Showing posts with label COVID-19. Show all posts
Showing posts with label COVID-19. Show all posts

Wednesday, December 16, 2020

The Vaccines Are Coming!

The Vaccines Are Coming, Eventually

Nicholas Johnson
The Gazette, December 16, 2020, p. A6

The vaccines are coming! The vaccines are coming!

Hold it. No, they’re not. Not for most of us. Not now.

For maybe six months our “vaccine” remains “wear your mask, social distance, and wash your hands.”

By then, hopefully, over 70 percent of Americans will be vaccinated or next in line -- the participation required to restrain COVID-19. Can enough anti-vax folks be converted? Acceptance percentages are increasing, but a recent poll indicated, at that time, even 60 percent of nurses and 40 percent of doctors were not planning to be vaccinated.

There are reasons why most drugs’ clinical trials take years not months. Participants in the BioNTech SE (Pfizer) trial will be followed for two more years while the vaccine is being administered.

There’s no rational reason to refuse inoculation. But there are still questions, and evolving answers, as the world’s beta test group expands from thousands to millions. Here’s a checklist. [Photo credit: maine.gov]

Global pandemics require global eradiction. It took the World Health Organization 25 years to eradicate smallpox.

The BioNTech SE vaccine requires refrigeration at minus 94 degrees. Packing requires dry ice, now in short supply. Dry ice produces CO2 that, on planes, risks combustion.

Only 25 countries have access to minus-94-degree refrigeration, thereby excluding five billion people from vaccination.

Nor is equity guaranteed in the U.S. distribution to people of color, the poor, immigrants, prisoners, and low population rural areas.

Best case, distribution from manufacturers’ plants to Americans’ arms is a logistics nightmare, and the last mile is 50 governors’ responsibility. How has that been working for us the last 10 months?

What does “inoculation” mean? Will everyone show up for their second shot? What’s known about dosages? AstraZeneca discovered cutting the first dose in half dramatically improved results. Protection for mild infections only or more? For six months or a lifetime? Will annual vaccinations be required? Can those vaccinated still infect others? Has anyone been tasked with maintaining a national database of those vaccinated?

Little is known about the vaccines’ safety and effectiveness with children, pregnant women, and the oldest of the elderly. Five of the FDA’s Advisory Committee did not vote for approval, two because it was approved for those 16 and above. Two cases have revealed additional side effects for those with allergies. What additional side effects may emerge, for which groups, and how serious will they be?

Follow the money. Is this a profit maximization operation? Or is healthcare a right – especially when no one is protected from a global pandemic until everyone is? Who pays? Who profits? How much? Vaccine recipients? Individual states? The federal government? Pfizer’s CEO glowingly proclaimed its vaccine a success. The stock price escalated and he sold $5 million of his Pfizer shares at a profit.

Ultimately, every American who wants a vaccine can have one. By then we’ll know more about these vaccines. They can help mitigate COVID-19 cases and deaths. Sadly, our need, our goal is not mitigation but global eradication.
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Nicholas Johnson, Iowa City, is former Co-Director of the Institute for Health, Behavior and Environmental Policy. mailbox@nicholasjohnson.org

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SOURCES

Note: References for the data cited within this column are contained, below, sometimes with additional information, in the order in which they appear in the column.

70% for protection.

Janelle Wang, “Doctors: 70% Need to Get Vaccinated for Herd Immunity,” NBC Bay Area, last visited December 11, 2020, https://www.nbcbayarea.com/news/coronavirus/doctors-70-need-to-get-vaccinated-for-herd-immunity/2417183/ (“Doctors say at least 70% of people need to get the coronavirus vaccine in order to eradicate the pandemic.”)

60% nurses, 40% doctors won’t get vaccinated. David Martin, "Inside the Operation Warp Speed effort to get Americans a COVID-19 vaccine," CBS, 60 Minutes, Nov. 8, 2020, https://www.cbsnews.com/news/covid-19-vaccine-distribution-60-minutes-2020-11-08/ ("[New Jersey Health Commissioner] Judith Perisichelli: 'We surveyed 2,000 health care individuals, physicians and nurses and we know that over 60% of the physicians said that they would get the vaccine. We know that about 40% of the nurses said that they would line up to get the vaccine.'")

Ed Silverman, "STAT-Harris Poll: The share of Americans interested in getting Covid-19 vaccine as soon as possible is dropping," Stat News, Oct. 19, 2020, https://www.statnews.com/pharmalot/2020/10/19/covid19-coronavirus-pandemic-vaccine-racial-disparities/

Trials take years.

Elan Kantor, "How Long Do Clinical Trials Take?" Antidote, March 24, 2020, https://www.antidote.me/blog/how-long-do-clinical-trials-take (“Looking at the big picture, it takes approximately ten years for a new treatment to complete the journey from initial discovery to the marketplace. Clinical trials alone take six to seven years on average to complete.”)

Katie Thomas, David Gelles and Carl Zimmer, "Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective," New York Times, Nov. 12, 2020; print edition Nov. 10, 2020, p. A1, https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html (“Independent scientists have cautioned against hyping early results before long-term safety and efficacy data has been collected.”)

Pfizer to follow for 2 years.

Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102 (Pfizer's chief executive officer, Albert Bourla, told CNBC Monday that the drug maker will follow participants for two years to analyze safety and ongoing protection. 'As time progresses, we will find out about the durability of the protection,' Bourla said.”)

There are still questions.

“Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102 ("Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination before and experts caution that much remains unknown about its safety, how long it might work and who might benefit most.")

Smallpox.

History of Smallpox, CDC, https://www.cdc.gov/smallpox/history/history.html

-94F.

Catherine Ho, “Pfizer Vaccine Needs to be Stored at minus 94 Degrees Fahrenheit; Is the Bay Area Prepared to do that?” San Francisco Chronicle, November 9, 2020, https://www.sfchronicle.com/bayarea/article/Some-coronavirus-vaccines-need-to-be-stored-at-15711275.php

Dry ice; combustion.

Elisabeth Buchwald, “The perils of transporting millions of COVID-19 vaccines with dry ice across the U.S.,” MarketWatch, December 10, 2020, https://www.marketwatch.com/story/the-challenges-and-perils-of-transporting-millions-of-covid-19-vaccines-with-dry-ice-across-the-u-s-11607355179 (“there are safety concerns about transporting large quantities of dry ice, which can emit carbon dioxide, on airplanes. Packaging dry ice in a container that does not allow adequate release of the gas could cause the container to explode from the built-up levels of pressure, a process known as sublimation. Dry ice can also deprive a confined space of oxygen, making it difficult to breathe. . . . the U.S. Department of Transportation and the International Air Transport Association classify dry ice as hazardous when transported. . . . The FAA has said it would allow United Airlines … to carry 15,000 pounds of dry ice per flight — five times more than normally permitted, The Wall Street Journal reported.”)

David Gelles, “How to Ship a Vaccine at –80°C, and Other Obstacles in the Covid Fight,” New York Times, September 19, 2020, https://www.nytimes.com/2020/09/18/business/coronavirus-covid-vaccine-cold-frozen-logistics.html ("When dry ice melts, it emits carbon dioxide, making the air on planes potentially unsafe for pilots and crew." "Dry ice . . . is made from carbon dioxide, . . . created as a byproduct during the production of ethanol. . . . This spring . . . people began driving less . . . ethanol production slumped, and so did the supply of carbon dioxide.")

25 countries with refrigeration.

David Gelles, “How to Ship a Vaccine at –80°C, and Other Obstacles in the Covid Fight,” New York Times, September 19, 2020, https://www.nytimes.com/2020/09/18/business/coronavirus-covid-vaccine-cold-frozen-logistics.html (“A recent study by DHL and McKinsey found that a cold vaccine would be accessible to about 2.5 billion people in 25 countries. Large parts of Africa, South America and Asia, where super-cold freezers are sparse, would be left out.”)

Governors’ responsibility.

Katie Thomas, David Gelles and Carl Zimmer, "Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective," New York Times, Nov. 12, 2020; print edition Nov. 10, 2020, p. A1, https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html (“it remains unclear where people will receive the shots, and what role the government will play in distribution.")

Astrazeneca half-dose.

Kaiser Health News, “New Results Confirm AstraZeneca’s Half-Dose ‘Mistake’ Is 90% Effective,” December 9, 2020, https://khn.org/morning-breakout/new-results-confirm-astrazenecas-half-dose-mistake-is-90-effective/ (“The partial results published in The Lancet on Tuesday confirmed that the two full doses given at least one month apart appeared to be 62% effective, while a half dose followed by a full dose was about 90% effective.”)

Immunization meaning.

Katie Thomas, David Gelles and Carl Zimmer, "Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective," New York Times, Nov. 12, 2020; print edition Nov. 10, 2020, p. A1, https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html (“no one knows how long the vaccine’s protection might last.” “an independent board reviewing the data has not told her or other company executives other details, such as how many of the people developed mild versus more severe forms of Covid-19.”)

Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102 (“would people previously sick with Covid-19 be protected against reinfection? That remains unclear.”)

Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102 (“This first analysis only included data on 94 confirmed Covid-19 cases, meaning there is no proof yet that the vaccine prevented infection.”)

Children, pregnant women, elderly.

Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102 ("'We don't know anything about groups they didn't study, like children, pregnant women, highly immunocompromised people and the eldest of the elderly,' Dr. Gregory Poland, director of the Mayo Clinic's Vaccine Research Group in Rochester, Minnesota, said.")

Four dissenters.

Laurie McGinley, Carolyn Y. Johnson and Joel Achenbach, “FDA says it ‘will rapidly work toward’ authorization of Pfizer-BioNTech coronavirus vaccine,” Washington Post, December 11, 2020, https://www.washingtonpost.com/health/2020/12/10/fda-advisory-panel-recommends-covid-vaccine/ (“The committee voted yes, 17 in favor, four against and one abstention. . . . at least two dissenters objected to inclusion of 16- and 17-year-olds, given . . . how few had participated in the trial.”)

Alergies.

Danica Kirka, “UK Probes Whether COVID-19 Vaccine Caused Allergic Reactions,” Associated Press, December 9, 2020, https://apnews.com/article/uk-allergic-reaction-pfizer-vaccine-64ddccd70c38a39f880da27941db3540 ; The Gazette, December 10, 2020, p. A4

Who pays?

Riley Griffin, Drew Armstrong and Bloomberg, "Germany funded the development of Pfizer’s COVID vaccine—not U.S.’s Operation Warp Speed," Fortune, Nov. 9, 2020, https://fortune.com/2020/11/09/pfizer-vaccine-funding-warp-speed-germany/

Katie Thomas, David Gelles and Carl Zimmer, "Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective," New York Times, Nov. 12, 2020; print edition Nov. 10, 2020, p. A1, https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html (“Operation Warp Speed, the federal effort to rush a vaccine to market, has promised Pfizer $1.95 billion to deliver 100 million doses to the federal government”).

