Sunday, July 5, 2020

Got Them Phase In, Phase Out, Out of Phase Blues

A Houston nightclub that's refused to close back down

Treatment update (not much news this week)
Remdesivir: Remember from last week that a dose of the drug, which was developed using taxpayer money and costs Gilead $1 (one dollar) to manufacture, might be priced at $50,000 if the drug does save lives, but only $1,170 if it turns out not to? Well, even Gilead doesn’t turn out to be as piggy as all that, and has set its price to hospitals at $520 per dose if the patient has private insurance, $390 if they have government insurance. But, appallingly, until the end of September Gilead is making remdesivir available almost exclusively in the United States. I.e. places like Brazil and India where COVID-19 is raging (and which incidentally are unlikely to be able to afford even those “bargain basement” prices), will have to either produce their own illegal generics or go without. Remdesivir won’t even be sold in the United Kingdom, despite now being theoretically available on the National Health Service.
Vitamin D: Several people have asked, so I’ll comment. Some observational studies have found people with very low vitamin D levels to be more likely to be infected with the novel coronavirus. But people who are poor, malnourished, live in nursing homes, etc. are the ones most likely to have very low vitamin D levels, making observational studies useless. I might mention that vitamin D has been proposed to prevent or treat many other diseases in the last couple of decades, and aside from a possible strengthening effect on bones it’s always fizzled. I’m with a review by the authoritative British NICE: if you’re considering taking vitamin D in hopes of preventing or treating COVID-19, forget it.
Hydroxychloroquine (Plaquenil): Here we go again. By now nobody thinks it can treat COVID-19, but for some reason a huge study will be testing it as prevention. Given that we already know the drug does nothing to prevent or mitigate COVID-19 among people who are already taking it for lupus, this seems to me to be a waste of resources. 
Passive immunityResearchers at Tulane and, separately, at Sorrento Therapeutics, have come up with an artificial antibodies against COVID-19 that work in test tubes and might possibly be useful in prevention. Don’t hold your breath. 
Old vaccines: For months people have been floating the idea that existing vaccines against non-COVID-19 diseases such as tuberculosis (BCG) and measles/mumps/rubella might stimulate the “innate immunity” branch of the immune system in a nonspecific way, boosting resistance to the novel coronavirus. Now Robert Gallo, a worldclass virologist best known for his controversial role in the discovery of HIV, has leapt into the fray by proposing oral polio vaccine. The idea is plausible, and studies are underway.
New vaccines: Now even a New England Journal of Medicine article discusses how researchers might speed up vaccine development by deliberately infecting human volunteers. But these authors are more cautious than gung-ho, commenting that “A single death or severe illness in an otherwise healthy volunteer would be unconscionable and would halt progress,” and going on to basically rule out the approach by saying, “Critically, a rescue therapy should be available” – unfortunately, no such therapy is on the horizon.

Ostrich Variations
This internal guidance is designed to assist how Inseason actions discuss the COVID-19 pandemic. Option 1 - Preferred approach. Make no reference to anything COVID related. 
Coronavirus deaths are way down. Mortality rate is one of the lowest in the World. Our Economy is roaring back and will NOT be shut down.
-       @realDonaldTrump, June 26, 2020
We have made truly remarkable progress in moving our nation forward. We’ve all seen the encouraging news as we open up America again.
-       Mike Pence, June 26, 2020
The RNC looks forward to holding a safe event in Jacksonville to celebrate the re-nomination of President Trump and Vice President Pence.
-       Republican National Committee spokesperson, June 26, 2020
New COVID-19 cases in Jacksonville’s Duval county
I think we’re going to be very good with the coronavirus. At some point that’s going to just disappear.
-       Donald Trump, July 1, 2020

How long are Republicans – yes, it’s Republicans, not “Americans” – going to be able to keep up the pretense?

