America’s Dark Winter
After President Trump asserted that we’re about to turn the corner on the coronavirus pandemic at the last presidential debate, President-elect Biden brought us back to reality warning that America was about to experience a “dark winter.” This was not just a vague reference to the fact that the virus is rapidly spreading all across the country and that our problems will soon be multiplied when the nation will also be beset by millions of anticipated cases of seasonal influenza. It was a reference to “Operation Dark Winter,” a two-day national security exercise conducted in June of 2001 which contemplated a terrorist attack on American soil utilizing a laboratory-grown variety of smallpox. That exercise consisted of a series of round-table discussions involving political, military and health officials and was designed to explore our nation’s ability to defend itself in the event of a biological attack.
What was revealed was that a biological attack against the United States could not only cause massive civilian casualties but could also initiate a breakdown of essential governmental institutions, incite civic disorder and undermine confidence in our government and our democratic processes. In particular, it revealed that our private sector-based healthcare system was ill-equipped to handle the volume of patients that would be generated by such an attack causing the nation’s hospitals to be quickly overwhelmed. As the death toll mounted, there would be breakdowns in coordination between the federal, state and local governments. States would compete with each other in an effort to secure medicines and equipment needed in their own healthcare facilities. In addition, as shortages developed panic would ensue. Efforts to educate the population as to how to best protect themselves and their communities would go unheeded as confidence in governmental institutions dropped.
Among the lessons learned from Operation Dark Winter was that it is critical to detect infectious agents at the earliest possible moment and to take immediate steps to contain them. A second lesson was that the nation must have readily available materials and pharmaceuticals to fight the disease and that those items must be quickly dispatched to the places where the disease is spreading. Invariably the supplies on hand would be insufficient in any given place when infections break out, making it important that resources be shared between communities and states and that the sharing be coordinated. Also important in fighting an epidemiological threat is keeping the populace informed and marshalling their cooperation in the efforts to combat the spread of infections.
The findings of Operation Dark Winter led to the publication in 2005 by the Bush administration of a plan for dealing with infectious disease pandemics. That plan was updated and expanded by the Obama administration in 2016 into a 69-page document entitled “The National Security Council Guidebook” which called for (a) the creation of the White House National Security Council Directorate for Global Health Security and Biodefense and (b) the expansion of the Strategic National Stockpile which had been created in 2003 to provide back-up quantities of pharmaceutical products and medical supplies. The lessons learned in Operation Dark Winter and the steps outlined by the previous administrations to combat the spread of infectious diseases sadly were ignored and cast aside by the Trump administration which not only failed to keep the Strategic National Stockpile well-stocked, but also declined to invoke the Defense Production Act and left to the states the job of securing their individual needs for medical supplies and equipment.
We are currently experiencing a third surge in new coronavirus cases that dwarfs what the nation experienced last spring and over the summer. Over the past week the number of daily new confirmed cases reached over 215,000 compared to the first peak of approximately 39,000 confirmed cases reached on April 25th and the second peak of 85,000 reached on July 24th. Another measure of the severity of the current surge is the number of hospitalizations for the virus which now exceeds 100,000, over twice as many as were experienced at the peaks experienced last spring and summer. Even though the nation’s doctors and hospitals have become far more proficient in treating COVID patients, the daily death rate now being recorded has reached over 2,900 which exceeds the worst days of last spring when New York City hospitals were so overrun that they had to park patients in tents erected in Central Park.
What is now taking place comes as no surprise to epidemiologists who have been predicting for months that we would be facing periodic surges in the spread of the coronavirus as the nation goes through periods of shut-down fatigue. It was also predicted that the virus would spread faster when cold weather embraced the nation because viral transmission is accelerated when colder temperatures prevail and when humans tend to congregate indoors where airborne diseases flourish. It was also predictable that a new season of influenza would arrive this fall, further stretching the capacity of the nation’s hospitals and healthcare workers.