Pfizer CEO. Reuters Staff, "Pfizer CEO made $5.6 million stock sale on same day as COVID-19 vaccine update: filing," Business News, Reuters, Nov. 11, 2020, https://www.reuters.com/article/pfizer-albert-bourla-stake/pfizer-ceo-made-5-6-million-stock-sale-on-same-day-as-covid-19-vaccine-update-filing-idUSKBN27R1XL

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Tags: anti-vax, AstraZeneca, BioNTech, children, COVID-19, doses, dry ice, eradication, FDA, herd immunity, immunization, infection, logistics, mitigation, Moderna, Pfizer, smallpox, vaccine, vaccination

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Friday, November 13, 2020

Why Vaccine Is Not The Answer

Why Vaccine Is Not The Answer
Nicholas Johnson
November 12, 2020

Two days ago, in "Eradicating COVID-19 Should Be Goal" (The Gazette, November 10, 2020, p. A6), with strict space limits, this is all that was said about vaccines:
What about a vaccine . . . ?

Yes, a vaccine ultimately eliminated global smallpox. But consider the history. . . .

In 1959 the World Health Organization began its global eradication effort. The last death occurred in 1978, and WHO declared mission accomplished in 1980. Although . . . “vaccination” might mitigate [COVID-19's spread it is not] the answer. [Vaccination] is rejected by many, takes too long, and produces many thousands of avoidable additional deaths.
COVID-19 is a global pandemic. The world's people will not be safe from its spread until it has been eradicated in all nations. It took the WHO 21 years from start to completion of that task for smallpox -- and that was after it already had been eradicated in the U.S. and Europe! There is no reason to believe that global eradication of COVID-19 can be accomplished any quicker.

With a quick response and properly done, the test-trace-quarantine-isolate approach can eradicate COVID-19 from a given population and area in roughly two months. See "How to Eliminate COVID-19," (The The Gazette, April 4, 2020, p. A6). (Obviously, it would take much longer if there are delays in response, the coronavirus has spread to a large percentage of the population, and large areas and populations are involved -- as currently is the case in the U.S.)

1. Delay. So lengthy delays are one reason "why vaccine is not the answer." Obviously, a vaccine can be one of a number of efforts at mitigation ("flattening the increasing curve" of infected persons) along with mandatory masks, social distancing, shelter in place, limiting the size of gatherings, and closing some businesses. However, as the column, "Eradicating COVID-19 Should Be Goal," linked above, points out, mitigation efforts, while helpful, are not eradication.

There are many other drawbacks to vaccines in general and the Pfizer vaccine in particular. A list of categories (with discussion of each below) might include: distribution, new technology untested on humans, lengthy trials to prove they are safe and effective, the risks with "Warp Speed," groups omitted from study (e.g., children, pregnant women, eldest), lack of knowledge about nature of immunization, possibility of reinfection, impact on contagion, the widespread public rejection of vaccines, need for two doses.

2. Distribution logistics; Cold-Chain complications; Equitable distribution. Global distribution of a vaccine to 7.5 billion people is an extraordinary logistics challenge under the best of conditions. Pfizer's vaccine requires jumping over even more severe hurdles.

Cold-chain complications. "Wide distribution of Pfizer’s vaccine will be a logistical challenge. Because it is made with mRNA, the doses will need to be kept at ultra cold temperatures. While Pfizer has developed a special cooler to transport the vaccine . . . it remains unclear where people will receive the shots, and what role the government will play in distribution." [NYT] "A number of the leading Covid-19 vaccines under development will need to be kept at temperatures as low as . . . minus 112 degrees Fahrenheit . . . [until] they are ready to be injected into patients’ arms. . . . [These vaccines are] made with genetic materials that fall apart when they thaw. . . . Vaccines may be manufactured on one continent and shipped to another. They will go from logistics hub to logistics hub before ending up at the hospitals and other facilities that will administer them. . . . 'We’re only now beginning to understand the complexities of the delivery side of all of this,' said J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, a research firm."

Nor is temperature maintenance easy when shipping the vaccine by air. "When dry ice melts, it emits carbon dioxide, making the air on planes potentially unsafe for pilots and crew." Moreover, "Dry ice . . . is made from carbon dioxide, . . . created as a byproduct during the production of ethanol. . . . This spring . . . people began driving less . . . ethanol production slumped, and so did the supply of carbon dioxide."

"Pfizer has designed . . . boxes . . . [to] hold a couple of hundred glass vials, each containing 10 to 20 doses of vaccine. . . . All of this leads to another problem: Glass often cracks in extreme cold." Moreover, "There wouldn’t be enough cold-resistant glass vials to handle a frozen vaccine, said Brendan Mosher, Corning’s head of pharmaceutical technologies."

Equitable distribution. "[E]everyday pharmacies are unlikely to be equipped to stockpile large quantities of vaccines that require ultracold storage. . . . strict temperature requirements 'will make it very difficult for community clinics and local pharmacies to store and administer.'. . . [A] cold vaccine would be accessible to about 2.5 billion people in 25 countries. Large parts of Africa, South America and Asia, where super-cold freezers are sparse, would be left out. 'The consequence is to reinforce the staggering bias in favor of the wealthy and powerful few countries,' said Mr. Morrison, of the Center for Strategic and International Studies." [NYT-2]

3. New Technology. "Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination before and experts caution that much remains unknown about its safety, how long it might work and who might benefit most." [NBC]

4. Lengthy trials and "Warp Speed." "[I]t takes approximately ten years for a new treatment to complete the journey from initial discovery to the marketplace. Clinical trials alone take six to seven years on average to complete." [Antidote] [FDA] "Operation Warp Speed's goal is to produce and deliver 300 million doses of safe and effective vaccines with the initial doses available by January 2021, as part of a broader strategy to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics . . .." [HHS] [Photo credit: InsideHigherEd]

"Independent scientists have cautioned against hyping early results before long-term safety and efficacy data has been collected. . . . The data released by Pfizer Monday was delivered in a news release, not a peer-reviewed medical journal. It is not conclusive evidence that the vaccine is safe and effective, and the initial finding of more than 90 percent efficacy could change as the trial goes on." [NYT] Warp speed is a worrying speed when it comes to vaccines -- not the least of which is what we don't know for sure about its safety and efficacy, and the other topics in this blog post.

5. Trial's omissions. "'We don't know anything about groups they didn't study, like children, pregnant women, highly immunocompromised people and the eldest of the elderly,' Dr. Gregory Poland, director of the Mayo Clinic's Vaccine Research Group in Rochester, Minnesota, said." [NBC]

6. Immunization, Infection, Contagion. "It's also uncertain how long such protection might last. That answer can only come with time, as it's impossible to know yet whether immunity remains for months, a year, two years — or a lifetime. . . . Pfizer's chief executive officer, Albert Bourla, told CNBC Monday that the drug maker will follow participants for two years to analyze safety and ongoing protection. 'As time progresses, we will find out about the durability of the protection,' Bourla said. 'We will see how long the immunogenicity lasts and how long the cell immunity lasts.'" "This first analysis only included data on 94 confirmed Covid-19 cases, meaning there is no proof yet that the vaccine prevented infection." "It is unclear whether people who received the vaccine were less likely to be contagious." "'It's not necessarily going to protect you from infection, and it may not work for everyone,' Haseltine said Monday on MSNBC. 'But it should be useful for many people. And it should moderate the severity of disease.'"[NBC]

"[N]o one knows how long the vaccine’s protection might last. . . . [Pfizer senior vice president Dr. Kathrin] Jansen said that because the trial is continuing, an independent board reviewing the data has not told her or other company executives other details, such as how many of the people developed mild versus more severe forms of Covid-19 — crucial information that the F.D.A. has said it will need to evaluate any coronavirus vaccine." [NYT] "We don't yet have details about whether the vaccine blocked mainly mild cases, or if there is evidence that it seemed to prevent some severe infections, too. . . . [A]t this point, there’s no way to estimate how long protection from this or any Covid vaccine would last. The duration of protection will only become clear after the vaccines are in use for a while." [Stat] "[Dr. Gregory Poland, director of the Mayo Clinic's Vaccine Research Group pointed out] 'And would people previously sick with Covid-19 be protected against reinfection? That remains unclear.'" [NBC]

7. Public rejection. "Overall, 58% of the U.S. public said they would get vaccinated as soon as a vaccine was available . . .. That change suggests growing concern that the regulatory approval process for a Covid-19 vaccine has been politicized by the Trump administration . . .. 'There’s a historical level of distrust,' said [Harris Poll Managing Director Rob] Jekielek. 'And when you think about stalling the spread of Covid-19, these findings indicate that we face an increasingly bigger problem.'" [Stat-2] "[New Jersey Health Commissioner] Judith Perisichelli: 'We surveyed 2,000 health care individuals, physicians and nurses and we know that over 60% of the physicians said that they would get the vaccine. We know that about 40% of the nurses said that they would line up to get the vaccine.'" [CBS] The point of these percentages is the huge proportion of Americans who will not be vaccinated, making vaccination at best a part of a path to mitigation, but not eradication.

8. Two doses. "Pfizer has said it will not apply for emergency use authorization of its vaccine candidate until it has collected two months of safety information following the final dose of the vaccine. Pfizer's vaccine requires two doses, about a month apart." [NBC] Another drawback of the Pfizer vaccine is the requirement of two doses a month apart. For the populations within a school or workplace it is relatively easier to complete this routine: a week can be designated during which everyone will get the first shot, and a month later another week designated to give them the second dose, with records kept, and follow ups for those who missed one or the other dose during the designated times. But for individuals outside of such groups many things can interfere with the scheduled second dose: simple forgetfulness, a change of mind, the rationalization that one dose was probably enough, a trip or move out of town, being laid up with some other disease. The possibilities are endless. And there is still that resistance, described above in "Public rejection," of those unwilling to take any vaccine, for any disease, whether it's one dose or two.

