Meaning

Dear Members of the Baylor College of Medicine Community,

I cannot let this week go by without recognizing the passing of Dr. Peg Nosek, long-time tenured professor in Baylor’s Department of Physical Medicine and Rehabilitation. Dr. Nosek was the founder and executive director of the Center for Research on Women with Disabilities (CROWD), and had a long, productive academic career. She was a valued colleague, and someone who had much to teach and share. The broad brush-strokes of her 68 years, her life-long battle with a progressive neuromuscular disease and major contributions to science and public policy, are well summarized in a recent Houston Chronicle piece, which I strongly encourage you to read. I will return to Dr. Nosek towards the end of this message. She was a great woman, whom I was honored to know and who enriched the lives of those around her. I believe she still has lessons for us to learn.

The update on COVID-19 for the greater Houston metropolitan area is much as it has been. Choose your analogy, we have used them all. Brush fires are raging all around us; the flood waters are rising. Starting with the bad news, it remains clear that things will get worse before they get better. This week saw the largest increase in new cases in a single day ever, at over 3,000. By way of comparison, our daily case rate average two weeks ago was less than half that number. During the peak of our July surge, we never breached 3,000 daily cases, but as of today we have done so for two consecutive days. There is no sugar-coating it: This surge will continue and our hospitals and fatiguing providers will feel the strain. Our diligence around masking, distancing, and indoor crowd avoidance must continue into the foreseeable future.

However – with this virus there is always a “however” – there are hopeful dynamics buried in the numbers. The supra-3,000 peak is probably overstated, in that there appears to have been some reporting delays from the long holiday weekend. In addition, the total number of people being tested in city and county testing centers is sharply up, approximately twice the testing rate we saw in September, and slightly higher than the July peak. More tests will reveal more disease. It still appears that community cases are not translating into hospital admissions at the same rate they did in July, perhaps a sign that at-risk people are doing a good job of avoiding potentially infectious contacts.

The good news continues on the vaccine front. Both the Pfizer and Moderna trials are producing unexpectedly high efficacy rates with minimal side effects. Meetings of an independent advisory panel are scheduled (Dec. 10 and Dec. 17), which will likely result in FDA approval of both via Emergency Use Authorization (EUA). Great Britain has already approved the Pfizer vaccine for emergency use. Once the FDA grants EUA approval, vaccines should start to ship within days.

Our national race to develop safe and effective vaccines looks like it is shaping up to be a great success, although it is too early to declare victory. I refer you to a back-of-the envelope analysis of expected vaccine supply and demand from Dr. Bob Wachter, chair of Medicine at UCSF. 

In rough numbers – emphasis on the “rough” because there are many underlying assumptions – we probably need about 230 million immune people in the country to reach herd immunity. Between the Moderna and Pfizer vaccine, we should have about 45 million doses available by year-end. Since vaccination requires two doses, we should be able to vaccinate just north of 20 million people, which roughly equates to the total number of healthcare workers and first responders (19.3M) and people over 65 living in congregate settings (1.3M). 

That is a great first step, but less than 10% of progress necessary on our journey to herd immunity. To get to 230 million, we will need adequate supply and time to broadly distribute to people across the country. Between the Pfizer, Moderna and AstraZeneca vaccines (assuming there are no bumps in the road to approval), we will have a steadily growing, adequate supply by late summer/early fall. If this timetable holds, we should feel things improve in late Spring/early Summer. We are at the beginning of the end.

In the short term, 20 million people with vaccine-induced immunity against a need of 230 million might seem discouragingly small. But, put this in perspective. We do not know the actual nationwide prevalence of the virus, but based on studies in various communities, a reasonable estimate is 15%. Preliminary data in Houston put us at about 16%.

If you assume a U.S. population of 329 million, that means that approximately 50 million people already have a degree of disease-induced immunity. Think about the incredible pain, suffering and economic hardship we have endured to create 50 million immune people. By the springtime, vaccines should allow us to double that number. This time, our cost will not be measured in lives and livelihoods, but rather by a day or two of sore arms and body aches. This is the incredible power of vaccines.

Clearly, we are tired of it all, but we seem to be at another inflection point. Our health care providers performed admirably during the summer surge, but have not had the luxury of real time to recover. We follow the numbers closely, hoping (and at this point expecting) the current surge will not reach July levels, but planning in the event they do. We all are experiencing the same uncertainties and anxieties we felt in July, the difference being there is a clearly defined and realistic path to the end of all this.

A word about the Thanksgiving holiday, and a return to Dr. Nosek. 

I have spoken to many people about their holiday experience. I was gratified that literally everyone to whom I have spoken had a good plan (household celebration only, carefully designed gathering incorporating good practices, or commitment to a well-formed bubble). I also heard almost the same thing from everyone when asked, “How was your holiday?” The answer was always some variant of “different, but nice.” Thanksgiving was not what any of us would have wanted, but still had meaning. 

In reflecting on the incredible life of Dr. Nosek, I think there may be a lesson for us during these pandemic times. Although I cannot presume to speak for her, if she were able to share with us reflections on her life, they would no doubt include the struggles she endured. But, I strongly suspect most of her reminiscences would be of friends, colleagues, relationships, accomplishments and other trappings of a rich and meaningful life. 

This holiday season will be like no other – a bridge between crisis and resolution. My hope for all of us is we will look back at this time as one that was difficult, but was still filled with friends, colleagues and relationships. To quote Nietzsche, “He who has a why to live, can bear almost any how.”

Stay well.

James T McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs

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