Tagged bioethics

TETRIS Is Dead. So Is the CDC. And the FDA. And 188,000 Americans.

            “We are not anywhere near done with this and I think we have more days ahead of us than we have behind us.”

            Ashish Jha, MD, Harvard School of Public Health, August 28

            “The problem here is the credibility of the FDA is crumbling before our eyes. This is an agency that so many of us in the scientific world have looked up to, trusted it, we know that they have these really rigorous scientific protocols, but that’s all changed this year.”

                        Seema Yasmin, MD, Stanford University, September 2

            “Obviously there are places around the world that have been able to control this. What I’m starting to feel is the existential threat is the human behavior. I’m discouraged and frustrated… Other countries are essentially vaccinated right now, not because they have a vaccine, but because they did these things, they are back to normal. They reduced their death rates into the dozens or hundreds, not the hundreds of thousands.”

                        Sanjay Gupta, MD, Emory University, September 4

Dear Students,

You remember what TETRIS is, right?

TEsting. Contact TRacing. ISolation.

Those are the “these things” Dr. Gupta is referring to above, along with mask wearing and social distancing, that have enabled other advanced countries with large populations to have hundreds of deaths from COVID-19, while we have hundreds of thousands of deaths.

Good News:

  1. Many other countries have got this under control, and they are immediately using TETRIS to bring any new breakouts under control. Per capita hospitalizations and deaths are a tiny fraction of what they are here now, and that gap will only widen as they prevent and control their second wave—which we won’t have because never controlled the first wave, only smushed it down and smeared it, and that only a little. Our second wave will come on top of an enduring first wave.
  2. Cases per week have gone steadily down in the U.S. for at least a month, and that is good news if real. As you know I was skeptical of case rates when they were going up because politicians were saying daily that the rise was only because of more testing. Now when we know testing is going down, because it was badmouthed by politicians and the CDC recommended doing less of it. You don’t hear politicians saying one reason for the decline in case rates is less testing. Deaths, being a lagging indicator, have gone down only slightly. Also, the southern states are doing somewhat better while the midwest is having its big first wave, and the northeast is rising but from very low levels.
  3. Vaccine development is proceeding around the world. Phase III testing is going slowly and will be difficult to interpret because of marked underrecruitment of minority people, who are way overrepresented among the cases, hospitalizations, and illnesses.
  4. Finally, the sum total of well-designed research has shown that steroid treatment (like dexamethasone) reduces deaths in patients severely ill with the virus. Death rate for 1,700 people across 12 countries was 32% with steroid treatment and 40% with placebo. That amounts to saving 1 in 5 very sick COVID-19 patients who would otherwise have died.
  5. There is a lot of talk about, and even some progress in, cheap rapid testing, but the deployment of these tests has been slow due to manufacturing bottlenecks and general badmouthing of testing by politicians. Nevertheless as these tests become more available, we should make progress against our U.S. pandemic (near the world’s worst), but that would require a revival of TETRIS and a modification of behavior based on test results.
  6. The CDC has issued a mandate against evictions until January 1, as a public health measure. But the CDC does not have a police department and it will leave enforcement to local authorities. There are many exceptions that would still allow people to be evicted, and after January 1 all those protected will owe all back rent. Perhaps there will be another Congressional stimulus package by then to soften that blow.

