Tagged disease

Sick Man, Sick Land

           “All of the information medical professionals want to know, all the things that are happening, vital signs, what his clinical exam looks like, what does he look like as a patient, are we treating the actual patient or are we treating a political ideology or a title or an office, and without that information at your disposal it’s hard to think about what are the processes going forward, how are we keeping this evidence based, how are we keeping this patient centered, are we doing the best we can to manage this actual human, this actual person‘s disease and if we are, we need to be transparent with it.” Dr. Myron Rolle, former NFL player, now a Neurosurgery Resident playing defense on the front lines of COVID-19, Massachusetts General Hospital, discussing the White House handling of Donald Trump’s case

            “Do you think these rallies like the White House event a few weeks ago are likely to become superspreader events?” Jake Tapper, CNN

            “Yes, I really do, and the virus is the constant here, it is very contagious. You put people together for long periods of time, longer than 15 minutes, closely clustered, maskless, those are the ingredients for a superspreader event. The challenge has been there are so many newly infected people every day in this country, contact tracing has basically become a futile task. How do you contact trace 50,000 people every day? It would be an entire sector of our society dedicated to doing that. But what we did and we have some reporting on this, we were able to go back to these cities, Tulsa you mentioned, Phoenix, and then Oshkosh, Wisconsin, in the beginning of August. you know after people are exposed to the time they get hospitalized is typically a few weeks, right?… It’s hard to actually contact trace back to the event, but hospitalizations is a truer measure. In Tulsa as you mentioned Herman Cain [former presidential candidate and Trump supporter] may have been exposed at that event and subsequently died. But we know hospitalizations went up three-fold a few weeks after Tulsa. We know in Phoenix hospitalizations were about 2000 per day at the time of that rally and went to 3000… Oshkosh—hospitalizations went up 20 percent within that time period after the rally so, again, cause and effect is always gonna be challenging to draw but look what happened in all the cities a few weeks after. People got sick. Hospitalizations went up. Was it directly related to the rallies? We may never know. But in places where the virus is already spreading like this? It’s really challenging.” Dr. Sanjay Gupta, CNN

            “The next 6 to 12 weeks are going to be the darkest of the entire pandemic.” Dr. Michael Osterholm, leading epidemiologist, Meet the Press, Sunday, 10/18

            “Its not like it’s a mystery anymore of how to beat this thing, it’s just a matter of implementing what we know.” Dr. Ashish Jha, leading epidemiologist, 10/19

 

Dear Students,

I am writing in a different mood from my usual fact-based, hyperlinked style. My mood, I have to say, has become more meditative, and even sad. I have not avoided politics completely in past updates, but now I have come to a point where it is impossible to discuss the health of Americans in this dangerous moment in history without taking a political stand. The behavior of our current president is severely damaging to the public’s health, more so every day.

Because of his arrogance and negligence, he himself was colonized by SARS-CoV2, as were his wife, his teenage son, and many of his closest associates. He invited the virus into his body in late September, either at the superspreader event celebrating his Supreme Court Justice pick on the 26th, or in the next few days of intensive, close, maskless debate practice.

His young aide Hope Hicks became ill on Thursday, October 1st, and was confirmed to have the virus too late to protect many, including the president. Whether she gave it to him or got it from him is impossible to say, because of consistent lying about the president’s frequency of testing, not to mention refusal to reveal the results. In the small hours as Thursday turned to Friday, it was announced that both he and the First Lady had tested positive.

Friday afternoon he was ‘coptered to Walter Reed Army Hospital and admitted. After a number of days of concealment and lying by his doctors—both of which are still going on—we learned that he had had a significant fever, that his blood oxygen had been below normal on at least two tests, although no numbers were offered except that it was below 94 and above the low 80s. Since he had serious lung symptoms and signs, it is inconceivable that he did not get a chest X-ray, a chest CT, and possibly other lung studies; however, the results of those studies were not shared with us.

Similarly, we were never told the reason for his impromptu visit to Walter Reed Hospital a year ago. Lies were told first about it being an early start to his annual physical, then about it being a follow-up. He and his doctor officially denied that he had been evaluated for transient ischemic attacks (temporary strokes), but he bragged about his performance on a cognitive test with a very low ceiling, meaning it was only intended to rule out big brain problems such as stroke and dementia.

The first medical information we got about him was a letter from his personal physician saying he would be the healthiest man ever to become president. Obviously that physician could not have made the comparison, and he admitted that Trump had dictated the letter to him. Later we found out that he had a cholesterol in the 260s, since brought down. He is also reported to have a common cardiac problem, which based on his cholesterol levels in the past and on his obesity, would most likely be coronary artery calcification.

That’s about all we know of his underlying conditions (other than age and body mass index) relevant to his recent case of COVID-19. Based on the medications he was given, it is widely agreed that his doctors at Walter Reed—some of the best in the world—were very concerned. The main medications were:

  1. An experimental antibody medication that the president refers to as Regeneron—the name of the company that makes it, since the drug does not yet have a name;
  2. Remdesivir, an antiviral medication that many (including me) have thought was very promising but which a new WHO study (published since Mr. Trump got it) has cast doubt on;
  3. Dexamethasone, a standard steroid treatment for inflammation in many diseases, proven to save lives in advanced COVID-19.

Mr. Trump got all three treatments within the first day or two of his symptomatic illness, very unusual for dexamethasone. His doctors were either extremely worried from the outset or they were giving him VIP treatment, not always beneficial to the VIP.

He was also given supplemental oxygen, only instituted because of low blood oxygen and/or difficulty breathing, and fever-lowering medications, including dexamethasone. We never heard anyone on his medical team mention those medications when they repeatedly announced that he was fever-free.

He was released from the hospital Monday evening. He did not speak spontaneously but he had made a few brief videos for public consumption. After climbing the White House steps he removed his mask, appeared to have difficulty breathing, and did not speak.

If his course of dexamethasone was usual, it would have lasted ten to fourteen days. We have not been told if or when his dexamethasone was tapered to zero. If he was indeed tapered and has not been taking it for the past week or so, then it is quite possible he had a mild case in the less serious than most who are hospitalized.

