Tagged war

New Sheriff, New Bad Guys

      “We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and in the streets, we shall fight in the hills; we shall never surrender.” Prime Minister Winston Churchill, House of Commons, June 4, 1940

     “C’mon man, gimme a break!” President Joe Biden, January 21, 2021, answering a reporter who asked if a million vaccinations a day was enough

Dear Students,

Don’t get me wrong. I love Joe Biden. I supported him when most of my family and friends supported Elizabeth Warren—who by the way was the smartest person running for president, and had policy views most similar to mine—or Bernie, or others. Also, I didn’t think anyone as old as me should be president again. Yet I supported Biden because I was fairly sure that he had the best chance of winning, and because I was completely sure that he is an exceptionally good man. Although I did not say this to many people, I thought that he might be a great president.

Also, he is off to a good start. The new sheriff is laying down the law—on racism, LGBTQ rights, economic rescue, environmental protection, masking, social distancing, and vaccinations. But as far as the virus goes, he does not get a break from me, and no, it is not nearly enough.

Dr. Peter Hotez, a distinguished physician-virologist who is probably the most knowledgeable person about the pandemic after Dr. Fauci—but who can speak more freely than Fauci even now—wrote an op-ed piece in the Washington Post on January 26th in which he described the new variants of the virus as a “looming catastrophe” that will bring us to 600,000 deaths by May. We need to deliver 500 million doses of vaccines—into Americans’ arms—to end community transmission. Do we want to wait 500 days? By that time the new variants will have run all over us. We need to do it by summer. Which is why Dr. Hotez is calling for 3 million vaccinations a day.

This means that we need more than two vaccines; a vast and rapid (warp-speed?) expansion of vaccination centers beyond those already planned; unprecedented invocation of the Defense Production Act; imaginative use of the armed forces, even beyond the National Guard; and innovative use of syringes and other equipment to minimize vaccine waste. A good account of the current vaccine development situation in terms of science is here, but we need more than science, we need wartime logistics.

We also need a new level of seriousness about masks, social distancing, and handwashing. If we don’t ramp up our use of these measures, we will surely face more lockdowns, with all the associated economic, social, family, educational, and psychological pain.

If you have studied with me, you recognize that we are in an evolutionary arms race with this virus. All infectious agents adapt and evolve. They evade our defenses—both vaccines and treatments. That’s why after almost four decades we don’t have a vaccine against HIV, which evolves even within one person. That’s why we need a new flu vaccine every year. That’s why every year, thousands die of TB and malaria because they are infected by strains that resist all known treatments.

If we don’t (culturally) adapt and evolve in the face of this new virus—or should I say these new viruses?—we will lose, and as always, black, brown, and Native American people will lose most. We will not win this arms race, this by far most deadly of all our wars, by asking for “a break.” We will only win by fighting the virus every hour of every day, in every place, in every way.

Good News

  1. The new sheriff is really, really different from the old one. His deputies can shoot straight and they know how to round up bad guys—bad viruses. The heads of the CDC, FDA, HHS and many other agencies responsible for fighting disease are superb people, not third-raters and sycophants like their predecessors; they are already speaking directly and frequently to the American people, without fear of censorship for delivering scientific truth. For the first time there is a national plan, and it is a fairly good plan. With it, we are building a shield against the virus that we never had before.
  2. There has been a significant decline in the past couple of weeks in the number of US cases and hospitalizations but not yet deaths, probably related to the end of the big holiday surge.
  3. The Pfizer and Moderna mRNA vaccines are working safely, and pretty soon a few million Americans will have approximately 95 percent protection (two weeks or so after their second dose). Preliminary data suggest that protection levels could be even higher in the community than they were in clinical trials.
  4. The Janssen/Johnson & Johnson (J&J) vaccine will likely be approved (like the first two) for emergency use in the U.S., within a couple of weeks. Despite being less protective than its predecessors, it is more effective than the seasonal flu vaccine and easily passes the threshold of 50 percent protection set by health authorities. It hides the DNA—the gene—of a SARS-CoV-2 spike protein inside the Trojan horse of a cold virus disabled from reproducing. It has tremendous advantages: first, it only requires one shot; second, it does not require any specialized freezing or cooling equipment (DNA being much more stable than mRNA). These advantages will make it literally a lifesaver in rural America and in the developing world.
  5. The Oxford/AstraZeneca vaccine, despite some stumbles in the Phase III trials, is being used in the UK and was just approved by the European Union. It requires two doses but no special freezers, and will probably be added to the US vaccine arsenal in April. It is similar in principle to the J&J but uses a non-reproducing chimp adenovirus (instead of a human one) as the Trojan horse. The DNA is stable at higher temperatures, but it is still being worked out what the ideal doses would be.
  6. A monoclonal antibody drug (bamlanivimab, Eli Lilly) has shown 80 percent effectiveness in preventing infection in a randomized controlled trial in nursing home patients, and even greater effectiveness against deaths. This would have been tremendously important a few months ago, before we had vaccines, but now that we do, it’s not clear how the antibodies will be used—especially since they may interfere with vaccine effects.