Bad News

  1. The latest models from IHME and Johns Hopkins agree on where we are now, and the graph shows three projections as to where we are going, depending on one of threee assumptions. The most likely scenario (dark blue line) shows where we will be on January 1 if we keep on doing what we’re doing: 300,000 deaths total, and adding about 3,000 deaths a day. If we had universal mask use, that total would be around 230,000 and the daily deaths would stay under a thousand for a while in the fall before doubling or tripling again with the cold weather (more time indoors) and the flu season giving many both viruses. If we continue to have easing of social distancing mandates, we are expected to have 600,000 total deaths and almost 12,000 cases a day by years end. You will hear some politicians say that these projections have been wrong throughout in overestimating the future damage. This is a lie. Except for the very beginning when nobody knew anything, the IHME reference scenario has been too optimistic. Testing is going down or staying at low levels in most states, contact tracing is beyond inadequate, and isolation is accordingly moot.
  2. We’ve learned that infected people are most likely to infect others during the first week or ten days of significant viral load, which is why superspreader events attended by healthy people are the major U.S. source of viral spread right now. These are most likely to be indoor, largely unmasked, crowded events. Viruses linger in the air for hours in many such spaces. These superspreader events have included Mardi Gras, church services in Arkansas and elsewhere, funerals in Georgia and Ohio, and a Boston meeting of executives at Biogen, a large molecular technology company, among many others. The Sturgis motorcycle rally in South Dakota in early August has resulted in at least 70 cases so far (it’s difficult of course to track folks from an event like that). These are in addition to the well known virus petri dishes known as cruise ships, prisons, nursing homes, meatpacking plants, choir practices, and now colleges and universities. Luck matters, since one person can be a key superspreader, and neither you nor they know which one in the crowd they may be.
  3. In the past month or two there has been a wave of oh-so-careful openings of colleges and universities, and now there is a national wave of even faster closings. (See my update predicting this and explaining why it was inevitable.) Despite evidence of universities acting to cover up coronavirus cases, we know that there have been outbreaks at many, and they are rapidly spreading the virus to the local communities. As of September 3, “More than 100 colleges have reported at least 100 cases over the course of the pandemic, including dozens that have seen spikes in recent weeks as dorms have reopened and classes have started. Many of the metro areas with the most cases per capita in recent days — including Auburn, Ala.; Ames, Iowa; and Statesboro, Ga. — have hundreds of cases at universities.” Thousands upon thousands of students are now being sent home, where they will bring virus to their communities. (See my update on “Bye-Bye Grannie.”)
  4. “Sloppy coronavirus immunity” is a term that has been used to describe the handful of documented cases of people getting the virus twice (it also applies to other coronaviruses, like the common cold). At least one of the reinfected patients caught a different strain, so as you know viral evolution will play a role. It should also apply to the question of how effective any immunity from a future vaccine will be, and how long it will last. Vaccine refusal in the U.S. has been at high levels for decades, and this vaccine will be no exception, unless the rushing of it and the prior erosion of public trust swells the ranks of anti-vaxxers to unprecedented levels (especially if, as is likely, it requires two shots). Imagine a COVID-19 vaccine that gives us about the same level of protection as the seasonal flu vaccine (~50%), lasts about as long (<1 year), and is accepted by 50% of the population. So we’d have seasonal protection for a quarter of the population, have to repeat the shots every year, and we’d still have to have over a hundred million more cases and hundreds of thousands more deaths to get to herd immunity.
  5. Harold Varmus, a Nobel Laureate and former National Institutes of Health head, and Rajiv Shah, president of the Rockefeller Foundation, published an article on August 31 called, “It Has Come to This: Ignore the CDC.” Their statement is based on the latest of a series of false, incompetent, and frankly craven pronouncements of “advice” issued or changed by the political appointee at the top of that organization, obviously in response to pressure from those who appointed him, non-doctors and non-scientists all. When Stanford’s Dr. Seema Yasmin said (above), “the credibility of the FDA is crumbling before our eyes,” she was likewise referring to the latest of multiple instances of knuckling under by the political appointee directing that organization. This would be (together with the CDC) following orders from non-doctors and non-scientists in the White House to order states to prepare for widespread distribution of a vaccine by November 1 or sooner. These non-experts say that it is purely coincidental that this is two days before our national election on November 3. The vaccine will be deployed with great fanfare on the basis of far-from-complete Phase III trials, it will put minority people at greatest risk, and there will no time to find out what damage is done by this half-baked but highly touted vaccine before people vote.
  6. The principal advisor on the pandemic in the White House is now Scott Atlas, MD, a neuroradiologist and health policy wonk at Stanford’s right-wing Hoover Institution. Dr. Atlas has no qualifications in infectious disease, epidemiology, or virology, but he is happy to parrot the long-standing White House views playing down the virus. He has denied reports by several reliable sources that he argues openly in Task Force meetings with Dr. Fauci and Dr. Birx (the real experts) and he has more than hinted that he favors “herd immunity” as a strategy, which would entail far more American deaths than the huge numbers projected above. Like an overpopulated herd of deer, we would be culled.

I must say it surprised me to see the expression on Dr. Gupta’s face and hear him say he is “discouraged and frustrated.” I am too, and that’s why it’s been so long since my last update. Frankly, I expected more from him. He’s one of my greatest heros—a top-flight brain surgeon and medical school professor, the most inspired and gifted medical broadcast journalist who ever lived, and, I’m proud to say, our colleague at Emory.

My expectations for him were totally unfair. Unlike me, he has rubbed his nose in this stinking situation all day every day for eight months. Also unlike me, he probably has not had a dark view of human nature lasting a lifetime, based on a different branch of science—behavioral biology. So yes, he has a right to see the “existential threat” in “human behavior,” and he has more right than me to feel discouraged and frustrated, having worked his heart out 24/7 to prevent things from getting anywhere near this bad. Which it wouldn’t have if people had listened to him. It will still save many lives if people start listening now.

Mardi Gras: outbreaks. Memorial Day Weekend: big outbreaks. July 4th weekend: ditto.

So we’re in the Labor Day Weekend now.

What do I think is going to happen?

What do you think is going to happen?

Stay safe,

Dr. K

PPS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York TimesCoronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter.

Readin’, ‘Ritin’ & Russian Roulette

            “We can’t become immune to this level of suffering…Georgia is in no shape to open its public schools in most of the state, the virus levels are too high.”