9. Follow the money. Pfizer claimed to have received no taxpayer money. "Vice President Mike Pence was among Trump administration officials saying support from the government’s Operation Warp Speed program helped accelerate the development of the vaccine . . .. [Pfizer's] Chief Executive Officer Albert Bourla has repeatedly said that the drug giant has avoided taking taxpayer dollars for research and development purposes. . . . Pfizer didn’t receive any funding from Operation Warp Speed for the development, clinical trial and manufacturing of the vaccine. Rather, its partner, BioNTech SE, has received money [$445 million] -- from the German government." And Pfizer was promised in advance the U.S. government would buy 100 million doses of the vaccine for $2 billion. ("The Trump administration agreed in July to pay almost $2 billion for 100 million doses, with an option to acquire as many as 500 million more, once that clearance comes. . . . As part of that agreement, the U.S. gets to decide who gets the vaccine first . . .."). [Fortune] Since two doses are required, that works out to $40 per person. Oh, and don't forget: "Pfizer [CEO] Albert Bourla sold $5.56 million worth of company shares on Monday [Nov. 9], the day the drugmaker said its COVID-19 vaccine was 90% effective based on interim trial results . . .." After Pfizer's stock price rose, and CEO sold off $5.56 million worth of Pfizer stock one can't help but wonder what he knew that we don't. [Reuters]

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SOURCES

Antidote. Elan Kantor, "How Long Do Clinical Trials Take?" Antidote, March 24, 2020, https://www.antidote.me/blog/how-long-do-clinical-trials-take

CBS. David Martin, "Inside the Operation Warp Speed effort to get Americans a COVID-19 vaccine," CBS, 60 Minutes, Nov. 8, 2020, https://www.cbsnews.com/news/covid-19-vaccine-distribution-60-minutes-2020-11-08/

FDA. "Step 3: Clinical Research," U.S. Food & Drug Administration, https://www.fda.gov/patients/drug-development-process/step-3-clinical-research

Fortune. Riley Griffin, Drew Armstrong and Bloomberg, "Germany funded the development of Pfizer’s COVID vaccine—not U.S.’s Operation Warp Speed," Fortune, Nov. 9, 2020, https://fortune.com/2020/11/09/pfizer-vaccine-funding-warp-speed-germany/

HHS. "Fact Sheet: Explaining Operation Warp Speed; What's the goal?" Coronavirus, HHS, Oct. 28, 2020, https://www.hhs.gov/coronavirus/explaining-operation-warp-speed/index.html

NBC. Erika Edwards, "Pfizer's Covid-19 vaccine promising, but many questions remain; Pfizer's vaccine is a new type of technology that's never been used in mass human vaccination," NBC News, Nov. 10, 2020, https://www.nbcnews.com/health/health-news/pfizer-s-covid-19-vaccine-promising-many-questions-remain-n1247102

NBC-2. David Gelles, "How to Ship a Vaccine at –80°C, and Other Obstacles in the Covid Fight; Developing an effective vaccine is the first step. Then comes the question of how to deliver hundreds of millions of doses that may need to be kept at arctic temperatures," New York Times, Sept. 19, 2020, print edition Sept. 19, 2020, p. A7, https://www.nytimes.com/2020/09/18/business/coronavirus-covid-vaccine-cold-frozen-logistics.html

NYT. Katie Thomas, David Gelles and Carl Zimmer, "Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective," New York Times, Nov. 12, 2020; print edition Nov. 10, 2020, p. A1, https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html

Reuters. Reuters Staff, "Pfizer CEO made $5.6 million stock sale on same day as COVID-19 vaccine update: filing," Business News, Reuters, Nov. 11, 2020, https://www.reuters.com/article/pfizer-albert-bourla-stake/pfizer-ceo-made-5-6-million-stock-sale-on-same-day-as-covid-19-vaccine-update-filing-idUSKBN27R1XL

Stat. Helen Branswell, "Four reasons for encouragement based on Pfizer’s Covid-19 vaccine results," Statnews, Nov. 9, 2020, https://www.statnews.com/2020/11/09/four-reasons-for-encouragement-based-on-pfizers-covid-19-vaccine-results/

Stat-2. Ed Silverman, "STAT-Harris Poll: The share of Americans interested in getting Covid-19 vaccine as soon as possible is dropping," Stat News, Oct. 19, 2020, https://www.statnews.com/pharmalot/2020/10/19/covid19-coronavirus-pandemic-vaccine-racial-disparities/

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Wednesday, July 08, 2020

Be Afraid, Be Very Afraid

Your Risk Isn't Just COVID-19 Symptoms, It's What Comes Later

Do you know the long term harms COVID-19 may do to your brain, lungs, heart, kidneys and the rest of your body?

Over 500,000 persons worldwide have died from the disease -- and one quarter of them used to live in the United States. But there is now increasing evidence that may be only part of the damage the disease can do.

There has been a recent upsurge of young people becoming infected.

Unfortunately, if they are willing to ignore their moral obligation to avoid infecting others -- as apparently many are -- their use of analytical tools such as risk assessment, benefit-cost, and opportunity cost could rationalize their ignoring masks, social distancing and hand washing.

What's the worst that could happen? How serious would that be? How likely is it to happen? They may not become infected. If infected they may have no symptoms. If they have symptoms they may be mild and quickly pass. So the benefit of masking up is relatively small, and the cost of avoiding crowds, the opportunity cost of missing out on social opportunities at parties and beaches, is (in their minds) very high. Their behavior -- if one can overlook their selfish disregard of others -- is marginally understandable.

Videos of hundreds of young folks without masks gathered shoulder to shoulder, ignoring the warnings, makes it seem hopeless. How can their behavior be changed?

What if we were to significantly increase the "cost" side of their equation? And how might we do that? We could "start spreading the news" (to borrow a line from Sinatra's "New York") of the serious after effects of COVID-19 infections -- starting with the human brain and cognitive function (to focus the attention of college students).
In the years to come, it may well be medical professionals who focus on the brain and cognitive function who are seeing and helping many post-COVID patients. The reason is that hypoxia, cardiac dysfunction, blood clots, strokes and similar conditions — all of which have been observed, to one degree or another, in those suffering COVID-19 — can all have long-term effects on brain function and cognition.
Wilfred Van Gorp, "Wave of cognitive disorders in young people from COVID-19," The Hill (Dr. Gorp is the former president of the American Academy of Clinical Neuropsychology.)

Here are some more excerpts, this time from the BBC: Zoe Cormier, "How Covid-19 can damage the brain; Some scientists suspect that Covid-19 causes respiratory failure and death not through damage to the lungs, but the brain – and other symptoms include headaches, strokes and seizures," BBC, June 22, 2020
For Julie Helms, it started with a handful of patients admitted to her intensive care unit ...and it was not just their breathing difficulties that alarmed her. "[M]any had neurological problems – mainly confusion and delirium,” she says. “this was completely abnormal. It has been very scary, especially because many of the people we treated were very young – many in their 30s and 40s, even an 18-year-old.” [T]he neurological symptoms in their Covid-19 patients, ranging from cognitive difficulties to confusion ... are signs of “encephalopathy” (the general term for damage to the brain) ...

Now, more than 300 studies from around the world have found a prevalence of neurological abnormalities in Covid-19 patients, including mild symptoms like headaches, loss of smell (anosmia) and tingling sensations (arcoparasthesia), up to more severe outcomes such as aphasia (inability to speak), strokes and seizures. This is in addition to recent findings that the virus, which has been largely considered to be a respiratory disease, can also wreak havoc on the kidneys, liver, heart, and just about every organ system in the body.

“In fact, there is a significant percentage of Covid-19 patients whose only symptom is confusion” – they don't have a cough or fatigue, says Robert Stevens, associate professor of anaesthesiology and critical care medicine at Johns Hopkins Medicine in Baltimore, Maryland. “We are facing a secondary pandemic of neurological disease,” says Stevens. “We’ve now learned that the disease affects many different organ systems: patients can die not only from lung failure, but also neurological manifestations. If you had asked me a month ago if there was any published evidence that Sars-CoV-2 could cross the blood-brain barrier, I would have said no – but there are now many reports showing that it absolutely can,” says Stevens.

In fact, some scientists now suspect that the virus causes respiratory failure and death not through damage to the lungs but through damage to the brainstem, the command centre that ensures we continue to breathe even when unconscious. ... The brain is normally shielded from infectious diseases by what is known as the “blood-brain barrier” – a lining of specialised cells inside the capillaries running through the brain and spinal cord. These block microbes and other toxic agents from infecting the brain. If Sars-CoV-2 can cross this barrier, it suggests that not only can the virus get into the core of the central nervous system, but also that it may remain there, with the potential to return years down the line.

Though rare, this Lazarus-like behaviour is not unknown among viruses: the chickenpox virus Herpes zoster, for example, commonly infects the nerve cells in the spine, later reappearing in adulthood as shingles – roughly 30% of people who experienced chickenpox in childhood will develop shingles at some point in their lives. ... David Nutt, professor of neuropsychopharmacology at Imperial College London, says he himself treated many patients in the 1970s and 1980s who had suffered from severe clinical depression ever since the 1957 influenza pandemic in the UK. “Their depression was enduring and it was solid – it was as if their emotional circuits had all been switched off,” he says, warning that we could see the very same thing happen again, but on a much larger scale. “People who are discharged from the ICU with Covid-19 need to be monitored systematically long-term for any evidence of neurological damage – and then given interventionist treatments if necessary.”

And in Pittsburgh, through the Global Consortium Study of Neurological Dysfunction in Covid-19, Sherry Chou, a neurologist at the University of Pittsburgh, has coordinated scientists from 17 countries to collectively monitor the neurological symptoms of the pandemic, including through brain scans. ... Although the virus’s impact on the lungs is the most immediate and terrifying threat, the lasting impact on the nervous system may be far larger and far more devastating, says Chou. "Recovery from neurological injuries is often incomplete and can take much longer compared to other organ systems (for example, lung), and therefore result in much greater overall disability, and possibly more death,” she says.

The final sentence reads, "Patients experiencing lung failure can be put on a respirator, and kidneys can be rescued with a dialysis machine – and, with some luck, both organs will bounce back. But there is no dialysis machine for the brain."
See also, Julie Helms, et al, Strasbourg University Hospital, Strasbourg, France, "Neurologic Features in Severe SARS-CoV-2 Infection," Letter, New England Journal of Medicine, June 4, 2020.

There may be a subsequent blog post regarding the other medical conditions that can be triggered by COVID-19 infections. Until then, here's a Fortune magazine article that groups the potential consequences by areas of the body: Blood, Brain, Eyes, Gastrointestinal tract, Hands, Heart, Limbs, Liver, Lungs, Kidneys, Nose and tongue, Skin, and Toes. "What are the potential long-term effects of having COVID-19?" Associated Press, Fortune Magazine, June 16, 2020

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Monday, July 06, 2020

One, Two, Three and You're Out

Restarting Sports in Virus-Deep Florida was the Worst of Miscalculations;
Sports leagues should have ignored the welcome mat offered by the Sunshine State

Jim Souhan
Minneapolis Star Tribune, July 5, 2020
You can subscribe to the online Minneapolis Star Tribune for only $3.79/week (99c/week for first four weeks).
[This column was announced in my morning [July 6] Facebook post as follows:

Searching for threads of stand-up funny under a shroud of deadly serious can be as dangerous as it is difficult. But when dissenting from my FCC colleagues' opinions satire was often the only effective response to the outrageous and absurd. (See opinions in my book, Catfish Solution, https://tinyurl.com/y4m9rqop )

One skilled sports reporter found himself in a comparable position regarding COVID-19 and sports in Florida.]
A bunch of sports leagues have decided to stage their return this summer in Florida. Apparently Hades was booked for a coronavirus party. [Photo credit: Wikimedia Creative Commons]

Maybe the better way to think of it is that Florida is a corona­virus party. And the party promises to never stop.

The United States might have handled the pandemic worse than any other developed country, and Florida might have handled it worse than any other state. Sending thousands of athletes and staffers to Florida right now is like asking them to jump from the frying pan into the sun.

Restarting in Florida might be the worst idea in sports since the White Sox wore shorts. FC Dallas, in Orlando for the MLS tournament, had its Thursday game vs. Vancouver postponed because of eight positive tests. One NWSL team, the Orlando Pride, withdrew from that league’s comeback tournament after a handful of young players went to a Florida bar and later tested positive.

This is how badly these sports have miscalculated: They are getting outsmarted by Gary Bettman and Rob Manfred, the Ren & Stimpy of sports commissioners.

Bettman, who runs the NHL, took a look at the United States’ handling of the pandemic and crossed it off his list. He is expected to move the rest of his season to Toronto and Edmonton, just to be based in a country that understands that science is real whether you believe in it or not.

