—Ebola update:  Now up to 17 cases, with one 150 miles from Mbandaka and with no known contacts to the original transmission chains.  This suggests that transmission chains exist which have not yet been discovered.  A recurrent theme in all pandemics now is that there is “resistance” to some contact tracing and quarantine efforts.  923 contacts are under surveillance, follow up has been less than ideal, and only 806 of them have been vaccinated.  That said, they have established 6 vaccination rings including 1,574 contacts of contacts and 134 probable contacts.  Still likely to get worse before it gets better, at least for the time being.

—Coronavirus update:  Again, a lot to cover.

—First, dexamethasone.  Reports in the media that dexamethasone (low dose) has become the first drug to reduce mortality in hospitalized patients, especially those in the ICU.  Per those reports, ICU mortality has fallen from 40% to 30% with dexamethasone.  Dex is a generic corticosteroid, and functions to calm the immune system down.  Think of it as a “cease fire” order for Ah-nold and his commandos.  So, fits with our current thinking of the driving pathology of severe disease.

BUT… none of it has been published yet.  Only reported via the media.  Having been burned by two retracted publications in major journals and preliminary vaccine study announcements in the news media, some physicians are reacting with skepticism until they see the actual data.  Probably a good idea.

Hopefully, these results are accurately reported.  Is this enough to end the pandemic and lock downs?  Not by itself, at least not unless in addition to reducing mortality, it’s getting everyone out of ICU beds.  But if true, it means that there is more reserve for your healthcare system—SARS-CoV-2 will need to put even MORE people into the hospital to make up for the successful treatment.  So that would be a plus.

Again, if true.  Cross your fingers.  Say a prayer.

—Spread in the US.  Continues to be a mixed bag.  I think it’s safe to say that Florida (including 1/3rd of the workers at Orlando International popping positive last week) is the best evidence of a failed Memorial Day experiment.  The current peak is higher than the previous, and there are clearly two in Florida.  But that seems to be a uniquely Florida thing.  Other hot spot states like Arizona appear to be a function of increased testing, as much as anything.  The percent positive cases has stayed steady—as Arizona has tested more, numbers keep going up, and the still seem to be in the throes of the “first wave” there.  California is a similar story.  South Carolina appears to be reaching its “first wave” peak.  Texas appears to be a “function of increased testing” story, as the percent positive hasn’t moved too much—I think their current increase in cases is likely very localizable within the state.  The US as a whole is essentially flat to juuuust a slight uptick in new positive cases and overall percent positive.  The “hot spots” in the news are all pretty population rich after all.

—Other nations, for those readers residing there, seem to have good news this week too.  South Africa is likely at the peak for the “first wave”, and hopefully will trend down from here.  The UK continues to go lower.

—In other news around the world, and speaking of first peaks, Beijing is locking down more and more as the week goes along.  Blaming the current outbreak on imported salmon, the Chinese Communist Party continues a sharp campaign against logic and reality.  The real world continues to be in the lead, and it is clear that the virus has been successfully re-introduced into Beijing.  It’s worth noting this is pretty typical of the kind of “second wave” we have been discussing expecting.  Beijing was not hit (so far as we know) especially hard in the first major wave through China, as cases were concentrated in Wuhan and internal travel restrictions minimized spread into the capital.  

Despite what you may think or have heard, cases have continued to pop up in China.  A few here.  A few there.  Get one into the right place in densely packed Beijing, and you can ignite a nucleus of outbreak just like this.

Again, this kind of activity is the most probable case going forward for the coming year.  SARS-CoV-2 will simmer along, pretty much globally, spreading well below the level to threaten a healthcare system.  But, and you won’t know where or when, enough cases will break out in a local area (city, county, state) that the local area will need to take some additional rapid action.

Understand any travel, internal or international, will carry these risks.

