Thursday, June 11, 2020

Casa Dolce Casa

Worrying too much about COVID-19 (passengers at LAX)

Worrying too little about COVID-19 (demonstrators in Milan)
Treatment Update
Convalescent plasma: The best evidence we have thus far, a randomized Chinese trial, surprisingly found no benefit. Nonetheless, thousands of American patients have already received convalescent plasma on a “compassionate” or “expanded access” basis. Fortunately better data are in the works: Columbia University has begun double-blind placebo-controlled trials of preventive use in close household contacts of COVID-19 patients and therapeutic use in severely ill COVID-19 patients. Similar trials among hospitalized patients have begun in Nashville, at Montefiore/Langone in New York, and at the Brigham in Boston.
Remdesivir: It turns out there is a controlled multinational European study I wasn’t familiar with: INSERM’s DisCoVeRy Trial, but it’s been slow in getting off the ground (as of 3 weeks ago, only 2 out of 7 countries had enrolled any patients). And last week Gilead made a preliminary announcement of modestly positive results from its SIMPLE trial among moderately ill hospitalized patients. Unfortunately both these trials are open-label – patients and physicians what treatment is being given – and without placebo controls, limiting confidence in their findings.
Hydroxychloroquine: More bad news: a large placebo-controlled study enrolled people who had been intensely exposed to COVID-19, mainly health care workers or close household contacts of patients. High, even toxic, doses of hydroxychloroquine, started within a few days of exposure, did not prevent disease. On the other hand the huge Lancet study I called the next-to-the-last nail in its coffin has been retracted – not because it was inaccurate but because the owners of the database refused to make it public. The Guardian’s inflammatory headline, “The Lancet has made one of the biggest retractions in modern history,” greatly exaggerates. Even if hydroxychloroquine doesn’t massacre COVID-19 patients, there’s zero evidence it does any good. The latest, and final, proof is a randomized British study among 4700 hospitalized patients: hydroxychloroquine did nothing to help them, and if anything slightly increased mortality. All research into or use of this drug in COVID-19 should be abandoned.
Recovery: We all hope having COVID-19 will lead to lasting immunity, but there’s still no evidence in human beings. Now Harvard researchers have at least shown that it is true in nonhuman primates: macaque monkeys who had recovered from COVID-19 did not get sick when they were re-exposed to the virus a month later. This is an enormously important study.
Vaccines: The same Harvard group, partnering with Janssen, has developed a new candidate vaccine that seems to protect monkeys from getting sick and block the virus from multiplying – better, as I understand it, than the Oxford vaccine. Despite mediocre results in monkeys and none yet in people, AstraZeneca is charging ahead with plans to produce 2 billion (that’s billion, not million) doses of the latter by this September. The Chinese CanSino vaccine has also made progress, inducing a reasonably active antibody response in volunteers, though with a high rate of side effects. And Moderna has started a 600-person Phase 2 trial of its own vaccine. The race continues, but beware those who promise results at “warp speed.”
I’m disturbed to see yet another trial balloon suggesting we deliberately infect volunteers to hasten vaccine development. This is not only unethical but unnecessary: some settings carry such a high risk of infection that a protective effect of vaccines can easily be detected. For example, last March northern Italian hospitals, in April meat processing plants, now American church-goers and Brazilian favelados, and, always, residents of nursing homes and prisons. By the time any vaccines are ready for mass testing the ideal populations to test them may be different, but they will, alas, exist.
Masking: I am starting to think face masks may have some value. A new Chinese study, unfortunately retrospective, found that masks reduced disease among household contacts of presymptomatic COVID-19 patients; oddly, masks didn’t help once the patient had become ill. Another study, a review in The Lancet has concluded, with “low certainty,” that masks might be helpful. Just this week, the article that had convinced me masks were entirely worthless was withdrawn – the authors decided their findings were “uninterpretable.” The WHO has opted to revise its guidelines in a somewhat more positive direction, and I agree with them: wear masks indoors, when you risk being within 1-2 meters of another person for more than 10 minutes. Outside, masks are almost entirely irrelevant – virus particles are rapidly diluted and scattered in the open air. (Hikers don’t really need to slip on facial coverings when their paths cross momentarily.) A large study in pre-lockdown China found that 99.95% of COVID-19 infections were caught indoors. I hope the open air will protect those throngs of Black Lives Matter protesters, just as it protected the jostling pedestrians on Chinese streets, but all that shouting and all that tear gas are working against them.
