Where Are We Going?

It is time to contemplate that question, to think through what got us here and what sort of world we’ll have, and to set to work crafting the future we want to have. The following quote comes from the end of an article in “The Atlantic” published on March 25. Like The Hammer and the Dance that I highlighted last Friday, How the Pandemic Will End was written by a young, upcoming science writer, Ed Wong. I take solace that members of the next generation are speaking in such clear voices. We should take heed. Here are the ending three paragraphs:

“One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero. During the second term of his presidency, the U.S. turns further inward and pulls out of NATO and other international alliances, builds actual and figurative walls, and disinvests in other nations. As Gen C [current youth living the pandemic] grows up, foreign plagues replace communists and terrorists as the new generational threat.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation. Buoyed by steady investments and an influx of the brightest minds, the health-care workforce surges. Gen C kids write school essays about growing up to be epidemiologists. Public health becomes the centerpiece of foreign policy. The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.”

Those two futures stand in stark contrast. Let us strive to make the second future the one we build–and reject a future of xenophobia, blind nationalism, suspicion, strife, and rejection of science currently embedded in our national politics. We need to create the future of cooperation, speak of it to all who will listen, and support those who share the vision, support them on their way to the November Election.

I encourage you to read Mr. Wong’s entire article. Like many newspapers and periodicals, “The Atlantic” has suspended its paywall for coverage of the coronavirus pandemic. In a political climate where some wish to make an icon of walls, celebrate the symbolism of lowering this one. Here’s the raw link to the article, “How the Pandemic Will End”:


Keep to the high ground,

“The Hammer and the Dance”

“Flatten the Curve” is a great slogan and messaging tool, but it is not enough. We need a clear-eyed vision for how we get from now to a better future. 

The “Hammer” is the Protective Measures the world is struggling to put in place and maintain in spite of the naysayers and doubters. It works, but what is the end game? Do the same number of people have to catch this disease and some of proportion of them die, just dragged out over many months instead of one or two hellacious months of sickness and death ‘getting through it’? After all, the area under the curve of that now famous graph (posted below once again) for both With and Without Protective Measures looks much the same. 

Take heart. An end game for this pandemic is taking shape. It’s “The Dance” part of “The Hammer and the Dance.” The exciting thing it that the argument is coming from very bright, extremely dedicated, mostly young people pooling their efforts with the aid of the internet, pooling them in a network that ignores national boundaries. Settle down for a long, sometimes a bit wonky read and click on this link:


Even if this exercise in logic doesn’t catch fire, even if “Coronavirus: The Hammer and the Dance” doesn’t become the new buzzword, the concepts in this presentation are invaluable. These ideas in it need wide distribution, particularly to those in leadership positions, some of whom are foundering in their own bluster, bravado, and wishful thinking

Read. I hear hearty agreement from many medical friends I’ve already sent this link. If you also find this effort by Tomas Pueyo and his long list international, internet-linked collaborators valuable then click on and sign the petition to the White House contained in the document and then share this link with friends. The entire world is focused on this pandemic. Voices of reason and reasoned hope need to drown out the whiners and wishful thinkers. Everyone is listening. 

Keep to the high ground,

P.S. A few further musings: Nearly everyone has seen the “Flatten the Curve” graph shown below and nearly everyone regardless of political persuasion understands the basic idea: using social distancing and lockdown tactics we decrease the chance of overwhelming the health care system (as happened in Hubei and is now happening in northern Italy and New York City).

But, as one of my astute readers pointed out on his Facebook page, the area under the curve in the graph “With Protective Measures” is roughly the same as that depicted under the curve “Without Protective Measures.” That depiction suggests that, apart from avoiding the death of a few the health care system might otherwise save (were it not overwhelmed), were it not for that, it suggests we’re facing exactly the same numbers of infected and dead, just strung out over a much longer time period. That’s likely very wrong, as “The Hammer and the Dance” points out.

