As reminders…

Alpha–Variant first identified in the UK

Beta–Variant first identified in South Africa

Gamma–Variant first identified in Brazil

Delta–Variant first identified in India

Also as a reminder:

–Another week, another “coronavirus only” update. And we may not need the variant subtype reminder too much longer at this rate either…

–Around the horn, Russia and Romania are really the only places seeing solid sustained increases. India and the UK have had steady numbers lately. In the US, the Rt continues to hover around 0.9 nationally. The “cold weather states” are closer to 1, with Minnesota showing a very slight rise that has nonetheless now been long enough of an extension of the delta wave that ICUs are being pressured there. Again, this is likely a combination of sustained transmission at a high enough rate to put people in the hospital and keep them there, slowly filling beds up, and labor pressures as healthcare workers become increasingly difficult to come by (more anecdote on that later). Broadly speaking though, trends remain positive.

–While we are still waiting for safety data on SARS-CoV-2 vaccines in kids to be announced (and the FDA is still mulling Pfizer’s data package), there was actually some good data out of the New York Times this week. They compared hospitalization rates broken down by age group from data sets where those statistics were relatively easily available. One such source was Seattle, which showed the following:

They also had data from the UK’s NHS, which showed a similar trend (in fact, the trend in the NHS data is even more in the kids’ favor).

The NYT’s conclusion, and is valid based on the data, is that the risk of hospitalization for an unvaccinated child 11 or under from SARS-CoV-2 is approximately that of a fully vaccinated 50 year old, and borders that of a vaccinated 30 year old. Or put another way, it’s like the kids have an inborn advantage against SARS-CoV-2 correlated to their age that is equivalent to doses of vaccine already. So good news for the many of us who have kids in this age range.

This puts a premium on the safety data for the vaccine in this age group, as the risk of an average 11 year old from SARS-CoV-2 is quite low. On the other hand, if the vaccine (which, in Pfizer’s case, was a reduced dose compared to the adult and teen version) has adequate safety, you’ll push an already low hospitalization rate theoretically even lower with the vaccine.

Will be interesting to see that data when it is available, to say the least, and what FDA’s assessment of risk/benefit will be.

–All of that said, the virus does remain dangerous, especially if you get a case severe enough to result in hospitalization. I talk a lot about percentages and risk factors here, and that tends to sanitize the very real human consequences on the other side of those stats. Found out in just the past week that a radiologist I worked with in my previous clinical life died of COVID. Also found out the girl I took to prom junior year caught COVID while pregnant with her second. They had to deliver via C-section, and ~a month later, still cannot get her oxygenation rates up, and she’s now on ECMO (which is an “artificial lung”–the step over and above a ventilator). Her other child at home is 2 years old.

No, neither one of them was vaccinated.

–The latter was probably from concern about the vaccine during pregnancy. It is worth re-iterating that the delta wave, at least, has been particularly dangerous for pregnant women. All of the major obstetrics societies worldwide are stressing the need for vaccination for pregnant women. There is no known risk to the child from the vaccine, and from the mechanism of action that we have covered ad naseum now, there are not many obvious risks from the vaccine either. It is improbable that any of the particles containing the mRNA of the spike protein (using the mRNA vaccines as an example) will even reach the placenta before running into many of Mom’s cells and being absorbed first.

Similarly, if the spike protein or reaction to it were a danger to the growing fetus, we would have seen that as screaming headlines during pre-vaccine days from women who were pregnant and caught actual SARS-CoV-2–which makes a bunch of spike protein during an infection, and at what is often a higher sustained pace of spike protein production than the vaccine. We have not seen evidence of birth defects or complications due to SARS-CoV-2 or its spike protein crossing the placenta–thank God. It’s a dog that has not barked, despite ample opportunity.

–We talked about Merck’s oral anti-viral agent getting the fast track for FDA review last week. After we went to press, there were other commentaries, including risk/benefit discussion, about the announcement in the lay media that you can read here.

“Wait, so what do –you- think the side eff-“ I can hear you ask, and sorry for cutting you off right there Hypothetical Reader!

If you are asking me to comment on potential or theoretical side effects of a medication from a rival company seeking approval for that medication in an indication where my employer currently has a medication available, understand that I am happy to discuss its mechanism of action among friends (and not as medical advice) from a scientific perspective like I did last week. I thank you for understanding when I say I cannot discuss its side effects or the risks or benefits of taking one medication versus the other. Nor would you want me to, as there is an obvious potential bias from a conflict of interest there. You should talk to your healthcare provider, and of course, only use all medications as indicated and under the supervision of your healthcare provider.

