100,000

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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

Opening Gambits: Freedom Goes Viral

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            “With your talents and industry, with science, and that stedfast honesty which eternally pursues right, regardless of consequences, you may promise yourself every thing—but health, without which there is no happiness. An attention to health then should take place of every other object.” 

                        Letter from Thomas Jefferson to Thomas Mann Randolph, Jr., July 6, 1787

Dear Students,

The letter that includes the above passage was written as part of a series to a young man of great promise. Randolph was 18 on the date above, which happened to be two days after the 11th anniversary of the Declaration of Independence. The Constitutional Convention was under way in Philadelphia, but Jefferson was still posted to Paris. (The federal government, still based in Philadelphia, was suspended several times during the 1790s yellow fever pandemic.) He began the letter by apologizing for his delay; he’d been traveling in southern France and northern Italy.

There is plenty of other advice in the letters, but young Thomas had been seriously ill a couple of years earlier, and the elder Thomas was concerned. The young man did take care of himself, and when the Jeffersons returned in 1789, he courted and married Jefferson’s eldest daughter Martha. They had 13 children together; 11 survived to adulthood. They eventually became estranged because his drinking interfered with his health and their life, although she was at his bedside when he died at age 59. But first he was a colonel in the War of 1812, served two terms in Congress, and became Governor of Virginia.

His future father-in-law’s advice kept him healthy for decades, and when he stopped following it he paid the price. I wonder what Thomas Jefferson, perhaps the greatest founder of early American freedoms, would have thought of the people risking their health and that of others to protest social distancing—while crowding together and refusing to wear masks—in the name of freedom.

All 50 states and many countries are easing or marching boldly out of their lockdown phases. It’s too soon to know the results; I predict they will be fine in some places and terrible in others. However, even “terrible” is in the eye of the beholder. Sweden has twice the population of Norway but around 16 times the number of COVID-19 deaths. Swedes regret that so many elderly and vulnerable people have died, but they defend their strategy of valuing individual autonomy and freedom; they think that other countries will have to follow their lead to the elusive goal of herd immunity.

Clearly a large minority of Americans agree. New York is opening slowly and carefully, but only after rigorous measures put its severe epidemic almost completely behind it. Texas and North Carolina are opening  boldly while cases continue to rise. The US as a whole gives a false impression of decreasing cases, but that is due to the huge decline in the worst-hit state, New York; most of the country is flat or rising.

The First Amendment to the Constitution, insisted on by Jefferson and drafted by James Madison, is now being used by leading legal authorities to justify anti-lockdown protests; they don’t mention the limits on my freedom to falsely yell “Fire!” in a crowded theater, or on my freedom to drive myself home from a party where I’ve been drinking. Protests are different as long as they’re non-violent. Apparently, wilfully spreading viruses more dangerous than bullets (bullets don’t keep jumping from person to person) is non-violent.

Good News

  1. The pharmaceutical company Moderna reports that of 45 patients who received their experimental vaccine, the 8 who got two specific doses (25 and 100mg), mustered antibodies to the virus more strongly than those found in people who have recovered from the disease. This vaccine uses messenger RNA (mRNA), which the viruses uses to make its proteins; this is a new approach that could be a game-changer for other viruses.
  2. Some states are opening slowly, carefully, and systematically. California is expanding its corps of contact-tracers from 1000 to 13,000. New York is deploying both viral and antibody testing, as well as contact tracing, and is poised to reimpose any restrictions it lifts if conditions warrant that. In Germany, this sequence from lockdown to partial opening, to small outbreaks, to selectively reimposed lockdown has already cycled through. When we have broadly available testing and contact tracing, as only a few places are approaching now, we can reopen more safely.
  3. Hospital systems are no longer overwhelmed in most of the U.S., and increasing numbers of elective procedures unrelated to COVID-19 are being done. Important exceptions are small community hospitals in areas surrounding meatpacking plants, prisons, and other hot spots, which may still be headed for disaster.
  4. Stay-at-home orders have worked. A multicity ongoing study conducted by the School of Public Health at Drexel University, estimates that the successful stay-at-home patterns prevented more than 2 million hospitalizations and 230,000 deaths. There is no vaccine and no treatment that has any prospect of making this much difference in the near future.
  5. We are understanding more and more about the course of illness (look at the excellent Medscape graph below; no, really look at it), modes of transmission (very numerous), and symptoms, especially those outside the lungs, also numerous.

Bad News

  1. Just as one swallow doesn’t make a summer, 8 people responding doesn’t make a vaccine. The Moderna study is a very early Phase 1 trial. Phase 2 will involve hundreds of people, Phase 3 thousands. About a hundred other vaccine candidates are under study. I wouldn’t want to be a premature adopter of any of them. Remember that uselessness in preventing the disease is certainly not the worst possible vaccine outcome.
  2. I believe that bad blunders are being made in some reopenings. Time will tell, and it will take time because some states and localities are doing it right, some are not, and people in many places are taking more or fewer risks than their governments advise. I get that everyone is tired of being locked down. Imagine how tired we will be of death if the second wave (almost certain to come in the fall, complicated by flu season) has, like the second wave of the 1918-19 flu, far more cases and deaths than the first wave. All the carpenters in America working full tilt could not make enough coffins.
  3. The small rural hospitals that may soon be overwhelmed are far less resilient, flexible, and resourceful than the big urban hospitals that expanded their ICU, ventilator, and to a lesser extent PPE capacity, in a matter of days to weeks in April. Community hospitals, even if they could somehow get the beds, ventilators, and other equipment, do not have the expertise to use them. Perhaps an army of doctors, nurses, respiratory therapists, and others from major medical centers will fan out to the rural hotspots overnight, but those people are literally sick and tired. How much damn heroism can we expect?
  4. Lockdowns have worked, but they are ending in haphazard ways, with hopelessly inadequate testing and tracing. We just have to see what happens, and continue building up (high-quality) viral testing, antibody testing, and contact tracing. Experts keep hammering away at this advice for a very simple reason: We are not there yet. Here’s your mnemonic: TETRIS: TEsting, TRacing, and ISolation.
  5. There is so much more about COVID-19 and SARS-CoV-2 that we don’t know. First, it was “Children don’t get it,” then, “They might be carriers,” then, “They’re definitely carriers but they don’t get sick,” to “Hundreds of children are showing up with a devastating post-viral hyperinflammatory syndrome and some of them have died horrible deaths.” The number with this, Multisystem Inflammatory Syndrome in Children may or may not remain small. Also, loss of smell and taste went from “Maybe in some cases” to “Maybe in a lot of cases” to “Often the only symptom.”

Your fellow student Caroline Yoon sent me a marvelous question the other day in a message called “Your take on positive retests?” She was concerned about the apparent reinfections in South Korea and on the aircraft carrier U.S.S. Theodore Roosevelt, and asked whether there might be reactivation of a long hidden infection as with HIV. It could be reinfection or reactivation or lousy tests, no one knows. But here’s my answer:

“The evidence of possible reinfection is very concerning in the two places you mention. The South Korea cases may be attributable to testing difficulties; the negative tests they had may have missed continuing infection (false negatives; there is a lot of evidence that this can linger for weeks to months). Or, the positive retests may be due to what some call “virus litter”—fragments hanging around after the infection is over (a type of false positive). The interpretation is complicated by post-infection symptoms due to viral damage during infection that takes a long time to heal, or to overactive and prolonged immune responses. The dreadful syndrome that has been hospitalizing and in some cases killing children (fortunately still a small number) is thought to be a post-viral hyper-inflammatory syndrome, perhaps a kind of autoimmune overreaction.