The purpose of all of what we need to do in this crisis is to buy time. We and our leadership need to use that time to support efforts that will give us understanding and tools, understanding and tools which, if properly implemented, will make the area under the curve “With Protective Measures” ever smaller. We can emerge from this challenge with much clearer understanding of how to deal with the next worldwide crisis–and with much better worldwide collaboration–or we can descend into tribalism, nationalism, and racism, as we cast about for someone on whom to pin the blame. I vote for collaboration. Get on board. Cast off those who cling to nationalism, racism, tribalism, and their misbegotten, contemptible characterization of Corvid-19 as “the Chiinese flu.” Those folks are not leaders and cannot be allowed to lead.

The Fox Effect

At around midnight Sunday night, Trump tweeted “WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF. AT THE END OF THE 15 DAY PERIOD, WE WILL MAKE A DECISION AS TO WHICH WAY WE WANT TO GO!” Mr. Trump was directly channeling the argument Steve Hilton, a Fox News talking head, had made a little earlier in the evening. (Hilton presents the crux of his argument at 6:28 in the Fox News video you can watch at that link.)

I watched the video to verify the account of it presented here and copied belowfrom the Huffington Post (the quoted material is all in italics):

Hilton played a clip of Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, saying he was fine if people think the response to the virus was an overreaction.

Well, that’s easy for him to say,” Hilton said. “He’ll still have a job at the end of this, whatever happens.”

Hilton added: 

“Our ruling class and their TV mouthpieces whipping up fear over this virus, they can afford an indefinite shutdown. Working Americans can’t, they’ll be crushed by it. You know that famous phrase, ‘The cure is worse than the disease?’ That is exactly the territory we are hurtling towards.”

Hilton calculated that an economic shutdown in response to the virus would lead to a recession that could kill 1 million Americans. 

“Poverty kills. Despair kills. This shutdown is deadly,” Hilton said. He then urged Trump to reassess the plan within 15 days. After that, it would be time to stop the shutdown while keeping in place bans on large gatherings and measures to protect the elderly.

After Trump’s tweet channelling Steve Hilton, Fox Nation’s “Deep Dive” (that’s a paid subscription website) on Monday added fuel by featuring Dr. Marc Siegel, a talking head on Fox since 2008 (Is he on the payroll primarily because his views align with the network bias?). According to Dr. Siegel, “”About three or four weeks from now, we’re going to back off of these draconian measures because we won’t be able to stay together as a society if we don’t” You can read the FoxNews.com coverage of the Siegel appearance here. Note that Dr. Siegel, an internist, is using his M.D. degree to justify his opinions of sociology and economics, not medicine.

Monday evening on Tucker Carlson Tonight, Texas Lt. Gov. Dan Patrick added fuel by offering to risk his own life as an example of a supposedly selfless senior citizen (he’s 69):

“No one reached out to me and said, as a senior citizen, ‘Are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren?’ And if that’s the exchange, I’m all in … I just think there’s lots of grandparents out there in this country like me — I have six grandchildren — that what we all care about and what we love more than anything are those children. I want to live smart and see through this. But I don’t want the whole country to be sacrificed and that’s what I see.”

He added that it “..doesn’t make me noble or brave or anything like that… what we all care about and what we love more than anything are those children.” Patrick said that he will “do everything I can to live” and that if he gets sick, he will seek medical help. He went on to echo Trump’s argument that the coronavirus mortality rate in the United States — so far — is not as alarming as it is in other countries. (Just wait, of course, we’re early and Covid-19 takes a week or two to kill most of its victims.)

The trouble is that Mr. Patrick, who rose to the Lt. governorship of Texas from a career as a conservative talk show host after having gone bankrupt in business, is recommending a course of action that endangers not just his own life and those of the supposedly selfless seniors he claims to represent, but also the lives of the healthcare workers from whom he and others vow to seek help if they fall ill. All of these brainless talking heads conveniently ignore the fact that as of March 19th in the U.S. 38% of the 508 patients hospitalized for Corvid-19 were between the ages of 20 and 54. As of March 19, nine of these 20-54 year olds had died–but this is very, very early in what is likely to be a tidal wave of deaths among many age 20 and up. (As of March 19 there were no deaths or hospitalizations in the U.S. of people under age 20 from Corvid-19.)

