Bite Point

The Disservice and Injustice Wrought by Dental Insurance

Dental insurance companies are causing significant harm to the oral health of Americans through several mechanisms.

The first problem is that dental “insurance” is no longer insurance; it’s a yearly coupon.

The reason? Shrinking yearly maximums.

When dental insurance started on a large scale in the US in 1967, the most common yearly maximum was $1,000, and there were generally no payroll deductions. It was a perk.

Now, in 2023, 95%+ of the dental insurance plans we see patients carry are set at a $1,000 per year maximum.

We must use an inflation calculator in order to make sense of this. $1,000 in 1967 is $8,800 today!

Thus, patients today are getting 1/9 the value of their 1967-era predecessors, and are paying monthly payroll deductions for the privilege.

The second major problem for patients and their employers (who deserve to enjoy a workforce not rendered ill or unproductive by avoidable dental disease) is Denial. Deny, deny, deny; dental insurance companies positively revel in not making payments. And when they can’t deny something, their next go-to strategy is Delay. Delay payment to dentist or patient as long as possible.

Dental insurance companies are corporations, and corporations generally thrive on what economists call Negative Externalities—when the production or consumption of a product results in a cost to a third party—a cost to you and me. Air and noise pollution are iconic examples.

The unjust thing here is, the employer paid for this insurance product, the employee/patient also likely paid via payroll deductions, and far too often, they are cheated out of a benefit that they purchased in good faith.

A third problem with  dental insurance companies—one that is downright holding back advances in patient care in the U.S.—is that they don’t raise their payment rates at anything close to the rate of inflation. As an example, Delta Dental’s last fee increase in our region was in 2014, and they absolutely refuse to raise rates at any time in the foreseeable future. Dentists who participate in such plans—who accept their fee schedules—not only cannot afford new technology at these rates. We are now approaching and in many cases passing a “coffin corner” where the cost of providing services is greater than Delta’s payment rates. Participating in such plans means running at a loss, and eventual bankruptcy.

In the interest of brevity, we’ll just mention one other maddening fact about dental insurance companies. That is, they are all 501c non-profit corporations. And yet, they amass tens of millions of dollars in profits every year. How is this fair to employer, employee, patient and dentist?

It is time for dental insurance reform. An excellent first step is the passage in Massachusetts of 2022 Ballot Question 2, which mandates that dental insurance companies operating in the state of Massachusetts apply at least 83% of their premiums collected to patient care.

As a culture, we must start recognizing that dental “insurance” is but a yearly coupon, because of how much less dentistry it covers than it did in years past. And those without dental insurance must be educated and informed that there are other ways to afford care.

The three primary threats to human health in dentistry’s wheelhouse are periodontal disease, cavities and oral cancer. The hard truth is that none of these three diseases ever get better on their own, and they don’t even ever stay the same. They only worsen over time. Relentlessly. It is best for human health, and also always less expensive, to diagnose and treat these diseases early, before infection sets in or worse.

I want to educate folks that dental “insurance” is not insurance at all, but a yearly coupon. There’s a vast portion of the population who does not have dental insurance, and gets the notion in their head that “I can’t go to the dentist because I don’t have insurance.” I want to break down that dangerous myth before yet more harm is done.

Disinformation

As the Covid-19 pandemic enters its third year, and as our culture sustains damage from the illness and death caused by the Covid-19 virus, from supply chain disruptions, from widespread chronic anxiety, from disruptive political forces and from a myriad of other causes, one harmful force stands out to me above all others:

Disinformation.

When I grew up, there were relatively few sources of public information, and they all were controlled by powerful gatekeepers. If one wanted to publish a letter to the editor, or a novel, or air a commercial, or get an original piece of music on the air—one had to ask a gatekeeper for permission first. And denials were far more common than permission.

This system had serious flaws, obviously. A great deal of human expression was held back or suppressed.

When the Internet—the greatest connection machine we’ve ever known—came along, a revolution in information flow occurred. This was the first communications medium in human history in which everyone who has a receiver—has a transmitter too. Now, we don't have to ask a gatekeeper in order to say something in public. We can write a blog post, share our music with the world, self-publish a novel or start a podcast, and we don’t have to ask anyone’s permission to do so.

