Too many people are dying right now.
A few weeks ago, in a back-of-the-envelope calculation during an interview with Eric Topol of Scripps, I suggested that because of widespread vaccination of the most vulnerable elderly, we may have reduced overall mortality risk in the country by 90 percent. Topol thought that was a little high, but agreed that vaccines were delivering great protection against death and hospitalization, and while we would likely see some of each during the Delta wave, “it won’t be like the monster third wave.” More recently, the Dartmouth economist Andrew Levin, who early in the pandemic did major work calculating mortality risk by age, estimated in an interview with my brother that the effect was probably 75 percent — that given the same number of cases, we’d probably see about one quarter as many deaths as we would’ve seen a year ago, without vaccines.
The U.S. numbers are a bit wobbly these days, and there are huge variations state to state, reflecting disparities in vaccination rates, among other things. But at the national level, at least for the moment, the reduction of mortality risk seems to be considerably smaller. In the worst of the winter surge, the country was registering 250,000 new cases per day; at its peak, that surge was killing roughly 3,000 Americans each day (often a bit above, but with a few dips below). Today, we have a bit more than 100,000 new cases each day, though the numbers are still rising as part of the Delta wave. If we had reduced mortality risk by 75 percent, that would mean about 300 daily deaths. If we had reduced it by 90 percent, it would mean 120. Instead, in our seven-day average, we just passed 500.
Things may be even worse than that, though. In general, epidemiologists expect a lag of a week or two, perhaps more, between case peaks and death peaks — essentially the time it takes for a new case to progress through the full course of disease. Early in the pandemic, the lag was a bit longer, though in the U.S. during the winter surge, the gap between peaks was less than one week. And comparing case data from even one week ago with today’s death data reveals an even grimmer picture: about 75,000 cases per day then yielding the current average of 500 deaths, suggesting the mortality rate had fallen by less than half since winter. If you work from two-week-old data, it suggests that the mortality rate had hardly fallen at all. Applying the winter ratio to the case load from July 24 would predict an average of 600 daily deaths. On Friday, there were 763.
For a couple weeks now, concerned Americans have taken comfort in the Delta experience of other countries, namely the U.K. and the Netherlands, whose Delta waves had begun earlier and who had — very roughly — similar vaccination rates to ours. In those countries, as models would have suggested given our expectations for vaccines, caseloads dramatically diverged from hospitalizations and deaths, with case numbers growing much, much faster than severe disease, which stayed, all things considered, pretty low. That simply does not seem to be happening here, even though the vaccines are working well enough that hospitalization and death remain, for breakthrough cases, very rare. Could these trends reflect rates of under-testing? To some extent, of course. But how much?
On Saturday morning, looking at Friday’s figures, I emailed Topol to ask if he was as worried as I was. Yes, he said. We spoke again later in the afternoon.
These numbers are disorientingly grim to me. How are you thinking about what’s going on?
Well, I’m trying to use the other countries that have been through this already, or are concurrently going through it as a reference or an anchor. And I think our rate of rise of hospitalizations is really alarming. We saw quite a bit of hospitalization increase in the U.K. But this is so far worse than that. And many of those people are going to die.
Just looking at the U.K. and Israel, which had been our guideposts, I thought we would keep the hospitalizations pretty darn low — maybe a fourth of where we’d been in prior waves. And deaths 10 percent of prior waves. But we’re not doing that at all. If you look at the log charts of the U.S. and the U.K, you’re starting to see some real separation for death. It’s certainly going in the wrong direction, and it had been tracking incredibly closely, until recently.
Now, we are under-testing, too, compared with those other countries. That might be giving us a distorted picture of what’s happening here. But I just don’t know where we’re headed.
What I just can’t understand is why all three things are all moving up together so rapidly. Given everything we’ve seen in other countries and everything we think we know about the vaccines, even if cases rose dramatically, we’d expect much lower rates of hospitalization and death. But we’re not.
It’s like we didn’t have vaccines. Or worse. I was just putting this talk together and I made the same observation. I’m looking at the four waves, and, as you know, in the monster wave, we got to 250,000 cases per day. And at that time we had 120,000 plus hospitalizations [per day]. About half. What’s amazing is, we’re at about 120,000 cases now, and we’re over 60,000 hospitalizations.
It’s the same ratio.
Yeah. So when I look at that, I say, what happened to the vaccines?
Now, the rate of rise is being driven by several states, as you well know, not the whole country. And I guess the real issue here is, I don’t know if what is going so bad in places like Louisiana and Florida is going to become a diffused pattern, throughout the country. But there are some indicators that it might be.
What are you looking at?