Also worth mentioning there are other anti-virals coming down the line. We will cover their mechanism of action as they submit for approval as well.

–In vaccine updates, Moderna had a rough week, as the White House and press beat them up for not releasing their manufacturing process to make more of their vaccine available to low income countries. While Pfizer has sold doses at reduced cost to the US for donation to low income countries, Moderna has thus far not participated as vigorously.

“Wait, could this also be why Moderna’s review for full FDA approval has been slower than Pf-?” I hear you ask, Hypothetical Reader, and super sorry again for cutting you off!

If you are asking me to mind read, or opine on, the diligence and speed of -the- regulatory agency for Moderna AND my employer, for my employer’s largest market for nearly all of my employer’s therapies, thank you for your understanding Hypothetical Reader!

–Moderna did get approval for a half-dose booster for those at high risk for COVID (ie. older age, high risk conditions, and healthcare workers), despite early rumblings from FDA that they might not need a booster at all.

–In other vaccine booster news, early indications are that J&J may get a recommendation for a booster, and the headline noise is that the recommendation will be for a Moderna or Pfzier shot to be that booster. As a reminder, J&J is not a mRNA vaccine, so this is a “mixed” shot booster if this turns out to be the final recommendation.

–Socioeconomics… I’m going to bullet point this one this week.

• Lots of ink now being spilled “explaining” the cause of the increasingly global energy crunch. You will have seen this explained as either ESG mandates and government regulations increasing the costs of fossil fuel exploration (reducing supply of coal, oil, nat gas etc.) at the same time renewable energy initiatives have proven unable to close the gap –OR– you have seen this as prima facie evidence that had only the big fossil fuel companies got with the program sooner and invested more heavily in green energy, we would have more renewable power available to us now and only proves that we need more and faster investment in this space so that this kind of shortfall doesn’t happen again.
• These are, without exception, incomplete and wrong–and yes, I can say that quite comfortably even as a non-expert in mass energy production. Avoid the temptation to get lost in these articles, and definitely avoid the temptation to cite them to argue your preferred policy solution. Because these articles are wrong. How am I so certain of that? The first two major dominoes to fall in the global energy crisis were China and Europe. China is coal, nat gas and oil dependent and for long has not given a flying about CO2 emissions while growing its economy. While they are now trying to catch up on green energy (or at least look like they are), their problem is sourcing enough coal and nat gas right now. On the flip side, no one has adopted renewable energy generation faster or gets more of its kWh from green sources than a healthy swath of Europe. If anyone was going to have enough early adoption of green energy to see them through a fossil fuel squeeze, it’s Europe. Didn’t happen. Each of those is an inconvenient counter-example to the narratives in the bullet point above.
• The media got so much about the pandemic wrong (as we have covered). Now the same crew of journalism majors are tackling international energy production, its technologies, and how changes in demand, source of the next kWh and supply of available equivalent kWh, coupled with changes in regulation AND supply chain disruptions involving energy transport from the pandemic–from the same vast experience in all of those. What on Earth, based on just coverage of the pandemic over the last year, gives you any confidence their simplifications of global energy are right?
• Speaking of media getting it wrong on the pandemic, disinformation and censorship to counter it, this entire thread is worth a read.
• For those of you in the US, the good news is that even if the US tried to export its own nat gas to fill the shortages, it couldn’t. There is not enough capacity to turn it into liquid nat gas (LNG) for shipping overseas. So price action elsewhere in the world will not translate 1:1 here. That said, US energy companies are already warning that nat gas prices to heat homes this winter will increase by 30-50%. Electricity for the same will jump double digits as well, but not quite as high as nat gas.
• Consumer and producer price inflation was running quite hot and headlines are beginning to doubt just how “transitory” this inflation will be. As supply chains remain snarled, the prices you have seen rise inexorably for the stuff you buy seem likely to continue that direction. The Biden administration got the port unions to agree to 24/7 shifts to try to clear the backlog of container ships stuck in ports, not unloading. A start, perhaps, but will not solve the issue. Because now your problem is taking the stuff off containers and then by rail, river or road to warehouses. Bloomberg was already running articles two months ago about the difficulty of getting truckers after massive wave of retirements when they were essential employees and not terribly thrilled with their treatment. That linked article specifically is discussing the efforts to import more truck drivers from Canada and South Africa, because they cannot fill the shortage here. So how you will get the trucks to move containers from the ports is an open question. Same issue for rail, which is the second most popular way to schlepp stuff from one place to another (rail and truck combined for ~80% of cargo tonnage moved in the US). The articles on shortages in rail workers started in July. But let’s assume for argument’s sake that you solve the labor shortage in getting things off of ships, AND solve the labor shortages in moving them from a port to a warehouse destination by truck, rail, whatever. You still have not outrun your labor shortage issue. You can find similar articles about a shortage of warehouse workers right now too. One of our regular readers works for a very large company (you’ve heard of them) famous for its massive logistics operation with a number of gigantic warehouses all over the world, and among one of this reader’s duties is recruiting for those warehouses. To say they are having difficulty filling the positions is an understatement (our reader can you get you started today–frankly, “warm body” is becoming a nice to have, and not even a minimum qualification anymore, so desperately are they for bodies period in these jobs).
• “Well, just raise wages!” I hear you say, Hypothetical Reader. They have been trying exactly that. Just this week, in the NFIB SME survey 51% of small businesses reported openings they could NOT fill, with 42% of them raising wages to offset the shortages. That is the highest reading for those figures in 50 years. The price point to solve those shortages–the combination of pay, benefits and working conditions that fill these jobs and keep them filled–has not been discovered yet. They were chucking 6 figures at long haul truckers months ago–and that still hasn’t fixed the labor shortage there. 10,000 John Deere workers walked off the job this week when they could not agree with management on a new higher wage. Whatever the wage/benefit/conditions point is to get workers off the sidelines, it’s higher than the offers on the table right now. Promise you that.
• You’ve seen other signs of the labor shortages around you too, I’m sure. I was passing paper signs on the door to the gas station at the end of the block a few months ago offering $500 signing bonuses. Just yesterday, those are now full size banners across both sides of the building offering $1000 signing bonuses. While that’s great for those employees (who I hope, if not am sure, they are signing on long enough to keep the bonus, then quitting and going to the next signing bonus store down the street to cash there too), this will hit your bottom line before too long. None of these industries we have mentioned so far are high profit margin businesses. In fact, they are famously pretty low margin and prone to boom and bust cycles. Convenience store retail, for example, is one of the lowest net profit margins in all of retail. If they are paying $1000 a pop for signing bonuses just to man the shop and keep open, those higher wages are passing along to you. They don’t have the margin to eat that cost– and stay in business–at all. They have to pass the signing bonus and higher wage costs along to their customers as higher prices for everything in the store–on top of the price increases they are already seeing to buy what they sell in the store, and to get those goods shipped to them to put on their shelves. Rich Kids of Instagram may soon be flexing with an obnoxious picture of a Slurpee by their Rolex.
• Now, I have nothing against all of us earning more money, especially in some of these jobs that really, were not that great to begin with. My concern is that our wages may not be rising fast enough for the way prices are going up. After all, “yay increased wages for everyone!” rests on a BIG assumption–one which may or may not be true. That assumption is our wage hike is as large, or larger, than the increasing costs of the stuff we need to buy (which you have seen yourself at the stores lately, and shown in the still rising consumer and producer price indices). Because our wage hikes are only good if wages are going up as fast, or faster, than the price of stuff we need. If not, we are making more nominally, but affording less with it, and our standard of living will inevitably decline. It’s the slow motion collapse we mentioned again last week.
• That is why price inflation, where the same dollar buys less of a good than it used to, is the most regressive tax of them all. The Rich Kid of Instagram can still afford the Slurpee at the higher price of inflation–they have excess dollars. The construction worker or cleaning crew, though, will see their paychecks buy fewer and fewer Slurpees than they used to if these wage increases are less than the increase in the cost of everything else from all the supply chain shocks that have to be passed along.
• Inflation in low margin business that have to pass along costs, but touch everything (like energy and transportation) raise the price of everything and are paid by everyone. All the construction workers, lawnscaping guys and yes, truckers, in line at 7 am with their 3 Monsters and a Honey Bun apiece will be paying more for those Monsters and Honey Buns. Not just because we are paying truckers and clerks more, but because the energy and raw materials to make and ship those things to the point of sale is more expensive across the board. Again, this is what is seeping into the consumer and producer price indices.
• Not coming at a great time either. Bloomberg reports that the pandemic wiped out the entire savings of 20% of US households–proportionately higher among those making less than $50,000.
• So how else does all of this tie back into the pandemic? Well, you are fast approaching the “vaccinate or die” employee mandates. And companies are going to have to decide to follow through on threats of termination for at least some percentage of employees, and/or go short staffed. The leader for the union of Chicago Police officers warned this week that because of vaccine mandate rules, and the large number of union members electing to NOT get vaccinated in Chicago, police in the city expect to be at 50% capacity or less this weekend. The American Ambulance Association warned that if first responder medics are fired for failure to comply with vaccine mandates, their numbers are already stretched so thin that 911 services may be compromised focally around the country. They included the fun little fact that ambulance workers are being pilfered by short haul trucking, since it “pays them more to deliver packages than patients.” One reader had a family member in the hospital ICU for non-COVID related reasons, and had a nightmare of a time getting ordered tests like MRIs done in a timely fashion. As one nurse finally told them “We are completely understaffed. Wait, I am not allowed to say that. We do not currently have as many nurses as we normally do.” This was at the flagship tertiary care center for a major metropolitan area, too, for the record. There are rumors that the above average flight delays impacting Southwest over the weekend and American early to mid this week were “sick out” protests by pilots and ground crew. I know, Southwest blamed weather and air traffic control issues–but that somehow affected only Southwest and none of the other airlines flying the same cities this weekend, and left me a little less than convinced. But I don’t know that these are passive resistance protests either, and suspect if it were more organized like that, there would be a smoking gun email that had been sent to everyone setting a date for the “walkout.” Never attribute to malice that which is best explained by stupidity–or these particular airlines just being especially incompetent in getting flight crew to planes in a way that keeps them on time. Regardless, the growing trend is that labor shortages are everywhere, despite inflation in wages and prices (which should in theory be relieving these issues at some point), and may get acutely worse if there are widespread mass layoffs as vaccine mandate deadlines are reached and acted on.
• If those happen, they will definitely NOT help the current socioeconomic zeitgeist.
• The Bonfire of the Institutional Credibilities will make management of these very complex, very wicked problems that much harder. The race to keep cascading disruption from becoming cascading failure will not be easy, nor pretty.
• And dammit, I’m a doctor, Jim, not a politician.
• Finally, circling back to China on the socioeconomic portion. China is in between a rock and a hard place. Additional large real estate developers are beginning to default like Evergrande on their offshore debts as the housing market in China continues to weaken. To prop them up, China would need to accelerate the already increased liquidity to back stop banks holding what are likely bad debts from these developers, and/or make domestic investors whole or at least cushion their blow. Again, 70% of Chinese household savings is in real estate. If their market goes through a downturn, that’s a lot of unhappy campers. China’s problem is that their consumer and producer price indexes are also showing at least 10% inflation already. If China has to unleash liquidity to bail out housing, similar to the US in the global financial crisis of 2007-2009, that will only increase already severe inflationary pressure. At least some of which will pass along to the world, given China’s role in many global supply chains. But again, if wages don’t match or exceed that inflation, to the average person, their money buys less than it used to, and that’s a lot of unhappy people too. There is a very good chance that the average person in China is going to feel poorer one way or another in the near term. How they react to that, and how their government reacts to that, will be very important.