A decade ago, I was extremely optimistic about this. So much so that the ending of my first (self-published) novel, The Man Who Wore Mismatched Socks, points to this great freedom as the beginning of a glorious historical period in the life of humanity.

Unfortunately, I underestimated the dark side of human nature. Every tool we create, it seems, can be used for good or evil. And so now, disinformation, fearmongering and angermongering are a significant part of what is damaging our culture and disrupting our lives. There are people who spread disinformation because they can, and presumably because to do so is breathtakingly profitable.

Nowadays, I kind of miss Walter Cronkite.

Naturally, I’m not brimming with a solution to the vexing and harmful problem of disinformation. To paraphrase the iconic line by Dr. Leonard McCoy, “I’m a dentist, not a …” Well, who would it take to solve this, anyway? I’m not even sure. But I do want to share with you all a key insight that we need if we are going to, together, work our way out of this awful and dangerous mess.

Mary Parker Follett was an American social worker, management consultant, philosopher and pioneer in the fields of organizational theory and organizational behavior. She has been called the “Mother of Modern Management.” Ms. Follett passed away in 1933, so she performed her remarkable work a very long time ago. I have a great penchant for outliers, and for a woman in the 1910s and 1920s to be listened to, and respected, and her ideas acted upon by the male-dominated world of American business of her time was beyond remarkable. I’ve read her work and I can see why. Her unique brilliance was that she focused on the human element of business, and she regarded human beings as the most important component of any business enterprise.

Ms. Follett once told a little parable that is so relevant just now. I’ll present her parable here, in hopes that you gain insight and agency from her words.

“We need experts, we need accurate information, but the object is not to do away with difference but to do away with muddle. When for lack of facts you and I are responding to a different situation—you to the situation as you imagine it, I to the situation as I imagine, it—we cannot of course come to agreement. What accurate information does is to clear the ground for genuine difference and therefore make possible, I do not say make sure, agreement. The object of accurate information is not to overcome difference but to give legitimate play to difference.

“If I think I am looking at a black snake and you think it is a fallen branch, our talk will be merely chaotic. But after we have decided that it is a snake, we do not then automatically agree what to do with it. You and I may respond quite differently to ‘black snake’: shall we run away, or kill it, or take it home and make a pet of it to kill the mice? There is now some basis for significant difference.

“Difference based on inaccuracy is meaningless. We have not done away with difference, but we have provided the possibility for fruitful difference.”

Difference based on inaccuracy is meaningless. Indeed! Going forward, we all need to work together in order to re-establish a common cultural agreement on what Truth is. And we certainly need to be on guard against those who attempt to manipulate us with disinformation. Being on guard is critically important to protecting yourself and your family.

Stay safe and do good,

Rick Wilson DMD

Covid-19 RNA Vaccines, Explained

Covid-19 RNA Vaccines, Explained

As we approach a time when effective Covid-19 vaccines become available, I wish to explain to you all one further twist on these potentially life-saving medicines. All the major vaccine contenders now are RNA vaccines. What is an RNA vaccine, and are they safe?

First of all, what is a virus, exactly? A couple of biologists back in the Seventies made the delightfully snarky comment, “A virus is bad news wrapped in protein.” And that’s about the truth of it. Although viruses can do some remarkably complex things, they are blindingly simple in structure. A virus consists of the genetic material that codes for what it will do when it enters its targeted host cell—this can be DNA or RNA, depending on the species. And then there’s a protective protein coat, which contains all the devious machinery that allows the virus to enter that host cell once it encounters it.

That’s it. RNA and a protein coat. In Covid-19’s case, around 30,000 base pairs of RNA wrapped up in an absolutely weaponized protein coat, dang it, so effective is it at invading human lung cells.

Now, recall that there are several broad categories of vaccine types against viruses. Attenuated Vaccines contain a weakened form of the virus in question. Inactivated Vaccines contained killed virus, meaning that its DNA or RNA has been inactivated in some manner. And then Subunit Vaccines contain only some piece or fragment of the viral external protein envelope. Something that our body can recognize and mount an immune response to, but that does not contain any viral DNA or RNA.