Bad News

  1. The big bad news, and it is really bad, is that the virus has evolved new variants—new bad guys that will make the new sheriff’s job much harder. Of course, it has been evolving all along. A new paper, “Emergence of a Highly Fit SARS-CoV-2 Variant,” traces the first big leap the virus took last spring. As you know, “highly fit” in this context means spreading faster for more reproductive success. That first mutation was a single base change known as D614G that emerged in Southern Europe and by June was the dominant strain in the world.
  2. Viral evolution continued. In December a new “variant of concern” (B.1.1.7) was found in Southern England that contained multiple mutations and was determined to spread much faster and cause more severe disease. The mutations make it easier for a spike protein on the virus to combine with ACE2 receptors on human cells to gain entry. Hospitalizations doubled in the UK as the new variant became dominant there. More replication, more fitness, more dominance. It has been found in several US states and is predicted to be the dominant strain here by March. Fortunately, it does not evade already existing vaccines.
  3. A new South African variant (B.1.351) with different mutations of the spike protein—one of the mutations is on the presenting tip of the spike protein—is spreading rapidly and may soon threaten my old friends in Botswana. Two cases were found in South Carolina. Dr. Brannon Traxler, Interim Public Health director for the state, announced that they are independent of each other and have no travel history. She added cogently, “We know that viruses mutate to live and live to mutate.” Another independent case was found in Maryland. Given that we only sequence half of one percent of the virus samples taken in this country, it may already be everywhere. Like the English variant, it is more contagious and produces more severe cases, but unlike the English one, it also appears to be less responsive to existing vaccines.
  4. A new Brazilian variant (P.1) is worrying scientists. It is spreading explosively there and has been found in Minnesota. It may infect people who have had the disease before. It may or may not turn out to be implicated in the newly announced tragic COVID-19 deaths of nine children in the remote Amazonian villages of the indigenous Yanomami.
  5. There is no chance that one million vaccinations a day in the United States will stay ahead of the coming invasion of these new viral variants. The best, if not the only chance, is a great intensification of other preventive measures, the same that have been recommended all along. Unfortunately the behavioral trends seem to be going in the opposite direction.

On “Meet the Press” yesterday, top epidemiologist Michael Osterholm said, “The surge that is likely to occur with this new variant from England, is going to happen in the next 6 to 14 weeks. And if we see that happen—which my 45 years in the trenches tell us we will—we are going to see something like we have not seen yet in this country… Imagine where we are, Chuck, right now. You and I are sitting on this beach where it’s seventy degrees, perfectly blue skies, gentle breeze, but I see that hurricane, Category 5 or higher, 450 miles offshore. And telling people to evacuate on that nice blue-sky day is going to be hard. But I can also tell you that hurricane’s coming.”

Dr. Nahib Bhadelia of Boston University’s School of Medicine, asked to comment on Osterholm’s metaphor, said we are in  “the eye of the storm,” not sitting on the beach with the storm hundreds of miles out. She means that the worst part of the storm so far—December and January—is deceptively slacking off. As the hurricane moves over us, the lull of the eye passes, and we get slammed with another monstrous storm surge in March and April.

Dr. Osterholm went on to say that we need “an audible”—American-footballese for a last-minute yell on the field that changes the plan. He thinks we need to get as many people as possible vaccinated once right now, and forget about the second dose until later. There is controversy about this, but Osterholm is really smart.

