Wednesday, October 21, 2020



Treatment update

Remdesivir, the ACTT-1 Study: The final results of the Adaptive Covid-19 Treatment Trial, treating patients moderately ill with COVID-19 pneumonia, have now been published and are consistent with the preliminary report a few months back: remdesivir shortened the average hospital stay from 15 days to 10, with a hint of lower mortality. OK, but not extremely impressive.

Remdesivir, the Solidarity Study: Results of the giant, open-label World Health Organization trial have now been pre-published, and at first glance seem damning: remdesivir didn’t improve ventilation rates, time to discharge, or mortality. But the report doesn’t say how long patients had had symptoms before starting the study medications. Nearly 3 out of 4 were either on oxygen or already on a ventilator, so had likely been sick for quite a while. Any antiviral is likely to work better the earlier it’s given, so these negative results need to be taken with a grain of salt.

Hydroxychloroquine: The final results of the UK’s large, randomized Recovery trial are in. It had to be stopped early, when interim analyses showed that hydroxychloroquine patients were significantly less likely to leave the hospital alive within 4 weeks and more likely to wind up either on a respirator or dead. Anyone still having hydroxychloroquine dreams should wake up.

SACCOVIDTM – A new drug from OncoImmune, Inc., who describe it as “an investigational immunomodulator targeting the innate immune system” whatever that means. The manufacturers describe interim data from a randomized, double-blind clinical trial where 203 American inpatients receiving only oxygen therapy received a single intravenous infusion of Saccovid or placebo. Those who received active drug died or needed a ventilator half as often as those who received placebo, and recovered more often and faster. This is particularly interesting because our one valid immune drug, dexamethasone, works only in far-advanced cases. If these data are bourne out by final, published results, the drug could be a major breakthrough.

LY-CoV555On September 16th Eli Lilly announced preliminary results using this monoclonal antibody, and they sounded great. Among 452 COVID-19 outpatients with mild-moderate symptoms, the drug supposedly achieved a remarkable 72% reduction in the need for hospitalization, from 6% after 3 doses of placebo to 1.7% after 3 doses of antibody, without significant side effects. BUT: a different trial, testing the same product in hospitalized patients, has suddenly been halted due to a “potential safety issue.” Did some awful side effect pop up? Did early results show patients got worse rather than better? The company ain’t saying. 

REGN-COV2: Two weeks later than Eli Lilly, Regeneron announced somewhat less impressive results using its own antibody cocktail vs. placebo, claiming only that patients who received active drug got better faster and had lower viral loads. They may have lost to Lilly in the race to announce results, but they won hands-down in the publicity department when their concoction was the one administered to Donald Trump. And now that safety concerns have forced one Lilly trial to grind at least temporarily to a halt, Regeneron is pulling still further ahead. They’re promising to distribute their product free of charge in the US but it will be sharply rationed – there are only 50,000 doses for more than 2 ½ million active cases. 

Another contender:  The Eli Lilly and Regeneron concoctions have been joined by an antibody trio perfected by researchers at Berlin’s Charité Hospital. It seems to prevent COVID-19 infection and to lessen disease after a viral challenge – in hamsters. Promising but very preliminary.

I do wonder whether all monoclonal antibody treatments might diminish a patient’s ability to produce his or her own antibodies, in which case short-term benefit might come at the cost of losing longer-term immunity. The antibody vendors must know the answer to that one by now, but they’re not telling.

Vitamin D: People with severe COVID-19 often have low blood levels of vitamin D, but this finding is hopelessly confounded by patients’ preexisting state of health – the frail and sick don’t get much sun. Now a small Spanish study randomized placebo-controlled trial of vitamin D in hospitalized patients with moderate COVID-19 has reported great results. Maybe too great, in my opinion – 50% of placebo recipients vs. 2% in the vitamin D group landed in the ICU. No medication for COVID-19 has had anywhere near that miraculous and impact on any outcome. But moderate doses of vitamin D are safe, and a case can be made for giving supplements to D-deficient COVID-19 patients. A bigger study, aiming at prevention rather than treatment, is now underway in the UK.