Because so little is known about the monoclonal antibodies he took, we can’t be sure when his own antibody response would be expected to kick in, but 21-25 days is a reasonable expectation after the Regeneron antibodies clear. We do not know if or when he stopped taking dexamethasone.

These questions are important for two reasons: 1. Is he immune or even partly immune to reinfection? 2. Is he still potentially subject to self-attack by his own immune system, which happens in so many COVID-19 patients—including, probably, his wife, who yesterday dropped out of her first campaign event in months, reporting a persistent cough.

COVID-19 is a two- or three- phase disease in the serious cases. First, the virus does its nasty work on your lungs, but it remains in the cells lining the lungs and bronchi. It does not enter the bloodstream or affect other organs. It stays where you breathed it in. This can kill you, but often doesn’t.

Phase 2 is your immune system response. This produces an attack on the walls of blood vessels everywhere in your body. This, your own body’s response, is what damages your heart, kidneys, brain, blood vessels, and other organs. This is very often the cause of death, including in children. By the way, the same was true of the influenza of 1918-19, although most deaths were in young adults, who are relatively protected from COVID-19 death.

Phase 3, which we are learning occurs in more people than we thought, is what has been called the “long haul.” Long haulers have symptoms, probably due to the lasting effects of inflammation, for months after recovering from the main part of the illness. The virus is too new for us to know whether these months may turn into years.

When Former Governor Chris Christie, whose COVID-19 was almost certainly contracted while coaching the president for the debate, left the hospital after a more serious case than Mr. Trump’s, he said loudly and clearly that he had been wrong, that he had let his guard down, that he had underestimated the virus. He also said that everyone should take the virus very very seriously.

Mr. Trump said the opposite. He told us not to be afraid of the virus, that he had beaten it and we could too; we should refuse to let it dominate our lives. He said that he had been cured by “Regeneron,” a completely experimental treatment no ordinary patient can get. There is no cure for COVID-19 as yet. In the days that followed his discharge, Mr. Trump showed what are very widely recognized mental symptoms caused by dexamethasone: strangely elevated mood, disorganized thought processes, and hypomania.

He soon returned to his most intense level of campaigning, making long speeches without difficulty breathing. The most likely explanation for this recovery is that he simply dodged the bullet—he had a mild, short case irrespective of his medications. The second is that he really was greatly helped by the trio of medicines he was given: the cocktail of two antibodies given to very few people in the world; the Remdesivir; and the dexamethasone started exceptionally early in his illness. As far as we know, no one has ever been given this combination of drugs with this timing.

A third, and I think distant, possibility, is that he is not yet over it. It is only 19 days since he entered the hospital. His treatment may have postponed his Phase 2, the autoimmune attack, rather than putting it permanently aside.

Mr. Trump’s public remarks about the virus since he had it are something like a worst case scenario for almost every public health expert and every family mourning a COVID death. He has stepped up his rhetoric minimizing the virus and he has held two to three likely super-spreader events per day for the last week, many in states that have rapidly rising case loads and hospitalizations. He continues to violate and ridicule the only preventive measures we have, or will have, between now and when we can be widely vaccinated, and he continues to lie relentlessly about when such vaccination is likely. He has caused, and will continue to cause, many thousands of needless deaths, and the suffering of hundreds of thousands of survivors of the virus and of the loss of loved ones.

Which brings me to the question of the other kind of illness he may have.

For years now psychiatrists have been arguing over whether it is possible to give Mr. Trump a diagnosis from a distance. The American Psychiatric Association defends the Goldwater rule, which rejects such diagnoses of political or other public figures without examining them. This organization preemptively threatened sanctions against member psychiatrists who attempted to diagnose Mr. Trump without examining him personally.

Others, including a group led by Bandy Lee, a psychiatrist and ethicist at Yale Law School, have concluded that the well-established Duty to Warn applies to Mr. Trump. This duty holds that patient confidentiality may or must be violated when the doctor concludes that the patient poses a clear and present danger to others, based on what the doctor has learned.

Few psychiatrists would claim that they can glean more information in a face to face two-hour diagnostic interview with a new patient than they already have about Donald Trump in the public record, which, importantly, goes back through his adolescence and childhood. I have an MD but do not practice medicine and am not licensed to do so. I have a lifelong interest in psychiatry and neurology but I am not qualified in either, but neither do I have anything to fear from APA sanctions.

So I will not give you a diagnosis, but I will tell you the criteria for the diagnoses that are most frequently discussed as mental disorders Mr. Trump may have.

Narcissistic Personality Disorder (NPD, DSM-5 301.81):

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

Antisocial Personality Disorder (ASPD, DSM-5 301.7)

  1. A pervasive pattern of disregard for and violation of the rights of others, since age 15 years, as indicated by three (or more) of the following:
    1. Failure to conform to social norms concerning lawful behaviors, such as performing acts that are grounds for arrest.
    2. Deceitfulness, repeated lying, use of aliases, or conning others for pleasure or personal profit.
    3. Impulsivity or failure to plan.
    4. Irritability and aggressiveness, often with physical fights or assaults.
    5. Reckless disregard for the safety of self or others.
    6. Consistent irresponsibility, failure to sustain consistent work behavior, or honor monetary obligations.
    7. Lack of remorse, being indifferent to or rationalizing having hurt, mistreated, or stolen from another person.
  2. The individual is at least age 18 years.
  3. Evidence of conduct disorder typically with onset before age 15 years.
  4. The occurrence of antisocial behavior is not exclusively during schizophrenia or bipolar disorder.

Not surprisingly, both of these disorders are far more common in men than in women. When a person meets the criteria for both disorders, the term malignant narcissism is sometimes applied, although it is not an official DSM-5 (Diagnostic and Statistical Manual of the APA, 5th edition) diagnosis. In neuropsychiatric terms, it seem reasonable to hypothesize that someone who meets the criteria for both disorders has a lower than average inhibitory capacity of the prefrontal cortex in relation to the impulses stemming from the amygdala.

When a man (and it would likely be a man) who meets even some of these criteria is in charge of the “land of the free,” he puts millions of people at risk. Objectively, his personal behavior resulted in his family, aides, staff, associates, and their families becoming infected with SARS-CoV2. Whether they mostly got it from him (quite possible) or got it from each other under conditions he created and insisted on, he caused them to be ill. His wife is still coughing, too sick to campaign with him. His friend and debate coach Chris Christie spent a week in the hospital with a much more severe case than Mr. Trump had, and after his release he publicly announced that he was wrong and publicly advised Americans to do the opposite of what their president is encouraging them to do.