Recall what Dr. Traxler, South Carolina surgeon-turned-health official, said when she became the first American to announce the South African strain: “We know that viruses mutate to live and live to mutate.” She continued, ““That’s why it’s critical that we all continue to do our part by taking small actions that make a big difference. These include wearing our masks, staying at least six feet apart from others, avoiding large crowds, washing our hands, getting tested often, and when we can, getting vaccinated. These are the best tools for preventing the spread of the virus, no matter the strain.”

On December 15th, when I posted “Double Down or Double Deaths,” we had just crossed 300,000, but we were having the first vaccinations and hope was in the air. I said we could go to 600,000 if we don’t change our behavior. The IHME model now projects 582 thousand by May , 600 thousand taking the new variants into account. That’s the doubling. Considering we’re at 440,000 today, it’s not a stretch.  Depending on what we do and what the variants do, we could be anywhere between 600 and 2,400 daily deaths in May. The difference would be the equivalent of two 9-11’s every two days. And of course May will not be the end.

The new shield we got on January 20th is not nearly big enough or thick enough. And the new variants teach us that unless we think about protecting the developing world, protecting the whole world, which is the virus’s continuous playground, our shield will be full of holes.

Are you tired of the precautions? I am too. I want to hug my children and grandchildren so bad it hurts (and I don’t care that it’s ungrammatical). I want to see live theater. I want to eat out with my wife in any sort of restaurant, even McDonalds. I want to smile at people and see them smile back. I am tired of restricting myself for the benefit of myself, my community, and my country. I am, to use an  expression my mother might use, bone-tired. But I am not yet dead-tired. I will be dead-tired if and when the virus kills me.

And oh, by the way. In case you get to whisper in President Biden’s ear, give him this message from me: Mr. President, Sir, with all due respect, the next time a reporter asks you if a million vaccines a day is enough, do what you always said you would do: Level with us. Don’t say, ‘Gimme a break man.’ Say, ‘No, it’s not enough. We need three million a day at least, and  I promise you I will not rest until we have that. We are at war. We will fight this virus in the clinics and in the stadiums, we will fight in the pharmacies and supermarkets, we will fight on street corners and parking lots, we will fight in convention centers and on fair grounds, we will fight in the poor dense cities and in the bucolic countryside, we will fight with syringes and tests and masks and distancing; we will never surrender.’

Stay safe,

Dr. K

100,000

Dear students,

Before I share a few post-Memorial Day thoughts about the virus and this tragic and needless milestone, I would like to mention two people who have died recently but not from the corona or any virus: George Floyd, a black man who was killed by police in Minneapolis, Minnesota, by strangulation, while handcuffed on the ground begging for his life, and Ahmaud Arbery, a black man shot and killed by vigilantes while jogging, in a modern-day lynching in Brunswick, Georgia. These tragic and needless deaths were part of the same long-standing pattern of structural racism which, as you know, accounts for the huge over-representation of African-Americans in the deaths from COVID-19.

I am frankly confused about where we are in the pandemic right now, both in our country and the world. More Americans have died of COVID-19 than in all the wars since the Korean War, and it is quite possible that before this is over we may be able to include the Korean War in that count. I see what appears to be a wholesale abandonment of the science of public health and medicine by many Americans. I can’t tell you how many, but I am pretty sure it’s enough to keep the U.S. epidemic boiling (not simmering) for months. Maybe we get a rest in September before the second wave. Or will it be the third wave?

I’ve always told you the most important thing you have to know is the limits of what you know. So I’m telling you now. I don’t know. I don’t know. I don’t know.

I don’t know about future cases, hospitalizations, or deaths because the models are shot to hell by the unpredicted and unpredictable behavior of a substantial minority of Americans. I don’t know about progress in vaccines or treatment because every announcement is not a scientific publication but a press release that hugely moves stock prices, especially of the companies involved. Remdesevir and convalescent plasma are in wide use and seem to have some effectiveness, but convincing studies have not been published. I do know something about the anti-malarial drug Whaddayagottalose-oquine. Worldwide randomized controlled trials have been stopped because more people die with it than without it. I took it for years, first to prevent malaria in Africa, then for a minor autoimmune condition. On March 25th in a private email I said that more research was needed but that I would take it if I got COVID-19. Now I wouldn’t. Lesson? Anecdotes, even from smart people, are no substitute for real studies.

