[Check the byline, thanks!/~Rayne]

I figured it would be the oldsters in the family who would be my first worry. The grandparents still go to church, play bridge and golf, volunteer; they’re living typical retirees’ lives. They haven’t stopped mingling socially until this week.

But no. Last week I had to worry about my younger kid at college first. Fortunately they only had strep.

Last night the older adult child called, complaining of a migraine, dry cough, wheezing, and a tight chest. They’d already called the doctor about their symptoms; the doctor wouldn’t order a test because older adult child didn’t have a temperature.

All the other symptoms of COVID-19 except for a temperature. With so few tests available in Michigan, unless my kid checked ALL the boxes, there’s no way they’d be tested.

We’re pretty sure it’s not flu because the symptoms were slow onset rather than fast and adult child had a flu shot this year.

The kicker is that someone at work tested positive for COVID-19. It just hadn’t been announced across the business, likely because the business still needed to finish its plan for handling this situation.

Because my adult child couldn’t get a test, their spouse can’t say they’ve been exposed to COVID-19 and is likely now at work, probably spreading this around if indeed my adult child has COVID-19.

I won’t see my older kid or their spouse for a least a month now since we don’t yet know for certain if they have COVID-19 let alone how long exposed persons may be contagious. I dare not take the chance to see them because of my autoimmune disorder — not just because I might come down with COVID-19, but because hospitals may not be able to offer me an adequate level of care if there are no hospital beds or ventilators if one was needed.

When I saw this bullshit tweet this morning I almost levitated.

All the stress of our not knowing individual infection status and potentially exposing even more Michiganders is due to Trump, who instead directs his animosity toward an effective governor who isn’t getting the support she needs from the federal government.

My family and many others in Michigan and across the country are going through this Kafkaesque circus of uncertainty because the grossly-incompetent-when-not-corrupt Trump administration chose not to do the right thing and roll out testing back in January-February so that community acquired infections could be pinpointed earlier.

The one piece missing in this equation: why is it some people can get tested and others can’t? What arbitrary ju-ju allows Oklahoma to offer up a sizable percentage of its available tests for the Utah Jazz basketball players? Why are some political figures able to summon a test when others can’t?

Is this an additional layer of fuckery, not only the limitations on the number of tests available but an invisible prioritization of who can be tested? Does one’s political party affiliation make a difference, or the color of their state when it comes to getting a test for COVID-19 on a timely basis?

~ 3 ~

The UK did an about-face in its approach toward COVID-19. Boris Johnson backed off the idiocy of allowing the virus to simply run amok through the population to kill its most vulnerable citizens as well as those with the misfortune of being severly to critically ill while UK hospitals are overwhelmed by COVID-19 case load.

However, in spite of the noise made over the Imperial College’s latest assessment of COVID-19’s impact on the UK, nothing is being done. Leadership may have made some noises of surprise over the published mortality numbers but there have been no orders to lock down the country the way France has this past week, or Italy before that.

Instead, Johnson urged Britons to avoid pubs, restaurants and theaters.

He asked that the public only use the NHS “where we really need to.”

Britons were asked to avoid non-essential travel.

In short, a guidance was issued which appears wholly optional. It has no teeth.

Most importantly, Johnson did not order the country’s schools shut down, though young people are believed to be vectors for the virus. Murdoch’s tabloid-y outlet The Sun reports Johnson “hints” at shutting down schools in a few days, though a petition gathered more than 650,000 signatures asking for Johnson to do so immediately.

These numbers were pointedly ignored, though there was moaning at the number of deaths projected by Imperial College’s report — an estimated 250,000 souls. Johnson’s actions to date do little to mitigate let alone suppress COVID-19’S contagion, choices Imperial College explained as approaches to minimizing deaths.

\Johnson’s action to date fails to respond adequately to the swamping of UK’s health care system, particularly its intensive care systems.

Being on an island will not protect them, nor will having expressed a desire to leave the EU.

We won’t be able to help them, either; Trump has done little more than Johnson has for the U.S., relying instead on the states to do the heavy lifting of saving American lives.

If we survive this next year, those of us who are most at risk will owe our lives to the efforts of governors like Gretchen Whitmer, who must not only make the impossible happen with limited resources, but with an ignorant, mean asshat president whining about them at the same time.

~ 2 ~

One of our community members Surfer2099 has been digging away at pharma company Gilead Sciences; the company makes an antiviral drug, remdesivir, which has been used off-label to treat COVID-19 patients. As noted before in previous posts, the medication was shipped to China for tests without normal approval of the FDA.

Bloomberg reported yesterday that China wants to patent remdesivir (link to story at Reddit). It looks like China wants the patent in exchange for having allowed Gilead to test its drug on COVID-19 patients, bypassing the FDA’s test protocols in the U.S.

Surfer2099 noted that Gilead coincidentally launched a merger and acquisition the first week of March. How does such a move fit into the negotiations with China?

Don’t look away from this as remdesivir appears to have widening support in the treatment of COVID-19. If it’s the only drug approved by drug agencies including the FDA, there’s considerable money to be made with tens of millions of COVID-19 patients anticipated over the next 1-2 years.

~ 1 ~

Fortunately there was a little good news yesterday. A COVID-19 vaccine was injected into the first human volunteer in a Phase 1 trial. If successful, the vaccine will not be available for the public for at least a year and likely longer.

NIH Clinical Trial of Investigational Vaccine for COVID-19 Begins

The realistic time frame from this first injection to a public vaccine is at least 12 to 20 months under the best conditions, i.e., no reactions, no other hiccups like supply problems, no interference from outside entities like the Trump administration.

That’s how long we need to practice social distancing — at least 12 to 20 months. Settle in and develop a routine for the long haul.

~ 0 ~

This is an open thread. How are your friends and family doing with the changes we’ve had to make to our lifestyles?

Update, 3/18: The Detroit Free Press just reported that McDaniel’s test (finally) came back negative. That’s both a relief — given who she interacted with before being tested — and a real testament to how long it still takes for (even powerful) people ot to get a test result.

On Friday night, RNC Chair Ronna [Romney] McDaniel got a test for COVID-19, the first high profile Republican tested based on the inadequate testing guidelines rolled out by the CDC rather than concerns arising just from exposure. That is, she had exposure and flu-like symptoms and tested negative for alternative explanations before she took the test.