The result has been, and will continue to be, what Dr. Sanjay Gupta explains above in his answer to Jake Tapper’s question. Yes, the President of the United States is continuing to hold one superspreader event after another, and yes, the President of the United States has caused and will cause at least scores of thousands of unnecessary deaths, which are the tip of the iceberg of American suffering.

A few hours ago, an analysis published by the Columbia University School of Public Health estimated that between 130,000 and 210,000 of the 223,000 people who have died of COVID-19 in the US to date had preventable deaths. Suppose we take the lower number and cut it in half to get to a rock-bottom minimum. That would leave 65,000 needless deaths so far, approximately the number of Americans killed in the Vietnam War.

Or, consider how news outlets and people throughout the world react to the crash of a single jumbo jet that kills 350 passengers and crew; billions of people react with pity and grief, and eventually may get angry, trying to find out why the plane crashed and who perhaps should be held responsible. My very-lowball estimate of 65,000 preventable deaths so far is the equivalent of 186 jumbo jet crashes, or around one crash every day since the first US case.

As you know, I’m not enthusiastic about predictions, but the consensus model (thanks again to Dr. Craig Hadley) has us at around 5,000 cases a week right now, rising to around 5,500 over the next month. If protective measures are relaxed, we could go to over 7,000, or if they are more strongly applied, half that. If we stay between 5,000 and 5,500, we will have added 50,000 to 55,000 deaths by New Year’s Eve. I consider that a low estimate, but we could easily reduce it to 30,000 or less, or if we are reckless enough, increase it to 70,000 or more.

Thus with this very conservative model of models, we could save at least 40,000 lives by enhancing rather than relaxing protective measures. Taking into account the advent of flu season, the effect of winter driving people inside, and the holiday season creating larger-than-usual family gatherings, the maximum number of deaths, and therefore the potential number of saved lives, could be much greater.

This is without considering the impact of Mr. Trump’s more than daily superspreader events around the country for the last three weeks leading up to November 3rd. Mr. Trump’s behavioral role in causing the new wave of the pandemic we are in would be explained if it were possible to find in him traits 4 and 7 in the NPD criteria above, and/or traits 5 and 7 in the ASPD criteria. Speaking as a lay person who has access to all public information about Mr. Trump, I think it is legitimate to state that he has those four traits. This is not a diagnosis, but it is tantamount to finding that he is an effective ally of the virus in its spread through our people.

The chart, based on Johns Hopkins University data (not projections) suggests that we are well into the third wave of the US pandemic, with a steep rise in daily cases rivalling the maximum achieved nationally in July, and still very much on the upward swing. Thirty-one states have more cases this week than last, and only one, Hawaii, has fewer.

Hospitalizations (second chart), a much better measure, are already following suit, and many states, particularly in the Midwest and Great Plains, are beginning to see overflow crises comparable to what we saw in New York in March and April and in the southern states in July. Deaths will duly surge, although not as much as in the past, since fortunately we are saving more of those hospitalized.

What caused the third wave? Many factors. Dismally prepared college openings caused youth outbreaks which caused community spread. People let their guard down in crowded bars and restaurants. The President of the United States made fun of mask wearing and encouraged people to relax other precautions. Premature school openings were often reversed because of spikes in cases, not usually harmful to children but gravely threatening to teachers, staff, and families. And spread continued in and from nursing homes, prisons, and meat packing plants.

Good News

  1. While two major vaccine trials (AstraZenica, Johnson & Johnson) were halted because of adverse effects, including a death, two other major trials (Pfizer, Moderna) are progressing well and could request emergency use authorization from the FDA by early December. The FDA vaccine group is meeting today to discuss guidelines for approval.
  2. Although Remdesivir has proved disappointing in the most recent research, it has been successful in other studies, and it just became the first treatment approved by the FDA specifically for COVID-19.
  3. Another antiviral, now called EIDD-2801 has been extremely successful in a mouse model that carries transplanted human lung tissue. Unlike Remdesevir, it is an oral medication, and could be used as an outpatient treatment very early in the disease, or even prophylactically for those with known exposure. Human trials are under way.
  4. Antibody cocktails such as Mr. Trump received (part of his VIP treatment) are under study and may prove their efficacy in time, in ongoing trials.
  5. Former New Jersey Governor Chris Christie, after an apparently near-death-experience with the virus—which he likely caught from or because of Mr. Trump—has become a strong advocate of taking the virus seriously and applying all known preventive measures.
  6. The best news is that we already have a hugely effective vaccination program: First Shot, Social Distancing; First Booster, Wear a Mask; Second Booster: Wash Your Hands; Follow-up Examination: TETRIS (Testing, Contact tracing, Isolation). This is the vaccination program that has utterly beaten the virus in quite a few other countries. Will we ever use it?

Do the right thing, be patient, this will pass, live to brag about how you didn’t get it and didn’t give it to anyone else, stay safe,

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 TimesCoronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. With thanks to Prof. Craig Hadley, I also strongly recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning, which has outperformed most others in its projections.

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.

Rolling Thunder

            “What we’re seeing is that this illness has no mercy, against any kind of gender, age, or race.” Joseph Varone, MD, Houston physician, June 30th.

            “The epidemic is out of control across the southern United States.” Peter Hotez, MD, Houston pediatric virologist and vaccine scientist, July 7th.

            CNN’s John Berman: “Do you see an end in sight, or a plateau?” Rebekah Jones: “Absolutely not, especially if schools are opening next month, then we’re on a third wave of this first wave of catastrophe.” Rebekah Jones is a former Florida State data scientist fired last month for refusing to manipulate COVID-19 statistics, speaking on July 8th.

Dear Students,

These quotes, which you can find on CNN videos, come from three different kinds of experts, and all of them are visibly upset about what they are seeing and saying. But the greatest anguish is in the face and voice of Dr. Varone, who has been interviewed many times since the above quote, in his hospital, on the front line of the spreading American epidemic. He is devastated. He goes to work every day to take care of people of all ages who are more and more numerous and more and more sick with a virus that could have by now been controlled.