Manfred — a memorable figure from this summer’s disingenuous baseball negotiations — months ago considered restarting in Arizona, Texas and Florida. Then MLB must have hired someone with internet access, because he scrapped that plan.

Arizona, Florida and Texas are the Moe, Larry and Curly of the pandemic. Only recently has one of those states’ leaders begun acting like an adult. Texas Gov. Greg Abbott, after watching the virus sweep through his state and overwhelm even the massive medical centers in Houston, finally mandated the wearing of masks statewide.

As a former Texas resident, I recognize this strategy. It’s known as closing the barn door after a lot of people died.

The NBA plans to return to action in Orlando. This decision was made for obvious and cynical reasons. ESPN, which has a close financial relationship with the league, is owned by Disney. Orlando is an NBA city and can offer large, entertaining bubbles in which athletes can live.

This all would make great sense if Orlando wasn’t located in Florida, and if this didn’t seem like a pure money play by Disney and ESPN, rather than a decision made in the best interests of players’ health.

Four NBA teams were recently forced to close their home workout facilities because of the virus. Are we supposed to believe that the virus will respect the borders of teams’ bubbles in Orlando, home to international tourism and many residents who think of the virus as some worldwide hoax designed to make mask manufacturers rich?

The first American pro sports league to reopen was the National Women’s Soccer League. A few younger players from the Orlando Pride went drinking in a Florida bar. Subsequently, six players and four staff members tested positive for the virus, and the team withdrew from the league’s comeback tournament, which is being played in Utah.

The WNBA is set to return at the IMG Academy in Bradenton, Fla. The Miami Marlins and Tampa Bay Rays have started their summer training camps. The Tampa Bay Lightning and Florida Panthers have resumed workouts. Minnesota United and most MLS teams are practicing in Orlando, with the Loons scheduled to return to play next Sunday.

What makes anyone think any of this will work?

The most hopeful answer available is that athletes, disciplined by nature, will understand just how dangerous Florida is, and take all precautions.

For months, we’ve been wondering how basketball or soccer players can expect to sweat and breathe on each other and avoid the virus, but at least in practices and in games they are interacting with other athletes who have been tested and who have reason to be vigilant about their health.

Where their discipline will be tested is in the Florida wilds. The bars and beaches, the theme parks, the restaurants in which some of the patrons literally wouldn’t wear a mask to save your life.

Good luck with that, athletes. All you have to do is wear a mask, stay off Space Mountain, avoid the bars and shun the beaches. In other words, you might as well be in Edmonton.

_______________

[Footnote.
I believe this promotion of the Minneapolis Star Tribune, and praise of its sports reporter, Jim Souhan, is within the category of "Fair Use." (It is a "noncommercial" use of no financial benefit whatsoever to me; it relates to news and public policy regarding a global pandemic, the free dissemination of which to the public is of the highest public interest; its reproduction in this blog will enhance, however minutely (rather than diminish) the financial value of this material for the Star Tribune and author. Nonetheless, if either the Star Tribune or the author requests I remove this blog post I will be happy to do so.
Email: mailbox@nicholasjohnson.org]

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Wednesday, July 01, 2020

Digital Data Deception

What do "analog" and "digital" mean? Analog is approximate, digital is precise. A mercury thermometer, car gas gauge, or bathroom scale are analog -- you estimate numbers from a needle or sliding scale. Digital "readouts" on radios or clocks provide precise numbers.

But precise is not the same as accurate. Have you ever heard someone described as "often wrong but seldom in doubt"? That's digital. After the power outage, the digital clock is still precise -- precisely wrong. The grandmother clock is accurate -- but approximate.

-- Nicholas Johnson (Excerpt from the column "My Grandmother's Clock" in the syndicated column series "Communications Watch," Iowa City Press-Citizen, February 28, 1983)
For the past three months I have been graphing and posting on my Facebook page the reported Iowa COVID-19 cases (Saturdays) and deaths (Mondays).

Now I've stopped. Why? Because for six months now we have been driving, sometimes backwards, on four flat tires, in a ditch alongside a road to nowhere. To continue to watch and report on our odometer mileage, or our average miles per hour -- let alone those digitally precise numbers -- suddenly seems as foolish as it is futile.

I am angry at the politicians whose preeminent focus on reelection and campaign donors' interests have resulted in the avoidable deaths of tens of thousands of Americans. I am disappointed by those Americans who -- while understandably confused by the mixed messages they're receiving -- risk infecting others. And I am dismayed by the total collapse of America's former reputation as an intelligent and compassionate world leader -- while our continued shouts of "We're Number One!," "We're Number One!" are only supported by our world rank in COVID-19 infections and ineffectiveness of our response.
What an embarrassment that when Europe opened to travelers from a list of countries, including Algeria, Montenegro, Morocco, Rwanda, Serbia, Tunisia among others, because of the U.S. failure to intelligently control its COVID-19 spread we were, rationally, excluded from the list. Council Agrees to Start Lifting Travel Restrictions for Residents of Some Third Countries," Council of the European Union, June 30, 2020.

Equally embarrassing for Iowans is that our uncontrolled outbreaks of the virus have placed us on New York's list of states whose citizens must be quarantined for 14 days before entering New York -- or face civil penalties up to $10,000. Marina Villeneuve, "New York adds several states, including Iowa, to travel quarantine list, sends monitors to NYC; New York is urging travelers from eight additional states to self-quarantine for 14 days as it awaits a decision on the reopening of indoor dining in New York City," Associated Press, The Gazette, June 30, 2020; J. David Goodman, "N.Y. Will Impose Quarantine on Visitors From States With Big Outbreaks; New Jersey and Connecticut will also require visitors to quarantine for two weeks. The rule reflects a stark shift in the course of the outbreak," New York Times, June 29, 2020.
Even using the inadequate numbers (as of June 29, 2020), the United States, with 4% of the world's population now has 25% of the world's positive COVID-19 cases -- 2,558,000 -- more than any other country on Earth, and more than the next two nations combined (Brazil and Russia -- both led by authoritarian dictators). (Source: Johns Hopkins Coronavirus Resource Center.)

So what's wrong with the U.S. numbers?

The Numbers We Don't Have

You might start with the fact that roughly 90 percent of Americans (and 90 percent of Iowans) have never been tested. You could even end with that fact. Why go further? We not only don't know the names of infected Americans (and Iowans) we don't even know the accurate numbers of infected persons. It's like fighting a war in Vietnam or Afghanistan in which your enemy refuses to wear a uniform and is otherwise indistinguishable from the friendly folks. We have not a clue how many Americans (and Iowans) are wandering about infecting others.
[The CDC reports there have been 32,300,000 U.S. COVID-19 tests -- but that's tests, not people tested. (Source: CDC, COVID-19, Testing Data in the U.S.) Iowa reports 301,300 individuals tested. (Source: "COVID-19 in Iowa"). In other words, in Iowa and the nation as a whole roughly 90 percent of Americans have never been tested.]

As they say on late night TV, "But wait, there's more." You can add to that, if you must, the fact that about 50 percent (we can only guess at that number as well) of those infected with COVID-19 are either (1) in the incubation period (and therefore not now showing symptoms), (2) will never show symptoms, or (3) are experiencing such mild symptoms that they (and others) are unaware they are infected. All of which is made worse by a president who minimizes the threat, sets the bad example of refusing to wear a mask, urges less testing, and is seemingly incapable of understanding that neither the economy nor his political fortunes will improve so long as COVID-19 infections continue to spread (put aside his lack of both focus on the national interest and empathy for those afflicted).

The Numbers We Do Have

Then there's what may be wrong with the numbers we do have. Consider the "COVID-19 deaths." Which deaths qualify and why? Where does the data come from? How might some deaths be missing from the data? Who collects it?

Epidemiologists believe that what's more accurate than counting "COVID-19 deaths" is counting all deaths and comparing those numbers to prior averages. "Measuring excess deaths is crude, but many epidemiologists believe it is the best way to measure the impact of the virus in real time. It shows how the virus is altering normal patterns of mortality and undermines arguments that it is merely killing vulnerable people who would have died anyway." Josh Katz, Denise Lu and Margot Sanger-Katz, "What Is the Real Coronavirus Death Toll in Each State?" New York Times, June 24, 2020. "In places with large coronavirus outbreaks, researchers have recently found thousands of unexpected deaths beyond those captured in the official tally of COVID-19 fatalities." Kathleen McGrory, "Coronavirus may have caused hundreds of additional deaths in Florida; An analysis conducted for the Times shows a spike in unexpected deaths since late March," Tampa Bay Times, May 20, 2020.For a discussion of those and many other variables see the earlier blog post, "Deaths Data," June 16, 2020.

The numbers for "cases" are not of much use for a variety of reasons; those numbers are a function of the number of tests (among other things). Fewer tests, fewer "cases" -- which is why Trump wants less testing. We know nothing about those who haven't been tested. We're not told the number of infected who have no symptoms. There are problems with the test kits and the tests (and having a $26 million, no-bid contract with an inexperienced supplier). The Gazette reported that roughly 10 percent of the tests with those kits came back "inconclusive." Grace King, "Some Test Iowa results 'inconclusive,' Linn County officials say; 334 people tested in first four days of opening Cedar Rapids site," The Gazette, May 13, 2020. On June 26 The Gazette's Lyz Lenz reported that Test Iowa has left a trail of incompetence, inaccuracy, lack of transparency and "unusable" test results. Lyz Lenz, "'Unusable' coronavirus tests results plague Test Iowa," The Gazette, June 26, 2020.

No one has an incentive to report numbers higher than the reality. Many have an incentive to report numbers lower: partisan officeholders who want to minimize the appearance of disaster and chaos in order to maximize their favorability ratings, nursing home owners who know that reports of cases and deaths in their facilities are bad for business (and possible liability), meatpacking plant owners for whom closures can cost millions of dollars.

The Iowa governor announced that nursing homes need not report cases or deaths unless they had an "outbreak" -- which she defined a three or more cases. The Nebraska governor explained that packing plants did not have to report at all. "Vice President Mike Pence encouraged governors on Monday to adopt the administration’s claim that increased testing helps account for the new coronavirus outbreak reports, even though evidence has shown that the explanation is misleading." "Pence Tells Governors to Repeat Misleading Claim on Outbreaks,"New York Times, June 16, 2020. President Trump told his Tulsa gathering, "Here's the bad part, when you test the, when you do testing to that extent, you're going to find more people, you're going to find more cases. So I said to my people, slow the testing down please!" "Trump: 'I said to my people, 'Slow the testing down, please!'" Yahoo News Video, June 21, 2020.

Would anyone deliberately change numbers for political advantage? Consider Florida.

Rebekah Jones worked for the State of Florida, gathering the state's COVID-19 data and presenting it in "dashboard" form online for the public. (Presumably this was analogous to the State of Iowa's "COVID-19 in Iowa" site.) Her story, as reported by NPR, is that the State wanted to open up more businesses, had a plan for doing so that required certain data levels, and was about to launch it before checking the actual current data. Upon officials discovery they could not justify the opening, under the standards of their own plan, she was ordered to change the numbers. She refused to do so and was fired. Laurel Wamsley, "Fired Florida Data Scientist Launches A Coronavirus Dashboard Of Her Own," NPR, June 17, 2020 (text); Rachel Martin, "Florida Scientist Says She Was Fired For Not Manipulating COVID-19 Data," Morning Edition, NPR, June 29, 2020 (7-minute audio; "NPR's Rachel Martin talks to Rebekah Jones, a scientist who was fired from Florida's health department, who is now publishing a coronavirus dashboard of her own to track the state's COVID-19 cases").

