Wednesday, May 13, 2020

Phases, Musings, Hoaxes

Newport Beach, California, on April 25th photographed with telephoto lens (left) versus from the air (right)

Treatment updates 
Hyperimmune blood products: While some researchers try to coax “humanized” mice into making coronavirus antibodies, others now think they can get non-humanized llamas to do the same thing.
Heparin and its derivatives (dalteparin, enoxaparin…): Many COVID-19 patients develop blood clots, including pulmonary embolism which is the final cause in as many as a third of deaths. Fortunately clotting is one complication we know how to treat, using anticoagulants. Increasingly, it seems that anticoagulation may improve the chances of very ill patients to survive. So far the evidence is indirect, and randomized controlled trials in the works in Canada and France still haven’t started enrolling patients, but some major institutions are already giving heparin to all hospitalized patients. 
Hydroxychloroquine (Plaquenil): Yet another negative study, this one from one of New York City’s top medical centers – and reported in the world’s best medical venue despite not being a controlled clinical trial. At least in this one the drug didn’t cause any harm, but the hospital took action by immediately removing hydroxychloroquine from its standard treatment protocol.
Interferon (Betaseron): A randomized trial in Hong Kong has now been published and looks promising, though methodological weaknesses made it a less than ideal study. They found that adding ribavirin and interferon beta-1b to lopinavir–ritonavir, in patients with relatively mild disease and sick for less than a week, shortened the duration of viral shedding and got them out of the hospital faster. Of particular interest is the hint that combining multiple drugs – the approach we use against AIDS, hepatitis C, and tuberculosis – may be the way to go with COVID-19.
GS-441524: A questionable new entry. This unapproved drug, very similar to remdesivir, sold on the black market in China, may be useful for certain coronavirus diseases in cats. Don’t even think about it.
Vaccines: Anthony Fauci now says maybe millions of vaccine doses could be available by January 2021. Does he really think so, or is this more gun-to-the-head fantasy? Fauci claims it’s the same timing he’s predicted all along, but on February 26th he said on CNN, “In order to get a vaccine that's practically deployable for people to use, it's going to be at least a year to a year and a half at best.”
I nurse a secret hope that Trump will listen to the #firefauci folks. First, because kicking out the man Americans trust the most about COVID-19 will increase the chances that voters this November will evict a President who is palpably not up to the job. Second, because an Anthony Fauci no longer under Trump’s thumb will finally be able to say exactly what he thinks, without mincing his words or pussyfooting around. We need his straight shooting.

Monday messages
“We will revive our economy, and we will transition into greatness… I’ve noticed that some states could be moving more quickly.” – Donald J. Trump
“If we skip over the checkpoints… then we risk the danger of multiple outbreaks throughout the country. This will not only result in needless suffering and death, but would actually set us back on our quest to return to normal.” – Anthony Fauci

Presidentially yours
A few days ago Obama put in his two cents' worth, calling the administration’s response to the COVID-19 crisis “An absolute chaotic disaster.” I only wish he’d done it in a prime-time television interview rather than in a semi-private telephone call. 
The Occupant of the White House, around the same time (coincidence?), took to calling the FBI’s investigation of confessed felon Michael Flynn “Obamagate.” This was too much even for such loyalists as Lindsay Graham..
As former Presidents George W. Bush and Bill Clinton provide video messages charged with compassion and hope, the current one is long on self-praise and short on empathy.
But Trump’s antics can’t distract from reality, especially not as the corona noose tightens around the White House. While he urges recklessness on common mortals, he has had himself, Mike Pence, their guests, and close contacts tested every day for the coronavirus. Nevertheless Pence’s press secretary, a “valet” who serves Trump his dinner, and the First Daughter’s personal assistant all managed to come down with COVID-19. Despite his evident anxiety and notorious germophobia, Trump continues to snub social distancing – Pence won't self-quarantine. Like masks, I guess quarantines are for wimps and leftists. By the way, do you all know who gets to be Acting President of the United States if both Donald Trump and Mike Pence are incapacitated? Nancy Pelosi!

Clickbait x 3
I have to confess to narrative overload. My brain starts to turn off when it encounters the testimony of yet another weeping nurse, yet another doctor who’s spent all day intubating, yet another patient who made it by the skin of his teeth. But I found this virologist’s account of a relatively mild brush with COVID-19 to be beautiful, intelligent, informed, and heart-rending. 
A bunch called End Coronavirus have found a very nice way of summarizing the state of the pandemic in various countries. Their graphs are based on the number of reported cases, my unfavorite measure, but their webpage is useful nonetheless.
The Italians say “there’s no two without three.” On May 4th, the day Italy began its Phase 2, Beppe Severgnini wrote a lovely encomium to his country and its citizens – the decisions they’ve made, how they’ve coped, and the good that can come out of it all.

