Wednesday, September 23, 2020

Surprises from Africa to October, and Most Outrageous Trophy

 

Dance of death with plague victims, 1493 woodcut


Treatment Update

There’s not much treatment news in the last couple of weeks: 

-       Yet another negative study of convalescent plasma, this one coming from India, yet again flawed by poor donor selection – and yet more details of Trump’s in-person pressure on regulatory agencies to approve plasma therapy. 

-       Ruminations on using highly toxic ultraviolet light to purify indoor spaces. 

-       Speculation that since the ubiquitous disinfectant povidone-iodine can kill the novel coronavirus in test tubes, painting your nostrils with it might block COVID-19 from developing. Shades of old Trumpian fantasies, and totally untested. Shall we hold our excitement until the stuff has been tried in at least one actual human nose? 

 

But vaccine news has provided more than enough excitement to compensate. I suggest you consider orienting yourself to the issues by checking out the superb and authoritative take of one top vaccine expert, Dr. Paul Offit. If you can’t access that discussion at Medscape (sometimes nonphysicians can’t), there’s a less deep one for the general public at WedMD.

AstraZeneca: The biggest clamor was around the Oxford vaccine having to suspend its Phase 3 trial because of a potentially devastating neurological complication, transverse myelitis, in a British woman who had received it. This is a very big deal. Transverse myelitis, which can cause paraplegia, is an autoimmune phenomenon that can be part of multiple sclerosis but can also occur in reaction to an infection – or a vaccine.

AstraZeneca started up again after only a week’s pause, but is recruiting new volunteers only in the UK and Brazil. An independent British regulatory authority apparently decided the neurological event (the second among AstraZeneca volunteers) was unrelated to the vaccine. The company refuses to give any details, on privacy grounds that seem to me and others to be wrong-headed not to say contrived, depriving the public and the rest of the scientific community of information that could be either reassuring or damning. American authorities aren’t convinced either, so the trial is not being restarted in the United States, at least not yet, and with what we know I personally wouldn’t volunteer. Critics are suggesting that if one more neurological event occurs the vaccine should be scrapped permanently – even though the company has already taken in at least $2 billion from countries around the world as down payment on a billion promised doses. 

The way La Repubblica described the suspension news was touching: “Halt to testing of the Italian-British medication.” In reality the only Italian aspect of the AstraZeneca vaccine is that one of its many production plants is in Italy! Italians aren’t big flag-wavers, but they do love to feature local connections – say, mentioning at the drop of a hat that the US may soon have its first Italian-American in the White House (Jill Biden’s father, Donald Carl Jacobs, would have been Giacoppa if the name hadn’t been Americanized on Ellis Island). 

Pfizer: This company has finally said for the first time that they have in fact performed animal studies of their vaccine, claiming “high levels of neutralizing antibody in various animal species, and beneficial protective effects in a primate SARS-CoV-2 challenge model,” but they don’t hint at details, much less promise to publish full results. It has now at least pre-published Phase 1-2 studies in human beings of two candidate vaccines. Both stimulated the immune system into producing antibodies, though one did a lot better than the other. Unfortunately the superior version also caused severe reactions, so they’re going forward instead with the other one, currently known as BNT162b2. Not extremely encouraging.

Sputnik V: The Russians have now published the Phase 1-2 evidence that made them approve this vaccine, and it’s scanty at best. About 75 volunteers were involved but as far as I can figure from the paper in The Lancet only 40 of them – mostly healthy men under 30 – received the final two-jab course. They developed anti-COVID-19 antibodies at levels higher than moderately ill COVID-19 survivors but lower than those elicited by some other candidate vaccines. Even less encouraging.

Research protocols: Three of the chief contenders have now released the protocols describing exactly how their Phase 3 trials, the ones aiming to show real-world efficacy, are being run. Moderna and Pfizer did it first, which gets them some points for transparency, with AstraZeneca trailing after. The plans themselves are disappointing, though – and I’m not the only one who’s noticed their defects. The endpoint all three companies are going for is symptomatic COVID-19. For Pfizer and AstraZeneca this could mean nothing but a brief sore throat with a positive swab. Moderna is a bit better, requiring volunteers to have respiratory symptoms plus fever or other systemic symptoms if they are to count as a case. But what we want from a vaccine isn’t protection from getting a few days of cough and fever, what we want to know is whether it will make us less likely to wind up with heart or brain damage, or on a respirator, or dead. All three companies would also be ready to stop the trial after only a small number of people – as few as 32 in the case of Pfizer (very bad), 75 for AstraZeneca and Moderna (merely bad) – have gotten sick. Insisting the vaccines be shown to prevent severe disease and requiring a proper number of cases would cost more and take more time, but in my opinion it is essential. Doctors are going to be advising billions of healthy people to be injected with a brand-new medication. We need to have complete confidence that the vaccine will ward off serious COVID-19, that it’s not going to kill anyone, and that the process of testing and approval has not been rushed.


Black October


Activist filmmaker Michael Moore has called it again. He was one of the very few pundits to predict Donald Trump’s elevation to the White House in 2016, giving him major creds for political soothsaying, and back in June, in his podcast The Rumble, we listened to him forecast Trump’s October surprise. Here’s how it ran: on October 25th the President goes on national television, announces a COVID-19 vaccine has been perfected on his WarpSpeed watch, and has himself shot up on live TV, scoring his highest ratings ever. The syringe will of course contain nothing but salt water.

This brilliant strategy seems more and more probable, and given the appalling kowtowing that’s been displayed in recent weeks by Stephen Hahn, the head of the US Food and Drug Administration, the agency empowered to approve all medications, it looks like the Trump team might pull it off. The risk of premature approval is so great that the vaccine companies have felt compelled to issue a statement swearing they won’t rush the science in requesting authorization, and both Hahn and senior FDA officials have had to say they won’t rush the science in bestowing it. But if Trump does get to carry out his stunt, in addition to being medically risky – that’s never fazed him – the timing has to be perfect. He has to be sure the real vaccine won’t be injected into any real people until after the election, because a monkey wrench will immediately land in the works.

How so? A personal story: nowadays people who need to be vaccinated against typhoid fever usually just swallow a few benign capsules. But I’m old enough to have gotten the previous incarnation of the typhoid vaccine, a shot in the arm that laid me up in bed for 24 hours, staring up at the ceiling alongside my similarly indisposed ex.

Compared to current candidate COVID-19 vaccines, that typhoid jab was a stroll in the park. If you shoot human beings up with the made-in-America Moderna vaccine, at a dose comparable to the one that worked well in monkeys, most of them lose days of their life to fatigue, body pain, fever, and headache, especially after the second dose. Candidate vaccines PiCoVacc (from Sinovac) and ChAdOx1 (Oxford-AstraZeneca) pack just as much of a whallop, the China BiotecPfizer BNT162b2, and CanSino ones a little less. I can’t say for the Johnson & Johnson/Janssen vaccine, since it’s only just now starting its first human trials.

If 40% of Americans already say they wouldn’t get vaccinated, what’s going to happen when the early adaptors land flat on their backs for days with fever, muscle pain, and headache –worse than the mild flu symptoms that Trumpians expect from the coronavirus? Even I, an enthusiast for nearly every vaccine that’s come around (exception: human papillomavirus) might drag my heels. And if the first vaccine turns out to be less than perfect, how many people will step forward to try a second one?

We can just imagine how few would get vaccinated when, as one Midwestern colleague wrote on Medscape, his patients are already suspicious that “the vaccine will contain anything from substances designed to promote sterility, to nano chips that will be injected to later track & control us.” 

Michael Moore

A bright side for the Dark Continent


Consider the buffalo. The breeds that live in India and Southeast Asia are happy to work the fields, under a yoke. The African ones would rather run you through with their horns. Same thing with elephants – the small-eared Eastern kind help clear forests all over Asia, while the floppy-eared African variety can’t be tamed at all. Africa has impoverished soils, years-long droughts, unspeakable viruses from Lassa Fever to Ebola that make the leap periodically from animals to humans… Ten out of 10 of the world’s poorest countries, and 22 of the poorest 25, are in Africa. By whatever measure you use, the continent always seems to start out with two strikes against it…

…except when it comes to COVID-19. Developing countries in South America and Asia, notably Brazil and India, are doing miserably, running neck and neck with the USA in terms of daily new cases and deaths. Major African capitals can reach twice the population density of New York City, and everybody including me expected that when the coronavirus reached Africa it would hit the ground running and decimate all those shantytowns, which given the widespread lack of modern medical services on the continent would mean an authentic holocaust. In all of Kenya – not one of the poorer countries – there are only 259 ventilators; Italy had ten times as many per capita when it was first faced by COVID-19, and even those proved far too few.

An African shantytown


Instead, miraculously, the pandemic has merely limped along in Africa. Except for relatively wealthy South Africa, the case numbers, and the death rates per million (well under 100) look more like the sterling figures of Finland (62 deaths per million) or even Japan (12) than like Italy (581) or the US (618). Some of the apparent advantage is doubtless due to undertesting and underreporting, and the disease is continuing to spread, but most experts agree that Africa has had surprisingly few cases and low mortality.

How come Africa is, for once, an exception to a world-wide disaster zone? Could its very poverty somehow give it an advantage?

The answer may actually be yes. This blog has mentioned the theory that vaccines against tuberculosis, polio, and measles/mumps/rubella can stimulate the “innate immunity” branch of the immune system in a nonspecific way, boosting resistance to the novel coronavirus. It now seems that repeated attacks of malaria, and chronic infections with diseases including HIV/AIDS, tuberculosis, syphilis, and schistosomiasis, as experienced by far too many Africans, may bring the same kind of hyperactivation of the immune system providing partial protection from other infections. I noticed one hint of this in my clinical medical practice, when I observed early on that patients who grew up in Subsaharan Africa commonly had what for Europeans would be an abnormally high amount of gamma globulin – a/k/a antibodies – in their blood. I eventually found out that this was a well-described phenomenon, and decided I could start start ignoring that particular finding without further workup if it was merely a sign of an immune system supercharged by multiple challenges from infectious agents. What a wonderful paradox, if it turns out that the constant exposure to devastating diseases has kept Africans from suffering the full brunt of the COVID-19 pandemic!

What is happening in Africa, though, as in the rest of the developing world, is devastation from the cultural and economic repercussions of the pandemic. According to the United Nations, the lockdowns are reversing decades of progress on poverty, healthcare and education, leaving the poorest and the most vulnerable even further behind. 

And the dire economic straits of Western countries during the pandemic are in turn further draining the Third World of resources, as immigrants who collectively sent home $554 billion to their families last year find themselves unable to keep up those remittances. It has been estimated that this shortfall alone will cause between 40 and 60 million people in the developing world to fall into extreme poverty (defined as living on $1.90 per day or less).

Mask, No Mask



Long-time readers know I’ve never been big on masks. I still haven’t lost my suspicion that they lead to a false sense of security (as per the Rome busses jam-packed with masked riders), and recent research from Johns Hopkins tends to confirm my opinion that they are much less valuable than physical distancing for stopping disease spread. Now, though, I’m finding one argument in favor to be fairly persuasive. Two experts think that universal mask-wearing might not only decrease the rate of COVID-19 infection, but could increase the relative rate of asymptomatic or mildly symptomatic disease among people who do get exposed. Here’s their reasoning. They start with the hypothesis that clinical COVID-19 severity may partly depend on the size of the inoculum – the more viral particles get into your body, the sicker you’re likely to get. The evidence for this is good in animals, and suggestive in human beings. They go on to present evidence that universal mask-wearing might cut down both the amount of virus that emerges from a person who’s carrying the coronavirus and the percentage of that smaller amount that gets into the person who gets infected. Completing the syllogism, masking all around should make for milder disease. Plausible, though still to be demonstrated.

No Masks at the White House Department: 
Mike Pompeo coughing into the face of the chief of Israel’s Mossad

Herds of misinformers

I’ve written many times about the terrible proposal that a country could reach herd immunity without a vaccine by allowing the novel coronavirus to burn its way through the population until so many people are immune, 60% or more, that the rest will be protected. Terrible not because it wouldn’t work – it would – but because it would cause unspeakable carnage. Now, though, there is the very real possibility that Donald Trump has already started to use the American people as guinea pigs for the herd immunity fantasy. Under the rosiest of assumptions (getting sick gives you long-lasting immunity, only 65% of the population needs to become immune, and only 2.5% of diagnosed cases will die – in the USA until now 2.9% have died), going for herd immunity would mean more than 5 million Americans dying of COVID-19 and many times more going through hell and/or surviving with severe consequences. What’s my evidence that this is the new favored White House approach? 

1)    Trump’s new favorite pandemic expert, radiologist Scott Atlas, promotes it.

2)    Trump himself has said so, though he garbled “herd immunity” into “herd mentality.”

3)    According to Rachel Maddow the omniscient – it's not easy to assess from public sources – the federal government has quietly stopped telling states with the highest rates of new cases that they should take steps, such as mandating masks and closing bars, that would decrease the rates of infection.

Now, how about already dropped hints that some places might be approaching herd immunity already? Let me start with the case of New York City, begging forgiveness for flogging a horse that’s only half dead and for getting a little wonkish in the process. The New York Times reported a month ago that 27% of coronavirus antibody tests done on New Yorkers had been positive. But that does not mean that 27% of New Yorkers have COVID-19 antibodies, because – as I’ve pointed out several times – tests are done on people who are particularly likely to have been exposed. We already know from better sources that about 7% of New Yorkers had COVID-19 antibodies in April, and eyeballing the curve of diagnosed cases in New York State we can estimate that the percentage will have risen to 10% by mid-August: 


Can we make these various numbers jibe? We know the people being tested are self-selected by having good reason to think they were exposed or infected, and we can assume reasonably that by August a high proportion of the latter – let’s guess 50% – had gotten antibody tests. In New York City as a whole 15% had been tested, of whom 27% tested positive. Twenty-seven percent of 15% means 4% with known infections. Double that, to account for the 50% or so of high-risk individuals who have not yet been tested, and you get 8% – not far from the 10% I estimated using other means. If you look at the hardest-hit part of New York City, the Corona neighborhood in Queens, 23% of the populationhad been tested and fully half of them tested positive. Double that and you can estimate that 23% actually had antibodies against COVID-19 – high, but far from herd immunity levels. 

Then there’s Sweden, which followed something vaguely like the herd immunity strategy without getting the country anywhere within range of success except in achieving per capita death tolls 6-10 times higher than its neighbors. Sweden’s pugnacious chief doc Anders Tegnell seemed for a long time to be placing his bets on herd immunity, which he now denies one day and re-espouses the next. Lately the Swedes have had very few cases and almost no deaths. Because they’ve attained herd immunity? Not a chance. Wild claims that 25% of Stockholm residents were infected in the spring have been roundly refuted by serological studies of blood samples. One found that a mere 3.8% of Swedescountrywide had antibodies to the novel coronavirus, while another found a 6.8% rate in hard-hit Stockholm in June. The real reason Sweden is doing well is because the Swedes have been sensible. The elderly have sheltered in place despite the lack of an obligatory lockdown, whoever can works from home despite not being ordered to, indoor socializing is minimal, people follow WHO advice to keep their distance. And the other reason it’s doing well is that Sweden did eventually limit public gatherings, ban visitors from nursing homes, and start fining or even closing bars and restaurants where the customers were too crowded together.

Herd immunity will remain a mirage until we get a vaccine.

But, hey, herd immunity may actually have been reached in one place, the Brazilian city of Manaus. This spring a devastating COVID-19 epidemic was allowed to decimate the Manaus population without any mitigation measures worth speaking of, and cases have now faded away to nothing. I’ve looked into the numbers. Manaus has about 1.8 million inhabitants. The State it’s in, Amazonas, has double the population, but I’d guess Amazonas’s 127,000 known COVID cases were concentrated almost entirely in the city. Since the ratio of diagnosed to total infections is known to be about 1 to 10, that would suggest about 1.3 million Manaus inhabitants have been infected, 72% of the population. Maybe enough for herd immunity! 


Who’s your pick for Most Outrageous? (Donald Trump disqualified for cheating)


On wearing masks: “It’s reminiscent of the 1930s in Germany, when people on their own bodies were tattooed.”

-        Arizona state representative John Fillmore

On shelter-in-place measures: “Forcible imprisoning of people in their homes against all of their constitutional rights.”

-        Elon Musk

On the Centers for Disease Control: “There are scientists who work for this government who do not want America to get well .  . . these people are all going to hell.”

-       Michael Caputo, saboteur-in-chief (now ex-) of the CDC’s Morbidity and Mortality Weekly Reports 

On containment: “Stopping COVID-19 cases is not the appropriate goal.” On reopening schools: “Worst of all, social distancing rules...”

-       Scott Atlas, radiologist, top advisor on the White House Coronavirus Task Force


On infrared thermometers: “They’re killing us . . . The health authorities don’t want us to know, because they’re all in cahoots with occult powers who want to sell us more medicines.”

-       Dr. José Mena Abud, Mexican dentist 

On how to overcome the pandemic: “The tractor will heal everyone.”

-       Alexander Lukashenko, President of Belarus

The cause of the pandemic: “Same-sex marriage

-        Patriarch Filaret of the Ukraine, currently hospitalized with  COVID-19

 On treating COVID-19: “Bill Gates has had the cure since before the pandemic.”

-       Patrizia Rametti, from Matteo Salvini’s League party

Coronavirus is a cover-up for . . . child sex trafficking”

-       QAnon-inspired email to BBC television

On face masks: “The exhaled viruses will not be able to escape and will concentrate in the nasal passages, enter the olfactory nerves and travel into the brain.”

-       Russell Blaylock, MD, retired neurosurgeon, current snake oil hawker

On anti-COVID-19 measures in general: “Not unlike the divide-and-conquer dehumanization agendas that preceded the Holocaust”

-       Kelly Brogan, “holistic psychiatrist”

On COVID-19: “You can’t catch what doesn’t exist

-       Skin Kerr beauty salon in England



On coronavirus disaster scenarios: “You know what, I’m ready. My daughters aren’t starving to death. I’ll eat my neighbours.”

-       Alex Jones

An oldie but goodie: “5G radiation is greatly stimulating the coronavirus (COVID-19) pandemic and also the major cause of death”

-       Martin L. Pall, PhD

On infrared thermometers: “Aiming a laser ray at our pineal gland for a virus that has a 99.9% survival rate”

-       anonymous Australian nurse

On COVID-19 vaccines: “If you don’t mind aborted baby tissue, fetal tissue, to be injected into you, then go on and get the vaccine.”

Todd Bell, pastor of the Calvary Baptist Church in Sanford, Maine

A California church in August

This fake pandemic was designed to usher in the Evil New World Order and to enslave all people on Earth into a Communist Dictatorship”

-       post on the Facebook page of an Australian politician

Concern about COVID-19: “Just another political stunt . . . There are the obituaries and funeral announcements that are simply not adding up to the actual amount of deaths.”

-       Lisa Malakaua, Hawaiian activist and blogger

Why people get sick: “If God wants me to get Covid, I’ll get Covid.”

-       Don Satterwhite, a Pentecostal minister in Oregon

The cause of the pandemic: “The Jews poisoned the wells.”

-       OK, so the year was 1348, and the disease was the bubonic plague. Same difference.



Sunday, September 6, 2020

COVID-19 in Italy: The Good, The Bad, And The Ugly

 

Viewing Raphael at the Scuderie del Quirinale gallery in Rome  

Treatment updates

Remdesivir: The manufacturer’s announcement I described back in June, reporting peculiar results in patients hospitalized with moderate COVID-19, has now been published. Those randomized to get 10 days of therapy (they actually got an average of 6 days) did no better than controls, while those randomized to get 5 days (they actually got a similar average, 5 days) were marginally better off than controls on day 11, the benefit barely reaching statistical significance. These results were so weak that the researchers themselves felt obliged to describe their results as “of uncertain clinical importance.” Does this drug really deserve its lucrative superstar status?

Tocilizumab: This once-promising drug did no better than placebo, in a proper randomized trial, at bettering clinical status or mortality of severely ill COVID-19 patients at 28 days. The authors considered the trial a bust – but their drug cut the time to hospital discharge by a full week, better than what’s been reported for the above-mentioned remdesivir. Hmmm…

Icatibant: A hypothesis around for many months but highlighted lately claims that bradykinin, a molecule involved in inflammation, holds the key to COVID-19’s mysteries. Now a pilot study of the bradykinin blocker icatibant, very small and methodologically weak, has suggested it might conceivably help some severely ill COVID-19 patients.

Convalescent plasma: In my last post I called the Mayo Clinic study very promising. But, good God, it certainly didn’t suggest, much less prove, that convalescent plasma cures 35% of COVID-19 patients! The US Food and Drug Administration chief who made that outrageous claim did walk it back a smidge a couple of days later, but that’s nowhere near enough. We’re used to the FDA being unduly influenced by Big Pharma, but for the physician-scientist at its helm to tout outright lies to the public, presumably following the President’s wishes, is far far beyond the pale. Stephen Hahn should have resigned on the spot. How will we ever be able to trust in an FDA-approved vaccine?

Designer antibodies: Two companies with products in this convalescent plasma-like category, Eli Lilly and Regeneron, are having enormous trouble getting their treatment trials going in the United States because of . . . lags in testing!!! Italy, a country much poorer in cash and medical resources, is managing to test everybody arriving from high-risk countries, fast. I find it impossible to believe American hospitals can’t manage to even for a well-funded Big Pharma clinical trial.

Vaccines: Italy joined the race, in its small way, on August 24th, injecting a first volunteer with the Grad-COV2 candidate vaccine, hailed by the Italian press. To me it seems premature to inject human beings with a vaccine when all we know about it is that it stimulates the immune system in mice. As far as I can tell it has never been tried in monkeys, and even the vaccinated mice haven’t been challenged with coronavirus. Elsewhere, the Oxford/AstraZeneca vaccine, now called Covidshield, has become the first major contender to run a Phase 3 trial in India; the Russians are belately starting such trials of Sputnik V after approving it for clinical use. And now, in perhaps the worst possible COVID-19 news, Trump has joined Putin in the Cart Before Horse department, strong-arming Anthony Fauci into going along with possible pre-election approval of a half-baked vaccine, risking not just Americans’ faith in vaccines but also their lives.

Mouthwash: Put this one in the Department of Dream On.

Testing: The Centers for Disease Control have been bullied by the White House into quietly issuing a shocking guideline saying that people without symptoms don’t need to get swab testing, even if they’ve been exposed to COVID-19. This negates the very concept of contact tracing, the technique at the core of epidemic control, and means that safe reopening of colleges goes from unlikely to impossible. After the FDA, my trust in another agency crucial to our health bites the dust. In the meantime, a rapid antigen swab test suitable for use in doctors’ offices, the BinaxNOW Covid-19 Ag Card, has been given emergency authorization for American use by the FDA; the manufacturer, Abbott, claims it is much more accurate than its previous rapid swab test, which missed as many as half of COVID-19 cases. This cheap new test could be a game-changer.

Anticoagulation: COVID-19 is characterized by widespread blood clotting, so it makes  sense to treat it with anticoagulants. But several small retrospective studies and autopsy series have failed to show much benefit. Now a larger retrospective study from Mt. Sinai in New York, my medical alma mater, compared hospitalized COVID-19 patients who did vs. didn’t  receive heparin-type anticoagulants  and found that the ones who did were less likely to die. The problem, as for the Detroit study of hydroxychloroquine I tore apart a few posts back, is that “standard care” probably improved over the course of the study, and by the end of the New York City epidemic doctors were prescribing anticoagulants across the board. So patients who received them were likelier to have been hospitalized late in the epidemic, when treatment was better all around. It’s impossible to verify, since the article doesn’t report the average dates of enrollment in the two patient groups.

 

Italy and the coronavirus: The Good

I wish that when we went into lockdown, we looked like Italy. When Italy locked down, I mean, people weren't allowed out of their houses. Americans don't react well to that kind of prohibition.

-       Dr. Deborah Birx, Donald Trump’s Coronavirus Response Coordinator, August 17, 2020

Dear Dr. Birx,

You’re spot on about the Italian lockdown. But Italians don’t react well to “that kind of prohibition” either. On the contrary – they’re famous for sneaking past no-entry signs, smoking under no-smoking signs, barreling along at 80 in 35 mph zones, fastening their seat belts under their butts. The difference is that they’re no fools, they can tell what’s important from what isn’t, and once they understood that their lives depended on it they did the right thing.

-       Susan Levenstein, MD, Rome, Italy

Much of Europe is having to fight off a second wave of COVID-19, with Belgium, France, Spain, and Germany all reinstating some restrictions. Eastern Europe is even worse. The notoriously anarchic Italians are amazing both Americans and themselves by remaining among the winners, with a swab positivity rate hovering around 2%; it’s 6% in the USA. As Roger Cohen wrote before coming down with COVID-19 himself, “Italy coheres and America breaks apart.” 

How come Italy, famed for disorganization, disobedience, and discord, is doing so well? I sketched the reasons for France2 TV:

1)    As Dr. Birx points out admiringly, Italy’s Phase 1 was one of the strictest and lengthiest lockdowns in Europe, with a truly astonishing level of compliance from its population, who for 12 weeks had to carry a pass every time they left home to certify they were out shopping for food or medications (masked and distanced), or walking for exercise. All within 200 yards of home; no driving except to the hospital.

Life under lockdown was made bearable by community and family cohesive spirit, the willingness of corner grocery stores to make deliveries, and the constant availability of products such as surgical face masks, disinfectants, and toilet paper – no T. P. Arias here. 

2)   The virtues of the Italian health care system, welfare state, and political system shone. Nobody pays for primary care visits, hospitalizations, or COVID-19 swabs, medications never cost more than a couple of bucks, most workers have 3-6 months paid sick leave, and despite some leeway for individual regions the central government has generally been able to dictate policy countrywide… A Facebook friend commented that one reason Italy has done well is “Because despite political differences Italian leaders actually care about their citizens.” Imagine!!! In short, Italy has revealed itself to be a civilized, unified country in a sense that the United States is not. 

Currently hospitalized COVID-19 cases: Italy



Currently hospitalized COVID-19 cases: USA


3)    Despite some grumbling, Italy has not seen the anti-mask, open-it-up madness that has trickled in the US from the White House on down.

4)    Italy has been smart about reopening, with almost all regions resisting opening the bars, nightclubs, and discotheques that have contributed to the second wave in Spain and the ongoing disaster in the United States. Lombardy did make a stab at allowing discotheques in June – for outdoor dancing only – but when the authorities saw the crowds on night one they closed them back down. 

5)    Italy is long over the worst of its testing shortage. For months it’s had so few new cases and so many trained trackers that they can do real contact tracing, finding all the people who have spent 15 minutes within 6 feet of, or shared a closed space with, every person who’s tested positive, and quarantining them for 2 weeks. 

6)    The authorities are offering voluntary random spotchecks with free swab tests at locations such as Ikea parking lots, which have turned up many thousands of asymptomatic cases.


7)    Traditional health mania may be contributing to Italians’ unexpected acceptance of the new normal: fearing pesticide residues on the peel, many won’t just pick up an apple and eat it, instead deftly wielding knife (and sometimes fork) to transform the flesh into neat naked quarters.

8)    But, mainly, Italians have on the whole been careful. 

Stores have no trouble enforcing the mask ordinance, and many add obligatory hand disinfection. 

During patient visits we’re both masked, the window wide open, and the air con blowing. I wash even better than usual after each patient and disinfect anything they might have touched, from chair to stethoscope. It’s a drag, but it makes sense. The waiting room is well-ventilated and near-empty – no accompanying family or friends – and all items that risk repeated handling (including alas the copy of my own book) have been removed.

       We’ve attended only one concert. It was not only outdoors, with assigned seats yards apart and masks whenever you stood up, but the organizers gathered names and phone numbers in case they needed to trace contacts.


We saw the marvelous Raphael exhibition at the Scuderie del Quirinale, twice. Masked groups of six were ushered between one room and the next every five minutes at the sound of a bell. I’d have appreciated another couple of minutes per room, but it all felt perfectly safe. Again, names and phone numbers all around.

One of the joys of emerging from quarantine was scoring an appointment with my hairdresser (he was strictly walkin in the past). Masks, distancing, judiciously worn gloves...

We haven’t eaten indoors in the presence of other people yet, but we’ve enjoyed several tiny social dinners in courtyards or on terraces. All my patients claim to follow the same strategy, though I admit they’re no random sample.

 

Italy and the coronavirus: The Bad 

Italy may be avoiding a second wave, but it has had a ripple. New cases have crept up from 200 a day during July to 1200-1700 now. Recent cases are evenly divided among three groups: people tested because of symptoms, cases detected by tracing and testing the contacts of COVID-19 patients, and asymptomatic cases detected by random mass screening.

What went wrong?

High jinks 

Italy isn’t immune to the raves where young people have been blowing off steam in Europe. There was a rash of indoor bashes in northern Italy back in June. Now, with Carabinieri finding and fining many of the organizers, the ravers seem to at least be sticking to open fields, which are less coronavirus-friendly even without masks. In Rome some discotheques have tried opening on the sly, and gotten busted. The Rome police have even sealed off some of the most popular hangout piazzas – Bologna, Santa Maria in Trastevere, Trilussa.



Vacationers

Several regions, notably Tuscany and Sardinia where young vacationers are the backbone of the summer economy, defied the national shutdown of dance locales, and irresponsible youth (is there any other kind?) have fueled Italy’s modest second wave. Hundreds returning home from fancy Sardinian vacation spots have carried the virus all across Italy. In one locale, modestly named The Billionaire, half the staff including the jet-set owner have tested positive for COVID-19, and at least one wound up on a ventilator. Their clients all left coordinates for contact tracing, but lots of the names and cell numbers have turned out to be phony, reducing the health authorities to making public appeals for club-hoppers to get tested.


The Billionaire, Flavio Briatore's Sardinian nightclub

I have to say if there’s any circumstance the bug can be caught out of doors it’s the groups of 20-year-olds piled up on Italian beaches, making out en masse. And when is “outdoors” not outdoors? When it’s one of those vast Italian discotheques whose dance floor is only nominally outside.  


A Lumbardy discotheque with “outdoor” dancing, reshuttered after one night

Globe-trotters

The disease is also being imported by Italians returning from foreign vacations, especially young nightclubbers, driving the average age of newly diagnosed cases down to 30. Italy now requires everybody returning from Spain, Greece, Croatia, or Malta to be swabbed for COVID-19 shortly before or after arriving. It’s gone surprisingly smoothly, with rapid testing centers set up in boat ports and airports – results within an hour – and a mushrooming of drive-by locations that email results in 24-48 hours.


A drive-by swab center. The sign says "Don't get out of your car"

Furriners

Many of Italy’s newly diagnosed COVID-19 cases have been among foreigners. Some have Italian residency but slip in from high-risk countries, often aware that they have been exposed to the virus. Huge outbreaks have been documented in the Bangladeshi community, with well-publicized cases of swab-positive immigrants landing in Italy with fake no-COVID certificates or sneaking out of self-isolation to bum around on trains and busses, spreading the virus as they go. Rumanians, too, were sneaking over the border, by the nocturnal busload and in private cars. Italy responded by cancelling flights from Bangladesh, ordering returning Rumanians to quarantine, and performing mass testing in both communities. Other hotspots involved Nigerian farm workers and camps holding illegal migrants – hundreds of African “boat people” have, not unreasonably, fled from crowded detention centers when fellow-inmates started to test positive. 

With the minisurge in cases, the number of COVID-19 patients in Italian ICUs has nearly tripled. The death rate lags, staying mostly in the single digits since the last week of July. And with ICU patients now much younger than in Italy’s dreadful first wave, and younger COVID-19 patients are more likely to survive an ICU stay, perhaps the death rate will stay low…




Degrees of nuts

American colleges opened complete with frat houses, karaoke bars, and bacchanals: 51,000 cases among students as of September 3rd, including 800+ at the University of Iowa and North Carolina State, 1300+ at the University of Alabama. San Quentin imported the disease more or less deliberately from another California prison: 2100 cases and 19 deaths. Over-the-top weddings and undistanced schools have handed Israel a second wave many times worse than the first and still ongoing

Ultra-Orthodox wedding in Israel, August 2020


Israel's first and second waves of COVID-19

The frightening Australian second wave has apparently been fed by hotel staff who were extorting sex from recent arrivals in return for letting them sneak out in defiance of quarantine. Spain, despite having peaked at over 9000 new cases in one day and briefly rivaling the US in daily cases per capita, is still allowing indoor bars and nightclubs to stay open, at only slightly reduced capacity. Trump isn’t the only COVID-19 idiot around.

Italy has dodged those bullets, but people are definitely getting sloppier. Even when they obey the requisite 3 feet of physical distancing it seems paltry. I actually felt a momentary shock when friends sent a photograph of 10 of them sitting, “distanced,” at an indoor restaurant table. 

Around Rome moderate prudence seems the norm. Lots of masks even out on the street, one customer at a time in small shops. Supermarkets aren’t overcrowded, no lines on the sidewalk, but there’s not much distancing once you get inside; people seem to think if you’re wearing a mask you can get as close as you want. Coffee bars vary, with some unfussy about masks or distancing, but the risk is relatively minor given the Italian way of coffee: drop in, knock one back, and head out the wide-open door within five minutes.

Outside the big city I gather things are different. Small-town spies tell me they see folks greeting each other with baci e abbracci – hugs and kisses – and visiting indoors cheek by jowl. 

Official Italy is slipping too. The careful screening of incoming travellers seems to have gone by the boards. My husband and I, arriving on a flight from Paris but on a journey originating in the United States, were interrogated in detail and had to provide an address and telephone number for where we would spend our quarantine – the health authorities phoned to check on us every single day. Lately if you’re not coming from a high-risk location they just wave you through. (They’re doing a good job of ensuring people coming in from Spain etc. get tested, though they really ought to make them have a second swab a few days later.)

Public transport is supposed to run more frequently and to plaster “Do Not Sit Here” signs on half the seats, and private cars are being allowed into the closed center of Rome to ease the burden on busses. But the second time I took a tram I waited nearly 20 minutes, the car was packed, the windows were sealed shut, and all the Do Not Sit Here places were occupied. No more public vehicles for me… At least everyone was masked. 


Busses: the dream

Rome bus: the reality


Polls say that if a vaccine against COVID-19 were available, 41% of Italians would probably not choose to get it. But that percentage is about the same in the United States – where one preacher in Maine has told his flocks that the new vaccines contain “aborted baby tissue” – and in Germany, another safe home for no-vaxxers.

Putting food on the table

The coronavirus pandemic has taken an enormous toll on an already frayed Italian economy, though the Financial Times and the New York Times think they’ve done pretty well at juggling money and lives. The economy had been creeping back after the 2009 crash, with official unemployment (considered an underestimate) finally dipping below 10% last year after a peak of 12.7%. Now it’s back only to 11%, but experts call this relative stability “an optical illusion.” The worst hit have been the young, concentrated in decimated industries such as tourism and hired on temporary contracts. Throughout the pandemic half of Italians fear their jobs are at risk, and half of the newly jobless are under 35. 

Italy’s second quarter GDP is down 18% from last year, and at its lowest level since 1995. Pandemic aid packages have expanded Italy’s budget deficit to 12% of GDP and public debt to 162% of GDP – the EU fortunately responded by temporarily suspending its fiscal rules and providing cash support for the labor market.

Many ordinary folk have had €600 ($710) wired into their bank accounts a couple of times, a pittance, and only if they’ve been paying their taxes properly. The already desperate millions working under the table in the “black” economy are eligible for nothing at all. Government assistance has given some small businesses enough of a windfall to make up most of their lost income, and the strings attached requiring workers be kept on the books have avoided some layoffs. But, again, people working off the books or in the gig economy, and small-time independent contractors, are up shit creek. In June 45% of Italians said their income had dropped due to the pandemic and another 35% expected it would.

I ask every patient who comes into my office, and every friend, how they’ve been bearing up under the strain of the moment. Several have burst into tears. Early in the lockdown Italians kept going on shock and community spirit, but once the adrenalin ran down anxiety and depression took over. I’ve heard of 4 suicides.

I commented to one Italian friend who’s old enough to remember World War II that this was the first time since then that people had to tolerate such disruption of their lives. He agreed but added, wisely, “The pandemic is worse. During the war we still had our dreams.” Now people everywhere have lost all sense of the future, and their dreams along with it. 

 

Italy and the coronavirus: The Ugly 

Build The Wall

The ugliest is the neotrumpian antiimigrant frenzy being whipped up by the country’s right wing in the persons of frankly fascist Giorgia Meloni and merely racist Matteo Salvini. As I’ve said, many of the cases in the recent COVID-19 surgelet have been among foreigners. But by far most are Italian born, bred, and transmitted.

Open it up

Andrea Bocelli singing in Milan’s Cathedral


Marginally less ugly are the varieties of COVID-19 minimizers.

As Italian deaths fell mutterings about herd immunity arrived – is there less disease around because by now everybody’s immune? No! No! A thousand times no! In Milan, an epicenter of the Italian epidemic, mass antibody testing was done recently on bus drivers who had worked at its peak and would have been at extremely high risk. Only 7.7% were positive. A similar rate of coronavirus exposure was found in Milan blood donors in early April. In Rome’s Lazio region, in mid-June, the antibody positivity rate was only 2.4% among people who chose to be tested, the likeliest to be positive. 

With less disease around, the sabotage to mitigation measures is heating up a little. A few professorial types blast the lockdown after the fact. The prominent publicity-hound physician Alberto Zangrillo continues to minimizedenying the threat of a resurgence even as his long-time patient Silvio Berlusconi is hospitalized for COVID-19 double pneumonia. It comes as no surprise that right-wing leaders such as the League’s Matteo Salvini are too macho to wear face masks, but I was saddened to hear Andrea Bocelli, the blind kind-of-sort-of tenor, boast on TV that he used to sneak out of his houseduring the lockdown. Ummm, might that explain why he and his entire family got sick with COVID-19? Says Bocelli: “I know lots of people, and I don’t know anybody who wound up in intensive care. So who says it’s serious?” 

None of this comes anywhere near the levels of protest and resistance seen in the United States, though, or even Germany – there unmasked and crowded tens of thousands turn out for protests waving Imperial cum Nazi flags and hoping that Donald Trump will “Save them all.” A right-wing COVID-denier Rome demo on September 5th drew only 1500 people.

COVID denier demo in Germany


At bottom, Italians may simply have more common sense than Germans. Just take a look at pictures of those right-wing rallies. Even at Salvini’s blame-the-immigrants open-it-up events you can see plenty of masks, though admittedly not all cover the nose.

Matteo Salvini COVID denier demo in Ventimiglia