Build and run hospitals that don't kill their patients – F Nightingale

 kw: book reviews, nonfiction, history, bacteriology, public health, epidemiology, antibiotic resistance

The title of this review is not quite a quote, but is the conclusion Florence Nightingale drew from her work in Istanbul during the Crimean War in the middle 1850's. The following diagram tells its own tale in the text block; please read it all:

Then pay attention to the blue wedges. Their areas, measured from the center, represent Preventable deaths, deaths of soldiers who died of infections that occurred in the hospital. The modern adjective for "doctor caused" is iatrogenic, and a near-synonym for "hospital sourced" is nosocomial. The appallingly filthy conditions in the hospital at Scutari, and the gore-drenched hands of the doctors going from patient to patient without washing, are summed up in those two adjectives. Thus it was when Florence Nightingale and her team of nurses arrived at the Scutari hospital in November 1854.

The rose diagram (Nightingale called it a "cobweb diagram") on the right shows the horrific toll from seven months before her arrival until five months afterward. Its last two months plus the other rose diagram also show the gradual reduction in overall deaths and particularly preventable deaths as her recommendations, and then demands, were instituted. The risk of dying because one had entered the hospital was reduced, month after month, and was almost eliminated after January 1856.

This and other "cobweb diagrams" proved to most medicos that there was a physical Something that carried contagion from patient to patient in unsanitary conditions, and from doctor to patient on soiled hands. In the 1850's, "germs" were unknown as agents of disease. Also in the mid-1850's, John Snow in England used black dots on street maps to demonstrate a similar fact: that a physical Something had gotten into water and spread disease. One of Dr. Snow's maps motivated the city council to disable a certain contaminated water pump, the famous Broad Street pump.

Facsimiles of that map and the rose diagrams are found in So Very Small: How Humans Discovered the Microcosmos, Defeated Germs—and May Still Lose the War Against Infectious Diseases, by Thomas Levenson. The book is a rather detailed history of the strains of knowledge that led up to the discovery by Dr. Robert Koch that specific microbes cause specific diseases, in the 1880's. This was two centuries after Leeuwenhoek first saw, and drew, and wrote about bacteria he found in scrapings from his teeth.

The author makes much, repeatedly, of the blindness of those with a theory to any evidence that overturns it. Thus "miasmas" were thought to cause diseases during those two centuries, and early-Enlightenment "cancel culture" was waged against anyone who advocated anything different. An abridged quote by Max Planck states, "Science progresses one funeral at a time." My father said it this way, "It's the Moses Method: spend forty years in the wilderness and let them all die out."

The Postulates of Robert Koch were originally developed as criteria for contagion based on studies of anthrax, cholera and tuberculosis. These and many other diseases are caused by bacteria that are visible with a microscope. That is, they are larger than about 1/5th of a micron. The common gut bacterium E. coli, for example, is in the form of rods about 3/4 micron in diameter and 2-3 microns long. Later the Koch Postulates were expanded to other organisms (including fungi) and near-organisms (such as viruses), as technology developed methods of detecting and visualizing them.

The first vaccine was developed in the 1790's by Edward Jenner. The first antibacterial drugs, primarily Salversan and the Sulfa drugs, were developed after 1910, and antibiotics were developed starting in 1929 with Penicillin. We are now about a century into the "age of antibiotics", laid on a foundation of vaccination. Public health measures such as clean (later chlorinated) water and sanitary sewers, followed by vaccinations and antibacterial drugs, have reduced infant and childhood mortality to almost negligible levels in Western countries, such that life expectancy for a newborn is now about 80 years. In a cemetery I visited when researching family history of the 1800's, half the graves were for infants and children under the age of five. Think about that.

The last section of the book deals with antibiotic resistance. Here, the author declares we are at risk of losing the war, after having won so many battles for the past century. He relates the case of a woman, diagnosed with a formerly "easy" microbe, but the strain that has infected her is fully resistant to every antibiotic the hospital has available. The doctor appeals to the CDC, which has twice as many kinds of antibiotic on hand. None of them is effective. The woman dies.