I can find no follow-up report on the status of her test — though both Saturday and Sunday’s Michigan test reports included the description of a positive test for someone who could be her.

Oakland County, adult female with history of contact with someone with a confirmed case.

[snip]

Oakland County, adult female with contact with a person with COVID-19.

Meanwhile, on Saturday NYT updated a story — first published Friday afternoon — on how Kimberly Guilfoyle’s birthday party a week ago exposed a number of high profile people to the illness. The update quoted aides bitching that McDaniel revealed that she had “publicly acknowledged her illness.”

The president has sought for weeks to play down the severity of the outbreak and been especially sensitive about giving the impression that he himself was at risk. Indeed, several advisers to Mr. Trump on Saturday privately expressed irritation at Ms. McDaniel for publicly acknowledging her illness.

This is not confirmation McDaniel tested positive. Rather, it’s silence and expressed “irritation” about McDaniel’s honesty where other prominent Republicans like Matt Gaetz and Mark Meadows — to say nothing of the President himself — have disclosed both taking the test and their negative results without similar irritation.

As such, it’s an indication that the White House no longer wants to talk about the multiple exposures people within the White House and top ranks of the government or the Republican Party have had, and probably would not tell us if someone who had been exposed tested positive.

Negative or positive, McDaniel is entitled to her privacy, and I wish her the best with whatever was causing her symptoms. But President Trump has a duty to convey the seriousness of this disease and explain how easily one can come in contact with a person who, at the time, appears healthy, but who nevertheless might be contagious.

He hasn’t done that. As of yesterday’s press conference, however, he exhibited a new sobriety about this disease.

In the days ahead, the number of positive cases in a number of states are going to spike, in part reflecting second generation infections, in part because for the first time testing is becoming more widely available. For its part, Michigan announced a new case reporting, covering what will sure to cover those spiking numbers today, that eliminates the kind of individualized information that would allow someone to track a known potential case.

Which suggests that at the moment where we’ll finally begin to track asymptomatic transmission, the public will have less information with which to do so.

That probably explains why governments across the country just got more serious about stopping transmission without such critical data.

Because President Trump’s response to the Covid-19 outbreak largely consists of having press conferences designed to goose the stock market where he calls out a series of big corporations, I will start tracking the paid leave policies of those companies getting all this free advertising. This is particularly important to track given that the House excluded employers with over 500 employees from the paid sick leave benefit in their bailout bill. As you’ll see, a few of these employers rolled out some version of two weeks of sick leave in response to the crisis — but some appear to be written to require a diagnosis of the virus before granting the leave, which is too late to prevent further infections. Others appear to have no sick leave available to the workers providing our food during the crisis.

Until someone with more resources replicates this effort, I will update it as Trump provides more free advertising during the crisis.

Albertsons (President and CEO Vivek Sankaran mentioned on March 15). No leave benefits listed on website. Left message.

Amazon (mentioned on March 15). Emergency policy matches Whole Foods. Diagnosed or quarantined workers can get two weeks paid leave, and employees can have unlimited time off without pay. Delivery workers will have to apply for grants to obtain paid time off.

Campbell Soup Company (CEO Mark Clouse mentioned on March 15). Paid sick leave not differentiated in public benefits package.

Cargill (Chairman and CEO David MacLennan mentioned on March 15). Standard policy provides two weeks of short term disability at 100% of pay, and 6 weeks at 60% of pay. No paid sick leave mentioned.

Costco (CEO Craig Jelinek mentioned on March 15). Paid sick leave is a standard benefit, though on an accrual basis.

Dollar General Corporation (CEO Todd Vasos mentioned on March 15). Barebones benefits publicly listed.

General Mills (CEO Jeff Harmening mentioned on March 15). Expanded paid leave benefits for salaried and non-union production workers, including up to eight weeks of short term disability, in 2019.

Google (mentioned on March 13 and 15). Set up a fund to provide paid sick leave to contractors and temporary employees otherwise not eligible. Also provides pay for hours that furloughed employees would have worked.

Hy-Vee (Chairman, CEO, and President Randy Edeker mentioned on March 15). Website lists paid vacation and personal time, but not sick leave; does claim family medical leave.

Kroger (CEO and Chairman Rodney McMullan mentioned on March 15). Most employees do not get sick leave.

Publix Super Markets (CEO Todd Jones mentioned on March 15). Full time employees accrue paid sick leave, but not part time employees.

Sysco (President and CEO Kevin Hourican mentioned on March 15). Ties pay during leave to paid time off (that is, treats pay as an accrued benefit, not as paid sick leave).

Target (CEO Brian Cornell mentioned on March 15). Enacted an emergency policy offering 14 weeks of paid leave for employees who have tested positive for the virus or who are under mandatory quarantine. It is waiving its absence policy for employees who are not diagnosed but feel too sick to come in or are taking care of children.

Tyson Foods (Donnie King, who is neither CEO nor President, was mentioned on March 15). Hourly workers do not get paid sick days.

Walmart (CEO Doug McMillon mentioned on March 15). Enacted emergency policy offering sick leave to all hourly workers, without the normal 1-year eligibility requirement. If employees choose to stay home it comes out of their regular paid time off. In case of a quarantine, employees will get two weeks of paid leave, which will not count against their existing benefits. If an employee is diagnosed with coronavirus, that person will get two weeks of leave, with up to 26 weeks of “pay replacement” if the employee is unable to return to work.

Whole Foods (Dave Clark mentioned on March 15; John Mackey is the CEO). In response to coronavirus crisis, offered unlimited unpaid time for during March, and two weeks of paid time off if someone is diagnosed with Covid-19. Suggested workers should share their paid time off.

It’s rough being a career member of the US State Department workforce in the Donald Trump era. In general, much of the work of these people is not particularly affected by the changes in presidential administrations. Passports get issued to US citizens who wish to travel abroad, and visas get processed for those who wish to visit here. Those posted at embassies abroad listen to what is happening around them and report the most interesting stuff back to Foggy Bottom in DC, and they take what they’re told by Foggy Bottom and share it with the country in which they are posted. Big things change, like treaty negotiation postures and diplomatic postures on big picture issues, but the nitty gritty stuff is pretty ordinary and non-controversial.