So what is going on here? It looks like a Wall Street Journal opinion piece got the ball rolling about a week ago. Steve Hilton’s rant on Fox last Sunday, March 22, (detailed above) was channeled by Trump in his tweet later that evening. Dr. Siegel and then Dan Patrick on two other Fox programs on Monday, the next day, noting that Trump was paying attention, pumped up Trump’s faith that the economy should take precedence over people’s lives.

Trump has spent his life stepping on other people in pursuit of money (Trump University). He despises scientists (climate change is a “Chinese hoax”). He is convinced of his native intelligence and overall superiority (stable genius). His worst nightmare is being upstaged (reports on Tuesday suggest Dr. Fauci is losing favor with Trump). Trump desperately wants to be seen as in control–at center stage making the big decisions. Tumult and controversy are at the center of his character.

Fox News is playing to Trump’s confirmation bias. Fox News is calling the shots for our emotionally wobbly and fact-challenged president. If Trump declares, “Go back to work!” will the country follow–or repudiate him?

Or, as a friend suggested (while simultaneously admitting it sounds like a conspiracy theory), is this all an elaborate scheme to goose the stock market in the hope of playing the jump for profit. After all, what the Trump family is doing with the Trump money remains opaque to the electorate.

Meanwhile, people are dying all over the world while these fools propose sacrificing working Americans and thousands of health care workers on the alter of money.

Keep to the high ground,

P.S. As I keep reading on the Fox News/Donald Trump circular confirmation bias amplifier I find that others are writing of the same thing. Below are links to two articles I consider outstanding:

Heather Cox Richardson: https://heathercoxrichardson.substack.com/p/march-23-2020?token=eyJ1c2VyX2lkIjo3ODU0MTcsInBvc3RfaWQiOjMyNzg3MSwiXyI6IkZBMFhHIiwiaWF0IjoxNTg1MDczNTU2LCJleHAiOjE1ODUwNzcxNTYsImlzcyI6InB1Yi0yMDUzMyIsInN1YiI6InBvc3QtcmVhY3Rpb24ifQ.kvxJotVOvZVZo81YHNmEAVilFT61EefKipJqzowVbdA

Justin Baragona of The Daily Beast provides a masterful summary of the Fox News amplifiers:


COVID-19 Numbers and Hope

Summary First: There is hope, hope with many “ifs”, but hope. Good daily data is hard to come by, but new “cases” reported in China are very low or zero now. There is hope in that fact.

Worldwide, as reported on Saturday, March 21st, nearly 90,000 “known cases” have recovered. “Recovered” suggests there are 90,000 people out there with good antibodies against this disease–and those are only the folks we know about, people with diagnosed illness who were tracked.

IF, as suspected, there are many in the general population of the world who have been exposed to SARS-CoV-2, people who never had symptoms or only mild symptoms that didn’t bring them to medical attention, and IF those folks developed good protective antibodies, then the future is not nearly as bleak as many of us currently fear.

Why? Epidemiologists current best suggestion is that each infected individual is passing the disease on to 2.2 others. That is the Basic reproduction number, the R0, for Covid-19. (Click that link if you like numbers.) Postulating random transmission with that Rof 2.2 suggests that once 55% of the population is immune, the disease will cease to spread.  That’s an ideal world number but it offers this hope: If immunity (which we are not equipped to broadly measure for this or any other virus because it’s expensive and time-consuming) is growing among asymptomatic individuals in the world population, then this scourge has an end point–herd immunity–when 55% of the populace is immune. The other 45% remain vulnerable–but are still relatively protected by the immunity of the herd.

This hope in no way suggests we should abandon our efforts to “flatten the curve.” Flattening the curve still buys time. Flattening the curve will decrease the number of people who will be diagnosed, suffer, and die of this disease on our way to herd immunity while that immunity quietly builds.But maybe, just maybe there is light at the end of this tunnel–as the Chinese experience may now be demonstrating. We still have quite a knothole to get through to get there.

Here’s the much less condensed version of that same argument, along with a lot of other thoughts and speculation:

In an imaginary world in which all human interaction were totally curtailed for fourteen days there is evidence to suggest the Covid-19 might stop dead in its tracks. Going through that thought experiment and its assumptions might be useful.