“The possible reinfection cases on the Roosevelt are more concerning to me than the South Korean ones, because conditions have been so controlled. The now 13 sailors who have retested positive did so after 14 days of quarantine and two consecutive negative tests. We haven’t been told whether any of the 13 have shown symptoms. Today it was announced that the Roosevelt will leave Guam and go back to sea—presumably, one hopes, without those 13. This will be an informative, I hope not dangerous, experiment, as the ship had over 1000 cases at one time not too long ago.

“I wish I had more definitive answers. Sometimes the best we can do is admit our ignorance, while pushing science forward to alleviate it.

“Stay safe, best wishes, and thanks again for your questions, Caroline.”

“Dr. K”

Eric A. Meyerowitz, MD; Aaron G. Richterman, MD, MPH,

A Quick Summary of the COVID-19 Literature So Far – Medscape – May 18, 2020.

Les Jeux Son Faits: COVID-19 Update to Students

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“If some areas, cities, states, or what have you…prematurely open up…my concern is that we will start to see little spikes that might turn into outbreaks.” Dr. Anthony Fauci, answering Sen. Patty Murray, May 12, 2020

“When the outbreak started, sir, we had an aggressive contact tracing program, but unfortunately as the cases rose, it went beyond the capacity…so we lost the containment edge.” CDC Director Dr. Robert Redfield, answering Sen. Tim Kaine, May 12, 2020

“The purpose of science is not to open the door to infinite wisdom but to set some limit on infinite error.” Bertold Brecht, Life of Galileo

Dear Students,

Les jeux son faits. Or in English, the die is cast. Or in plain American, the dice have been rolled. Think of a slow motion video with a close-up of a hand releasing the small dotted cubes. We watch them seem to float through the air, then one, then the other touch the table surface ever so gently, then they bounce and float again, and then…

Never have I hoped so much that I would lose a roll of the dice, because I (among others) have hypothesized disaster. I want to come up “snake eyes” and slink away from the game. I want the majority of states opening up to come up with sevens and elevens. I want the American people to win this great gamble. We know so little about this virus that there’s a chance for an unlikely outcome, on either side.

No matter now though. Les jeux son faits. The video is so slow that it may take two weeks for the rolling dice to come to rest.

I am not going to repeat what I said in my previous updates about patience and precautions. My news this week is about what in our course we always called “Nuts & Bolts.” The slogging may be a little heavy in places. After all, I’m the professor. Knowledge is news. Knowing what you know is good news.

Good (Science) News

  1. We have known the sequence of this virus, SARS-CoV-2—causing the illness COVID-19—since early January. It is a single strand of RNA of a strain new to humans, with a wide adaptability, causing disease in many mammals. There is a bat coronavirus that is 93% identical to it, but other human SARS-CoVs are only 80% identical. It has a large genome for an RNA virus, with multiple “hot spots” for mutations, although it mutates slowly compared to flu.
  2. Corona, meaning crown, refers to the club-shaped surface proteins (aka “spikes”) that cover the surface created by the RNA with the help of human cells’ machinery. It has to get into our cells, and we have known since March that it does that because the spikes recognize an enzyme on cell surfaces called ACE2, normally part of a complex sequence controlling blood flow and blood pressure. Spike proteins use ACE2 to (sort of) pry open the cell. Once in, the RNA replicates itself and makes spike and other proteins protecting it and countering our immune system. It can do this (I’m estimating) a gazillion times.
  3. The first and still most accurate test for active cases of the virus uses a version of PCR (the polymerase chain reaction) to amplify the virus’s RNA enough to measure it accurately. Last month a device from Abbott called ID Now that amplifies viral RNA much more rapidly was approved for emergency use. Last Friday (5/8) the FDA approved for emergency use a first-in-class test for viral antigens, meaning fragments of viral proteins. It is also possible to infer the presence of the virus indirectly from very high levels of IgG antibodies (Abs, pronounced “ay-bees”). At-home testing is partly approved; DIY sample collection, send in the sample.
  4. With regard to establishing who has had the virus and recovered (or never showed symptoms), there are up to 12 approved antibody tests and 200 more in development. Most of these are qualitative, especially the rapid-diagnostic ones (RDT; 10-30 min) using finger pricks, saliva, or nasal swabs. They tell you you either do or don’t have IgG or IgM antibodies to the virus. ELISA assays (2-5 hr), showing how your antibodies combine with viral proteins in a dish, can be quantitative. Neutralization assays (3-5 days) put your cells and Abs in a dish with the virus and quantify the amount of Abs needed to block the virus from entering the cell.
  5. Treatments under study include antivirals (Remdesivir and others developed for older viruses), immunotherapies (which, like interferon beta, strengthen the immune system), convalescent plasma (from recovered patients), immune globulins (Abs purified from same), monoclonal antibodies (Abs specific to viral proteins, mass-produced from cloned cells), and others. Remdesivir shortens hospital stays in very sick COVID-19 patients from 15 to 11 days. (For true nerds, Remdesivir mimics the RNA base adenine; it slips into adenine’s place in viral RNA replication, dashing the virus’s reproductive dreams, partly.)
  6. Roughly 100 labs around the world are developing COVID-19 vaccines by varying methods to increase the chances of success. This includes DNA and RNA vaccines matching part of the viral genome, proteins mimicking part of the spike, and other strategies. The first clinical trials were begun 62 days after the virus sequence was published, by far the fastest time ever, around 10 more were added by late April, and more will begin soon. Dr. Fauci said today that, “this is a virus that induces an immune response, that people recover, the overwhelming majority of people recover from this virus… The very fact that the body is capable of spontaneously clearing the virus tells me that, at least from a conceptual standpoint, we can stimulate the body with a vaccine that would induce a similar response.” So he considers it “much more likely than not that somewhere within that time frame [12-18 months] we will get a vaccine.”

Bad News

  1. The supply chain is not robust for any of the above, and will not be for many months. Remdesivir, the only proven (in an unpublished study), partially effective treatment is being rationed to states and hospitals, forcing doctors to play God. There is not yet a serious plan to ramp up new pharma factory building to meet the coming demand for treatments or vaccines, if and when they are proven.
  2. We continue to have a poor grasp of the nature of this virus. It behaves differently in different countries, perhaps more so than be explained by the varying quality of social hygiene. No one knows how many asymptomatic cases there have been, why there is so much variation in the length of presymptomatic infectiousness (~2-14 days, average around 5), why young adults have mild or no illness, why children are usually asymptomatic carriers but (rarely) develop a just-discovered life-threatening illness (viral? post-viral?), why it attacks the lungs in most patients but in some attacks the heart or other organs while sparing the lungs. One thing we do know: it is very contagious. In evolutionary terms, it’s very clever: “I’ll infect the active young without (usually) killing them, because they’ll carry me around the globe.”
  3. Testing for active infection is currently around 250,000 a day nationally. Even the Federal government says we will probably need to get to 1.5 million a day, and other public health authorities and economists say will need 20 million a day or more to safely get the economy, including education, back up to speed. Our government brags that we have more testing per capita than South Korea. Yes. Now. After that country has beaten down the first wave of the pandemic because it had scores or hundreds of times more testing than we did in February and March. Contact tracing is practically non-existent so far, and hundreds of thousands of tracers may ultimately be needed. See what other countries have done here.
  4. Testing is less sensitive (does it pick up everyone who has the virus?) and specific (does it identify accurately those who don’t) as it becomes more rapid. Antibody testing is far behind active virus testing, which is far behind that in other countries. Ab testing is also less accurate. Regulation of antibody (serological, post-illness) testing is chaotic; companies governed by profit motive abound.
  5. Only one treatment (Remdesivir) is proven effective in COVID-19 illness, and Dr. Fauci (who almost leapt out of his seat with excitement when he first announced it) today called the effect “modest.” There are no meaningful treatments yet. Remdesivir helps (we think) but as mentioned is being rationed to a fraction of the patients who need it. This rationing will be repeated with any future proven treatments. The treatment ultimately will likely be a cocktail of different drugs, as with HIV, but that took years to develop. A smart friend of mine, Cynthia Fox (author of Cell of Cells) says her motto is CCC—Cocktails, Cocktails, Cocktails!
  6. The bottleneck for vaccine deployment has nothing to do with lab science, it has to do with three phases of clinical trials. That’s what will take 10 to 16 of the 12 to 18 months (minimum) needed. Why? because some vaccines have triggered devastating immune responses, sometimes deadly. I remember 1977, when the swine flu vaccine caused hundreds of cases of a nervous system disease, and the 1990s, when early rotavirus vaccines caused very serious intestinal complications requiring surgery. I want you to trust vaccines, but only vaccines that have been properly studied for safety and efficacy. Unlike the lab development phase, that can’t be rushed.

