Even in this life-and-death situation for so many people, CDC remain staunch in defense of double-blind testing.  Now that several months have passed, politicians, commentators, scientists and doctors have all been humbled. Perhaps there is an opening for non conventional thinking.

Steven Collinson’s editorial,  (CNN) Trump peddles unsubstantiated hope in dark times, politicizes a scientific question. Mr. Collinson would have done better to focus on the medical issues. He chose instead to follow the path of Socrates, an otherwise great thinker who made a great mistake. Socrates declaimed that all he had to know he could learn from “men in the city.” He saw no need for natural science. Socrates was the first thinker to politicize science.

Double blind testing is dear to medicine, because for all but the last 150 years, medicine killed more people than it healed. Double blind testing is ritual purity, because it removes human judgement from the outcome. It would have saved humanity from these deadly treatments:

• Bloodletting.
• Purgatives.
• Roentgen therapy, X-rays as a healing source — not to be confused with legitimate radiation therapy.
• Thorotrast.
• Thalidomide in pregnant women.
• The opioid epidemic.
• In the 1918 flu epidemic, a massive dose of aspirin, as much as 30 grams in one dose, was frequently prescribed, which by itself would kill the patient.
• To the above, add the lay healers, swallowing chlorine bleach. Laetrile, and, in many cases, herbs.

Yet during World War I, military surgeons packed wounds with pure sugar, which worked to prevent gangrene. Pure sugar is toxic to bacteria.  Nobody thought of double blind testing while Doctor Sawbones waited.The history of medicine is littered with treatments that worked, yet are forgotten:

• Coley’s toxins.
• Arsenic for some neoplasms, which has recently been revived as an import from China.

The Wikipedia article on Coley’s toxins begins with the statement,

“There is no evidence that Coley’s toxins have any effectiveness in treating cancer, and use of them risks causing serious harm.^[4]“

The statement is false. It is true is that Coley’s toxins were extremely dangerous, yet acceptable as a personal choice in a time when no alternative treatment, even palliative, was available. If you ignore the opening statement, and read the article without the prejudice of the opening statement, you may conclude that there is a better than even chance that Coley’s toxins did some people some good. The rest faced inevitable death.

Today you have better alternatives, treatments that target the immune system blockade, without risking deadly bacterial infection.

Now refocus on the statement, “”There is no evidence that Coley’s toxins…”  It’s wrong! It is more correct to say, “If someone offers to treat you with Coley’s toxins, run in the other direction.” But somehow, it got dumbed down. Why?

It is an expression of two cultures:

• Medical culture, which medical practitioners subscribe to, based on science but going beyond science to include paternal responsibility towards the patient and the public.
• Consumer culture, which accepts the paternal role of professional medicine, with simplification of the truth.

With all this culture, and the very sophisticated statistical methods of research medicine, something is missing: modern decision theory. It’s missing because double-blind testing is the medical equivalent of ritual purity. We need it now.

To be continued shortly.

Inspired by the brave Italians, let’s do a little singing. In NYC, there aren’t many balconies, but there are plenty of fire escapes:

Luciano Pavarotti – Funiculì Funiculà

There is actually a joke-inside the joke. The song is not from opera. It was written as a  joke by an Italian newsman.

Now belt it out!

I wrote this so long ago, it’s fresh as a daisy. Just substitute “COVID-19” for “Ebola”:

Ebola Vaccines, Medical Ethics, and Manslaughter.

It’s about conflicting values:

• Purity of the scientific approach, which requires double-blind testing.
• Fear of legal liability.
• Saving lives now.

The system rewards adherence to norms. If, like many pandemics of the past, there is a second more deadly wave, the practically impenetrable defense is “We didn’t see it coming.” No good deed goes unpunished.

Health care is the one area of our lives where we accept a level of paternalism that is otherwise unacceptable. You don’t have to be a libertarian to see the value of a partial exception for COVID-19:

Legislation that permits a private individual, and a vaccine company of good scientific repute which has completed favorable Phase 1 trials, to make a contract that limits liability for the many vague and unsubstantiated complaints that can be wrongly blamed on a novel antigen.

