August 13 covid-19 update

This week in brief: South Africa is flattening its curve of new infections, and deaths are much lower than I would have expected at this point in the epidemic. The U.S. continues on the same trajectory it's been on for the last couple months, and is adding more than 1,000 deaths a day (on average). Italy is still keeping its epidemic well under control, with fewer than 50 covid-19 deaths in the past week. While it's easy to think of Italy's success as predictable and barely deserving commentary at this point, remember that back in March, Italy was stunning the world with the severity of its epidemic and its high death rates. I'll say it again - there is nothing inevitable about the course of this epidemic in various countries, and we are choose our future through our collective actions and decisions.

South Africa IS changing the course of its epidemic. The easiest way to see this (for me at least) is by looking at the log graphs, which are the middle row. Log graphs show exponential growth as a straight line. So if you hold a straight edge (ruler, edge of your cell phone, whatever) up to that green line in the cases by week (log scale) graph, and follow the trajectory that South Africa was on 4-5 weeks ago, you'll see that it was on track to catch up with the U.S. in terms of cases by the end of August. (Yes, a country of 59 million people was set to reach the same number of total cases as a country of 330 million people - that is the terrible power of exponential growth.) I'll remind us all of the caveats here (which we've discussed extensively in past posts) - that confirmed cases are only a small fraction of total infections, and that an epidemic may seem to be slowing if testing is falling further behind actual infections. But as I've looked at the test positivity rate for South Africa in the past few weeks, I haven't seen evidence of this (see the last couple posts for more on this).

There's one other thing working in South Africa's favor, but not the United States's favor. South Africa is currently in the middle of winter, the season when transmission of the virus should be the worst. So as South Africa moves into summer in the remaining months of 2020, this should further slow the epidemic. People will increasingly move outdoors, where greater distance between people and more air flow keeps the spread of the virus in check. The U.S. is in the opposite position of coming to the end of summer, when transmission should have been lowest, and moving into winter. Things will likely only get worse over the next few months as we move indoors and breathe each other's exhaled air in enclosed spaces (and many buildings in the U.S., including schools, have very poor ventilation). See below for an insightful article on the reality that winter is coming in the northern hemisphere.

I'm short on time this week so am just going to list some interesting things I've been reading, in no particular order and with a minimum of commentary:

1. On the topic of "winter is coming" in the northern hemisphere, this scary but prescient piece from Stat News (always a good source), which quotes Michael Osterholm (who is worth listening to at every opportunity): Winter is coming: Why America’s window of opportunity to beat back Covid-19 is closing

2. Some of you may have read (or read about) the research letter published in Journal of the American Medical Association (JAMA) a couple weeks ago, which was widely interpreted to mean that children in fact are efficient spreaders of the virus. I didn't feature the research in these posts because after reading the original study and some responses (at JAMA's site) written by people with far more expertise than I possess, I had serious doubts that the research was actually saying what people were saying it was saying. I know it's counterintuitive, but I continue to think that in-person school for younger kids (<10) is not going to turn out to be a super-spread event. This New York Times piece, written by a pediatrician and professor (Naomi Bardach), lays out the case for why this is true: Kids Aren’t Big Covid-19 Spreaders. Really. She's also very quotable in this article, on the insanity of the fact that in the U.S. we've opened bars and restaurants before schools.

3. Yet there's still so much we don't know about how this virus is spreading (coronavirus conundrums abound), teenagers are likely equivalent to adults in their ability to transmit the virus, and nowhere in the U.S. should we be seeing school hallways packed with unmasked teenagers (common sense does not abound): Children and the virus: As schools reopen, much remains unknown about the risk to kids and the peril they pose to others

4. This is now a few weeks old, but for anyone needing convincing that hydroxychloroquine isn't a miracle cure (or who has friends / acquaintances / conspiracy-prone great aunts who need convincing), this is a good and thoroughly exhaustive summary of the research to date, even if you can hear the author angrily gnashing his teeth as he writes (he has no interest in sticking to careful, neutral language): Hydroxychloroquine to treat COVID-19: Evidence can’t seem to kill it

5. I am quite sure that this study showing a TRIPLING of neonatal mortality during Nepal's lockdown is not an outlier, when it comes to collateral damage of this epidemic (and ensuing lockdowns) on healthcare access and outcomes, especially in the developing world. To quote, "Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care." (I know it may not sound like it due to the neutral and dry academic language, but trust me, the researchers are gnashing their teeth in frustration and anguish over this cost to the lives of women and children.) Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study

6. In preparation for teaching a class in a couple weeks, I am re-reading Steven Berlin Johnson's brilliant book about London's cholera epidemic of 1854, John Snow, and the Broad Street pump (the modern science of epidemiology basically started there). I just found out SBJ has a podcast about coronavirus, which I am hoping to binge-listen to this weekend. So I am recommending it (out of the many many coronavirus podcasts out there) without having heard a minute of it, but because I am confident in SBJ's ability to tell the story of an epidemic in a way that is gripping, accessible, and deeply insightful. Fighting Coronavirus: A new podcast on how we’re going to make it through the COVID-19 crisis, and the world we want to live in when it’s over.