This is the part that I truly hope I can help you all feel comfortable with. A Subunit Vaccine does not contain the genetic blueprint for the virus! A piece of protein is all it is. Sometimes when we get a Subunit Vaccine we feel a little off for a couple of days, but that’s from our immune response, not from the vaccine itself.

But how does a piece of a virus protect us against the whole virus? Well, our immune system can “recognize,” by making antibodies that fit them like lock and key, various different parts of the surfaces of viruses and bacteria. One good marker molecule is all it takes to fight the invader effectively.

It’s only the Covid-19 RNA that can harm us, and yet, select just the right piece of its protein coat (I believe they chose the "spike glycoprotein"), and that’s enough for our immune system to mount an effective response to the whole virus.

To make a Subunit Vaccine, a virus of concern is injected into many, many hen’s eggs, often for multiple generations, egg after egg after egg after egg, and each time incubated for several days to make more copies of the virus. Finally the fluid containing the virus is harvested from the eggs, the viruses are killed, and the desired viral proteins are cleaved off and purified over several days. Somehow, scientists are able to isolate and separate a specific viral coat protein from this yellow yolky mess, to use in their vaccine. There are also newer, recombinant subunit techniques, in which yeast is induced to manufacture the protein of interest, by altering its genome. All of these processes take six months and more to accomplish.

Oy! Complicated stuff. But at least we finally have the answer to that age-old question that periodically vexes us.

Why did the chicken cross the road?
Apparently, to get away from the egg-obsessed biologist!

In contrast to these time-consuming and labor-intensive methods, RNA vaccines induce some muscle cells in our arm, at the site of the inoculation, to make the viral coat protein. What scientists do is to identify the exact section of Covid-19’s RNA that codes for the desired coat protein. Then they cut that section of RNA out and isolate it. It’s been a huge challenge to stabilize that small section of RNA for shipping, and also to protect it from being instantly destroyed by the human immune system once injected. But they’ve done all that now, so here’s what happens when we get one of these RNA Subunit Vaccines:

The scrap of viral RNA that codes for the desired Covid-19 coat protein is injected into, say, our left arm. The muscle cells there say, “Oh, ok, here’s some RNA, I have to make this protein now.” Their ribosomes, our cells' amazingly cool protein-producing factories, read this scrap of RNA and assemble the Covid-19 coat protein. This vaccine RNA strand does NOT become a permanent part of our genes in any way; it’s not DNA, and it degrades completely in a day or two. It’s gone.

Meantime, thousands upon thousands of copies of the Covid-19 coat protein have been manufactured by ribosomes and pumped into our bloodstream. Our immune cells mount their response to what they perceive as a big threat, antibodies are made by the tens of millions, and voila! We have immunity to Covid-19 at long last. Without ever having been exposed to the whole virus at all. How long the immunity will last is currently unknown. It may be necessary to have yearly Covid-19 vaccines in order to maintain immunity.

(Best in Show Ribosome image from https://www.thoughtco.com/ribosomes-meaning-373363 )

RNA Subunit Vaccines can be made fast and, once made, adjusted and adapted with great speed when a virus mutates. They’re safe, fast and flexible. The one real concern is, what if the viral protein closely resembles something else in our body, and we end up with an auto-immune illness? This is possible with any vaccine, yet it seems unlikely with Covid-19. Humanity has been assaulted with so many coronavirus species for so many thousands of years that it's highly unlikely that the protein chosen for these vaccines resembles any of our own protein structures.

I hope this all eases your mind about receiving such a vaccine in the near future when they become available.

 

Once again, I’ll end with a quote from my favorite poem, A. E. Houseman’s Terence.

“Therefore, since the world has still       

Much good, but much less good than ill,               

And while the sun and moon endure     

Luck’s a chance, but trouble’s sure.        

I’d face it as a wise man would,

And train for ill and not for good.”

Maintaining Oral Health While Limiting Pandemic Anxiety

Our 30th President, Calvin Coolidge, was a man of few words and an extremely pragmatic, practical, skeptical New Englander.