At the moment, our only defense against such "superbugs" is to continue to improve public health measures, and to more fully educate the public about risk mitigation. Alongside this there is a diatribe against the political confusion that surrounded SARS-Cov-2, the agent of the COVID-19 pandemic. The author is fully in the Fauci camp. That is unfortunate, because to my knowledge, Dr. Fauci lied so frequently and so self-contradictorily that a large proportion of "COVID" deaths must instead be attributed to governmental overreach and misapplication of treatment measures. An example is the push to provide millions of ventilators to help patients that developed pneumonia. About half died. The real misinformation was the incredible outcry against the use of Hydroxychloroquine and Ivermectin. The most damaging misinformation was, on the one side, that either of these was antiviral (they aren't), and on the other side, that they were "totally" ineffective. 

Both medicines are immune system modulators. Taken early, Hydroxychloroquine tamps down cytokine reactions, reducing or preventing pneumonia. After pneumonia begins, Ivermectin tamps down a different immune reaction, reducing the pneumonia so the body can recover. In any case, the body eventually eliminates the virus on its own, if the patient can be kept alive long enough. Ventilators all too frequently made things worse. OK, enough of that.

Where I truly fault with the author is that he never mentions phage therapy. Bacteriophages, bacterium-destroying viruses, were used before antibiotics were known, and before the viruses themselves had been seen with electron microscopes. They are agent-specific, meaning that a phage that is "tuned" to a certain strain of strep will not affect other bacteria. That is in great contrast to antibiotics that kill off most of a patient's gut microbiota, which requires some time to recover after the patient recovers from the disease. Many doctors I have read claim that more research into phage therapy can make most antibiotics unnecessary, even as they are already obsolete.

To end on a side note (not in the book): The title So Very Small got me thinking. I suspect not many folks really appreciate how small microbes are. This illustration from The Visual Capitalist will help:

Human hair diameter depends on hair color. Blond hair is the thinnest, 50-70 microns, and black hair like that of my Asian wife is the thickest, 150-180 microns. A micron is a 25,000th of an inch. The first thing you could call a microbe in this illustration is the "bacterium", the little blue comma near lower left. The comma shape indicates that the organism is probably the Cholera bacterium. It is the largest item shown that is larger than one micron. Viruses of COVID-19 and of most strains of influenza are about two tenths of a micron in diameter, or about one-tenth the size of the bacterium shown; the illustration shows the virus as much too large. Other viruses of other shapes range widely in size, but are almost all smaller—usually a lot smaller—than one micron. A bacteriophage is shown, appearing 2-4 times as large as it should, compared to the illustration of the bacterium it attacks.

Small things don't always have small effects. In the case of disease-causing bacteria and viruses, they really can have effects bigger than we may know what to do about!

A lesson we are slow to learn

 kw: book reviews, nonfiction, epidemiology, airborne pathogens

When I saw the title, Airborne: The Hidden History of the Life we Breathe, by Carl Zimmer, I imagined a survey of the microorganisms that make their way into the air. Instead I found a historical survey of certain attitudes that the medical establishment has held, primarily a stubborn denial that bacteria and viruses and other micro-pathogens can travel long distances along with the air. By the end of the book, it appears that this denial persists to this day alongside an ever-strengthening view that airborne spread of disease is of paramount importance. I say "appears" because in the political climate of the past five years, the great majority of clinicians and epidemiologists have judged it prudent to say as little as possible about it. Political matters are so hyper-polarized these days that they taint or contaminate every aspect of national life.

The term "Covid-19" does not appear until the fifth of five sections of the book, on page 350, eight pages into the chapter "Disease X". Beginning on page 345 the virus is called SARS-COV-2. This is a curious inversion of time: I don't remember learning the name SARS-COV-2 until more than a year after the WHO (as reported on p 350) announced that the name of the disease would be Covid-19.

The first 340 pages of Airborne present a blow-by-blow (-by-blow) history of the small number of researchers who studied airborne microbes for decades and yet died or retired without their findings being recognized as at all relevant to the prevention or treatment of disease. This in spite of the fact that non-medical folks (darn near everybody on the planet) recognizes that, just as dust and smoke can be carried miles and hundreds of miles by wind and even breezes, so must the microbes which are ever-so-much smaller and lighter.

These days, I sometimes marvel at how clean the air in my house is. When the sun shines through a window, I'll see scattered specks of dust in the sunbeam, but I recall that in my childhood a sunbeam was really a beam, so dense it appeared solid. This was considered normal in the 1950's and before. We dust areas like the top of the piano weekly or monthly; it used to be a daily task. When I would catch a childhood disease such as measles, mumps or chicken pox, my mother would say, "Well, if you can see a sick kid, his germs can get to you." Forty years later, before an effective vaccine for chicken pox was developed, we sent our son to visit a friend who was sick with chicken pox so he could catch it. That is one disease that is deadly to adults but kids just shrug it off (and scratch a little).

