WHY AMERICA IS SO SICK

Blame it on our national failure of discipline and imagination

The American strategy for overcoming COVID-19 does not exist. The virus is out of control in almost every state. More than 160,000 people have died, and many more are going to die, most of whom are nervously watching the news right now just like everyone else. This terrible, bitterly sad reality was avoidable had we acted in an informed, organized, and disciplined way as a country. Instead, our worst selves continue to overcome us.

We can’t even see the truth clearly: Critically important data that reveal the depth of our collective failure is now being diverted from the CDC to the White House alone, and some individual states are actively suppressing data for political reasons. Statistics on the true numbers of healthcare workers who have both caught this virus and died from it have been similarly withheld from the public.

As a new school year begins, arbitrary and incoherent state re-openings continue, and more than 1,000 people keep dying each day, we’re waiting for vaccines. That’s our plan. Biotech companies are racing to develop them, in part to do good, in part from scientific ambition, but also because there are great sums of money to be made.

Vaccines may deliver us in the end. But this is not certain, and either way it won’t be quick. It will be a year or more before this country is fully vaccinated against COVID-19, and that will be too late for many regardless of how well any vaccine ultimately works.

But we’ve had a crude vaccine all along. It’s been right in front of us since the start. It’s called PPE, and we need to urgently correct our narrow and unimaginative view of how this technology could be used.

PPE — personal protective equipment — has no glamour to its name. It’s not big science. It’s awkward to use. But it works, and right now it arguably offers the single best hope of blunting the cruelty of this pandemic until more effective measures are available.

People think of PPE as something doctors and nurses wear. They think of gowns and masks, goggles and gloves, like priestly vestments.

But anyone can wear PPE, and PPE takes many forms. As a nation, we have explored none of the ways in which the entire concept might be broadened and improved to protect both the public and the economy. As the disastrous experiments in Florida, Texas, Arizona and elsewhere have so clearly demonstrated, until this illness is controlled, meaningful economic recovery is impossible.

Despite the scientific advances of the past hundred years, and a frenzy of ongoing research, there is still no effective treatment for COVID-19. With the exception of viral testing, the tools at our disposal today are overwhelmingly low-tech measures little different from our options in 1918: lockdowns, social distancing, contact tracing and selective quarantines.

When employed with competence, discipline, and collective will, these tools work. South Korea, a nation of 53 million which reported its first confirmed case on the same day as the United States, has lost a total of 302 people to COVID-19 as of this writing.

Other Asian countries, such as Taiwan, Singapore, Japan, China and even Vietnam have saved innumerable lives through simple public health interventions, and most of Western Europe, after a slow start, has rapidly caught up to the high levels of performance demonstrated by many Asian nations.

There is no magic to these Asian successes. There is instead the simple fact that competent, aggressive public health containment measures were begun early, and that everyone wears masks in public all the time.

Nonetheless, as the months pass, these containment measures grow increasingly difficult to sustain for both economic and psychological reasons regardless of where one is on Earth. But PPE, and especially better PPE, is not impossible to sustain.

Many of those currently asserting their right not to wear masks in public seem to forget that society places an abundance of limits on individual freedoms in the interest of the collective good. We even have a word for those limits: They are called laws.

You cannot sell illicit drugs to the public. You must pay taxes. You must wear seat belts and put your children in car seats. Drunk driving is prohibited because the public has the right not to be killed by drunk drivers.

Masks, of course, are no different. Why are we even having this discussion?

The most basic type of PPE is a cloth face mask. According to a recent study, had people in this country reliably worn even bandanas since the beginning of the outbreak, at least 15,000 lives would have so far been saved.

The next step up is surgical masks. They are only slightly more effective. The chief virtue of both cloth and surgical masks is not to the wearer, but to everyone else: they block larger droplets, and consequently reduce the ability of an infected person to spread the virus to others. Although better than nothing, surgical masks were never designed to protect the user from aerosolized infections, and SARS-CoV-2 is at least partially transmitted through aerosols — very fine microscopic particles that can remain in still air for extended periods of time.

To protect against aerosols, you need an N95 respirator. They are made from denser material and form a tight seal on the face. They are uncomfortable to wear for long periods and must be fitted.

But when used correctly, they filter 95% percent of the smallest viral particles, and are highly effective at preventing infection. They protect both the user and everyone else. They range in price, but typically cost between $1 and $6 apiece. Though not designed for reuse, they can be disinfected and reused.

Next, there are elastomeric masks, made of durable materials, with screwin filters. They are more comfortable than N95 respirators, but remain awkward to wear, and allow the user to exhale unfiltered viral particles, a distinct disadvantage from a public health perspective. They typically cost under $50, and can be safely reused many times.

Finally, there is the gold standard of PPE: powered air-purifying respirators, or PAPR’s, which are comfortable to wear, reveal the face, facilitate communication, and offer the best protection to the user. Like elastomeric masks, they are designed for cleaning and reuse, but also suffer from the drawback of allowing viral particles to be exhaled. They are the most expensive, and usually cost a few hundred dollars each.

Desperate times call for desperate measures, and these are desperate times. Every essential worker on the job, whatever it is — in meatpacking, in warehouses, in schools, in retail, in all the many necessary places where people must gather closely together for hours — should be wearing N95s or their equivalent with eye protection by now, and every frontline health-care provider should be wearing an N95 or the equivalent with eye protection, or a PAPR, while on duty. Instead, most are still wearing surgical masks.

More than six months after the virus’ arrival on our shores, hospitals around the country continue to scramble for basic and often poor-quality equipment upon which many people’s lives depend, and the absurdly politicized public debate over cloth face masks continues.

Workers in other essential industries, at best, are wearing cloth or surgical masks, and few if any employees have received proper training regarding infection control and procedures. Many of these essential workers are minorities, many of these jobs are poorly paid, and the working poor cannot isolate themselves. Instead, they bring the virus home to their families.

Large-scale technical solutions — cheaper PAPRs powered by widely available lithium batteries, for example, that could be mass-produced at scale, or improved N95 masks — have not been seriously explored as public health initiatives, even in hospitals and other obviously high-risk environments. Teachers, college professors and countless others are now being forced back to work in unsafe conditions, and unemployment benefits are being cut for those who decline to return.

The iPhone 12, designed and developed in the United States, and manufactured in China, will soon be shipped by the millions around the world. It is a stunning piece of mass-market technology that will cost between $700 to $1,100.

If we can make a device as sophisticated as the iPhone 12 and distribute it within weeks, we can assuredly produce far larger numbers of light, reusable, improved PAPR’s or other forms of more advanced PPE that could save untold lives in the months to come.

Why aren’t we doing this? Where are our vaunted technology companies in this crisis?

Power is always good at slipping punches. But no disingenuous rhetoric should obscure the fact that U.S. corporations have chosen not to invest in expanding the PPE supply chain at levels remotely proportionate to the threat we are facing, and have instead relied primarily on increased Chinese PPE production to meet anticipated needs.

In this, they have the mystifying complicity of the federal government, which in the early days of the pandemic turned down an offer to produce millions of the masks right here at home.

The reason, as is so often the case in America, is money. PPE production was long ago off-shored to China, Mexico, and elsewhere.

Building factories in the U.S. is expensive, and corporations have concluded that they will not get a return by heavily investing in domestic PPE production when the pandemic will be over in a year or two. In the meantime, accurate data on the available supply of PPE in this country, and the status of PPE supply chains, has also not been released to the public.

The U.S. government could have forced American corporations to invest in domestic PPE production and more robust supply lines. Despite the obvious fact that our inadequate PPE supply represents a grave national security threat, the current administration has failed to do so.

As a result, nearly seven months into this pandemic, last week I picked up a chart of a patient in a small ER at the edge of the city, where I was working with one other doctor. On the chart was written “83-year-old female with cough, fever, muscle aches, and chills for three days.”

At this point, symptoms like that mean only one thing.

In a bin by the nurse’s station were an assortment of recycled N95 masks in varying sizes. I went through them until I found one I thought would fit. It was in a plastic bag, with a date written on the bag with a Sharpie.

It was stained by the make-up of a previous user. It smelled strongly of disinfecting chemicals. The rubber straps were pale and cracked.

I put it on. It seemed to fit. I put on a gown, and then the plastic face shield hanging beside the door.

I entered the room.

She was Native American, thin and frail on the gurney. She peered anxiously at me through thick glasses, and coughed. She was hard of hearing, so I had to shout my questions through the mask.

“Do you think I have coronavirus?” she asked, finally, shaking under the blanket, miserable and afraid, blinking rapidly at me.

“I’m sorry Ma’am,” I answered, after a moment. “But yes, I think you do.”