I feel as if I am in a time warp. I am watching heroic doctors and nurses in Los Angeles, Phoenix, Tucson, Houston, El Paso, Miami, and other southern cities describe, on the verge of tears, the exact same overwhelming of hospitals that we saw two months ago in Queens, Brooklyn, and The Bronx.

Hardened medical professionals are begging—in mirror images of their April northern counterparts—for us to behave differently. They are telling us that they can’t handle any more coronavirus patients. They are running out of ICU beds, and if they had the beds, they would not have the professionals to staff them.

All the governors of these southern states had to do was watch how Andrew Cuomo of New York get that state’s epidemic under control, and do the same thing—except that they didn’t have to be taken by surprise and be a little late with it like he was. But instead of imitating him, heeding his warnings, and starting earlier, they denied they would ever have to face what he faced. Now they are facing it, and are headed for worse.

In the past few weeks I have likened the surging case numbers to lightning and have repeatedly said that I would wait to hear the thunder, namely the surge in hospitalizations. Leaders of our country and of many states told us we could ignore the case numbers because they were only the result of more testing. Never mind that the case numbers were rising much faster than the number of tests. Never mind that the proportion of tests coming out positive keeps going up and up and up.

We were also told that because the surging cases were at an average age that was younger we would never see a surge in hospitalizations.

But they already knew that younger people too could get very sick, and that younger people inevitably also infect older ones, so this was not wishful thinking, it was lying. Lies on top of lies. Lies, lies, and more lies.

In Miami-Dade County, since June 24th, hospitalizations have gone up 87%, ICU patients 91%, and patients on ventilators 108%. That is a doubling time of a little over two weeks, and it’s not just Miami. More than 50 Florida hospitals have reached their ICU bed capacity. The 7-day average of new daily hospitalizations in Florida meandered around 150 during April and May, declined into early June, hit an inflection point around 110 on June 7th, rose steadily, hit another inflection point around 170 a week ago. The average climbed more steeply from there, reaching around 270 on July 7th. There is no indication yet of the slightest  bending down of this curve.

In Texas, the count is reported differently, as the total number of people in the state in hospitals with COVID-19 on a given day. This number hovered under 2,000 in April and May, rose slowly but steadily in early June, then rose more steeply, increasing almost every day, to a total of more than 9,000 on July 7th. The Phase 1 opening in Texas began on May 1st, and proceeded despite rising cases, which were not supposed to produce rising hospitalizations—unless you believed the science, which said they were almost inevitable.

In Arizona, the number of COVID-19 patients in hospitals (click on the icon for “Hospital COVID-19-Specific Metrics” in the lower right then on the appropriate button across the top), the number on ventilators, and the number in ICU beds have all risen steadily and sharply since early June. According to The Arizona Republic, “85% of current inpatient beds and 91% of ICU beds were in use” as of Wednesday, July 8th. Native Americans are suffering most, extending the pattern of white people bringing them deadly diseases beginning with the arrival of Columbus.

California’s governor announced on Wednesday that hospitalizations for COVID-19 have increased 44% and ICU admissions by 34% in the past seven days. For Los Angeles County, the three-day moving average of patients hospitalized with the virus peaked at around 2,000 on April 29, declined to around 1,300 on June 15th, and rose twice as fast to return to around 2,000 yesterday. Available ICU beds are around all-time lows for the epidemic. “This is the explosion we warned about,” said a professor of public health at UC Irvine.

And in our own state of Georgia, where Emory will reopen partly live on August 19th, the seven-day moving average of the number of people hospitalized with COVID-19 declined steadily from 1,500 on May 15th, stayed under a thousand for most of June, then rose much more sharply than it fell, doubling to almost 2,000 today, with no end in sight. On Tuesday, Brian Kemp, Georgia’s governor, announced a marketing campaign to encourage Georgia businesses to be safe, including no mandatory anything.

Hospitalizations are rising in more than 20 states, so I could go on, but you get the idea. In every state, black and brown people suffer more than whites, and where there are Native Americans, they suffer most. All these states are trying to backtrack on aspects of their openings. (See the impact of early opening here.) They can still do something, but it better be big, and it better be now.

All the above graphs are what are known in statistics and business (among other fields) as hockey-stick curves. It’s what start-up companies dream of. You’re holding the hockey stick and your sales are flat for a while (the part of the hockey stick that you hit the puck with) and then there’s a long upward zoom that goes to the sky, or at least up to your chest. The upward zoom is straight and fast.

For sales, this is a great curve. For a disease outbreak, not so much.

Remember, we are now counting hospitalizations, the thunder. There is no argument that more testing leads to more hospitalizations; not even the world’s most empty hairdo could argue that. Only more disease leads to more hospitalizations, especially in a time when you’re hoping to stay out of the hospital and doctors are trying to keep you out. Also (a teensy reminder of good news from prior updates) remdesivir, dexamethasone, more sophisticated oxygen management, and maybe even a resurrected chloroquine are shortening hospital stays. Yet admissions stay ahead of discharges. Way ahead.

But what about deaths? Ah yes, the deniers are still holding that ace: declining or stable deaths. There are three reasons: 1. the above treatments have made the disease less deadly; 2. the average age of cases is going down steadily, and younger people are less likely to die of it, so far; and most importantly, 3. death is a lagging indicator—hospitalizations are doing the hockey-stick thing now, but we have to wait a few weeks before we know about deaths.

I would add that these upward-leaping hospitalizations also lag infections, by days to weeks. So whatever risks Americans took on the July 4th weekend are not yet reflected in these numbers. All that is ahead of us.

At the risk of straining the metaphor, we had the lightning (skyrocketing cases), we’re having the thunder (the hospitalization hockey stick), but we have not yet had the flash floods and drownings: a sudden surge in deaths on top of the 132,000 we have had already. We may not have it. But we have to do more than hope.

Sometimes when I watch an interview with a nurse or a doctor, and I remember those who risked or gave their lives to save us from our own stupidity, it’s hard for me to hold back tears. As the celebration of our independence passed, and it was not balanced with any wisdom about how to use that freedom, I was not proud of my country.