                        Dr. Ashish Jha, CNN, August 10th

            “I don’t know how long we’re gonna keep playing Russian Roulette with our children, Andrea. It’s not safe to do.”

                        Dr. Lipi Roy, Andrea Mitchell show, August 13th

Dear students,

My grandson proudly started third grade this week. Virtually. The teacher and the school are in Georgia, but he and his family are in upper New York state, which thanks to the leadership of Gov. Andrew Cuomo and the discipline of New Yorkers, is practically virus free. His sister will also be taking full advantage of the beauty and safety of upstate New York, as she attends a Georgia kindergarten virtually.

On the other hand, thanks to the “leadership” of Gov. Brian Kemp of Georgia—along with the lack of discipline of its citizens—hospitalizations and deaths in our state have climbed relentlessly. My newest grandchild and his two moms were hiding out in our house in Atlanta from early March until his six-month birthday in late June. That was because Atlanta was much safer than their home city, Brooklyn. But by June Atlanta and Brooklyn had changed places, and they are much safer in their home than they would be in ours

Dr. Sanjay Gupta, who lives in Georgia, weighed all the facts, including his three daughters’ need for education and a normal life, and he and his wife decided they would start school virtually. They did this after examining the school carefully and concluding it was taking all recommended precautions.

 

Photo by the very brave 15-year-old Hannah Waters of the unsafe opening of her school

Georgia is famous now for the chaos and recklessness of its school openings. The photo of the school hallway, which you’ve seen if you haven’t been hiding under a rock, was taken by 15-year-old Hannah Waters, during a class change at her Dallas, Georgia high school. She was suspended for her pains, until an outcry forced school authorities to reinstate her. Meanwhile they threatened other students who might also be considering blowing a whistle on this deadly situation.

Hannah Waters is famous now too, because her photo immediately went, um, viral. She’d been planning to return to school, but students and faculty there began testing positive. There are at least 35 cases and counting, so Hannah will be learning virtually.

Let’s be clear though: the word “suffering” used by Dr. Jha above, and the word “deadly” in my last paragraph, do not apply to Hannah’s fellow students. They are very unlikely to suffer much and extremely unlikely to die. But this is not true of the teachers, cafeteria workers, and janitors. And it is not true of the parents and grandparents of the students. And it is not true of the others in the community they will infect.

Hannah’s fellow students will bring suffering and death to others, as they have throughout the pandemic, without suffering and dying themselves. This, we know, is the virus’s evolutionary strategy, and it is working like a charm. The virus can pervade the crowd of kids in that hallway like an invisible toxic gas or radioactive rays, except that unlike the gas or the rays, the kids can take the virus anywhere.

The chaotic process of Georgia schools and school districts opening, finding infected children, and closing down again has been so widespread and bewildering it’s frankly impossible for me to follow, and it’s happening in much of the rest of the country as well. Cherokee County, an Atlanta suburb, opened on August 3rd by unanimous decision of the school board, and reported that 1,193 cases of COVID-19 were quarantined by August 12th.

Some districts and counties around the state will have live options. The Atlanta City Schools will be all virtual, and of the nearest counties, Dekalb, Cobb, Fulton, plus the suburban cities of Decatur and Marietta, 100 percent will be 100 percent virtual. Go a little farther away from Atlanta and you’ll still be eligible to choose to put your kids at risk. Except that these rules are changing day to day.

Very confusing. Easy to follow though is the relentless Presidential drumbeat of Have-to-open-Have-to-open-Have-to-open-schools. The nation is marching to a different drummer. 35 of the 50 largest school districts in the U.S. will open online only, and others, like New York City, are reconsidering their plans for a safe hybrid open.

Let’s consider what little we know about COVID-19 and children. First, the good news, which won’t take long to relate: very few children have gotten very sick or died from the virus since the beginning. That’s good news for the virus too, since these kids can mobilize it like crazy.

Some other bad news:

  1. Kids between 10 and 19—Hannah’s classmates—can transmit the virus just as well as adults. A new, large, careful South Korean study of 59,000 people who had been in contact with one of 5700 infected cases showed that kids 10-19 years old are very effective at infecting others. This study was done during a period of school closure.
  2. Kids under 10 can also transmit the virus, and have been important vectors bringing it home to their families. The South Korean study above found that kids under ten were less likely than older kids and adults to transmit the virus to others, but they can and do transmit it. A new study published in JAMA Pediatrics showed that younger children carry more SARS-CoV2 viruses in their nose and throat than older children or adults. As Dr. Gupta notes, the jury is still out on how infectious they will be when schools are open.
  3. The impact of #2 has been limited so far, since young children have mostly stayed home. Now that millions are going back to school, we will find out just how big a deal this sort of family transmission can be.
  4. Some kids do get sick and die with COVID-19. For unknown reasons, a small percentage go through the same process as adults. A nine-year-old African-American girl became the fifth child in Florida to die of it; this was in July, and there have been many more since. Her family took her to the hospital, they sent her home, and she collapsed due to heart failure. SARS-CoV2 attacks the heart as well as the lungs, in children as in adults. Her name was Kimmie, she loved unicorns and making TikToks and YouTube videos. She had a contagious goofy laugh and she had no underlying conditions.
  5. And there are also strange tragic accidents; the youngest victim in Georgia was a 7-year-old African-American boy who drowned in his bath when a sudden fever gave him a seizure; seizures are very common in children with COVID-19 fevers. It was only after his death that anyone knew he had the virus, and he had no underlying conditions.
  6. Some children develop a rare but deadly post-viral disease known as multisystem inflammatory syndrome in children—MIS-C. Four children have died of it very recently in Louisiana alone. There have been at least 570 cases nationwide. It is not the virus itself, it is a process nobody understands that is triggered by the virus. It attacks widely throughout a child’s body. A 12-year-old girl named Juliet suffered cardiac arrest and was “about as close to death as you can get” according to her doctor. Jack, age 14, woke up in agony and with heart failure and was hospitalized for ten days and sent home with residual damage. It’s a horrible disease and in the worst cases it’s a truly horrible death.
  7. And in a crowning irony, an 8-year-old named Hermione escaped on an evacuation flight from Wuhan Province in China where the epidemic first raged, only to contract COVID-19 six months later at home in America, after China had long since conquered the virus. Hermione’s father and grandparents also have the virus.

It’s worth noting that when we shut down schools in March, there were around 5,000 cases of COVID-19 in the U.S. Now as we reopen them, there are more than 5,000,000.

I know, there are places where schools can reopen safely, but many places where kids are being pushed back into school are not in that category. I know, there are ways to make schools safer, but they are not being consistently implemented and even where they are children are still getting the virus. I know, virtual learning is much less effective than live learning. Trust me, I know. I taught more than 150 students that way starting in March and will be teaching another 250 starting next week.

But somebody help me out here. Apple, Microsoft, Google, Facebook, Netflix, and Zoom (among others) have seen their shares go through the roof since the pandemic started. (Full disclosure: I like millions of others have participated, if only through retirement plans.) Is there nobody at these companies who can figure out a way to make virtual learning work better? To make it fun for kids of all ages? To get computers and tablets and broadband too into the hands of all who need them?

Our kids love screens. We fight constant battles with them to get them off screens. Now their lives depend on learning through screens. Is there no one among all the brilliant nerds and geeks in the United States of America who can design virtual learning that will engage children and really really teach them? Is there no one in the colleges of education that can ally themselves with the nerds and geeks?

I’m begging. Please.

Meanwhile, stay safe,

Dr. K

PS: In other news:

  • The United States notched its largest number of deaths in a day for the summer so far: 1500. Most recent days have seen more than a thousand deaths each. Testing remains completely inadequate in our country, and contact tracing is almost nonexistent.
  • The Russians are deploying a vaccine that is not ready for prime time—it has not been studied in anything like a proper way. Let’s hope that the people in Russia who are being used as guinea pigs get lucky. Bad vaccines don’t just fail to work, they can kill people.
  • Georgia’s governor, whom my friend Kathy calls Deathcount Kemp, has dropped his lawsuit against Mayor Keisha Lance Bottoms to stop her from mandating masks in her (our) city. Like they say down here, she whipped his butt, scared him silly, and he crawled off with his tail between his legs, where a different anatomical organ was supposed to be.

PPS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York Times Coronavirus Resource Center (NYT).

Lightning, Thunder, Flash Floods…Drownings

“Obviously if you do more testing you’re gonna see more cases but the increases that we’re seeing are real increasing in cases, as also reflected by increasing in hospitalization and increasing in deaths.”

           Dr. Anthony Fauci, Congressional Hearing, July 31

“It’s very frustrating as an epidemiologist to see these cases at numbers continuing to rise without a national strategy, without adequate testing, without contact tracing as we need it—all of the things we’ve been talking about for months and months and these numbers are going to continue to go up until we do have these things in place.”

           Dr. Ann Remoin, UCLA, August 2

“What we are seeing today is different from March and April. It’s extraordinarily widespread.”

           Dr. Deborah Birx, White House task force, August 2

“It’s like a policy of mass human sacrifice.”

           Rep. Jamie Raskin, D-Maryland, Congressional Hearing, July 31

Dear Students,

At this writing, a tropical storm is progressing from the Caribbean up the east coast of Florida and will proceed north from there, affecting to some extent even the northeastern U.S. This is below hurricane status but still has hurricane-speed winds and has badly flooded some Caribbean islands. Storm surges will follow after the wind and rain die down. There have been drownings. They will be very sad and perhaps to some extent avoidable.

But as you know if you’ve been following my updates, the drownings in the title above are metaphoric—the deaths are all too real, but they do not involve storm waters. Americans are drowning and dying in the flash floods of viruses, being killed partly by the accumulation of fluid in their lungs as part of the crash of lung and heart function under viral attack. And the numbers of dead are hundreds to thousands of times higher than will be caused storm drownings.