On a brief vacation, President Coolidge and an old friend were riding horses in Vermont.

His friend said to Coolidge as they rode through the rugged Vermont farmland, "See how closely they have shorn those sheep."

"On this side," said the President.

We only really know what we can verify by direct observation. And sometimes, the culture overlooks an important observation for a very long time, as we shall explore here.

Our situation is sobering: I wish all of our practice family well as we enter into a dangerous surge in Covid-19 cases across the nation. Noting this alarming increase in cases, I  wonder how many people have been harmed by other diseases because they did not seek medical care. Broad reporting indicates these numbers are turning out to be nearly as large as the Covid-19 statistics. Thus, we are all strongly advised even at this time to continue our normal health care, including any specialists we normally see and, of course, that includes dentistry.

Most Covid-19 deaths involve the virus itself and also a bacterial superinfection; the host gets weakened, and then other bad actors move in to take advantage. In some cases, perhaps in many cases, the bacteria that cause these dangerous superinfections in the lungs are traceable to periodontitis—gum disease. The germs that cause periodontitis thrive in a small band of gum tissue around our teeth and are particularly vicious. Many are extremely effective at evading the human immune system. Further, current science informs us that when present, these bacteria invade the bloodstream, and also travel directly to the lungs, day after day, hour after hour.

This scenario makes sense if we think about it carefully. One of the most powerful defenses we have against infections of all kinds is shedding. The outer layer of our skin completely renews itself from the base up every 28 days or so. Our intestinal lining regenerates even faster, with a turnover time of an astonishing 4–5 days. Our corneas, nasal passages, hair and so on—every external part of us is, in a manner of speaking, continuously falling off and being renewed from within. It’s rather wasteful, but apparently also necessary, as it makes it very difficult for bacteria and even viruses to invade. They can’t gain any footing.

Teeth are different.

Teeth are the one and only place in the body where a hard tissue comes through to the surface. (Fingernails are a specialized skin structure.) Teeth don’t shed, teeth don’t have turnover, teeth don’t renew. They only time they fall off is during Flyers games.

Unfortunately for us, in their own strange haven’t-got-a-brain way, bacteria “know” this about our teeth and are constantly, relentlessly attacking us at this unique interface, this special place where our teeth come through to the surface, this vitally important 3-millimeter-wide band of protective gum tissue in our mouths. This is why periodic examinations and continuing care in which we remove the plaque and tartar from the teeth remain so important, even—perhaps particularly—during this pandemic. In fact, a June 26 British Dental Journal paper by Sampson and Kamona suggests a link between oral hygiene and the severity of Covid-19 outcomes. Current evidence shows that periodontal disease has a terrible effect on cardiovascular health, as well. There’s hope, of course—periodontal disease can be treated, and even more importantly, prevented!

In these strange and anxious times, we are all balancing one risk against another. As you know, in our practice we have put in place airflow and surface disinfection and patient-flow protocols such that our dental office is one of the safest indoor spaces in Philadelphia. We live and work by mindful mask wearing, handwashing and by the nature of a dental practice with five treatment rooms, social distancing. We vigorously encourage you all to maintain your periodontal health by keeping your continuing care visits with us.

We all need to keep our guard up, and conscientious dental care is significantly contributive to overall health.

If Calvin Coolidge, that eminently practical man of few words, were to come back today as a periodontist—which would be an absolutely wild thing, in my view—I know exactly what he would say, to the dental profession, to the medical profession, and to all the patients he would treat:

“Focus on the part that doesn’t shed.”

Covid-19 Immunity Through Masking

Please allow me to share a rare piece of encouraging news in these challenging times we're in.

In a September 8th paper in the prestigious New England Journal of Medicine, Drs. Gandhi and Rutherford present to us a remarkable idea.

As we know, face masks help prevent the spread the of Covid-19 virus by blocking viral particles from entering our bodies via the nose and mouth. And yet masks also appear to do something else, something remarkable.

Often, tiny amounts of the Covid-19 virus get past masks and into our bodies, when we are in stores and such. The small "viral load" is too minimal to cause disease in most people. The number of virus particles is low and our immune system destroys them. And that's the thing: We mount an immune response to Covid-19. Repeated tiny viral loads are like vaccines! And thus the authors state:

"Universal facial masking might help reduce the severity of disease and ensure that a greater proportion of new infections are asymptomatic. If this hypothesis is borne out, universal masking could become a form of 'variolation' that would generate immunity and thereby slow the spread of the virus in the United States and elsewhere, as we await a vaccine."

This is the sought-after "herd immunity" we've all heard talked about.

And yes, I had to look up "variolation," even though I pride myself on knowing many medical terms. Again, from the authors: "Variolation was a process whereby people who were susceptible to smallpox were inoculated with material taken from a vesicle of a person with smallpox, with the intent of causing a mild infection and subsequent immunity. Variolation was practiced only until the introduction of the variola vaccine, which ultimately eradicated smallpox."

Here is the full article:

https://www.nejm.org/doi/full/10.1056/NEJMp2026913

For the science geeks in the audience, there's actually a third beneficial thing that mask-wearing does for us, which is to "tame" or "domesticate" the Covid-19 virus:

https://https://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2020/07/covid-19-may-very-well-be-with-us-permanently.html

We Philadelphians should be proud, as we wear masks in higher numbers than folks in many other areas of the U.S. And this concept of repeated tiny doses of the virus--tiny amounts of a poison, in effect--bestowing immunity puts me in mind of the ending of my favorite poem, Terence This is Stupid Stuff, by A.E. Houseman. Here it is. The madcap tale of an ancient king who avoided being poisoned by taking poisons--in small doses. Enjoy the relevance, stay safe, and hang in there on this mask thing. Someday, it will be over.

 

There was a king reigned in the East:
There, when kings will sit to feast,
They get their fill before they think
With poisoned meat and poisoned drink.
He gathered all that springs to birth
From the many-venomed earth;
First a little, thence to more,
He sampled all her killing store;
And easy, smiling, seasoned sound,
Sate the king when healths went round.
They put arsenic in his meat
And stared aghast to watch him eat;
They poured strychnine in his cup
And shook to see him drink it up:
They shook, they stared as white’s their shirt:
Them it was their poison hurt.
—I tell the tale that I heard told.
Mithridates, he died old.

SARS-CoV-2 Vaccines, Explained

 

We are coming up against a time when a vaccine against Covid-19, also called SARS-CoV-2, may become available.

Viruses mutate very rapidly, changing their surface proteins and such. The virus variants that are best at evading the human immune system are the ones that prosper, which makes our challenges in fighting them very difficult. Yet, effective vaccines againsts the Covid-19 virus are now being developed. It may be that, like influenza vaccines, new Covid-19 vaccines will need to be administered each year, in order to keep up our collective immunity.

There's one thing I am certain of regarding a Covid-19 vaccine in modern America, however, and that is that in all respects, it will be a politically and culturally charged issue.

Thus, I wish to explain the four types of anti-viral vaccines, so that you are all prepared for the time when we will face the personal and societal decision on being inoculated.

Similar-Species Vaccines are not common today, but were very important historically. The world-changing smallpox vaccine used cowpox, a poxvirus that was similar enough to smallpox to protect us against it, but not cause disease in humans. The Covid-19 vaccines currently being developed are not of this type.

The next category is Live-Attenuated (weakened) Vaccines. Attenuated vaccines can be made in several different ways, but they all involve passing a virus through a non-human host in the lab. Sometimes, for up to 200 cycles. The goal is to produce a version of the virus that can still be recognized by the human immune system, but cannot replicate (make copies of itself) well inside our bodies. Examples of attenuated vaccines include MMR (Measles, Mumps, Rubella), Chickenpox, Influenza, and Rotavirus.

There is one concern with attenuated viruses: that they may, through random mutations, regain the ability to replicate within the human body and cause illness again. The most significant example of this in the U.S. was the oral polio vaccine, which was an attenuated virus. In extremely rare cases, it mutated fast enough to cause polio again, so we switched the polio vaccine to the next category of vaccine types in order to 100% avoid this complication.

The next category is Inactivated Vaccines, which are produced by "killing" the pathogen with chemicals, heat and/or radiation.

(Sometimes, to be as certain as possible of total kill, researchers even expose the virus in question to repeated recordings of the rants of modern American Members of Congress and other politicians ...)

Note, I placed the word "killing" in quotations marks above. This is because a virus, in a philosophical sense, isn't really alive at all, at least in some ways of looking at it. Viruses are inert outside of their host, and don't really "do" anything at all until they make their way in and start causing trouble. It's a very weird concept to grapple with.

Any event. I imagine the technical trick with making inactivated vaccines is to wreck the virus DNA or RNA, so that it can't do anything to harm us, and yet leave the outer protein coat relatively intact. In this way, our immune system can still recognize the protein shapes it has to in order to fight the virus. It's a clever balance!

The fourth category of vaccines against viruses is the newest one, in use since the 1980s, and it's really clever: Subunit Vaccines.

What if we could take just parts of the protein shell, that our immune system can recognize, and not have any viral DNA or RNA at all? Without its DNA or RNA, a virus isn't a virus. Its genetic code is what enables it to harm us by telling the cells it enters to do something that the virus "wants" instead of going about their normal business. Robbed of its genetic material, such a mere shell of a virus makes the iconic country singer who's lost his gal, tore his best jeans and crashed his pickup truck look like the luckiest guy in the world.

To make a subunit vaccine, just one viral gene coding for one vaccine protein is inserted into producer cells in culture; often, yeast. The yeast (bless the little beasties, who also make us bread and beer) pump out this one protein, a vaccine is made with it, and even though our immune system doesn't get to "see" the whole virus, often times, one piece of it is enough to stimulate an effective immune reaction. Those red spikes on Covid-19 look like mighty fine targets, don't they?

The Hepatitis B and HPV (human papillomavirus) vaccines are examples of subunit vaccines.

What does this all mean for us as we go forward? The Covid-19 vaccines that reach commercial development are not going to be similar-species vaccines, so we can forgo that category.

For me, if a Covid-19 vaccine is a subunit vaccine or an inactivated vaccine, I have no worries at all about receiving it. Sign me up to go first, give me twenty boosters, I'm not worried about a thing.

If the vaccine is an attenuated one, I'll still get it, but even as a health care worker, I'm inclined to hold back for just a little while, to ensure that no Covid-19 infections result from it. Especially considering that this whole enterprise is a rush job. Probably just a month or so would be enough to make the call.

In my view, though, the rigid anti-vaxxer stance is foolish, misinformed and just a staggering example of human confirmation bias, in which no amount of real-world facts can change emotionally charged beliefs.

We get to have our own opinions, yes. But we don't get to have our own facts.

I sincerely hope that this post helps you all understand anti-viral vaccines better than you did before, and gives you the confidence to receive them, should Covid-19 vaccines become available.

Oh, and this year of all years, please get your flu vaccines.

And floss.

Effect of Cumulative US Inflation upon Typical Dental Insurance Yearly Maximum Real Value

Effect of Cumulative US Inflation upon Typical Dental Insurance Yearly Maximum Real Value, since 1967.

Also of note: In 1967, the majority of employers gave away dental insurance free, as a perk. Today, the vast majority of employers pay the premiums via payroll deductions from their employees' salary, that range from $240 to $600 per year.

Is it worth taking $240-$600 from your pay to gain the inflation-adjusted equivalent of $125 of your 1967-era predecessor's dental benefits?

COVID-19 May Very Well Be With Us Permanently

"There is always potential for a conflict of interest between microbe and host because the genetic makeup of the microbe differs from that of the host. Natural selection will favor microbes that act in their own genetic interest as circumstances permit." --evolutionary biologist Paul Ewald, PhD.

As circumstances permit.

Right now in America, circumstances permit the COVID-19 virus to act very aggressively in its own interest. New infections are increasing at a rate where even the logarithmic graph is scarily steep. As I write, nearly 150,000 have died of this disease and soon four million will have been infected, with disturbingly variable effects on their bodies. COVID-19 is a calamity on the scale of a world war, and we haven't even sent our children back to school in the fall yet.

What can we do?

Dr. Ewald has explored in depth the relationship between the characteristics of pathogens and their virulence. He's also researched how host behavior modifies pathogens--something that happens with surprising speed, due to the rapid generation times and high mutation rates of bacteria and viruses.

This interview is an excellent introduction to this way of thinking about human disease:

https://www.pbs.org/wgbh/evolution/library/01/6/text_pop/l_016_06.html

Here's the heart of it, in an answer Dr. Ewald gives towards the end:

"We can summarize this information in a nutshell by focusing on how dependent disease organisms are on the mobility of the host for transmission. If a disease organism is very dependent on healthy hosts moving around [and] contacting susceptible hosts, then we expect natural selection to favor extreme mildness in those disease organisms. If, however, the disease organism is not dependent on host mobility -- for example, if the disease organism is transmitted by mosquito, or contaminated water, or because it's durable in the external environment -- then we expect that natural selection will favor high levels of harmfulness in those disease organisms."

This is, in fact, what we find in the study of infectious diseases. And mosquitos, ticks, contaminated water or food--these are called vectors. External factors that spread disease.

What, then, about America's severe difficulties with the COVID-19 pandemic?

My current thinking is, that careless and maskless people are acting as human or cultural vectors, just as a mosquito acts as an insect vector in malaria, or as water acts as an environmental vector in cholera. And these countless human cultural vectors in America are not only causing more new infections. It's worse than that.

Human cultural vectors are also actually selecting for more virulent, dangerous, damaging strains of the COVID-19 virus. This is because the virus can "afford" to immobilize, severely harm and even kill its human hosts under these conditions of reckless human behavior. Even when COVID immobilizes and kills, it still spreads widely during the incubation period, before the patient becomes ill enough to be immobilized.

With specific regard to schools of all types, if, this fall, students are placed indoors in close proximity with no changes in protocols from how life was before the pandemic, the COVID-19 virus will likely exploit this sudden change in its target hosts' behavior. Currently, it's rare that COVID-19 causes severe harm or death in young hosts. But if effortless viral transmission routes are set up amongst millions of young people in school settings, there's a possibility that random mutations that really harm the young will out-compete the present forms of the virus' RNA in those populations. COVID-19 may depend upon human mobility to spread--but its incubation period is long enough that it can infect others for days before host immobilization due to illness occurs. And there's that pesky variability as well--asymptomatic or lightly symptomatic carriers who remain mobile can infect even more of their peers than those who are taken severely ill.

Is there a way out of all this?

It is likely (almost certain) that if we make it more difficult, through our human behaviors, for the COVID virus to spread, then those milder mutations that do not severely harm and immobilize their human host will out-compete those mutations that debilitate and kill. Because the virus cannot, under those more challenging conditions (from its point of view), “afford” to kill its host.

We would then tame the COVID-19 virus. Dr. Ewald often uses the phrase "domesticate the virus."

The well-known human behaviors that can tame COVID-19 include wearing masks, washing hands frequently and before touching one's face, "respiratory etiquette," social distancing, and surface disinfection. Less talked about but vitally important human behaviors involve proper airflow management in buildings, changing HVAC systems into active virus-killing machines, radical improvements in food handling, managing aerosols created by everything from dental treatment to sneezes to flushing toilets, and probably hundreds more strategies that our culture hasn't even begun to think about or implement yet.

With our backs to the wall now, I'm starting to believe that taming COVID-19 through intelligent and effective human behavior is our only option. A vaccine against any coronavirus species just doesn't seem likely due to the mutation rate and the decrease in levels of antibodies to them over time. Herd immunity is a fantasy—in naturally acquired COVID-19 infections, antibodies and B-cell mediated immunity appear to fade in months, just as they do with all other coronavirus species. Treatments will improve, but one does not "cure" an endemic virus that numbers in the trillions (quadrillions?) planetwide and keeps changing its RNA coding with every passing hour.

COVID-19 appears likely to be a part of our environment permanently, going forward.

And I believe our only viable strategy to defeat COVID-19 is to domesticate it, through intelligent and effective human behavior.

The Covidian Calendar

The International Association for the Advancement of Time will be rolling out a new calendar shortly. Guessing the Gregorian has had its day.
The new months are:

January
February
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary
Coviduary

Using the Number e to predict COVID19 Progression

The number e is one of the most powerful, profound, mysterious, mystical things I've ever encountered. I mean in all of life. Let's use its power to explore the growth rate of the COVID-19 epidemic in the U.S.

From my very favorite explanation of e:
https://betterexplained.com/articles/an-intuitive-guide-to-exponential-functions-e/

"e is the base rate of growth shared by all continually growing processes. e lets you take a simple growth rate (where all change happens at the end of the year) and find the impact of compound, continuous growth, where every nanosecond (or faster) you are growing just a little bit."

"e shows up whenever systems grow exponentially and continuously: population, radioactive decay, interest calculations, and more. Even jagged systems that don’t grow smoothly can be approximated by e."

Let's get right to COVID-19 now. For those with interest in math, explore that chap's  delightful and intuitive exploration of e and its magical properties.

Starting on March 18th, I've taken the total number of cases of COVID-19 infection in the U.S. and divided by the previous day's total. Here are the results:
1.46    March 18th
1.50
1.40
1.25    
1.39
1.30
1.25    
1.24
1.23
1.21
1.18
1.15
1.13, on March 30th
1.14, on March 31st

Now let's convert those numbers to percentage growth:
46 % (on March 18)
50 %
40 %
25 %
39 %
30 %
25 %
24%
23 %
21 %
18 %
15 %
13 % (on March 30)
14 % (on March 31)

Now, e merges rate and time. That's one of its amazing powers.
The exponent to which we raise e signifies the rate of change and then the time passed.

We humans tend to think in terms of how we measure time. Hours, days, weeks, months, years. Let's see what the spread of COVID-19 would look like if we forecast several of those growth rates over one month--30 days of epidemic progression at the daily growth percentage that occurred on any of those days.

The formula is this: e^{x
x will be, in each case, the percent growth for the day times 30 days. We will start with one patient.
Thus, in these projections, we will see how many patients would be infected with COVID-19 one month after just one patient started off infected, at the growth rate for that day. Rounded to nearest whole number.}

^{13% growth}    e^{.13 x 30    49-fold number of cases at 30 days.}

^{18% growth}     e^{.18 x 30    221-fold number of cases at 30 days.}

^{25% growth}   e^{.25 x 30    1,808-fold number of cases at 30 days.}

^{40% growth}   e^{.40 x 30    162,755-fold number of cases at 30 days.}

^{If we were fortunate enough to slow this pandemic to 2% growth per day this month:}

^{2% growth}   e^{.02 x 30    1.8-fold number of cases at 30 days. How different than the others!}

^{We see how wildly different the month-end projections are given the different growth rates. Early in an epidemic, the growth rate is generally faster than later because at the beginning, the virus spreads far more rapidly than it could later. Put simply, that's because the virus is in a "target-rich environment." Nearly everyone is un-infected at the start and no one yet knows the dangers, or has changed their behaviors from normal.}

^{Now let's use e to come up with a useful projection. We start with today's known U.S. COVID-19 infections. (Many more of us likely have asymptomatic cases).}

^{On March 31, as I write this, there are 180,000+ known COVID-19 cases in the U.S.}

^{Starting with that, at the recent daily growth rate of 2%, by April 30 we end up with:
327,981 cases.}

^{At a 4% daily growth rate, by April 30 we end up with:
597,621 cases.}

^{At a 13% daily growth rate we recently experienced, by April 30 we end up with:
8,820,000 cases.}

^{At a 25% daily growth rate we recently experienced, by April 30 we end up with:
325,440,000 cases. Nearly all Americans.}

^{In real life, exponential virus infection curves steepen and they flatten. They usually flatten as the epidemic progresses because the number of un-infected "targets" decreases. Host behavior may change as well.}

^{Still. We now see, through the splendid magic and power of e, the importance of hand washing and social distancing. 327,981 cases by April 30 versus 325,440,000 cases by April 30. That's a 1,000-fold difference.}