Thursday, April 23, 2020

There's One Born Every Minute

An Open It Up protest in Texas

Treatment update
Remdesivir: Some treated COVID-19* patients, part of a clinical trial in Chicago, seem to be doing better than expected. But the results are preliminary, have not undergone peer-review, and do not include any real control group – nor, shockingly, does the broader study they are part of. All the remdesivir trials in China have been halted because – fortunately for the Chinese – they couldn’t find enough patients. But there may be an ulterior motive, because as of April 23 there is very bad news for remdesivir out of China: A randomized study reports zero difference between treated patients and controls in mortality at one month. The study was underpowered and the results preliminary, but certainly what we're seeing is extremely discouraging. Perhaps, as with other antivirals such as Tamiflu and acyclovir, the drug might have worked better if given earlier in the course of disease, but still…
Convalescent serum: In a Chinese case-control study of 325 COVID-19 patients – again, not peer-reviewed but definitely the best research yet – convalescent serum seemed to help critically ill patients to survive. More than 600very sick American COVID-19 patients have already received plasma as part of a huge study, though it may be difficult to draw conclusions without a non-treatment control group. That study is begging potential donors to volunteer, while in Italy similar research projects (with perhaps 100 patients enrolled so far) are still collecting donors on a “Don’t call us, we’ll call you” basis. Another small piece of good news: a single donation is now being used for two or three patients instead of just one.
Heparin: According to descriptions of tissue samples, hot off the presses from OklahomaNew York, and New Orleans, some COVID-19 patients have clots clogging small blood vessels – but only in the lungs, not all over the body as in Disseminated Intravascular Coagulation. These observations suggest perhaps heparin should be tried more widely, in very sick patients, but it ain’t no magic bullet.
Plaquenil: Finally a couple of halfway decent studies. In the first,  one hundred fifty Chinese patients with mild to moderate COVID-19 were randomly assigned to hydroxychloroquine or standard care. Outcomes were identical in the two groups: the virus remained in the nose for the same number of days, blood tests for inflammation didn’t improve, and symptoms resolved no faster. The researchers did some “data dredging,” examining all three measures in 14 subgroups, and found a positive effect on one of their three measures (symptom resolution), in one subgroup (patients who received no other antiviral therapy). Finding a “significant” result in one out of 42 analyses is a rate expected by chance, and the authors appropriately considered their trial to be negative. The second was a case-control study (a weaker design than a randomized trial), not yet peer-reviewed, that examined 368 COVID-19 patients in Veterans Administration hospitals across the US. Those receiving hydroxychloroquine went on to require ventilators at the same rate as those receiving usual care, and died at twice the rate.
Stem cells: A new entry from Israeli company Pluristem consists of placenta-based stem cells designed to rev up the regulatory side of the immune system and tamp down inflammation – a similar target to tocilizumab’s. Studies are still in a very early phase.
Light touch: Non-pharmacological aspects of treatment are turning out to be very important, because COVID-19 doesn’t behave like a “normal” lung infection. Some people who are gasping with near-death levels of oxygen in their blood are nonetheless capable of talking on their cellphones, while others who are barely short of breath are in the morgue 30 minutes later. As the weeks pass and these patterns become clearer, doctors on the front lines have adjusted their treatment approaches by keeping more people off ventilators, repurposing C-PAP machines, and sometimes simply asking patients to keep rolling over.
Vaccines: The notion of hurrying up the process by deliberately exposing vaccinated volunteers to the virus has unfortunately been gaining ground. I say it’s a fine idea – as long as the researchers themselves are the only volunteers.