Near where I live, Los Angeles County’s more vaccinated than Florida — it’s above average, not average, as Florida is. And it’s going through a big spike in cases and hospitalizations. And there are other indicators like that around the country, where just because you’re at higher vaccination levels, it’s not holding up as well as we’d like to see.
So where do we go from here? That is the unknown. Eventually Delta will pass through, though maybe it’ll come back, as we’re seeing now in other countries. But what things look like in the meantime, I think it’s a real uncertainty.
Before we focus on the sort of near- and medium-term future, let’s just talk about what’s already happened. In your mind, what could the explanation be for this? We have a relatively high vaccination level — it’s not great, but it’s far from zero, and the elderly across the country are, again relatively speaking, well-protected. Why is the same variant producing such different-seeming outcomes here than in other countries, like the U.K., where cases rose dramatically but deaths didn’t really follow?
I’ve been thinking about that a lot. I think the issues here are, we are substantially lower vaccinated than the U.K. for fully vaccinated. We’re pushing 15 points below the U.K. and Israel for vaccinations. And even though AstraZeneca isn’t as good for suppressing spread, it seems to be as good for preventing hospitalizations and deaths.
According to Our World In Data, the U.K. is at 57.5 percent fully vaccinated and 69.2 percent partially vaccinated. Israel is at 62.3 percent and 67 percent, though they have a younger population. The U.S. is at 49.61 percent and 58 percent. Those numbers vary a little source to source, but we are definitely behind.
We only got to 50 percent now. And we’ve basically been flat for many, many weeks, you know, peaked out in April. So I think that’s one thing. The second thing is Delta. Our vaccination defense has been leaking. We’re seeing a lot more spread in vaccinated people. And that’s a real problem because, unlike the U.K., which went from having a lot of restrictions to being totally wide open, and Israel, where as soon as they started to see problems, they went back to restrictions, we’ve been pretty much open the whole time.
But holding all else equal, if vaccines were still doing a good job preventing severe disease but a considerably worse job preventing spread, wouldn’t that drive the gap wider between cases and hospitalizations, or cases and deaths?
Yeah. But —
It’s a lot to hold equal.
What I’m hearing — and I’ve been helping with a bunch of patients — is that people who are breaking through are getting very sick. They’re getting Regeneron antibodies.
There may be something to this waning immunity story. It’s fuzzy, but the people who are getting hit are more apt to be people who were vaccinated very early. I had a patient in recent days, who’s in her 70s. She got vaccinated in January. And, I mean, she almost died. I mean, it’s just terrible. I think — I hope — the monoclonals are going to save her life. But she was a healthy 70-year-old lady, and just following her case was illuminating — she thought she was protected, but she also wore masks everywhere. She was on guard and still got infected and desperately ill.
Most people aren’t being that careful.
The vaccinated — who are now a very slight majority — those people just think the pandemic’s over. There’s still this sense that if you’re vaccinated, you’re good to go. I mean, I’ve even seen on television, you know, some of our leading health experts, tell people it’s perfectly okay to have indoor gatherings among vaccinated people. Well, it’s not true. So we’re getting bad advice.
This booster thing is yet another issue, because we don’t even know if they’re going to protect against a Delta. I mean, everybody’s assuming it, but there’s no data. You know, there’s some neutralizing antibodies from the Pfizer report in 23 people and there’s an Israeli pre-print, it says there’s waning immunity without any neutralizing antibodies. So we’ll see. But these are just classic spike-protein boosters. There’s nothing special about them to handle Delta. So I don’t know. I mean, I suspect they’re going to provide some protection, but I’m not sure I’m so confident it’s going to be great.
What about just the basic heterogeneity of the country? We’re so big, with so many pockets of vulnerable people, even in states that are, from a bird’s-eye view, well-protected. Could it be that what we’re seeing now is just the disease burning through those populations very efficiently and producing numbers that look large even in the national context?
I think that’s true. I think heterogeneity is definitely playing a role, but I also think the behavior is playing a substantial role. I mean, why did Florida succumb? As you know, it’s basically at the national average for vaccination, one percentage point below. But it’s been a disaster there, and they have promotion from the leadership of the state to do everything wrong. I mean, you know, they’ve mandated no masking.
But that should provide some hope, in the sense that other states will take a different course, presumably.
I don’t know.
Personally, I put a lot of stock into the fact that, even in states where the vaccination levels weren’t so high overall, that seniors seemed pretty well-vaccinated — I think when we last spoke, a couple of weeks ago, in the worst-vaccinated state, Mississippi, 76 percent of seniors had gotten at least one shot. That’s not 99 percent but I would’ve thought it would’ve shielded a lot.
