Wait - why is Jason talking about COVID-19? And why are these written like FaceBook posts? There’s a longer explanation here but the short version is that my day job for the past 15 years has been developing models of human health effects and medical response for chemical injuries and biological illnesses, including pandemics. I’ve been making these posts on FaceBook and I was asked to put them in a more shareable manner. I’m linking to the posts on the explanation page. These are the original, unedited posts. I’ll continue until I run out of things to say.
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Originally posted here on March 27th.
Hello again fam and friends -
I took a week off from COVID-19 posts but I’m back today. I want to do a little recap to catch us up to where we are right now and then I want to talk a little bit about where we probably should be right now.
First off, to be honest, I have no idea where to start. My first post (https://www.facebook.com/Jason.Rod/posts/10157043200357643) was about not panicking, but about how quarantine shouldn’t be equated with panicking. Since then I’ve seen a lot of folks stay home, take care of their community, take care of their neighbors, and take care of themselves. It’s been great to watch.
My second post (https://www.facebook.com/Jason.Rod/posts/10157048106292643) was about the mathematics of pandemics - about the importance of keeping the infectious people away from the susceptible people in the absence of vaccines or strong therapeutics.
My third post (https://www.facebook.com/Jason.Rod/posts/10157050713622643) was about crisis standards of care, and what happens when you start to tax critical resources. I talked about ventilators and how important they’d be during this pandemic. That wasn’t a thought that was new or novel - we (the disaster planning community) knew ventilators would be a chokepoint for a very long time. It’s why they’re in the Strategic National Stockpile.
Maybe I’ll extrapolate on this a little bit, because it’s non-intuitive to understand the importance of ventilators. Let’s say you have a severe infection and your lungs just start to fill-up with gunk. You’re essentially drowning; you’re not pulling in enough oxygen to keep your basic functions operating. The ventilators don’t cure you, they buy you time. They supply oxygen to your body so that your immune system can have the necessary time to attack the virus. They give you the time to not just fight the virus, but to heal your lungs. The ventilator does a very important job; one that cannot be turned off during your treatment which could last weeks in the case of COVID-19.
The problem becomes untenable when you have too many severe infections. Let’s say you start with a single severe infection and you put them on a ventilator. The next day you have two more severe infections. Now you need three ventilators. The next day you have five more serious infections, now you need eight ventilators. Eventually, that first person will come off the ventilator, but at that point you’ll have a hundred or so people on ventilators. Those hundred people will eventually come off the ventilator, but at that point you’ll have several thousand people on ventilators. The longer a patient needs to be on a ventilator, the more total ventilators you will need. And as cases increase exponentially, ventilator needs increase at an even faster rate, because the folks from last week still need their ventilator.
That’s how you get into crisis standards of care, during which doctors need to start their day by assessing how many ventilators they have, how many patients they have, and which patients have the best shot at a full life after treatment. That’s when you start to unhook the elderly. That’s when you start to unhook the folks with preexisting conditions. And they’re doing that because some 20, 30, or 40 year-old person thought they wouldn’t get sick but now needs a ventilator. It is a terrible decision for a doctor to have to make. That was the crux of my fourth post (https://www.facebook.com/Jason.Rod/posts/10157065548457643), when I talked about how case fatality rate is highly dependent on the level of care you can give people.
None of these things are new concepts. They pre-date me, and I’ve been working in this field for 15 years. My mentor laid it out for me in a way that I still like to talk about it. He’s been doing this type of work since the early 90s, following in the footsteps of his mentor who had been working in this field since the early 80s. His version of the history of disaster planning goes something like this:
Back during the Cold War, the disaster was always a large exchange of nuclear weapons. Planning was always based on, first of all, how do we get our weapons fired off first and how much loss will we suffer if we don’t. The idea of treating people, of doing anything outside of rounding up the folks who sheltered when the bombs dropped, was inconceivable.
But then the Cold War ended, and the question that was left was, “Can we survive one nuke?” In this case, the “we” was the US military and the answer was, “Yeah...and we can probably continue the fight.” Eventually that question got extrapolated to chemical munitions and biological attacks. In the late-90s the questions shifted even more. It now became, “Ok, we’ll survive and we’ll fight on...but can we also treat the injured?” And the answer there was also yes, and models and tools were developed to figure out how to treat the injured - how much stuff was needed, when was it needed, etc. In some scenarios, blood would be the bottleneck. In some it would be antibiotics. In many of these scenarios, ventilators became a bottleneck, particularly if you didn’t act quick enough.
Then 9/11 happened, and the question became, “Can an American city survive one nuke, chemical attack, or biological attack.” The biological attack had a counterpart- a major pandemic- I first entered this field around the same time people started becoming very interested in the pandemic question.
You see, with a nuke...the impact happens in one spot. There would be many injuries and deaths but, to be honest, probably not as many as you’re thinking right now. But the medical need is eventually over - more patients will show up in the weeks and months after the blast, but eventually that will taper off. You move all of the support pieces to that one area, you do the best you can over a several month period, and then you focus on rebuilding.
But with a pandemic, everything gets stressed. If you do nothing, you ultimately end up losing more people than you would with a nuke, but spread out over the entire country. You lose millions of people in the wide-open spaces of rural America, and the cities have too many people to account for.
So unlike the nuke, the chemical weapon, and the biological release, the answer to whether or not we can survive and treat people during a pandemic has always been, “Yes...if.”
And the “if” was always about messaging. It was always about rapid response, containment, testing, closing schools, social distancing. It was always about a strong federal response. It was always about cooperation with the states. That is the “if.”
I think we got to where we are pretty late, but I also think that many local and state governments are doing a good job of catching up. April is going to be bad. May will be worse if we become lax, or if other states and localities continue to not take this seriously enough. This is a once-in-living-memory event. Everyone alive right now, across the entire globe, will be talking about the spring of 2020 for the rest of their lives. It will shape our politics, our societies, and our economies for decades. In American History it will be one of the big three events alongside the Revolution and the Civil War.
And that’s even IF we continue to do the right thing in April.
Pandemics, as mentioned, are, “We can handle this...if.”
Love you all. Stay safe. Take care of your neighbors and take care of yourself.
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These are my opinions and thoughts and analyses - I am not representing any government agency or my company. More disclaimers on the main page.