Look at New York (which opened in such a way that its cases dropped in half after the opening), or almost any other advanced country and you will see how it should have been done. Heck, look at Uruguay, Rwanda, or our sister state of Georgia (in Asia, capital Tbilisi) and you’ll see how we could have saved at least a hundred thousand Americans.

To any young person going through this I say: I was young once, and I loved it. You are losing part of it, and I am sorry for your loss. But I promise you: if you do the right thing now, it will almost certainly be behind you in a year. And you will live to brag for six decades about how you made it through that deadly pandemic of 2020.

But if you get it and have lingering lung damage, as some young people do, you may not have the breath to brag so loud. And if you bring it to your grandparents and kill them, you will shudder with shame whenever 2020 is mentioned.

Your choice. That freedom’s real.

Dr. K

 

 

 

 

 

One Marshmallow

       “These plans are so unrealistically optimistic that they border on delusional and could lead to outbreaks of Covid-19 among students, faculty and staff.”

       Laurence Steinberg, The New York Times, June 15, 2020, referring to proposed college reopenings

Dear Students,

A few weeks ago, New York Times columnist Paul Krugman (winner of the Nobel Memorial Prize in Economics) wrote a column called “America Fails the Marshmallow Test.” This is a reference to a famous 1960s psychological experiment, in which a marshmallow (or cookie, or piece of candy) is placed in front of a young child, who is told she can eat that marshmallow now, but if she waits 15 minutes, she’ll get two instead of one. Studies stemming from this experiment became a cottage industry, and among the claims made by those involved, being able to postpone gratification for greater gain was a fundamental character trait in the two-marshmallow kids that predicted much about their later success. They were said to have better “executive function,” meaning their frontal lobes were better able to suppress the impulse to get one marshmallow now in order to get two later.

Krugman understood that a 2018 study apparently failed to replicate the marshmallow study, but wanted to use the metaphor for our country’s inability to wait a little longer before lifting social distancing restrictions. Actually, the marshmallow study was not debunked by the 2018 replication, which has been criticized for controlling away some variables (like early cognitive ability) that are intrinsic to what the marshmallow test tries to measure. Also, the replication did find that the test predicted some characteristics of adolescents, just not as much as earlier studies claimed. The critics of the critics—the marshmallow defenders—called their paper “Good Things Come to Those Who Wait,” with the running head, “Delaying Gratification Matters.”

Speaking of delaying gratification, it’s not just five-year-olds who are not good at it. Adolescents are not good at it either.

I know you don’t like to think of yourselves as adolescents, but the fact is that brain development is not complete until age 25 or so, and the main part of the brain that keeps developing is precisely those frontal lobes that are involved in executive functions: planning, reasoning, analyzing, and yes, postponing gratification. This period of extended frontal cortex development has been called youth, pre-adulthood, or emerging adulthood.

Psychologist Laurence Steinberg is the world’s leading authority on brain development in adolescence and beyond, especially in relation to executive functions. He has co-authored papers in law and psychology journals with titles like “Blaming Youth,” “Young Adulthood as a Transitional Legal Category,” and “Less Guilty by Reason of Adolescence.” He has tried to protect young people from the most severe punishments for acts which they literally did not have the brainpower to control.

Now Steinberg has weighed in on a question many of you have asked me about: College reopenings in August, including ours. Steinberg, who has spent his life as a college professor researching the young, wrote an essay two weeks ago called, “Expecting Students to Play It Safe if Colleges Reopen Is a Fantasy.”

Based on his 40 years of research on young people, he writes, “Most types of risky behavior — reckless driving, criminal activity, fighting, unsafe sex and binge drinking, to name just a few — peak during the late teens and early 20s. Moreover, interventions designed to diminish risk-taking in this age group, such as attempts to squelch binge drinking on campus, have an underwhelming track record. There is little reason to think that the approaches proposed to mitigate transmission of the coronavirus among college students will fare any better.”

The evidence on the other side is very strong. Steinberg and his colleagues recently completed “a study of more than 5,000 people between the ages of 10 and 30 from 11 different countries (including both Western and non-Western ones)… Consistent with large-scale epidemiological studies, we found a peak in risk-taking somewhere between age 20 and 24 in virtually every country.” There are three straightforward reasons.

Youth (not just adolescence) is a time of 1. heightened risk taking, and 2. poor self-regulation in all cultures. These two psychological features of young adulthood are in turn explained by 3. easier activation of the brain’s reward circuits, made even worse under conditions of emotional arousal and in the presence of peers.

To Laurence Steinberg, who probably knows more about not only the psychology but the neurobiology of young people than anyone else alive, college reopenings will be a “perfect storm” for viral spread. College reopenings are also being criticized by moral philosophers, college presidents, lawyers, and, of course, some epidemiologists. Dr. Anthony Fauci, our nation’s leading expert on the pandemic, says the matter is “complicated” and will depend on what region of the country you’re talking about.

It’s not always a bad idea to take a reward now even though it may be smaller. That’s why we have the proverb, “A bird in the hand is worth two in the bush.” Young people are designed to take risks for short-term rewards because that is how they test themselves, learn about life, find mates, make friends, and generally position themselves among their peers. Up to a point you have to take risks.

But we are not talking about a torn ligament, a bad hangover, or a brush with gonorrhea. This is a situation that has never before existed in my lifetime, not even during the early years of HIV/AIDS. I have repeatedly emphasized to you that the unknowns in relation to this pandemic are greater than the knowns, and that remains true. Right now cases are on the rise in the nation, in most states, and in almost every major city in the southern half of the country from Los Angeles to Miami.

The entire state university system of California will be 100 percent online. If you were in college in a rural area of Massachusetts or New York, you would probably be safe attending live, but you are not in one of those colleges. The situation in Atlanta is uncertain, but Emory says it is taking precautions that will make reopening safe.

Last week I said that case counts are like lightning, and that I was waiting for the thunder—hospitalizations and deaths. Being no longer young, I am able to wait. Some leaders claim that the only reason we have more cases is that we have more testing. I think this is wrong, but I don’t want to argue about it because I can wait. Others say we really do have more cases but because the age of infection is on average much lower than it was a month or two ago, we will never see the hospitalizations or deaths go up by much.

Lightning is flashing all across the southern United States, and some say it is starting fires that will be impossible to control and that will in the end kill many. State after state in the south are backtracking on their openings. But the states don’t really control behavior, especially the behavior of the young.