I think for Alpha it would have been beautiful. But for Delta it’s just not nearly enough.
I mean, one of the worst signals that I’ve seen is San Francisco. San Francisco is like Vermont, they’re even a little higher than Vermont for fully vaccinated — it’s 70 percent of the population of San Francisco county and it’s going through a very substantial hospitalization spike, unlike Vermont.
And that’s a bad sign because San Francisco has been kind of a rock throughout the whole pandemic.
They’ve been incredible. Even when the rest of California was doing poorly.
Yeah. Exactly. So I look at San Francisco as a bad bellwether for what might be coming. Why are they doing so poorly right now for hospitalization? Why is it so different than Vermont? If there’s that many people getting so sick, something’s just not right. But it’s hard to explain all these things, right? I mean, why, why did the U.K. on Freedom Day —
They took a U-turn! Just as they opened everything up.
Yeah. There were some models predicting they were near peak, okay. But it was kind of ironic, right? I was kind of joking: Maybe we should just have a Freedom Day declared in this country, but we can’t because we’ve already had Freedom Day for months.
In San Diego, too, we’re having hospitalization increases, too — not as bad as San Francisco, but our vaccination rates are quite good for California. But they’re not preventing a surge of new patients in the hospital.
And the rate of rise — it’s scary. We’ve never had a rise like this for the country. And, okay, a lot of it is from Florida and Louisiana. But the rate of rise is just … scary. The fact that this ratio is being maintained, compared to a monster wave, pre-dating vaccination …
Yeah, I mean, it’s terrifying.
To me, it speaks to just how formidable this virus version is, that it’s making people that sick.
Now right at the moment, the death rate is not following that same proportion, but there’s a lag, and [Friday] was a really bad day and the average is definitely heading up. It’s definitely not what would be expected and it is not what has been seen — that ratio of hospitalizations to cases is very different than what we’ve seen in the U.K.
But the trends are bad for deaths, too. It’s hard to know what lag to use when making calculations, because early in the pandemic the lag was a few weeks but the gap between the peak of the winter surge in cases and deaths was less than one week. And it may be closing because the disease progresses faster with Delta. But if you take our case number from two weeks ago, it was 50,000. And we’re at 500 daily deaths now. That’s really not far off the worst of the winter. It’s not a good picture.
No, no, it isn’t. But you know, right now people have a hard time saying that’s gloomy. All of a sudden you’re a fearmonger and you’re selling fear porn. But it’s hard to be optimistic. I’m actually a very optimistic person, but it’s hard to look at these indicators and feel at all optimistic.
When we talked a couple of weeks ago, the thing that you said that made me most hopeful was that you said you believed we should expect that the Delta wave would ultimately pass long before it had reached full penetration of the population. Do you still expect that, as has happened in the U.K. and the Netherlands, even if the wave is looking different here?
Well, the U.K. is starting to go up again. And we’ve seen this stuttering now in several other countries. India is just starting to go up, but in many other countries — South Africa and Denmark, so many countries — it looked like they were just going to come back to baseline and then instead they start back up again. So it looks like it’s unstable — you get this kind of rapid burn through, and then it’s not one where you’re staying at baseline for very long, or you never even get back to the baseline.
So that’s what’s different than the last time we spoke. On the other hand there, there are some countries who have done really well in containing this. These are countries that have 96 percent Delta, like Germany, Singapore — and there’s not even a wave. And then you have Netherlands, Portugal, and a few other European countries that have so far just had the U-turn and no instability after. So hopefully you don’t continue in that fight.
And maybe what we’re seeing in the U.K. or India is just a little wobble, I don’t know. But I think the revision here would be, since the last time we spoke, that it may not be as rosy. Most likely we will pass through this, in the next several weeks, I still think. There are some people speculating that opening schools is going to make this a longer ordeal and perhaps worse. I don’t know. I mean, we’re not doing so many things we could do to limit the issue of schools, like rapid testing —
It’s just incredible, isn’t it? September will be 20 months since the start of the pandemic, and probably 15 months since we were able to produce these at scale, and we still haven’t managed to connect the dots with them.
And so many other countries rely on that. That’s how they’ve done well with schools. And I mean, it’s so easy to just supply them for free. It’s just crazy that there’s been this complete ignoring of this potential.
But in the weeks ahead … I still think we’re gonna turn down again. We can’t just keep going up. But overall there aren’t yet any signs of slowing, though there are in certain states. And we could easily get back up to the highest level number of cases.
That’s about 250,000 new cases a day.
And if we do get there, and get there with 120,000 hospitalizations — I mean, I never would have envisioned that was possible.
This interview has been edited and condensed.