Now for my main topic: the latest COVID-19 cons and tall tales…
Drinking the Kool-Aid
Across the country this past weekend, angry demonstrators wielding signs saying “Stop the madness! It is just a cold virus!” “Let me work,” “Give me liberty or give me death,” or “Heil Witmer” [sic], and chanting everything from “Freedom now” to “Fire Fauci,” are demanding an end to social distancing and stay-at-home orders. Their positions are both dangerous and, fortunately, unpopular. (Atlantic has just published an excellent piece on the question of reopening, while Asian countries that let up on their containment measures are already experiencing a new wave of cases).
In Italy we would assume demonstrations like this were egged on by the Mafia. In Michigan, Texas, Virginia, Minnesota, Idaho, Kentucky, and the rest, the provocateurs are right-wing extremistsRepublican donorspro-gun activists, and the country’s President
Crowds are the coronavirus’s best friend. Mass meetings of a Korean church led to more than 5000 cases of COVID-19, and probably more than 100 deaths (I thank an anonymous reader for correcting my original inaccurate numbers). The biggest outbreaks in the United States right now are in locales where people are jammed together – a Ohio prison (1828 inmates, 109 staff) and a South Dakota factory (748 employees). Mardi Gras festivities probably killed a thousand New Orleanians. Is it wicked to hope the Great God Corona may have tossed a few lightning boltsinto those milling “Open It Up” mobs?

Hell Out of Bats 
The latest conspiratorial origin story for the COVID-19 pandemic is that bat virus escaped from a virology lab in Wuhan and spread around the world. Scientists consider that theory thoroughly debunked, even though Chinese have been untrustworthy throughout the COVID-19 story: trying to keep the epidemic under wraps, wildly underreporting their death figures, and producing many research studies that are sloppy, withdrawn, or proven incorrect. What really matters, in any case, is not where the pandemic came from but where it’s going.

While scientists worldwide race to find a vaccine against COVID-19 – there were 86 projects underway at last count – some think the whole enterprise is not worth the trouble.
One such school says it’s useless, that by the time a vaccine is developed the virus will have mutated to the point the vaccine won’t work. Or that maybe we’ll have to get a new vaccine every year, like the influenza jab. The New York Times added confusion by titling a recent opinion piece “The Coronavirus Is Mutating. What Does That Mean for a Vaccine?” Contrary to what that headline implies, the true answer is “Not much.” All viruses mutate, the novel coronavirus mutates more slowly than most, and experts don’t expect those mutations to cause trouble.
The other school says it’s unnecessary – we don’t need a vaccine, because convalescent serum and antivirals are going to be truly great. As far as I can tell this school has only one member, distinguished Italian virologist Giulio Tarro. The reality: convalescent serum may be our best bet at the moment, but it’s never been a wonder cure for any disease, and antiviral medications are a terrific idea in theory but in the real world they rarely do much. Tamiflu, the famous antiflu drug, shortens the illness only by a day or two, and only if it’s started very early. As far as I know there is exactly one example of a antiviral that’s brilliantly effective: acyclovir for herpes encephalitis, a brain infection that used to be nearly 100% fatal. But acyclovir only lowers the risk of winding up dead or a vegetable to 30%. My conclusion: Italians, as my husband always says, are dreamers.

Rapid blood tests for COVID-19, purporting to tell you whether you’ve had the virus and are therefore immune, have burst on the scene in Italy, where private hospitals will perform them on anyone who hands over enough cash, and of course in the United States, global epicenter of both COVID-19 and for-profit medicine.
There are two problems with this picture.
One is that the tests suck. They claim to detect 90% of cases, but in reality they are very inaccurate. Most of those unreliable tests come from China, but even the ones made in USA are not so great, at least not yet. Don’t take my word for it, or the word of USA Today – listen to the World Health Organization, which says those tests are not good enough to be used. This may change by a month from now, when more trustworthy companies such as Roche hope to roll out new, more accurate rapid tests.
Even if the tests were highly accurate, though, we still wouldn’t be sure how to interpret them. Are people who test positive immune from future infection? That’s the hope, but five months after the bug appeared on the scene we still don’t know for sure. Again, we may be closer to the answer a month from now, when studies by Beaumont Health and others, involving screening of high-risk health care workers, ought to show whether those with antibodies to the coronavirus in their blood can get reinfected.
The rapid tests, like a home pregnancy test, give a yes-or-no answer in minutes and are easy and relatively cheap. It is important not to confuse them with the quantitative laboratory-based tests, using an ELISA methodology, that are being used in the most important research studies and to determine which COVID-19 survivors have the wealth of antibodies in their blood that will make them good donors of convalescent plasma. Those lab-based tests require specialized equipment, take hours, and are very accurate.
Conclusion: don’t be the first on your block to get a COVID-19 blood test.