It was almost laughably predictable that Mr. Zimmer would make Anthony Fauci into a semi-hero. On my part, I count President Trump's second greatest mistake to be his failure to either fire or sideline Dr. Fauci after their first televised appearance together, when the doctor contradicted nearly everything the President had to say (…and the greatest mistake was initiating the practice of "stimulus"; it gave his successor's administration "permission" to "stimulate" us into a 30-trillion-dollar increase in the national debt). I began to designate "Dr Fakey" from that press conference. And when he said, "I am Science", he proved that he had lost connection with reality. Mr. Zimmer partially redeems himself by noting that Dr. Fauci was shunted aside by the Trump administration, months too late, and he does point out that Dr. Fauci and much of the medical establishment was motivate initially by the shortage of semi-effective masks, to tell the public not to mask. Later lies, however, are ignored.

Just by the way, I got N-95 masks from a hardware store; they are excellent dust masks! But no matter what masks people used in the 2020-2022 time frame, I never saw another person wear a mask correctly. I know what it takes to make a mask fit so that I can mow the lawn without choking half to death; I am very sensitive to grass clipping dust. But it happens that viruses such as SARS-COV-2 and influenza and the common cold are in these masks' "sour spot" (the opposite of a sweet spot!): too small for pore size to catch them and too large for electrostatic capture to be highly effective. N-95 means the "sour spot" still can stop 95%, but that means 5% gets through, which is enough for most people to get sick anyway. And an ill-fitting N-95 mask is really about an N-10 mask, or worse. OK, enough of that diatribe.

What I hoped to see in the "Disease X" chapter and its successors was an even-handed history. Sadly, too much was left out. The Chinese doctor in Wuhan who worked on gain-of-function research into coronaviruses, and published the results in prestigious journals such as Science, is never mentioned. Ditto the fact that her research was bankrolled by Dr. Fauci, using an accounting trick to get around a prohibition by President Obama. I do not mention the doctor's name, since doing so is a sure ticket to "cancellation", even today. The five state governors who required nursing homes to take in patients infected with the virus are never mentioned. The illness and deaths caused by their policies form the bulk of the First Wave of Covid-19. No mention is made that the Wuhan Wet Market doesn't have bats for sale. I could go on…

Even though I saw where the book was going by the 50th page or so, I read it all. Carl Zimmer writes very well and I generally consider him, if not a wholly honest journalist, one of the better ones. This book falls short of his usual standard. I don't consider the time wasted, however. Though the book's main text is 414 pages, at least 340 pages of it contain interesting and useful history.

Herd Immunity versus Herd Mentality

 kw: book reviews, nonfiction, pandemics, covid-19, sars-cov-2, politics, epidemiology, sociology

During what we now know was an early stage of the Covid-19 pandemic, Johan Anderberg wrote his analysis of the unique approach taken by Sweden, as compared to all the other First World nations: The Herd: How Sweden Chose Its Own Path Through the Worst Pandemic in 100 years, translated from Swedish by Alice E. Olsson and published in English in 2022.

The book covers from early March 2020 until the end of the year. Writing in 2021 a book to be published the following year, the author could not have foreseen how absolutely middle-of-the road the results would be in Sweden, or how the pandemic would play out for another two full years, followed by a sputtering endemic infection that has become a slightly-worse-than-usual type of flu. Four other coronaviruses are known to cause fall-to-winter colds, and now there is a fifth, that is a little more deadly than the other four, but on a par with Type A influenza.

The action centers on two significant men, Anders Tegnell, Sweden's state epidemiologist, and Johan Giesecke, advisor of WHO to the Public Health Agency of Sweden. Other important men and women played their parts, including the Prime Minister of Sweden, but these two, with Tegnell in the lead, helmed the Swedish strategy for coping with the pandemic, for at least the year 2020.