But now, there’s a new wrinkle: whatever you do, don’t do or say anything that will make the guy who sits in the room with no corners look bad. He does not react well. And that wrinkle makes even the ordinary nitty gritty stuff difficult.

“Domani Spero,” the pseudonym of the author of DiploPundit, means “See you tomorrow, I hope,” which seems a fitting moniker for someone who watches the ins and outs of the State Department. Says he, “DiploPundit wades into leadership and management issues, realities of Foreign Service life, ambassadors and nominations, embassy report cards, current events in countries and regions which may or may not include prominent U.S. interests, and other developments in the international affairs community.” His writing assume that his readers are familiar with State Dept jargon and acronyms, which can put some readers off. On the other hand, for those in and around the US diplomatic community, DiploPundit is a definite place to check in for details that might not make it into general media reporting. Along the way, he occasionally posts items that come from his “burn bag” (State Dept lingo for the receptacle for classified trash that must be burned, rather than taken to the curb), which is his place for receiving anonymous tips. These often come from current State Dept employees, raising issues that they do not feel comfortable in bringing to the attention of their superiors via in-house channels.

Four days ago, DiploPundit noted that the US Embassy in Kingston, Jamaica put out a classic non-denial non-response to a story in the local media. While he didn’t link to the story, he seems to be referring to the Jamaica Observer, which wrote this last Wednesday:

A second case of COVID-19 has been confirmed in Jamaica.

Health Minister Dr Christopher Tufton confirmed the second imported case via Twitter this evening.

Dr Tufton said the second case is a US Embassy employee who returned from the UK.

As you might guess, the US Embassy in Kingston started getting calls about this, their response boils down to “we’re aware of the report and will not confirm or deny it, but we’re working with Jamaican authorities and doing a really deep cleaning of all embassy facilities.”

Three days ago, DiploPundit wrote up a Burn Bag post, sent to him by “sickdips”:

“Members of the Embassy community at one post have fallen seriously ill with COVID-19 symptoms, but the State Department will not test them for COVID-19 or *MEDEVAC them. There is already limited medical capacity at many posts, which will be completely overwhelmed as the pandemic spreads. What is MED waiting for? Protecting our people should be our NUMBER ONE PRIORITY.”

MEDEVAC is exactly what it sounds like – medically evacuate – and MED is the acronym for the State Dept’s Bureau of Medical Services. When I went to MEDs page at State.gov, it had nothing but standard “here’s what we do” language and no news items related to COVID-19 among US embassy staffers.

This led me back to that non-denial non-response. In the middle, there’s one sentence that jumped out at me: “The U.S. Department of State has no greater responsibility than the safety and security of U.S. citizens overseas and locally-employed staff.” Remember what I said at the top? Don’t say or do anything to make the guy who sits in the room with no corners look bad. That’s what’s going on in this statement. “Make sure you tell everyone that we take care of US citizens!”

If sickdips saw this (whether Jamaica is the post about which sickdips was writing or not), it’s probably what prompted sickdips to drop a note to the Burn Bag. Fancy words about protecting the safety of embassy staffers are nice, but actions on the ground like refusing to test after exposure to a known carrier of COVID-19 suggest otherwise.

That was three days ago. The following day, DiploPundit posted a roundup of items about COVID-19 at various embassies, which laid out nine different countries (including Jamaica and Italy) where ordinary services are restricted or the embassies and consulates are completely closed for all but the most extreme emergencies. The list included this observation at the top: “As of this writing, we have not seen any public announcement or guidance from the State Department on COVID-19 for employees or family members. Let us know if we missed any statement from Pompeo or [Undersecretary of State for Management Brian] Bulatao.”

That last sentence was DP poking Pompeo and his chief aide for running the State Department with a very sharp stick, and doing it in a place where everyone in the diplomatic community could and would see it.

That was two days ago. Today, the State Department put out an updated health warning for US citizens thinking about traveling abroad. The short version is this: don’t. The longer version is this:

Global Level 3 Health Advisory – Reconsider Travel

March 15, 2020

The Department of State advises U.S. citizens to reconsider travel abroad due to the global impact of COVID-19. Many areas throughout the world are now experiencing COVID-19 outbreaks and taking action that may limit traveler mobility, including quarantines and border restrictions. Even countries, jurisdictions, or areas where cases have not been reported may restrict travel without notice.

On March 14, the Department of State authorized the departure from any diplomatic or consular post in the world of US personnel and family members who have been medically determined to be at higher risk of a poor outcome if exposed to COVID-19.

The first part of that is the language you’d find in a standard State Department warning, albeit these kinds of warning are usually aimed at specific countries or regions, not the whole world. But the second part of that — the part that begins “On March 14 . . . ” — is not standard. Not at all. It sounds to me as if someone at Foggy Bottom who read DiploPundit’s poke tried to address the concern, but “put it out with the trash” late on Saturday, hoping it wouldn’t get too much attention from the general media, and thus incur the wrath of that guy in the room with no corners.

This is a deeply serious development. This kind of “we’ll pull anybody out of anywhere” statement is damn near unheard of, and the only reason I say “damn near” is to give myself wiggle room should someone with greater historical knowledge step up. I can’t think of anything close, ever.

But even so, as broad and sweeping and unheard-of as this is, I don’t think on it’s face it is enough. As DiploPundit notes, “So the ‘authorized departure’ or voluntary evacuation depends on the determination of the local MED unit or based of current medical clearance?” You remember MED – the same folks that wouldn’t authorize testing personnel who had been in contact with an infected person?

Poke, poke, poke.

UPDATE from DiploPundit:

The cable released by State/M Brian Bulatao says: “Effective March 14, 2020, I hereby approve authorized departure (AD) from any diplomatic or consular post of U.S. direct hire employees or eligible family members (EFMs) as listed on employee orders and defined in 14 FAM 511.3 who, after confidential consultation with MED, have determined they are at higher risk of a poor outcome if exposed to COVID-19, or who have requested departure based on a commensurate justification in foreign areas.”

Our source, not from Public Affairs, interpret this to mean that MED approval is not specifically required but you need to refer to MED when you go tell your boss you want out.

The  last time we had a global authorized/ordered departure order was probably during Y2K, was it? (The State Department at that time also issued an edict stating that all embassies must be prepared to be self-sufficient for 30 days by January 1, 2000).