Also in today’s Senate hearing, Dr. Fauci said, “The idea of having treatments available, or a vaccine, to facilitate the reentry of students into the fall term, would be something that would be a bit of a bridge too far.” I hope he is being too pessimistic, but hope doesn’t make things happen. Sometimes, if we’re lucky, science does. And science needs patience.

Stay safe, Dr. K

Opening to What?

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            “I think right now, because there’s been good news really, that the opening up is starting to happen faster than we expected, appears to be doing so safely, then there is a chance that we won’t really need a Phase Four [Congressional support package].” White House economist Kevin Hassett, Fox News, Saturday

            “Is this guy serious?” Mayor Bill DeBlasio, later that day

            “It’s devastatingly worrisome to me personally because if they go home and infect their grandmother or their grandfather who has a co-morbid condition and they have a serious or a very — or an unfortunate outcome, they will feel guilty for the rest of our lives,” Dr. Deborah Birx, Sunday.

            “This is definitely government overreach.” Lockdown protester on social distancing

Dear Students,

Given our studies of evolution in disease (Darwinian medicine), you won’t be surprised to learn that the pandemic coronavirus is mutating and adapting, although fortunately more slowly than seasonal flu. Nor will you be surprised to see natural selection operating at different levels. We are not sure that a bat was the origin, but if bats have it you know they’ll be evolving too. And so will we. Here is how the city planning commissioner of Antioch, California put it in a Facebook post:

The shelter in place needs to end, we as a species need to move forward with our place on Earth…This virus is like a human version of a forest fire, a forest fire will burn through and burn off all the dead trees, old trees…The strong trees survive and the forest replenishes itself and flourishes once again… If we look at our population as the forest you will see many similarities. We have our old, we have our weak and we have our drains on our resources. This virus is targeting those sectors of our population. If we were to live our lives, let nature run its course, yes we will all feel hardship, we will all feel loss. I am sure everyone of us would lose a person who we hold dear. But as species, for our Nation and as a Planet we would we would strengthen when this is all settled. We would have significant loss of life, we would lose many elderly, that would reduce burdens in our defunct Social Security System, health care cost…make jobs available for others and it would also free up housing… We would lose a large portion of the people with immune and other health complications… But that would once again reduce our impact on medical, jobs and housing. Then we have our other sectors such as our homeless and other people who just defile themselves by either choice or mental issues. This would run rampant through them and yes I am sorry but this would fix what is a significant burden on our Society… Of course we would lose many of the “Healthy” maybe even myself but that is the way of the World!

I am sure you see the logic in this as clearly as you see its inhumanity. This is so-called Social Darwinism at its worst, and the end result is a Nazi-like culling of the “unfit” from our populations. Nazis carried out mass murders as “euthanasia,” and one of the ways they did it was to crowd Jews into ghettos where typhus and other deadly microbes were brewing and then (see above) “let Nature take its course.” A friend of mine, Tosia Szechter Schneider (now 92) lost her mother and other family members to typhus in one of those Nazi-encouraged experiments in letting Nature take its course. You may remember what Darwin said about this in The Descent of Man:

The aid which we feel impelled to give to the helpless is mainly an incidental result of the instinct of sympathy, which was originally acquired as part of the social instincts, but subsequently rendered…more tender and more widely diffused. Nor could we check our sympathy, if so urged by hard reason, without deterioration in the noblest part of our nature… If we were intentionally to neglect the weak and helpless, it could only be for a contingent benefit, with a certain and great present evil.

In other words, Darwin rejected the moral lapses that some people argued should derive from his own theory. He understood that being human gives us choices that other animals don’t have, and he wanted us to use those choices to protect the weak, not “let Nature take its course.”

            But you might decide Darwin is wrong and the Antioch commissioner is right. I hear some young people have suggested COVID-19 parties where you can infect each other, get a (probably) mild illness, and get it over with! I suggest the following song after you’ve had a few beers. (It’s sung to the tune of the title song in the ‘60s musical Bye Bye Birdie.):

Bye bye Grannie,

We’re gonna miss you so!

Sorry, Grannie,

But ya gotta go!

If you’re curious about this tune click the link now, because after Nature takes its course, no one left alive will remember it, and you’ll never hear of it again.

[Important disclaimer! I don’t really advise you to have a COVID-19 party!]

Good News

  1. “Good to be with you,” said Gov. Cuomo Sunday to one of the four governors joining him virtually and pragmatically in a new consortium. New York, the tip of a severed starfish point, has regenerated much more of the point by bonding with Connecticut, New Jersey, Pennsylvania, and Delaware to coordinate rules and to bulk-buy protective and testing equipment at better prices.
  2. Remdesivir, an antiviral that was developed for Ebola, has reportedly shown its ability to reduce ICU stays from 15 to 11 days in very sick patients. This, if it holds up, is great news. The drug will not be withheld in new trials (now unethical), but will be added to other study drugs in continued research. Bill Gates’s foundation and others are working aggressively (“The Therapeutics Accelerator”) on a treatment that would use monoclonal antibody technology to derive drugs from convalescent plasma, among other treatments.
  3. Testing of two main types (for current virus and for antibodies raised by past virus) is ramping up, although not nearly fast enough. Home self-tests (like the ones we have for pregnancy) should soon be more widely available. Contact tracing, far behind testing, is slowly improving. Random-sample testing in a few places is beginning to clarify how the virus has spread and who (by age, location, ethnicity, and gender) is affected most.
  4. New cases in South Korea that appeared to be reinfections of people who already had it (i.e. they lost their protection in weeks to months) now appear to have been head fakes (false positives), caused by what one expert calls “viral litter”—non-dangerous fragments of viral RNA lingering from the infection.
  5. As many as a hundred labs worldwide are working as hard and fast as they can on vaccine candidates. 95 percent of these could fail in clinical trials (the hard part) and we would still have a few to use. Factories are being built and adapted long in advance of this to produce up to billions of doses that will eventually be needed. Up to 14 vaccines have already entered Phase 1 clinical trials, much sooner than most experts expected.
  6. The modelers at the University of Washington (IHME, led by Chris Murray) have detected a heat effect that is much less than it is with some other viruses but greater than previously thought for this one. Therefore a hot summer will work to a modest extent against the social factors making things worse.