Just as the two men began to collaborate, on March 12, Giesecke quoted a 17th Century noble who had written to his son, "An nescis, mi fili, quantilla prudentia mundus regulatur" and thoughtfully provided a translation, "Don't you know, my son, with how little wisdom the world is governed?" (p.73) This attitude was the underlying basis for dealing with the hundred-odd world governments and hundreds of news agencies that questioned, then decried, then condemned the light touch taken by the Swedes.

Early on Tegnell and Giesecke sought not to limit transmission but, in the absence of a viable vaccine, to allow the infection to spread while taking measures to protect the frail elderly and other vulnerable persons, with the goal of establishing herd immunity. There is much discussion of this concept in the book, with an equation or two related to R₀, the expected number of persons one infected person infects. Later, discussion moved to such buzz phrases as "limit the spread" and "flatten the curve", which caused confusion and had no discernible effect.

I remember well that President Trump authorized the military to make available great numbers of hospital beds and ventilator equipment, many on Navy ships. These went largely unused. To my discernment, being put on a ventilator was a death sentence for 50% of patients who were thus treated, and a great way to lose a quarter to half of one's body weight and muscle mass for those who survived, leading to months of recuperation. 

This is as good a time as any to note that a good friend of mine, a physician, and I worked out a plan: 

1. Since the main killer of Covid patients is pneumonia, and the lung-filling fluids of pneumonia are primarily composed of sugars, at the first symptom it is best to stop eating, ingesting only water, for at least 2-3 days.
2. Rather than fighting a fever, seek to enhance it into the 102°F range (39°C), to support the T-cells that are fighting the virus. He intended to use hot water baths or to get in the car on a sunny day and turn up the heat all the way. I preferred to not use anti-fever medications such as Tylenol.

As it happens, the doctor and I, in spite of being "fully vaccinated", both contracted Covid-19 twice, and survived quite well. In my case, effective antivirals were available by that time, which no doubt helped a lot.

The Swedish epidemiologists didn't stay "in the silo" of epidemiology, but took a more sociological approach. They disdained the notion of locking down a society, and while the rest of the world (or at least Europe and North America and developed Asia) was mandating masks, forbidding church and other gatherings, closing schools, and issuing "6-foot spacing" guidelines, they kept Swedish society almost completely open.

It seems the rest of the world took their cue from an amateur scientist with no epidemiological training, Tomas Puevo, who published an essay, "The Hammer and the Dance", predicting that the attempt to attain herd immunity would result in 10 million deaths in the USA (pp. 124-5). The actual total by end-April 2024 was 1.2 million, and at the end of 2020, about 380,000. But politicians and some scientists worldwide bought into this totally, and we were all locked down.

I'll jump forward to the denouement, which begins on p. 288 with a bit of genuine epidemiology: comparing year-on-year death statistics to discern "excess deaths" that might more properly be attributed to Covid-19 (or any other epidemic agent). 

• In 2020, the total number who died of all causes in Sweden was 98,124. 
• The annual average for 2015-2019 was 90,962. 
• In 1993, the year of a bad flu outbreak ("the Beijing flu"), the figure was 97,008. 
• Swedish population in 2020 and in 1993 (rounded): 10,369,000 and 8,574,000. 
• Divide deaths by population. 
• In 2020: 9,463 per million
• In 1993: 11,310 per million 
• Population average 2015-2019: 10,109,000. Divide it out: 8,998
• Delta per million in 2020 = 465 excess deaths per million
• Delta per million in 1993 = 2,312 (almost 5x!).

Conclusion: The Covid-19 pandemic was far from being "the worst pandemic in 100 years". It was probably second-worse.

Note: CDC data (https://www.cdc.gov/mmwr/preview/mmwrhtml/00016654.htm) indicates that in an "ordinary" flu season, flu leads to about 10,000 deaths in the USA. In the 1992-1993 seasons, 45,000 such deaths occurred each of the two years. Dividing these figures by a population of about 330 million, we find that flu deaths are "usually" about 30 per million, while the sum of 1992 and 1993 deaths by flu comes to 273. The Beijing flu hit Sweden 8.5 times as hard as it did the USA.

Backing up to p. 223, where the scientific community "turned from evidence-based reasoning to the precautionary principle": One scientist wrote of the reasoning of Anders Tegnell, "If he's wrong, it costs life. If I'm wrong, what harm does it do?" This is a markedly false dichotomy, for the lockdowns and other draconian measures not only did much harm, they cost many lives in themselves, including a great increase in suicide among younger people. The scientist who wrote that statement doesn't deserve to be called scientific.