What they’ll see when they remove their heads from the sand
The Republican rush to reopen the economy just as the first wave of COVID-19 was in mid-crash has led to its inevitable result: new cases increasing in 40 of the 50 states, now surpassing 50,000 a day, with Anthony Fauci warningthey could reach 100,000. 
A NY Times headline ties major outbreaks to “Bars, Strip Clubs, and Churches.” The Onion’s satire, as so often, cuts a bit too close to reality: City Enters Phase 4 Of Pretending Coronavirus Over.
There are no countrywide statistics on COVID-19 hospitalizations (!), but we know hospital capacity is already near the breaking point from Miami to Mississippi to Houston to parts of California. Even open-it-up governors are having to reluctantly roll back their plans, and Arizona has drawn up official guidelines for choosing who will be put on lifesaving equipment in a pinch. The death rate hasn’t started to go up yet but inexorably, in a couple of weeks, it will.
This at a time when Western European countries have succeeded in bringing the pandemic to heel. In the past week deaths have averaged 18 a day in all of Italy, fewer than in Georgia alone, or North Carolina alone, or Virginia alone, three of the better off states. 
This graph would look even worse today
Some are surprised that a virus known for attacking the elderly has lately preferred the under-50's. I’m not. Between old folks sticking with our self-protective instincts, idiot Republican governors who opened up bars and nightclubs, and young people who think they’re immortal and call masks “submission muzzles,” the pattern makes perfect sense. A Facebook post last month saying masks are “stupid and so are the people wearing them” garnered 110,000 likes and 49,000 shares.
Even in areas where there are few enough new cases to make tracing and isolating contacts feasible, it’s not easy. In New York City, most COVID-19 patients hang up when the caller starts asking who they’ve been around. After a super-spreader party in one of the wealthiest towns of one of the wealthiest suburban counties in the United States, officials had to resort to subpoenas to get infected guests to name their fellow partygoers.
Here’s June at a glance, thanks to the National Geographic. On June 1st the dominant color in the United States was blue (number of cases per 10,000 falling).

By June 28th it was pink (cases rising), especially across the South and the West

Death tolls: the real McCoy

I’ve written about studies of excess all-cause mortality during the COVID-19 pandemic in New York CityItaly, and around the world, all of which agree that the number of deaths caused by the pandemic is much higher – generally by about one-third – than what you’d think from death certificates. I’ve been waiting months to see similar figures for the entire United States. Now we have some, and they’re even worse than expected: over eight weeks during March and April, in 48 states (two didn’t provide data), 87,001 more people died than predicted based on previous years, with only 56,246 of them (65%) attributed to COVID-19. So we can estimate that the real mortality due to the COVID-19 pandemic in the United States is about 50% higher than official figures claim, i.e. not 132,000 deaths so far but – alas – more like 200,000.

Finders keepers 
Remember those $1.4 billion in stimulus money sent to dead people? Including people who died as far back as 2018, whose vital status was so well known that their checks had “Decd” written after their names? Losers weepers, apparently – much of that money has left the government coffers for good, as cashed checks or directly into bank accounts. The feds can't even demand it back, because nothing in the law authorizes them to. In any case the IRS has no intention of doing anything beyond saying “pretty please.” 

Mutant COVID  Ninjas
There’s been lots of ink spilled this week over a mutation in the novel coronavirus that supposedly made it “10 times more contagious” in Europe and the US than in China. But this story has been around before, is based mostly on theoretical grounds rather than real-life observations, and has never impressed me. Early-phase R0, the number of people infected by each case, was calculated at 2-2.5 or 2-3 in China, and 2.4-3.1 in Italy. Most American states affected early in the epidemic had, similarly, R0s between 2 and 3In New York estimated R0 was sky-high, 6, due to high population density and universal use of mass transit. Later in the pandemic, with variable degrees of measures such as physical distancing, R0 becomes less reliable, but as far as I can see there is little or no real-world evidence that the disease has become any more contagious. What we do have excellent real-world evidence for is that enforcing good mitigation measures, as was done in Europe, will rapidly decrease contagion rates. And that failing to do so, or backtracking prematurely, as in the United States, will allow infection rates to soar – whatever R0 you start from.