Sign at the entrance of Berkeley's Tilden Park

Physical distancing: That same Lancet review of real-world research showed that physical distancing is an effective measure for preventing COVID-19 transmission, and that two meters are better than one. And new modelling studiesestimate that distancing in the form of lockdowns have averted half a billion cases and millions of deaths.
Excess of Zeal Department: A third of respondents to one poll reported having adopted high-risk anti-COVID-19 practices such as using bleach on food. One in four said disinfectant products had made them sick.
Ibuprofen: Another one of those switcheroos. At first experts were afraid ibuprofen would make COVID-19 worse. Now they’re trying a version of it to treat hospitalized patients.

Our Journey From Hell
During three months in the friendly Berkeley soil, our hearts lay down tenacious roots. We had to spend days, in the week before we left, driving around the East Bay to return the borrowed underpinnings of our California life to their owners: winter clothes, summer clothes, piano music, songbooks, a thermometer, a minispeaker, a 2010 Honda, jumper cables, a Midi keyboard with pedal, a mixer, and miscellaneous cables, connectors, and power supplies. Also assembling loot to carry away: for the plane melatonin, lorazepam, cherries, cashews, and one banana. For home Leggs stockings, Mack’s ear pillows, Tom’s fennel toothpaste, two bagfuls of Flossettes, and two boxes of Fig Newtons, not to mention the jeans running shoes socks sweatshirt shift sandals slippers I’d managed to buy before the stores closed, plus 10 books by various friends. And, fortunately, a friend’s spare suitcase to stuff it all into.
We began painfully plotting our logistics on May 7th, the day Alitalia left us in the lurch by cancelling the nonstop route between San Francisco and Rome. By infinite good fortune we managed to connect with an airline insider, a Girl In The Know who could tell us with authority which flights were most likely to leave, warn us against Lufthansa, recommend Air France as the only reliable link between the West Coast and Europe, and alchemize our Alitalia business class ticket home into Delta-Air France-Alitalia, SFO-LAX-CDG-FCO. Gaining a Guardian Angel brought balm to the soul and calm to the nerves.
The first leg she reserved for us, on Delta, left at 7 in the morning from the San Francisco airport, an hour’s drive away, and would have dumped us in LAX six hours before our next plane boarded – with all the lounges and restaurants shuttered. So when we found out that Southwest was running a flight to LAX, on time every day at 10.45 AM, from the much closer Oakland Airport, I immediately called our Guardian Angel to ask whether it would be OK for us to take that one. Of course, she said, regretting only that she couldn’t make our reservation so we’d have to pay for the ticket ourselves. We reassured her that the convenience was well worth $49 a head.
During the week before takeoff I must have spoken with our Guardian Angel half a dozen times. What was the latest dope on Southwest? Would 3 hours at LAX be definitely enough to make our connection? Was there a trick for getting into the Air France website? Why did Alvin’s reservation code work but not mine? How could I check in online? The day before our flight, hearing how nervous I was, our GA phoned the Air France supervisor, Alyssa, to be sure she would be on the spot in LAX the next day, poised to help in the unlikely case that any problems came up. Now that’s a Guardian Angel!
On the eve of D-day the contract of our US cellphone ran out. We figured what the hell, why traipse downtown and renew it when we were only going to be in the country for another 24 hours? After all, we had my Italian cellphone. I had vaguely noticed that it hadn’t rung in three months – but then probably our Italian friends were avoiding intercontinental calls?
A friend’s lift to the Oakland airport, the first time in 11 weeks we’d been in a car with another person, was spooky even with masks and wide open windows.