When Trump gave his speech last week about the “foreign virus” and the need to blockade the EU but not the UK, it was clear that Trump was acting out of his usual playbook: xenophobia, build bigger walls, get revenge on your foes and carve out loopholes for your friends. Since then, clearer heads have pushed Trump to include the UK in his travel blockade, as viruses do not care about the color of your passport. I suspect those clearer heads are folks like Anthony Fauci on the medical side and whoever at State authorized the evacuation of any diplomatic staff from any post over medical concerns.

God bless them both, because it clearly takes the concerted effort of a group of people who are willing to make the guy in the room with no corners look bad if he’s doing stuff that will kill innocent people. And make no mistake: he *is* doing stuff that will kill innocent people. (See Jim’s post on the Customs mess at airports last night.)

Domani spero, everybody. See you tomorrow, I hope.

Earlier this week, Donald Trump announced Vladimir Putin’s dream of travel restrictions in response to the the COVID-19 pandemic, “banning” travel from Europe, but excepting the UK, where there are many more cases than in a number of European countries. Trump eventually was forced to add the UK to the ban. As the new policy began to roll out yesterday in the major international US airports, there was nothing less than a clusterfuck of epic proportions. The feature image for this post comes from a Brooke McDonald tweet showing a huge crowd trying to clear customs at O’Hare. Here is a tweet from a Fox station in Texas showing the crowd trying to clear customs at DFW:

This is currently the waiting line for U.S. customs at DFW Airport, as international travelers are having to deal with a long wait as they re-enter the country. https://t.co/AkmAYw2tjg pic.twitter.com/c7RKkS0gzo

— FOX 4 NEWS (@FOX4) March 14, 2020

What could possibly go wrong? With large crowds of people coming back from infection hot zones, milling about for what was reported to be up to seven stress-filled hours, it’s hard to imagine a scenario more conducive to efficient spread of the virus.

Here is the New York Times on what unfolded:

Under the new screening rules, when travelers arrive at 13 designated airports they are to be interviewed by a Customs officer, who will also review the person’s travel history using a Homeland Security database. The officer will ask them about their current medical condition. If they don’t show symptoms, they will be asked to quarantine in their homes for 14 days. Depending on their symptoms and previous medical history, travelers could be subject to an additional screening by a medical professional at the airport. They could also be subject to a federal quarantine.

Seems simple enough. But in Trump’s era of never having enough of the right employees in the right place, this simple screening resulted in the massive delays. Here is the Acting Head of Customs and Border Protection on the situation last night:

We are aware of the reports of increased wait times at some airports across the nation. CBP along with medical personnel are working diligently to address the longer than usual delays. Nothing is more important than the safety, health and security of our citizens. Full statement: pic.twitter.com/JyPRSS9snr

— Acting Commissioner Mark Morgan (@CBPMarkMorgan) March 15, 2020

Yeah, right. Nothing is more important that the health of our citizens, so you trap thousands of people into tight spaces that are virtually guaranteed to have symptom-free people shedding large amounts of virus.

Here’s how that happens.

First, we know that virus can be spread by folks not showing symptoms. From CNN:

New studies in several countries and a large coronavirus outbreak in Massachusetts bring into question reassuring assertions by US officials about the way the novel virus spreads.

These officials have emphasized that the virus is spread mainly by people who are already showing symptoms, such as fever, cough or difficulty breathing. If that’s true, it’s good news, since people who are obviously ill can be identified and isolated, making it easier to control an outbreak.

But it appears that a Massachusetts coronavirus cluster with at least 82 cases was started by people who were not yet showing symptoms, and more than half a dozen studies have shown that people without symptoms are causing substantial amounts of infection.

Next, as the CNN article notes, the Boston cluster of cases arising from the Biogen conference resulted in many people being infected from a small number who were infected but asymptomatic at the time. From WBUR:

Among the coronavirus numbers that Massachusetts officials have shared recently, one is particularly striking: Of the state’s 95 cases detected as of late Wednesday, they say 77 stemmed from a meeting that the Cambridge biotech company Biogen held in late February.

In public health parlance, the Biogen meeting is looking like a “superspreading event.”

The article continues:

Yale professor Nicholas Christakis, a physician and sociologist who studies networks, says the current outbreak in Italy also stemmed from a “superspreader.”

“We know from genetic analyses in Italy that the epidemic there was started, we think, by two people, one of whom gave it to 43 other people,” he says.

But here’s the kicker:

Christakis from Yale says other factors could cause people to become superspreaders — like even a propensity to cough.

“Maybe they have a lung disease, for example,” he says. “And so they’re doing more coughing anyway. And so compared to a person who doesn’t cough, they transmit it more.”

The environment can contribute to spreading, too, he says — poor ventilation, overcrowding.

Yep. There we have it. Overcrowding can create superspreaders. And Customs and Border Protection just overcrowded thousands of people for long periods last night. In thirteen different airports.

I keep re-reading the description of the “screening” and don’t see how the outcome of screening would be any different if people cleared Customs in a normal way but were given a set of printed instructions informing them that if they were returning from Europe they should self-quarantine for at least 14 days and that if they have or develop any symptoms they should notify their health provider and/or county health department. At that point it would seem safer to have them call a call center where they can share their travel history with someone coordinating the DHS database. Making people mill around for so long really appears to have accomplished nothing other than spreading the virus.

Update

I started writing this post before finishing my coffee this morning, and so I missed this great article in the Washington Post:

Airports around the country were thrown into chaos Saturday night as workers scrambled to roll out the Trump administration’s hastily arranged health screenings for travelers returning from Europe.

Scores of anxious passengers said they encountered jam-packed terminals, long lines and hours of delays as they waited to be questioned by health authorities at some of the busiest travel hubs in the United States.

The administration announced the “enhanced entry screenings” Friday as part of a suite of travel restrictions and other strategies aimed at slowing the spread of the coronavirus. Passengers on flights from more than two dozen countries in Europe are being routed through 13 U.S. airports, where workers check their medical histories, examine them for symptoms and instruct them to self-quarantine.

And WaPo even went there:

But shortly after taking effect, the measures designed to prevent new infections in the United States created the exact conditions that facilitate the spread of the highly contagious virus, with throngs of people standing shoulder-to-shoulder in bottlenecks that lasted late into the night.

