A recent article in the Atlantic magazine sparked me to ponder the question, how can the US emerge from the chaos of the first, or perhaps second or maybe third wave of coronavirus infections without hundreds of thousands of more deaths? Seven months into the SARS-COVID-2 pandemic, knowledge about this novel virus has exploded as have treatments and effective strategies to slow viral spread across a variety of settings. 

Death rates have fallen as the chaos of the initial waves in NYC, California and Washington gave way to less hectic conditions. The atmosphere in hospitals was ripe for medical errors, which in normal times is a significant cause of injury and death. Understaffing, extended shifts, provider fatigue, time crunch, unclear protocols, fear of infection and the attendant fear of infecting one’s family are all factors that can lead to medical error. And the staggering number of deaths left providers reeling. They save lives; they had never been swamped by such an avalanche of corpses piling up in refrigerated trucks.

These same conditions have magnified the disparities in outcomes for darker skinned people. The urgency in overwhelmed conditions is the setting where implicit racial biases thrive, quietly creating different standards of care by skin color. Most providers are completely unaware of how their biases operate and are surprised when their outcomes are presented to them, something that hasn’t happened often as neither the data nor the time to review it has been available in the crunch. They meant no harm; they want to give the best care.

The media has helped support providers’ first reaction–deflection. It’s the risk factors in their communities they say, acknowledging but completely ignoring that the very existence of separate communities is the gift of systemic racism that keeps on giving. It’s the socioeconomic conditions, a piggybacked gift. Few providers know the scientific evidence that the daily battle to cope with racial prejudice is literally making Black and brown people sick through a process known as weathering. Weathering creates hypertension and cardiac disease while it accelerates aging. As adults age, their immune responses become blunted as evidenced in their increasing susceptibility to disease. This happens earlier in African Americans and contributes to their shorter life spans.

All of these themes blame the victims for fulfilling stereotypes sprung from white minds when their only options lie within societal conditions that force the vast majority of sufferers to resemble those stereotypes in the eyes of people primed with the superiority of whiteness. Nowhere in the narrative is the role of that priming in the implicit biases in all medical providers; a role that has been acknowledged by the medical community countless times. Somehow it never penetrates to the personal or the crisis at hand. George Floyd was not a thug; he was a gentle giant who struggled to recover from youthful mistakes and create a useful life.    

The effects of medical chaos were magnified in hospitals that were not large, because they had fewer personnel with direct experience. Medicine is best learned by doing, in situations that reinforce knowledge; those who don’t use an area of expertise lose how to apply it. They are less equipped for the unusual and unfamiliar; normally those patients would be transferred to other providers but there was no room in those facilities. These were traumatic circumstances for health care workers and the mental impact can not be underestimated. They never feared being infected if they followed proper protocols; they never felt their institutions could not protect them. They felt betrayed in the midst of new PPE restrictions that they knew were unsafe to their patients and themselves. This pandemic will have a lasting effect on healthcare over the next decade. 

Having weathered that awful first wave in sequential locations as it rolled through different states, this new wave of viral infections will produce better outcomes, hopefully for everyone. But as infection rates are rising in over 41 states totalling over 80,000 new cases per day and 25 states are at >80% ICU bed capacity, the death rates will begin to rise again from the current approximately 1000/day. Whether states or perhaps individual facilities have used the time to plan and stockpile appropriately for a resurgence can only be revealed as the story unfolds. Given the Coronavirus Task Force disappearance from the news cycle and the administration’s insistence that the pandemic is no more, it seems unlikely that FEMA or any federal agency will provide any better assistance than in the first round. In fact, it seems unlikely that governors will even look in that direction unless they’re chalking up points in a campaign.

In the meantime, the Superspreader in Chief is holding multiple rallies a day to crowds packed in like sardines yelling at the top of their lungs as they respond to the PiedPiperPresident’s manic mixture of disinformation, personal injury narratives and falsehoods from unmasked lips scattering aerosols which he claims are virus free. On the theory that he is now immune, is he even maintaining a testing regimen? His emittances may be sterile, but there is no objective source to verify his assertions about this or anything else. In general, 45’s pronouncements have been more false than true. His rallies are in open defiance of state regulations and unfortunately, when the president leaves after a couple of hours, state health officials, often in surrounding states, will be reporting these cases and resulting deaths over the next month. 