Our first taste of trouble was being busted at the checkin counter for overweight. Southwest was famously generous about checked baggage – two bags per passenger – so we’d figured one each would be fine, mine 40 pounds and my husband’s around 53. Nope – it turned out Southwest had a 50 pound weight limit instead of the usual 70, and even an ounce of excess would set us back $75. Perhaps we should have seen the ten mortifying minutes it took to open our bags in public and shift a few books as a bad omen…
Instead we breezed through security and skyway, sat down in row 5, and would have been fine if the plane hadn’t been too full for COVID comfort, and if there hadn’t been a drunk in the front row yelling incoherently about George Floyd and swatting away his mask. Alvin and I exchanged glances – weren’t the crew going to kick him off? No, they merely wheedled him into covering his face, and off we taxied. Only as far as the runway, though, where instead of taking off we made a U-turn and headed back to the terminal. There the crew talked the poor schlemiel down and gave him a gentle heave ho, as they should have in the first place. But now the clock was ticking. During our half hour at the gate Alvin and I alternated hikes down the aisle, to press the crew about our international connection. Were they offloading the guy’s checked luggage? Fixing his paperwork? Negotiating with the cops? Incredibly, we arrived in LA only 20 minutes late, rushed to the international terminal, and reached the Air France checkin counter at 1:00 PM. Our plane was scheduled for 3:20. Whew.
Joyful at having made it, we handed over our passports. The agent quickly found us on his computer and said, “Your tickets have been cancelled.”
What????? Our trip began in San Francisco, he said, and since we hadn’t gotten on the SFO-LAX flight the rest of the journey no longer existed. I smiled some more and explained that the airline knew perfectly well that we were taking a more convenient flight from Oakland. I dropped the name of the powerful Girl In The Know, and punched her phone number into my cellphone. No answer. Her office number, no answer. The gate agent and I glared at each other until he helpfully offered a way out: we merely had to pay a penalty and he would reinstate our tickets: 1500 euros ($1700). Each.
But I had an ace up my sleeve, the supervisor. I asked to speak with Alyssa, then presented our plight in as winning a way as can be managed from behind an N95 mask. Sure, she knew all about us, all except for the crucial fact: that we had flown to LA on Southwest Airlines, with the knowledge and approval of our Guardian Angel. She said she would speak with the GA, and picked up her phone. In a minute we were hugely relieved to see her chatting away amiably. The nightmare would soon be over.
But no – she hadn’t found our girl, and whoever she had been speaking with said forget it. Sure, Alyssa had told our GA the day before that she would take care of us, but skipping a flight was too dreadful a crime to remain unpunished. No way the system would let us check in without getting those 3000 euros. And the next flight to Rome was in 3 days.
I spent the next hour pacing the hall, my heart beating wildly in my throat, trying a phone call, a text message, and an email every 5 minutes. I contacted a mutual acquaintance in search of more numbers to call – a husband’s? – and in the process learned that my Italian cellphone couldn’t receive voice calls. No wonder it had never rung. So when I wasn’t actively tying messages to carrier pigeons I stared continuously at my texting app. Too bad we hadn’t ransomed our damned American cellphone. 
The clock reached 2:10, closing time for the gate was 2:20, les jeux sont faits, rien ne va plus. My husband Alvin Curran, the calmest and most optimistic person in the world, started trying to convince me we should fork over the 3000 euros. At 2:18 we saw Alyssa get on the phone again – had our Guardian Angel phoned? At 2:20 they called me over, just me: Levenstein and only Levenstein, the one with the Italian passport, can check in. At 2:22, two minutes after the gate had officially closed, they let Alvin do the same. After which the entire Air France staff started joshing us like we were all old buddies.
We’ll never find out why the Girl In The Know didn’t know our taking that flight from Oakland was a mortal sin, what trick had to be done on the computer to enable us to take off, or what incantation she had to pronounce in order to make it happen. Nor do we care.
I’ve been living for 40 years in Italy, where alcoholic beverages are foods, not drugs. As I put it in my memoir, Dottoressa, “In Italian, ‘You look like you need a drink’ is a nonsense sentence.” But as Alvin and I shuffled like two automatons in the direction of the gates, I pronounced the classic words, “I need a drink,” knowing it was a wish destined to come quickly true – business class boards first, and as soon as you climb on board they bring you a glass of champagne. But not on this flight! An ineffable interference between COVID-19 and the map of the plane dictated that business class had to board last. And until our meals were on our trays, there was no sign of booze.
On the way to the gate we had a final misadventure: both of us got stopped by LAX security. In my case because my purse strap overlying a banana had cast a gun-looking shadow. In Alvin’s because homemade salmon spread packed in a little plastic container counted, like toothpaste, as a liquid. Preassembled into a sandwich the spread would have been fine, said the inspector; but he took pity and waved us through anyway. 