Even in Sweden, by the end of 2020 the situation was no longer driven by science (protestations by fraudulent scientist Andrew Fauci notwithstanding), but by politics, specifically the totalitarian politics of control and the amassing of power. So-called "cancel culture" took control, such that the final sentence in the chapter titled "Science!" is, "What was regarded as a scientific discussion in Sweden was deemed to be misinformation in other countries." (p. 247). This is still true!

Considering the polarizing politics that arose from this, or rather that took advantage of it, I need to point out that on p. 243 the author quotes Glenn Kessler's article in The Washington Post that claimed Donald Trump issued 16,241 false and misleading claims in his first three years in office. He is apparently unaware that the article was debunked within a week by real journalists at the New York Post and The Atlantic. They found that at most, Mr. Trump lied outright no more than a handful of times; rather, Kessler printed thousands of lies in his article. True to form, Kessler just doubled down and issued further claims. The debunking has been so covered up it is hard to track down the truth. In actuality, since 2015 The WaPo, NYT and other "leading" publishers committed tens of thousands of lies against Donald Trump weekly, and continue to do so.

Let's look at some charts from Worldometer, which is cited a few times in the book. Note that the last update to their figures was April 13, 2024. Reporting has become too sporadic and unreliable for them to continue. I must add that early reporting is also somewhat questionable, and in particular, nothing that was "reported" by China or North Korea (DPRK in Worldometer) should be relied upon.

First, to discuss the summary for the whole world:

The fluctuating death rate shows the progress of the different "waves", ten of them, counting the late, rather tiny, bump from November 2023 to February 2024. The biggest wave of cases, in early 2022, with a wave of deaths that is lower than two of the others, shows how infectious the Omicron variant of the virus was, and how much less deadly it was.

When The Herd was written, the third wave, counted worldwide, was just ending. These figures help us establish some criteria. New daily cases in 2022 peaked at 500 per million persons, and exceeded 100 for much of the year; at all other times there were fewer than 100. The current case rate is 2/million or less.

The worldwide Covid-19 death rate exceeded 1/million persons for all of 2021 and the first third of 2022, and then, as the Delta variant petered out, it dropped very low and apparently remains well below 100 total deaths daily, or some 0.012 deaths daily per million population. As mentioned, this is in line with seasonal influenza. This is why, although some nutty politicians continue calling for restrictions to be imposed again, nobody is paying attention.

Next, let's look at how Sweden fared in all this:

It is worth noting that, while the daily case rate prior to August 2020, worldwide and in Sweden, is almost not visible on these charts, the daily death rates in this period were quite high. The very early death rate exceeded 10% of (known) cases. Two factors combine: figuring out how many actual cases there were was very difficult early on, and the large number of deaths represent "low-hanging fruit", or people who were at death's door already. In the USA, this was exacerbated in five states whose governors required nursing homes to take in people dying of Covid-19, which spread through those nursing homes like wildfire, killing many. I contend that those five governors are the five greatest mass murderers of the early 21st Century.

During the second wave at the end of 2020, Swedish politicians were spooked that Covid-19 deaths had again exceeded 100 per day (10/million in a population of just over 10 million), and as is noted in The Herd, began to swerve from the open stance of the prior year.

The figures in brown at top right of these charts show that the total case rate in Sweden was three times the world average, and the total death rate was just under three times as much.

Arguably, the country worst hit by the pandemic was the USA:

I am not sure whether the lockdowns in the USA were the worst in the Free World, but in my experience they were pretty bad. They varied from state to state. The first wave of deaths was not quite as bad, on a per-capita basis, as for Sweden, but the second wave was clearly worse. After the end of 2021, the USA case rate was much higher than that for Sweden, and this apparently continues, but after the middle of 2022 the Covid-19 death rate in the USA is quite a bit lower than Sweden's.

Compared to the world, the total case rate for the USA is 3.7 times higher and the total death rate is just over 4.0 times as high.

I originally prepared two more similar graphs, for the UK and for Norway, but instead I'll present the following:

The vertical axis is deaths from Covid-19 per million population of a country. Sweden, shown as "Swe", is right in the middle. The USA is to its upper right, with the UK in between. Among more authoritarian European countries, I've marked Bulgaria, Hungary, and Bosnia/Herzegovina, which had three of the four highest death rates in the world. The highest was Peru, for reasons I won't plumb here. By contrast, look at Canada and Norway ("Nor"; in each case except "World" the title is to the right of the dot). Nearly all the dots below them are countries in Africa and poorer parts of Asia, places which had few infections and very low death rates. 