If life were a gaming table, our mutual choices, of citizen and vaccine maker, would be:

• Keep playing.
• Step away from the table

But it’s not a game, and we can’t step away from this.

This is a short continuation of U.S. spy agencies monitor COVID-19, concerns about India, mainly for people who understand the basics. The primer will come later. We now know that there are at least two strains of COVID-19, which compete by the laws of natural selection.  (Oxford Scientific) On the origin and continuing evolution of SARS-CoV-2. Type L produces severe disease; Type S is comparatively mild.

The following was mentioned in COVID pandemic “could be over by June” Chinese adviser; Third World Reservoir.   Delving deeper,

• In China, selective pressure towards Type S may have occurred, resulting from stringent quarantine, a reduction of virulence.
• Yet Type L evolved from Type S, in the direction of greater virulence. It is logical to extend the inference: Early in the Wuhan transmission chain, before quarantines, Type L was selected, with greater virulence.
• This partly thought and partly real experiment implies that social behavior, particular to a society, strongly affects the competition of Types L and S.

Village India, like Village Pakistan, harbors the remains of tribal culture in the panchayati raj system of local government, dating to 250 AD. Villages contain strong elements of extended family, frequently acting in ways that are officially forbidden by  central governments. Items that occasionally make international news  include honor killings and femicide, with infanticide too common to report.

Now assume that in some village somewhere in the Third World,

• There are not already circulating corona viruses with enough sero-similarity to provide some immunity.
• COVID-19  arrives, quickly differentiating into something like Type L and S.
• The sanitary infrastructure is weak, so isolation is impossible.

How natural selection acts on types L and S depends upon social choices innate to the villages. Types L and S may not even be identified by a village as related diseases. Customs older than recorded history provide the framework for response. Which custom will dominate?

• The village implements a non selective quarantine, nurses the sick, and disposes of the dead with aseptic funerary rituals. No selective pressure.
• The severely ill die before expulsion. As with Ebola, preparation of the dead for burial is a major driver. Type L out-competes Type S.
• Expulsion of the severely ill. Type L-infected dies alone on the road. Possibly selective for Type S.
• Inside-out reverse quarantine. With leprosy as the precedent, the village nurses the mildly ill and expels the severely  ill. The severely ill person transits to another village, and is taken in by relatives. Type L out propagates Type S.

While the China experience suggests that quarantine allows Type S to out compete Type L, the inside-out reverse quarantine does the opposite. It promotes Type L, of greater virulence.

See COVID-19: A Warning. Other ways in which virulence can be promoted will shortly be discussed.

(Reuters) Coronavirus pandemic “could be over by June” if countries act, says Chinese adviser. Quoting,

The global coronavirus pandemic could be over by June if countries mobilize to fight it, a senior Chinese medical adviser said on Thursday, as China declared the peak had passed there and new cases in Hubei fell to single digits for the first time.

In the world we live in, this has no chance of happening. Even if everybody rolled up their sleeves and acted correctly within their power, it could not happen. China is unique, the world’s first surveillance state, with capabilities of contact tracing unapproached anywhere else. The acquiescence of China’s citizens to strict measures of control is also unequaled.

The headline of  earlier CNN article, Will the new coronavirus burn out like SARS … or is it here to stay? poses the wrong question. Like many wrong questions, it has no answer:

• SARS did not burn out. It was contained. Containment was feasible because covert infections were not contagious.
• Flu strains, and common colds, for which many viruses are responsible, do burn out, by the development of herd immunity.
• In the absence of public health interventions,  for an historic example, have a look at syphilis. It took about 50 years to convert from a quickly fatal illness to the modern form, which by comparison, is mild.
• COVID-19 will not burn out in a reasonable time frame, unless you consider 65 weeks reasonable.
• Although local containment is possible, COVID-19 cannot be contained globally, because of the prevalence of covert infections, asymptomatic and contagious.
  
• Containment efforts will prolong the time to “burnout.”
• Containment efforts are nevertheless required, so healthcare systems are not overwhelmed, and to preserve the fabric of society.

