Tagged Politics

Robin in the Coal Mine

            “‘Michigan is an outlier that’s profound,’ said Dr. Eric Topol, a professor of molecular medicine at Scripps Research in La Jolla, Calif. ‘This is a precedent in the country. It’s about plasticity, flexibility in responding, in being able to pivot.’ He added that tens of millions of doses were sitting unused across the country, and ‘in some states, you can’t even give them away…’ Vaccines could have been surged to Michigan weeks ago when signs of its new wave of infections were appearing, he said, like signs that are now showing up in other states, such as Minnesota. ‘We have this incredibly powerful tool, and we’re not using it…And it’s just an outright shame.’” The New York Times, April 13, 2021

            “Hi this is Michael Moore and this is an Emergency Podcast System episode… I appeal to my friends across this country and across this world: please stand for Michigan. Please come to our aid. The level of COVID cases has doubled, then it tripled, then it quadrupled…  We need to act immediately. This is a surge that’s out of control… Sadly the CDC has decided, the Biden administration has decided, not to give Michigan any more vaccines during this very sad turn of events. Now I think that’s wrong. And I think that we need to demand that the vaccine—the Pfizer vaccine that is made in Michigan, in Kalamazoo Michigan—that we get as many of these vaccines into as many arms as possible…to help put a stop to this UK variant. But if it gets ahead of the number of vaccinations…we may not catch up. And believe me there’s no Covid border around the state of Michigan. This…will happen where you live… So number one, the CDC needs to send more of the vaccine to Michigan, in hospitals, doctors, clinics, every pharmacy…This needs to happen in the next few days, not next week, not next month. The Governor of Michigan has to shut the state down…just for a little bit, this is not some long-term thing here this is just right now, immediately, to try and bring an end to this rapid, rapid epidemic in Michigan… Both are wrong; the CDC is wrong, the governor of Michigan is wrong. Let’s get this fixed right now. Please call your Congress people and your Senators at their switchboard on Capitol Hill 202-224-3121. Please contact the governors office…in Lansing, Michigan, and please go on WhiteHouse.gov and send a note to President Biden and ask him to please increase the amount of doses to the state of Michigan this week, right now, let’s not let this thing grow…it’s critical right now, this doesn’t need to happen… This just has to end. Everybody get your shot, everybody wear a mask, everybody keep your social distance and wash your hands. Be kind to each other. And politicians, the Governor, please, please…close it down just for a little bit. And the CDC: you’ve got to send us more vaccine…” Documentary filmmaker Michael Moore, Podcast #182, April 12, 2021

            “[Michigan] State Representative Steve Johnson, a Republican, said he doubted that many people would comply with a lockdown order. ‘For [Governor Whitmer] to try to continue those measures would have been political suicide,’ he said.” The New York Times, April 13, 2021

Dear Students,

The American Robin is the State Bird of Michigan, and it’s shown here singing its heart out on the graph of the new massive surge in the state. Michigan’s coal mines were tapped out decades ago, but there’s a saying about “the canary in the coal mine” that warns miners of toxic gas, not by singing but by dying.

Plenty of people in Michigan are doing that job for us in America, where we just keep digging ourselves deeper into a hole that the Michigan Robin is trying to warn us about. Of course, it’s just the Michigan population of the American Robin, just as the Michigan virus is part and parcel of good ol’ American SARS-CoV-2.

Michael Moore is right to say that Michigan’s Governor Gretchen Whitmer should ideally shut down the state again. But as that state legislator Steve Johnson points out, it would be political suicide.

If only that were the worst form of suicide it could be.

Last spring lockdowns led a Trumpist mob to stage an armed coup in the State Capitol building, a coup that actually succeeded in shutting down the legislature for several days. Obviously it was another robin in the coal mine, warning us of a similar coup attempt on our nation’s Capitol on January 6th. We have not seen the last of these.