How Did We Get Here?

At least since the global pandemic of bubonic plague that reached Europe in 1347 humans have known the benefits of isolating those infected. During the late 20th and early 21st Centuries the best pandemic-fighting strategies have been explained in everything from fiction to films, from plays to playbooks from scientific, government and military experts. It is not, as we say, "rocket science." Indeed, this year has seen common sense successfully applied by responsible governments around the world: Australia, Canada, Georgia (nation), Germany, Hong Kong, Iceland, New Zealand, Singapore, South Korea, Taiwan, Vietnam -- and most recently Thailand (among others).

We have some of the world's most respected epidemiologists. Our CDC was looked to (and often present) everywhere. We'd had experience with pandemics, we'd written the playbooks on how to fight them, step by step. It's common sense. The steps could be laid out in a 15-minute YouTube video.

So why do we have more infected and dead individuals from this coronavirus than any other nation? How could our federal and state governments -- and the American people -- have been so woefully inadequate in their response to this global pandemic when compared with all of the other 193 UN countries and seven billion people on Earth? We can't blame immigration or China. All the successful countries also had immigration and China. (Thailand is even a favorite vacation spot for the Chinese.) No, the reason we have lost nearly twice as many American lives in three months from COVID-19 as we lost in Vietnam in 19 years is largely because (among other things) (1) the federal and state governments failed to start with the most effective strategies (total test-trace-isolate), and (2) delayed so long in doing even the wrong things.

A pandemic spreads rapidly. It's like weeds in a garden, a cockroach infestation, or erosion in a farm field. Stopped at its inception -- when the first COVID-19 cases were reported -- it can be brought under control and eventual elimination relatively quickly and easily (compared with our chaotic disaster of a response). The inevitable subsequent resurgences can also be more easily handled.

Compare our lackadaisical approach with what happened in Beijing a week or so ago.
Beijing’s new infections emerged two weeks ago . . .. As of June 22, the authorities had taken samples from more than 2.9 million people over the previous 10 days . . .. Wu Zunyou, the head of the Chinese Center for Disease Control, said last week that the outbreak was “under control.” In an interview this week . . . he predicted the number of cases would not exceed 400.
(Source: "China says it has tamed an outbreak in Beijing, at least for now" (sub-head within story with main headline: "U.S. Hits Another Record for New Coronavirus Cases"), New York Times, June 27, 2020)

In other words, the Chinese were testing in Beijing -- every day -- about the same number of people as Iowa has tested in four months! And as a result the Chinese virtually eliminated a COVID-19 resurgence from one of the world's largest cities in a couple weeks.

Or, if you'd prefer something a little closer to the size of many Iowa towns, check out one of my first columns on the importance of testing, "How to Eliminate COVID-19," The Gazette, April 4, 2020 (Vo, Italy, tested everyone in the city and eliminated any threat from COVID-19 in about three weeks).

There are many physical and mental health, economic, social, educational and other consequences of our delay. But the most dramatic is the number of predictable, unnecessary, preventable deaths. Joseph Guzman, "Experts: 90 percent of US coronavirus deaths could have been avoided if measures had been taken just two weeks earlier; Two medical experts say issuing social distancing measures just two weeks earlier could have drastically changed the trajectory of coronavirus deaths in the United States," The Hill, April 16, 2020.

The most efficient, speedy and effective way to deal with a COVID-19 (or other viral) global pandemic, knowing they happen from time to time, is to:
(1) prepare for it in advance. ("Preventing disasters is part of the job description of those getting the big bucks to lead corporations and government. ... Leaders’ performance should be judged by not what they propose to prevent 'next time' but by what they failed to do to prevent 'this time.'” Nicholas Johnson, "'Never Again' is Not Enough in Response to School Shootings," USA Today, March 6, 2018)

(2) Once informed of a potential pandemic anywhere (as we were repeatedly during the November 2019 through February 2020 period) be on the lookout for the first cases in the U.S.

(3) Immediately respond (in hours, not days, weeks or -- as in our case -- months) with the test-contact-trace-treat-separate/quarantine/isolate-test-again response with everyone showing symptoms and those with whom they've come in contact.

(4) "Wash, rinse, repeat." In other words, keep after each case as it pops up. The goal is to prevent the exponential explosion of a disease spreading throughout the population. This approach is designed to, ultimately, produce the entire elimination of the coronavirus (as was done globally with smallpox). This is the most cost-effective, economy-protecting, life saving, efficient way to quickly battle COVID-19.
This approach was available to us during January and even February. It is no longer (except for small pockets of infected persons). As of today there are 2.6 million confirmed cases. Some estimate the total number (including the untested) would be 10 to 20 times that number. Dan Mangan, "Coronavirus cases are likely 10 to 20 times higher in US than reported, former FDA chief Gottlieb says," CNBC, April 21, 2020; Joel Achenbach, "Antibody tests support what’s been obvious: Covid-19 is much more lethal than the flu," Washington Post, April 28, 2020.

There are, of course, other approaches to COVID-19 none of which have been, so far, successful in eliminating it. Because there is no vaccine, cure or treatment for the disease none of these options are fully satisfactory.
(1) "Herd immunity": A nation just waits until, finally, everyone has been infected -- this appears to be some American politicians' current unspoken favorite by default. This has three drawbacks. It maximizes the number of deaths. It takes a very, very long time. And the scientists don't yet know if it will work. If you are infected, and don't die, does that mean you can never get it again? They don't know. Even if you are immune, does that mean you can't give it to others? They don't know. And, if either are true, how long does your immunity last? They don't know.

(2) "Hospital capacity": focus on the ability of the healthcare system to handle the infected and dying. So long as the community, or state, has enough hospitals, healthcare workers, beds, intensive care facilities, ventilators, other equipment, and PPE you're OK. The problems with this one are that it is hard to predict the caseload, imposes excessive burdens on healthcare workers, and it does little to nothing by way of reducing the spread of the disease.

(3) "Mitigation": monitor and enforce efforts designed to minimize the rate and extent of spreading the disease, such as closing places where the disease is most likely to spread (e.g., bars, indoor arenas), wearing masks, maintaining six-foot distancing between people, forbidding groups of more than six (or 50). This approach requires acceptance of the ongoing numbers of infected, dying and dead from the coronavirus so long as those numbers are steady, or increasing only slightly ("flattening the curve"). That is mitigation advocates' benchmark for decisions regarding opening or closing businesses and events. Such measures may slow the rate of increase in infected persons, but it neither eliminates the virus nor provides any information about the roughly half of the infected who are without symptoms.

(4) "Mitigation light": the difference between "mitigation" and "mitigation light" is like the difference between those who follow "the ten commandments" and those who consider them "the ten suggestions."
At this point in time probably the best bet is to do what you and I can to encourage national and state leaders to crank up the enforcement of the epidemiologists' recommendations and their acceptance as national standards -- while complying with them ourselves.

I wish I had better news for you, I really do. But I don't. This is my current take on our current condition and probable future. Meanwhile, I pull such comfort as I can, while keystroking in the living room, from the rhythmic, if approximate, tick-tock, tick-tock from my 120-year-old grandmother's clock in the kitchen.

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Tuesday, June 16, 2020

Deaths Data

For the 2009 fall semester the University asked me to add to my teaching load one of what it was calling "First Year Seminars." These were small-section classes for entering first years taught by selected professors from a variety of colleges and departments, with subject matter of the professor's choice.

My choice? General Semantics. It probably had not been taught at Iowa since my father's lectures in the 1940s and '50s, when it was said to have been one of the most popular among students, and chosen for broadcast throughout the coverage area of the University's AM radio station, WSUI.

My book, What Do You Mean? and How Do You Know? An Antidote for the Language That Does Our Thinking For Us [Prairie Lights; Amazon], created for that seminar, consisted of four chapters from my father's writing and eight of my own. (Two K-12 teachers, present for my presentation with that title at a Herbert Hoover Presidential Library event in 1997, used these ideas in their teaching "American History from the Perspective of Minorities and Women," which course was described in a third person's doctoral dissertation and subsequent book.)

This is not the time to attempt a full explanation of general semantics. Perhaps that should be saved for an essay on its relevance as a necessary first step toward the elimination of systemic racism. But this brief quote at the beginning of the first chapter may be useful:
"General semantics" is not about "semantics" -- as in the expression, "Oh, you're just arguing about semantics." It's not about "defining" words, their historical etymology, or cognates. General semantics deals with language as human behavior; for example, the disparity between what we say (that largely reflects what's going on inside our brain) and the "reality" we think we're describing -- and the consequences of that confusion.
With this long introduction, and short explanation, let's take a look at "what we mean" and "how we know" about the number of Iowans' deaths from COVID-19.

What Do You Mean?

For the most part we know what we mean by "dead," the word and the reality are fairly clear (though there is some ambiguity in cases of "brain dead" and other variations).

The official State of Iowa "Covid-19 in Iowa" site labels its data under "Current Cases": "Individuals Tested," "Individuals Positive," "Total Recovered," and "Total Deaths."

We can assume that "deaths" means an individual's death was in some way associated with COVID-19. If a person has tested positive for COVID-19, had symptoms associated with the virus, no other medical conditions weakening their immunity, and died, it would be difficult not to add their number to "total deaths." But what if they had not been tested before they died, but had one or more of the symptoms of COVID-19 at the time of death? Are they part of "total deaths"? What if (whether tested or not) they had COVID-19 symptoms that weakened their immunity, but also preexisting conditions (say, pneumonia)? Is whoever determines "cause of death" free to report they died of pneumonia and not record it as part of "total deaths" (from COVID-19)? In other words, does it make a difference in the counting whether someone has died from COVID-19 or just with COVID-19 -- along with, perhaps, many other conditions? [Chart credit: Nicholas Johnson, using State of Iowa data.]

Where and by whom, within the healthcare system, is the determination made as to whether a deceased should be counted among "total deaths" or not? Is there, somewhere, written instructions regarding these choices? Are they publicly available online? If so, is there any oversight of the compliance and noncompliance with these procedures and definitions?

How Do You Know?

There are powerful incentives for elected officials (state, county and local), meat packing plants, nursing homes, prisons, and other institutions to minimize their responsibility for the spread of this global pandemic, Americans infected, with the stresses it has created on our hospitals, healthcare workers, families and businesses of all sizes -- not to mention the more than 116,000-and-rapidly-climbing deaths of Americans.

The Iowa governor announced that nursing homes need not report cases or deaths unless they had an "outbreak" -- which she defined a three or more cases. The Nebraska governor explained that packing plants did not have to report at all. "Vice President Mike Pence encouraged governors on Monday to adopt the administration’s claim that increased testing helps account for the new coronavirus outbreak reports, even though evidence has shown that the explanation is misleading." "Pence Tells Governors to Repeat Misleading Claim on Outbreaks,"New York Times, June 16, 2020.

