‘This Epidemic Is Hundreds of Micro-Epidemics’
Back in March when the Covid-19 outbreak was in its early days, I asked my brother Steve to join me on The Vermont Conversation, a radio show and podcast that I host, to talk about what we could expect with this new virus. Steve Goodman, MD, MHS, PhD, is an associate dean at Stanford Medical School, where he is also a professor of epidemiology and population health and of medicine. When we spoke in March, Steve described the coronavirus as a tsunami about to overwhelm us. His words were prescient: nine months later, over 350,000 Americans have died from Covid-19 and at least 20 million people have been infected. Vermont, where I live, once an outlier with few Covid infections, now averages about 100 new cases and several deaths per day.
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I asked Steve for his thoughts on the Year of the Pandemic: where we are, how we got here, and how it ends. We spoke on December 30, 2020; you can hear our full discussion on the Vermont Conversation podcast. This partial transcript has been edited for length and clarity.
David Goodman, Elemental: President-Elect Biden said recently that the toughest days of the pandemic are ahead of us. That’s an extraordinary prediction from our nation’s incoming leader. What do you see as you look ahead?
Steve Goodman: The Covid-19 rates across the country right now are reaching peaks not seen before. The rates are starting to come down in a number of states, but they are coming down from very, very high levels. And the post-Christmas surge may be frighteningly large. It is clear that many families gathered indoors without masks and then went back to their communities, which is a potent way to spread the virus nationwide. There could be another Covid bomb that detonates just before Biden comes in.
We already have over 350,000 dead, with daily death tolls surpassing 3,000 people. How bad can it get?
We’re at a very high level but I think it is going to turn around in the next few months. We’re just beginning to see the first signs of that even if the Christmas surge temporarily reverses it. Biden’s team takes science seriously, will message consistently and forcefully about what should be done, and with more immunizations, we will have a countervailing force. A large percentage of deaths come from the elderly. Sixty percent of the deaths are in people 75 and older, 80% are in those 65 and older — and they only make up about 17% of the population, with a much smaller percent living in long-term care facilities. So if we just immunize the folks over 75 and those who live in long-term care facilities, we immediately reduce the number of deaths by 60–70%, taking pressure off the medical care system.
“There could be another Covid bomb that detonates just before Biden comes in.”
If we were to vaccinate everyone over 50 years of age, is that enough for us to then resume some semblance of normal life?
If death is the only metric and we could have everybody over 50 immunized tomorrow, then yes, we would probably be able to get back to normal life. But it’s a long way between now and then. And age and death are not the only factors here. It’s easily going to be six to nine months before we can get anywhere close to vaccinating the percentage of the population that would get us back to “life as normal.” Between now and then we’re going to have to continue to maintain virtually everything we’re doing now, including masking and distancing.
This epidemic is hundreds of micro-epidemics. It’s hyper-local. Vaccine uptake is going to vary, as is the degree of distancing and masking. So while we might be able to control the virus pretty well across the country, we’re still going to see hotspots. We also know that there’s a lot of hesitancy about the vaccines right now, especially in minority and high-risk communities. That may fade as millions get vaccinated, or it may increase if we start to see side effects that we’re not anticipating. It’s about continued messaging, surveillance, and trust within the communities that these vaccines, about which we don’t have full information, are on balance good for them.
The other critical thing that we don’t know is how long the vaccine protection lasts. We have good reason to believe it will last at least nine months to a year, but we don’t know that yet. There’s a lot to learn.
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You testified before the FDA in December about both the Pfizer and Moderna vaccines. What’s new and special about these mRNA vaccines?
The M is for messenger and RNA is the nucleic acid which is the key intermediary between DNA, our genetic code, and the formation of proteins, which make up the substance of our bodies. There’s never been an mRNA vaccine approved for general use. mRNA vaccines are extremely clever. They provide a blueprint — the mRNA — that gets into the cell and tricks it into creating the same spike protein that appears on the surface of the coronavirus, but there’s no virus. Then the body reacts and creates antibodies to that protein, so if the virus ever invades, the body is poised to attack infected cells which show the spike protein.
These vaccines look to be extraordinarily safe. About 2 million Americans have now been vaccinated and we’re only seeing a few reactions. The threat from Covid-19 is much, much greater than any possible threat of the vaccine itself, so the risk-benefit ratio right now looks to be pretty spectacular.
“I’m surprised that we’re in a third wave. I thought we would learn our lesson…I didn’t think that every area of this country would be in denial until they were overwhelmed.”
How did the richest country in the world become home to the worst outbreak of Covid-19 in the world? Is this a failure of traditional public health measures or is it something else?
This is a story that will be told and retold as a cautionary lesson. What’s obvious is that we did not have leadership from the top. We did not have a consistent public health message or a dependence on science. And we did not have anything remotely like a national strategy to combat anything. We saw it right from the beginning in the president’s downplaying of the virus’s seriousness, which he told Bob Woodward he knew to be false at the time. That was particularly shocking. In order to get people to do what they probably would not like to do — wear masks and stay away from other people — you need planning, and a consistent, rational justification from the top. We had none of that.
Instead, there was a tremendous amount of strife, controversy, and counter-messaging. Advisors told the president what he wanted to hear, advancing a bizarre idea that the more “low risk” people that got sick, the more we would be protected. It’s not a plan that could ever have worked. The failure at the top made it very difficult for others to build their own effective responses, even though most governors desperately tried. There was also a neutering and silencing of our main public health agency, the Centers for Disease Control.
I don’t think there was a failure of public health per se, but there has been a failure of investment in public health over decades. Prevention efforts have been repeatedly cut, including those around epidemic prevention. So our public health infrastructure was not up to the task. Even with ideal leadership from the top, we didn’t have the people, the things, the communication infrastructure — we had almost none of the pieces in sufficient volume to respond to this. I don’t want to call it a public health failure because everybody in public health was trying so hard; none of them failed. But when no resources are devoted to the infrastructure, it is completely predictable that the response to one of the great challenges of our generation would be inadequate.
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2020 is the Year of the Pandemic. When we talked in March, where did you think we would be by the end of the year?
I’m surprised that we’re in a third wave. I thought we would learn our lesson. I thought that Ohio would learn from New York, and Indiana would learn from Ohio, and the Dakotas would learn from Indiana. I didn’t think that every area of this country would be in denial until they were overwhelmed. I thought back then that there would be more federal response once they actually realized the seriousness of this. So I am surprised that there hasn’t been a nationally coordinated response by now.
I also never saw coming the politicization of basic public health measures, that it would be seen as a weird badge of honor, or toughness, or machismo not to wear a mask and to engage in mass spreading behavior. It’s all contributed to this disaster.
I did see the potential for disaster if nothing much was done. I didn’t anticipate so little being done, and particularly that there would be so many people working to make it worse.
How does this end?
I think we’re at the beginning of that ending, but it’s going to be a long last chapter. It’s going to end in this country with a more coherent, integrated, coordinated public health response combined with more effective, and hopefully fair and just distribution of vaccines, as fast as we can get them out. I can’t quite see life getting back to normal on a national basis until sometime between June and September.
Even if it “ends” here, what will happen around the world, in India, in Africa, parts of Asia? That’s where we’re going to have to be looking and helping a huge amount.