The Thermometer Brigade
In many COVID-19 conversations, temperature is a star. Passengers entering planes, hospitals, and the United States of America have no-touch thermometers pointed at their foreheads, and Amazon aims long-distance thermal cameras at its employees. Many believe screening for fever – in schools, theaters, restaurants – should be a major tool in the new-normal life we all so fervently await. But while fever is one of the most common symptoms of COVID-19, it’s by no means universal. As many as half of hospitalized COVID-19 patients in China and the US had no fever on admission, and patients with milder or asymptomatic infections are even less likely to have fever. It’s foolish to rely on mass temperature screening as our way to detect infection.

Soapy vegetables
Lots of folks are spending their days washing their spinach in soapy water (yecch) and scrubbing their squash with Purell or Amuchina (double yecch). This is absurd. You can’t get sick by ingesting coronavirus, and the virus is killed by cooking.
Disinfecting shopping bags? Leaving your shoes outside the door? Consumer Reports, other experts, and still other experts say don’t go overboard! Do wear disposable gloves when you shop, do patronize only stores that are fussy about social distancing and disinfect their carts, do do your damnedest to keep six feet away from other customers. When you get home do wash to Happy Birthday x2 before and after you unpack the groceries, and do wash any surface you’ve set your shopping bag on. If you’re a fearful sort you can leave packages unopened for a few hours, but there has not been a single case reported of someone getting COVID-19 from handling a box of food or a delivered package. Likewise you may want to leave your shoes at the door once you start thinking hard about what their undersides may have picked up; one of the times I wash my own hands is after changing from shoes into slippers. But the only evidencethat the novel coronavirus can be found on soles comes from COVID-19 wards in China, not from your local sidewalk or your supermarket.

The W.H.O. bogeyman
Donald Trump had a spike in popularity for a couple of weeks last month, pulling the wool over many eyes about his handling of the coronavirus crisis, but as the deaths rise and the pandemic spreads into the small towns of America’s heartland his ratings have fallen again. So he needed a new shiny object to distract people’s attention. What he fixed onwas the World Health Organization – arguably the entity that did the most, the earliest, and the most consistently to draw attention to the pandemic threat. Yes, the WHO made mistakes, especially by taking China too much at its word during December and early January, but it more than made up for them by immediately supporting the January 23 Wuhan lockdown, declaring a world health emergency a week later, and sounding dire warnings nearly every day since. If the Trump administration had acted on those warnings by following the WHO’s recommendations for testing and social distancing, tens of thousands of American lives might have been saved. Trump’s decision to cut off funding to the WHO is scandalous.

Let me wade into the mask controversy with a minority view. The CDC now suggests people wear face coverings when outside their homes, the State of New York wants people to be masked where social distancing “would be impossible,” and as of April 22nd California won’t let you into a store without one. The idea is not that a healthy person will be protected by wearing a mask him/herself, but that people who are infected without knowing it are less likely to infect others if they’re wearing a mask. 
The rationale: some (not all) of the countries that kept the pandemic under control put masks on their population; masks seem to help against influenza; and several studies using machines to generate particles say that masks do a good job of containing them. Also, until not long ago the CDC was urging people to refrain from wearing surgical masks largely so health care workers wouldn’t run out. In a backhanded way, this suggested to the rest of us that the things actually do work.
I used to think masks might be somewhat helpful to keep sick people from spreading the disease. What changed my mind was tracking down the only study to study the question by having actual COVID-19 patients deliberately and systematically cough out infected material. Neither surgical masks nor cloth masks substantially decreased the amount of coronavirus that arrived on a petri dish 20 cm away. Incidentally, for both types of mask much more live virus was found on the outside surface of the mask than on the inside. These researchers did not test the N95 (FFP2 or FFP3) respirator masks, the ones worn by health care workers that are thought to protect the wearer.
Being an open-minded scientific sort, I will charitably mention a study that does not support my position, which analyzed data collected five years ago in Hong Kong. The researchers found some blocking effect of surgical masks on viruses, including coronaviruses, that were causing common cold symptoms. Their methods are not entirely clear, but it seems they somehow collected air exhaled by sick patients while they breathed, and coughed, for 30 minutes. In my opinion this is not very relevant to whether masks will keep asymptomatic COVID-19 patients from infecting people they pass on streets and in store aisles.
At last call the World Health Organization seems to weigh in on my side.
Some are convinced mask-wearing will help psychologically and will encourage healthy behavior. I think the exact opposite: masks will bring a false sense of security, making people less likely to practice proper social distancing, just as many gay men started having unprotected anal sex again as soon as the first mediocre AIDS treatments came out. When one store forced me to wear a mask, even I felt safer – despite knowing better than anybody that it was giving me no protection whatever. While we wait for further research to settle the question, listen to The New York Times: "“This is just the next step,” said a retired corrections officer, Stanley Woo, 63, sitting down to play chess in a park in Forest Hills, Queens, with his old friends and his new mask."
Chess in Forest Hills. Look like six feet to you?

*You may have noticed I’ve switched from “covid-19” to “COVID-19.” It’s an acronym – C for corona, VI for virus, D for disease – so it really ought to be all-caps, like USA.

Thursday, April 16, 2020

Tunnels and Lights

An Italian bookstore, newly reopened

Treatment updates: the big guns
Convalescent serum: Since I last wrote the recruitment of recovered American covid-19 patients has proceeded apace, blood banks now vying with hospitals to find donors. The Red Cross has set up a donor website in addition to the National COVID-19 Convalescent Plasma Project one that I linked to last week. Patients with confirmed diagnoses are already donating plasma at the New York Blood Center, and they soon will be in at least another nine statesIn Italy, the Tuscan blood bank has begun sending letters to recovered covid-19 patients inviting them to donate plasma, withLombardy and Veneto soon to follow suit and Lazio, Campania, Marche and Molise the next comers.
Remdesivir: Some good preliminary news: the manufacturer has reported outcomes for the first 61 covid-19 patients given this antiviral on compassionate grounds. Most promisingly, with remdesivir only 18% of the patients on ventilators died. Compare that with the experience in New York City hospitals without remdesivir – 80% of covid-19 patients placed on ventilators died. This report is NOT a controlled trial, but its results encourage such trials to go forward.
Hydroxychloroquine: Its reputation is based on a single dubious study in France, and that study’s plausibiility slides from bad to worse. The society whose journal published it has said officially the article “Does not meet the society’s accepted standard.” And the first author, Didier Raoult, turns out to be a shady character. He was once temporarily banned from publishing, after being caught out falsifying research results, and the rest of his bibliography is nearly as dubious. In an as yet unreviewed paper, a different French group studying covid-19 patients with pneumonia has now reported hydrochloroquine to be useless. 
If you want to follow covid-19 treatment research for yourself and can handle technical language, here’s a constantly updated page.
Minor contenders touted in the media
Nitric oxide: a trial of this inhalant is now underway at the University of Alabama.
Heparin: Desperately ill patients sometimes develop Disseminated Intravascular Coagulation, widespread blood clotting, treated with blood thinners such as heparin. In a Chinese study, covid-19 patients with DIC supposedly died much less (40% vs. 64%) if they were given heparin. But this was a retrospective study, not a clinical trial, and heparin is standard therapy in any case. No magic bullet.
Ivermectin: This drug for head lice and pinworms turns out to block the growth of SARS-CoV-2 virus in test tubes and may soon be tested in human beings. Its chief promoter looks like a charlatan; I wouldn’t hold my breath.
BCG: Dubious statistics suggest that covid-19 takes less root in countries where this tuberculosis vaccine is widely used (which include China). Studies are underway to see whether BCG might give a general boost to the immune system  and help fight off covid-19 – “the equivalent of a Hail Mary pass.” 
Viagra: A pilot study is on in China. Lots of luck.
Snake oil department
Ozone: A quack treatment with no known efficacy, considered by the American Food and Drug Administration to be “a toxic gas with no known useful medical application,” being pushed as a treatment for covid-19. 
Colloidal silver: The FDA has issued warning letters to its manufacturers for fraudulently claiming effectiveness against covid-19. 
There is no evidence that any supplement or foodstuff, from zinc to elderberry to CBD to sauerkraut, can help prevent or treat covid-19.
Of the scores of research teams racing to develop one, four have already moved beyond animal testing to trials on human volunteers. But the timetable is all over the map.
-       Most experts continue to think a vaccine should be ready to roll out in autumn 2021.
-       Others are afraid it will take years.
-       The research team in Oxford, England, thinks theirs may be set for widespread use as early as this September.
-       One virologist has hinted that a vaccine could be obtained even faster if researchers overcame their moral scruples and deliberately infected volunteers with coronavirus.
Be aware that even a functioning vaccine may not eliminate the pandemic. We hope the winning entry will act like the measles vaccine, which gives permanent 97% protection after two doses. But it might instead turn out to be like the yearly flu vaccine, which only reduces infections by 50% or so. What we already know about immunity to coronaviruses is discouraging. Some coronaviruses cause the common cold, and immunity after you’ve had a case lasts only a couple of years, even though natural infection is better than vaccines at goosing the immune system.

Italy update
Italians are flexible, resourceful, and sensible. One friend writes, “The natives are observing with great dedication the lockdown and distancing rules, and – as if in tandem with the Easter season – we haven't seen so much hand washing in the Bel Paese since Pontius Pilate strode the dusty streets of Rome on his disgraced return from Judea. This shocking discipline reminds me a bit of the overnight adherence to the no-smoking regime, years ago, which no one would have predicted.” But another correspondent emphasizes the negative: neighbors having a drink together on the roof, biddies distributing olive branches door to door on Palm Sunday.
Much of the economic impact of the Italian epidemic is cushioned by generous sick pay, unemployment benefits, and universal health care without co-pays or deductibles. An emergency decree forbids layoffs, slashes rents, pays baby-sitters, etc. Self-employed workers are supposed to receive bonuses totalling $2500 over three months, supplemented by contributions from some professional societies. (My composer husband will get neither, because he receives an Italian pension – €124 ($136) a month!) But the millions who work off the books in Italy’s vast underground economy aren’t eligible for unemployment benefits or bonus payments, so the shutdown of the economy will cause real suffering. Two weeks ago a few people rolled their full shopping carts up to the checkout line in a Sicilian supermarket and refused to pay, and more serious unrest was widely anticipated. It never materialized.

Italy is shaking off covid-19, with the number of people in intensive care units now decreasing steadily:

New cases continue to be diagnosed, however, and there are still 500+ deaths every day, mostly in the ravaged North – likely new infections inside nursing homes, within patients’ families, and in factories that exploit legal loopholes to keep their workers crammed in. 
One Rome high-rise inhabited by 600 Eritrean squatters houses 18 definite and 33 suspected cases of covid-19. The authorities, instead of doing mass testing and moving people out as necessary to enable social distancing, have sent the army to keep the whole building under quarantine. They did, however, distribute milk, pasta, tomatoes…and chocolate Easter eggs.
Some Italian cities are now offering “drive in” covid-19 testing for people with relatively mild symptoms. In Rome, you start the process with a phone call to 06 3306.2738, 06 3306.4748, 06 3306.2847, or 06 3306.2707.
As of April 15th, 121 Italian physicians have died of covid-19.

Italy has taken initial baby steps toward reopening the economy, allowing a bizarre list of productive activities: dry cleaners, forestry, computer factories, and stores selling books, stationery, or baby clothes. But several regions where the fires of covid-19 are still burning, such as Lombardy, have declined the invitation.
Donald Trump and his buddies are chafing at the bit to do the same and more. The militia sorts are openly defying stay-at-home orders, some ministers held in-person Easter services… Is it time yet? And if and when, how?
In the United States it’s clearly too early, whether your chosen authority is Anthony Fauci or The Onion. Lacking consistent federal guidance, our shutdowns have been patchwork, in dribs and drabs. Every state experiences a different epidemic according to whether and how much it’s closed up shop, how well people are complying, and who is being tested. While California enters the downslope of the first-wave curve, New York still loses more than 700 people to covid-19 every day, and the death rate rises sharply in New Jersey, Georgia, Connecticut, and Michigan. How could guidelines be countrywide? I won’t go into details, just state a few principles:
First of all, when the number of active cases is low enough, we can finally do as we should have when the first cases appeared: test all suspected cases, isolate those who test positive, track down and test everybody who’s had contact with them, and quarantine the positives among those contacts. Germany was the only Western country to do this, under the exemplary leadership of Angela Merkel, and they have had 3800 deaths as compared with more than 13,000 in other European countries with comparable populations. 
Second, we need explicit criteria for determining restrictions. The Imperial College study that got social distancing going in both the US and the UK famously modelled the benefits of various mitigation strategies. But it also, less famously, modelled an ideal strategy over time, using the number of covid-19 patients in intensive care units as the indicator of when restrictions should stop and start:
A conservative model of an on-again off-again coronavirus lockdown

Based on an “on” trigger for the United Kingdom of 100 ICU cases in a week and an “off” trigger of 50 cases, and assuming testing, isolation, and quarantining, they calculated that while we wait for a vaccine, social distancing could be lifted a third of the time.
Now that we’ve gotten used to social distancing, though, I think we can accept some degree of it as the norm for the duration. With moderate social distancing, we should be able to lead a relatively normal life most of the time, as long as criteria are established and rigorously followed. Forget about packed baseball stadiums and sold-out Broadway shows, but there could be picnics, restaurants with proper table spacing, sports events and movie theatres with six feet between spectators, church services, dinner parties… Dinner parties!!! I can imagine drive-in stands where people can get swabbed for active infection, obtain their results in five minutes, and if negative be given a certificate good for a week’s freedom of movement. 
In addition to PCR swab tests for active disease, blood testing for antibodies against the coronavirus should play an important role. People with antibodies will probably be shown to be immune, at least temporarily, so they could work, socialize, and attend events with impunity. Some are hoping that mass blood testing will show that enough people are already immune to protect the rest by “herd immunity.” This is unlikely, since protection only seems to kick in when more than 90% of the population are immune, but we can hope.

Privilege and covid-19
Coronavirus is not an equal opportunity bug, with poor and minority populations suffering the most. This has been shown on a neighborhood level in New York, on a county level in Michigan, and on a statewide level both there – African-Americans make up 14% of the population but 40 percent of the dead – and in Louisiana, where the corresponding percentages are 33% and 70%. Many of the poorest states also have governors who resist stay-at-home orders, including South Dakota, where at least 350 workers at a single meat processing plant – largely immigrantsspeaking more than 80 languages – have tested positive for the coronavirus. 
As Charles Blow points out, African-Americans and impoverished populations are more likely to have underlying conditions and limited access to health care, more likely to be doing “essential” manual or service jobs without the luxury of working or sheltering at home, and more likely to share crowded living quarters; social conditions are at least as important a risk factor for severe covid-19 infection as medical conditions. 
The underprivileged, who rarely have adequate unemployment compensation, sick pay, or healthcare insurance, will also suffer more from the economic effects of a shutdown. Their children need those free school lunches, and often can’t attend virtual classes for lack of internet access. 
But the greatest tragedy due to socioeconomic discrepancies may be at the world level. When covid-19 hits the global South in force, the impact could be devastating. In the developed world the novel coronavirus seems to be more or less as contagious and deadly as the influenza virus that a century ago infected one-third of the people on the planet and killed 20 to 50 million. That pandemic hit at a moment when populations had been weakened by wartime suffering, and when there were no intensive care units, no ventilators, no oxygen therapy, no antivirals, not even antibiotics. 
This suggests that covid-19 is intrinsically much deadlier than the 1918-19 flu. In areas of Africa, South America, and Asia with few modern hospitals and high rates of chronic disease and malnourishment, it may well cause a holocaust.Statistics from many of those countries are unreliable, but the upswing may be starting now – India, despite fighting back early and hard, went from 1000 cases on March 29th to 12,000 on April 14th
For diseases with no pharmacological cure, such as covid-19 and Ebola, supportive care in modern ICUs is crucial. The death rate for Ebola was 74% in Africa, 18.5% in the US and Europe.
As the New York Times points out in an editorial entitled “The Global Coronavirus Crisis Is Poised to Get Much, Much Worse,” South Sudan – population 12 million – possesses exactly three ventilators. Already local quacks are touting useless nostrums: Benin’s Valentin Agon, whose apivirine has “successfully treated dozens of Covid-19 patients,” South Africa’s Kim Joachim Mvuselelo Cools, who peddles Magic of the Healers Juice. (American hucksters plug the likes of Superblue toothpaste.) While the economic devastation of anti-pandemic shutdowns in impoverished nations could kill more people than the virus.