[NB: Check the byline, thanks! / ~Rayne]

It’s absurd that I’m happy my college student child tested positive for strep throat. Whew, what a freaking relief that they only had a bacterial infection which has killed humans throughout history! Thanks to science we have effective antibiotics to treat this kind of infection, one of which is already working away and making said student feel better. …

Literally just heard from my student that Michigan State University now has one confirmed case associated with its campus. I can’t find a published report yet, more details later; so much for the brief respite provided by streptococcus.

Brace yourself for the bad news which so far is the nature of COVID-19.

~ 3 ~

Drugs. Let’s get into them.

Beleaguered Italy is using the rheumatoid arthritis medication tocilizumab off-label to treat patients in ICU. It may become their protocol for treatment of patients who develop acute respiratory distress syndrome (ARDS).

COVID-19 apparently spawns a “cytokine storm” the same way the 1918 Spanish flu virus did. Health care professionals say COVID-19 kills via fulminating viral cardiomyopathy, (inflamed heart tissue), not hypoxia (suffocation due to lung failure).

The onset of inflammation can be sudden with the cytokine action but at a later stage in the infection, which is different from the 1918 bug. The Spanish flu affected mostly younger people whose immune systems over-responded to the virus, where COVID-19 affects older people whose bodies may already have inflammatory responses at work because of cardio vascular disease or diabetes.

(We don’t know yet why some young people without preexisting conditions have become very ill and in some cases have died. Some may be related to smoking, others could be related to an undiagnosed condition. More study will be necessary; in the mean time, young people should protect both themselves and the older and sicker people who could catch COVID-19 from them.)

China tried tocilizumab on roughly 20 patients and found this monoclonal antibody halted the storm, acting on interleukin 6. There’s a preprint unreviewed study online but I can’t open it now or would include it. An immunologist in Italy came to similar conclusion about the use of this med and consulted with Chinese docs. See this story in an Italian news outlet (open in Chrome and translate).

There are other meds being tested in China — antivirals remdesivir (mentioned in a previous post), favipiravir, lopinavir/ritonavir, umifenovir — but there I haven’t seen any information about their application treating COVID-19 cases as detailed as there is for tocilizumab.

Pharma manufacturer Roche has agreed to provide to Italy the tocilizumab which should not only help reduce burden on hospitals’ intensive care units but build a body of data about the drug’s success in short order. China has also approved the drug’s use on certain COVID-19 patients.

I want to emphasize here this is NOT a cure for COVID-19. It’s a treatment for patients whose heart and lungs are in distress, requiring intensive care and a ventilator. What this drug may do for many of these patients is prevent them from needing ICU and ventilation, while their bodies continue to fight off the virus.

~ 2 ~

And more drugs — this time, antivirals.

A number of existing drugs have been revisited for repurposing against COVID-19 instead of their original intended purpose. Antiviral remdesivir and antimalarial chloroquine are among them.

Chinese researchers posted a paper about in vitro results, not peer reviewed (at least I didn’t see that it was).

There’s a paper about chloroquine alone; in vitro studies suggest it may work against COVID-19. Chinese researchers have a number of in vivo studies in progress, but no data has been released.

Chloroquine by itself as an effective therapy would be a miracle in that it’s an old drug now off patent and available as a generic, super cheap to produce. Can’t imagine Big Pharma would like this. But we won’t even face this conflict if we don’t get data from in vivo studies.

What I haven’t seen yet is adequate research related to the ACE2 receptor to which the COVID-19 binds itself to attack the body. There’s a study under way about a decoy protein drug called APN01, but I haven’t seen any details yet. A discussion about the ACE2 receptor can be found at this link.

I’d like to see more work done in related to ACE2 receptor mechanism. I’m worried we’ll end up too focused on antiviral remdesivir because there may be some political hijinks behind this drug.

Gilead Sciences, the drug’s manufacturer, shipped a bunch of this drug to China without federal approval, for tests which I assume mean human experimentation on actual COVID-19 patients.

About the same time this happened two weeks ago Gilead launched a merger/acquisition of Forty-Seven Inc, a clinical-stage immuno-oncology firm. It looks fishy yet likely to go unexamined because of the mounting desperation to have a drug therapy in hand before the anticipated explosion of cases arrives at hospital doors. In short, it’d be too easy to extort the U.S. into using this drug.

What really takes the cake is that a former Gilead lobbyist, Joe Grogan, is now the director of White House Domestic Policy Council. Grogan has already undermined Trump’s drug pricing initiative to the benefit of pharmaceutical companies. How do we know Grogan isn’t still representing Gilead’s interests, perhaps encouraging the government to turn a blind eye to corner-cutting on remdesivir?

~ 1 ~

Now it’s time for some more blunt talk with the family members.

I have a health care power of attorney or a health care directive prepared, signed, witnessed, copies distributed with one copy in my fire safe. If the worst should happen and the doctors need direction if I become incapacitated, my patient advocate is authorized to order what I want done. I have more than one advocate in a chain in case the primary advocate can’t act on my behalf.

I also have a will prepared, signed, witnessed, etc. If I’m picked off this month my kids will be disappointed that I haven’t yet finished Swedish Death Cleaning in the basement, but such is life and death. (Sorry, kids. You’re stuck dealing with all of the grandmas’ china sets and fragile antique lamps. Heh.)

I put the question to you now: are you ready? Have you done the legal legwork to help your loved ones whether family and/or friends if you’re incapacitated or *knock-on-wood* die?

Get it done if you haven’t. Stop putting it off because there’s no more time for lollygagging. We’d all like to deny we could get very sick, lose control of our lives, even die, but nature has a way of having the very last word if you don’t provide one.

Need a resource for that health care directive? See the folks at AARP — they have links to free resources for each state.

Just as important is establishing a plan for what friends/family should do if they can’t reach you. Trusted friends/family members should have current phone numbers, addresses, alternate key locations, emergency contacts, so on. They should also know who the patient advocates are and how to obtain access to the relevant documents if advocates don’t already have them.

This doesn’t have to be heavy; some of this effort we should have been doing all along as part of your disaster preparedness planning. Think about the families and friends affected by hurricanes Katrina and Maria, and imagine COVID-19 as a kind of hurricane which won’t flood your house but could certainly upend your life. You’d be prepared for a hurricane. Be ready for this one.