I would think an ambitious epidemiologist could make a career of finding out whether there was something more than dumb luck that "blessed" the Third World. But I also must note that I have, from the beginning, strongly suspected that the USA was targeted by China, which released this bug with malice aforethought. I am flabbergasted by the number of American pundits who defend China at every turn. I know enough Chinese people to have an inkling of their way of thinking. Not every war goes fast. The Chinese way is patient, slow, and—insofar as they can ensure it—irresistible. To their way of thinking, WW3 has begun, and if they can manage it, our enemy will remove our head before we notice we have died.

The core message of this chart is that lockdowns had no discernible effect. Every European nation and most others locked down a great deal more than Norway, which stayed open during that very crucial first year, and has remained more open than most other countries thereafter. As a preacher once said about faith healing, "God may heal you today, but eventually you are going to die of something."

We learned from this pandemic that we have more to fear from totalitarian politicians than we do from a global disease outbreak. Sweden showed that society could remain open, taking only certain rather cautious measures, without harming the citizens either medically or politically. It is hard to tell whether any country achieved herd immunity, but it is certain that with the exception of Sweden, most countries fell victim to herd mentality, from which they are still in a very slow recovery.

Who's afraid of the big bad COVID?

 kw: analysis, epidemiology, immune system, vaccination, herd immunity

The magic number is 7. We'll get back to this. 

The first thing to understand about a pandemic disease is the ratio of infection to symptomatic illness. Only then can you understand the progress of the disease through time in a population. This ratio is the first thing a national disease-monitoring organization such as CDC should determine. However, they have not, or if they did, they are not telling. I have sought other sources.

Dr. Anthony Fauci, without citing sources, claimed a few times that of the total number infected with SARS-CoV-2 virus, about 40% have no symptoms. An estimate out of South Korea claims 30%. But both of these are actually talking about asymptomatic carriers, those who have no overt symptoms but can still spread the disease. A few test surveys that I have been able to find showed a different picture. In a test survey, everyone in some population is tested, such as residents in a dormitory. Reports popped up, were public for a few weeks or less, and then vanished. They had a narrow range of numbers of the ratio of infection to illness. From these I got the magic number above. Stated a better way:

For every 7 persons whose test showed they were infected, one was ill and the rest had no symptoms.

 The range of magic numbers was between 5 and 9. For one test survey it was 10. Therefore, in the earlier stages of the COVID-19 pandemic, when there were no accurate tests, the numbers of known cases was only 1/7th of the actual number of infections.

If we combine that with the 30%-40% "claimed asymptomatic carrier" rate, we can surmise the following, for a total of 1,000 infected persons:

• 143 will be ill at some point (we're not counting deaths yet; some of these will die).
• Between 61 and 95 will be "carriers" who have no symptoms, for a total of 204 to 238 who can infect others.
• The remaining 762 to 796 who are infected will recover without consequence, for themselves or for others.

Now to re-examine the first bullet point above: How many of the 143 will die? Spoiler: less than 2, and maybe much less than that.

I am going to use data from the charts supplied at Worldometer, as faulty as it is. The definition of a "Case" has changed over time. Early on, people with certain symptoms were "presumed positive". Later, testing was implemented. To date, in the U.S. about twice as many tests have been performed as there are persons in the country. However, there are those who get a test every week, some (like myself and my wife) who have been tested 3-4 times, and well over half of U.S. residents have never been tested. At the present time, the number of "cases" includes test results, which depends on the accuracy of record-keeping (We all have heard stories of people who were in line to get a test, had "signed in at the door", and then before getting tested, opted out and left; later they got a letter in the mail stating that they had tested Positive. Maybe the person in back of them in line was the one really tested, or something. We'll never know).

There is the further problem with "no Flu season in 2020-21". Really? Is that believable? Reasonably accurate tests for SARS-CoV-2 were just coming into use during the winter of 2020. COVID "cases" were among the "presumed positive". I contend that between 30,000 and 60,000 U.S. residents who are counted as "COVID deaths" actually died of Influenza. There are also those who died while they were infected with the virus, but they did not die OF the virus (car accidents, suicide, etc.). News of such events is being suppressed, so it is hard to gather statistics. Let's hope the number is small. With all those disclaimers, let's look at this chart, taking it (mostly) at face value.