Black Lives Matter: more on a natural experiment
Evidence is accumulating that – surprisingly – the anti-racism protests following the murder of George Floyd did notlead to substantial rises in COVID-19 cases, presumably because of being outdoors. In fact they don’t seem to have led to any at all beyond perhaps one small outbreak in South Carolina. According to a summary by the Washington Post,Minneapolis, ground zero of the protests, has seen case numbers fall steadily during the past month, including in neighborhoods with large numbers of protesters in the streets. Same thing in New York City and in Philadelphia, Seattle, and Oakland. A study analyzing cellphone data in 300 cities concluded there was “no evidence that net COVID-19 case growth differentially rose following the onset of Black Lives Matter protests.” Officials in Houston have suggested the protests may have been one of the factors in their recent case surge, but I suspect all those prematurely reopened bars (see photo at top) deserve more of the blame.
Convincing those these data may be, even I find it hard to put my money where my mouth is and ignore physical distancing when I’m outside. Especially after spending three months in Berkeley, where people would cross the street if they risked passing within ten yards of you. Sitting at one of the tables crowded into my favorite outdoor bar, in the Colle Oppio park, can make my skin crawl.

Postscripts on Trump’s Tulsa fiasco
P.S.: the BOK Center actually did place “Do Not Sit Here, Please!” stickers on every other seat, to ensure physical distancing. Then Trump campaign volunteers went around the hall tearing them all off.
P.P.S.: remember Herman Cain, the black pizza chain executive who made a brief and unfortunate presidential run back in 2012? The poor guy picked up COVID-19 at that infamous Tulsa rally and is currently hospitalized in Atlanta
Cain at the Tulsa rally. No distancing, no mask
P.P.P.S.: Various campaign staff, Secret Service personnel, and Trump, Jr.’s girlfriend were also likely infected at the same event. 

Back to school? Zap the Zoom! 
Everybody wants to get students away from their screens and back into classrooms. Parents are sick and tired of playing teacher, juggling their work schedules, and having the kids constantly underfoot. Kids are sick and tired of having nobody to play with but their parents. Teachers are sick and tired of jumping through hoops to make virtual lessons as well as the real thing, and finding it doesn’t work. The good news is that reopening K-12 schools is feasible and safe. Children rarely get COVID-19 themselves and, in surprising contrast to other respiratory viruses, very rarely infect adults with COVID-19, so elementary schools can get back to business; to tell the truth, given the evidence from countries where schools never closed or have already reopened, I’m not convinced it was necessary to close them in the first place. Teenagers are mature enough to tolerate wearing masks and being spaced out in classrooms, and they gohome at night, so high schools can get going too. But residential colleges are another story. Many plan to reopen in the fall, causing considerable debate. I agree with one Times op-ed writer that the reopening plans are “So unrealistically optimistic that they border on delusional.” Adolescents think they’re invulnerable, and if they’re invulnerable they’ll party. Come on, you were all 18 once, you know I’m right.

Riding herd

Herd immunity is like hydroxychloroquine, an idea that won’t die until someone puts a stake through its heart. Will the novel coronavirus spread quietly around the globe until herd immunity will protect all the non-infected? Dream on. If the virus were left to itself and infected everybody, it would cause at least 50 million deaths worldwide. Fortunately, everybody prefers mitigation to that nightmare scenario. 
Even in New York City, where COVID-19 spread like wildfire, a recent CDC estimate – running antibody tests on blood drawn for other purposes – revealed that only 7% of the population had been exposed to it as of April. A previous survey covering the same period had come up with 20%, but it used much poorer methodology – and even 20% was lightyears away from the 60% or more needed for herd immunity. 
Sweden, which flirted with a herd immunity strategy by instituting a soft lockdown based on people’s good sense, is doing miserably. Its new cases continue relatively unabated while they fall precipitously in the rest of Western Europe, and its total number of deaths per million is coming within range of Italy’s. Nevertheless, only 6% of its population has COVID-19 antibodies. In late April many of us found the Swedish model interesting, and it gained a less than full-throated endorsement from the World Health Organization’s Mike Ryan. But Ryan later took it back, and by now both Sweden’s former chief epidemiologist and the present one,  who designed the gentler approach, consider it midguided.