What is the process by which (and by whom) deaths -- in general, not just COVID-19-related -- are reported? Who reports, and to whom, when someone dies in a hospital, at home, or elsewhere? What oversight is there for these alternative reporting channels -- hospitals, long term living and nursing home facilities, funeral homes, those performing autopsies, police at the scene of an accident causing death, someone who dies at home?

Where can one go online to find, say, total deaths in Iowa for the past five years, by months? (The latest I found was 2017, broken out by conventional causes of death.) An alternative way to measure COVID-19-related deaths would be to look at Iowa's mortality statistics for February through June for 2016-2020. One would need to correct for variations in 2020 data from prior years' averages; for example, a decrease in deaths from automobile accidents during 2020 due to less driving during the pandemic. Having done that, it would be possible to see any increase in total deaths during those months in 2020 that could rationally be related to COVID-19. As such, it could be one way of confirming (or questioning) the State's official "total deaths" statistic.

At a time when trust is in increasingly short supply, one recalls President Ronald Reagan's advice, borrowing the Russians' expression, "trust, but verify." One of the first steps in verification is to ask the two questions, "What do you mean?" and "How do you know?"

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Sunday, May 17, 2020

How You Can Help Fight COVID-19

"[I]n early May [Iowa Governor Kim] Reynolds . . . stopped announcing daily cases and deaths on TV . . . [and] sending out those statistics with news releases to the media and posts to the governor's website . . . at a time she is increasing the ability of Iowans to sit down for a meal at a restaurant, get a haircut, work out at a gym and go shopping [saying] 'Iowans are going to take the responsibility to decide if they are ready to go out and participate at the businesses or go to a restaurant.'"
Vanessa Miller, "As Iowa Reopens, Stat's Virus Data Elusive; Citing Lack of Help from Reynolds, Some Keep Their Own Tallies," The Gazette, May 17, 2020, p. A1

In other words, we're being asked to make our own decisions about avoiding COVID-19 -- and at a time when our Governor has stopped reporting deaths during daily video reports, and otherwise obfuscating what data remains.

What to do? I guess we'll have to gather our own data. Fortunately there's a way to do that -- one that takes less than a minute a day, costs nothing, and is risk free.

Willing to help? Read on.

What I'm talking about is the creation of Professor Tim Spector, MD, Genetic Epidemiology, King’s College London, and Professor Andrew Chan, MD, MPH, Harvard Medical School and Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health.

It's an app for either iPhone or Android called Covid Symptom Tracker, and over 3.6 million people have downloaded the app and report in every day on their symptoms. If you are symptom-free, as thankfully I have been, it literally talkes less than a minute to click on the app, select the "me" profile, click on the "I have never had a COVID test," and "I feel physically normal."

If enough people in your county have signed up your app then displays the number of people in your county who are reporting COVID symptoms.

I am in Johnson County, Iowa, and at the time of writing we need an additional 223 people (May 17; today, July 3, we need 188) to participate to get that report.

To get the app go to your app store and search for "covid symptom tracker." It should be at the top of the list. If not, look for the logo displayed here.

And thank you! Spread the word.

More about Covid Symptom Tracker

To find out more about this project from those who created and run it: https://covid.joinzoe.com/us/about

And see:

Andrew Jacobs, "App Shows Promise in Tracking New Coronavirus Cases, Study Finds; The app, which allows people to record their symptoms, was remarkably effective in predicting infections. The most reliable indicators, researchers found, were loss of smell and taste," New York Times, May 13, 2020, p. A4 ("In the absence of widespread on-demand testing, public health officials across the world have been struggling to track the spread of the coronavirus pandemic in real time. A team of scientists in the United States and the United Kingdom says a crowdsourcing smartphone app may be the answer to that quandary.

"In a study published Monday in the journal Nature Medicine, researchers found that an app that allows people to check off symptoms they are experiencing was remarkably effective in predicting coronavirus infections among the 2.5 million people who were using it between March 24 and April 21.")

Charlotte Jee, "A New App Might Help Researchers Monitor the Spread of Coronavirus," MIT Technology Review, March 25, 2020

David M. Halbfinger, "How Are You Feeling? Surveys Aim to Detect Covid-19 Hot Spots Early; Scientists have persuaded Britons and Israelis to fill out questionnaires about their health, to get ahead of the coronavirus by getting resources to the right place. The U.S. is next," New York Times, April 1, 2020

"COVID-19 Symptom Tracker App," News, Massachusetts General Hospital, March 31, 2020

# # #



Andrew Chan, COVID-19, Covid Symptom Tracker, epidemiology, Governor Kim Reynolds, symptoms, Tim Skpector, Vanessa Miller

Thursday, April 30, 2020

January 20: Another Date Living in Infamy

AND
COVID-19: THE ESSAYS COLLECTION
Contents
Letter to The Gazette
Sources for Letter
Supportive Commentary and Other Thoughts
Introduction and Qualifiers
Nonfeasance, Malfeasance, Involuntary Manslaughter, and the Sum Total of Human Knowledge
Sampling President Trump's Comments
Why Test-Trace-Quarantine-and-Test?
A Global Pandemic Calls for Global Solutions
Doing the Wrong Thing Better
South Korea's Awesome COVID-19-Fighting Apps
Exponential Growth
Why Infamy?
Nick's COVID-19-Related Writing
January 20: Another Date in Infamy
Nicholas Johnson
The Gazette, April 26, 2020, p. D2

Jan. 20, 2020 is "a date which will live in infamy," to borrow President Franklin Roosevelt’s labeling of the Dec. 7, 1941 bombing of Pearl Harbor. Jan. 20 was the day both South Korea and the U.S. had their first CORVID-19 cases. [South Korean President Moon Jae-in and first lady Kim Jung-sook wearing masks to prevent contracting the coronavirus disease (COVID-19). Photo credit: Yonhap via Reuters]

Twenty days later South Korea had flattened the curve. Along the way it had the second highest number of cases globally, but by April 20 the threat was over -- while keeping many businesses and factories open.

A Seoul official credits “quick government intervention, tracking and isolating infected personnel, and a transparent information hub” – plus a dozen amazing apps. All things we could and should have done.

WWII cost $4 trillion (today’s dollars) and 407,000 lives. Our unconscionable federal lack of prompt response to the virus will cost much more in unnecessary dollars and deaths. And that’s why this year’s Jan. 20 is another “date in infamy.” For sources and more see, https://tinyurl.com/y7swfgqy

Nicholas Johnson
Iowa City

# # #

Sources

Kanga Kong, "Seoul’s Full Cafes, Apple Store Lines Show Mass Testing Success," Bloomberg News, April 18, 2020

David Lee, "Coronavirus: lockdowns are not the reason Hong Kong and South Korea are beating Covid-19. Model citizens might be," South China Morning Post, April 21, 2020

Aylin Woodward, "South Korea controlled its coronavirus outbreak in just 20 days. Here are the highlights from its 90-page playbook for flattening the curve," Business Insider, April 18, 2020

Doug Whiteman, "The Financial Facts You Never Learned About World War II," MoneyWise, July 4, 2019

"World War II Casualties," Wikipedia.org

# # #

Supportive Commentary and Other Thoughts

Introduction and qualifiers: Like many policy wonks, and everyone tracking the print, online and broadcast news since the revelations from China in December and January, my disproportionate focus has been on the global COVID-19 pandemic. I claim no expertise regarding these issues. I am neither trained nor experienced in medicine, epidemiology, or public health. Although I once served as a co-director of the Iowa Institute on Health, Behavior and Environmental Policy, our major focus was on America's 400,000 annual deaths related to tobacco use -- not global pandemics. My facts and opinions come from material publicly available to everyone -- including what's public of what President Trump could and should have known from reports and his staff since last November (and earlier). (Rem Rieder, "Contrary to Trump’s Claim, A Pandemic Was Widely Expected at Some Point," FactCheck.org, March 20, 2020)

Nonfeasance, Malfeasance, Involuntary Manslaughter, and the Sum Total of Human Knowledge

As a law student I served as assistant (the school called assistants "Quizmasters") to an elderly, quite proper, kindly and helpful professor. As such I sat through his contracts course, although I had earlier taken the class from another professor, to better assist with grading papers. I do not recall his question on the occasion I'm about to describe, nor do I recall the student's answer. But I clearly recall the shocked expression on the professor's face -- one I had never before seen -- and his long pause before responding. Finally he spoke, in his soothing drawl: "Young man, you have a capacity for subtracting, rather than adding, to the sum total of human knowledge."

Those were the only personally judgmental words I ever heard him speak, but they leapt from my aging memory bank the other day when I heard our president ask one of his epidemiologists whether a cure for COVID-19 might be the injection of bleach or other disinfectants into the bodies of COVID-19 patients. "That," I thought to myself is another example of "subtracting, rather than adding, to the sum total of human knowledge." (Allyson Chiu, Katie Shepherd, Brittany Shammas and Colby Itkowitz, "Trump claims controversial comment about injecting disinfectants was ‘sarcastic,’" Washington Post, April 24, 2020 (with video of remarks)

It is reminiscent of the old saying directed at an unhelpful participant in a group dealing with a crisis: "Lead, follow, or get out of the way." When it comes to COVID-19, Trump won't lead, he won't follow the example of other world leaders or the advice of America's experts, and he refuses to get out of the way.

Which brings us to the distinction between "malfeasance" and "nonfeasance."
"Malfeasance. Intentional conduct that is wrongful or unlawful, especially by officials or public employees. Malfeasance is at a higher level of wrongdoing than nonfeasance (failure to act where there was a duty to act) or misfeasance (conduct that is lawful but inappropriate)."
Malfeasance, Legal Information Institute, Cornell Law School.

We're not concerned with the "legal" definitions, or legal consequences. For our purposes the point is simply that a public official, such as our president, can fairly be judged not only by the intentional harm that he does but also by the harm that results from his inappropriate responses -- and by his failure to act at all when action is clearly called for.

The Code of Iowa, Chapter 707, deals with "Homicide and Related Crimes." One of the definitions of first degree murder is when "The person willfully, deliberately, and with premeditation kills another person." Section 707.2 (1)(a). What if a person has no intention to "willfully, deliberately" kill anyone, but "unintentionally causes the death of another person by the commission of an act in a manner likely to cause death or serious injury"? That is one of the definitions of "involuntary manslaughter." Sectiion 707.5 (1)(b)
As an interesting sidebar, note that there is an equivalent law governing "death by smart phone." It is "a class 'C' felony when the person unintentionally causes the death of another by any of the following means: Driving a motor vehicle in a reckless manner with willful or wanton disregard for the safety of persons or property .... [A] person’s use of a hand-held electronic communication device to write, send, or view an electronic message while driving a motor vehicle shall be considered prima facie evidence that the person was driving the motor vehicle in a reckless manner with willful or wanton disregard for the safety of persons or property ...." Section 707.6A (2)(a)(1).
The point of this mini-essay is not to make a legal case for the criminal prosecution of the president or anyone else. It is to make a moral, ethical and theological point with huge economic and public health consequences. What we are dealing with is not "just Trump being Trump." We are suffering under a president whose non- mis- and malfeasance comes dangerously close to the definition of involuntary manslaughter, actions that are unnecessarily costing tens of thousands of lives, trillions of dollars of lost wages, profits and taxpayer dollars, and uncounted human misery.

Sampling President Trump’s Comments – And the Facts

The following President Trump quotes, and references to information available to him in advance of the COVID-19 global pandemic are taken from the Seth Meyers episode, "Trump Wants Everyone to Forget He Ignored Repeated Coronavirus Warnings: A Closer Look," "Late Night with Seth Meyers," April 8, 2020. A video of that 13:38 minute episode can be found here. Each quote is preceded by two numbers: the first is the time into the show where the quote appears, and the second is the date when Trump uttered the quote. Because the video shows Trump actually uttering these words no further documentation is provided of written sources that may have reported the remarks.

1:30 3/6/20 "I just think this is something, Peter, that you can never think is really going to happen."

1:37 3/6/20 "It's an unforeseen problem. What a problem. Nobody, nowhere."

1:40 3/11/20 "We're having to fix a problem that four weeks ago nobody ever thought would be a problem."

4:52 3/11/20 "You read about them. You read about them from 1917, and you read about them from lots of other times."

1:44 3/14/20 "It's something that nobody expected."

1:46 3/19/20 "I would view it as, it's something that just surprised the whole world."

3:57 3/19/20 "So there's never been anything like this in history. There's never been. Nobody's ever seen anything like this."

1:24 3/19/20 "Nobody could have predicted something like this. Nobody knew there would be a pandemic, or an epidemic of this proportion."

4:35 4/4/20 "Nobody's seen this, I would say since 1917, which was the greatest of them all. Probably the greatest of them all, right? 1917. There's been nothing like this since probably 1917. That was the big one."

11:50 4/4/20 "What have you got to lose? Try it."
The Seth Meyers' episode also listed the following briefings and reports that contradict the President's repeated statements that "no one knew" a global pandemic was coming.
"Obama officials walked Trump aides through global pandemic exercise in 2017: report"

"In 2017 and 2018 threat assessments, intelligence analysts even mentioned a close cousin of coronavirus by name, saying it had 'pandemic potential.'"

"In 2018 . . . the director for medical and bio-defense preparedness at the National Security Council, told a symposium that 'the threat of pandemic flu is our number-one health security concern.'"

"Top administration officials said last year threat of pandemic kept them up at night"

"White House Economists Warned in 2019 a Pandemic Could Devastate America"

"Intelligence report warned of coronavirus crisis as early as November: Sources"

"U.S. intelligence reports from January and February warned about a likely pandemic"

"Trade Adviser Warned White House in January of Risks of a Pandemic"

"Memorandum to President" (NSA, COS, Covid-19 Task Force), Feb. 23, 2020
Why Test-Trace-Quarantine-and-Test?

When I was a young boy, maybe four or five, I recall the day I slowly slid off of the front porch swing to go back in the house, looked up and saw an 8-1/2" by 11" poster tacked to the door and its bold, capital letters that spelled out “QUARANTINE.” I could not spell or pronounce it and had to ask my parents what it meant.

What it meant was that I was supposed to stay inside.

It was neither the first nor last time the Iowa City public health folks put it there. Who knows how many times our kindly family doctor brought his small black bag and came to see me. He would take my temperature, put on my chest the stethoscope he always wore like a necklace, give me one of his cherry-flavored candy “pills,” and tell me to rest.

This was not medical malpractice. There were simply no vaccines for what I had. And I had a variety, though the only ones I now remember are chicken pox, influenza, measles, mumps, pinkeye, strep throat and whooping cough. Having the disease – if it didn’t kill you – provided an immunity from getting it again, kind of like making your own vaccine.

So what’s this got to do with our current global pandemic? Simply this: the idea that quarantine is an essential element in fighting a pandemic is scarcely a new one.

On July 27, 1377, the city council of what is now Dubrovnik, Croatia, passed a law providing that “those who come from plague-infested areas shall not enter [the city] or its district unless they spend a month on the islet of Mrkan or in the town of Cavtat, for the purpose of disinfection.” Dave Roos, “Social Distancing and Quarantine Were Used in Medieval Times to Fight the Black Death,” History.com, March 27, 2020.

Of course, even if we were following the 1377 advice from Dubrovnik, and we’re not, in order for an area-wide quarantine to eradicate a disease it is necessary to know who has it.

Which brings us to the qualities of COVID-19 infections and possible responses to a coronavirus pandemic.

COVID-19 Basics
(1) The coronavirus can pass from one person to another.

(2) The number of infected persons increases exponentially. (See Exponential Growth, below.) As a result, delay is deadly. It means that one infected person may become three the next day, but two weeks later the one has grown to 16,000.

(3) Most significant, not everyone who is infected -- and therefore capable of infecting others -- displays symptoms.

Their symptoms may develop a few days after the infection, they may never show symptoms, they may be over their infection but still capable of infecting others.

Because we’ve only tested a small fraction of Americans, we cannot be certain how many of the infected have no symptoms (are “asymptomatic”). If we only, or primarily, test infected persons showing symptoms we will never know. However, a guess at 50 percent is probably in the ballpark. (See the percentages for Vò, Italy, and the cruise ship Diamond Princess in How to Eliminate COVID-19.)

(4) Are those who have survived the disease immune to a second infection -- similar to my childhood diseases? However reasonable a hypothesis worthy of testing, at this point we don’t know. Is such a person incapable of passing the disease to another? We don’t know that either.

Possible COVID-19 Responses
(1) Do nothing. Don’t be proactive (proactive examples: support research; create plans for responding to possible pandemics; maintain stockpiles of medicines, equipment, PPE (personal protective equipment for health care providers), test kits, identify facilities where the infected can be placed). Allow the virus to run its course; many will fall ill and some will die, but ultimately “herd immunity” will protect the surviving population – if the hope and assumption is valid that everyone, once infected, now has a lifetime immunity from the disease.

(2) Mitigation. Accept the fact that the disease will continue to spread exponentially but suggest practices that will reduce somewhat the number infected any given day. This would include recommending “social distancing,” “shelter at home,” limiting gatherings to 10 persons or less, in an effort to “flatten the curve” while accepting the increasing numbers of persons who have been infected or died.

(3) Concentrate on “hot spots.” Use triage to find and address those in close quarters, often with clusters of the infected with symptoms -- cruise ships and aircraft carriers, long term living facilities, schools and dormitories, manufacturing and industrial plants (such as meatpacking plants). (Our failure to be at least this rationale is inexplicable.)

Our Response
Our response has been a mix of (1) and (2).

Meanwhile, not only have there been a large body of official reports and scientific literature warning of the coming of this pandemic and the best ways to respond, there are numerous examples of what the successful countries have done.

Examples would include Australia, Germany, Hong Kong, Iceland, New Zealand, Singapore, South Korea, Taiwan, Vò (Italy) and Wuhan (China). See, for example, Peter Beaumont, “Coronavirus Testing: How Some Countries Got Ahead of the Rest,” The Guardian, April 2, 2020. Of course, some have been more successful than others; some have experienced a second wave once restrictions were lifted. But there was a similarity in the approach of each.

As the world’s scientists successfully demonstrated while they rid the planet of small pox (”History of Smallpox,”Centers for Disease Control and Prevention), the best way to fight a global pandemic is what would be today the “test-contact trace-quarantine-test” approach. It’s the most efficient, fastest, cheapest way to get an economy back to normal while holding lost lives and dollars to the absolute minimum.

Test everyone (not just those with symptoms), “trace” their contacts and test them, quarantine all who are infected, then test again to make sure you got everyone.

That’s what the world’s most successful coronavirus-fighting nations have done. It’s what we could have done.

But aren’t we beginning to test now? Yes, but with the exponential growth in infected people since last January we’ve already suffered the lost lives and trillions of dollars the approach could have saved.

As Letter to The Gazette put it:
Jan. 20 was the day both South Korea and the U.S. had their first CORVID-19 cases.

Twenty days later South Korea had flattened the curve. Along the way it had the second highest number of cases globally, but by April 20 the threat was over -- while keeping many businesses and factories open.

A Seoul official credits “quick government intervention, tracking and isolating infected personnel, and a transparent information hub” – plus a dozen amazing apps. All things we could and should have done.
Instead, our response is reminiscent of a bit from a Seinfeld episode. Jerry and Elaine needed a rental car, made a reservation, and went to pick up their car, only to be told there were no cars. Jerry says, “You know how to take the reservation. You just don't know how to hold the reservation. And that's really the most important part of the reservation. The holding." “The Alternate Side,” “Seinfeld,” Season 3, Episode 11 (video).

We understood the part about testing, we just missed the bit about “quick government intervention” and the need to test everyone.

On January 22 President Trump told a reporter, “It's one person coming in from China, and we have it under control. It's -- going to be just fine." (CNBC, "Interview: Joe Kernen Interviews Donald Trump on CNBC From Davos - January 22, 2020," Factbase, January 22, 2020)

Sadly, on January 22 we could have had “it under control.” We could have been “just fine.”

“Test-trace-quarantine-test” remains the only way to beat this thing (absent the miraculous appearance of a vaccine in less than 18 months). Thankfully, mitigation and “flattening the curve” do reduce the stress on hospitals and health care providers. But sadly, at this stage, it only prolongs the unnecessary loss of tens of thousands of lives and many trillions of dollars. It does not eliminate a spreading coronavirus -- as we could have done had we started on January 20 instead of April 20.

A Global Pandemic Calls for Global Solutions

Throughout the essays in this blog post I have often emphasized that the most effective response to a global pandemic, in terms of minimizing infections, deaths, costs and economic harm, is the test-trace contacts-quarintine-and test again approach. Thursday morning (May 7) I posted to my Facebook page:
The only way to beat a global pandemic is to eliminate every infection (as was done with smallpox). That requires testing everyone. As of this morning (May 7) the percentage of Iowans who have NOT been tested for COVID-19, 97.997%, is even slightly higher than the national average (97.66%). Just saying.
One of my rewards from blogging (in addition to knowing you actually read this far) is to discover -- after trying to think some issue through for myself, writing it up and posting it here -- that someone who has the credentials to write about it has come to the same conclusions.

So it was last evening when I awoke, looked to my iPhone for something to put me to sleep, and spent 15 minutes watching a TED talk. The speakers were persons new to me, epidemiologist and philanthropist Larry Brilliant, along with TED Conference curator Chris Anderson. Brilliant's talk was titled, "A Global Pandemic Calls for Global Solutions."

Here's how "TED" describes it:
"Examining the facts and figures of the coronavirus outbreak, epidemiologist Larry Brilliant evaluates the global response in a candid interview with head of TED Chris Anderson. Brilliant lays out a clear plan to end the pandemic -- and shows why, to achieve it, we'll have to work together across political and geographical divides. 'This is not the zombie apocalypse; this is not a mass extinction event,' he says. 'We need to be the best version of ourselves.'"
And here is the video:


Doing the Wrong Thing Better
"Much of what is published for boards ... teaches trustees how to do the wrong things better." John Carver, "Remaking Governance," American School Board Journal, March 2000, p. 26.
In 1998 I was elected to a three-year term on the School Board of the Iowa City Community School District. Iowa City's beloved Librarian of the Iowa City Public Library, Lolly Eggers, was a major participant in my campaign in many ways. As befits a librarian, one of those ways was to loan me her copy of John Carver's book, Boards That Make a Difference (1997). As it turned out, that book not only influenced my own thinking about the role of board members generally, but shapped much of what the School Board did during the next three years.

Many members of boards have given little thought to the process of governance, the inter-relationships between individual board members and "the board," which powers and functions are collaborative (with administrators or staff) and which are exclusive to the board. How would a board know if it was ever "successful"? If you're interested in more, and what it meant to our school board at that time, see the goverance page on my Web site "Board Governance: Theory and Practice".

I mention this because, as the opening quote indicates, even when one is going about a task the wrong way there may be an alternative that at least results in "doing the wrong thing better."

And so it is with American politicians; that is, the president and many governors, who have chosen to do the wrong thing to protect the health and lives of Americans -- as well as our economy.

There were ways they at least could have gone about "doing the wrong thing better."

The right thing, the approach of the world's leaders who most effectively and promptly eliminated the pandemic, saved their people's lives, minimized their misery, and most quickly restored their economies, is "test - contact trace - test contacts - isolate and quarantine - test again." Bear in mind, this is a virus that multiplies both fast and exponentially (and even more so among those clustered together), and does not create symptoms in roughly half of those infected. Moreover, the experts do not yet know how much, if any, immunity to the disease those once infected have gained by having once had it , whether they can get it again, and whether they are still spreading it to others. Without a vaccine that has been sufficiently tested to provide confidence it is both safe and permanently effective, totally erradicating the virus appears to be the only effective way of regaining both a nation's health and its economy.

To test and treat only those with symptoms -- and to fail to test anyone who is not already in a hospital with symptoms -- at best, substantially extends the time during which the numbers of infected and dead continue to grow. "Social distancing" and "shelter in place" efforts at "mitigation" and "flatening the curve" do reduce the stress on hospitals and health care providers, it's true, but they only lengthen the time before a nation's people and their economy can recover.

There are elected officials whose speech and action suggest they perceive a political advantage to minimizing the seriousness of the pandemic, attacking media reports and disparaging the experts, emphasizing the economy over public health by removing restrictions before it's safe to do so, and frustrating transparency regarding the numbers of infected and dying persons.

As long as they insist on doing "the wrong thing" how might they go about "doing the wrong thing better"?

What might we learn from the business strategy of focusing on one's "profit centers" and "cost centers"? As Peter Drucker, among others, pointed out in the 1960s, some businesses put 90 percent of their attention and resources into products or services that are only producing 10 percent of their profits.

Whether one's goal is to focus on care for others by improving health, reducing misery and death, or to focus on economic recovery, growth, profits and returns for investors, the answer is to go fishing where the fish are, to seek out and eliminate the virus where the percentages of infected persons are the highest. This might not be the best way to eliminate the virus from a nation, or the world, but it is at least "doing the wrong thing better."

The experts have known, predicted and reported where those places would be long before COVID-19 struck (a global pandemic that was itself predicted). They are places where people are gathered in groups, especially when those groups are large and contained within enclosed places -- as we've seen when the largest sources of the newly infected have been reported coming from cruise ships (and later aircraft carriers), long term living facilities (independent living, assisted living, and nursing homes), prisons, workplaces (such as meat packing plants), and other gatherings (such as indoor and outdoor sports facilities and megachurches).

And who within these groups are most likely to be seriously ill and even die? That also was known ahead of time: the elderly (those over 60, or 80), and those with pre-existing conditions that tend to weaken their immunity to disease.

So if a government official doesn't want to eliminate the global pandemic by testing and contact tracing everyone, where should they start, if they want to get the biggest, fastest, cheapest return on their efforts, the greatest boost to their economy and their political career, and the most support from those constituents who value humane policies or answers to "what would Jesus do"?

Why, nursing homes, of course. Iowa has 434. Nursing Home Inspect, Iowa, Propublica. That is where you will find the Iowans who are: the oldest, with the most diminished immunity, already needing health care, gathered together in an enclosed space.

So how have the President, Iowa Governor, federal and state governments, and the nursing homes responded? Not well. The Gazette reports (Rod Boshart, "Iowa sees deadliest day yet from coronavirus; Reynolds indicates state's peak of the disease has passed," The Gazette, May 5, 2020 [print edition: May 6, 2020, p. A1]) the following:
46 percent of the 207 Iowans who have died from the disease were 81 or older -- although they were only 5 percent of the 10,111 Iowans who have tested positive.

56 percent of those who have died were associated with Iowa's nursing homes.
(As another example from that story of rapidly spreading COVID-19 among those closely gathered in enclosed spaces was the outbreak at a Tyson's meat packing plant in little (7456 population) Perry, Iowa, in which 58 percent of the employees (730 of about 1260 employees) tested positive.)

In terms of preventing the spread of infection (as distinguished from treating those hospitalized with symptoms, who can often be identified without testing) the most productive focus is on those who are infected but show no symptoms (are asymtomatic). They are the stealth spreaders of the disease. How many of them are there? The percentages vary. Most individual reports I've read were around 50 percent. (See, e.g., "As Many as 50 Percent of People with COVID-19 Aren’t Aware They Have the Virus," Healthline.)

However, a New York hospital reported 88 percent of those testing positive were asymptomatic. Dena Goffman and Desmond Sutton, "We tested all our patients for coronavirus — and found lots of asymptomatic cases; Our New York City labor and delivery unit found 88 percent of infected patients had no symptoms," Washington Post, April 20, 2020.

Even if the Iowa Governor was insistent on not testing every Iowan, had she at least focused the state's efforts on a thorough test-contact trace-isolate/quarantine-and test again of every Iowa nursing home resident and staff member she could have cut Iowa's COVID-19 deaths in half, slowed the statewide spread dramatically, and sped up the state's economic recovery.

And that would have been how to "do the wrong thing better."

South Korea’s Awesome COVID-19-Fighting Apps

The source for the following information is Aylin Woodward, "South Korea controlled its coronavirus outbreak in just 20 days. Here are the highlights from its 90-page playbook for flattening the curve," Business Insider, April 18, 2020.
how many people were infected in each geographic area and city in real-time, constantly updating national and local government websites that tracked cases and the number of residents tested.

free smartphone apps that sent people emergency text alerts about spikes in infections in their local area.

important social-distancing protocols via text.

telemedicine via smartphone apps. Its Coronavirus-19 app, for example, gave patients the ability to input their symptoms and then get diagnosed with a cold or get connected to a doctor by phone, where they would be screened for coronavirus symptoms and given a preliminary diagnosis.

up-to-date information about the number and type of face masks currently available at any given store for purchase.

Once a resident tested positive, or was suspected of coming into contact with a coronavirus patient, the government encouraged users to voluntarily download self-quarantining apps that helped users monitor their condition and connect them to a doctor if needeed.

These apps also set off an alarm on a users' smartphone when they ventured out from a designated quarantine area.

After tests confirm a positive case, officials use interviews, GPS phone tracking, credit-card records, and video surveillance to trace an infected person's travel history

anonymized data about where each patient went before they were diagnosed on a public website so others can check to see if they have been near a patient.

two smartphone apps that provide information on the movements of confirmed patients in the region...

an app that sounds an alarm when users get within 100 meters of a place that a confirmed patient has visited recently.

another app helps employees plot the safest routes to and from work that don't intersect with previous paths of infected individuals.

an app to monitor symptoms of travelers coming into the country and provide them with medical advice.
Exponential Growth

To understand the existence of COVID-19, and means of eliminating its adverse public health, economic and political impact, one needs an understanding of a little bit of math. It's called "exponential growth."

In Joe Kernen's Davos interview of President Trump on January 22 he asked, "Are there worries about a pandemic at this point?" The President responded, "No. Not at all. And -- we're -- we have it totally under control. It's one person coming in from China, and we have it under control. It's -- going to be just fine." (CNBC, "Interview: Joe Kernen Interviews Donald Trump on CNBC From Davos - January 22, 2020," Factbase, January 22, 2020)

Let's contrast "arithmetic" growth (adding the same number every day; such as, 1, 3, 5, 7 and so forth) with "exponential" growth (such as 2, 4, 8, 16, 32 and so forth).

Suppose, hypothetically, for the 14 days following January 20 the infected person had infected 2 people every day. That would be an "arithmetic" increase (3 infected persons the next day, 5 the next day, 7 the day after that). The total after 14 days would be 29 infected persons -- clearly a substantial and worrisome increase over 1.

Now let's compare that with how many infected persons there would be after two weeks if the growth in the number was "exponential."

We need go no further than Wikipedia for a definition of "exponential": "The formula for exponential growth .... The growth of a bacterial colony is often used to illustrate it. One bacterium splits itself into two, each of which splits itself resulting in four, then eight, 16, 32, and so on. The rate of increase keeps increasing because it is proportional to the ever-increasing number of bacteria. Growth like this is observed in real-life activity or phenomena, such as the spread of virus infection...." ("Exponential growth," Wikipedia.org)

In other words, an exponential increase is not just the same increase every day, it is also a daily increase in the rate of increase. If every infected person infects two others every day, instead of the number of additional infected persons going from 1 to 3, 5, 7, and so forth, they would go to 2, 4, 8, 16, 32 and so forth.

So how many infected persons would there be after 2 weeks if the growth was exponential? 16,384. That's a lot more than 29, and more representative of what we're dealing with.

For an example from Iowa, during the first week of the reported infected (March 8-15) the number went from 3 to 18. Had the numbers continued to increase at that amount (15 per week) for the next 7 weeks our total on April 26 would have been 120 infected persons. During the last week, April 19-26, it went from 2,902 to 5,476 -- an increase of 2,574 (and a weekly average increase for the 8 weeks of 684 per week). (Bing, "COVID-19 Tracker," and "The latest: Another 384 cases reported in Iowa, 6 more deaths," Des Moines Register, April 26, 2020, 11:26 a.m.)

Why “Infamy”?

Curious about the use of the word “infamy” in the Gazette Letter, above?

It is not intended to suggest an analogy between the “attack” on Pearl Harbor by the Japanese military and the “attack” on the U.S. by the coronavirus.

Rather, the word “infamy” is used in its dictionary sense of an “extremely bad reputation, public reproach, or strong condemnation as the result of a shameful, criminal, or outrageous act.”

In short, the Letter’s use of “infamy” refers to the damaged reputation of a (usually public) person resulting from something they did (or as I use it, failed to do) not a reference to their behavior as such.

December 7, 1941 was the beginning date of the “infamy” of the Japanese. January 20 was the beginning date of the “infamy” of those among America’s political leadership – including the president – who failed to take the immediate actions taken by other world leaders to eliminate COVID-19 and its cost in deaths and dollars.

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Nick's COVID-19-Related Writing

"COVID-19 Home Test Kits & Other Thoughts"/"Find Your Household Thermometer," The Gazette, March 22, 2020

"COVID-19: Your Reading and References List," April 2, 2020

"How to Eliminate COVID-19," The Gazette, April 4, 2020

"January 20: Another Date in Infamy," The Gazette, April 26, 2020

"January 20: Another Date Living in Infamy," (the essays collection), April 30, 2020

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