–So I got my flu shot at the walk in clinic employee health services was running. Walk “through” is probably a better description, because they run the line so that you go in the front door and literally out one of the back doors. But it exited me in hallways that I used to walk quite a lot during an average week, right under where a lot of the oncology medical and stats teams tended to be located. I would be in them on days when I had a meeting in oncology’s part of the world.

I had not been in those hallways in 18 months or more at this point. I used to run into at least another person or two, bustling to another meeting. The marketing floor, in between the floor I was on and the medical/stats floor above was always loud and talkative. Even the medical stats floor would be full of people, moving between conference and focus rooms or impromptu meetings in the lounge and social areas.

They’re all empty now. All of them.

All of that happens online now.

I don’t know why, but being back in those halls, with the month-appropriate ghosts of what work here used to be like, suddenly emphasized just how much, how rapidly, and how radically the world shifted since early 2020.

I heard through the grapevine the CEO has been surprised that fewer people than he expected have come back to campus. Most of the other areas that are here are only on site a few days a week. Odd that people prefer no or shorter commutes, no masks, closer to family when given the option (if they are still getting the work done). Really odd, huh?

I think the ghosts and memories of those hallways will stay, the new inhabitants. If any hardy small band of survivors one day returns to those halls, like explorers of a lost city, will they even know, remember, what life was like there? What battles fought against cancer, what victories won, defeats commiserated?

I don’t think we are going back to that same world. Not after the lifetime that passed these 18-20 months ago or so, and only seems to edge further from that. The more months go by, the more -this- (and I wave an arm you cannot at the room around me now) becomes the Way Things Are. And the rest fades to memory, and nostalgic walks through quiet abandoned halls and cathedrals.

–Your chances of catching coronavirus in most places in the world are equivalent to the chances that contrasts between the old ways of doing things, and new ways, are always striking, and look, and feel, worlds and ages apart. Full thread here (keep hitting “more replies” on the main thread).

<Paladin>