Some number of virus particles enter the nasal passages of a host human. Some of the virus particles gain access to the cytoplasm of some number of the host’s cells (cytoplasm is the innards of the cell, innards bounded by the cell’s outer membrane). In the cytoplasm the virus hijacks the cell machinery to the virus’s own use: making thousands or millions of copies of itself until the cell bursts and releases new virus particles that infect adjacent cells. Unchecked, it is easy to see how this process might quickly overwhelm the host. (Notice that the numbers of virus particles to which the host is exposed might be an important variable in this ramp up.)

The immune system of nearly every host will start to make antibodies that destroy viral particles. It is a race. If the host’s immune system is up to the task, the antibodies will win. The host human will get better or may not even have had any symptoms while this is all happening. In this ideal world the antibodies will remain available and on high alert to kill any new arrivals of SARS-CoV-2, i.e. this patient is immune, he(she) is no longer susceptible to a new presentation of virus (his antibodies kill any virus that manages to replicate in his cells). This person no longer sheds any intact viral particles that can infect someone else. In a population of host humans eventually there are so many hosts who are immune that the virus cannot propagate–that’s called herd immunity. 

We think we know the following about SARS-CoV-2:

1) The incubation period (the time between exposure and the first symptoms) is around 3-6 days.

2) In a very small, but very detailed, study I read within the first six days after the onset of even very mild symptoms these patients were making effective antibodies to the virus, antibodies that damaged viral particles badly enough so they are not infective.

3) In the same study, shedding of large numbers of virus particles occurred before there were notable symptoms–that’s why the disease spreads so fast–we don’t know who is harboring and spreading the virus. But viral shedding of infective particles ceased as the antibody response took over.

KEY POINT: Testing for immunity (presence of effective antibodies) can be done but it is very expensive and time-consuming. Such a test cannot possibly be used broadly to tell if a given individual human host has made antibodies and is immune. It would be nice, but that is a long way off, much further off than a vaccine–and a vaccine available for widespread use is likely a year away at the very least.

In this imaginary and ideal world everyone would be strictly quarantined for fourteen days, during which each and every exposed person would incubate the virus, shed virus (to which no one would be exposed), and mount an effective antibody response that would destroy the infective power of any virus that remained. (Some other hosts would, in roughly the same period, die and their remnant virus would be incinerated with their corpse.) Finally, all those immune folks with great antibodies, some of whom weren’t even aware they had been ill, would be released into population and contribute to herd immunity, just in case there were a few bits of virus still harbored somewhere.

In this imaginary and ideal world the whole epidemic would be over and life would magically return to normal.

Too much to hope for? Probably. Nonetheless, we have the Chinese example, something the rest of the world should watch very carefully. With 17,836 cases as of last Friday evening we in the U.S. were roughly comparable (on a per capita basis counting the entire population of the U.S. as the basis) in “case” numbers (with all the caveats that go into counting a “case”), we were roughly comparable to the point at which Wuhan shut down–and Wuhan shut down with the sort of clang and determination that probably only an authoritarian society can muster.

Regardless, Wuhan sharply flattened its curve and, insofar as the Chinese are vigilant about detecting and pursuing contacts when cases reappear, their effort offers some hope–but only if we work together, recognize the gravity of the situation and the importance of isolating ourselves for several weeks. In the absence of martial law we are going to not only have to work at social distancing–we’ll need to engage in a group effort to socially shame those who flaunt their independence from the group effort.

Keep to the high ground,

P.S. I fear we, the United States, are the Wuhan of the following quote from epidemiologists Dr. Helen Jenkins of Boston University, and Dr. Bill Hanage of Harvard:

It’s really instructive to compare what happened in Wuhan and what happened in Guangzhou. In Wuhan, they shut down when they had 495 cases in a city that is roughly the size of New York. In neighboring Guangzhou, by contrast, they took action when there were seven cases. The epidemic curve in Guangzhou was completely manageable. As we all know, in Wuhan it was absolutely catastrophic. 