Still, the surge in COVID cases we are now experiencing wasn’t projected to be more devastating than its predecessors. With each successive wave of infections, we were supposed to learn how the virus was transmitted and devise ways in which to retard its spread. It was also expected that we would develop new techniques for treating the virus as well as vaccines and therapeutics that would prevent its spread and diminish its lethal potential.
What epidemiologists did not foresee was that the virus would find a willing ally in our federal government that would enhance the virus’ lethal rampage by abdicating its responsibility to procure and distribute the resources required by healthcare workers. Nor did epidemiologists contemplate that the federal government would be providing the nation with disinformation about the seriousness of the situation, thereby weakening the nation’s efforts to contain the spread of the virus. Thus, the threat to our nation’s national security envisioned in Operation Dark Winter has been converted into a national disaster whose death toll is already projected to exceed that of World War II and could even surpass the over 620,00 Americans who died in our Civil War.
Particularly discouraging is the fact that the most pessimistic projections of last spring are now being approached. When the President’s Coronavirus Taskforce first started holding its daily press conferences last March, it projected that without intervention the United States could sustain a million deaths as a result of the pandemic. With efforts to contain the virus, however, the death toll was projected to be less than 100,000. Even that lower estimate was already much higher than what other industrialized nations were on track to experience because the United States, unlike them, had ignored the threat posed by the virus for over two months allowing it to spread unchecked before any meaningful steps were taken to control it.
Not only did the Trump administration ignore the principal findings of Operation Dark Winter, even now it’s continuing to act as if the virus will simply disappear. No nation-wide plans for combatting the spread of the virus are being formulated, much less implemented. Similarly, no efforts are being taken to coordinate the production and distribution of necessary supplies for healthcare workers and no efforts are being made to motivate the nation’s citizens to act responsibly. Quite to the contrary, both the White House and the Department of State have announced that they will be hosting a series of large indoor gatherings to celebrate the year-end holidays, gatherings that are destined to become super-spreader events.
As bad as the current situation is, it is projected to get much worse over the next four months. This can be attributed to three factors: First, the number of people who are likely to become infected is a function of the number of those who have been recently infected. Stated another way, one million contagious persons (roughly the number of persons who contracted the disease in the past seven days) can infect almost ten times as many people as 100,000 contagious persons. Secondly, the death rate of hospitalized COVID patients which has declined significantly since the first surge last April is likely to go up again as hospitals become overwhelmed and are unable to accommodate all persons requiring care. This is already happening in a number of states, compelling the reinstitution of the type of business lockdowns that were imposed last spring. This is a problem that affects rural areas even more than large metropolitan areas. That’s because rural areas tend to have fewer hospital beds than urban areas in relationship to the size of their respective populations. The third factor is the increasing burnout rate of public health officials and medical care providers. While temporary hospital facilities can be quickly established, trained medical personnel are not as easily replicated.
The sole coronavirus-related activities currently being undertaken by the federal government relate to the production and distribution of vaccines believed to be 95% effective against the virus. At this point, however, we can’t even be sure that level of effectiveness can be achieved because testing of the vaccines has been truncated in order to speed their delivery to the public. Normally, all pharmaceuticals are subject to two large-scale clinical trials before they are even submitted to the FDA for approval. In this case, only one such trial has been performed for each of the three vaccines which are now seeking emergency approval and those trials were much smaller than the trials normally conducted on new vaccines.
There are also numerous other problems associated with these vaccines that should dampen the administration’s reason for optimism. First is the problem of side effects. Many of those participating in the clinical trials experienced high fevers, headaches and muscle aches which could serve to discourage a significant segment of the population from becoming vaccinated, a problem that even exists in the absence of unpleasant side-effects. Secondly, in order to achieve maximum effectiveness, both the Pfizer and Moderna vaccines require two inoculations administered a few weeks apart. Because of adverse reactions, many people receiving their first inoculation may decide to forego the second, a phenomenon revealed in the clinical trials. The two-injection process also imposes extensive record keeping issues that do not arise with a single-dose vaccination. There are also countless manufacturing, distribution and administration problems that can be expected as a result of the requirement that both the Pfizer and Moderna vaccines be maintained at very low temperatures.