Mi Feng, the spokesman for the National Health Commission quoted in the Reuters article, was not intentionally misleading. He simply omitted context for the rest of the world. Messages of hope frequently do this; they should not be condemned. It is up to us to supply the context.

The estimate of How Long Will the COVID-19 Epidemic Last? Napkin Calculation,  for true “burnout” is 65 weeks. “Burnout”, a word which tells you nothing, happens when enough herd immunity has developed to change the chain of transmission from growing to shrinking. The estimate is crude, but better than hope.

A painful paradox: Intervention, which presently means quarantine and travel restrictions, without other measures, will prolong the 65 weeks. (You may choose your own number, provided you supply justification other than hope). The fastest way to herd immunity is the cruelest, with unjustifiable loss of human life.

This is the way it will happen in most of the world. Like all the plagues of the past, COVID-19 will “burnout”, with the understanding that plagues end when either

• The concentration of animal vectors has declined.
• Human depopulation has occurred.
• Herd immunity has been acquired.

Since Wuhan bats do not mingle with humans like plague rats, this leaves mostly herd immunity. It would take more than the current lethality of COVID-19 to cause the occurrence of natural selection, the “survival of the fittest.” See COVID-19: A Warning.

Now what about the Third World, when herd immunity is acquired, at the expense of great human suffering? COVID-19 will not vanish. Exiting epidemic, It will go underground, persisting as an endemic, mostly mild disease. The Third World will become a disease reservoir.

This presents a problem for a developed country which has exercised effective measures of travel restrictions and quarantine. It means that the population is “naive” with respect to COVID. Having had no exposure, they are as vulnerable as they were before December 2019. Yet constant vigilance is not feasible with a disease that has covert characteristics.  This is constant, imminent catastrophe.

How can the developed countries acquire herd immunity, while avoiding the suffering of the Third World? There are two ways:

• Spontaneous mutation of COVID-19 to a strain that produces mild disease, which out competes virulent strains. Two strains have already been noted in China. See (Oxford Scientific) On the origin and continuing evolution of SARS-CoV-2. Type L produces severe disease; Type S is comparatively mild.

Although selective pressure towards Type S may have been observed, resulting from stringent quarantine, let’s not rely on it. In fact, it appears that Type L evolved from Type S, in the direction of greater virulence.

• Ignoring luck, vaccination is the alternative. Even if vaccination programs have limited duration, there is a fascinating potential benefit: the COVID-19 virus may change to become less virulent. The result: herd immunity that endures beyond a vaccination campaign.

We’ll explore how this could happen in the next post.

It is disturbing how little of the $8B appropriation is for vaccine development. This must be corrected, stat!

Reference:  (DIVA, pdf) The reproductive number of COVID-19 is higher compared to SARS coronavirus. Contained within the article is a permalink:  http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-168415 . Quoting,

“Teaser:Our review found the average Ro for 2019-nCoV to be 3.28…”

We’re going to do a napkin calculation, closely related to what scientists call a power-of-10 job. There is no claim of accuracy.  Even if we wanted to be sophisticated, there are things in the way of accuracy. The basic reproduction number, R_o, will not be known with any accuracy until this is all history. It’s one of the weaknesses of epidemiology, better at analyzing the past than predicting the future. Nor is there any reason to assume that R_o will be constant with the seasons, and subtle seasonal changes in social behavior.

For this napkin calculation, assume that

•  The number of people in the U.S. who are infected is actually 10 times the reported figure of 700 as of 6 a.m on 3/10/2020. The number is 7000.
• Having COVID-19 confers long lasting immunity.
• R_o, which applies to a population that has never seen COVID-19, is constant.
• The epidemic is not stopped by other means, such as quarantine, drugs, or vaccination.
• R_o = 3.78, a little higher than the reference. It is, after all, an estimate.

We want to know R, which unlike R_o takes into account herd immunity. When a  certain percentage, a majority of the population, has had COVID, with or without symptoms, R drops below 1.  Here we go:

• U.S. population: 327 million
• Percentage of the population to have experienced COVID, for R to drop below 1:  73.5% = 240 million.
• The generation time is the average time it takes an infected individual to infect others. Example: If a person is infected on March  1, and infects 4 more people before recovery, at March 7, 14, 21, and 28, the generation time is 17.5 days.
• If we assume that COVID keeps infecting with R=3.78,  that implies, starting with 7000 infected, 8 generations to reach 240 million.
• The above is not correct; R decreases as time goes on, so more than 8 generations are required. But for simplicity, to keep it a napkin calculation, let’s go with it.
• Assume the generations time is three weeks.
• 8 generations = 24 weeks.
• Now apply a correction for the gradual decrease of R as the number of people who haven’t had it declines: Multiply the above by the magic number e= 2.71828.
• This gives 65 weeks till the reproduction number drops below 1.

In  the world of this very rough estimate, the epidemic takes a downturn 65 weeks from present. It assumes  no modifications by medicine and public health, and a lot of mostly avoidable human suffering.

But there you have it. If this were the pre-scientific world of past plagues, and the pathogen had characteristics similar to COVID-19, it would be close to the truth.

Now you can panic. But do it in style.

(Reuters) Turkey’s Erdogan asks Russia to step aside in Syria.

They will largely do this. The Russians may draw a line on the map, and they may take local action against Turkish deployment beyond that line. If that occurs, it will be the high point of tension, followed by a little freeze, followed by deescalation. This post-conflict pattern has been demonstrated: (BBC) Turkey’s downing of Russian warplane – what we know.

In 2014, when Syria was almost a complete political vacuum, I proposed a reinstatement of the Ottoman Empire, which was dissolved in the aftermath of World War 1, to serve British and French colonial ambitions. Articles: (2014) Turkey & the New Ottoman Empire, and (2016) Turkey in Syria; The New Ottoman Empire; a Brief Note about Cultural Affinity. Additional mentions here.

This colonial redraw is the direct antecedent of today’s map of ethnic conflict, fueled by artificial boundaries that cut across ethnic lines. In some cases, this strategy was intentional, to make these regions more amenable to foreign governance.

Ottoman Syria was a stable component of the empire for 400 years. The semi-representational methods of Ottoman governance, which achieved stability of a multi-ethnic region, remain a marvel to historians, if not a modern aspiration. A reprise in northern Syria, with organic connection to Turkey’s economy, might well have resulted in durable solution. No alternative of the striped-pants brigade has as much life to it.

Turkey’s involvement in Syria reached a high point in the attempt to prevent the recapture of Aleppo. It failed because it was actuated by proxies with insufficient power. Other constraints to greater activity:

• The tatters of the proclaimed “Zero problems with our neighbors” foreign policy.
• Sensitivity to war casualties typical of a modern nation.
• Reluctance or refusal to engage Islamists of any stripe on the battlefield.
• Turkey’s transition from a member of the Western Alliance to an independent, mini “great power”, which requires a state of balance with Russia.

Russian concerns are a delicate balance of:

• Desire to continue peeling Turkey away from the West, with the eventual removal of nuclear weapons from Turkey.
• Reliance on the Bosporus, a choke point for the Black Sea warm-water ports.
• Recognition that Recep Erdoğan was, and is, an Islamist. (Hoover) Erdogan The Nationalist Vs Erdogan The Islamist.

The Russians complain, with justification, that Turkey was not acting with effect against terror groups in the Idlib region. The location of Abu Bakr al-Baghdadi at the time of U.S. action was on the edge of Idlib.

There is a tendency for Islamists to cloak themselves within the current political scene. This was demonstrated by Mohamed Morsi, who came to power by popular election, and proceeded by subtle and then less subtle steps to dismantle Egyptian democracy. (That el-Sisi finished the process is not germane here.)

Erdoğan has also subverted Turkish democracy. He began by showing up to chair meetings he had no standing in, and continued (like el-Sisi), with constitutional change that opens the door to further weakening. The huge number of Gülen movement imprisonments goes beyond the modern meaning of sedition; it is an authoritarian clamp-down. (BBC) Reality Check: The numbers behind the crackdown in Turkey.