This past weekend we commemorated those who gave their lives for our freedom; they died hoping we would use freedom wisely. Yesterday we flew our flags at half-mast to mourn 100,000 dead Americans. Today I want to celebrate the new warriors at the front of the coronavirus wars.

Good News

  1. Dr. Richard Levitan, 59, a leading expert on teaching intubation, left safe Northern New Hampshire to volunteer for ten days at New York’s dangerous Bellevue hospital. After his first exhausting shift he went to his brother’s apartment, where he was staying, and was kicked out by the building’s other residents. He found some kind of lodging, completed his ten days, and wrote an article teaching others throughout the world how to deal with COVID-19 pneumonia.
  2. If you click on one link in this message, make it Dr. Sharon Duclos, a Family Medicine specialist in Cedar Valley, Iowa, and watch the video, recorded on May 6th, the day before the local Tyson meatpacking plant, the source of the cases that overwhelmed Dr. Duclos and her colleagues, reopened under government orders. She appeared calm today (May 28) at a press conference with other local medical leaders; she is at around minute 14:30 in this new video. She implored people to keep taking precautions, “as we go through the little lulls and valleys, and the peaks that will occur with this, for months to come.” More on this below.
  3. Sylvia Leroy, 35, was a labor and delivery nurse at Brookdale Hospital in Brooklyn, where patients she cared for were positive for the virus. She got it. She was 28 weeks pregnant with her second child. Her own hospital did not take proper care of her. She was transferred to Mount Sinai where she got better care but went into cardiac arrest for some four to eight minutes; the doctor who called Sylvia’s sister was crying herself. They delivered her baby, Esther, by C-section. The baby needed oxygen but was “pink and healthy.” As of May 20, Sylvia was very slowly recovering from brain damage; Baby Esther was doing well. See their GoFundMe page here. Her sister once asked her why she didn’t go into private practice. “And she said to me, ‘This is an underserved community. Who is going to help them if I don’t help them?’”
  4. Dr. Ryan Padgett, 45, who played football for Northwestern in the Rose Bowl, was one of the first U.S. doctors to get the virus. It was still February, and nobody knew anything, but he was taking care of a string of patients from one nursing home in Kirkland, Washington. He was in great shape, hardly ever missed a day of work, but in March he was near death. He recovered, but still had more recovery ahead of him, when he said, “As an emergency physician, you walk into every single room and take care of whatever is there. Going back, I don’t think that will change. I hope not.”
  5. Dr. Theresa Greene, an emergency physician in Miami, temporarily lost custody of her 4-year-old daughter because she takes care of COVID-19 patients. She said, “I think it’s not fair. It’s cruel to ask me to choose between my child and the oath I took as a physician. I won’t abandon my team at work or the patients who will increasingly look to me to save their lives in the coming weeks, but it’s torture.” She and her husband have amicably shared custody since their divorce two years ago. Why is this under “Good News”? Nobody’s sick. Nobody died. However unfair it may be, mother and daughter will live to put this separation behind them.

Bad News

  1. Madhvi Aya, 61, was a doctor in India but a senior physician assistant in the U.S. She worked at a hospital in one of the poorest sections of Brooklyn; it was overflowing with coronavirus patients, and she was there until she got sick herself. At the end, in a different hospital, she was alone after texting with her husband, mother, and daughter, whom she had been very afraid of infecting. She often said, “We have to take care of our patients first.”
  2. A nurse who must keep her identity secret for her own protection was on a bus in Chicago, coming home in her scrubs from a difficult shift, coughed into the crook of her elbow, with a mask, and was punched in the face by a man who accused her of trying to give him the virus. He gave her a black eye. Attacks on coronavirus heroes in all frontline professions have been happening all over the world. “It’s not going to stop me from coming to work every single day and taking care of the people I take care of,” she said.
  3. Immigrant Celia Marcos, 61, worked as a nurse at Hollywood Presbyterian Medical Center for 16 years until her death in April from COVID-19, which she almost certainly contracted from a patient. Her family and colleagues state that she was not provided with proper PPE, which the hospital denied. Her son Donald said, “when the call of duty came, she will do the best that she could.” He also said she “coded seven times” before she died. In their last conversation he said, “when you get out of that hospital, you will retire immediately.” She barely was able to say yes. Both were crying.
  4. Jason Hargrove, 50, a bus driver in Detroit, loved his job and did it faithfully, carrying essential workers and others to their own jobs. A passenger openly coughed near him without covering her mouth, and he recorded a Facebook video about the incident. He was worried about the other passengers and himself. He said, “I feel violated.” He died of the virus 11 days later. He left home by 5am and disinfected his bus every day. He would tell his wife, “Baby, when you get off work, make sure you grab me some more Lysol… I gotta make sure that my people are protected.”
  5. Dr. Lorna Breen, 49, head of the emergency medicine department at NY Columbia-Presbyterian Hospital, contracted the virus while heroically trying to save others. She recovered, but the hospital told her to stay home. She moved from NY to her parents home in Charlottesville. There, with no history of mental illness, she took her own life. Her father said, “Make sure she’s praised as a hero.”