So: our metaphor likens the features of a storm in weather to the features of the resurgent viral pandemic. You know I am not impressed by a surge in cases alone, if only because our mendacious political leaders falsely claim that more testing leads to more cases. For the record, once again: it is a lie that we do more testing than any other country, and it is a lie that 99 percent of the cases detected are benign. There are simple ways to use case records to refute these lies, such as rising or falling ratios of positive tests to total tests, but I decided not to get into an argument with unscrupulous men who have the most powerful megaphones in the world. I decided to wait for a measure that has no relation at all to the amount of testing: hospitalizations.

I suggested we think of the case surges as lightning and the hospitalizations following as thunder. As we began to see a month ago, the lightning strikes across the southern half of the nation were followed a few weeks later by rolling thunder. Hospitalizations surged, hospitals overflowed, health care workers were overwhelmed, and in general the southern states that had been feeling superior to New York followed exactly in New York’s path, in a way that was as predictable as it was completely unnecessary, since New York had blazed the path—both on the way up and on the way down.

I said at that time that I was not sure that deaths would follow hospitalizations, because the average age of victims was younger, and the treatments for advanced cases were better. I said that if the cases were lightning and the hospitalizations were thunder, the next stage could, but hopefully would not be, flash floods (overwhelmed lungs and hearts) and drownings (COVID-19 deaths).

This hope was dashed, and the surge in deaths is here. That is why Dr. Fauci told Congress on Thursday that the increase in cases is real, “as also reflected by increasing in hospitalization and increasing in deaths,” contradicting the lies of his boss and the leaders of several southern states.

 

Bad News

  1. The huge surge in America’s cases in June, which did not occur in any “advanced” country (or even in countries like Georgia, Rwanda, and Uruguay) was not a second wave, it was a devastating extension of the first wave. All advanced countries and some developing ones completed their first wave by reducing cases to tens or hundreds per day. The lowest we ever got was 20,000 a day, and now we have 67,000, more than double the mid-April maximum of around 31,000. Every day.
  2. Rep. James Clyburn, House Majority Whip, chairing Thursday’s congressional hearing on the coronavirus, showing the surge

    These cases are not caused by increased testing, and the U.S. does not have a good testing program. Our per capita testing is behind a number of other countries, who are testing more and finding fewer cases. Also, we are doing the wrong kind of testing, taking an average of four days and often much longer to get results. These results are useless for contact tracing. As Bill Gates said months ago, what are you supposed to do, send apology notes to the people you infected before you knew your own result?

  3. But then again, we do not have serious contact tracing, certainly not where the epidemic is worst. I and many others said months ago we would need an army of contact tracers, and we barely have any. It may be that with the numbers of cases we have now (at least 4.5 million), contact tracing is no longer a possible strategy for controlling the disease. Imagine contacting all the 67,000 new cases each day, finding all their contacts, testing them, and isolating those who (a week later) turn up positive, and then contacting their contacts, and—you get the idea.
  4. Nationally, hospitalizations are clearly up again, the “rolling thunder” I wrote about on July 9th. This, as I showed you, was especially true in 20 states, and now it is true in more. Even averaging in the big declines in the northeast, weekly hospitalizations per hundred thousand were around 10 in mid-April, 4 in mid-June, and back up to 7 in mid-July. Multiply each of those numbers by 3,300 to get the approximate totals. Further increases are likely.
  5. Daily deaths in the U.S., the best indicator of the progression of the pandemic, peaked in mid-April at around 2,300. They bottomed in late June at around 550. As of today they have been over 1,000 for the last few days. The increase in July was steady, large, and real. Bear in mind that these national figures average in an ongoing decline in deaths in the northeastern states, so much of the rest of the country is at an all-time high. Deaths are a lagging indicator, so they could go higher. Black, Latinx, and Native American people are affected much worse than whites. Prison inmates, nursing home residents, and workers forced into dangerous conditions in meat packing and other workplaces are most at risk.
  6. All the above statistics were coordinated, analyzed and reported by the Centers for Disease Control, a collection of 1700 scientists ideally suited to this task. It was taken away from them two weeks ago and placed in the hands of the much less experienced and much more political Department of Health and Human Services. The only reason I can see for this change is that the people in power in Washington were not satisfied with their efforts to muzzle the CDC and distort its work, so they just admitted what they were doing and made the collation of statistics purely political.