P.P.S. There are many things that could mess up (or enhance) my imaginary and ideal world, factors beyond our societal skepticism and unwillingness to conform. There are many unknowns: How long will the observed antibodies offer immunity? Does the virus mutate like the influenza virus does and so might it return in another wave another year? Are there people who will continue to shed infective virus while remaining entirely asymptomatic like “Typhoid Mary” spread the salmonella bacterium that causes typhoid fever? On the flip side, what portion of the population will make antibodies and become immune to SARS-CoV-2 without ever knowing they’ve been ill? There are abundant opportunities for research–if proper funding is restored to these efforts.

Sa Special–COVID-19 and Numbers

Late last Thursday I realized I could see the two extremes of our present disaster simultaneously: no new cases of COVID-19 in China even as the Chinese loosened the lockdown on one extreme–and dire reports from Italy of health worker fatalities, an overwhelmed health care system, and challenges in dealing with the backlog of corpses–all that on the other extreme.

Then on Friday morning the Spokesman reported a case of COVID-19 in a retirement community, Holman Gardens, in Spokane Valley–in spite of screening staff, a recommendation for social distancing and many residents having self-quarantined. Message: these measures alone are not sufficient. We need to lock down. Disapproval–shaming–of those who refuse to socially distance is necessary and appropriate. If we do all this and do it well there is light at the end of the tunnel.

“But, but,” I heard someone say, “We hardly have any cases here.'” That is so wrong… Why? All along the use of the word “case” of COVID-19 has lulled the population into a false sense of security. We know, the media should know, and the media should explain again and again that each “case” is a very imperfect and fraught representation of a much larger reservoir of infected people who are not yet (and may never) develop symptoms. In nearly all reporting, a “case” is counted only when a person tests positive for Covid-19. As we’ve read, the U.S. is sti”Cases” only provide a general indicator of the spread of infection. The number of cases reported will always lag the actual number of people infected by and possibly spreading SARS-CoV-2 (That’s the name of the virus. Covid-19 is the disease it causes.) A headline that reads “512 new cases of Covid-19” is not useful. It is the change, not the absolute number that is important. Consider: If there were 726 new cases reported the day before the 512 new cases reported today, that would be great news–the rate of spread would be slowing. Conversely, if the previous day’s new cases had been 262, a report of 512 today would suggest continued exponential growth–not good–no tapering off–yet. (Of course, a graph of data covering several days would be even more meaningful. Also, all the numbers are less meaningful if there is a large change in the commonness of testing.)

Thanks to the Trump and his administration’s lack of preparedness due to a toxic combination of ignorance and willful denial of its own study and science in general (“no one knew”) we in this country are woefully behind in testing. Keep that in mind every time you read an isolated number representing new “cases.” We get an “F” rating among developed countries for testing and an “F” rating for leadership–starting at the very top.

Take no comfort in case numbers. They are merely rough indicators. Even if we all self-quarantined in place for two weeks with no contact, i.e. absolutely no opportunity for the SARS-CoV-2 to pass from one human to the next, the daily new case numbers would still increase for at least a couple of weeks on account of the incubation period.

I searched yesterday for information of other countries that are not yet making news that we commonly see. I found it. The New York Times is offering coronovirus coverage with no paywall. Have a look at the bar graph a little way down the page. Every country listed (most of the roughly 195 countries in the world, with North Korea not reporting) reports at least one “case.” ALL the countries reporting more than a hundred cases, excepting Mainland China, also show an increase in reported new case numbers in each reported time segment. Many of these countries are likely to have even less preparedness the we have in the U.S. Remember it was only three weeks ago, February 26th, that Mr. Trump either in willful ignorance or willful denial was reassuring us:

So we’re at the low level. As they get better, we take them off the list, so that we’re going to be pretty soon at only five people. And we could be at just one or two people over the next short period of time. So we’ve had very good luck.” — Trump at a White House briefing.”

As of yesterday Friday evening (March 20), three weeks and two days later, we have 17,836 “cases” reported in the U.S. (and 238 dead). With that demonstrated exponential growth in mind, with an increase in reported “cases” in nearly every country in the world, and with “case” numbers so vastly unrepresented the number of infected people, I predict we, as a world, are in for a very, very rough next few weeks–at least.