Tocilizumab (Actrema)One randomized, double-blind, placebo-controlled trial among hospitalized patients with COVID-19 pneumonia found only a somewhat shorter hospital stay in survivors. Now the manufacturer announcesthat in a second one those getting the drug were less likely to need ventilators but just as likely to die, and stayed in the hospital just as long. I am unimpressed.

Breast milk: Chinese scientists are suggesting that human breast milk might help prevent or treat Covid-19. What to make of that?


Johnson & Johnson/Janssen: I fell in love with their JNJ-78436735 vaccine. It requires only one dose rather than two, and is stable for months under refrigeration (no freezer needed). It worked well in monkeys, both for immune reactionand symptoms, though the symptom study used two doses of vaccine and didn’t do lung biopsies to prove its case. In Phase 1-2 human studies a single dose stimulated both antibody production and T-cell immunity – at the cost of some flu-like symptoms that fortunately hit older volunteers less. Their Phase 3 trial’s research protocol beats those of Moderna, AstraZeneca, or Pfizer hands down. First, their primary endpoint is not “any COVID-19” but “moderate-severe COVID-19,” including in older volunteers. Second, they plan to enroll 60,000 subjects, twice as many as their competitors. Third, they’ve picked high-risk locations in Argentina, Brazil, Chile, Colombia, Mexico, Peru, South Africa, and the United States. Fourth, they require 2 months of follow-up for complications. And, finally, they’ve ruled out premature peeks at their results. BUT: the JNJ-78436735 story sadly hit a wall on October 13th – all its trials were halted because of an unspecified disease in a volunteer. As I write we don’t even know whether that trial participant received vaccine or placebo, much less any medical details.

Moderna: According to their latest article, their mRNA-1273 vaccine produced an immune response in 20 people over 55, including 10 between 71 and 74. Similar results have been reported by Pfizer and, in a much larger group, by Johnson & Johnson. AstraZeneca and the major Chinese researchers have have only used younger research subjects.

Pfizer: This company, which has the weakest Phase 3 protocol of all for its BNT162b2 vaccine, for weeks conducted a shameless publicity campaign boasting that theirs will be the first vaccine approved in the United States, with hints at filing for an emergency authorization from the US Food and Drug Administration by the end of October, in time to give Trump an electoral boost. This was so outrageous, both scientifically and ethically, that 60 of America’s top physicians felt compelled to write a letter to the Pfizer CEO begging him not to do so. On October 15th, he finally ate his words and said that application wouldn’t be filed until at least the second half of November. (Phase 1-2 results showing the vaccine was safe and stimulated an adequate immune response, prepublished back in August, have now come out in final form.)

Astrazeneca: The Phase 3 trial of one of the top vaccine contenders remains in limbo after the development of neurological conditions in two trial volunteers (one in July, one in September). The Food and Drug Administration is still reviewing safety data before it allows more subjects to be enrolled in the United States – news unlikely to reassure the vaccine manufacturers, or the public. 

Novavax: This US-based vaccine company, part of the Warp Speed gang, is a new entry for me – I missed its studies in monkeys, which showed a robust immune response, protection against colonization in the nose or the lungs after challenge with the novel coronavirus, and near-total prevention of lung disease. And its Phase 1-2 results in 105 volunteers, published at the beginning of September, which said the vaccine was safe and elicited a robust immune response. A Phase 3 trial kicked in 4 weeks later but’s it’s awfully small – even if they get all the 10,000 subjects they’re aiming at, there may not be enough COVID-19 cases among them to tell whether the vaccine actually works. They haven’t yet published their research protocol, but judging from the company’s announcement it steers clear of two major pitfalls: moderate-severe COVID-19 is a primary endpoint, and they’re not planning on premature interim analyses.

Down Under: A candidate vaccine developed at the University of Queensland in Australia has done well in hamsters, according to a press release. The first human volunteers were enrolled in mid-July, and Phase 3 studies are planned to start around the end of the the year. But thus far, as far I can tell, not a word of actual data has been published, prepublished, or even announced.