The July 4th weekend is coming, and millions of young people will take the one marshmallow. What will you do?

Dr. K

Between the Lightning and the Thunder

Dear Students,

As you know, when you see the sky light up because of a bolt of lightning, it takes a few seconds before you hear the thunder, because of the difference between the speed of light and the speed of sound. The lag varies, and the loudness of the thunder varies.

That’s my metaphor for today, the day after the sacred American holiday of Juneteenth, the day the last large group of African-Americans were freed from slavery in 1865. It’s also the day that 19,000 people are converging on an indoor space in Tulsa, Oklahoma, currently experiencing a rise of COVID-19 cases. About 90 percent of them will not be wearing masks, and almost none of them will be six feet away from the nearest person. One million people competed for the privilege of being one of those 19,000. Interviews show that as they enter the arena they are not worried. At this hour (5pm Saturday) the arena is already packed with early arrivals.

If you can’t guess my hypothesis about their level of risk, you haven’t been paying attention to anything I’ve said since January.

But, it’s a hypothesis. When I see lightning, I listen for thunder, but I don’t always hear it. Sometimes it’s too faint. Also, my hearing is not that great any more.

So the lightning might be crowds—including crowds of left-wing protesters—and the thunder might be cases of viral illness. You might recall that there was a huge difference in the size of the 1918 flu epidemic in Philadelphia compared to St. Louis. The difference was directly attributable to a big parade in Philadelphia at the wrong moment, while there was no such parade in St. Louis. Parade: lightning; huge spike in cases only in Philadelphia: thunder.

But you might also remember that the count of cases does not impress me as the right outcome measure. That is because the number of tests strongly influences the number of cases. There are ways of correcting for that, but major state and national leaders continue to say that the rise in cases in some states is due to better testing, period.

Consequently, I am not going to write today about the number of cases; instead, I am going to wait for a much better measure: the number of hospitalizations, and then, the number of deaths. So I am going to use the metaphor differently: spike in cases: lightning; spike in hospitalizations and deaths: thunder.

I don’t know for sure that today’s party in Tulsa will even result in lightning; it will take a couple of weeks to see a spike in cases there, and leaders in Oklahoma and Washington will say that it’s because so many people at the party got tested. So that would for me just be the lightning. A spike in hospitalizations and deaths two to four weeks after that would be the thunder. We would be in August.

There is my kind of lightning—rapidly rising cases—in Arizona, Texas, and Florida. In two weeks we might see my kind of thunder begin to roll. We will see. Science takes patience. I am not wanting to be insensitive. I am recognizing that half the country and half its leadership do not expect that thunder.

You might also remember that in 1918, Philadelphia carpenters could not make coffins fast enough. Maybe St. Louis sent some carpenters there.

So while we wait to see if Tulsa needs carpenters, I’ll make this update about nuts and bolts: 5 vaccines, 5 treatments. Most are good news.

5 Vaccines

There are at least 130 to 140 vaccines in development around the world. The 5 I’m going to mention are the ones already chosen by Operation Warp Speed, a Federal government program to fast-track development and prepare for mass production (hundreds of millions of doses; the world will need up to 7 billion) if one or more  of these works. It is not clear what criteria were used to choose those 5, but it is likely that the name “Warp Speed” will increase the number of vaccine refusers. Fast and good don’t always go together.

Two of the 5 are messenger RNA vaccines, which deliver coronavirus mRNA into our cells, where they make surface spike proteins that can raise a specific immune response to the viral envelope. No mRNA vaccine has been approved for use in any disease, although some are in clinical trials for other diseases. Three of the 5 are viral vector vaccines, which use a partly disabled different virus to deliver coronavirus genes into cells, to make the surface proteins that provoke the immune response. This principle has yielded an effective vaccine for Ebola and an ineffective one for HIV.

Interestingly, none of the 5 Warp-Speed candidates is a weakened or killed whole-virus vaccine (polio, chickenpox, measles, mumps, etc.); a protein-based vaccine (HPV/cervical cancer); a recombinant vaccine, such as genetically engineered yeast that produces viral proteins in our bodies (shingles, hepatitis B); or a DNA vaccine, in which coronavirus genes are introduced into our cells (none such approved for human use).

In other words, three proven principles were not chosen for Operation Warp Speed.

  1. Moderna (mRNA): Press release said it worked in 8 people, stock price skyrocketed, then crashed on expert skepticism. Phase III (large) clinical trials to begin in July if all’s well. No similar vaccine approved for anything in humans.
  2. BioNTech/Pfizer/Fosun (mRNA): Clinical trials under way; perhaps a few million doses available for emergency use in the fall if all’s well. No similar vaccine approved for anything in humans.
  3. AstraZeneca/U. of Oxford (viral vector is a chimp adenovirus): Phase II/III testing starting in England and Brazil. Could have emergency doses by October; has the manufacturing capacity to produce 2 billion doses eventually. The general principle has worked in Ebola.
  4. Johnson&Johnson/Beth Israel-Harvard (vector is a monkey adenovirus): Phase I/II safety trials begin late July. The general principle has worked in Ebola.
  5. Merck/IAVI (vector is a stomatitis virus): Merck actually used this method to make their successful Ebola vaccine. Clinical studies on corona expected to start this year.

Bad news: No knowledgeable person thinks it’s likely we will have a vaccine widely deployed before 2021 at the soonest, although a few think it’s possible.

Good news: Never before in human history has so much money, effort, and scientific talent been thrown at developing a vaccine for one disease.

5 Treatments

  1. This past week, the tried and true (and cheap) anti-inflammatory drug dexamethasone was announced in a press release to reduce COVID-19 death rate in very sick patients. No peer-reviewed publication, no data available for other scientists to examine. But, as doctors joke, dexamethasone works for everything (it’s sort of cortisol x 20), so why not this?
  2. Remdesivir, an antiviral originally developed for Ebola, may or may not have significant benefits, but it’s approved for compassionate use.
  3. Convalescent plasma, which contains anti-COVID-19 antibodies from people who fought off the virus, has been proved safe in a Mayo Clinic study of 20,000 hospitalized patients, and may be effective in reducing mortality, perhaps especially if given earlier rather than later.
  4. In a very disappointing, even scandalous outcome, peer-reviewed papers published in two top medical journals proved flawed and had to be retracted. Not only can’t we rely on press releases, we may not be able to rely on top journals. Also, maybe, hydroxychloroquine isn’t dangerous in this disease, just (probably) ineffective.
  5. Triple antiviral therapy combined with immune-boosting interferon beta was more effective than the same with one of the antivirals omitted, suggesting that as with HIV we will more likely succeed with combination therapy than one magic bullet. None of the three was remdesivir. Boy, do we have a lot to learn.