—Sweden has reported that herd immunity, as measured by antibody testing, has been “slow to develop” despite their lack of lockdown and high rate of community infection as a result.  There are two possibilities here.  One is that, indeed, herd immunity is slow to develop.  Which would suck.  The other, again thinking back to the CD4+ paper where T-cells “trained” for other members of SARS-CoV-2’s family could also react to SARS-CoV-2 in vitro without ever seeing it before, is that some patients, possibly even a majority, have an immune system that takes a different route.  Broadly speaking, your immune system decides to fight by making antibodies to a threat, to bind, isolate, and remove it, or by activating cellular immunity, which have special classes of T-cells like CD8+ cytotoxic T-cells.  These are specialized to kill pathogens that live and grow inside of other cells, where antibodies would not be able to reach them.  This response is popular against a lot of viruses.  If the immune system slants that way, it is possible that antibody production would be minimal in some (possibly many) patients, and certainly below the level of even accurate assays to reliably detect it.

In short, not sure yet if absence of antibodies is really absence of immunity.  More data is necessary to know for sure.

—You may have read about the D614G mutant SARS-CoV-2.  This particular strain swaps one amino acid for another at position 614 in the spike protein, used for SARS-CoV-2 to bind and invade a human cell.  When D614G moves into a region, it tends to quickly become the most common strain there, suggesting D614G is more infectious.  So there is a paper studying this out from the Scripps Institute that got some press earlier in the week.  In short, they took another virus altogether and put the two different forms of spike protein on it, one with the “D” at 614 and the other with the “G” at 614.  The “G” form, the new mutant, does better at keeping the spike protein on the virus particle, especially when leaving a cell it has successfully invaded.  That means it is more likely to successfully invade again.  This meant that the “G” form was more efficient at invading human cells when attached to another virus altogether in a petri dish experiment.  Your in vivo results may vary, but it’s a reasonable hypothesis.  They also found that the “G” form was not better at binding the ACE-2 receptor targeted by SARS-CoV-2 than the “D” form—just more likely to be present in high numbers on the releasing virus.  They also found that convalescent plasma with antibodies to SARS-CoV-2 was just as effective at neutralizing the “G” form as it was the “D” form.

A lot of the news reporting was “TERRIFYING NEW SARS-COV-2 MUTANT IS MOAR INFECTIOUS!”  

The actual science is a little less dramatic.  And it’s still not clear if this actually means anything clinically, other than this strain outcompetes others for hosts, and once it hits your town, is likely to be THE coronavirus you will find there for awhile.

—We mentioned that associations of increased IL-6 with likelihood of more severe coronavirus disease in some publications may be a case of correlation without causation.  If you will recall, that’s because IL-6 levels tend to increase already as you age.  Since SARS-CoV-2 is likely to be worse as you age, IL-6 may simply be identifying older patients who will be having a more difficult time with SARS-CoV-2 because they are old, not because IL-6 is actually doing anything to make SARS-CoV-2 worse.  In Italy, a study of a drug aimed at IL-6 directly was halted early when it was clear that the drug was not going to do better than other treatments in reducing hospitalization, length of hospitalization, or death.  Back in April, another similarly targeted drug also did not show benefit in patients with severe or critical disease.  That said, the developers of both drugs (note I am not naming them because neither is my employer) are regrouping to see if there is a subset of COVID-19 patients who may benefit from these therapies.  You can find the publicly available information here.  If they did not merely get unlucky, this would be evidence that IL-6 association with severe COVID-19 is really correlation without causation, and a marker of aging.

No word on if the drugs made the patients younger, at least.

—Lastly, the WHO dropped hydroxychloroquine from its multi treatment arm “Solidarity” study in already hospitalized COVID-19 patients earlier today, after a new data cut showed that hydroxychloroquine does not reduce mortality in these patients.  And so on the drama goes with an old ass drug.

—I have learned a lesson from the coronavirus pandemic, and response to it, that I would not have expected prior to living through one.  I mentioned before how I was mystified by how the Black Death ever made it to England, since the British Isles had plenty of warning it was coming, and the English Channel between them and the disease.  It spread there anyways.  Further, the Black Death spread across the Old World continents despite a much slower rate of travel, and far fewer travelers (particularly distant), in a world that was much more rural than our modern one.  The Black Death did that pretty much at the speed of transportation at the time.  It was never really slowed, and was effective no matter the political system it encountered, from far spread, centrally powerful empires, to city state republics, to the largely locally administered feudal manor.  We look at their theories of disease (“bad humors”, not the starving Yersinia infected fleas), their technology, outdated political systems, and attribute that to their ignorance.

Of course we would have done better.  We know more now.  Of course.

We look at Ebola in the DRC, and read about how villages resist changes to their burial customs.  We marvel at how they refuse vaccination, often on the premise of conspiracy theories of an untrusted government trying to control them.  We shake our heads and marvel at just how dysfunctional the government of the DRC, how ineffective, and how unfortunate its people to have been so betrayed by their government and leaders for so long that they cannot trust them even for obvious truths. We look at those outbreaks and say to ourselves “It’s Ebola fergodsakes!”  Of course we would isolate.  Of course we would line up for the vaccine, even demand it.  Of course we would listen to medical experts and unite in our communities to do our part to control the virus.

Of course.

I was wrong.  Of course.  The deeper lesson is that this is human nature.  When even epidemiologists with models predicting the most dire outcomes are sneaking out of quarantine for their affair,  when Plandemic rides the airwaves, when recommendations contradict themselves or take on the appearance of “rules for thee, but not for me” (like the governor of Illinois bussing construction workers to continue construction on his new vacation home in another state, all on taxpayer dime).  Well, we don’t do better.  We are all medieval mongols.  We have all sipped tea in a levantine souk as the day’s trading ended.   We have plowed our fields in simple, honest work as French peasants in the 1340s.  We have furrowed brow with worry over the weight of our decisions for Clan as Scottish ceannard cinnidh in 1346.  We are all the boy in a far flung corner of the DRC, in a place where his family has lived for as long as anyone can remember—millennia perhaps–watching hazmat suits file into town.  We are all the same. 

Individual values, individual choices.  At some point, something, for someone, is worth the health risk.

Even draconian China, nailing shut the doors of residential compounds and tracking everyone with an Orwellian nightmare of a surveillance system has never been down to zero cases in the country per day.  At least in reality (no matter what their official mouthpieces have said).  

Thank God Ebola is so relatively difficult to catch.  For a highly infectious disease, the window to recognize it as novel, and dangerous, and test everyone to find out who has it, and has been exposed and then convince or coerce them into isolation long enough to eliminate transmission of the new pathogen is so small…  It is a miracle, a true miracle, that SARS and MERS did not break out before this.  For once a critical mass of people are infected, and that is a shockingly small critical mass, at least one will have some incentive they deem compelling plus the opportunity to defect.  And the pathogen spreads.  And spreads.  Novel enough, infectious enough, it’s like the moral of the Black Death Choose Your Own Adventure.  Once it’s present close enough, or in enough people, you can assume everyone will be exposed.  Everyone.  The rate of transmission will approximate the speed of transportation afforded by technology and geography at the time.

“The fault, dear Brutus, is not in our stars, but in ourselves.”

—Homo sapiens is the last of the big game hunting hominids.  That’s our ecological niche.  Omnivores, social animals who are opportunistic pack hunters, letting them take down prey animals many times our individual size.  We don’t have the size, strength and 30 mile per hour sprint of a bear.  We don’t have the stealth and claws and teeth of a panther.  Those are solitary animals, solitary hunters.  Humans work in groups.  The reason those click bait top ten lists work so well that they are a trope is that they speak to your very DNA.  You are so innately hierarchical in your thinking that you can rank order anything.  Top ten movies.  Top ten bears. That’s how your DNA hunts.  It needs one clear leader to call the approach on that moose—especially if all you have are bow and arrow and spear.  Sports are so addictive because they give you a team, a tribe, a pack.  Politics too.

So there was a publication just a few years back that made the New York Times bestseller list.  It was a biography of Ghengis Khan, and an updated look at the rise of the Mongol Empire.  I’m blanking on the name now, but I’m sure it’s on my Kindle somewhere.  One of claims made was that the spectacular success of Ghengis and the Mongols, letting them conquer and control the largest contiguous empire ever, came down to how they lived.  Born in the saddle on the endless Asian steps, they were highly mobile because they had to be.  Everyone knows that the recursive bow, from horseback, made the Mongol army.  But there was no Mongol war college that gave rise to Ghengis.  Instead, this author argued, their strategic and tactical success was born from the herds of horses and sheep the Mongols raised.

Watch a sheep dog, like a border collie, or German or Australian shepherd, work a flock of sheep once.  You’ll learn a lot about sheep and a lot about a herding dog.  Wolves have preyed on sheep for so long that the shape, bark, and menace of a dog will provoke a defensive reaction from sheep.  For sheep, that instinct is to herd up.  That instinct is so strong that sheep cannot tolerate being out of sight of other sheep for long—they have been taught by evolution that a sheep alone is a sheep about to be taken down and killed.  So a sheep that turns the wrong way is easily corralled by a working dog whom humans have bred to hate not having everyone together.  The dog just has to make a run at the errant sheep, or menace, and the sheep will return to the fold.  Running back and forth, closer and closer to the flock, makes the line that the dog is running a wall in the eyes of the sheep.  Moving it closer and closer, the dog drives the flock where the dog (and the human shepherd calling the shots) wants it to move.

The Mongols did the same.  Using their fast cavalry, they would menace an enemy.  Just show up and show themselves on their horses.  The enemy would react—not that dissimilar to a flock, as it turns out.  Just by having the Mongol cavalry show up and threaten tactically, over and over, the Mongols would steer the enemy to a battlefield suitable for them, and cut the enemy down.  

Sheep dogs, of course, have been bred to not cut the sheep down.  But the effect is the same.  Menace, show themselves, create an element of fear—and you can slowly mold the flock to where you want it to go.  Individuals that break from the herd you snap at specifically, force them back into line.

Of course, humans aren’t sheep.  Anyone mentioning the “sheeple” in a comment section is a useful indication that anything else they have written there is best avoided.  Humans don’t automatically seek the flock. We seek a pack, a tribe–but to be driven into a dense flock takes a lot of fear and effort. We had an Australian shepherd as a pet once.  The poor dog would be driven nuts when the family was scattered in different rooms.  She would wander forlornly, room to room, trying to get the pack back together. Humans in a tribe can be united, even when separate, and one, even when distinct.

Homo sapiens is a pack animal.  And given the right fear and menace, can be herded as the Mongols discovered.  But you can break free, once you see what the Mongols, or the sheep dog, is really doing.  Sheep don’t choose a flock.  Homo sapiens can choose their tribe—and more importantly, can unite those tribes in common cause.

E pluribus unum.

I have been thinking about that more as we careen from crisis to crisis in 2020.  No matter which news you turn on, there is something new to fear.  Or be told to fear.  Ben Hunt calls it the “nudging state.”  Matt Taibbi calls it the inevitable result of a broken news and social media model that needs you constantly whipped into emotional frenzy for the attention it sells to advertisers to feed itself.  Naval calls it “weaponized addiction.”  Listen to it long enough, and you don’t become a sheep.  You become one of Ionesco’s Rhinoceros.

As the widening gyre spins, and the center cannot hold, there are more and more rhinoceros about.  

Remember the Black Death.  Remember Ebola in West Africa and the DRC.  Remember that the fault is in us, and they are no different, as humans, than we are.  There was a lot of fear, and much to be fearful of.  I am now, truly convinced that every generation has read the symbolism of John the Revelator, and convinced themselves he was writing their present.  

Wars, earthquakes, famine and disease have come and gone.  They have always come and gone.  Humanity persevered.  When times were worst was the opportunity for our best.

Do not give in to fear.

I say that again.  Do not give in to fear.

See the sheep dogs for what they are.  Expect an unusual year.   Expect rhinoceros—Lord knows they are loud enough already, and you can hear them with both ears.  So expect them.  Do not become one.

That is harder than it sounds.  At times, you will have rhinoceros tendencies of your own.  Stop yourself.  Reset.

And remember—any rhinoceros you do meet probably doesn’t want to be a rhinoceros.  They only became one for fear of other rhinoceros.  Recognizing that cause is the only way known to medicine able to reverse the process.

If we don’t, it will end badly.  

Don’t give in to the mob(s).

—Your chances of catching Ebola are equivalent to the chances that the guys out there claiming on the Internet this week that by the Julian calendar, the Mayan “end of the universe” date is really June 21, 2020, and not December 2012, are right.

—Your chances of catching coronavirus are equivalent to the chances that the guys out there claiming on the Internet this week that by the Julian calendar, the Mayan “end of the universe” date is really June 21, 2020, and not December 2012, are right.

This is 2020 after all.

Either way, thanks for reading.

https://www.youtube.com/watch?v=wIuLYJLw6MQ

<Paladin>