Human challenge trials: Buckle up. British researchers who have been threatening for months to deliberately infect human volunteers with COVID-19 in the name of speeding vaccine development are now plowing ahead. In January they’ll start puffing coronavirus into the noses of healthy young volunteers, to determine the minimal number of viral particles that will produce a measurable infection. Several months later they’ll enlist another bunch of volunteers, shoot them up with various vaccines, expose them to that minimal dose of coronavirus, and see what happens. The unethical nature of the whole endeavor – never in modern medical history has such a trial been done with an untreatable and potentially fatal germ – is in my opinion worsened by the plan to pay subjects something like $5000 for their participation. Even its main justification is questionable: by late spring, when the challenge studies finish, all the major vaccine contenders will already have the final results of their large-scale Phase 3 trials in COVID-19 hot spots.

Getting emergency approval for vaccines in the US

All but one of Phase 3 protocols share 3 worrying weaknesses:

1)    Trial subjects won’t be observed for long enough after vaccination for us to feel reasonably confident no major side effects are going to pop up;

2)    Trials can be stopped after very early peeks at the data, if a very few patients (32, for Pfizer) have gotten sick;

3)    Getting sick is defined as a positive COVID-19 swab pus even the most minimal of symptoms, such as a sore throat. 

Only Johnson & Johnson has ducked these bullets, and its trials are unfortunately on hold.

The US Food and Drug Administration developed its own, stricter criteria for emergency-use authorization. Incredibly, the White House attempted to block them, in hopes that some half-baked vaccine might get approval, possibly from Health and Human Services Secretary Alex Azar – bypassing the FDA – before the November election. On October 6th, though, the Food and Drug Administration released their guidelines anyway. They define criteria for stopping trials early, require evidence that the vaccine prevents not just any COVID-19 but moderate-severe COVID-19, and demand that trial subjects be followed for possible vaccine side effects for at least 2 months after their second dose. The White House finally cried uncle and approved the guidelines – after they’d been posted. In the latest New England Journal of Medicine, FDA officials lay out their rationale for requiring lengthier follow-up, noting concerns that vaccine-induced immunity could fade quickly and observing that the World Health Organization requires a median 3 months' follow-up for COVID-19 vaccines in its own emergency use program. 


RED ALERT stampeding herds 

The real COVID-19 news of the week is bad: the White House’s all-out embrace of the herd immunity strategy, after they ran it up the flagpole a month ago and nobody saluted. I have dealt with this rotten idea before (see Surprises from Africa  to October and Got Them Phase In, Phase Out, Out of Phase Blues) but gladly repeat myself. Herd immunity, as the head of the World Health Organization recently reminded us, is a concept developed to help decide how many people need to be vaccinated in order for the unvaccinated to be protected. It would be, as the organization patiently explains, unethical to apply the concept to pandemic containment. Allowing the novel coronavirus to burn its way unchecked through the population of the United States, even with some attempt to shield the vulnerable (see RED ALERT Europe below), would lead to between 2 and 5 million COVID-19 deaths, and leave tens of millions of survivors with long-lasting symptoms ranging from exhaustion to brain fog to shortness of breath to heart failure – 10% of all COVID-19 patients become long-haulers.

The main instigator of herd madness is Trump’s chief advisor, radiologist Scott Atlas. He has now been backed up by a document portentously named the Great Barrington Declaration (Great Barrington, Mass., is home to a Koch brothers-funded think tank). This concludes: “Those who are not vulnerable [i.e. community-living, generally healthy people under age 65] should immediately be allowed to resume life as normal. Simple hygiene measures, such as hand washing and staying home when sick should be practiced by everyone to reduce the herd immunity threshold. Schools and universities should be open for in-person teaching. Extracurricular activities, such as sports, should be resumed. Young low-risk adults should work normally, rather than from home. Restaurants and other businesses should open. Arts, music, sport and other cultural activities should resume.” Tell that to the families of the more than 40,000Americans under 65 – about 2000 of them under 35 – who have died of COVID-19. Or to the myriad people with “mild” COVID-19 who remain sick for weeksmonths, or perhaps forever.

The star Declaration signatories were 3: 

1)    Jay Bhattacharya, a Stanford epidemiologist and co-author with John Ioannidis of the infamous Santa Clara County pseudostudy of coronavirus antibody prevalence; 
2)  Sunetra Gupta of Oxford, best known for having come up in late July with the fantasy that the UK had already achieved natural herd immunity. Look at what happened in the UK just a month later:

3) Martin Kulldorff, a Harvard biostatistician with no pre-pandemic history of madness or skullduggery that I know of. 

