March 11, 2021

One year. 525,600 minutes as Jonathan Larson taught us in his anthem from ‘Rent’. One year ago today, the World Health Organization officially classified Covid-19 as a pandemic and the coronavirus crystallized into the national consciousness in a way that it had not in the past. I had seen it coming. I know enough about virology and epidemiology from a physician’s training to know it was out of control and coming our way several weeks earlier. I, naive as I was, assumed that the combination of the resources of the US government and our national character of pulling together in adversity were going to help us brace for the impact and deflect the damage. I hadn’t understood just how hollowed out and damaged our institutions had become or how fractured we were as a society until those first few weeks when a combination of willfulness, ignorance, and spite took over what should have been a time of courage and sacrifice laying the groundwork for the next year of our lives that would profoundly affect us all.

I had written the first piece of what was to become these Accidental Plague Diaries the evening before. I was well aware of the issues and what was happening but I was afraid to write about it, to actually give it form and shape with my words and make it more real. Eventually, the shadow on the horizon loomed too large and there was no way I could not write about it and still make sense of the world and so I wrote… and wrote… and wrote. Producing over a hundred essays over the course of the year exploring the virus, the disease, the impact on the health system, the impact on society, historical parallels, and how I found myself changed by what was happening around me. I am in the process of editing a significant portion of them into book form and hope to have it published this summer. As I reread and edit those early pieces, the emotional state of last spring – the not knowing, the understanding that my professional world could collapse, the steeling myself for the losses that would happen – comes creeping back. I’m more optimisitic now in general but still feel like I am carrying a huge weight from everything that has occurred since pandemic day a year ago.

On that day, there were a total of 29 known Covid deaths. As of today, there are nearly 531,000 – roughly the same number as in Jonathan Larson’s famous lyric. An average of one person a minute every minute for a year suddenly gone leaving a hole in our social fabric and a bereft group of family and friends wondering why? Pandemics are not new. They crop up routinely like other natural disasters such as earthquakes or hurricanes and have been since the human race decided that hanging out in groups is beneficial. The difference this time around was an ignoring of the pandemic for political reasons leading to a death toll many times higher than it needed to be. Numbers are down, vaccine is out, but the mortality rate remains about 1,500 a day nationwide. That’s enough to cut a full year off American life expectancy – two and a half years for most American populations of color and less for white populations. Covid was the third highest cause of death for 2020 – bested only by heart disease and cancer.

President Joe Biden signs executive orders regarding his administrations’s response to the COVID-19 pandemic, at the White House in Washington, Thursday, Jan. 21, 2021. The sprawling 200-page national pandemic strategy Biden announced here includes speeding production of COVID-19 supplies, increase testing capacity and requiring mask wearing during interstate travel. (Doug Mills/The New York Times)

The new administration is half way to the hundred day mark. It seems to have solved the problems of vaccine manufacture so there should be plenty of doses in the pipeline over the next month but has not yet completely solved the issues of vaccine distribution. The previous administrations plan of just distributing to state health departments, chronically underfunded institutions without much clinical infrastructure, turned out not to be the wisest of decisions and, as new rules have been put in place and vaccine is now sent to health systems used to creating clinical programs, things are improving in the get the shots in the arm deparment. We’ve still got quite a ways to go. UAB is opening up a 5th mass vaccination site this next week and I am pretty certain that the backlog of older and at risk people waiting for vaccinations will be cleared in our area by tax day. The VA, for all its faults, as a clinical system with access to supply from federal channels has done a heroic job with getting its patients vaccinated. The local VA has now given at least one shot to more than 50% of its active patients.

There’s been some good news on the vaccine front. New numbers out this week show that the Johnson and Johnson vaccine, where earlier studies showed less efficacy post vaccination than Moderna and Pfizer, is pretty much equally effective after six weeks. So it doesn’t really matter which of the three you get. Six weeks after the initial inocculation, you’re pretty protected. There’s also new data out of Israel (the country which has done of the best jobs in getting its entire population vaccinated) suggesting that all of the vaccines significantly lower transmission rates in the community as well as protecting the individual. Pretty much all of the adult US population seeking vaccine should be well protected by late spring. Then comes the problem of trying to handle the significant portion of the population which will refuse for political or other reasons. As long as that sector of the population remains the size it is, the virus is going to continue to be an issue. I don’t have a solution for this one.

A number of people have approached me about getting vaccinations for frail elders bed bound at home who cannot easily be gotten into cars for drive through vaccination settings. It’s a population near and dear to my heart, the people that made me realize that geriatric medicine was my calling and around whom I have designed my career. I know what the problem is. The legislation regarding vaccine has the cost of the medication itself borne by the federal government. However, providers are allowed to charge an administration fee (waived by most programs currently) to cover their costs for supplies/labor etc. Delivering vaccine to homes is a labor intense proposition. Even using the Johnson and Johnson that does not require the cold chain still means a skilled vaccinator having to go out and administer. As all of the vaccines are under emergency use protocols, there are things that must be done in terms of paperwork and patient monitoring that are not necessary with approved vaccines like flu shots. It will take 30-40 minutes per household to deliver shots and, with travel time, you might be able to get in ten visits a day per vaccinator. No one has decided that they want to be the organization that is going to absorb these costs (with the exception of the VA locally) which is why it’s just not available. The state doesn’t have the money. Almost all health institutions are for profit in some way and aren’t going to want to take on a considerable unreimbursed cost. It will get solved eventually but things are a bit at an impasse.

Until all of these kinks can be worked out, even if you’re vaccinated, you know what you still need to do. Wear your mask. Wash your hands. Keep your distance. Like we’re doing on our imaginary beach in Penzance.

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