Cutting through the crap
The Los Angeles Times was the first to circulate the claim that the novel coronavirus may have been around in California as early as the fall of 2019. There is no evidence this is true.
It has also been suggested that the way the coronavirus starves the body of oxygen is not by attacking the lungs but by binding directly to hemoblogin in the blood. This is, as Rachel Maddow might say, bullpucky.
I wouldn’t have thought anyone doubted the dangers of the pandemic any more, but wild theories still circulate that deaths from other causes are being falsely attributed to the coronavirus, it’s more common to die “with” the virus than “from” the virus, and so forth.
The respected journalist Fareed Zakaria has spread a version of this on CNN and in the Washington Post, suggesting that the reason fewer people than expected have died so far in the US is because the virus is not really very dangerous. His source is the contrarian epidemiologist Dr. John Ioannidis, who has written, and I quote, “If we had not known about a new virus out there, and had not checked individuals with PCR tests, the number of total deaths due to ‘influenza-like illness’ would not seem unusual this year.” 
This is utter nonsense. Here are the numbers of total deaths in northern Italy as compared with past years – not from “influenza-like illness” but from all causes. More than twice as many people than expected died, overall, during the pandemic.
Death rates from all causes in selected northern Italian cities: 2020 vs. predicted

It has been debated whether American covid-19 deaths have been overcounted or undercounted. But in New York Cityhundreds, perhaps thousands, of coronavirus victims who died at home alone didn’t make it into the official statistics, with a true death toll perhaps 70% higher than official reports. There’s no need to quibble over details – just look at this graph of total deaths in New York City since the year 2000. 

A horrendous spike, 2730 more deaths than expected, reflects the September 2001 terrorist attack. And an even more horrendous spike, 5330 more than expected, occurs between March 4th and April 4th of this year, with covid-19 the only possible reason. 

Zakaria and Ioannidis are right that many people infected with the novel coronavirus have few or no symptoms, and that the mortality rate of the coronavirus is therefore lower than it appears from diagnosed cases. So what? The reason covid-19 failed to decimate the US population is not that it is mild, but that prescient local politicians were relatively quick to enact stay-home orders, following the effective Italian model.
Forgive me for saying that those prescient politicians do not include Governor Andrew Cuomo of New York, despite his excellent leadership later on. My husband and I had been supposed to go to New York on March 13th, but we cancelled at the last minute, figuring the city would be too dangerous: once the coronavirus hit it would spread like wildfire, since the city’s iconic subway system would be a petri dish. Friends wrote that they tried to pick less crowded cars, hold the poles in the crook of their elbow, etc., but the virus seemed destined to win, as in fact it did, killing at least 10,899 people. 
Then, on March 16th, seven counties in and around San Francisco made the radical move of telling people to shelter in place. A lightbulb should have gone on instantly inside the head of Governor Cuomo and Mayor De Blasio, but it didn’t. If New York had issued a stay-at-home order on March 17th instead of waiting until March 22rd, hundreds if not thousands of lives would have been saved.

Personal notes from my gilded cage in Berkeley
You know how when you have laryngitis you hear a singer and can’t fathom how they’re doing it? Or when you have a sprained ankle and marvel at a passing jogger? I might have thought watching movies would be like that, night after stay-at-home night. But no, those scenes of crowded dance floors and hot kisses look perfectly normal. What did touch that nerve of unreality was reading an oldish New Yorker, writers all obsessed with unthinkables – art openings, restaurants, political rallies, trips to Europe – blessedly unaware that the world was about to, or could ever, grind to a halt.
A light now flickers at the end of my own refugee tunnel. Alitalia has kept up daily nonstop flights from New York to Rome, but they are nightmares. I’ve heard of people being abandoned in transit at JFK for days on end. I’ve read about repatriation flights taking off from New York and Madrid with every seat occupied. Other planes sat on runways for hours with hundreds of passengers packed cheek to jowl. Following scandalized interrogations in the Italian Parliament, Alitalia now claims it will start inflight social distancing… but even better, they’re promising a brand new nonstop flight from San Francisco to Rome. It will be inaugurated on June 1st, and my husband and I will be on it.