The names of some of the other distinguished scientists who signed the Declaration, such as Dr. Johnny Bananas, Professor Cominic Dummings, Dr. I.P. Freely, Dr. Johnny Fartpants, and Dr. Person Fakename, may have been purged, but their presence in the original list speaks volumes about the credibility of the whole endeavor.

Other signatories have admitted ignorance: “I don’t know exactly how it would work,” “Measures for preventing coronavirus transmission are not my area of expertise.”

Within hours of the herd immunity news Anthony Fauci had labelled it “total nonsense”; other experts call it “ghastly,” “a dangerous fallacy,” “dangerous,” “mass murder,” and “a recipe for carnage.” You should know that Fauci, who is now being attacked openly by Donald Trump, has had to hire security to protect himself and his family after receiving death threats.

(When you mention herd immunity, somebody will jump in and say “Sweden.” I suggest you read Gretchen Vogel's excellent article.) 

Then there’s Manaus. In Surprises from Africa to October I suggested this city in Brazil’s Amazon region might be the only place in the world to have achieved herd immunity, following an absolutely horrendous COVID-19 epidemic. I guesstimated that 72% of the population of Manaus might have antibodies to COVID-19. Well, now Brazilian scientists with access to real data have prepublished an article concluding the real number is 66%. Can I pat myself on the back? …But even that 66% may not be enough for herd immunity, since Manaus is now seeing another surge in cases and hospitalizations.


Digging mass graves for Manaus COVID victims, April 2020

The White House seal of approval makes it likely that the slash-and-burn herd immunity idea, rather than remaining on the fringes where it belongs, may actually be put into place as a concrete strategy. Especially in the Trumpian heartland, where Republican governors follow their leader, and where masks, distancing, and other mitigation measures happen to be most needed at the moment. COVID-19 is on the attack in hitherto unlikely spots in deep-red Nebraska, Iowa, North and South Dakota, and Wyoming, plus Mississippi, Alabama, Tennessee, Oklahoma, Missouri, Kentucky, Indiana, and Minnesota. In the swing state of Wisconsin, the ICUs are so full they’re having to open field hospitals. 

One concrete way the White House is trying to implement the herd immunity strategy is by actively discouraging testing of asymptomatic people, and tracing/quarantining contacts. Herdist-in-chief Scott Atlas said, “When you start seeking out and testing asymptomatic people, you are destroying the workforce.” Is the guy simply, as one expert suggested, “In over his head”? 



The herd immunity debate can learn from Italy’s experience. My adoptive country succeeded better than most other European countries at tamping down the pandemic. At the end of the summer, though, a second wave started in 20-somethings who got the bug partying on vacation – the mean age of new cases was 30. Just what herd immunity champions want, right? But young adults do occasionally see their parents, eat in restaurants, work out in gyms alongside older people . . . so by now the average age is up to 42 or 43, COVID-19 wards are being reopened, and the number of COVID-19 patients in Italian ICUs has gone from 40-ish in mid-August to 870 on October 20th. In Rome’s Lazio region two-thirds of the dedicated COVID-19 ICU beds are now full, with some hospitals overflowing. I feel the coronavirus’s grip tightening around me – for the first time in my 5 months back in Rome friends and patients are getting sick or being exposed, with barely a day passing without a request for advice.

The daily death toll is only just started to rise, but on October 20, terrifyingly, Italy had such a bad day and the United States such a good day that their number of deaths per million was an identical 1.5. 

The vast majority of new cases in Italy are transmitted within families, so I fantasize the young folk may have already infected nearly all the parents they can, so the second wave might be close to peaking. But Italy’s contact-tracing system is starting to be overwhelmed, and the government’s solutions (2 new COVID-19 decrees in the last week) are far from adequate. Yeah, ice cream parlors that don’t serve sit-down will have to close at 6 pm, staggered school hours may thin out the crowds on busses, and people are being encouraged to work from home. But that’s about it. They’re leaving the gyms open, allowing restaurants to keep serving customers indoors, stuck to the distancing standard of only 1 meter (3 feet), inadequately tutoring households on how to isolate COVID-19-positive members, and leaving the busses at “80%” capacity (and even that minimal limitation is never enforced).

Social non-distancing at an Italian restaurant, September 2020

Italy remains one of the best-off countries in Europe. Things are horrific in the UK, Spain, France, Switzerland, and much of eastern Europe such as Poland and the Czech Republic, with reopening plans getting rolled back everywhere. Even virtuous Germany, which beats out all the other major Western countries, has had to announce curfews for bars and restaurants and new limits on gatherings in places like Berlin where cases are rising.


RED ALERT TRUMP: The most dangerous COVID-19 lies at his Oct. 15 town hall

On herd immunity: Moderator: “Do you support herd immunity as a strategy? Essentially, just let people get sick?” Trump: “The cure can not be worse than the problem itself.” (Hey, wasn’t that a yes-or-no question?)

On protection against COVID-19: “You have a report coming out two days ago, that 85% of the people wearing masks catch it.” (Proving that one wrong isn’t rocket science.)

On advisor Scott Atlas and COVID-19: “He’s one of the great experts of the world.” (He’s a radiologist.) 

On observed vs. expected deaths during the pandemic: “We’re a winner on the excess mortality. And what we’ve done has been amazing. And we have done an amazing job. And it’s rounding the corner.” (US excess mortality is actually one of the highest in the world.) About that corner we’re rounding, here’s the map of new cases in the week ending October 17th:

On health insurance: “We’re always protecting people with pre-existing conditions.” (Trump’s lawsuit to remove those protections will be considered by the Supreme Court this fall  – COVID-19 would be a pre-existing condition for millions of Americans.)

On QAnon:  “They are very strongly against pedophilia. And I agree with that.” Moderator: “But there’s not a Satanic pedophile cult being run by- Trump: “I have no idea.” (Not COVID-19, but I couldn’t resist.)

On being personally in debt for $421 million: “When you look at that, the amount of money, $400 million is a peanut.” (Ditto.)


Would that it were!

Curious how the Dems managed to pull the wool over your eyes? This guy knows: “Lawyer Dr. Reiner Fuellmich . . . is seeking to file an international class action suit for crimes perpetrated by those who he says used fraudulent testing to engineer a fraudulent pandemic.”

Tuesday, October 6, 2020

Stethoscope Extra: A Few Quick Thoughts on Presidential COVID

Donald Trump has COVID-19. No surprise – he disdains masks and those who wear them, and doesn’t even pretend to keep his distance including in closed spaces with other people. People in his West  Wing behave as though the pandemic didn’t exist, using frequent testing as a manly substitute for all that other wussy stuff. Since the rapid tests they use miss about 50% of COVID-19 cases, it was inevitable that the disease would penetrate the White House walls sooner or later.

Everything you are being told about his illness is spin. No surprise there either – the man is a pathological liar who recruits liars to his inner circle, and who happens to be obsessed with seeming fit, systematically hiding potentially negative information about his health.


Where he got it

Hope Hicks was sick enough on Wednesday, September 30th.that she was given a separate room on Air Force 1. That day Trump’s aides thought their boss seemed under the weather, before a COVID-19 rapid test was positive Thursday. Impossible to say whether Hicks gave it to him, he gave it to her, or – more likely – they both got it from a third person.

The third party was likely to have been one of the guests at a real party, the super-spreader Barrett nomination celebration on Saturday September 26th, 4 days before Hicks and Trump fell ill (a classic incubation period). At least 7 other attendees are known to have tested positive. Coney Barrett herself is not responsible for the White House outbreak, because she already had COVID-19 months ago. Though the announcement of the nomination was made outdoors, where it’s harder to transmit disease, it turns out there was also an indoor reception inside the White House afterwards. No masks, no physical distancing:

The White House attempted to keep Hicks’s illness secret. and probably would have tried to do the same with Trump’s if he hadn’t gotten too sick. We only found out because someone leaked the swab tests to Bloomberg news. 

The people around Trump are dropping serially into the COVID-19 chasm, from Melania to Hicks to Kellyanne Conway to personal assistant Nick Luna, campaign manager Bill Stepien, chair of the Republican National Committee Ronna McDaniel, advisor Chris Christie, and press secretary Kayleigh McEnany. Not to speak of Senators Mike Lee and Thom Tillis, whose diagnoses may disrupt Republicans’ rush to fill RBG’s Supreme Court seat as well as Tillis’s own re-election campaign. Some other staff and guests have tested negative, but even the best PCR tests for COVID-19 – and we don’t know whether that’s what they’re using – have a real-life false negative rate between 3% and 37%.


Whom he’s exposed

If you have been exposed to someone with COVID-19, you immediately go into quarantine for 2 weeks on the chance you too might have the disease. Not our President, who knew Wednesday at the latest that his close advisor Hicks was ill. 

The most infectious period for is from two days before a patient develops symptoms through the first day they feel ill. Aides and journalists thought Trump seemed unwell on Wednesday, but let’s say charitably that he became ill only on Thursday when his test came out positive, so Tuesday Wednesday Thursday were the worst days for disease transmission. 

Tuesday, of course, was the “debate” where Trump spent 98 minutes yelling and spitting at Joe Biden from a 10-foot distance. Fortunately Biden is fairly unlikely to have been infected, because he was almost certainly beyond the reach of droplets, and because aerosols are relatively unlikely to be active at that distance. So far he seems well and has tested negative, but only time will tell.

On Wednesday, the journalists and Air Force personnel on the Presidential plane unwittingly shared their space not only with an unmasked and infectious President but with an unmasked Hope Hicks who was already thought to have COVID-19. Trump also hung out at close quarters with reporters at the White House and held a rally in Minnesota, where he schmoozed unmasked with local Republican heavies and attended a fundraiser inside a private home.

On Thursday, already feeling unwell and fully aware of Hicks’s diagnosis, Trump went to a $250,000 a head fund-raiser in New Jersey and knowingly exposed dozens of his own donors.

On Sunday he insisted on exposing his Secret Service protectors by leaving the hospital for a photo-op jaunt deemed “Insanity” by Dr. James Phillips, a physician in the very hospital where Trump was being treated. This showed utter disregard for the health and the lives of his companions in the hermetically sealed vehicle.

Monday evening Trump wore a face mask on his way home from Walter Reed, but he removed it as soon as he crossed the threshold. This may have been because he was having such a hard time breathing through it, and he may have replaced it as soon as he caught his breath, to protect the hundreds of staffers inside the White House. I wouldn’t bet on it.


How are exposed people being protected?

They’re not. A Centers for Disease Control team is standing by to do contact tracing, but the White House hasn’t called them in, and has declared it has no plans even to track down, test, or quarantine the attendees at the Barrett and Bedminster events.

None of the journalists who rode on the Presidential airplane on Wednesday were told, at the time or afterward, that they were being exposed. They only found out from the media.

All the people in Trump’s inner circle should be in quarantine, from Ivanka to Jared to Mark Meadows to Trump’s debate prepper Rudy Giuliani (whose bad cough means he’s likely infected, whatever the swabs say). Instead, they’re out in the world, with Mike Pence insisting he’s heading to Utah for the vice-presidential debate this Wednesday. 

Did Pence really have no contact with any of those infected people within the last two weeks? Didn’t sit in a room close to the President or the campaign manager or the rest? Hard to believe, and if he did have contact he should be in quarantine. If necessary, he and Kamala Harris can hold their debate virtually.


The medication non-scandal

Much is being made of Trump’s supposedly receiving unique and untested cocktails of medications that could be doing heavens knows what kind of harm. There’s plenty of mystery and scandal in the story of his illness, but in my opinion his therapy does not fall into either category. 

Remdesivir, given daily for 5 days, is an antiviral which may shorten the course of COVID-19 patients though it’s never been shown to save lives or prevent deterioration to ventilator dependency. The earlier any antiviral drug is given – e.g. acyclovir for shingles or Tamiflu for influenza – the better it works, so the only reason ordinary folk aren’t starting courses of remdesivir the moment they test positive for COVID-19 is that it requires intravenous infusion. It made sense to give this as early as possible.

Monoclonal antibody medications are similar to convalescent plasma therapy in that they give you somebody else’s antibodies, but they the fancy antibody cocktails are concocted to be particularly high-dose. They, too, are believed to work better in neutralizing the coronavirus if they are given soon after a person is infected. Later, the amount of virus  in the body can become so great that it overcomes the neutralizing capacity of those external antibodies. And still later, the patient produces enough of his or her own antibodies that the ones being infused don’t add anything. I am somewhat surprised that the White House medical team chose to administer the Regeneron antibody cocktail, which judging from the company’s own statement has had somewhat less impressive results than the similar produced made by Eli Lilly, which reportedly reduced by 72% the need for hospitalization among COVID-19 patients receiving a dose early. 

Oxygen: COVID-19 patients need it only if they have pneumonia, a condition where infected fluid deep in the tiny air spaces of the lungs prevents sufficient oxygen from getting into the blood. The fact that oxygen was administered to Trump on Friday means he definitely had developed COVID-19 pneumonia early on, though his doctors have scrupulously avoided using the word.

We also know that Trump has relatively severe pneumonia, because he is being given the steroid, dexamethasone. This drug is never given to patients with mild or moderate COVID-19, because it does not help and may even made things worse. Note that all steroids hep you up, and they can make even the stablest person act off the wall. So dexamethasone side effects may have contributed to Trump’s poor judgement in making a foolhardy political theater field trip outside the hospital on Sunday. (I’m being generous…)

None of the doctors have mentioned blood thinners, but he almost certainly is receiving them, because that’s fairly standard treatment for anyone with COVID-19 who is ill enough to be hospitalized and therefore considered at high risk for blood clots.

The rest of the medications he’s getting are all fluff, from famotidine to zinc to melatonin to vitamin D, but there’s no reason to expect any of it will give him side effects or make him worse. Fortunately nobody seems to have offered him hydroxychloroquine, oleandrin, or Clorox.

The only scandal about the President’s treatment is that he was discharged from Walter Reed last night. Medically speaking this is total madness. First of all, he was not well enough  to leave the hospital – visibly short of breath after the minor effort of climbing the White House stairs; ordinarily, he would have had to sign out of the hospital against medical advice. Secondly, COVID-19 is notorious for taking a turn for the worse a week or so after the patient first develops symptoms, so the next few days are precisely when his health is most vulnerable. He will of course have better care inside the White House than anybody else could in their own home, including x-rays, blood tests, and intravenous medication, but that kind of turn for the worse can be sudden and disastrous in an elderly, hypertensive, obese patient, and is a reason in itself to keep such  a patient in  a hospital setting. I’m not entirely amazed by Trump’s preferring the appearance of health over its reality, but I’m shocked that his doctors went along with him.


The osteopath non-scandal

Dr. Conley, the White House physician, is a graduate of an osteopathic school of medicine, and has a D.O. (Doctor of Osteopathy) rather than an M.D. after his name. Some commentators, including Rachel Maddow, have considered it a scandal that the President is being cared for by “an osteopath” rather than “a doctor.” It is not a scandal – for many decades the curricula in American osteopathy schools has been nearly identical to what is taught in regular (“allopathic”) medical schools, with the osteopathy part deemphasized to the point that many D.O.’s don’t do any manipulation at all. A D.O. is considered equivalent to an M.D. for purposes of medical licensure or entering specialty training.

In this the United States is very different from most of Europe, where osteopaths get their first training as physical therapists and where they all practice manipulation therapy.



I’m no pundit, but my take on the political implications for Trump is that they are devastating. The whole basis of his campaign – ignore the pandemic, promise a rapid return to economic boom, exploit racism and right-wing conspiracy theories to the max – has exploded, and when all that’s on the news is COVID COVID COVID it’s Joe Biden who benefits. Trumpian loyalists will never abandon him, but to the voters who are still on the fence this stark demonstration of the failure of the Trumpian approach to COVID-19 is unquestionably likely to push them in the direction of the candidate who has respected science and advocated measures to protect himself, anyone around him, and  the American people.

If he’s sick, then they planted it when they tested him. – a Trump supporter


When I first heard, I did wonder if he made it up to get out of the next debate or win sympathy – a Biden supporter

Not to speak of the fact that the candidate, his campaign manager, and many of his top surrogates are all in isolation with COVID-19, and others may need to quarantine.

I’m sure you’re all aware by now that if Pence and  Trump were to be incapacitated at the same time, the  presidency would pass down the line of succession to . . . Nancy Pelosi.