Subversion of democracy is not a Russian concern. Erdoğan the crypto-Islamist is.  Since 1991, Turkey and Russia have not shared a border. But the intervening states, Armenia, Azerbaijan, and Georgia, are weak and porous. The recent history of the Middle East suggests that the ambition, and potential for Islamic export and aggression  correlate with national transition from secular to Islamist.

If it were necessary to choose a single word to define U.S. foreign policy, it might be one of “preserve”, ‘protect”, or “defend.” For Russia, it would be “if.” Because Russia is a threatened continental power, this leads to complex constructs, that begin with “If Turkey…”.

At the current level of Erdoğan‘s Islamism, the “if”  still allows accommodation of the Turkish occupation. Provided that the remaining terror pockets of Idlib are eliminated, it offers practical advantages to Russia:

• A reduction of the area of control required of Assad’s overstretched forces.
• Leverage with Turkey. As an arrangement that lacks the pretense of legitimacy, Turkish occupation is a useful pressure point.
• Continuance of a Turkey-Russia alliance, in the context of the Russian “if.”

The era of Ottoman collapse is beautifully depicted in the 1988 movie (Youtube) Pascali’s Island, starring Ben Kingsley. It poses the eternal question of the spy: Is anybody listening?

(CNN) New coronavirus cases in California and Oregon are second and third of unknown origin in U.S. has a video, titled “Doctor says your mask won’t help you against corona virus. Here’s why.” Anderson Cooper interviews a pediatrician, who says as much. This is followed by (CNN) Masks can’t stop the coronavirus in the US, but hysteria has led to bulk-buying, price-gouging and serious fear for the future. Quoting,

“The CDC says that healthy people in the US shouldn’t wear them because they won’t protect them from the novel coronavirus.”

Scarfing up surgical masks when healthcare system has a critical shortage is antisocial. The priority of masks for healthcare workers is for our collective benefit. This does not justify assertion of a fact that does not exist. There is modest evidence that surgical masks offer risk reduction. But there is now a tendency, ranging across the media, and including VP Pence, to manage this subject for the wrong reason, to prevent panic.

The correct statement is that nobody knows for certain whether surgical masks are protective. A study of  mask use by clinicians to protect from general upper respiratory infections, including flu, suggests, with a caveat, that they are. See (NCBI PMC) Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis.

This is a meta study, which extracts new information from prior studies by fancy math. The article acknowledges that at the objective level, in the lab, N95 masks filter infectious particles, while surgical masks do not. Yet from the section Interpretation,

“Results of our systematic review and meta-analysis show that there was no significant difference between N95 respirators and surgical masks when used by health care workers to prevent transmission of acute respiratory infections from patients.”

The caveat:  The article authors note that the study has low statistical power, meaning that there is a more than negligible chance that the above conclusion is false.

Follow the logic: If N95 masks protect, and surgical masks work about as well in clinical settings, then surgical masks protect. Remember the caveat. Now translate that into unmanaged news-speak:

Surgical masks might offer some level of protection, but nobody knows for sure.

How do we explain the apparent discrepancy of lab tests versus clinical experience? An easy guess: While the mask doesn’t stop droplets, it changes the physics of the inhaled air stream. It reduces the formation of vortices (rotation in the air stream, see vortex) that rip at the delicate mucous lung lining,  and enhance transport particles deeply into the lungs.

That’s what I would like to see. Treat people like adults, and they are more likely to act as such. Even if you’re into managing, there is another reason to avoid it: If and when the shit hits the fan, they are more likely to follow your lead.

Don’t believe everything a doctor tells you. You just got a second opinion. A surgical mask could also prevent you from being smacked by gobs. I’m not waiting for the study.

An ethical alternative: Wear a scarf. (Oxford Academic, Annals of Work Exposures and Health) Simple Respiratory Protection—Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 20–1000 nm Size Particles. From the abstract,

“A shortage of disposable filtering facepiece respirators can be expected during a pandemic respiratory infection such as influenza A. Some individuals may want to use common fabric materials for respiratory protection because of shortage or affordability reasons. To address the filtration performance of common fabric materials against nano-size particles including viruses, five major categories of fabric materials including sweatshirts, T-shirts, towels, scarves, and cloth masks were tested…”

The conclusion is that the performance of improvised filters, such as scarves, overlaps surgical masks. Quoting

“Fabric materials may provide respiratory protection levels (i.e. total inward leakage) similar to the levels obtained using some surgical masks, which have been measured to be <10 (Oberg and Brosseau, 2008)…”

Individual virus particles are too small to be stopped. The authors have a theory complimentary to airflow modification.  They propose that like surgical masks, fabric improvisations are of benefit because much of the virus shed by an infected  individual is bound to larger particles.

Wear a scarf.

(Reuters) U.S. spy agencies monitor coronavirus spread, concerns about India: sources.

If you’re into thought-experiments,  get started with (NCBI PMC) The U.S. Military and the Influenza Pandemic of 1918–1919.  Attend to this question: Are there civil environments in less developed countries that can reprise the process  in those U.S. military camps that  selected for increased virulence?

Modern, urban India is similar in social organization to other modern countries, so propagation is likely to be similar in nature, though greater in scope. Of note, though, India is historically light on  influenza, the closest proxy for experience.

Rural, “Village India”, has different social characteristics:

• Relative immobility.
• Such mobility as there is, is based on kin relationships.
• Likely erection by local authorities of ineffective barriers that actually select for characteristics of virulence.
• General absence of infrastructure to support modern hygiene.
• An incredibly rich microbiota “soup”,  which may promote diverse forms of transmission, including  human-nonhuman-human.
• Lots of opportunities for genetic reassortment.
• By comparison to China, an absence of top-down pervasive social control.

Factors that support rapid mutation might coincide with selection for virulence.

Yet India isn’t much troubled by the flu!

The next article is the promised layman’s intro to epidemiology.

On page 147 of the 1935 printing of Rats, Lice, and History, (pdf Archive.org ) epidemiologist Hans Zinsser writes about the Plague of Justinian,

“It is interesting to note that this epidemic displayed one of the characteristics so often referred to in modern epidemiology — namely, when the outbreaks begin, the number of sick and the mortality were relatively slight, but both rose with appalling violence as the epidemic gathered velocity.”

 It is understood that while worsening conditions of life in an epidemic exact a toll, the primary change is increase in the virulence of the pathogen.

Zinsser had personal experience with the notorious modern example. (NCBI PMC) The U.S. Military and the Influenza Pandemic of 1918–1919 relates the observations of medical officer Alan M. Chesney. Quoting (boldface  mine),

During Chesney’s first documented period, the month of June to July 27, the 5th Artillery Brigade had 77 “relatively mild” cases of influenza. During the second phase, July 27 to August 23, 200 men of the 58th Artillery Brigade became ill, about 6.5%. None of them died, but the outbreak was serious enough that the next brigade cleaned out the barracks, even washing the walls, before they moved in. Despite this precaution, during Chesney’s third phase, August 23 to November 8, more than one-third of the 6th Artillery Brigade, 1,636 soldiers, contracted influenza and 151 died. Chesney concluded that “…these successive outbreaks tended to be progressively more severe both in character and extent, which would speak for an increasing virulence of the causative agent.”¹³

Like the stories of Zinsser’s captivating book,  this factual account omits the mechanics of why virulence can increase. Since that time, epidemiology has evolved from a preponderance of mystery to an inexact science. In the past several months, epidemiologists have used a lot of hopeful words, with reluctance to make predictions. Only within the past week or so has CDC confided that COVID-19 is inescapable.

Like the social sciences, epidemiology lacks the bedrock of hard science master equations. But there is math; it just has to be tweaked to fit the circumstances.  The next article offers an intuitive approach to Zinsser’s assertion and Chesney’s experience. The predator-prey equations, explained in words, are a good place to start. Intuitive epidemiology is accessible to a large audience., including you.

The warning: In large parts of the world, particularly within conflict zones, but also without, conditions exist for an increase in the virulence of COVID-19.

To be continued shortly.