So let’s take a deep breath before all hell breaks loose again, no we haven’t gotten there yet, and take time to review what new information about SARS-CoV-2 has accumulated since January, 2020.

Remember this is a novel virus to humans and we had absolutely no information about it. We were starting from scratch, even after the Chinese made available sequenced RNA to create laboratory tests. There is scientific research on other SARS viral subtypes; there is one that infects pigs and even one that is part of the array of viruses responsible for colds in humans. Cases of MERS continue to occur, particularly in areas with camels. But COVID19 is not like any of those other viruses; it spreads asymptomatically. It can cause severe disease but it’s lethality remains unclear as cases mount but interventions and medical protocols and treatments have been evolving to lower death rates. We are still unsure of the range of short term complications let alone had time to assess long term complications and morbidities.

It’s hard to remember that early in the pandemic the importance of asymptomatic community spread was unknown. In the initial wave of testing, particularly with the shortages of supplies, criteria for testing were symptoms and a history of foreign travel. Those narrow indications meant that many cases went undetected but worse, many African Americans were excluded from testing and turned away from hospitals until their symptoms became severe or they died at home, adding to their higher death toll. Reports indicate that 41,533 of about 48,222,000 African Americans in the US, or almost 1 in 1000 have died from COVID19 so far and that by the end of 2020, that number will rise to 1 in 500.

Asymptomatic spread increased the urgency of viral testing to determine who was spreading the disease. From the beginning, testing was a disaster. In making the decision to create its own test rather than use the WHO test which was up and running very quickly, the CDC displayed a stunning lack of vision about the dimensions of the pandemic. The CDC test was meant to be used by CDC labs meaning that all specimens would be processed through the agency with assistance from public health labs. Remember how critically underfunded public health departments across the country are. It is simply the wrong model for the billions of tests needed in recurrent testing regimens.

After steering in the wrong direction, the CDC had the option of switching to the WHO test when it’s own test proved to be contaminated but bullheadedly forged right ahead. At the same time, it was refusing to allow academic centers to develop their own tests or to expand  their viral tests used in research labs more broadly to the population. Fortunately, the University of Washington was able to release some research findings to the health department which helped the state to move early to try to contain community spread of the disease. Afterwards the early problems with supply shortages slowly resolved into such long turnaround times for results that they became essentially worthless for isolation strategies to limit the spread of disease. 

Lately issues surrounding testing have disappeared from public attention. A recent Google search for my area listed almost exclusively private sites which required a referral and payment. Many drive-in sites have closed. Most hospitals including Emory Healthcare’s multiple facilities restrict testing to their patients only. Fewer people are getting tested even as the number of cases are rising precipitously in my state.  In conjunction and more disturbing is the escalation in the percentage of positive tests, in some states exceeding 20%. Remember when one criteria for reopening states was a positivity rate less than 5%, and then Republican states simply ignored it.

In states where cases are spiking, testing centers are being overwhelmed; ironically, that may not be as bad as it could be because politically invested right wingers who have asymptomatic and mild disease will take a “principled” stand against it. As long as El Trumpe hawks the inane idea that high COVID19 case numbers are the result of extensive testing rather than disease revealed in people who are the first part of a strategy to limit disease, that core will hold. This situation will complicate assessing the impact of disease and dampening the spread, but those people were never going to comply with quarantine anyway unless placed under house arrest or a life altering experience.  

In the interim, there has been considerable research in developing new COVID19 tests. Early FDA abandonment of pre-market evaluation of new products led to a proliferation of invalid and inaccurate tests that were being marketed over the internet to a frightened public and even government agencies. But the FDA’s retrenchment has created hurdles for subsequent inventors. The gold standard test, a PCR, has high sensitivity, meaning it correctly identifies people with infection, as well as specificity, meaning people who don’t have COVID19 infection will test negative. But it is so sensitive that a tiny amount of viral RNA will result in a positive test long after viral loads are so low that the person is no longer infectious. One NY Times investigation found that the number of positive PCR tests with low counts and therefore no longer infectious may be as high as 50%. And because PCR requires specialized reagents and equipment, it’s expensive and difficult to perform. Those characteristics limit who and where as well as the maximum number of tests that can be done. As for the big picture, the objective is not to document who has been infected, it’s to stop the spread of disease by removing infectious people from contact with others. Isolating people with positive tests who are not infectious costs both people and resources needlessly,