Under the Russian Tsars, young men were drafted into the army for 25 years. As a child I knew an old man who had chopped off the first joint of his own trigger finger to avoid that fate. And why do I mention this? Because many, maybe even most of you, have told me you want to become nurses, physician assistants, or physicians. You are signing up for roughly twice the length of service that the Tsars demanded of young people. There will be another pandemic like this in your career. You will be called on. Even medical students have been called on in this crisis. You will not say no when you are asked to put your own life, and that of your loved ones, in danger, because that is your oath. Even when you think or know that you are risking your life for stupid people who put their own lives in danger, you will serve. Know what you are signing up for.

It was very interesting for me to watch today’s press conference on local television in Black Hawk County, Iowa. This is the cutting edge of the U.S. pandemic going forward. The local Tyson meatpacking plant reopened because the governor and the president said so, and because it was in their financial interest. Three leading local physicians and county health officials spoke. They stated that they did not know what was going on at the Tyson plant and would not be getting that information. They said they could not do contact tracing of confirmed cases. A county health official laughed at the idea of testing health care workers in nursing homes, because they don’t have the resources to do it.

Don’t think about New York any more. Think about Black Hawk County. Times ten. Or maybe times 100.

Stay safe,

Dr. K

Human Nature in High Places

Statesmen understand human nature. Why not psychologists and social scientists?

apg_obama_nobel_091009_mn1Most psychologists don’t like human nature, or at least not the idea of it. Clinicians, life coaches, and corporate motivators dislike it because it implies unchangeability. Anyone who took college psychology knows how to modify behavior, from direct instruction to manipulative advertising.

And then, what fool surveying the huge variety of human personalities, needs, and tastes would dream of trying to characterize all that as one thing? Well, some fool might, but not the philosophers, evolutionists, historians and political leaders who have long used the phrase. They’ve always meant something complex, varied, and big-but not limitless.

 Barack Obama, for instance. Read more

Barack Obama on War and Human Nature

Is Barack Obama an evolutionary psychologist?

Since I criticized President Obama’s speech last year in Cairo (and even “rewrote” it) and later pointed out the names and deeds of those who did not get the Nobel Peace Prize because he did, I think it’s only fair that I resume this blog after a long hiatus by writing about his Nobel Prize acceptance speech in December.

I have to say that it stunned me. Read more

One World?

Prof. Mari Fitzduff, who I’m honored to call a friend, set me thinking the other day when she commented on a proposed speech I wrote for President Obama to substitute for the one he gave in Cairo. But before I share our exchange, you need to know that Mari is the director of the Conflict and Coexistence Program at Brandeis University, where she moved after many years as director of INCORE, the International Conflict Research Institute in (as she always says it to avoid taking sides) “Derry/Londonderry,” Northern Ireland. In that role she played an important part in the years and years of mediation that finally brought a blessed end to that terrible conflict. Read more

A Philosophy of Violence and Sacrifice

A wise man with a provocative theory of violence may help us understand and save ourselves.

I just returned from a meeting in Paris (alright, a meeting followed by a marvelous three-day vacation) at which, along with some very pleasant wining and dining, I spent several days talking about imitation and violence. What do these two seemingly separate things have in common? According to René Girard, everything.
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