Experts are more optimistic about an effective combination therapy sooner than a vaccine. But don’t forget, Sarsie-2 is consulting his Uncle Charlie Darwin every few hours about how  best to evolve and adapt.

As I write, at 7pm Saturday, a crowd of unmasked thousands packed into an arena in Tulsa is waiting for their President to deliver a campaign speech. Fortunately for those people, the arena is not full.

You may know that the President was persuaded to move his rally there from Juneteenth to June 20th in response to outrage from Americans of all ethnic groups who understand the symbolic meaning of Juneteenth. You may or may not know that the rally is being held a stone’s throw from the place in Tulsa where the greatest mass murder, an attempted genocide really, against African-Americans, just 99 years ago.

Remember, if your country refuses to stay safe, you can still protect yourself and your loved ones. Use your mind. Use your brain.

Dr. K

“I, Corona”: My Exclusive Interview with the Little Guy Who’s Changing the World

Dear Students,

I have a special treat for you today, an exclusive interview with SARS-CoV-2, his first ever, on his life and times so far. I was able to arrange this through my special friend Charles Darwin, whom Sarsie—his preferred nickname—likes to call Uncle Charlie. Sarsie doesn’t think he’ll be confused with his older brother, SARS-CoV-1, whom he calls “pathetic,” nor does he think highly of his cousin MERS. “I mean, really, a few months in one or a few places, and then, poof! they’re pretty much gone.” He has a certain grudging admiration for cold viruses.

            But I’ll let him tell you in his own words. By the way, he insists on he/him/his, because as he puts it, “I don’t have the equipment to reproduce, so I gotta beg, borrow, or steal it from someone who does. I just put in my genes, and they do the rest. Also, let’s face it, a guy like me, who puts ambition above everything…I mean, I’m most likely gonna be male, right? Yep. My whole species, and my brothers and cousins too.”

            He asked me to call this column “I, Corona,” as an hommage to Isaac Asimov’s science fiction classic, I, Robot. “I didn’t like his three ethical laws, of course, but when he got to the part about robots that secretly run the world, I could definitely wrap my envelope around that. But why keep it a secret? Just take the world over and run it, I say.”

            What follows is a lightly edited version of our interview, with my questions removed. Not that there were many. He doesn’t let a human get a word in edgewise. So I listened and learned.

            “Yep. I’m on the move for sure. My bros and cousins were well meaning, all princes in their way—and we’ve got more princes than the Saudi Royal family—but I’m the Crown Prince (get it? Corona? Crown?) and I will be King.

            “By the way, this whole debate about am I alive? Am I alive? Are you kidding me? I’m alive and I’m eating you alive.

            “But back to the family. We’ve only been around a hundred thousand years, less than you even, but then again, we reproduce in 48 hours, you take 20 years. Do the math. Ex. Po. Nen. Shl. As Uncle Charlie would say, we can sure do some evolving.

            “The family divides up the spoils, but we’re not all equally successful. Some of the corona cousins specialized in farm critters. It’s a dirty job but somebody’s gotta do it. Let’s be honest, though, you’re not goin’ down in history for makin’ a chicken cough or givin’ a pig a belly ache. Then there’s the bunch I call the Corona Sniffles, they’ve done alright for themselves actually, they got around, they hang around, they evolve, they come back. No drama, mama, but Uncle Charlie would be proud.

            “SARS-1 did alright for himself but he just couldn’t get transmissable enough, and on top of that he only jumped from Jim to Jane, or from Zhang Wei to Mei Ling, after he gave Jim or Zhang symptoms. Jane and Mei knew to keep their distance. So my Sarsie-1 bro hit Guandong Province in China, got to Toronto somehow, and got locked in with quarantine. 8,000 cases, 800 deaths, a little economic slump, that was about it. One wave in 2003, so far done and done.

            “Cousin MERS was a killer though, too much for his own good. You kill a guy, he ain’t passin’ you on. Also Cousin MERS was never good at jumping from one of you sorry humans to the next. Probably more of you have gotten him from camels than each other. He broke out in Saudi in ’12, trickled around to 27 countries since, 2,500 cases, 800-some-odd deaths, well controlled by even your bumbling species, nothing to write home about.

            “You can see where I’m goin’ with this. I’ve done more in eight months than the rest of them put together. I’m the Crown Corona Prince by acclamation. I mean, let’s look at the facts. Okay, I was trapped in bats for I don’t know how long. I was bummed. Do you have any idea what a bat cave smells like? But I took a deep breath—the kind I make impossible for you—and channeled Uncle Charlie. He counseled patience: “Be like a Buddha Virus, bide your time, mutation and evolution will do the rest.

            “Boy, did they ever. You helped, by bulldozing forests and setting the bats I was riding free. My hosts got snared, sold, and eaten, and I was on my way. Okay: I’d evolved my way from bats to humans, but would I be like my cuz MERS, get stuck in a bat-to-human trap like he did (mostly) with his camel-to-human song-and-dance? No way. Or would I maybe take a leaf from my bro Sarsie-1’s book and only jump from Jim to Jane when Jim was already sick and Jane could avoid him like, well, the plague? Nope again.

            “I did everything by Uncle Charlie’s playbook, evolve, wait, mutate, evolve. Jump from bats to you folks (Whoopie!): Check. Jump from Zhang Wei to Mei Ling: Check. Now, jump from Zhang to Mei before Zhang gets sick—three days, a week, two weeks: Check. Now, don’t even make Zhang sick at all, ever. Or Mei Ling. True, a cough or a sneeze will spread me yards in droplets and aerosols. But if Zhang and Mei are rehearsing in the same chorus for a couple of hours, or even sitting at different tables at a restaurant with the right air circulation system, that’ll work fine for me. If they exchange looks and fall in love and do a Chinese version of French kissing, I’m golden.