Lab tests that measure anti-COVID19 antibodies are also available. These are more rapid than PCR, but the test’s target is not the virus itself; it’s human antibodies formed in response to viral invasion. With COVID19, a novel virus, this means that infection could only have occurred recently. Since antibodies form only after viral invasion has occurred and remain after it has been purged from the body, their presence indicates that the virus has been present but not that it remains or whether the person is infectious. And that ultimately is the goal, to stop the virus from jumping to other hosts. At the same time, the type of antibodies measured, immunoglobulin G, take 1-3 weeks to develop; a person with a negative test could still fall ill if they have been exposed recently. They may be transmitting the virus while they are being tested. In the grand scheme of things, it is better to have a test that over-identifies positives than negatives since no one with a false positive will transmit the virus but someone with a false negative can.

Two Abbott Pharmaceutical rapid antigen tests which test for viral particles have been used at the White House for screening visitors and staff under FDA Emergency Use Authorization. The problems of false negatives were clearly demonstrated in recent White House superspreading events although it is not clear that the MAGAPresident was even getting tested regularly. Hope Hicks did have a positive test result which was hidden at the time she developed symptoms, but if she had daily testing, she would have been infectious in the days before that when her tests were negative because it takes 3-5 days before symptoms appear.

There are a couple of other types of rapid coronavirus tests in development and awaiting FDA approval that are even cheaper than the Abbott tests which cost around $5, although undoubtedly that is not what a patient would be charged. The newer ones are rapid lateral-flow antigen tests which can be done at home and produced in tens of millions or more per week. Lateral-flow antigen tests detect 100th or 1000th as many viral particles as PCRs, but if the goal is to identify people who are currently transmitting virus, that is adequate because COVID19 grows rapidly within the body and is transmitted when present at high levels. These tests improve with repetition, providing a map of increasing viral load and infectiousness which can change from morning to evening but that map more precisely pinpoints the infectious period and what contacts are at risk of disease.

Once Transactional Donald decided to privatize the federal response, the picture emerged that multiple private entities often requiring physician referral as part of the criteria, severely limited access to testing further. But it also corrupted the data flowing to the CDC and public health agencies because many private requisitions lacked standard demographic information, obscuring further the scope of the disease. Thus early in the pandemic, the number of cases going undetected may actually have exceeded those that were, a result of the restrictions limiting testing to the most severe cases. In June 2020, the CDC estimated the actual number of cases is probably 10X more than those reported. Not even COVID19 deaths could be determined properly because many home and nursing home deaths did not get tested. 

A couple of small studies using high doses of virus concluded that the virus could be spread on surfaces, but this mode of transmission has proven rare outside the lab. A recently released study found that viral particles can survive on cell phones for up to 28 hours and on other surfaces for as long as 48 hours. However, the crucial question is whether the presence of coronavirus on surfaces can be linked with cases of infection, a particularly daunting question to answer when asymptomatic spread is a significant mode of disease dispersion and viral testing has been so limited. Unfortunately this early perception has led to an enormous amount of time and energy wasted on obsessive surface cleaning, huge costs for just about every entity that interacts with the public and gigantic profits for disinfectant manufacturers.  

We better understand risk factors for severe disease, comorbidities like obesity,  diabetes, cardiac disease, hypertension and age over 65. Younger children are less likely to become infected but adolescents are as similarly contagious as adults. Both groups tend to have mild or asymptomatic infection, but occasionally will develop severe disease.

Authorities do agree that the rate of viral transmission is lower outdoors than in enclosed spaces, even large ones. Intuitively, this makes sense, particularly if the area of main concern is within 6 feet. An outside area allows for social distancing. One can envision in the open air, viral particles are blown away. That probably depends on the duration of the proximity and the activities occurring. We have seen that indoor choir practices have been the center of multi-victim infections. Is the same true for outdoor choral events, if they are on a stage displaced from an audience, if they are socially distanced? Those questions send us into the transmission twilight zone.