 

Good News

  1. The first vaccine to enter Phase 3 clinical trials is the one being jointly developed by the biotech company Moderna and the National Institutes of Health. This is a real-world trial in which 15,000 people will get vaccine and the same number placebo, which gives it sufficient power to see whether the vaccine protects people from community spread, and whether it is safe. It allows representation of age, sex, and minority populations. It is an mRNA vaccine of a type not approved for human use before. (For more on different vaccine types, see my update of June 20th.)
  2. The University of Oxford/AstraZeneca vaccine, based on a chimpanzee adenovirus carrying coronavirus genetic information, is expected to start Phase 3 in August, and the Pfizer/BioNTech one, like Moderna’s an mRNA vaccine, in September. This website monitors vaccine progress. “Experts estimate that a fast-tracked vaccine development process could speed a successful candidate to market in approximately 12-18 months – if the process goes smoothly,” the website says. I think that means 12-18 months from when they started earlier this year. Roughly 150 vaccine projects are under way worldwide, the above three being among the five prioritized in Operation Warp Speed (stupidly named because it will increase anti-vaxxer rejection).
  3. Dr. Anthony Fauci, the nation’s top infectious disease expert, did an amazing job Thursday testifying to Congress for almost four hours (with a little, actually very little help from two other officials, and a lot of speechifying from Representatives of both parties) before the House Select Subcommittee on the Coronavirus Crisis. He managed to thread the needle of telling the truth without saying anything that might get him fired, something no other government scientist or physician can do. But if you want to hear the real Dr. Fauci in a real conversation with other scientists, being himself and saying what he thinks and knows without pausing for many seconds before carefully answering, listen to the July 17th episode of This Week in Virology (TwiV-641).
  4. Treatments are also being sought throughout the world. The ones working now are: Remdesivir, an antiviral developed for Ebola; dexamethasone, a tried and true general-purpose anti-inflammatory; and convalescent plasma (probably). On the near horizon are monoclonal antibodies derived from convalescent plasma, other anti-virals, and combinations of anti-virals. Remember that a triple antiviral therapy changed HIV/AIDS from a deadly to a chronic disease, and plays a vital role in limiting spread. (Contrary to my own hopes, since I safely took it for malaria prevention, hydroxychloroquine doesn’t work. Also, ingesting or injecting bleach or other cleaning products will kill you.)
  5. The new recommendation of face shields or goggles along with mask wearing, social distancing, handwashing, and reversal of some of the most ill-advised state openings (bars, indoor rallies, packed houses of worship, etc.) all show promise of bending the curve downward again—cases first, then hospitalizations, then deaths—across the southern United States. Midwestern and North Central states have yet to be walloped by the two-by-four of COVID-19, and they are not learning from watching the suffering of others, so they are clearly next.
  6. The most exciting new development that I have heard about recently is a revolution in testing proposed by Michael Mina, a virologist and clinical pathologist at the Harvard School of Public Health. Rapid, less accurate testing is the key. (Abbott’s ID Now test, which I told you about on May 12th, is only one example.) The gold standard, PCR, is very accurate, but if it takes a week or more to analyze it is almost useless. Strips of cardboard mass-printed with molecules that detect virus in swab samples have not been widely deployed yet because they are not considered accurate enough. However: They are accurate enough if used when a person has enough virus to be infectious. At $1 a day, they can be used often by everyone, with results in minutes.

I want to say something about school and college openings, which are starting now. This is a mass experiment, with the lives of students, teachers, parents, and grandparents being put at risk, with conflicting guidelines about how to do it, and with low likelihood of compliance with guidelines anyway.

Major League Baseball is failing at safe reopening, even with their vast wealth and tight organization. More than 6,600 cases have been identified on college campuses that have mostly not yet opened for the fall semester. Young children (usually) do not become very sick from this virus, but they are quite effective transmitters of it to each other and to adults. Middle and high school kids are more effective spreaders. What has happened at summer camps and in the first school openings is not reassuring.

Rebekah Jones, a scientist fired by the governor of Florida for refusing to fudge the state’s statistics the way he wanted her to, said on July 8th, “If schools are opening next month, then we’re on a third wave of this first wave of catastrophe.”

Black leaders were in the news this week. Former President Barack Obama spoke brilliantly at the funeral of civil rights giant and “Conscience of Congress” John Lewis, whose last live appearance was at a Black Lives Matter protest. He died of pancreatic cancer. Rep. James Clyburn, Democrat of South Carolina and House Majority Whip, chaired the hearing of the Subcommittee on the Coronavirus Crisis, where he and Dr. Fauci told the truth. Herman Cain, a leading black Republican and former presidential candidate, died of COVID-19, which he probably caught while proudly attending a crowded Trump rally in Tulsa, Oklahoma, on June 20th.

Stay safe, you know how.

Dr. K

PS: Please don’t rely just on me. The best resource on what is happening specifically in the state of Georgia is Dr. Amber Schmidtke’s Daily Digest. More generally, I recommend the following: The Bill & Melinda Gates Foundation COVID-19 Update, aka The Optimist; for the science of viruses, especially the new coronavirus, This Week in Virology (TWiV) podcast; Dr. Sanjay Gupta’s podcast, Coronavirus: Fact vs. Fiction; COVID-19 UpToDate for medical professionals; and for the current numbers: Johns Hopkins University (JHU); Institute for Health Metrics and Evaluation (IHME); Our World in Data (OWiD); The New York Times Coronavirus Resource Center (NYT).

 

 

16,000 George Floyds

“I can’t breathe.”

            Eric Garner, July 17, 2014, as he was being strangled to death by New York City police, for selling single cigarettes on a streetcorner in Staten Island

“I can’t breathe.”

            Elijah McClain, August 24, 2019, as he was being strangled by Aurora, Colorado police, for no reason, resulting in cardiac arrest in the ambulance and death days later

“I can’t breathe.”

            George Floyd, May 25, 2020, as he was strangled to death by Minneapolis, Minnesota police, for allegedly using a counterfeit $20 bill

“Once you get to the other side of it, you can breathe a little bit better… You think you’re gonna die during one of those episodes, I mean, you know you’re gonna die.”

            Kevin Harris, after recovering from the coronavirus infection that almost choked him to death

Dear Students,

These four men had two things in common: being African-American, and having someone or something strangling them. Kevin Harris did not die gasping for breath as the others did, and he was not strangled by police. But he was being strangled by racism.

I’ll come back to this and to the number 16,000, but first consider another number: 3,446. That’s the number of black people who were lynched in the United States between 1882 and 1968, accounting for 72.7 percent of the lynching victims in that time frame—when they made up around a tenth of the population.

We don’t have a record of what most of these 3,446 people said while they were dying, but most of them were murdered by being hanged by the neck until they were dead. They were not dropped to break their necks quickly as in a movie prison. They were usually “strung up” so that the group or mob could watch them struggle. Many were tortured and mutilated before and during the process. It was festive. Children were present. People took photos. They made postcards to send relatives and friends.

Some of the victims proclaimed their innocence before being hanged for crimes they did  not commit. Some spoke messages to loved ones. On March 9, 1892, three black men who had started the new People’s Grocery in Memphis, Tennessee were dragged out of their store by a white mob and lynched; it was simply too much of an affront to white rule for black people to have their own grocery store. One of them, Thomas Moss, said before he was murdered, “Tell my people to go west. There is no justice for them here.”

We don’t know what lynching victims may have said or tried to say while they were actually being strangled by the noose around their necks. They must have known there was no point in begging. But you can bet they were thinking: “I can’t breathe.”

A lynching is defined as a premeditated extrajudicial homicide by a group intending to punish someone or make an example of them. We don’t yet know whether the policemen who killed Eric Garner, Elijah McClain, and George Floyd intended to kill them, but we know that they showed utter disregard for these men’s humanity in their excessive, brutal, completely unnecessary, and ultimately fatal use of force—in each case in the face of victims and even bystanders begging them to stop.

I think it’s fair to say that they probably wanted to kill some black man some time, and this was their chance; otherwise, why would they have shown such disregard for black lives? The police were acting in a criminal manner toward each of these men; and ordinarily, when a homicide is committed in the course of another crime, it’s murder.

We also know that black people are killed by police at a rate between 2.5 and 3.5 times that of whites. We know that many white police officers, not just “a few bad apples,” are overtly or even proudly racist. And we know that the inadequate, even chaotic patterns of selection and training in police departments across the United States at best allow and at worst foster such racism.

This is all part of a pattern that anthropologists call structural violence: day to day destruction of human life by authorities as part of the normal course of things in, for example, colonialism, or the domination of one religious group over another. But if the victims of structural violence commit acts of violence themselves, even in protest or self-defense, only those acts are considered violent, not the day to day acts of the people in power oppressing them.

Today’s heedless murders of black people by white police extend the structural violence of lynchings, which in their day extended the structural violence of slavery, going back 401 years to 1619, when America first became a slave society. No one can doubt that centuries of whips and chains, hanging trees, and police brutality—all condoned or even depended on by the larger society and its day to day need for intimidation and control—deserve the name “structural violence.”

But what about Kevin Harris, who couldn’t breathe because of a new coronavirus?

Well, it turns out that structural violence—including American structural racism—requires a lot more than whips, chains, nooses, guns, and the knees and choke-holds of policemen. It requires a system that relentlessly maintains huge disparities, day by day and generation to generation, between white and black people—in wealth, education, job opportunities, income, education, incarceration, and perhaps most painfully, health and illness.

Are unprevented and uncared-for diabetes, heart disease, hypertension, asthma, AIDS, influenza, and now COVID-19 less violent to a human life than whips, nooses, and chokeholds? I don’t think so, and neither do the growing number of physicians and public health experts who see the structural violence of untreated, preventable disease as just as much or even more an extension of slavery than police brutality is.

On the day that Kevin Harris described his near-death from strangling by the coronavirus, there had been a total of 182 deaths in the whole United States, yet it was already clear that blacks were affected more than whites. As of this writing, more than 140,000 Americans have died of this virus.

But the number 16,000 is not the total number of African-Americans who have died, not by far. It is the number who have died but who would not have died if black people only had the same death rate as white people. In other words, it is the number of extra black people who were killed by the virus just because they were black.

Thankfully, Kevin Harris did not become one of those unfair, unnecessary, extra black deaths. But 16,000 others did. So far. And it’s not over yet. And proportionately more black people than white are being added to the numbers every day. So the excess of 16,000 is only the beginning.

What explains it? The basic deprivation of health is part of the long story of American structural racism and structural violence. Everything about underlying conditions that makes us more susceptible to COVID-19 is more common in black than white people. That includes, but is not limited to, diabetes, heart disease, hypertension, asthma, and a wide spectrum of acute and chronic non-COVID infectious diseases.

And every form of preventive and curative care is withheld from black people but given to whites. Our lack of universal health care is unique among the wealthy countries of the world. We stand out from the world in this exactly the way South Africa did before apartheid ended.

Take a look at the graph in the picture. The American anomaly is astounding. All other advanced countries have had declining maternal mortality for decades. Ours has been rising starkly, and experts agree that a large part of the reason is our gross and growing racial disparity. Infant mortality has declined slightly, but is much higher than in other developed countries, mainly because of how we neglect minorities. Black infant mortality is more than double that of whites. So the structural racism that began in 1619 begins again at the start of every black life.

Oliver Wendell Holmes, Sr., the great 19th century physician, wrote, “The woman about to become a mother should be the object of trembling care and sympathy wherever she bears her burden or stretches her aching limbs. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly.” We always follow that advice. For white women. Black women and their babies are from that moment guaranteed to be more vulnerable to everything, including COVID-19.

In the pandemic, it’s good to stay home if you can. Most black people can’t. Their work requires that they expose themselves to others on public transportation and at their jobs. They are some of the doctors and many of the nurses and respiratory therapists, but they are also overrepresented among the cleaners and sanitation workers, the delivery people, the workers in groceries and restaurant kitchens, and many others who can’t stay home where it’s safe.

But that’s not all. Crowding is good for the virus, and it is much more of a problem for blacks than whites.  Poverty too. Lack of education. Lack of trust in authority (with good reason). Lack of clean air (the virus loves dirty airways). Polluted water. Lack of access to healthy food, which is much more expensive than junk food and much harder to find in black neighborhoods.

Black men are overwhelmingly over-represented in prisons in this country, and given that prisons are well known hot spots for COVID-19, they become another tool of structural racism in the pandemic. Given that incarcerated men are forced to work, manufacturing license plates and the like, incarceration of black men has been seen as a modern form of slavery.

The water crisis in Flint, Michigan, where the government was discovered to be pouring lead into black homes and poisoning children’s brains, has proved to be a problem in many other cities. The disparity between blacks and whites in wealth is far greater even than the disparity in incomes; white American families’ wealth is stored mostly in their homes, which many fewer black people own.

These homes, this wealth, is passed from generation to generation among whites, and in every generation it becomes a more solid foundation for permanent disparities in education, because schools in America are funded locally, from taxes on homes that whites are much more likely to own.

But in addition to the structural racism that withholds health, medical care, wealth, homes, education, opportunities, fruit, vegetables, and water, we have to add air: “I can’t breathe.” So said an unknown number of black police-chokehold victims, 3,446 black lynching victims, and 16,000 excess black coronavirus victims, so far.

If you have easy access to air, be grateful. Not everyone does. Breathe out. Breathe in. Don’t take it for granted.

Stay safe and be well, if you can,

Dr. K

PS: Many of you have been asking me whether I think you should come back to campus. This article should help you decide. As always, you should weigh the risks and difficulties you may face where you are staying now; some people may be better off on campus, assuming it really is open to you a few weeks from now.

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

Opening to What?

            “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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Craig Venter’s “Creation”

It’s not creation, but it’s a technical achievement full of promise.

To say that Craig Venter’s latest contribution is garnering hype would be one of the understatements of the year.  The paper, whose title begins “Creation of a Bacterial Cell…” was published in the print version of Science on July 2—Daniel Gibson was the first of many authors, Venter the last—but it had already appeared online on May 20 and generated a lot of comment, not least of all by Venter himself. Read more

The “New Biology” and “The Self”

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I told a very smart neurobiology graduate student named Monica yesterday that I’d been asked to speak on “The New Biology and the Self.” She said, “What’s the new biology?” I said, “I don’t know, but that’s the least of my problems. What’s the self?” Read more

What Do Bioethicists Do?

Want to make your life better with the help of medical technology? It might be between you, your doctor, and the President’s Council on Bioethics.

Bioethics has become a booming industry, and it goes way beyond conventional medical ethics. But what exactly do bioethicists do? Are they just a bunch of self-appointed moralists who want to tell everybody what to do? Are they representatives of particular churches or religions?

A year or so ago Read more