Bad news

  1. Rules are being relaxed by states in an uncoordinated way, without a flicker of national leadership, except in the direction of greater risk. Few if any of the states reopening have met the national standard, put forth recently, of having declining cases for two weeks; most still have rising cases. The Federal government has ordered meatpacking plants, essentially petri dishes for the virus (like cruise ships and prisons), to reopen and stay open, and these are and will be places from which many American communities will become disaster areas.
  2. As Bill Gates remarked on CNN Friday, the so-far modest impact of remdesivir is not going to make us say, “Let’s go to the movies.” Experts note that a smaller study (but a good one, and large enough to show a substantial effect if there were any) in The Lancet found no effect of the same drug. The larger study praised by Dr. Fauci has not been published or peer-reviewed, and all we have so far is a press release and his word.
  3. Testing and contract tracing, the life blood of safe reopening (and therefore of economic recovery) is primitive in our country. We have around 200,000 tests a day nationally, done for the sick and a few others (like health care workers) in most places, but otherwise haphazardly. Expert opinion on how many tests we need range from 5 million a week to 20 million a day. Given that we are most infectious in the first few days of symptoms, or even before, tests that take days to get results are of limited value in controlling the pandemic. “What’s the point?” Bill Gates asked the other evening. “Do you just send apology notes to the people you infected in those 3 or 4 days?” The Gates foundation is supporting the scale-up of rapid testing.
  4. Perhaps the biggest unanswered question is what is the extent of our immunity after having had the virus and how long it will last. Could it be like chickenpox, one and done for life? Or more like flu, protection for a season? The same questions apply to vaccines; this year’s flu vaccine was 50 percent effective.
  5. Speaking of vaccines, the 12-18 month time-frame often mentioned for getting to distribution of a safe and effective vaccine would be by far the shortest in history. Animal models have limits; Dr. Sanjay Gupta reminded us the other day of an old doctors’ saying: Rats lie, monkeys exaggerate. Perhaps the brute force of a hundred labs parallel-processing various methods will accelerate the time to large human trials, but those trials take time. Many will fail and some may fail dangerously.
  6. Internal Trump administration memos revealed today project 3,000 cases per day in June, about double what we have today and higher than the highest peak so far (~2500 in mid-April). These new projections may to be what led President Trump to say yesterday that total deaths could go to 100,000. Given how optimistic he has been in the past, this could be interpreted as meaning that he is deliberately choosing economic activity over preventing mortality, and we should be prepared for more.

Almost half the country is officially open to some extent as of today. “Government overreach”—for your protection—is (temporarily) ending in many states. Watch the states, as well as other nations (with much better testing) that are opening and see what happens. It’s interesting that Dr. Birx (quote up top) misspoke slightly in expressing her worries about the people who don’t do social distancing in protests: “they will feel guilty for the rest of our lives”—the line between “their” and “our” indeed blurs.

Nationally, we’ve been stuck on a fairly stubborn plateau of cases and deaths as states with increases replace those with declines. Projected cases, hospitalizations, and deaths that two weeks ago gave me hope of a more normal summer before a possible fall wave were based on the assumption of serious social distancing through May. That hasn’t held, and all models are projecting more deaths. The latest today (May 4) from IHME projects 134,000 deaths by August, almost double the number projected 6 days ago. I wish I could tell you that college will be live in the fall. As Gov. Cuomo said today, “Know what you don’t know.”

I don’t know for sure, and I’m sorry to have to say it, but it seems to me we have chosen mobility over sheltering and death over life.

The weather’s great, go out (seriously), enjoy a walk or a run alone or with someone you trust. Wear a mask (as Cuomo says, it’s a sign of love and respect for others, because it protects them from you), stay at least six feet (two meters) away from anyone not part of your household, go home as soon as you can, and wash your hands obsessively. While you’re out, observe the crowds who aren’t doing the above, and if you’re religious say a prayer for them, because in a couple of weeks they are going to need it.

As for you, please to take to heart what Tim Cook, head of Apple, said to the new Ohio State grads in his online commencement address: “I hope you wear these uncommon circumstances as a badge of honor.” This is my hope for you in your own futures. Do the right thing now, and live to brag for the rest of your lives about how you made it through COVID-19. As you have heard me say many times, you are lucky to have great gifts, and the world has a right to expect leadership from you.

Dr. K

Note: Please don’t just rely on me. I recommend the following good sources: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; This Week in Virology (TwiV) podcast; IHME (U. of Washington) model website; COVID-19 UpToDate for medical professionals; and for all readers: Why the Coronavirus is So Confusing. Dr. Ashish Jha of the Harvard School of Public Health said on Thursday, “I grew up as a public health person loving and admiring the CDC, arguing and believing that it is the best public health agency in the world… But in this entire pandemic, it’s been one fiasco after another. And it’s either possible that all of the scientists all of a sudden forgot their science, or there’s something at the leadership level that’s really hindering them.” 

 

 

 

 

 

 

 

 

 

 

 

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 Reply to Opening to What?

Important Disclaimer

4

Dear Students,

My eldest daughter, who has two sources of expertise on this—she was an Emory College student, Class of 2000, and is an attorney (JD, NYU Law, 2005)—has texted to caution me that not all of you may realize that I was being sarcastic in my last announcement:

“You have to tell people not to do this: ‘Then there’s the experiment proposed by the Doctor-in-Chief or DiC. You can really help out here. Swallow, or better still inject Lysol or another disinfectant. I think he meant, like, in your veins? Also, get some really bright (but maybe not too thick) flashlights and stick them in all the places where the sun doesn’t shine.’ You can blame it on your lawyer daughter. But you put it out there without making it expressly clear that nobody should do this and that they will die. You can’t (not you). Please. This is one of those situations where you should defer to my expertise. I love you.”

So, I am deferring to my daughter’s expertise. When I paraphrased President Trump’s advice about disinfectant, I was being satirical and sarcastic. I was mocking him. As she says, “NO ONE SHOULD DO THIS AND IF THEY DO THEY WILL DIE!”

President Trump also now claims HE was being sarcastic. You can judge for yourself here

Also, please read this warning from the manufacturer of Lysol disinfectant:

Regarding the use of thin flashlights in bodily orifices, you may use your own judgment. But please don’t lose your sense of humor.

Dr. K

…and then there are experiments

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“We will allow gyms, fitness centers, bowling alleys, body art studios, barbers, cosmetologists, hair designers, nail care artists, aestheticians, their respective schools, and massage therapists to reopen their doors this Friday, April the 24th.” Gov. Brian Kemp (GA), 4/20

“If there’s a way that people can social distance, and do those things, then they can do those things. I don’t know how, but people are very creative.” Dr. Deborah Birx, White House Briefing, 4/21

“My daughters who are, you know, 13 and 14 and 11, I mean, right away they’re asking me, ‘How does that work, Daddy?’” Dr. Sanjay Gupta, CNN, 4/21

Dear Students,

Y’all remember what an experiment is, right? Like, you’re in a lab with a lot of mice genetically engineered to mimic Alzheimer’s. They build up clumps of amyloid in their brains, and they get even dumber than other mice. You find a molecule that binds to amyloid and say, “What if I could get it to attack the amyloid clumps?” You randomly assign mice to get or not get your cute molecule, and presto, the ones who get it clear the amyloid clumps from their brains. “Whoopee,” you think. You and some brain docs recruit a few brave volunteers with early Alzheimer’s to take Cute Molecule. (Hopefully they didn’t volunteer because they were already demented.) Did their amyloid clear? Equivocal, but then again you didn’t kill anybody. You move on to a larger trial, with a matched control group. You don’t know who got Cute Molecule in different doses or who got a vitamin pill, and neither do they. Double-blind. Results: still equivocal. Back to the drawing board. But wait. You analyze the results again and find that the highest dose of Cute Molecule helped some patients. “Whoopee!” More studies.