While emergency approvals and initial distributions of the vaccines are expected within days, it is likely to be a few months before a significant percentage of the population can be vaccinated against the virus. Widespread application of the vaccines is critical because the virus will continue to spread rapidly as long as there are a large number of individuals without immunity. Even assuming that there are already 120 million Americans who have contracted the virus (roughly eight times as many as have tested positive), vaccinating an additional 50 million Americans (which could take several months) would still leave approximately 160 million Americans vulnerable to the disease. Thus, we are likely to experience at least five (if not more) months before the vaccines will begin to have a noticeable effect in containing the spread of the virus.
Throughout the fall, the Trump administration was under the influence of Dr. Scott Atlas, a neuroradiologist who played an epidemiologist on Fox News. Dr. Atlas espoused achieving herd immunity by allowing virus to freely run its course until a high percentage of Americans become infected and thereby immune to the virus. When this happens, the number of potential further victims becomes so diminished that the virus ceases to spread and slowly disappears. It is generally believed that herd immunity begins to take effect when roughly two-thirds of the population has become infected. Herd immunity can also be achieved when a large percentage of the the population is immunized through a vaccination program, with the principal difference being that a vaccination program does not entail a large number of individuals actually becoming sick and dying.
To avoid that problem, Dr. Atlas suggested that those most vulnerable to the virus (i.e., the elderly and those with other serious medical conditions) be sheltered while the virus attacks those healthy enough to defend themselves against its adverse effects. Unfortunately, knowledgeable epidemiologists are united in the belief that it’s simply not feasible to isolate the vulnerable members of the population, a conclusion echoed by the entire faculty of the Stanford Medical School where Dr. Atlas once taught. Their recommendation is that the nation impose strict social separation policies and face mask requirements until enough Americans have been immunized against the disease to prevent it from taking further lives.
The sad truth is that we may already be well on our way toward herd immunity with its attendant staggering number of deaths. That’s not as far-fetched as it may sound. The Institute for Health Metrics and Evaluation is currently predicting that as of April 1st the U.S. will have experienced 538,000 deaths resulting from the coronavirus. That’s almost twice the current number of such deaths. That projection is largely premised on the assumption that we will continue on our current course of action which certainly seems likely for at least the next 45 days until the Biden administration takes over. As noted above, it is already estimated that approximately 120 million Americans have already become infected with the coronavirus. If the number of infections grows at the same rate as the number of deaths (actually, it should grow at a faster rate as a result of improvements in treating the disease), there would be 240 million Americans infected with the virus by the end of March. That would mean that by the time the vaccines currently awaiting FDA approval are widely applied over two thirds of the nation’s population would have already been infected which is the point at which experts say that herd immunity could begin to set in.
The big unknown is the extent to which the coronavirus has already made inroads beyond the number of confirmed cases. The 8 to 1 ratio of actual infections to confirmed cases noted above is simply the current best estimate. If the ratio is higher, herd immunity may kick in even earlier than April 1st. If the ratio is lower, herd immunity will not occur until later in the year when the available vaccines will begin having a noticeable effect on retarding the spread of the virus. Irrespective of when the spread of the virus is ultimately arrested, there is little doubt that we will be experiencing the type of dark winter that was envisioned in the 2001 war game bearing that name. It could be thought of as three straight months of daily 9/11-level casualties.
While the lethal onslaught of the magnitude that we are currently facing was first experienced in this country during the Spanish flu pandemic of 1918, the reason underlying our current plight was first identified in 1970 by the cartoonist Walk Kelly in his “Pogo” cartoon when his main character observed, “We have met the enemy and he is us.”