But meanwhile, a group of deadly serious armed plotters were planning to kidnap Governor Whitmer, ending her administration, and some of them were planning to kill her. This planned assasination and coup was aborted by the FBI, but the next one may succeed. That doesn’t mean that she doesn’t have a duty to keep the people of Michigan safe, she still does.

But it’s pretty sickening when CDC Director Rochelle Walensky sits in the complete safety of her office in Washington and turns down a threatened and vulnerable Governor who is begging for vaccines. Walensky and President Biden have miserably failed the people of Michigan, and they will soon be failing much larger swaths of America, by insisting on a pigheaded policy of distributing vaccines exactly in proportion to a state’s population.

That means not only the Michigan surge but other state and regional surges to come will be ignored while millions of doses of vaccine sit unused. Biden and Walensky are already planning how to distribute internationally hundreds of millions of doses that will comprise a huge American surplus in a few weeks time.

Do I understand that vaccines take weeks to start working? Yes I do, and you know I do if you’ve been following what I’ve said all along about them. But that just means that Biden and Walensky failed Michigan weeks ago as well. Dr. Ashish Jha, one of the leading public health voices throughout the pandemic, tweeted on April 8, “This is very upsetting. Michigan is struggling. We need to be surging tests, vaccines to the state.” The idea that it is too late now is in my view absurd. Vaccines now could prevent millions of Michigan cases a few weeks down the road, even with one dose of a two-vaccine regimen.

What Walensky and others are saying to justify not doing this is a disgusting evasion. They are playing a political game. You can be that if this surge were in Texas or Florida they would not be withholding vaccine. Michigan is a blue state, like the color of the sky behind the robin. Biden’s people are afraid of seeming to favor Democrats, so they are letting Michigan and its Democratic Governor twist in the wind.

That’s the game—avoiding blame—instead of avoiding illness and death.

Walensky said, “The answer is not necessarily to give vaccine.” Not necessarily? What kind of mealy-mouthed answer is that? And, “The answer to that is to really close things down, to go back to our basics, to go back to where we were last spring, last summer, and to shut things down.”

So, Dr. Walensky, is your boss going to send troops to protect Governor Whitmer and her family? Are you going to stand beside her in Lansing when she faces another anti-lockdown mob that wants to kill her?

Michael Moore understands the value of “everybody wear a mask…keep your distance, and wash your hands.” He is also, like Governor Whitmer, begging, begging for a surge of vaccines for Michigan.

Dr. Eric Topol, whose twitter feed has been a vital source of information for me and thousands of others throughout the pandemic, thoroughly understands and promotes the tried-and-true precautionary measures, and knows, as I do, that they would be a faster response to the Michigan crisis than additional vaccines would.

He also said about extra vaccines for Michigan, “We have this incredibly powerful tool, and we’re not using it…And it’s just an outright shame.”

Where Dr. Walensky or anyone else gets the idea that vaccines and masks are substitutes for each other is beyond me. I do think however that we are watching a political game run by Biden in his Michigan vaccine-refusal gambit, just as we so often watched Trump play as President.

The irony is that Trump’s political game worked against blue states like New York and Biden’s political game is working against the blue state of Michigan.

Good News

  1. Biden’s performance in rolling out the vaccination program nationally, despite my grave reservations expressed above, has more than met expectations. I criticized him for thinking at first that a million shots in arms a day was an achievement, at a time when experts were saying 3 million a day were needed. Biden deserves credit for getting to that number as an average, with maximums up to 4.6 million. We will have 200 million jabs by the end of Biden’s first 100 days, double his original goal.
  2. Biden and his associates frequently wear masks in public and preserve social distance, setting desperately needed examples for the American people—examples which, very happily, are the opposite of what we had for the previous first year of the pandemic. Biden takes frequent opportunities to encourage these measures as well as thinking about ways to address the looming problem of vaccine hesitancy.
  3. Data continue to emerge confirming the safety and effectiveness of the two mRNA vaccines, which represent a completely novel kind of vaccine science and one of the greatest achievements in the history of medical science. In addition to safety and efficacy, the mRNA technology afforded an unprecedented platform for speed in development of the original vaccines without compromising safety, and it will continue to provide a platform for speed in the relentless arms race against new variants of the virus, allowing for the development of variant-specific new vaccines and boosters with unprecedented speed. (Read the moving story of Dr. Kati Kariko, the brilliant and heroically self-sacrificing lab-science gypsy who helped lay the mRNA groundwork.)
  4. Just in the last few weeks some uncertainty has been removed about whether fully vaccinated people can contract, carry, and pass on the virus asymptomatically. The answer increasingly appears to be, for the most part, no, even with the much more transmissable and more virulent UK variant. Also, current protection against hospitalization and death, at least with the UK variant and the main one preceding it, appears to approach 100 percent.
  5. Monoclonal antibodies (aka passive vaccinations) have continued to prove themselves as useful if not magical. They still require intravenous infusions but are increasingly doable in outpatient settings, and they prevent early cases from progressing to hospitalization. Increasingly too, they are being introduced for people who have no symptoms but positive tests for active virus and even for people who just have known exposure. Vaccines are not much use in these situations. Research on intramuscular injection of monoclonals is under way, and if successful would greatly enhance the deployment of this lifesaving technology.

Bad News

  1. The Johnson & Johnson (Janssen) vaccine has been halted because of a blood clotting problem affecting about one in a million vaccinated people (6 in the US; one died and one is gravely ill). This is a similar adverse effect to that suspected with the AstraZeneca vaccine. In both cases the nature of the clotting disorder is unusual, and so unlikely to be part of the background clotting problems expectable in such a large population. The J&J patients were women of reproductive age, suggesting an immune system problem. The halt, if it has to continue, removes a single-dose vaccine from the toolkit, a loss for the US but a much more important loss for the world.
  2. 200 million doses in American arms by the end of April (Biden’s 100 days) means 100 million people fully vaccinated, approximately 30 percent of the US population, or less than half of the level needed for herd immunity. Even adding the immunity of people who’ve had the virus doesn’t get us near herd immunity, which is at best months away—without taking the newest variants into account, with their potential for resistance against immunity and vaccines.
  3. Vaccine hesitancy, particularly common among Republican men, will play an increasingly large role as more of the country is vaccinated. Children will not even begin to be vaccinated until late summer at the earliest. Herd immunity is not a slam-dunk; it will be an increasingly uphill slog as long as vaccine acceptance is politicized.
  4. I have become increasingly convinced, thanks to Michael Osterholm who along with a few others has been arguing this for months, that we should be using our vaccine doses very differently. Namely, we should administer twice as many first doses of the two-dose vaccines rather than insisting that people get a second dose within a few weeks of the first. As Osterholm cogently argues, using two doses to give two people first doses results in 80 percent protection for both, while giving two to one person and none to the second person results in an average of 47.5 percent protection, since the two-dose person has 95 percent protection and the other has zero. Mathematical models easily show that Osterholm’s strategy gets to herd immunity faster.
  5. Last, and most important, the pandemic is not an American problem or a developed world problem but a global one, including a general threat of global instability. We have not even begun to fight the global war against the virus. Herd immunity for the world will take years to achieve. You don’t need to care about humanity, just the long-term repercussions for you. The virus loves the global stage, which is its evolutionary playground. We already have growing numbers in our country of the South Africa variant (B.1.351) and the Brazil variant (P.1). What new variants will evolve in the slowly vaccinated populations of poor countries and bounce back to us in ’22 or ’23? Stay tuned.

Michigan, the robin in the coal mine, represents what much more of America will be facing in the months ahead. If the Biden administration does not drop its political games and surge vaccine supplies to states and regions that have surging virus—whether blue or red—we will be wasting time and vaccine doses and causing preventable deaths. The time may come soon to tally up the deaths cause by the Biden administration’s sometimes willful errors, just as we have done with Trump. They won’t be as many, but they will be substantial. Biden doesn’t get a pass on a bad decision because it followed two good ones.

Also, we need to look at the evidence for Osterholm’s claim that vaccinating twice as many people once would save many thousands of lives. We only found out recently how much protection one dose of the two-dose vaccines gives us. As Dr. Topol said, “It’s about plasticity, flexibility in responding, in being able to pivot.” New knowledge brings new responsibility.

Old knowledge helps too. Mask up. Keep your distance. Avoid gatherings. Use caution until we see what the new variants can do. This is not over, not even close.

Stay safe,

Dr. K

PS: Please don’t just rely on me. The most important recent addition I have is Dr. Michael Osterholm’s weekly podcast from CIDRAP, the Center for Infectious Disease Research and Policy of the University of Minnesota; it drops on Thursdays. He combines realistic assessments and warnings with uplifting stories about how people are finding light and small victories in the pandemic. 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). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. I also recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning. For an antidote to my gloom, check out the updates of Dr. Lucy McBride, who doesn’t see different facts but accentuates the positive.  

 

 

 

 

 

 

Superspreader Insurrection

     “The vaccine is the weapon that will end the war, but it won’t hit critical mass until June, September or even December. If we float along relying solely on the vaccine, the way many states are, we are looking at months of shutdowns and the economic, mental, and spiritual hardship they bring.…We can’t do that. We just can’t let that happen. We can’t float along, watching the pain, the hardship and the inequality grow around us. That’s not what we do in New York. We must take control of our destiny.” Gov. Andrew Cuomo, State of the State Address, January 12, 2021

     “If quick action isn’t taken, then the highly infectious B.1.1.7 variant of COVID-19 will become the main variant in the United States by March, further burdening our already overburdened health care system.” Frank Diamond, Infection Control Today, reporting on Centers for Disease Control warning, January 18, 2021

Dear Students,

My wife Ann and I got our first dose of the Pfizer vaccine on Friday, and while we’re not changing our precautions at all yet, it’s a huge relief to have gotten started. We’re both over 65, which puts us in priority Group 1A in Georgia, but there was a lovely personal touch as one of my former students who is in practice in Atlanta reached out to us and said her office had vaccine. She was sitting right where you are around 15 or 20 years ago. Slightly sore arms were the only side effect.

Since today is the holiday honoring the Rev. Dr. Martin Luther King, Jr.’s great legacy, it behooves us to remember that of the 400,000 Americans killed by the virus so far, a greatly disproportionate number are black. African Americans have also borne a disproportionate share of the economic devastation. I have written about this before, but I am emphasizing it again today. In 1963, two days before my 17th birthday, I was present in Washington for Dr. King’s “I Have a Dream” speech. We have come a long way since then, but we still have a long way to go.

Case in point: the insurrection that took place in the same city on January 6th was overwhelmingly white, and many among them were avowed white supremacists. Nobody thinks that if the rioters had been black they would have been allowed to get as far as they did in taking over our government.

Two days from now the same huge mall that I stood on with two hundred thousand others on that day in 1963 will be decidedly empty, despite the fact that President Biden will be inaugurated.

One reason it will be empty is the virus of course, which Biden has so much more knowledge of, and so much more appropriate caution about, than his predecessor. But the twenty thousand National Guard troops deployed to D.C. this week are not there to defend against the virus. They are there to defend against another right-wing insurrection.

The attempted coup on January 6th at the Capitol, designed to prevent the transfer of power to a duly elected new president, was also a superspreader event. Very few of the rioting revolutionists were wearing masks, and they certainly weren’t observing any kind of social distancing.

More surprising perhaps, some members of Congress who were hiding from them also did not wear masks, despite being crowded into rooms where they were sheltering from violence. Some of them mocked their colleagues and their official physician who were wearing and distributing masks. These members of Congress were Republicans.

Since the pandemic began, 62 members of Congress have contracted COVID-19, 44 Republicans and 18 Democrats. At least 7 have tested positive since the insurrection, most likely because of mask refusal by Republicans. Looking at the course of the American epidemic, blue states were affected first but controlled the spread better, and red states have had a much worse fall and winter surge, especially after controlling for rural and urban populations.

I try not to get too political in these updates, but these are the facts.

Some students have asked me what will be different after President Biden is inaugurated at noon on Wednesday. My answer is: a lot. First, we have to get there, and the possibility of further disruption by Trump supporters both before and after Wednesday is real.

But here is the good news:

  1. Biden has already appointed the most competent and experienced physicians and scientists to deal with the pandemic. There is a world of difference between them and the people they are replacing. This includes the heads of the CDC, FDA, HHS, the Coronavirus Task Force, and many other positions, starting with Dr. Anthony Fauci, who will finally have the ear of the president and the ability to speak directly to the American people.
  2. Biden has a detailed national plan for rectifying the dismal failure of the vaccine rollout, with an attainable goal of having 100 million doses delivered in the first 100 days of his presidency. Far from abandoning the states to their own floundering, he will work closely with the states and their governors to properly organize distribution and injection.
  3. Similar national plans for huge expansion of testing will be implemented, giving America its first detailed knowledge of who has and who is spreading COVID-19. Ditto (see #2 above) on working with the states.
  4. Public health education for preventive measures against the virus (masking, social distancing, etc.) at a national level will be hugely improved, along with increased mandates where possible, and the standards and models set by people in national government will be positive instead of negative.
  5. President Biden will invoke the Defense Production Act much more extensively than his predecessor, giving manufacturers well-compensated mandates to produce more vaccine, vials, syringes, freezers, protective personal equipment, and many other sorely needed products to fight the war we are in, as has happened in previous wars, but so far very inadequately in this great war against the pandemic.
  6. While the Senate is only narrowly controlled by Democrats, Biden, like Lyndon Johnson before him, is a ‘man of the Senate.’ He spent most of his life there, knows the institution and its ways, and is friends with many sitting senators. He may not get 100 percent of the funding he wants to fight the virus, but he will know how to compromise and he will get a lot.

The bad news is:

  1. Political opposition to all of the above will continue. That includes resistance to public health measures, vaccine refusal, and pretty much everything else the new administration wants to do. The same people who brought you 400,000 deaths will do all they can to bring you at least a couple of hundred thousand more. Continuing insurrection will make all this worse.
  2. New variants of the virus, especially the B.1.1.7 strain first identified in England, are spreading fast in the United States. This is partly because they spread at least 50 percent more efficiently, and partly because our precautionary measures have been so inadequate and the vaccine rollout such a failure. Continuing insurrection will make this worse too.
  3. 100 million doses of vaccine in the first 100 days (i.e. by the end of April) will get us nowhere near the herd immunity that all vaccination campaigns aim for. Even with the (probably) soon-to-be-approved one-dose vaccine from Johnson & Johnson added to our current options, we will still have protected only a fraction of Americans.
  4. And probably the worst news of all is that we could easily have a late spring and summer surge in the new variants, given the laxity of proper precautionary measures, and the slowness of even a greatly improved vaccine rollout. The dual graph comes from the new CDC paper on this. On the left is a reasonable model of what will happen with vaccination but without strict precautionary measures. On the right, a likely result of vaccination with masking, social distancing, and so on.

So, due entirely to our own failures, the overall pandemic will likely be with us through the summer and possibly into the fall of this new year and beyond. But it won’t be as bad as it is now, it just won’t yet be normal. Of course, we could change all that if we did the right thing.

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 Times Coronavirus Resource Center (NYT). For uncannily accurate warnings, follow @Laurie_Garrett on Twitter. I also recommend this COVID-19 Forecast Hub, which aggregates the data from dozens of mathematical models, and this integrative model based on machine learning. For an antidote to my gloom, check out the updates of Dr. Lucy McBride, who doesn’t see different facts but accentuates the positive. For an up-to-date account of the clinical facts by the marvelous front-line doc Daniel Griffin, listen to TWiV episode 701, a marvelously clear step-by-step from exposure to recovery in 39 minutes.

 

 

 

Hope

Dear Students,

I’ve waited almost a month this time between updates, the reasons being (aside from having other responsibilities) that I saw no basic change in the situation, no real news that I felt a need to help explain, and my own general discouragement with the situation. Also, I always want to be able to offer hope, something we all badly need more of.

There is certainly news now. Hope is also the name of the former teenage model who rose to become the communications director of Fox News and then one of the closest aides to the President of the United States. Yesterday it was announced that she had tested positive for COVID-19, and that she had symptoms. Since she had been in constant close contact with President Trump, he and his wife, the First Lady, also a former model, were carefully tested and as of early this morning, both have the virus.

I mention the modeling because Mr. Trump has always tried to associate with beautiful women, and beauty carries with it a certain aura of superiority and invulnerability, but the virus doesn’t see it that way. Hope Hicks has symptomatic COVID-19, and Melania Trump is carrying, probably has infected others with, and may soon have symptoms also caused by SARS-CoV-2. They have joined the ranks of some seven million other Americans who could not avoid this infection.

The President also has thought himself invulnerable and has consistently acted as if he believed it. He has minimized the virus and failed to take or encourage needed precautions. Now the virus has proved him wrong. He has not only failed to protect the 208,000 Americans who have died from the virus and the millions more who have suffered in surviving it—some of whom will suffer for many years to come—but he has failed to protect his 31-year-old trusted and trusting aide, his wife, or himself.

There is a German word you may know, Schadenfreude, which English speakers appropriate for a certain emotion that English has no singular word for. It means literally something like damage-joy,* or taking pleasure in someone else’s suffering. It’s a natural human reaction, and if we are honest with ourselves, when we see others suffering we often have the fleeting thought, It’s not me.

Taking joy out of the suffering of people at the apex of American power is as wrong as it would be to celebrate the illness of anyone else, and as an MD I would be violating my oath if I felt that way. So I do all I can to suppress these unethical sentiments, and suppression starts with knowing myself, knowing that such feelings may be there.

But I have to say objectively that there is hope, the other kind of hope, in the fact that these people are now infected, and that others at the top are being tested, quarantined, and may become infected and even ill. There is poetic justice, surely—not the same as Schadenfreude—in the very powerful people who have failed to provide and even discouraged TETRIS (Testing, Contact Tracing, and Isolation) being put through this basic process themselves and, unless they are utterly stupid, being grateful for it.

But where is the hope here? It lies, quite simply and I think strongly, in the fact that the scores of millions of people who have believed the lies these people told them—the virus is no big deal, it only affects a few people, it will disappear like a miracle, we already have a cure in hydroxychloroquine, you can inject disinfectant, masking shows weakness, a vaccine is a few weeks away, we have turned the corner—these many millions of believers will now watch the leader who has lied to them, and those closest to him, directly face the consequences of his own mendacity, ineptitude, and forceful opposition to science.

I hope—I hope—that many lives will now saved by the example, this time unwilling, set by the most prominent man alive, the same man who has up to now set the wrong example and thereby caused scores of thousands of needless deaths. At a minimum, I hope that he will  not go to Wisconsin, the state with the worst reversal of fortune and the fastest rise in cases, and speak to crowded rallies of mainly unmasked people, as he had planned to do this weekend. Those cancellations alone will save lives.

I hope that, going forward, many of those who worship President Trump as a savior, almost a god, will now see that their idol has clay feet, that the virus is not overblown, and that they should start to listen to someone other than him if they want to protect their families and themselves, as he failed to do. This is not taking pleasure in the fact that he and those closest to him are infected. It is simply expressing the hope that lives will be saved by this new example—or more exactly, counterexample.

As the graph shows, we are turning a corner. We have probably entered the second wave, without ever as a country really leaving the first behind. With five percent of the world’s population we have a fifth of the world’s cases and a fifth of the world’s deaths, largely because Mr. Trump has been a never-ending superspreader of misinformation about the pandemic of COVID-19. Maybe now he will, against his will, become a source of truth.

Recall that the second wave of the pandemic of 1918-19 was much larger and more devastating than the first. That may or may not happen this time. To a large extent, it’s up to us. I hope that by this time next year we really will have turned the kind of corner that puts this behind us, but what happens between now and then depends on what we have learned and what we do.

Don’t be among the college students who have already played a large role in starting the second wave. Don’t go to parties or mix in crowds. Keep your distance even in small groups, even in pairs, unless you have quarantined together. Wear a mask wherever you may encounter other people. Wash your hands for a count of twenty frequently. Get a flu shot or risk getting and spreading both infections at once.

We will get through this, and as I have said before, if you do the right thing you will live to brag to your children and grandchildren about how you survived and how you protected others. Your stories will help them get ready for anything, because they will learn how you were ready for this.

Stay safe,

Dr. K

*I had mistakenly translated schadenfreude as “shadow-joy.” I mistook schaden (damage) for schatten (shadows). Thanks to Shebardigan and Misha Pless for correcting me.

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.

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).

 

 

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

The Day After

Note: This appeared as one of my contributions last week to a private email group including a number of lawyers. Three of them, including a retired Democratic Congressional Representative, endorsed my proposals. A fourth, a former Republican member of the Georgia State House, was “appalled.” The photo was included in my email. The proposal was emailed to the group Thursday, October 5, 2018, and I haven’t altered it for this posting.

Three illegitimate “Justices,” now one third of the court and three fifths of the ultra-right majority

Here’s what I think will and should happen the day after Kavanaugh is confirmed: Read more

The Pendulum Swings Back

Americans love the center, and are also fond of gridlock.

/images1I recently ended a decade on the Board of Trustees of the Russell Sage Foundation, which funds research in various branches of social science and psychology that bear on issues like race, immigration, poverty, and inequality in all its forms. It was endowed in 1907 by Margaret Olivia Sage in memory of her husband Russell Sage, and she specified that she wanted her legacy to be used toward “the improvement of social and living conditions in the United States.” My farewell remarks were made at an annual dinner two days after the election, and it being a foundation with traditionally liberal concerns, many present were worried about the direction of the country. I said this:

A couple of years ago at this event I was seated next to Barbara Solow, a respected economic historian and at eighty-something a charming and lively dinner companion. We were in the depths of the economic crisis, two wars were not going well, and some people were saying they had never seen worse times. I asked Bobbi, a child of the Depression and a Radcliffe student during the war, how worried she was. Read more

Human Nature in High Places

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

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

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

 Barack Obama, for instance. Read more

And the Nobel Peace Prize Goes to…

Whatever we think of the choice for this years prize, the runners-up deserve some attention.

Since even Obama reacted with disbelief to the news, saying in effect what everyone else said—that it was based on expectations, not accomplishments—I thought I would look into other nominees who were in effect runners-up.

One was Hu Jia, a Chinese dissident and AIDS activist Read more

Who Lies About Health Care?

Because I was involved in health care reform in the ’90s–two books, four or five New York Times op-ed pieces, a couple of essays in Newsweek , and two testimonies before U.S. Senate committee—a lot of people ask me to help them separate fact from fiction in the current debate.

Tensions are high. When a congressman from South Carolina, long and widely known as a fool and a boor, yelled, “You lie!” Read more