Those are experiments.

And then there are experiments. Like the one Doctor—oh, I meant Mayor—Carolyn Goodman of Las Vegas proposed. She told Anderson Cooper on CNN, “We offered to be a control group…and I was told by our statistician you can’t do that…and I said, Oh, that’s too bad because I know when you have a disease, you have a placebo that gets the water and the sugar and then you get those that actually get the shot. We would love to be that placebo side so you have something to measure against.” Her fascinating hypothesis: the parts of Nevada that stay locked down won’t have less COVID-19 disease than Vegas, which she encourages to reopen its casinos, bars, and restaurants.

Students, this is your chance to be one of those brave volunteers pioneering in Doctor—I mean Mayor—Goodman’s big experiment! Fly to Vegas and elbow in among those crowds of gamblers from everywhere in the reopened casinos. If you are serious about gambling, this is the experiment for you!

Or, come back to Georgia and get a massage, a tattoo, a haircut, a perm, or a manicure. Those are some of the businesses that Doctor—I mean Governor—Brian Kemp reopened in our state! Maybe you’ll be the experimental group and North Carolina, the adjacent state that’s staying locked down, will be the controls. Really, what’s the worst case scenario? You help prove that our neighbors to the north are right—AND you are going to look sooo good in your coffin!

Then there’s the experiment proposed by the Doctor-in-Chief or DiC. You can really help out here. Swallow, or better still, inject Lysol or another disinfectant. I think he meant, like, in your veins? Also, get some really bright (but maybe not too thick) flashlights, turn them on, and stick them in all the places where the sun doesn’t shine.

But I digress.

[See disclaimer here]

Good News

  1. New York, by far the worst-hit state, is definitely healing. As the governor says, 400+ deaths a day is nothing to celebrate, but it’s far down from the peak, and the pressure is beginning to ease a bit in the hardest hit hospitals. Intubations have been lower than extubations for days, and New York (as promised) is sending ventilators to states that have not yet reached their peak. What goes around comes around.
  2. The Starfish model that I wrote about last time is working for America. Most governors, including many Republicans, are leading their respective points of the star and ignoring the decayed head. This is making our country resilient enough to defeat the virus with an adaptive, headless network. Large majorities of Americans are keeping up social distancing and are worried about opening too soon.
  3. A different point of the headless star, the U.S. Congress, passed another near-$500 billion relief bill, to save more of America’s small businesses from the virus (especially minority-owned businesses—the most vigorous part of the category). Also, the bill will strengthen production of personal protective equipment (PPE), swabs and reagents vital for testing, and actually deploy real testing programs.
  4. NY and LA have instituted something I’ve been waiting for: random sampling of their populations for antibody testing. This gets a snapshot of the impact of the virus: where it has been, how many people had it without symptoms, how it spreads, who is most vulnerable, and what the real numbers are—total cases, which leads to believable case fatality rates.
  5. A retired farmer in Kansas wrote Gov. Cuomo that he had saved five never-used N-95 masks from his farming days. His wife has one lung and is diabetic so he is saving four masks for his family. But he sent the fifth one to Cuomo, asking him to give it to a nurse or doctor in New York. The man said he didn’t expect an answer, but the Governor read it and reread it on national television. There wasn’t a dry eye in the house. That farming couple and others like them are another point of the resilient American star.

Bad News

  1. The fact that New York is sending ventilators to other states of course means that they have not passed their peaks of need but are still on the upswing (Utah, Mississippi) or in a plateau (Texas) of deaths. (Interactive graphs here.)
  2. Some states (Georgia, Florida, South Carolina, etc.), fortunately not many as yet, are as headless now as the nation is, and are pioneering ill-advised early opening. They can’t be effective points of the national starfish. But the mayors in most cities in those states—in Georgia, the mayors of Savannah, Augusta, Albany, Macon, Rome, and Atlanta—are the points of the now-headless state starfish. They will save the state, just as the wiser governors save the nation. The mayor of Savannah, for instance, has urged his citizens (in Georgia’s oldest city) to call their barbers and manicurists and pay for an appointment in the future, but not to go now.
  3. All the money from Congress so far does not begin to meet the need. It does not help the states to support first responders, provide adequate PPE, or deploy adequate testing and especially, contact tracing. Senate Majority Leader Mitch McConnell has advised states to declare bankruptcy, which is not legal, rather than use Federal funds to help hard-hit states. Much more is needed to rebuild crumbling infrastructure and finally build the health care delivery system we need. This would provide millions of needed jobs and leave our children with a more workable country.
  4. We are still woefully under-testing, and we need a ten-fold increase just to test for the virus itself. (The Rockefeller Foundation just issued a detailed plan for expanding testing and reopening the country). Crucial antibody (serological, you-had-the-disease) testing is far behind in numbers and most available tests are not accurate. A huge newly-trained force of people is needed to trace contacts.
  5. All experts agree that a second wave of the pandemic is highly likely in the fall and will intersect disastrously with the regular flu season, which it didn’t do this year. This includes the head of the CDC, the Surgeon General, Dr. Fauci, and Dr. Birx, who all risk being fired by openly contradicting their boss on this prediction. The best we can hope for is that we will have learned and that the next wave, even if it is worse, will not catch us flat-footed the way the first wave did. Watch the secondary waves already occurring in Asian countries.

Many experiments are under way and we will see how they turn out. That includes controlled experiments on treatments and vaccines, and uncontrolled experiments by politicians on volunteers who do not understand the risks they are taking by participating. The Mardi Gras experiment resulted in a large increase in Louisiana cases. The Wisconsin in-person primary election on April 7th is believed to have caused at least 19 cases, including at least one poll worker. Daily new cases in Wisconsin have seen an upturn (here, and graph below) in the two weeks since the primary. Live, in-person worship services, funerals, and other religious gatherings have resulted in many deaths, including an outbreak in Albany, Georgia after a funeral and the death of a pastor in Virginia who led live services. His wife also got the virus, and their daughter begs us to understand how serious the risks are. We will see what happens in Georgia barber shops and on Miami beaches.

Stay safe. Let me know if you’d like me to continue these updates beyond the end of the semester.

Dr. K

Do I Have It, Did I Have It, Am I Recovered, Am I Immune?

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“A house divided against itself cannot stand.” Gov Andrew Cuomo, quoting Abraham Lincoln, quoting Matthew 12:25 and Mark 3:25

“The paranoia of stupidity is always the worst, since its fear of destruction by intelligence is reasonable.” American playwright Arthur Miller

“You can’t always get what you wa-ant. But if you try some time, you just might find, you get what you need.” The Rolling Stones, from home, yesterday

Dear Students,

A book called The Starfish and the Spider, published in 2006, was about the strength of decentralized organizations. The metaphor is not ideal, but if a spider loses its leg, it’s crippled, and if it loses its head, it’s done for. A starfish can regenerate its cut-off leg, and in some species the leg can regenerate the whole starfish. The authors argue for the strength of acephalous or headless organizations. Wikipedia and the Internet are examples. The Aztecs quickly fell to the Spanish conquerors, but the dispersed, leaderless Apache Indian tribe resisted them for centuries.

Good News

  1. The resilience of the United States as a headless organization is being tested as never before, at least since the American Revolution. How many times have we now heard, “It’s up to the governors”? Well, guess what? The governors have gotten the message! They are fighting the would-be COVID conqueror with the resilience of a headless organization. This includes Republican Governors Larry Hogan (Maryland), Mike DeWine (Ohio), and Charlie Baker (Massachusetts), and Democratic Governors Andrew Cuomo (New York), Gretchen Whitmer (Michigan), and Gavin Newsome (California). They keep asking for Federal help, and people are dying for lack of it, but they no longer expect it from the executive branch, and they are getting the job done.
  2. The Congress is another leg of the starfish. It is drafting legislation to provide funds for millions of free tests a week, both for the virus (you have the disease) and for the antibodies (you had it). New York State, which accounts for almost half the U.S. cases and deaths so far, is pretty clearly over the worst. Following Germany and other countries that understand science, New York will implement massive random antibody testing to get a snapshot of how the virus spread through its population, calculate real mortality rates, and begin finding out who may be immune.
  3. As for treatment, hydroxychloroquine has not yet worked but is still under study, as is the antiviral remdesevir, which looks much more promising. The use of convalescent plasma (from recovered patients) is also being aggressively studied. All three are in short supply, but doctors can request any of them for individual patients outside of controlled trials. Vaccines are in development in labs throughout the world.
  4. Stay-at-home measures, social distancing, obsessive handwashing, masks, and other preventive strategies have dampened the curve in many states and in the U.S. as a whole, although they have not crushed the curve anywhere. Some states will begin returning to normal life in stages recommended this week by the Coronavirus Task Force, starting as early as the first week of May. Every person who voluntarily stayed at home has been part of the headless organization defeating the virus and saving literally countless lives.
  5. Recessions and even depression do not costs lives, but contrary to intuition they save lives. This has been shown for the Great Depression, the Great Recession and other downturns. Deaths from auto and other accidents, heart disease, lung disease, and infant mortality all go down. Deaths from suicide and addiction probably go up, but overall deaths decline. Obviously if a recession coincides with a pandemic, a lot of people are going to die from the pandemic, but the idea that recession itself will cost lives in the aggregate is false.
  6. Lady Gaga and Global Citizen yesterday presented One World: Together at Home, a two-hour concert from the homes of an astounding array of huge celebrities (see highlights here). As of today they have raised $128 million for WHO, the UN, and other headless organizations fighting the virus, some abandoned by the United States.

Bad News

  1. However successful the states are on the headless starfish model, the absence of Federal funds, especially for testing, will hamper their response and cost lives. Some states are opening up too much too soon and are ignoring the fact that unknown numbers of their citizens are infected and spreading the virus without having symptoms. New research shows that sneeze droplets travel much farther than 6 feet.
  2. There is another, negative aspect to headless organization emerging: large, angry protest movements both denigrating and flaunting public health measures. This has been framed in terms of “freedom” and “liberation” and encouraged from what is left of our country’s head, but the result is massive dense crowds of people with no protection against each other. This will have an effect similar to that of Mardi Gras in Louisiana.
  3. Hydroxychloroquine trials have been disappointing so far, both because of lack of positive effect and cardiac side effects. Compassionate use of remdesivir has been more promising but it also has side effects and controlled trials must be completed before it is widely used. Ditto for convalescent plasma. Many vaccine experts doubt the timetable we have been encouraged to think about, which is 12 to 18 months.
  4. Twenty public health experts interviewed for a long article in today’s New York Times have urged us to prepare for return of the virus after the first wave, and to see this as a process that may take years. Scientists have criticized the main model that the Federal government is relying on for its normalization plan, while others have provided more plausible models that see the virus returning in multiple waves.
  5. Congress is at this writing deadlocked on major measures to provide funds for serious testing and alleviate economic suffering. Some health measures improve in recessions, but mental health measures are probably not among them, despite stress reduction for some people.
  6. The impacts of poverty, racial oppression, age, and gender are clear in this pandemic as in so many diseases. Poor people, African-Americans, and the elderly are prime targets due to preexisting untreated conditions. Women are the majority in front-line occupations, although men are more like to get sick and die. Nothing will change in the long run without changes in our society and our health care system.

“Do I have it, Did I have it, Am I recovered, Am I Immune?” These are the critical questions that we cannot yet answer. Washington says there are plenty of test kits, but the governors (both parties) say there are no swabs to do the tests and no reagents for the labs to do the analysis. Imagine that you can sit for the SAT or the MCAT, but you don’t get a pencil. Or imagine that you get a pencil and fill in the bubble sheet, but it can’t be graded.

We can’t end social distancing except as guided by widespread testing which is not yet available.

Below or attached, two graphs of the influenza pandemic of 1918-20, which we studied early in our course. The first shows overall mortality in various cities. Notice that the bumps in mortality came in three waves, the first being the smallest. The second shows the difference between the curves in Philadelphia, which had a parade of 200,000 people on Sept. 28, 1918, and waited two weeks after the first case to implement social distancing, and St. Louis, which instituted social distancing two days after the first case.

Please, be a part of the worldwide headless organization that will defeat this virus.

I know you are disappointed to be losing months of your youth, months of normal college, and for many of you the ceremonies of graduation. I am truly sorry. But I want you to have the rest of your youth and the rest of your life, and that of your parents and grandparents. We will figure out a way to make it up to you about commencement.

The “paranoia of stupidity” that Arthur Miller refers to is driving some people into the streets and into the arms of the virus. Yours is the intelligence that can subdue that paranoia.

You can’t always get what you want, but if you try some time, you just might find, you get what you need.

Stay safe, Dr. K

   

The Virus Has a Vote: Update to Students April 12, 2020

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“Whatever happens over the summer, this virus is going to be back with us in the fall. And so we have to prepare for the fall as well.” Dr. Ashish Jha, Harvard School of Public Health, 4-5-20
“What we are doing is working, and therefore we need to keep doing it.” Dr. Anthony Fauci, 4-9-20
“If we are not expecting a second wave, or a mutation of this virus, then we have learned nothing.” Gov. Andrew Cuomo, 4-10-20
“The worst thing that can happen is we make a misstep and we let our emotions get ahead of our logic and facts and we go through this again in any manner shape or form.” Gov. Cuomo, 4-11-20
“Well you know I did just finish a 24 hour shift overnight so forgive me if I’m a little brutally honest, but at some point we have to accept that we open up the economy and X amount of people are going to die and the question is what is that number and what are we willing to accept. You know as we flatten the curve, if we don’t time this right there may be another spike, and this won’t be flattening the curve, it will be flattening the roller coaster. So myself, the front line health providers, we don’t want to flatten this curve, we want to crush this curve.” Dr. Sudip Bose, Emergency Physician & Iraq War hero, 4-11-20

These quotes from experts and leaders over the past week, in order of when they were said, are more eloquent in their message than I could be. The so-called first law of medicine, If it’s working, keep doing it, is operating here. But so is the first law of life: Hope for the best, but prepare for the worst.

Good News

There is a lot of good news to celebrate this Easter Sunday, and it’s more than just hope.