            “But think about it: I can’t win big in Uncle Charlie’s sweepstakes by staying in one corner of Wuhan. So here’s where your species really starts to help me. Homo sapiens? Homo dumbellus is more like it. That young doc in Wuhan who tried to blow the whistle on me last year, right at the start? Whew, that was a close call. That could have ended me maybe, but thankfully his bosses shut him up fast. They even made him apologize for making me up! That was a great moment in my career, gave me just window I needed to zip around Wuhan.

            “He was some kind of hero. Poor guy got sick from one of the patients he tried to help, and I killed him. Wasn’t trying, you know, but there it is. He gave his life to tell the truth and save your species from mine. Not fair, but that’s how Uncle Charlie’s law swings. Or, you might say, how the fortune cookie crumbles. Sorry, couldn’t resist; but I spent enough time in China to know fortune cookies don’t crumble there, only in America.

            “Speaking of which, I was getting folks to carry me out of Wuhan to all over, even while the Chinese did a 180 and started to shut me down. They had the right government and the right science and the right culture to do it, and I was done there in a couple of more months. People cared about each other. They believed their doctors and scientists after that first blooper. They show the world how your species could win the war against mine. Or could have.

            “Some learned, some didn’t. I was rockin’ and rollin’ man. Jims and Janes, Fritzes and Gretchens, and especially Sergios and Claudias were leaving Wuhan and taking me home as a souvenir. I got a foothold on the Pacific Coast of your country in January, but that was small potatoes compared to Italy and Spain. Those folks love their grandmas, so instead of quarantining them they killed them. Okay, I killed them, but they gave me free rein.

            “Who’s they, you want to know? The young people. The ones who couldn’t sit at home. The ones who were chock full of me and I didn’t even make them sneeze. They were my ambassadors. Healthy young humans doin’ their thing, havin’ fun, hustling, moving. They’re the reason I left my Sarsie-1 bro and MERS cousin in my dust. They took me to every place on the planet. You humans talk about flyways for the flu. You mean geese and ducks. They fly south and north on two routes. They overlap a tad in the arctic. Geese? Ducks? Your species has a hundred thousand flights a day that go from everywhere to everywhere. And every one of them is carrying someone carrying me. Flu too by the way. He and I are gonna make beautiful music together. There’s gonna be some Darwinian mutual back-scratchin’ for sure.

            “Anyway, Italy mourned. Doctors and nurses were crying in the hospital halls. But I was headed for the U.K. and New York! That clown Boris thought he could pull a Sweden. I tried to help him see the light by laying him low for a while, but he squinted and bumbled again. Herd immunity? You have to be kidding me. That’s years away everywhere.

            “Treatments? Some day. Right now they’re just making a dent for the sickest, and may help me evolve resistance. I admit it’s been hard for me to reinfect someone I got to once before. I’m working on that, according to Uncle Charlie’s rules. We’ll see. The flu comes back every year in a different form. Every year a new vaccine that’s maybe half effective, and half of Homo dumbellus doesn’t even bother with it. Is that the sort of standoff I could live with long term? As they say in North Dakota (where by the way I’ll be heading soon), you betcha!

            “Meanwhile, Boris the Clown can’t hold a candle to that donkey’s rump Bolsonada in Brazil. It’s like Sweden without the modicum of leadership and with twenty times the population. Wow! Talk about a field day for me! They can’t dig graves fast enough in São Paulo. Mind you, it’s no great deal for me to be buried in a hole in the ground. But it’s the cost of doing business.

            “And then of course there’s the Clown of Clowns, the fat one with the orange face and pouffy yellow hair, the It’ll-be-gone-like-magic Gotta-open-up-our-country Whaddya-gotta-lose happy hero of every virus in Darwin’s kingdom. Sorry, it’s your country, I don’t want to hurt your feelings. But really. Open up the meat plants: Check! Don’t worry about the prisons and nursing homes or the small towns around them: Check! And then you got those folks yelling about freedom. “Don’t put your mask on me!” I love them so much I want to hug them. I do hug them.

            “And now these protests. I’m sorry, they have a right to grieve, but it doesn’t matter to a guy like me whether the crowds are righteous or not. I don’t give a flying fig whether I infect a Democrat or a Republican, as long as it’s a warm body. I am a teensy little Darwinian machine obeying Uncle Charlie’s laws to the letter. Good thing for me that guy in New York isn’t running your whole American show. I’d be beaten back into a corner for the summer and then you’d be gearing up to fight me and my buddy Flu-Boy in the fall.

            “But this is a zero-sum game, my species against yours, and I don’t think I’ll be in retreat during the summer. Maybe if you wake up in July and lock down again I’ll give you a five-minute break in September. But I’m not promising.

            “Good thing for me too that there aren’t more women running more countries. Seems like most of the countries that have kept me down or out are run by females, and the countries I win hands down are run by overgrown, overblown boys. Maybe you are actually two species: Homo sapiens, the ones with the reproductive equipment who know how to protect their own; and Homo dumbellus, the ones with DNA donation, the big shoulders, and the bluster.

            “Better believe it when I tell you you’ll be seing me around.

            “What? You think I’m ruthless the way I’m taking over the planet? How the hell do you think your species did it? You poisoned the earth, killed off half the other animals and plants, and brutalized each other beyond belief in your own species. You packed yourself into the crowds I swoon for. I can become King of the World without doing a fraction of the damage that you’ve done. It’s a miracle there were any bats left for me to evolve in.

            “But now you are really really helping me, so keep up the good work!

            “And oh, please, I’m begging you, whatever you do, please please re-elect Empty Hairdo, the Leader of the Free World who will never ever figure out how to keep it free from me.”

            Well, students, now you’ve heard it, Sarsie in his own words, uncensored, from the horse’s—or the virus’s—mouth.

            And don’t knock his hopes and dreams. He’s just following Dr. Darwin’s prescription. For him.

            Dr. D’s advice for us? Stay safe, be well, and keep in touch—from a distance.

Dr. K

100,000

Dear students,

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

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

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

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

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

Good News

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

Bad News

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

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

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

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

Stay safe,

Dr. K