The blue and brown curves are 7-day averages, as calculated at Worldometer. Blue is cases reported each day, however such cases were determined. This is for the U.S., and the axis to use is labeled "100k" and so forth. Five waves of infection can be seen; they peaked in April 2020, late August 2020, January 2021, April 2021 and late August 2021.

Each peak has a corresponding peak in daily deaths, the brown curve. The axis is labeled "2k" and so forth. These curves are scaled to have visible parity during the third wave. Note that the peaks in deaths and the curves for daily deaths are offset from the peaks and curves for cases…except for the first wave. At the beginning, people didn't get help until they were at death's door, so many of those who died did so within a day of being admitted to a hospital, and they had been reported as a "case" on the day of admittance. Thus, let's look at the same chart, with cases shifted 15 days back, which makes the third wave overlap as well as possible. 

This presentation makes the dates harder to discern. I presented a similar chart on August 1, just 2 months ago, when the fifth wave was just beginning, stating "Herd immunity has arrived." This conclusion was based on the anomaly about Wave 4: there was no peak in the death rate, and during the summer of 2021 case rates were lower than at any time since mid-March 2020.

The 5th wave is the Delta wave. It is smaller than Wave 3 because it is occurring primarily among the unvaccinated (in which I count those formerly infected: "vaccinated by God"). It also appears to have about a 15-day delay between discovery and death. However, look at the subtle vertical shift over time. The death rate is lower in proportion during Wave 5 than it was previously. And the gorilla in the room is the very high death rate during Wave 1.

What happened during Wave 1? Firstly, we had no clue what was going on. There were no effective treatments. President Trump ordered certain companies to ramp up the production of ventilators. It turned out that ventilators caused more deaths than they prevented. They aren't supposed to be used for weeks at a time. But even more, many of these deaths occurred in nursing homes where the virus ran rampant. This was aggravated in five states whose Governors ordered COVID patients moved from hospitals back to the nursing homes they came from, creating the first super-spreader events. 

Secondly, there were no effective medicinal interventions yet. Now there are two for early use (coded IVM and HCQS), and also monoclonal antibody treatments such as Regeneron, which was used to treat President Trump. Thus, the blast of early deaths represented the "low hanging fruit". A large proportion of the most vulnerable Americans died in Wave 1. Most variants of the virus that have arisen later cause fewer deaths, and we have medicines that work better. So let's look at another couple of charts.

For these I used the 7-day averaged number of cases or deaths at the peak of each wave. These are not totals for each wave, be clear on that. For a few cases in one state or another, and in the U.S. during Wave 4, where there was no peak in the death rate, I used a date 15 days delayed from the peak in cases.

The chart on the left has the data for the U.S. along with the five states whose governors forced COVID patients into nursing homes. Each bar represents the ratio of peak death rate divided by peak case rate, in each wave. The chart on the right has data for seven states I found of interest, including some in which I have lived. The one I find of particular interest is South Dakota (I lived there 8 years), which seems to have had a better handle on this disease than the rest, particularly in Waves 1 and 5.

The "easy take-away" is this: During Wave 1, D/C was about 7% nationwide, ranging from 4.5% to 9.5% for the five states shown on the left, and (except for NH) between 1.7% and 4.5% for the seven states shown on the right. The death rate has continued downward since then.

While state numbers hop around a bit, the national averages for the five waves are

7%, 1.7%, 1.4%, 1.0%, 1.1%

Let us return to the magic number, 7. On average, for 7 infections, there is one illness. Is all the testing finding every infection, whether ill or not? Not really. The vast majority of tests are done by those who either think they are sick, are feeling sick, or fear/think they have been exposed. So, if there are 6 people out there with no symptoms for everyone who has symptoms, and very few of those 6 are getting tested, they are still not known.