  1. New York, by far the worst hotspot in the U.S., has convincingly passed its peak of intubations, and that means the worst of the worst is over for New York. Daily death rates continue to be tragically high, but they are a lagging indicator and they too are plateauing. The overwhelming of hospitals has happened, but it may not get worse.
  2. Christopher Murray’s model, often cited by the Federal government task force, from the University of Washington’s Institute for Health Metrics and Evaluation (IHME), is now projecting a total of 61,545 deaths for the U.S., down from 100,000 or more projected just a few weeks ago.
  3. The West Coast states, notably Washington where the first U.S. cases were, but also Oregon and enormous California, have done an amazing job of keeping this in control from the beginning.
  4. Clinical trials of convalescent plasma, antibodies from same, hydroxychloroquine, remdesivir (an antiviral), and other potential treatments are proceeding. Some are being prescribed under the principle of “compassionate drug use” approved by the Food and Drug Administration (FDA), although their effectiveness is a long way from proven. Many promising vaccine candidates are under study.
  5. Testing is being gradually ramped up, with viral testing (to see if you have it) up to between 100,000 and 200,000 a day. Antibody testing (to see if you’ve had it) has begun in some areas.
  6. Some top Washington officials say the country may go back to normal activity on May 1. Others see a carefully planned phase-in of normal activity over the subsequent weeks to months, guided by testing, testing, testing.

Bad News

  1. Many parts of the country are behind New York on the curve. Some will succeed as the West Coast states have. Others, where social distancing has not been followed, may be disaster zones.
  2. When you read the fine print on the IHME website, you find that they are only claiming to model “the first wave” of the pandemic. They have nothing to say about future waves. (Below I discuss a more realistic conceptual model that is speculative but helps me to think about what our longer-term future may look like.)
  3. Very few states have done what the West Coast states have done from the outset, and some have done the opposite. If Los Angeles relaxes its controls too soon, it is projected to look like New York by late summer.
  4. Early results from small clinical trials have concluded that it is ethical to continue them. This means two things: a) they are not doing obvious harm to volunteers; b) they are not so dramatically effective that the trials have to be stopped so that everyone gets the treatment and no one gets a sugar pill. They could still turn out to be useful, or have bad side effects, or both. If a vaccine is available in 12 to 18 months, it will be by far the fastest vaccine development time for any novel virus.
  5. Testing remains woefully inadequate across the board, and claims to the contrary are demonstrably false. There are not enough viral tests for health workers at risk, much less for a suitable sample of Americans. If we do 200,000 tests a day, it will take half a year to test 10% of the country. Antibody tests, which if they work well enough can probably clear many people to go back to normal activity, have barely begun.
  6. The IHME models, which are the ones quoted by and guiding Federal government officials, are premised on current strict levels of social distancing continuing through May. Earlier relaxation of vigilance is projected to increase deaths, as mentioned by Dr. Sudip Bose, the emergency physician and war hero quoted above.

The model in the graph below (or attached) is a conceptual rather than precisely mathematical model, and I have problems with it, but I think it broadly shows how we should be thinking. It comes from an odd place, namely Morgan Stanley investment research (thanks to Dr. Craig Hadley for alerting me to it; the head of the unit that produced the graph is Matthew Harrison). It has errors (it assumes that children can’t pass the virus on and it is too optimistic about the timetable for a vaccine). It may have been updated today, and I will let you know if I can access it. Meanwhile, it is conceptually valuable in showing us how to think about how this will unfold. You know I consider you leaders. Use your excellent brains to navigate uncertainty, especially when so much depends on how we steer.

Note: I made a mistake in an earlier announcement about the effect of the Great Recession on life expectancy. It actually increased life expectancy and reduced mortality at all ages. The improvement was due to decreased deaths from heart disease, auto accidents, and homicides, among other causes. There were increases in opioid related deaths and suicides but these did not offset the improvements. Improved life expectancy in the Great Recession has been shown in both the U.S. and Europe. A similar paradoxical effect has been clearly shown for the Great Depression of the 1930s and is probably true of other economic downturns. I did see one study claiming to show the opposite, and that’s what I expected, but the weight of evidence goes against my expectation. That’s science for you.

Stay safe, Dr. K

 

 

Letter to my students on COVID-19, April 5, 2020

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“I skate to where the puck is going to be, not where it has been.”

Wayne Gretzky, widely viewed as the greatest hockey player of all time

Volunteers
Volunteer Georgia health professionals on their way to New York

Dear Students,

This is my outlook on the COVID-19 pandemic as of Sunday, April 5, 2020. I pay close attention to many sources of information and sift or curate them as best I can. This is a constantly changing situation and you should not rely too much on me. As I’ve told you before, you are the future leaders of our country and our world and you must ultimately lead, not follow. Please let me know if you have information that is different or if you think I’ve made a mistake.

In my favor, I have been talking to you about this virus since our class began in January and I updated you every Tuesday and Thursday until Emory closed. Since then, I’ve been updating you every few days to a week. I try hard to get this right and not to scare you too much. I did try to scare you when we talked about Ebola, polio, and the flu pandemic of 1918-19, and I always said the next pandemic was a matter of when, not if. I did not know that this was it when I first mentioned it in January, but now everyone knows.

Good News

  1. The CDC has found that homemade masks or bandanas covering your mouth and nose when you leave your house will help to slow the spread. First Lady Melania Trump endorsed this, as have many other opinion influencers. It is not a substitute for social distancing, hand washing, and other measures, and it would be disastrous if people thought it was. It is an added measure on top of all those things. It is designed mainly to protect others, not you. When you breathe, talk, laugh, cough, or sneeze into the mask, the cloth will capture half or more of the moisture, and that means half the viruses if you are infected but don’t have symptoms. (You can experiment by spraying water into a glass through a cloth; only some moisture gets through.) If you do have symptoms, you must assume you have COVID-19, and self-quarantine completely until you are symptom free for three days. Call your health professional for specific instructions, and don’t dial 911 unless you are short of breath. Do not try to buy medical-grade masks; you will be taking them away from medical professionals and you may cause some of them to become sick and die. An example of how to make a mask is here.
  2. Rapid tests for the virus itself are slowly becoming more available, and antibody tests for whether you have already had the virus but recovered will become available more slowly. Widespread testing will be a game changer for control of the American epidemic, as it has been in China, South Korea, and other places.
  3. We have real leaders in this country who are regularly speaking out: Gov. Andrew Cuomo of New York, (Republican) Gov. Larry Hogan of Maryland, Speaker Nancy Pelosi, Dr. Anthony Fauci, and others. They speak honestly and to the best of their ability accurately about how to beat the virus and mitigate its economic effects. They don’t just call it a war, they act like it’s a war. Governors of many states are bypassing a mostly passive Federal government and attempting to help each other.
  4. Fortunately not all states are experiencing this wave of the pandemic simultaneously, so people and equipment are beginning to move where they are most needed. New York has by far worst crisis, so it is calling loudly for help. The state of Oregon sent 140 ventilators* to New York; this is a small fraction of what will be needed but it is a very important symbol. Twenty-two thousand health professionals from other states have gone to New York to volunteer. New York is worst now, but it will be better first, probably within a few weeks. It will then have excess ventilators and professional volunteers to send to other states as the crest of the wave moves around the country.
  5. Studies of treatments are proceeding, including convalescent plasma donated by people who have recovered from COVID-19; antibodies derived from that blood fraction; hydroxychloroquine, which has antiviral action in lab studies (and which I took for years to prevent malaria when I was in Africa, and then again for years for a skin condition); azithromycin, an antibiotic with possible antiviral actions; and specific newer antiviral drugs. I am hopeful that one or more of these will prove effective within weeks to months, much sooner than we have a vaccine. However, it is immoral to take hydroxychloroquine for prevention or self-medication at this time; it is not proven to work, and it is in short supply for people with lupus and other autoimmune diseases, who desperately need it.