Everybody asks me how we prepared to meet the health dangers of air travel. Not much, actually. Our fellow passengers ran the gamut from bandit bandanna to full plastic-tape-up-the-legs hazmat. We brought two N95 masks, two surgical masks, and a few pairs of gloves apiece, plus a fistful of disinfectant swabs. No adult diapers, garbage bag wraps, or sheets to sit on. We ate the airplane food. There’s some science now to back us up: contaminated surfaces transmit less COVID-19 than once feared.
The airports were neither crowded nor empty. We mostly stuck with our N95 masks, though lugging our bags hurredly between terminals I couldn’t breathe through mine and ripped it off. On the plane we switched to surgical masks for comfort, and for sleep I took a token approach, hooking one earloop and draping the rest over my face. We had intended to always wear gloves inside terminals and when not in our seats, but it was too much trouble, and we wound up mostly using soap and water, Purell from dispensers, and hand wipes. I rashly allowed a neighbor to handle my carry-on bag and hoist it into the overhead compartment. 
When I’d picked our seats online business class was mostly empty, and half of them were x’ed out for physical distancing. When we got on board, every seat was occupied. Yes, you’re automatically more “distanced” in business, but still… The odd configuration of Alvin’s and my seats – side by side but angled closest at the foot end – left our heads so far apart that the only way to exchange a word was to remove our masks and holler.
The flight to Paris was smooth, the flat bed comfortable, and the food good. Our brief layover was largely spent having thermometers pointed at our heads and completing in duplicate copy a “Self-Declaration Form Justifying Travel in Italy of Persons Arriving from Abroad” – we were arriving from Los Angeles, travelling for repatriation, would self-isolate at home (specifying address and phone numbers), and would get there by taxi. 
In Rome we survived more thermometer guns, spaced ourselves in front of the authorities waiting for our Self-Declarations, reached the authorities, were told the form we’d slaved over in Paris was the wrong form, took the right form (with identical text), filled it in, and handed it to health officials at a table. Once they had recovered from the momentary consternation caused by someone with an Italian passport completing a form in English, the rest was gravy: explaining that quarantine meant not setting foot outside the apartment for 14 days and instructing us to call our National Health Service GP so he in turn could alert the local health authorities, who would check in on us by telephone every day about symptoms and fever (as they have in fact been doing).
Our bags came out fast, and we skedaddled. The detail that most struck us was the complete absence of the gypsy cabbies who usually line the route from baggage claim to door muttering “taxi, taxi” under their breath. Outside, there were scores of legit cabs. The driver at the head of the line refused to stuff our bags into his car, preferring to hand us over to a Fiumicino cabbie with a larger vehicle. I specify the city because though the cab ride from the Da Vinci airport has a fixed price, by some Roman quirk the fixed price varies according to whether the taxi is based in Rome (€48) or Fiumicino (€60). We groused, but after 22 hours traveling we were too tired to hold out for long. 
In front of our apartment house we handed the cabbie a credit card. Since 2015 it’s been obligatory to accept them. He doesn’t accept them. We scraped together 60 euros in cash, nearly depleting our meagre supply, and grumbled non-stop as we hauled out our bags. Everything we hate about Italy.
The maid had stopped by once a week, so the furniture wasn’t padded with dust. There was wine on the rack, food in the freezer, plants thriving on the roof – the car even started. But when we eagerly turned on the shower, it came out cold. After a couple of hours uselessly fiddling with the boiler, panic took over – do we have to stay filthy for two weeks? Next morning we ask the plumber to come, quarantine be damned. N95 masks all around, and a sprint from the door to the boiler on the balcony. His deep diving detects a broken whoozit – the sparker that sets the gas ablaze – that’s hard to find, he says, and he’s booked up the rest of the day. Then he looks into our masked faces, takes pity, calls around, finds a whoozit-stocked shop at the other end of town, drives over and back, gets the boiler going, and launches into a tirade against the idiotic COVID-19 conspiracy theories of right-wing politicians (“They want to sell us to China”) and the orange-vested crowds chanting “The coronavirus doesn’t exist!” In exchange we’re glad to offer a tirade against Trump, plus most of our remaining cash. He’s happy, we’re happy. Everything we love about Italy.
P.S. Two days after we landed an entire Italian family were diagnosed with COVID-19 fresh off the plane from Chicago via Frankfurt. Sent chills down our spines. Fortunately just 3 days from now we’ll have survived the incubation period.
Out our window in the jet-lagged dawn

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