Where are we now: Omicron & Irrational Hope – Michael Fine

By Michael Fine, contributing writer, RINewsToday

Where We Are Now: January 9 -14, 2022.  Omicron and Irrational Hope.  

© Michael Fine 2022

Okay, Dr. Fine, I imagine some of you are saying.  January 7th came and went.  You said we’d see 12,000 new cases in Rhode Island in a single day by then.  And here we are, with no more than 6,000! And truth be told, you’d be more on target than you may know.  

Part of Rhode Island’s jump in numbers over the last week was due to increased testing, which is up by about 30 percent over two weeks.  When you correct for that increased testing, our adjusted number of new cases, everything else being equal, is up by “only” 10 or 20 percent in ten days.  Not the 300 percent I was projecting.  All of which means Rhode Island is likely “only” the third or fourth most infected state in the nation at the moment, instead of the most infected state by a large margin, which is what the raw number suggests, not that our adjusted rank makes me feel any better about where we are now.  

Rhode Island is something like 16^th or 17^th in the nation for recent hospitalizations and deaths, which may mean that what we are looking at is just the result of lots of testing of people with mild disease – but it also may mean we haven’t yet seen the hospitalizations and deaths that might result from our recent surge, which lag any increase in cases by two to three weeks.

My first response is, whew!  I love to be wrong when being wrong suggests that we have fewer people ill than I thought we would have, and fewer hospitalizations and deaths, which follow new cases by about two and three weeks, respectively. That means we have “only” 3,500 to 4,000 new cases a day after you correct for the new testing to keep the denominators straight, or thereabouts.  Which will lead to “only” nine to ten deaths a day in two weeks, if Omicron is half as virulent as Delta, instead of the 13 to 15 deaths a day I’d be projecting before adjusting for the new testing.  Not that the adjusted numbers make me feel that much better about where we are now with tested positive cases.  Or that we really know anything yet about Omicron’s virulence when compared to Delta, so that all projections are more vapor than substance.

5 Things

There are five things that might account for the slower growth in cases than I expected, only some of which give me any hope. People could be staying home and masking, and many who read this are – and that would slow the spread of Omicron.  Rhode Island is about half immunized with Moderna, and Moderna could be more protective than Pfizer, remembering the numbers on which my projections are based come from Israel, which is an all-Pfizer immunized nation. Then, vaccination itself may be slowing the spread more than studies from Israel would have predicted they would, which would be a very good thing.  Immunity from recent Delta infection might also be more protective against Omicron than we’ve realized, which might help to slow Omicron’s spread in Rhode Island since we’ve been so heavily infected with Delta. 

More likely, however, that the slower growth in cases is because we still have Delta circulating – we were at about a thousand new cases/1000/per week of Delta in Rhode Island when Omicron hit — so, likely Delta is still spreading in some communities, with more slowly growing spread.  And likely Omicron hasn’t wormed its way into some of our communities quite yet, so in those communities, likely Omicron spread was delayed, but is coming. That’s the source of my concern.  

Some communities are now testing 32 to 40 percent positive.  I just heard about one school in a densely populated community, now closed for two weeks, where students and staff were more than fifty percent positive last week.  So most likely Omicron moved first into our most densely packed communities, is infecting those now, and will spread to other places in Rhode Island this and next week.  I hope I’m wrong, but those very big numbers of daily test positives – over ten thousand a day, could still be coming at us in the next two weeks, with lots of hospitalizations two weeks later and too many deaths – as many as 25 to 30 a day – in the weeks after that. Projections are just that – projections – but forewarned is forearmed, if we take the time to prepare.

But we are not really preparing as far as I can tell.  We are just testing more people and vaccinating as many as we can.  Vaccination helps protect individuals against hospitalization and death and likely slows but appears not to stop the spread of the virus.  