“Freedom now” – to terrorize
The demonstrations of know-nothings egged on by Trump, whose motto ought to be “Live free, die soon,” have escalated to feature mobs of white supremacist militiamen flaunting Confederate flags, nooses, and automatic weapons on the streets and inside statehouses. At least one African-American lawmaker felt she could go to work only with an armed escort. There’s also been an overall uptick in episodes of black citizens being harrassed and even murdered by armed white mobs. I have found the descriptions and images of these events so personally upsetting that I refuse to link to them.

How deadly is COVID-19?
I still can’t stop thinking about the Stanford study that purported to show that the coronavirus is much less nasty than it’s made out to be. For more on why I’m so obsessed, here’s a critique that’s particularly useful for understanding the key statistical issues, and another concentrating on senior author John Ioannidis.
This week I reread Ioannidis’s hyperinfluential 2005 article, “Why Most Published Research Findings Are False,” and found it, unsurprisingly, less convincing now than on first reading. All it did was to accurately point out many well-known research pitfalls, accurately say that many researchers fall into them, add some gobbledegook, and make a quantum leap toward the “most” of his title. I ask, does it say something that he published his screed in the open-access venue PlosMedicine instead of a reputable scientific journal?
By the way, for all you people who are convinced you had COVID-19 way back when. Yeah, OK, there was a case in California on February 6th, and yeah there was even one last December in France. But whatever you yourself were sick with, it was almost certainly not COVID-19.

Mutation madness
We now have yet another pre-print, self-published by researchers without peer review, that’s wreaking havoc. A bunch of reputable American scientists claim that a mutation has made the coronavirus more transmissible and possibly more deadly. The original paper is Greek to me, but the experts who have belittled it to the Washington Post and The New York Times are easier to follow, as is the debate on Twitter – though perhaps I shouldn’t be overoptimistic.

Baby steps
Many countries are reopening their schoolhouse doors. All plan to leave extra space between students, but their other tricks run the gamut: temperature checks, classes one day per week, classes on alternate weeks, open windows, one-way halls, outdoor classes, free coronavirus swabs. France opened its preschools first, Germany its high schools, each based on perfect reasoning.
Back in the USA, the CDC has produced a sensible next-phase roadmap, with detailed and one would think uncontroversial guidance to help stores, child care facilities, etc. plan their reopening. The White House tossed it in the trash, apparently because it included some recommendations for how to hold church services – can’t risk alienating those crucial evangelical voters!
By now we’re all so used to lining up six feet apart outside supermarkets that maybe art lovers will be willing to do the same. Some museum directors in upstate New York are betting on it: creating one-way visitor pathways, installing hands-free faucets, moving lectures outdoors, and encasing their receptionist desks in plexiglass, all with the aim of convincing the State it’s safe for them to be on the list of places allowed to reopen.
Meanwhile, country-rock singer Travis McReady is planning on holding a live concert in an Arkansas venue this Friday, in front of 229 fans, the first such event in a long time, with the added fillip of challenging the governor for favoring churches over musicians.
A reader has pointed out to me that the financial issues I mentioned last week that make it difficult for American theaters and concert halls to reopen with social distancing are somewhat less relevant in Europe, where governments heavily subsidize the arts. In fact the city  of Verona has chosen to take a financial hit of 20 million euros in order to get culture going again by staging a series of weekend concerts in August and September, with the orchestra seated in the center on spaced-out stools and an audience of 3000 scattered around a Roman amphitheatre that usually holds 13,500.

Keep your distance
Last week I mentioned the violent enforcement of physical distancing orders by some New York City police. Failure to follow the guidelines is supposed to lead only to a summons, but scores of people have been arrested instead, and the vast majority of them are non-white. What Mayor De Blasio, husband and father of African-Americans, is doing defending this behavior is beyond me.
Italy is different. On the first day of loosened restrictions the media featured images of the Milanese turning out on the streets in droves and socializing at close range. The cops were nowhere to be seen, much less enforcing physical distancing. But, then, Italian cops have generally had a light touch. They have their moments of bossiness and even cruelty, but they’re usually soft-hearted – a cop once ripped up a speeding ticket after my spontaneous display of tears. So perhaps the police force had merely decided to let the revelers have one party day before clamping back down on the distancing.

Hopefully that little orgy of mindless mingling, and the reopening of some Lombard factories a few weeks back, won’t interrupt the downward trend in COVID-19 deaths in Italy – I’ve been predicting they may hit zero by the end of this month. 

 The novel coronavirus has thankfully been retreating in my home town as well, though not before killing off – officially – one in 720 New York State residents as of yesterday. But here’s a shocking postscript to that already shocking statistic. The official New York City data say there were 18,871 deaths from COVID-19 between March 11th and May 2nd. But the CDC has now compared the total number of deaths in the city, from all causes, with the same period in past years, and reports that the excess attributable to the pandemic is not 18,871 but 24,172. Who were those extra 5000-plus? Some with COVID-19 didn’t make it to the hospital on time or at all, others had COVID-19 masquerading as a heart attack or a stroke, still others had real heart attacks etc. but were so afraid of catching COVID-19 that they didn’t go to the Emergency Room. Similar phenomena all over the world have demonstrably led to an undercount of pandemic deaths by at least 25%.

A totally unscientific poll
I asked my Facebook friends in Italy to tell me their personal best and worst experiences of Phase 2. Here are some of their replies: 
The best
-       Driving to Monte Antenne with my little dog and admiring his happiness. 
-       Taking my husband out for a gelato. 
-       Having my first gelato in 55+ days. 
-       The ice cream parlor reopening on Via Principe Eugenio. 
-       Driving to our residence in the Northern Apennines. 
-       We drove to a friend's house and visited through the window. 
-       Visitors being allowed. 
-       Hearing owls at night. 
-       Going running in the park. 
-       My first constitutional along the Ticino river. 
-       Cycling through a relatively empty Rome in the sunshine. 
-       Going around the city by bicycle and seeing people going for a walk in places where usually they move by car. 
-       Walking through Villa Sciarra. 
-       Seeing the Ponte Coperto (I'm in Pavia) for the first time in 10 weeks. 
-       The way the local market has organised itself to arrange deliveries and pick up of fresh fruit and veg has been inspiring and helps give a great sense of the community helping each other. 
-       Riding the scooter beyond 200 m. 
-       Taking my first bus ride downtown, so thrilling! 
-       As in phase 1, I am painting, so I could be quite happy till phase 3 and beyond! 
-       Breakfast at my corner coffee bar, even though it was takeout, and getting to chat with people who happened to be there too. 
-       Getting a takeout cappuccino at my local bar. Heaven!
The worst 
-       Taking my dog to the vet after our Monte Antenne outing for a possible foxtail in his paw (COVID-19 scenario in the clinic included). 
-       The sirens of ambulances and emergency vehicles still fills me with dread. 
-       Not being able to go to a beach or our country house. 
-       Having no idea when the grocery store will be open. 
-       Realizing that my well-planned sabbatical was not really a sabbatical. 
-       As a misanthrope, I loved the first stage, the silence, the empty streets; I miss it. 
-       Traffic noise and fumes have increased. 
-       The disapproving looks I get when trying to go out to exercise (safely and courteously). 
-       The thought that many shops and businesses won't survive. 
-       Putting on latex gloves. 
-       Not being able to go to church for mass. 
-       Seeing the coffee bars open to takeaway, but not wanting to add to plastic waste by getting a coffee. 
-       The restriction imposed to meet only your relatives – I don't need moral lessons.
Frankly, I had figured people’s biggest complaint would be of people ignoring social distancing. Surprise – none of my respondents, and no emails from friends, have even mentioned it, making the notoriously anarchic Romans look better than their famously disciplined Milanese counterparts. Or maybe some of those images of thoughtless crowds in Milan were deliberately shot using technical specs that would make people look bad – see the images at the top of this post.

Department of Misinformation
Dr. Judy Mikovits, a scientific fraudster and all-around nutcase, rose to evil stardom this week with a video that was viewed more than 8 million times in the 4 days before YouTube, Vimeo, and even the ever-tolerant Facebook removed it from their platforms. Like zombies, though, internet videos can’t be killed, and tracking one down was child’s play for me. Among other rants, it plugged an old conspiracy theory about the coronavirus being created in a laboratory so billionnaires can profit from a vaccine, invented a new one that wearing a face mask activates the virus in your body, and tossed in an astonishing set of attacks on Dr. Anthony Fauci.
Dr. Scott Jensen, a Minnesota GP and politician, is claiming that COVID-19 isn’t actually killing all that many people – that his colleagues, goaded by “deep state” bureaucrats who are motivated by hatred of Donald Trump, are certifying it as the cause of death even when it’s not, thus inflating the official death tally. (Reality check from Anthony Fauci: the number of deaths from COVID-19 is “Almost certainly higher” than the official count, definitely not lower.)
Then there’s Phil McGraw, a television personality who’s opined on Fox News that a vastly more important health threat than COVID-19 is… swimming pools! (His figures were off by only a couple of orders of magnitude.)
The Tanzanian President, John Magufuli, has suspended the head of his national laboratory for saying COVID-19 cases were increasing, ordered secret burials to hide the extent of the epidemic, and had a planeful of a surefire herbal cure brought in from Madagascar. But as compared to the American hoaxsters, he ain’t even a contender. 

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