Bad News

  1. We have inadequate leadership at the very top in Washington, giving out inconsistent messaging, with no national strategy for supply and logistics for COVID-19 care—ventilators, N-95 masks, shields, gowns, and other personal protective equipment (PPE), and consistent only in predicting unrealistic time frames for ending the pandemic and getting the country back to work. The government in Washington has declined to order a national lockdown for social distancing, to mobilize the armed forces to help the hospitals and the states, to order manufacturers to make desperately needed ventilators and PPE, or even to set an example for our people in things like social distancing and wearing of masks.
  2. The hospitals in New York, Detroit, and New Orleans are already overwhelmed, but the word overwhelmed will be given new meaning in those cities in the next week or two. Large numbers of health professionals, police officers, firefighters, EMTs, and other first responders are already sick and more will be. Many who are not sick are crying every day. Some, understandably, are quitting in fear of bringing this deadly virus home to their families. Similar effects will be felt in other cities throughout the country over the coming weeks. Hospitals built out in convention centers and mega-tents were ready but almost empty for days until they were allowed to take COVID-19 patients. U.S. Navy hospital ships are almost empty because they still will not take COVID-19 patients.
  3. Many people still do not take social distancing seriously. Gov. Kemp of Georgia reopened the beaches and parks in our state after closing them. In many states social distancing is not enforced and not likely to be until it is too late. According to current official government projections, the United States will see a minimum of 100,000 to 240,000 deaths if we strictly follow social distancing and other precautions. We are not yet doing that. The number of deaths in the U.S. passed 9,000 today and is doubling approximately every 3 days, which would put us over a hundred thousand in 10 days or so. If we act properly and lengthen the doubling time to 4, 5, or 6 days, it will take longer to get there. But bear in mind that the increase continues to be exponential at those longer doubling times.
  4. The Congress, especially the Senate, has offered too little too late to offset much of the disastrous economic effects of the pandemic, and as usual the poor and minorities will suffer most of the consequences, including worsening health, inadequate access to care, and premature and preventable death. Poor families have the greatest psychological vulnerability to the post-traumatic effects of this experience. Families at all socioeconomic levels have seen increases in domestic violence.
  5. Something that I have been reluctant to mention in these announcements, but which more and more authorities are considering, is the possibility that this is only the first wave. The flu pandemic of 1918-1919 had three waves. We must watch closely what happens in China, South Korea, and Japan as they declare the virus beaten and relax social restrictions. The virus is currently spreading in the Southern Hemisphere of the planet and may get worse in their winter, even as it may get better at the same time in our summer. I wish I could promise you that Emory will have live classes again in the fall.

We all need to adapt to situations that are psychologically abnormal. You can do it. Facetime or Skype with your friends and family. Have Zoom rituals, club meetings, and parties. Go outside with a homemade mask and run or walk while social distancing. Watch those movies you always wanted to see, binge-watch those hot TV series, even maybe read a book that’s not assigned for school.

Whether we have one wave or more, we will in time have treatments and a vaccine. Those who have had the virus and recovered will slowly begin normal life again. They will help restart the economy. This will end.

Your great-grandparents lived through World War I and the flu pandemic of 1918-1919. Your grandparents lived through the Great Depression and World War II. Your parents lived through the Vietnam War, 9/11, terror of terrorism, and the Great Recession. If any of your generations were in the developing world, they saw and lived through other terrible things. You can live through this. Just do what you’re supposed to do and help others as best you can. Do your homework and study. Come to class online. You are still a college student and you still have great dreams. You will live to see your dreams come true.

Dr. K

  • A note on terminology: I said in an earlier announcement that a ventilator is the same as a respirator. The Medline Plus dictionary of the U.S. National Library of Medicine says, “A ventilator is a machine that breathes for you or helps you breathe. It is also called a breathing machine or respirator.” However, other authorities use the word “respirator” to mean something entirely different, namely the top-flight hospital grade N-95 masks that screen out at least 95 percent of airborne particles not carried in oil. Because of the two meanings of “respirator,” I will avoid this word going forward. COVID-19 is the name of the disease caused by one of many coronaviruses; this coronavirus is designated SARS-COV-2. However, we all know that today “coronavirus” or even just “the virus” will pretty much get the message across.

What I told my students this evening about COVID-19

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Dear students:

“Facts are empowering. Even when the facts are discouraging, not knowing the facts is worse.” — Gov. Andrew Cuomo, New York

 

Data as of March 30, 2020

 

 

Good news:

Some very good things have happened, although very belatedly, since last week:

  1. As of yesterday, President Trump accepted the advice he has been getting for over a month from experts, about the size of the pandemic (at least 100,000 deaths at best), the inadvisability of having different rules for different parts of the US, and the need to extend rigorous social distancing at least until April 30th. He is no longer calling for the churches to be full on Easter Sunday (April 12th) as he did last week.
  2. Diagnostic tests that report results in 5 to 15 minutes have been developed by several laboratories; they are also easier and safer to perform than previous tests. It is possible that massive increases in testing will happen in the next week or two. Promising tests for whether you have had the virus should be available soon. Human (Phase 2) studies are looking at treatments (antibodies from recovered patients, antiviral drugs, etc.) and at vaccine candidates. These are months to over a year away.
  3. The navy hospital ship Comfort has docked today in New York City with 1000 hospital beds and 1200 trained health care professionals. They will take non-COVID-19 patients, allowing hospitals to focus on those with the virus and reduce the spread to other patients. Smaller ships are going to New Orleans and elsewhere. Quite good hospitals have been or are being built in huge convention centers, parks, and fairgrounds in a number of hard-hit cities. Some of these will take COVID-19 patients.
  4. The logistics (supply chain) of ventilators, N95 masks, and other personal protective equipment (PPE) was brought under a nationwide command, including: manufacturing many more of all these; making sure they get where they are most needed, when they are most needed; importing large numbers of needed items from across the world; and figuring out how to sterilize and otherwise safely use them for more than one patient simultaneously (ventilators) or in succession (PPE).
  5. Increasingly effective social distancing throughout the country.

It might be true to say that all these things are “too little, too late,” but I prefer to put the emphasis on “better late than never.” In fact, much better late than never.

Bad news:

  1. The President has continued to spread misinformation that, like his previous misinformation, may be deadly, and to do other things that put people in danger. Yesterday he said it was a mystery how hospitals that used to need 10,000 to 20,000 masks now need 300,000, and strongly suggested something “worse than hoarding” as the reason. Here is the reason: doctors who routinely needed masks for 1 of the 20 patients on their shift now need masks for 19 out of 20. You do the math. Two days ago, he said he had told the Vice President not to return calls from Michigan’s governor because he doesn’t like the way she talks about him. How many people will die in Detroit in the next week or two because of those delays?
  2. Massive widespread testing both for having the virus now and for having had it and gotten over it are needed right now and not yet available.
  3. Military resources for treatment, logistics, and public health measures are still woefully underused. If you say it’s a war, act like it’s a war.
  4. Command and control measures at Federal government disposal for increasing the manufacture and distribution of needed equipment have still not been properly deployed. Many hospitals are already overwhelmed, and more will be. If you say it’s a war… (see above).
  5. Social distancing remains spotty in many places. Some houses of worship (not most) are holding crowded live services. Dense groups of young people are hiking together in Georgia national parks. Some entertainers are holding concerts and encouraging rebellion. Experts say if we do everything right, we can keep the deaths in the US to as few as 100,000-200,000. We are not doing everything right.

We were supposed to “flatten the curve” to save the health care system. Now the peak is coming April 15th or so in the first states. The overwhelming of hospitals will start then (actually, it’s started already) and spread like a wave throughout the country. We must proceed with mitigation and be as ready as we can for those peaks.

Check out the graph. This is what “American Exceptionalism” means today.

See you tomorrow,

Dr. K