Thomas Jefferson University

Jack Colford, MD, MPH, PhD
UC Berkeley

Lynne Agar, APRN, MPH

Margarita Fallena, MD

Shelley Ross, Ph.D.

Rohini Haar, MD, MPH
UC Berkeley School of Public Health

Maimuna Majumder, PhD, MPH
Boston Children's Hospital & Harvard Medical School

Sangeeta Ahluwalia, PhD
RAND Corporation/UCLA

Laura Whiteley, MD
Brown University

Patience Afulani, PhD
UCSF

Vernon Chinchilli, PhD
Penn State College of Medicine

Pamina Gorbach, DrPH
Fielding School of Public Health, UCLA

Judith Hahn, PhD
University of California, San Francisco

Steven Pergam, MD, MPH

Benjamin Lerman, MD
Alta Bates Summit Medical Center

William Davidson, M.D.
PNHP

Constance Regan, Ed.D.

Cynthia Baum-Baicker, Ph.D.

E John Wherry, PhD
University of Pennsylvania

I heard some scary numbers last night. It took 99 days from the first U.S. case to reach 1,000,000 cases. The next million came over 73 days. The next million came over 45 days. You got from there to 4,000,000 in about two weeks. The U.S. epidemic is completely out of control everywhere outside of a few states that were hardest hit early on and took it seriously enough to beat it down.

And idiots want to reopen schools? Teachers in Florida are writing living wills en masse naming Governor DeSantis as their substitute decision maker. Teachers in Iowa are sending their governor (who is also forcing all schools to reopen) drafts of their obituaries listing COVID-19 as their cause of death with the date left blank.

Nothing short of a nationwide complete shutdown and reset, together with an exponential increase in testing, contact tracing and PPE manufacturing capacity, is going to be enough to wrestle this virus to the ground. You want to pin your hopes on a vaccine? You have managed to to administer just north of 50,000,000 nasal swabs in six months; at that rate good luck at getting everyone vaccinated in less than three years.\

Over 78,000 new cases today, a new record. 1,141 deaths. The number of viable courses of action is shrinking fast.

[dales]

With attitudes exhibited like this, the situation appears to be hopeless.

A San Francisco Muni bus operator was assaulted with a bat after he asked three passengers to put on masks on the bus he was driving on Wednesday afternoon, according to the SFPD.

The three men reportedly boarded the bus at 11th and Division streets in SoMa without face coverings. The driver told the passengers they needed to put on masks if they wanted to remain on the bus, as required by San Francisco’s health order.


"The victim pulled over the bus to escort the males off. As the victim was escorting the males off the bus one of the males pulled out a wooden bat and struck the victim several times, which caused the victim to be injured," the SFPD reported. "The suspects fled the scene on foot in an unknown direction."

The driver suffered non-life-threatening injuries and is recovering.

Police have not provided a description of the suspects as of Friday morning.

[Gob]

If our response had been as effective as Germany’s, estimates show that we would have had only 36,000 COVID-19 deaths in that period in the United States.

The US also had the advantage of not getting cases until well after Germany had started dealing with them.

[Long Run]

1. Another shut down is not going to happen.

2. We need to continue and improve efforts to limit the spread while we return to more normal life.

3. On a per population basis, and after taking into account the differences in how data is created, the U.S. is mid-pack in dealing with COVID. Everyone's numbers look bad compared to Germany's -- France, Italy, UK, Netherlands, Canada, Sweden, etc. Perhaps Germany did the best job at limiting the spread (at least so far), or maybe they have a different way of counting their data, or both.

4. Given that the U.S. is the most diverse country, has the most decentralized systems for dealing with this type of issue, has the least restrictions on individual behavior (hundreds of protesters standing shoulder to shoulder for hours at a time anyone?) and is a hub and the most visited and mobile country in the world, it is unrealistic to expect the U.S. to have relatively good numbers.

[Scooter]

Precisely. Even with the benefit of hindsight of the disastrous early situation in some European countries, the situation is deteriorating to the point where hospitals will be sending people home to die because of a lack of resources to care for them, echoes of what was happening months ago in Italy, which led to corpses being stacked in churches because they couldn't be buried fast enough.

[Econoline]

Italy was the first Western nation to experience a major wave of infections, and things went pretty badly there at first because that nation had some of its own economic and demographic disadvantages to overcome...but they rose to the challenge and Italy’s current death rate is less than a 10th of the USA's.

These days Americans can only envy Italy’s success in weathering the coronavirus, its rapid return to a kind of normalcy that is a distant dream in a nation that used to congratulate itself for its can-do culture. Italy is often referred to as “the sick man of Europe”; what does that make us?

[BoSoxGal]

1. Another shut down is not going to happen.

2. We need to continue and improve efforts to limit the spread while we return to more normal life.

3. On a per population basis, and after taking into account the differences in how data is created, the U.S. is mid-pack in dealing with COVID. Everyone's numbers look bad compared to Germany's -- France, Italy, UK, Netherlands, Canada, Sweden, etc. Perhaps Germany did the best job at limiting the spread (at least so far), or maybe they have a different way of counting their data, or both.

4. Given that the U.S. is the most diverse country, has the most decentralized systems for dealing with this type of issue, has the least restrictions on individual behavior (hundreds of protesters standing shoulder to shoulder for hours at a time anyone?) and is a hub and the most visited and mobile country in the world, it is unrealistic to expect the U.S. to have relatively good numbers.

There is no indication that outdoor, mostly moving and mostly masked protests have triggered outbreaks; there is every indication that the opening of bars and restaurants, hair and nail salons, other close communication services (tattoo parlors, etc.) and the large house parties being held in communities all over the country are the trigger for outbreaks. There is actual tracing being done and plenty of evidence on the news and posted online, you can find it with little effort if your mind is actually open to truth rather than politics.

[Long Run]

There is no indication that outdoor, mostly moving and mostly masked protests have triggered outbreaks;

Yes, I've read the news reports which all quote each other or the same "researchers". There are two possibilities, the first being the protests have little impact and thus provide us with a lot of information about the virus and should change how we approach this. Or, the "research" is so limited that it is not helpful. How would any researcher really know or be able to figure out the impact? The majority of cases cannot be traced to a source. Add in that the vast majority of people who go to the protests are not volunteering that information unless they get sick, and even then are highly unlikely to tell a government employee they've been to protests. So all you have to go on is statistical information. There, you have a mixed bag of increased cases, but as you note the spikes can be blamed on other factors (e.g., more young people going to bars), but does that fully account for the increases? fwiw, LA County has consistently taken the position that the protests there have been a significant contributor to the spike they are seeing, even as they acknowledge it is difficult to impossible to find evidence one way or the other.

If the protests have not caused an increase in cases, then much of what we have feared about the virus can be ignored. Large gatherings of people in close proximity are fine, as long as it occurs outside. Let's fill up the outdoor seating at bars and restaurants, baseball stadiums, tennis stadiums, outdoor concerts, family and friend gatherings, etc. It's all okay if we do it outside. Somehow, I don't think thinking people are going down that path. Either a lot of what we have been told about COVID transmission is wrong, or the articles about the protests not spreading COVID are wrong; can't have it both ways.

[BoSoxGal]

Did you actually watch any protest coverage on TV? Those folks weren’t sitting or standing for hours shoulder to shoulder, they were moving and in the great majority of cases they were social distancing on the march. Not all, but definitely most. Not at all equivalent to filling stadiums with spectators to sit in one spot for hours watching sport or concerts.

[BoSoxGal]

By the way, we had large protest marches here in the northeast. Where’s the huge spike? Didn’t happen. At the same time of the protests, our bars and restaurants were closed to indoor service, we had mask orders in place and limits on gatherings.

But sure, it’s irrelevant.

[MGMcAnick]

I had a customer on Tuesday who informed me that she had been a nurse for over 30 years. She called ahead to see if I would mind if she and her husband were maskless. She said that wearing a mask would do no good, and that they wouldn't wear them. She actually stated that she was smarter than "that Dr Fauci". Yeah right, and so is president Drumpf. I didn't try to explain it to her.

There is a new city ordinance that says we all will wear masks INSIDE businesses. So, we conducted our business outside in 95° heat. I wore my mask anyway. The customer isn't always right.

The state has refused to make a rule on mask wearing, as well as school reopening. It has a lot to do with having an intelligent Democrat Governor and a majority republican state legislature. Both rules are to be left as local options. I can see that in the two remaining, very rural, counties that still have no virus cases. One size doesn't fit all. Of course that was six rural counties, out of 105 total, last week. There never was much of a shut down here, except for schools and some non-essential business. Strangely, liquor stores were deemed essential, but bars where social closeness is practically mandatory, were not.

[Scooter]

1. Another shut down is not going to happen.

Then you are doomed to fail. The current situation in the South and the Southwest is far worse than when the initial shutdowns were imposed, and the numbers are moving in the wrong direction. Hospitals are bursting at the seams, and the dead are being warehoused in refrigerated trucks because morgues and funeral homes are already overflowing with corpses. Where is the path leading away from catastrophe?

2. We need to continue and improve efforts to limit the spread while we return to more normal life.

You've been trying that for two months and it has brought you to this pass. What comes next as you are on track to exceed 100,000 cases per day in a week or so?

3. On a per population basis, and after taking into account the differences in how data is created, the U.S. is mid-pack in dealing with COVID. Everyone's numbers look bad compared to Germany's -- France, Italy, UK, Netherlands, Canada, Sweden, etc. Perhaps Germany did the best job at limiting the spread (at least so far), or maybe they have a different way of counting their data, or both.

Looking at the data on a cumulative basis, the U.S. far outstrips any country in western Europe (excluding the microstates), Sweden and Canada. The U.S. death rate is indeed middle of the pack, but only because deaths in hard hit European countries peaked early and have now tapered off:

Code: Select all

            Total  Total
            Cases Deaths

Austria     2,244     79
Belgium     5,594    846
Canada      2,998    235
France      2,765    462
Germany     2,458    110
Ireland     5,230    357
Italy       4,062    581
Netherlands 3,069    358
Portugal    4,874    168
Spain       6,833    608
Sweden      7,819    564
Switzerland 3,944    228
UK          4,387    673
USA        12,830    448

(per million population)

The data for new and active cases and new deaths tell a much starker story of a U.S. in an abysmal class all on its own:

Code: Select all

              New    New Active
            Cases Deaths  Cases

Austria      12.8    0.0  162.3
Belgium      19.0    0.3 3247.1
Canada       14.1    0.2  144.2
France       17.3    0.2 1064.6
Germany       9.8    0.2   75.9
Ireland       3.9    0.0 1067.4
Italy         4.2    0.1  203.3
Netherlands  11.2    0.0    N/A
Portugal     30.7    0.7 1303.2
Spain        48.2    0.1    N/A
Sweden        8.1    1.0    N/A
Switzerland  17.7    0.2  192.8
UK           11.3    1.8    N/A
USA         235.6    3.5 6257.2

(per million population)

At this rate, the U.S. will have the highest total deaths per million in a matter of weeks.

ETA:

4. Given that the U.S. is the most diverse country, has the most decentralized systems for dealing with this type of issue, has the least restrictions on individual behavior (hundreds of protesters standing shoulder to shoulder for hours at a time anyone?) and is a hub and the most visited and mobile country in the world, it is unrealistic to expect the U.S. to have relatively good numbers.

I'm sure that the fact that the U.S. is one of the few countries in the world* whose head of state and his minions have decided to politicize the virus, and the responses to it, played a big role.


* Brazil being another, with similar consequences

[BoSoxGal]

I feel a lot of despair these days; even if I remain smart and don’t catch the virus myself, I am gutted watching my country burn down around me. It really won’t matter much if Trump is defeated in November if this forest fire continues raging for the next 6 months killing another 150,000+ and devastating our economy for many years to come. We can’t even hope for widespread vaccination until late 2021/early 2022, and we can’t even really hope for that when 47-50% of Americans are already saying they won’t get a vaccine when it is available.

I’m watching the death throes of my country. I’m not sure I want to keep watching.