~ 0 ~

Treat this as an open thread. Tell us what’s in your basement or closets you need to unload because no one in your family wants it.

Jim here.

This will be a short post, mostly to give us a new conversation thread.

But there are a few things that show us that reality is setting in in our society, if not necessarily in the White House. Virtually all professional and college sports are now shut down. Most universities are online only now. Many public schools have closed. More and more businesses are allowing employees to work from home.

We are now in a liminal space. Our church introduced me to that term while we are searching to replace a minister who recently retired. A liminal space is that time between what was and what will be. Thanks to COVID-19, normal is what was. It is gone and will be gone for quite some time.

Sadly, the beneficial effects of the social distancing that is finally coming into being will be delayed. Before we get to the benefits, we will experience the whirlwind that has been unleashed by months of denying the virus. This is just my estimate, but from all the published comparisons between the US outbreak and Italy’s, we are just a few days, probably less than a week, away from hospitals in the hot zones being over capacity and having to resort to excruciating levels of triage, literally choosing who lives and who dies.

Also, Republicans are being dragged kicking and screaming into the realization that our healthcare system and our gig economy mean that huge swathes of our population, without government intervention, face bankruptcy and death with no chance of treatment.

Each of us will have to choose how we live in this liminal space. For those who are able to go along with social distancing, we will need to learn to eat all our meals at home. We will need to find ways to occupy our time if we aren’t working and the usual sports entertainment is unavailable. But it is vital that we realize that despite being physically separated, we must embrace our shared humanity and the shared experience of facing the unknown together.

Maybe there’s someone who lives close to you who is even higher risk than you are. Perhaps you can give them a call and ask if they’d like you to leave a meal at their door. Maybe you have acquaintances whose employment has disappeared today. Maybe you can slip them a few bucks if you can afford it. Maybe they’d also like a meal at their door.

Even more frightening, is the “what will be” for folks who must continue working. Somehow, grocery stores will have to stay open. Police and fire services have to continue, along with EMS, of course. Healthcare workers are soon to be completely overwhelmed and most likely sequestered for the duration of the outbreak in areas where hospitals near capacity. If you know families of those workers, maybe they could use a hand with errands or meals. They will be terrified about their loved ones staying healthy while on the front lines of this battle. Support those families any way you can.

In the meantime, many thanks to all in this wonderful emptywheel community who have been chiming in with timely updates and analysis. Please keep it coming. So many people are getting so much help from you. But also, let’s have some fun too, to ease the tension. Share a joke. Share ideas for entertainment streaming for those sequestered. Above all, know that we are all in this together and our best bet for getting through it is to work together (just don’t cough on me or touch me).

[NB: Check the byline, thanks! / ~Rayne]

My second kid, who attends a Big 10 university, is sick. They’re running a temp, have a headache and sore throat. Fortunately they have no other symptoms like a dry cough and chest congestion. They wouldn’t meet the criteria for COVID-19 testing even if they develop a dry cough common to 68% of those infected with the virus

We had the awkward conversation about avoiding coming home for at least two weeks — even if the school shuts down, which it now has. This scenario is increasingly likely for all other Michigan and Midwestern colleges/universities. With the damage to my lungs from an autoimmune disorder we can’t take the chance my kid has something besides a common cold. I never expected to have to tell one of my kids not to come home.

~ 3 ~

By now you’ve probably heard about the initial quarantine of Lombardy region of Italy, and then the subsequent quarantine of the entire country. It’s bad. Italy is about two weeks ahead of Washington state in the virus’s spread.

A Twitter thread by a UK anesthesia and intensive care registrar passes on a report from a friend in A&E (ER department) in northern Italy (includes Lombardy).

Tweets by an academic in Austria (next to Italy):

Some doctors admitted in public interviews that the Lombardy system's in overdrive & that choices have to be made as regards access to ICU etc. I've seen this discussed on Twitter as the "black code" (codice nero). Not sure if already there. Or even at the point shared above.

— Dr Elisa Perego (@elisaperego78) March 10, 2020

The “codice nero” or “black code” to which she refers is a label applied to patients who are DOA or for whom death is imminent. During triage they are apparently applying this to patients over 60-65 years old who arrive in respiratory distress because they have no equipment for them. Other accounts from Italy mirror both the news reports about hospital conditions.

A news report from France covering Italy’s crisis (open in Chrome and translate) notes concerns about COVID-19’s possible impact on southern Italy because it has even fewer resources. Hence the failed quarantine in the north.

In this news report from Brescia which is in northern Italy (open in Chrome and translate) you’ll note they are out of beds and are putting patients on cots, evident in the photo at the top  of the page.

Some better news: China agreed to supply Italy with 1,000 ventilators and 2 million masks. Additionally, they are donating 100K respirators, 20K protective suits, and 50K test kits as part of an aid package. Must have leftover supplies now that China is closing down their rapidly-built emergency COVID-19 dedicated hospital. See story (open in Chrome and translate).

These purchases and aid will not be enough fast enough, though. The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care has now published a guidance document today which appears to codify triage under current conditions. It’s grim.

“In a context of grave shortage of medical resources, the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.

It’s a matter of giving priority to ‘the highest hope of life and survival.’”

— Yascha Mounk (@Yascha_Mounk) March 11, 2020

Tom Bossert, Trump’s first Homeland Security Advisor, wrote an op-ed for the Washington Post published yesterday. He told Ken Dilanian/NBC, “We are 10 days from the hospitals getting creamed.”

ER doctor Rob Davidson from Ottawa County in West Michigan spelled out the anticipated challenge at video in this link:

"We have 3 ambulances in a county of 47,000 people. Once our hospital fills up—[and] if it hits our community, it will fill up very quickly—our 3 isolation beds that we have will fill up."@DrRobDavidson explains the reality for many rural hospitals as coronavirus spreads: pic.twitter.com/iynIpTa4Bn

— CAP Action (@CAPAction) March 10, 2020

Up to this video, Michigan had been lucky, having 39 negative tests out of the 375 tests it was allotted by CDC. Last night the state announced there had been two positive cases; Gov. Gretchen Whitmer then declared a state of emergency. In an email today, Michigan State University indicated a third likely case was associated with its campus — hence an announcement moving coursework offline as of noon today. MSU is one of four Michigan schools to make such a move.