Also established early was that the risk of viral transmission is minimal with short exposure intervals, even close ones without face masks. Atul Gwande reviewing practices in Singapore and Taiwan, both countries that have controlled their epidemics successfully despite their proximity to China, wrote that officials aggressively trace contacts and isolate only those who have had close contact with that infected person. Close contact was defined as at least 15 minutes at less than 6 feet without a surgical mask in Hong Kong while Singapore uses 30 minutes. If the exposure lasted less than that time period at less than 6 feet but more than 2 minutes, a worker could continue to work if they wore a surgical mask and had temperature checks twice a day. Those with only brief, incidental interaction could self monitor for symptoms. The CDC has recently altered its definition of close contact for contact tracing to include one or more encounters less than 15 minutes at less than 6 feet.

Of course, there were the initial recommendations that the general public should not wear masks in an effort to reserve surgical masks for medical personnel as large shortages in supplies were emerging. Traditionally, surgical masks have been reserved for the healthcare space, although they have come into common use in yard care and construction, more to protect against dust and particulate matter than infectious agents. But clear evidence did emerge that cloth facial coverings were surprisingly effective in reducing the risk of transmission. Some authorities estimate that covering the mouth and nose can lower the chance of infection by 10% for cloth compared with 30% for surgical masks. The most effective, N95 masks, lower the risk by 80-90% when properly fitted because they form a seal around the mouth and nose while surgical masks leave gaps around the nose and at the sides. Note they must be properly fitted and be held in place with straps around the head not over the ears. Two layers of cloth boost effectiveness; an additional filter as simple as a coffee filter may add to the protection. While a 30% reduction in risk may not sound like a lot, modeling around trends in COVID19 cases suggests that face coverings and social distancing can lower case numbers by 60% which would go a long way in tempering the pandemic aspects of viral spread to more of a slow burn. Coronavirus would eventually become another endemic disease similar to influenza. . . and life could resume. But it will probably not disappear as 45 is so fond of saying.

Still, there is much about COVID19 transmission that is not well understood. Zeynep Tufekci points to a number of gaps in knowledge such as why did the northern region of Italy have the majority of cases accounting for over 75% of the deaths concentrated in the first few months of their outbreak? This is being repeated in Italy’s second wave. Why did cities of similar density, age distribution, weather and travel patterns have vastly different numbers of COVID deaths? How did Japan, a country of densely populated megacities with a significant population of the elderly, escape logically predicted catastrophic outcomes? 

Tufekci summarized epidemiologic data suggests that the virus tends to spread in big bursts, not a steady pace like influenza. The majority of people may not infect anyone else, while there are incidents of a single person infecting 80% of the other people in a room. A paper from Hong Kong, where there is rigorous testing and tracing, found that 80% of transmissions came from contact with only 19% of the cases while 69% of cases infected not a single other person. This type of cluster spreading means that in any one location, the level of infection is dependent on who was the patient 0 in that setting. For instance in New Zealand, only 19% of their many patient 0s caused more than one additional case. In contrast, in South Korea, one superspreader was responsible for over 5000 other cases at a megachurch event. Interestingly, SARS-CoV-2 seems to share this characteristic style of spread with its predecessor SARS-CoV which caused the 2003 viral outbreak in Asia. MERS also seems to share this overdispersed pattern of spread, but it doesn’t yet transmit well in humans.

Why are some people superspreaders and others not? Part of the explanation lies in the number of people who come in contact with that individual. The person who lives alone or stays primarily at home is in a very different position than a resident in an elderly facility, a prisoner in a jail, a student at school or a politician on the campaign trail. But there is emerging evidence about other factors that are intrinsic to different settings.

Although the WHO has been slow to accept aerosolized spread of coronavirus and the CDC has only recently signed on, recent evidence has demonstrated that viral particles do form larger aggregates with moisture in the air that then drift throughout a room and accumulate over time at distances far longer than 6 feet. Thus poorly ventilated rooms crowded with occupants who are talking loudly, singing or cheering over some extended period have been central to superspreader events. People eating in the path of an air conditioner vent in a South Korean restaurant were all infected by a person sitting at a table near but not in that air current. This information emphasizes the role of ventilation systems in fighting the spread of this disease. 

Even with this list of conditions that must occur at the same time, the risk may vary by setting and activity. The key elements are a highly infectious person, crowding, poor ventilation and prolonged exposure. There may be other factors not yet clear, but a strategy to decrease super-spreading settings even if the presence of a highly infectious person remains unknown could represent a big step forward.

Is the president really the Superspreader in Chief? He may not be a highly infectious person, a designation that is impossible to unravel from the tangle of events and large number of individuals involved in the White House outbreaks. But he is consistently creating the conditions for overdispersion. Even though his MAGA rallies have primarily been outdoors, some are in partially enclosed structures. No matter the location, they are all crowded with the majority of the audience unmasked and shouting. The larger the crowd, the higher chance that one or more highly infectious persons will be present. For instance, following one MAGA rally in Bemidji Minnesota, state health officials found 9 cases among those who had attended the rally during the window when they would have become infected. At least one person was likely infectious when they attended. Two other cases attended a protest against the MAGA event, an ancillary route of spread surrounding mass gatherings. The fact that these gatherings were outdoors may have tempered the spread somewhat but the data is incomplete, since participants from other states were likely in the crowd and Minnesota officials would not have access to data from those other states, or even knowledge of which states were involved.

 This is a major pitfall in this state based response concocted by the self designated Wartime President, although he seems to have dropped that moniker when he announced that the war has already been won. Still, a Trump administration laser focused on controlling the spread of coronavirus could have provided names of the attendees to the health department because the demographics and contact information of every ticketed MAGA rally attendee goes into a database which the campaign mines for delivering political propaganda, contributions, merchandising and soliciting volunteers. Still, at least 4 counties across 3 states have reported a surge in cases after a MAGA rally; attendees resume their normal routines shopping, eating, working.

But that guy is not campaigning to remain in the White House. If the AmericaFirst President has demonstrated anything over the last 4 years it’s that he’s a TrumpFamilyFirstPresident and to hell with everyone else who isn’t stroking his ego while greasing his palm. Mark Meadows, chief of staff, admitted that the administration is focused on treatments and vaccines but there is no way to control the virus. And there it was. Finally an admission that clarified the thinking behind the abdication of a federal emergency response at the outset. As Governor Cuomo of New York summarized it, 45 put up a white flag before firing a shot and surrendered. In his transactional mind, it’s either the economy or the disease and it’s not even a contest for 45, despite the successes of multiple countries around the world. But the AmericaFirstPresident can follow no other example, except perhaps Vladimir Putin whose response in Russia has been similar to his. Just today even Putin has imposed a national face mask mandate, and he has the machinery of state to enforce it.

So he produced one of his reality TV dramas which incorporated his favorite elements, profits for private corporations who smoozed him at various fundraising events. They were incorporated into every phase of federal action including PPE, testing supplies and outlets to do testing, vaccine development, potential treatments, logistics, etc. He added a competitive component by setting states vying for supplies against each other and FEMA, a contest that raised prices by multiples to profit his friends. Even the “persuasion” of companies to shift production to PPE and ventilators under threat of the Emergency Production Act proved extraordinarily profitable for those companies. One more touch, the MAGAPresident used his pulpit to bully political enemies, i.e. Democratic governors, to incite his Scrump of 2nd amendment supporters, white supremacists and associated Trumpophants to revolt against state attempts to control the virus. In all, it was quite a pageant, but it wasn’t meant to impact the pandemic, only the perceptions of his Trumpophants in a mad dash to remain in the Oval Office. And so it has not.

Tufekci suggests in Atlantic that overdispersion should inform contact tracing efforts, which admittedly have been lackadaisical and ineffective, in part because viral testing results are delayed. The other part is the politicization of the pandemic itself where Trump partisans have made a principled stand against government intrusion and are seized with a paranoid fear of being tracked by the government [deep state]. GOP governors waddling behind their orange tinged mother goose have not invested the needed resources into contact tracing either, in an effort to present a united front supporting the idea that the pandemic is not a threat. That is becoming an increasingly difficult dance for some as cases mount and ICU bed availability disappears. And almost no state has the necessary funding, given the stinginess of elected Republicans officials including the Senate holding up pandemic relief.

Still, there is a theoretical path forward by concentrating on eliminating superspreader events, either by eliminating the settings or isolating the spreaders. The idea is to identify transmission events rather than infected individuals. Tracing contacts backward from the case to find a superspreader and tracing forward from that individual will yield a much higher number of potential contacts than the traditional forward tracing from a case who may not infect anyone else. Think about it like this. Some people are connectors; they’re the glue in a social circle and also connect one social grouping to another. They’re the people who organize social gatherings. That individual is more likely to widely disperse infection because they are in contact with more people. 

The use of rapid testing is critical to this approach. As Tufekci details, using a rapid test for a coronavirus infected person and 10 of their 20 forward contacts can help determine who doesn’t have the disease because rapid tests are good at negative results but may miss some positives. If all of them are negative, there’s a good chance that none of the 20 are infected which can be confirmed with PCR testing. But, if a couple are positive, then a superspreader event has been identified and all 20 people can be treated as if they’re infected and should be isolated until a PCR test can be done on each of them individually. All of that information can be determined in less than 30 minutes. 

We are behind the eight ball already with trust in authority and government near zero, proven factors in the success in other countries. For better or worse the credibility of the CDC is in the toilet, both at home and abroad. There is a noted absence of an investment in the public good or even a belief there is such a thing. National cohesion has been replaced by partisan identification, particularly hostile on the right. And there is that American sense of rugged individualism that has hardened into freedom is the right to do whatever one wants and the hell with everyone else. The death of societal respect for science and focus specific expertise has elevated conspiracy theories over public health messaging.  Let’s hope that conspiracies control fewer people than the media has been telling us or those people will be outliers in a hopefully broader swath of the population who agree to a commitment to national recovery. 

 And finally, in the wake of the chaos that is the Trumpnado, Americans seem unable to “know” what they can’t see in front of their faces. The death of local news is one contributor; the AJC has more national stories than local news and its formerly excellent reporting from across the state has been reduced to a few items from the surrounding Atlanta metropolitan area. Many local papers have disappeared completely so while the AJC updates coronavirus numbers daily, that information is only available in quick summary fashion from the local news broadcasts, which are also disappearing or a state or public health website. That’s probably a less frequent stop than national paper sites like the New York Times or Washington Post which have elaborate daily dashboards down to state and county level. Both are read extensively, but how much of that readership is in small towns, rural areas or across the south is anyone’s guess. 

None of my Gen X children read newspaper websites; they check news or Twitter feed summaries of news organizations at best without filling in the details. And they only click on what grabs their attention. Watchers of Trump/FoxNews don’t hear any coronavirus statistics. In sum, most people don’t seem to comprehend the scope of the pandemic. The PiedPiperPresident tells them that it’s no big deal several times daily as it echoes through the news cycle and social media. Unconsciously, this simple repetition does impact the brain. If people don’t know anyone who lines up at a food bank or who isn’t talking about whether they can pay their mortgage or rent, then the pandemic is being overblown. People are pissed that their local bar is closed or their favorite restaurant has one third capacity or is only doing take out or closed altogether. They are tired of their kids being at home zooming into school. 

But incredibly, they seem unable to connect those things to rising coronavirus infection rates while the Trumpbeat “the pandemic is over” keeps reverberating through their brains. It is an unfathomable disconnect. As long as the virus is raging, people will not return to the level of previous economic activity, but if they did, the viral storm would upgrade to a tsunami. In fact we’re already seeing the uptick in reopened states where a significant number of people are not following proper public health behaviors. Is it because those boobs are spending more time at home? Is it because the virus is invisible? Is it because infection is invisible in a majority of people who have it? Or is it because they just don’t care about all the dying if they can drink at the local bar?   

Americans will have to make sacrifices but not necessarily in the form of a broad national shutdown which hasn’t yet happened in the US although it seems like it might have. Our lockdowns went state by state sometimes county by county or city by city as partisan politicians jockeyed for the glow of El Trumpe’s approval and by extension, better access to badly needed resources and local leaders fought back against poor public health choices.

The current recommendations for hand washing are givens. The first sacrifice is simply to accept scientific and public health expertise, which should not be considered a sacrifice but apparently is by some. But using that expertise, we can think about fashinoning more targeted strategic approaches to allow public interaction and isolates only those who are potentially infectious. This shift will make the pandemic response more palatable to disaffected individuals. But it does mean that the executive branch will have to name our situation as a federal emergency and mount a federal response. Clearly, that transition can not happen without a change in the Oval office save lightning striking it’s current occupant and rewiring his brain. If the right revolts at the change, referred to in their propaganda to loss of states’ rights and individual freedoms, there will be a tug of war but hopefully the federal government has emergency powers which not even the new SCOTUS can overturn. 

Returning to the theoretical from the political reality, a strategic approach to face mask wearing could incorporate consideration of the length of interactions at distances within 6 feet. If a mask is not covering both nose and mouth, an encounter that lasts less than 15-30 minutes without raised voices, or singing poses a low risk so people need not worry in that setting. For the general public, it is probably easier just to wear the mask all the time than to time interactions. Still people walking or running in the street or a park need not worry about wearing a mask for passersby. It goes without saying that face masks represent no sacrifice at all, no matter how much liberty people believe they are surrendering.

One element that can be dropped is the obsessive focus on surface disinfection because surface transmission of COVID19 is minimal. Surfaces can still be cleaned, but don’t need to be disinfected in between uses. News clips of primarily foreign countries where workers are spraying the streets and sidewalks may be reassuring to the populace, just like disinfection rituals here are, but represent wasted effort and resources that could be otherwise directed more effectively. The NYC subway system is a much nicer way to travel because it is being thoroughly cleaned, so cleaning is a nice thing, but detergent is fine. Cleaning will also help lower the spread of influenza as we enter the winter months. Filtering of ventilation systems however is a far more important matter.

One thing that will have to be sacrificed is large gatherings with their potential to super-spread the virus. Large gatherings will have to remain prohibited and even smaller gatherings that can’t be socially distanced or mask wearing is impossible like meals may not be feasible. However, as the holiday season approaches, there is a way to approach friend gatherings that make them safer and eliminate mask wearing. That way is to have participants test before gathering. Positives would stay home; negatives will gather and maintain their own bubble, while routinely observing  public health measures when leaving the bubble. As icing on the cake, attendees could retest on arriving home and notify the party if one of them had become positive. Probably testing should wait for 2-3 days to increase the probability that the virus will be detected. This is a feasible approach even with the irregular availability of testing and long result intervals, although that problem can be easily remedied by not reimbursing labs with turnaround times longer than 24 hours.

Home for the holidays: test before you gather, positives stay home. Maintain a bubble during gathering, taking usual precautions when someone goes out. Retest when you return home and notify others if you turn positive.

 A more strategic approach to restricted activity is possible if viral testing is made abundant, low cost if not free, easily accessible and includes rapid less sensitive tests that can also be performed at home. But individuals must test consistently and abide by the results, including notifying authorities and quarantining at home for a 10-14 day period during further assessment when the positive test result can be confirmed by PCR testing. This step will probably require something like fines for noncompliance. But imagine if everyone knew their status before they left home! That doesn’t actually sound like a big sacrifice, just adherence to the rules, something that appears to have gone out of fashion these days.

The strength of rigorous testing is evident from the success of the NBA and WNBA. It also demonstrated the importance of compliance with the rules, and that bubbles can’t be sealed, but testing can identify and isolation could prevent spread. Players could engage in close physical contact for extended periods without transmitting the disease. At the same time, the NFL, and MLB are examples of the importance of minimizing the intrusion of unknown sources of coronavirus. Travelling and playing in different stadia has led to multiple positive tests in football and baseball, causing games to be cancelled or rescheduled. The political lesson is that with enough money and the will, infectious coronavirus spread can be stopped. These were very wealthy private organizations who could take their own initiatives to protect their workplaces; similar efforts could be made by others that could limit spread. For instance, Amazon can afford to rapid test employees before entering the workplace and send positive testees home to isolation, with accompanying medical expenses paid and paid leave off. All the largest distribution centers, like Walmart, could do the same. Some universities have adopted frequent student testing as well, but unfortunately, most public school systems can’t afford even minimal testing of teachers and students. 

To have 100% compliance, the government will have to create a program that will support workers during their isolation which would also include medical costs for those without medical insurance and guarantee expedited access to medical evaluation, possibly through local health departments. Residences for those infected who live in shared households, the homeless and those institutionalized who are unable to quarantine must also be provided. 

Aggressive contact tracing is a critical accompaniment to a universal rapid testing approach. But the focus will concentrate on limiting superspreader events, using the backward contact tracing methods discussed above. Again, if rapid at home testing were available and people honestly stayed in isolation when positive, people could return to concerts, stage and movie theaters, college football, basketball sports arena and even, smaller sport seasons like lacrosse, ultimate frisbee or soccer. Until then, these events will remain off the table and private gatherings should be kept under 20 attendees, unless people pretest just before going. My family has used periodic testing to gather now a couple of times, so the strategy works even with current PCR tests turnaround times, although our negative results are not always available before we gather. In that sense, we’ve been lucky.  We have seen that churches and some synagogues will continue to break the rules and that is where identifying superspreading individuals can make a significant difference, especially in smaller districts with fewer medical resources that are likely to become overwhelmed. 

As far as reopening or keeping schools open, the low infection rate among younger children should guide who is in classrooms and who remains online. Schools includes pre-K and early childhood education which is critical to child development particularly during the first 36 months. We are battling lost time as pre-K is 2 years at the longest and almost a whole year has been lost already. School grades above elementary can resume classes in buildings with consistent viral testing and compliance with quarantine rules. But the buildings can be made safer by improving ventilation systems and incorporating HEPA filtering, whether in classrooms or attached to the ventilation systems. They might consider using ultraviolet lighting that is used to sterilize medical chambers. All of these changes are expensive and given the lack of investment in public school systems for decades maybe impossible but if they stopped spending on disinfectants and returned some of their stockpiles, they might be able to make small changes. It goes without saying that preferential treatment should be given to schools in the zip codes where nonwhite students and poor students predominate, since those communities have been the worst hit by COVID19 infections, deaths, job losses and  inadequate internet connectivity leading to educational neglect, all added on to pre-pandemic insufficient educational opportunity warped by implicit racial bias. Our children, the future of the country are something Americans must refuse to sacrifice. 

El Trumpe continues to say that Americans are tired of COVID19 and want to move on. SARS-CoV-2 has no ears. The virus has one purpose–to seek out a human cell that will reproduce a bevy of progeny that will ensure the survival of the organism. Not even the PiedPiperPresident can dissuade the virus from its mission. On the contrary, he has enlisted a COVID19 ally to do exactly the opposite. The embrace of the inane strategy to await herd immunity by his latest addition to the task force, Scott Atlas, is guaranteed to insure profligate viral growth. Atlas currently has 45 in his pocket, having auditioned as a Trump/Fox News pundit, the Chief exec’s favored route into his administration. Atlas is carrying the right message, so comfortably nestled into Trump’s penchant to look inward rather than consider the realities facing his AmericaFirst. The RealityTVPresident is about shaping reality, not living it. With reelection in mind, the task is to deny COVID19’s existence and ignore the economic realities for millions without jobs or savings or food or rent money or a sense of their future. He worships the stock market as an indicator of economic well being, a notion as shallow as the man himself. Atlas has emerged as the dominant influence on the Coronavirus Task Force and the illusion of a response that disguises continuing federal inaction is the rule of the day. 

Atlas Risen is definitely moving the country in the wrong direction. The President is creating multiple superspreader events every day as the campaign comes to a close. The Vice President emerging from a hotspot among his own staff has continued to add his own potential COVID19 particles to his superspreader events as well as endanger secret service agents, Air Force 1 personnel and staff rather than self isolate. There will be a lot more deaths before January, 2020 because many Americans have chosen not to do the simplest things. Right now, our death toll of at least 224,000 people is equivalent to exterminating the whole population of Des Moines Iowa. Why then do so many Iowans not care? Trumpophants say “I don’t know anybody who has it” as if that is the standard for what’s happening around them. And yet they are willing to believe in Qanon, none of which can be seen or verified. It says so much about the death of empathy in conservatives and the rise of a cult that engulfs people as thoroughly as a burqa covering noise cancelling headphones. Without empathy, we may not be able to change the course of COVID19. The death of empathy may strike a deeper blow to the nation than the deaths of so many of its citizens.

From the Equal Justice Initiative 2020 calendar

On October 27,1986 the Anti-Drug Abuse Act of 1986 created a 100-1 sentencing disparity between crack and powder cocaine possession drastically increasing mass incarceration of African Americans.