A sensation of chaos

So it looks like the virus will spread until it infects everyone it can reach.  And so for the next few weeks we may keep having school closures and business closures because too many people will be out at once, not enough police and fire protection for the same reason, and the sensation of chaos, I fear.  (Some police departments have fully half of their staffs out sick this week, I’m told).  CDCs shifting recommendations, which have become more difficult to understand over time, add to this perception. And the perception that government can’t get it right, that the left hand doesn’t know what the right hand is doing, that we are woefully unprepared, will add to our sense of being a divided nation and cause some of us to abandon hope, a very dangerous state of affairs indeed, given our political morass.

What would preparations have looked like? 

If we had been on top of our game, we would have used the Defense Production Act two years ago and started to manufacture N95 masks in the US, and so we would have had an adequate supply on hand now, instead of having to wait for cargo ships to unload masks made in China again, the source of both N95 and KN95 masks. (The otherwise adequate KN95 version are masks manufactured in China to the Chinese standard, not the American standard, thank you very much.)

If we had been on top of our game, we would have had a zillion rapid tests manufactured in the U.S. and already widely deployed, so we would be able to test everyone in a school daily, as well as everyone who enters a public place on entry.  (The President brags about 500 million rapid tests which might actually be distributed in the next few weeks.  That’s a nice big number but is only one or so test per person, when you do the math.  We need one test per person per day for the next month for testing to be effective in stopping disease transmission.)

If we had been on top of our game, we would have mass produced rapid PCR testing machines and their reagents and put one of those machines in every school so we could test all our kids twice a week. (Rapid PCR machines can run a PCR test in 35 minutes. Each machine costs about $20,000. Their reagents cost between $50 and $75 a test.) Why, oh why, didn’t we take that very good technology, scale it up, and put one of those machines in every American school?  We built a zillion B52 bombers in no time during World War II.  Why couldn’t we do this?

If we had been on top of our game, we would have grabbed the two antivirals that were in clinical trials last spring and that showed good results by the summer (one so good that the trial was stopped in November) and pushed its production, and pushed the production of the monoclonal antibodies that appeared to be working, so that now we wouldn’t be caught flatfooted in the middle of a variant surge with no supply – and now have no good way to stop hospitalizations and deaths in infected vulnerable people, who we’ve known were vulnerable despite vaccination since the summer.  

And, if we were at the top of our game, we’d have thousands and thousands of public health workers recruited, trained, and deployed right now, so we could stop depending on volunteers in our vaccination clinics and hospitals, and so we had workforce for testing and masking and the deployment of the antivirals and monoclonal antibodies that we should be deploying right now.

Yes, hindsight is always twenty-twenty, but our failure on masks, testing and the public health workforce makes it clear that we’ve never approached controlling this pandemic with requisite commitment and seriousness. This is a battle that we have never mobilized a fight against. I keep calling our response the penny-wise-pound-foolish, day-late-dollar-short snowflake response, and every day I get more convinced I am right to call it that.

And yet, the open question in the minds of many is still whether preparations and prevention actually save lives. It’s hard for us in the U.S. to know now because we failed to prepare adequately. That said, the question has become most acute in the last few days, when it became apparent we don’t have adequate supplies of the medicine we need to save lives. Paxlovid, a combination of the two antiviral medications with activity against Omicron, and Sotrovimab, the monoclonal antibody that is active against Omicron, are both in very short supply and likely won’t be widely available until at least February but more likely not until April.  Which means the one intervention that might prevent hospitalizations and save lives isn’t available to the people who need it. 

At the same time other places like Toronto, who has done everything right, is also experiencing an explosion of disease, and is up to 597 new cases/100000/week from 14, remembering Rhode Island is up to over 3000 new cases/100000 per week, up from about 300 in the same time period. Now the Boston Globe is reporting that the University of Washington’s projections suggest that Rhode Island will have another 250-300 or so deaths by the middle of February, regardless of what we try to do to prevent those deaths. Maybe our masking and staying home and even closing schools when they become overwhelmingly infected is just delaying hospitalizations and deaths, which is what many people think.  Maybe we are just delaying the inevitable?  

How long can we stand all this?

And how long can we can stand all this, anyway, all this masking and so forth?  I can’t tell you how desperately I want to hear live music again.  I suspect many people are like that, in one way or the other.  We want to live, not cower in our houses in fear.  We might give prevention a week or a month, but this is getting ridiculous.  What good is not dying, if the result is not living?

I have a scientific answer and a novelist’s answer.

The scientific answer is that I think the University of Washington is wrong, and that we can still save more lives, as late as it is to start trying to do so, and that we only have to stay bottled up for another four weeks or so to do that. Omicron is going to recede, likely in another three or four weeks, a little more slowly than I hoped, but it won’t last forever, or even very much longer.  And we can do better by shaving points, by masking inside everywhere so we get to 95 percent masked (the University of Washington used 80 percent for their projections – not enough!) by protecting those at risk just a little longer until the antiviral and monoclonal antibody supplies arrive (remember Balto!), by rapid testing everyone in congregate setting every day, by vaccinating everything and everybody that moves, by isolating infected people ten days, not five, by not shopping and by avoiding bars and restaurants.

Better yet, if we do this ourselves, then we will have done what government seems unable to do, which is to lead with courage, sacrifice a little, and build back better ourselves, while injecting a little juice into our common life and maybe also into our democracy itself. 

I’m guessing we can save 50 to 100 lives that way, in Rhode Island alone. I can’t prove that, and we will never know if I was right or not because of the paradox of prevention (you can’t count what didn’t happen) BUT there is little or no real cost in trying.

Which brings me to the novelist’s answer.  So what if I’m wrong?  So what if all I’m talking about is just irrational hope, if nothing we do now matters, and those 250-300 people who are likely to die according to these projections die anyway? Their loss will be a tragedy, yes, but in the meantime, we will have created irrational hope once again!  

The phoenix out of the ashes? Isn’t that a good thing?  Aren’t we the people of irrational hope?  Isn’t that who we want to be?  Exemplifying hope for better, longer and happier lives, hope for better health, hope for more justice and more equality, and hope for a future that is even better than the past?  Don’t we want to be the people of irrational hope?  Or are we the people of bars and restaurants and partying through the apocalypse? I don’t know if we can save lives, but I think it is worth it for all of us to do our level best to try.  

Want to make America great again?

Let’s step up to the plate, even if the damn Pawsox did move to Worcester.  I think irrational hope is exactly what America’s greatness was and exactly what America’s greatness is and will be again.

Be careful out there.  If we try, try and try, we’ll succeed at last.

Many thanks again  to Nick Landekic, who provided me with tons of data and publications over the last twenty months, and whose knowledge of Covid-19 is encyclopedic; to Deborah Faith, MPH, for her unending editorial support and great editorial suggestions, and to Kendra Tanquay, for her support of my writing over many months.

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Michael Fine, MD was the Director of the Rhode Island Department of Health from February of 2011 until March of 2015. His career has been devoted to healthcare reform and the care of under-served populations. He served as Medical Program Director at the Rhode Island Department of Corrections; and founder and Managing Director of HealthAccessRI, the nation’s first statewide organization making prepaid, reduced fee-for-service primary care available to people without employer-provided health insurance.

Dr. Fine practiced for 16 years in urban Pawtucket, and rural Scituate, RI. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the former Physician-in-Chief of the Rhode Island and Miriam Hospitals’ Departments of Family and Community Medicine. He was co-chair of the Allied Advocacy Group for Integrated Primary Care.

He currently serves on the Boards of Crossroads Rhode Island, the state’s largest service organization for the homeless, the Lown Institute, the George Wiley Center, and RICARES. Dr. Fine founded the Scituate Health Alliance.

Dr. Fine is past President of the Rhode Island Academy of Family Physicians, has served on a number of legislative committees for the RI General Assembly, chaired the Primary Care Advisory Committee for the RIDOH, and sat on both the Urban Family Medicine Task Force of the American Academy of Family Physicians and the National Advisory Council to the National Health Services Corps.