We were told that we needed to achieve 70% "fully vaccinated" to gain herd immunity. That was based on an infectivity rate for the Alpha variant, which is pretty much out of the picture by now. Back to variants in a moment. To date (Oct 1, 2021), just over 185.25 million Americans are recorded as fully vaccinated. This is called 56.1% of the population in news reports, but of course no children under age 12 have been vaccinated, and it isn't certain that they ever ought to be, at least with today's vaccines. That's 48 million, or 14.4% of the population. So the proportion of those12 and older who are fully vaccinated is about 65%. Getting close! But let's remember, the 2-shot "vaccines" are claimed to be 95% effective, while the one-shot version is 65% effective. We can expect about 90% overall effectiveness, so the "actually immune" adults in the U.S. total about 58.5%. One more factor must be considered.

The number of past infections that have resulted in recovery is 33.7 million, or 11.8% of persons 12 and older. 58.5+11.8 = 70.3%. By the criterion set by the CDC, we have achieved herd immunity. More vaccinations and more recoveries happen every day, so we are moving farther and farther into "herd immunity" territory.

So what's with Wave 5? I call it the Delta Wave. A word on variants.

There are many "serotypes" of the SARS-CoV-2 virus. A year ago it was reported that about 30 were circulating in the U.S., and more than 100 were known in China. It's practically impossible to get useful data out of China any more, so we don't know how many serotypes exist. A Serotype is a minor variation in the RNA of the virus. Not all have any practical effect. But a few do. The serotypes are grouped into families by RNA similarity and by clinical measures including infectivity and virulence. So far, there are 12 such Variants.

Infectivity is a measure of how many virus particles one must ingest to cause an active infection, for a person of "average immunity" (a quantity that has never been quantified). Those 5%-10% of vaccinated persons for whom the vaccine "didn't take" have lower immunity, didn't respond strongly enough to the mRNA agent in the vaccine, and so didn't develop a useful antibody defense. They were easier to infect before, and remain easier to infect. For most of us, there is some number, perhaps 1,000 particles, that are sufficient to swamp our early immune response and trigger active infection (whether we ever get symptoms or not, and I picked 1,000 "out of the hat"). We may be exposed to 100 particles several times, and out body fights them off, all the while getting more "wise" to the virus. That produces natural immunity without infection.

Reversing the logic, we have the case spreading rate. For a virus of average infectivity, someone who is infected might infect two other persons during his or her period of active infection. The 70% figure for achieving herd immunity was based on a case spreading rate of 3. I have read claims that the Delta variant is more infective (a smaller number of particles are sufficient to cause active infection), such that the case spreading rate is 6. 

Some claim that if this rate is greater than 5, herd immunity is no longer possible. That is nonsense. Those who state such things have their math wrong. They are using a simple ratio, but the math actually requires inverting a Weibull distribution, and never goes to 100%, meaning that herd immunity is always possible. However, it does get harder to achieve when infectivity is greater. For example, polio has a very high infectivity, as does measles, but we rely on herd immunity in both cases by striving for vaccination rates of 95% of the population, primarily by requiring all school children to be vaccinated for measles and polio (and a bunch of others).

Virulence refers to the likelihood of serious illness or death. If we look at Wave 1 above, it appears that virulence was such as to cause a 5% death rate, before we found effective treatments, and now it is about 1%. Untreated, AIDS and Ebola have a near-100% death rate. Influenza has a virulence about 1/10th as great as SARS-CoV-2, with a great range depending on the yearly variant.

So, although there are hundreds of serotypes out there, we hear of only Variants ranging from Alpha to Mu, the 1st and 12th letters of the Greek alphabet. Waves 1 through 5 were due to Variants Alpha and Lambda (11th). A Variant is a collection of similar serotypes. Delta was the fourth variant identified, but was kept out of the U.S. until late this summer. Now it is dominant.

If the Delta variant were to arrive in a totally naïve population, a big, big Wave of infections would occur. The comparatively smaller size of Wave 5 shows that it is occurring among the non-immune, which presently comprise 30% of adults in the U.S. All the variants so far known cause only mild infection in the vaccinated. Yes, there have been a number of vaccinated people who caught the disease and died. They are among the 5%-10% identified earlier. The mRNA vaccine didn't produce a useful response in them.

Now, a final word about the magic number, 7. For at least Waves 1 through 4, reduce the death rate by a factor of 7 to get a true death/case ratio. It is likely also true for Delta, so we find that actual death rates for the five waves are:

1.0%, 0.25%, 0.2%, 0.14%, 0.16%

That's a low death rate, and I repeat, we have achieved herd immunity for Alpha and Lambda, and we're on the way to achieving it for Delta.