That’s scary and sobering–but remember that China went into lockdown and is starting to emerge with no new reported cases. (Yes, China controls what people get to hear, but after an initial stumble, they’re not likely to suppress a recurrence. Too much is at stake. They know the cost.)

On Monday I’ll cover more of the reasons to hope. There are some. Meanwhile, remember this meme I saw on Facebook (paraphrased): Our parents, grandparents, and/or great-grandparents lived through the Great Depression and all the privations and death of World War II. We are called upon to sit on the couch for a few weeks. We can do this!

Keep to the high ground,

COVID-19 Some Basic Biology

COVID-19 is a new virus to humans. Researchers are busy trying to answer some of the basic questions. Today I offer two links that provide such basic information. The first link is a two part Twitter thread. (I didn’t even know you could do this on Twitter, but a lot of people actually get their information there.) It was written by Professor Palli Thordarson of the School of Chemistry of the University of New South Wales in Sydney, Australia. I think he was surprised at the popularity of what he had written. Here’s the link:


The German government and health system, unlike our own, were better funded and better led. They got ahead of the curve on the COVID-19 pandemic, chasing down contacts as early as the end of December. I do not have the numbers at my fingertips, but Germany has, so far, done better containment and has a lower death rate than other developed nations. The following article provides some detail on the transmission of SARS-CoV-2 in the form of a case study of nine people with known exposure whose virus shedding was intensively monitored during their course of Covid-19. (technically, SARS-CoV-2 is the virus, Corvid-19 is the disease the virus produces.) Here’s the link to the story:


Here’s the link to the original research paper:


This study is just one of many that will need to be done before this virus and it’s associated disease is better understood. Several take-home points (not hard and fast conclusions, but good information):

1) Patients with clinically very mild disease can shed lot of virus early on when they might have only mild upper respiratory tract symptoms (a “cold”). Hence the rapid spread with severely ill patients popping up unexpectedly.

2) Generally, severely ill patients shed even more virus.

3) All nine patients developed antibodies to SARS-CoV-2 within about a week of the appearance of the first mild symptoms, antibodies that neutralized (i.e. destroyed) the infectivity of the virus particles the patients bodies continued to shed. That’s an important point, because testing for virus particles with the common method, something called PCR (polymerase chain reaction) detects bits of viral RNA, but that RNA may be “dead” from the standpoint of disease spreading capability. It suggests that the current recommendation for isolating an exposed patient for fourteen days may actually be time enough for them to become non-infectious. Moreover, the development of functioning antibodies raises some hope that most patients after mild illness will be immune to this virus for some period of time (as yet to be determined). [In this study infectivity was assessed by “cell culture,” a more expensive and time-consuming method than the PCR method.]

Below I repeat the rational for social distancing–Flatten the Curve–that I shared last Friday. We are all in this boat together.

By the time this is over most of us will have been infected by Covid-19. Some of us will become very ill–and some of us will die (people from almost age groups, but more so among the elderly and among those with pre-existing medical problems). For those who experience severe pneumonia medical help for our breathing will be life-saving. The idea of all this pre-emptive closing of events is to “flatten the curve.” Here that is in graphic form:

I also offered the link below in last Friday’s email.  It is a great animated illustration of COVID-19 epidemiology.


Keep to the high ground–and I’ll be back Monday week, i.e. March 23,

COVID-19 Thoughts

With quarantines, case changing and pre-emptive closing down of large gatherings we are trying to avoid what happened in China and what is now happening in Italy:


By the time this is over most of us will have been infected by COVID-19. Some of us will become very ill–and some of us will die (people from almost age groups, but more so among the elderly and among those with pre-existing medical problems). For those who experience severe pneumonia medical help for our breathing will be life-saving. The idea of all this pre-emptive closing of events is to “flatten the curve.” Here that is in graphic form:

If you want to delve more deeply into the epidemiology and mathematics of this here’s the best I’ve seen:


Keep to the high ground–and I’ll be back Monday week, i.e. March 23,