We need to see more moves like this to increase social distance if we are going to “flatten the curve” of demand for medical services. It will not be just COVID-19 cases affected by the additional demand on the system, but all other health care needs including emergencies. If we don’t slow down the spread of the virus, ALL mortality may increase in addition to COVID-19 cases.

~ 2 ~

Particularly aggravating as the U.S. tries to wrap its head around this growing crisis is the active, malign action of the White House.

A House Oversight and Reform Committee (HORC) hearing today focused on U.S. coronavirus response; the White House interfered with its continuation by calling an emergency meeting requiring the attendance of the hearing’s witnesses, including CDC Director Robert Redfield, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and Terry Rauch, director of the defense medical research and development program for the National Institute of Health.

The HORC meeting was cut short without having answered all questions the committee had, although not before Dr. Fauci was able to provide a reality check to the committee.

“Is the worst yet to come, Dr. Fauci?” Rep. Carolyn Maloney, chairwoman of the House Committee on Oversight and Reform, asked Fauci on Wednesday.

“Yes, it is,” Fauci replied.

While this coronavirus is being contained in some respects, he testified, the U.S. is seeing more cases emerge through community spread as well as international travel.

“I can say we will see more cases, and things will get worse than they are right now,” Fauci said. “How much worse we’ll get will depend on our ability to do two things: to contain the influx of people who are infected coming from the outside, and the ability to contain and mitigate within our own country.”

He added: “Bottom line, it’s going to get worse.”

A report published at 12:29 p.m. after the meeting was suspended revealed the Trump White House ordered public health officials to treat certain meetings on COVID-19 as classified.

The sources said the National Security Council (NSC), which advises the president on security issues, ordered the classification.”This came directly from the White House,” one official said.

This is absolutely unacceptable. The public has both a right and need to know about the course of the virus’s spread and its government’s response. There is no constructive, positive reason for secrecy apart from hiding corrupt or incompetent decisions, which in this case could result in Americans’ deaths.

In fact, this arbitrary secrecy may already have resulted in Americans’ deaths if state and local public health authorities could not make informed decisions because necessary information was denied them.

U.S. Vice-President Mike Pence, the administration’s point person on coronavirus, vowed on March 3 to offer “real-time information in a steady pace and be fully transparent.” The vice president, appointed by President Donald Trump in late February, is holding regular news briefings and also has pledged to rely on expert guidance.

The classification order also makes Pence’s vow look like a lie to the public if on March 3 Pence knew there was information about the government’s response withheld by classification.

Constituents should demand their representatives and senators address this both by holding more investigative hearings into this unwarranted secrecy, and by disclosing whatever information they can obtain about COVID-19 and executive branch response so that the public and their health care system can act appropriately. Further, they need to provide support in a way that states can use without interference by the White House.

Congressional switchboard: (202) 224-3121

~ 1 ~

This weekend’s real live drama revolving around cruise ship Grand Princess’s docking at the port of Oakland hints at a solution to the bullshit obstruction and abuse of power surrounding the federal government’s COVID-19 response.

Note in the video that California’s Gov. Gavin Newsom takes center stage, leads and directs the release of information.

Gilding the lily a bit, because the real work was done much farther below Pence’s office.

What was particularly interesting was the lack of response from Trump. We could have expected him to badmouth Newsom the way he badmouthed Inslee, but he didn’t. Perhaps Trump was too busy playing golf.

Or perhaps he didn’t want to draw attention to Newsom.

The docking happened, people were moved, and it happened without a lot of hullabaloo.

That’s exactly what we want — effective, speedy resolution meeting the problem head on.

This same model could work across the entire country if governors work cooperatively and collaboratively to share information and best practices, and are willing to be the point person out in front. The National Governors Association could provide the bipartisan vehicle for networking; it’s outside the purview of the White House, can’t be forced to operate under federal classification.

Granted, taking this approach means governors run the risk of mean tweets from Trump. Screw him and his germy iPhone. Residents in every state want calm and effective leadership they can trust and see in the days ahead. Governors should provide it — particularly since governors are a lot closer to their constituents than Trump is.

Every state should already have in place a process by which their residents can decide what action to take if they believe that they or their family members are infected with COVID-19. There have been far too many reports of individuals making calls to 911 and asking for ambulance rides to the hospital for testing. Such unnecessary use of resources, from calls to 911 operators to ambulance response to demands on hospital personnel represent heightening the curve, not flattening it.

States’ departments of health should have a published decision tree online for residents to use to decide their next course of action. It’s clearly not enough to tell the public “What to do if you’re sick” if they are calling 911 for non-emergency situations.

Website design has also been poor, forcing people who may already be panicky for lack of information to wade through a website to get what they need to make a health care decision, and in some cases design ignores that many residents rely on mobile devices.

Nor has the information process made it all the way down to county and city level.

More effective outreach across broadcast and social media is also needed to manage expectations in the days and weeks ahead.

A collaborative effort by governors could reduce costs to create a comprehensive communication plan across each state and across the U.S. — all while avoiding the obstructive influence of the White House.

Until governors catch on, though, each of us will have to push our state and local health departments to do better BEFORE the coming crisis. There is no extra time, there is no room for failure. Check to see how your state and local health departments are working right now.

And in saying this I’ll tell you my own county is screwed up. The web page with FAQ about COVID-19 doesn’t render on mobile devices. It doesn’t tell residents what to do if they have symptoms matching COVID-19. I really need to call and have a little constructive chat with them because the county hospital is less than a mile from my house. I don’t want problems I can anticipate on my back porch.

A pretty good example of how a county health department’s COVID-19 website should look is Santa Clara County, CA. See SCCPHD — the only nit I have with the site is that it needs a decision tree, something a little less fuzzy to help residents who are either panicky or not well educated.

Santa Clara County has also published a nice handout on social distancing. Really worth copying by other state and local health departments.

Wish I could give you a link to the websites and phone numbers you’ll need to address this personal assignment but I can’t. Do share in comments what you’ve learned in your search.

~ 0 ~

One more thing for the physicians among us who might be willing to translate this into layperson’s English:

@DrRobDavidson
This appears to have been written by a physician in WA, (about a week old, likely) front-line inpatient care of COVID-19 patients. Not able to verify, but clinical data, as described, is consistent and, if accurate, sounds a loud warning on many fronts

— DocBurke (@burke_doc) March 10, 2020

Threadroll link here.