The case of the vanishing virologist
Missed Anthony Fauci lately? Turns out he has to ask Trump’s permission to go on TV, and he often doesn’t receive it, because the country’s top infectious disease expert can’t be trusted to stay on message. In any case, the President regularly undercuts the guy’s suggestions. But then Trump has lost any interest he ever had in the pandemic – he’s supposedly cut COVID-19 out of the list of topics he’s willing to attend meetings about.

Knocked out of the park
Everybody from advertisers to fans is desperate to get pro sports back on track. They’re racking their brains for tricks on managing it in the COVID-19 era, from playing to empty stadiums to travelling the circuit in “bubbles.” But the virus is proving bubble-proof and has been sabotaging the whole enterprise by infecting golfersbasketball playerstennis stars, and football players, while some soccer stars have decided to give the next season a pass in favor of staying healthy.
We’re used to courageous athletes like Muhammed AliTommie Smith, and Colin Kaepernick standing up for what they believe in. But it has to be a special historical moment when Kaepernick gets an apology like “We, the National Football League, believe black lives matter.” Apparently the upcoming ouster of the Confederate battle emblem from the Mississippi state flag – a goal of activists for decades ­– may have been due less to a sudden wokeness of local politicians than to threats by the National Collegiate Athletic Association and the Southeastern Conference to cancel games in the state if that flag kept flying.
Mississippi's old state flag
A monstrous gift?
Donald Trump has officially added his imprimatur to the lawsuit that is right now – in the middle of a spreading pandemic when millions of people have lost their jobs and thus their medical insurance – attempting to repeal the Affordable Care Act and thus leave tens of millions more without access to health care. Just to tell you how far off base this is from ordinary Americans, the people of Oklahoma, a deepest-of-deep-red state where Trump bested Hillary Clinton by 65% to 29%, voted this week to expand Medicaid under the ACA.
I considered billing Trump’s unspeakably cruel act as a gift to America, because it ought by itself to guarantee that the bastard loses the election this fall, dragging his party down with him. A Democratic Congress and Administration should be able to come up with a new improved version of the ACA that not even Trump’s judges will be unable to undo.
But, on reconsideration, that level of cynicism was too much even for me.


  1. Thank you thank you thank you, please keep writing!

  2. I look forward to your blog post even though it does not make for happy reading. Many thanks for your insights

    1. Thanks so much. I'm happy to know you're out there reading them - and maybe the next post will be a little more cheerful, for various reasons.

  3. Sempre precisa e affidabile Susan.
    Ti leggo sempre molto volentieri.

  4. Susan, I am a consultation-liaison psychiatrist working in a safety-net SF hospital with numerous Covid-19 cases. I so appreciate your thorough and timely analysis of this public health challenge and political debacle, and will be sharing this post and your website with my colleagues. Thank you, and be safe!
    -David E.

    1. Thanks so much, David, I am genuinely moved by your comment. (I was almost a psychiatrist - that's why I originally went to med school. You might be interested in reading my memoir, Dottoressa: An American Doctor in Rome, for more about that and much else.)

  5. Deep admiration, long standing friendship--I so appreciate your insights, humor, irony, and ability to make readers feel a little bit amused even though there is nothing amusing in what you report! Thank you, as always, Susan.

    1. I kind of wonder what was special about this particular post - the most comments ever.

  6. You might have the most comments because it succinctly describes, validates, or educates what most of us are thinking. You are able to accurately comment on a diversity of topics. Keep up the good job!

  7. Two takes on the chaos coming to campus this fall:

  8. I love reading your posts! Never commented before simply because I didn't notice the commenting section on the bottom. How may I share so that another person can read and decide if they would like to subscribe? Grazie!

    1. Thank you thank you thank you. At the very bottom of each post is a row of small icons that you can click on to send someone the link by email or to share on Facebook or Twitter. Unfortunately the things are so tiny that I don't think anybody ever notices them!

  9. The Euro evidence on school openings is important. But Israel has not fared so well. How does one evaluate such differenet outcomes?

    1. Thank you for pointing this out. I actually looked rather deeply into those Israeli outbreaks, because they seemed so odd, and it seems that those schools totally ignored social distancing (according to students who posted about it on social media). Here's a link: