COVID year in review
As the calendar changes from 2020 to 2021, it’s only natural that we take stock of many things that have changed over the past year.
We’ve been through so much with COVID - so much news, so many deaths, so many trials, and so much stress. We’ve also learned a ton. I know that I certainly have. The beginning of a new year seems like a good time to take a look at what we’ve learned.
Let’s get to it.
The key to containing a pandemic is testing
Rapid, cheap, frequent testing is the way that you stop a pandemic.
The places that have done this well are almost back to normal. The places that haven’t are struggling with more deaths, suffering, and economic destruction than we should be having.
It says a lot that I have never been tested for COVID. I’ve seen a few hundred of these patients, including more than a few false negatives. The US has never made testing easy and quick - it is our single biggest pandemic failure, and that’s saying something.
I don’t want to belabor this point, but I do want to emphasize it: Testing is the solution to a pandemic, but it needs to be fast, frequent, easy, and cheap to matter.
“Slow down the testing, please” is the opposite of what we should be doing.
We’ve learned a ton about treatment - mostly stuff that doesn’t work
In the early part of the year, when the pandemic was just unfolding, part of what drove a lot of news was the possibility that something might work to combat this new viral pneumonia.
As it was happening, there were guesses about quite a few different medications to treat hospitalized patients. The trials were ongoing, and in the meantime everyone on the ground used clinical judgment to make these decisions essentially blindly.
Now looking back, it shouldn’t be surprising that we don’t have many treatments - this is an acute viral illness, the type of disease that doesn’t have a track record of being treated all that effectively with medications.
Think about the flu - when you get sick with the flu, Tamiflu isn’t a miracle cure. It helps a bit, but not that much. We don’t really have anything that does much for a cold.
Acute viral illnesses are generally treated with supportive care - fluids, electrolyte management, supplemental oxygen - rather than miracle cures. Most of the viruses that we have great treatments for, like Hepatitis C or HIV, are chronic diseases.
So with the benefit of the hindsight, it’s not surprising that a severe acute viral respiratory illness doesn’t have a miracle drug. It would be more surprising if it did.
I’ve broken the different treatments into tiers based on their varying levels of effectiveness below:
Game-changing treatments
The list of really important COVID treatments is short: dexamethasone.
As of January 2, 2021, this is the only medication that seems to have a major benefit in helping patients with severe COVID. The benefit of dexamethasone appears to be the biggest in the patients who are the sickest. It’s the only thing that’s going to make a real difference if you’re sick enough to end up on a ventilator.
Dexamethasone has the kind of impact in severe COVID that we rarely get with medical treatments. It’s a huge deal.
Treatments that work a bit
Also a short list: remdesivir.
Remdesivir is an antiviral drug has a clear benefit in COVID, especially if given early in the course of the disease. It doesn’t seem to be as useful in the sickest patients, but it’s well tolerated and a useful adjunctive treatment.
Treatments that make me say “meh”
Convalescent plasma: giving blood plasma from COVID survivors seemed like it would be a great treatment, but unfortunately doesn’t appear to be effective.
Bamlanivimab: a monoclonal antibody against the SARS-CoV-2 spike protein. Although it reduces viral load, it doesn’t really seem to reduce death or clinical worsening.
Antibody cocktails: giving a bunch of antibodies that attack the virus reduces viral loads, but no proof of benefit. I’m not impressed just yet, especially given the bamlanivimab example.
Vitamin D: doesn’t seem to work even if we all really want it to.
Melatonin: same story as vitamin D.
Fluvoxamine: an antidepressant that got a bunch of press after a low quality study published demonstrating minimal benefit. I wrote about this on my newsletter previously. The data aren’t impressive.
Ivermectin: an antiparasitic drug that has a similar story to fluvoxamine.
The mother of all opportunity costs: hydroxychloroquine
The best way to understand the impact that this medication has had on us during the pandemic is through an economic lens: the opportunity cost of hydroxychloroquine is massive.
All of the resources that we spent arguing about, thinking about, studying, and administering hydroxychloroquine is time and money that should have been spent on other things that had a better chance to help.
What else could we have done with $88 million? Imagine if we spent it on rapid testing instead of stockpiling tens of millions of useless pills.
The best pandemic example of medical reversal: blood thinners
I’ve written before in this newsletter about medical reversal. It’s a paradigm shift that happens when we find out that a treatment that’s been widely used - but hasn’t been well studied - doesn’t improve patient outcomes when we study it.
Giving blood thinners (anticoagulants) in COVID is the prime example in this pandemic.
We thought that because so many patients with severe COVID developed problems with blood clotting that blood thinners would be a useful treatment. So many people were so certain of this that it ended up in the protocols for many patients admitted to big academic medical centers.
Unfortunately, it doesn’t work (and there’s a signal that it might be harmful).
The biggest story of the pandemic has been our institutional failures: none of the emperors have any clothes
We should talk here about the way that the CDC bungled testing, the way that the FDA misled us about treatments, or how the Surgeon General missed the boat on masks, all institutional failures that were partly due to politicization and partly a manifestation of Hanlon’s razor.
Each of these failures unquestionably worsened the pandemic and has led to more deaths and ore suffering. We can only hope that new leadership brings a new process and better results.
An underappreciated institutional failure here: the US has no national clinical trial infrastructure like the UK’s RECOVERY consortium.
The lack of a coherent clinical trial network is why it’s taken us until the end of 2020 to learn about anticoagulation and (at least part of) why we wasted so much money on hydroxychloroquine.
This seems like it should be a no-brainer. After all, if we can develop vaccines at Warp Speed, why can’t we do a similar thing to figure out which treatments work and which ones don’t?
We should be prioritizing this moving forward.
A related thing that I’ve learned: leadership matters a lot more than I ever realized
Ultimately, a fish rots from the head. If you don’t have leadership that cares about fighting a pandemic - and I mean real success, not just the illusion of success - nothing that anyone learns about how to contain or treat a virus matters as much as it should.
“Slow the testing down, please” is the original sin of our pandemic failures. It explains so much about everything else that went wrong this year.
While I hope that we can learn from this and do better, it’s certainly been eye-opening and quite disheartening to live through failure after failure from these institutions.
Vaccines: the good and the bad
We have two vaccines that are amazingly effective and safe that are starting to be rolled out. The end of the pandemic is in sight.
I remain convinced that the development of these vaccines are some of the most incredible scientific achievements that we will ever see - to go from identification of a virus to Phase 3 clinical trials showing 95% effectiveness of a vaccine within less than year is simply remarkable.
And it’s proof that we can do things better.
Unfortunately, though, a vaccine isn’t the same as vaccination, which we’re all viscerally learning with the distribution hiccups and systemic errors. If our new administration can get this right, the second half of this year may feel like a return to normal.
What does the new COVID variant mean?
It’s too soon to tell here.
There’s some concerning data about increased viral spread along with the reassuring suggestion that perhaps the vaccines will work against it anyway. But it’s too preliminary to draw conclusions.
I’ll readdress this when there’s some useful information instead of just idle speculation.
In closing - it’s been a tough year
There’s no other way to say it. This year has been really hard in so many ways. While there’s certainly optimism heading forward, I am not ready to count my chickens just yet.
With that in mind, I wanted to share something concerning that I’ve been thinking about since I read it initially. It was shared by Dr. Paul Bieniasz, a virologist at Rockefeller University, an actual world expert in virology:
Thank you for reading! If you’re enjoying my newsletter, please consider sharing with your friends and family and encouraging them to subscribe!
I always appreciate any feedback or thoughts you might have. You can reply directly to this email to reach me directly.