This is an open thread.

The internet is full of ideas for dealing with the economic problems associated with the outbreak of COVID-19. As usual, the first suggestions are for tax cuts to protect the corporations facing problems. I assume tax cuts for business entities like the airlines are the logical outcome of my general rule that the point of neoliberal caitalism is to protect the interests of capitalists. But tax cuts are the only bipartisan policies possible, because Republicans only care about tax cuts and have no interest in sound policy; while Democrats are happy to oblige their donor class, and wring their hands about the mean Republicans who won’t let them do anything for their voters. Another widespread ideas is a payroll tax cut; that would benefit people who keep their jobs in the downturn.

Good policy starts with the identification of the problem. At a first approximation, I think the problem involves the following:

1. Sick people. They require medical care, and many can’t afford it, even if it’s available, and even if they have insurance.

2. Unemployment. There will be an uptick in unemployment. Maybe employers close down, maybe business is slower, maybe people don’t want to be out in public and around possible vectors of the illness.

3. Shortages of goods. This will include many of the goods we get from China, but it will also include medical supplies and equipment, and drugs. There will be spot shortages of other goods.

Tax cuts aren’t going to address those problems. Sick people don’t have income, and tax cuts won’t matter to them. Unemployed people won’t have income either. Increasing the amount of money in the hands of consumers and businesses will only create inflation in goods in short supply if the money is spent. Using the money to pay down debt will stabilize some companies and people, but any money used to buy stocks or bonds will not stimulate anything except the wallets of Wall Streeters. I doubt that people will increase their spending on restaurants or movies or other public activities because of fear of contagion even if they have more money from the tax cuts.

The thing that will work is direct government spending on infrastructure. It puts the unemployed back to work. It won’t increase prices for goods that are not in short supply. For goods in short supply, increases in prices will encourage businesses to expand to supply the new needs. Hopefully this will include mostly resources we have here in the US, or can set up here in reasonably short order. We don’t need vast amounts of plastic crap, more computers or smart phones, and other tech goods. What we need are roads, efficient electrical transmission lines, more solar power, better internet service, and other basic electronics that rely mostly on simple sturdy chips. We need new schools, new state and local agencies for a variety of purposes, more buses and subways and light rail, more affordable housing especially in urban areas, more research facilities, more drug manufacturers and a long list of things I don’t know about.

This is a public crisis. Therefore we have a social responsibility to pay for all medical treatment for infected people, all testing, and all necessary medicines. No one should be bankrupted or financially hurt by the cost of treatment of COVID-19. Also we should build public facilities to provide that treatment.

But alone, this isn’t enough. If people use the income from these jobs to bid up the prices of consumer goods in short supply, we will see an increase in inflation. Therefore the goal is to get people to pay down debt and to save the extra income for the future. This should be relatively easy. The fear induced by this crisis should make it obvious that things are going to change, and conservative finances are the best protection for all of us.

One more thing. I don’t believe in pay-fors as a general rule. But the fact is that almost all politicians either actually do believe or pretend to believe in them. This is a great time to demand higher taxes on the 1%, not because we need the cash, but to reduce their obscene domination of our politics (I’m looking at you Michael Bloomberg). Raise taxes on the rich to cover the costs of at least a portion of the expenditures I have described. That means at least the amount of payroll tax cuts, medical treatment for infected people, increased research into viral diseases, vaccines, and production of vaccines, and any additional cuts for corporations and other business entities.

So there’s my take. Please treat this as an open thread on these issues.

Discontinuity.

Abrupt change.

Collapse.

Chaos.

Whatever term you might choose to use, there’s no disputing that if the epidemiologists are correct, the COVID-19 pandemic will be the largest, most impactful world event since 9/11. How we respond to the pandemic will define our society, likely for generations to come.

The response to 9/11 was close to exactly the opposite of what I would consider best. Instead of asking why small groups of people felt so ostracized and minimized that violence was their last resort and then acting to address the root causes, the US chose to demonize and further ostracize Muslims in generally, thereby creating a much larger and endless supply of new terrorists to fight. Over a million people died, many more millions were displaced and an entire generation of US military lives were wasted. But a handful of people got filthy rich off it.

The business and political worlds of today live for these discontinuities. Back when I was running an agricultural biotechnology startup, we were instructed that Monsanto and their spin-offs were so successful because they stood ready to respond to market discontinuities in their areas of operation. Regular, 1-3% annual changes in markets were for chumps. Giant change is what mattered, and so be it if mom and pop seed operations were obliterated by consolidating the entire seed industry. Likewise, in business generally in that era, the rise of the big box store was seen as a John Galt-like hero development as the parasitic small stores disappeared. Today, Big Bezos seems to be feasting off even those big boxes.

On the political front, Naomi Klein laid out in excruciating detail in Shock Doctrine how various disasters have been exploited by the political class to advance the interests of the oligarchy. Both civil rights and economic opportunity for huge portions of the population have been eroded.

Naomi Wolf warned us a few days ago to be on guard against deterioration of our rights in the COVID-19 outbreak:

As coronavirus spreads I just want to remind everyone to be on guard agains power grabs against civil liberties, using virus as rationale. “Never waste a good crisis” to mask the advance an otherwise unacceptable agenda, is the silent mantra of many political leaders.

— Dr Naomi Wolf (@naomirwolf) March 4, 2020

Today, CNN reports on ongoing discussions between the Trump Administration and the airline industry. It appears that at least some in the industry are concerned that data collection being demanded under a public health guise will be used “for other purposes”:

The US aviation industry and the Trump administration are in a pitched battle over the response to the coronavirus pandemic, three sources familiar with recent calls between officials from several government agencies and US airlines have told CNN.

In a series of contentious conversations, agency officials and aviation executives have clashed over the administration’s demand that airlines collect new kinds of data from passengers to help officials track potential virus carriers.

Okay, on the surface, I’m all for public health officials being able to access information quickly on who was sitting near whom on a flight with an infected person and quickly contact those who need to self-quarantine and get tested. But how do we make sure that data doesn’t wind up being misused? Also, it appears that the Trump Administration also wants the airlines to collect information on recent other travel by passengers: