Monkeypox

Cases continue to dwindle away towards nothingness. We might follow for one more update, just to make sure there is no sign of a re-emergent wave, but for the moment, this epidemic of monkeypox appears to be current on its history. Pop up, infect some folks (in this case, quite a few folks), but then mysteriously burn out somewhere between the 3rd and 6th generation of newly infected hosts and disappear.

You may recall the very divided opinion about the WHO declaring monkeypox a “global health emergency,” one of only a few such declarations in the history of the organization. At the moment, the voices of caution that the outbreak may not really meet what should be high criteria for health threat and global spread risk are certainly looking good in their assessment. This designation was designed to free up resources for vaccination, particularly for underdeveloped nations, but increasingly, it appears they may not even be all that needed, let alone delivered in time to have done anything to control the epidemic.

Also, at this rate, establishment as an endemic STD in the United States, which was a real possibility given its sustained transmission numbers early in the outbreak, is increasingly unlikely.

Coronavirus

Wait… are we doing this?

We’re doing it.

Hell, yes we’re doing it…

Get ready!

Appearing here…

…one more time…

We’re bringing back the meme, baby!!!!

So the big news this week in coronavirus is that President Biden went on “60 Minutes” and said:

“We still have a problem with COVID. We’re still doing a lotta work on it. It’s — but the pandemic is over. if you notice, no one’s wearing masks. Everybody seems to be in pretty good shape. And so I think it’s changing. And I think this is a perfect example of it.”

Emphasis is mine.

Dr. Tedros, the Director General of the WHO, was a little more guarded in his assessment, declaring in a news brief:

“We have never been in a better position to end the pandemic. We are not there yet, but the end is in sight… We can see the finish line.”

Hence, the meme. The politicians are starting to declare the pandemic over (or nearly so)–and yes, I include the Director General of the WHO in that category.

So as you can imagine, around the horn, cases continue to fall in nearly every country in the world. Deaths due to COVID are way down (back to March 2020 levels). China is still enforcing zero COVID lockdowns, but there were rumblings of negotiations with Moderna to get their mRNA vaccine available in China for a face saving exit from “Zero COVID” by the CCP. I still think the Chinese people will largely see through that, but at present, largely lack the freedom to voice the obvious about their leadership. South Africa, our bellweather, still has minimal activity.

–“But wait,” I hear you say, Stating The Obvious Out Loud Hypothetical Reader, “If the president is on ’60 Minutes’ saying the pandemic is over, no one is wearing masks, and everyone seems to be doing alright, doesn’t that suggest to people that the omicron boosters the CDC just recommended to everyone age 12 and older may not be necessary?”

Yeah, Hypothetical Reader. The vaccination campaign for this virus has been the single biggest cluster, and continues to be a giant cluster. It took a couple of days, but everyone in Biden’s administration from the White House spokesperson to Dr. Fauci to the US Surgeon General have been trotted out to walk back the President’s statement, probably as soon as it dawned on someone that this is the exact implication here. And it’s a little hard to keep pushing for masks in Head Start programs (yes, still a thing) and vaccine mandates in the military based on the President’s statement. The WH spokesperson was the most entertaining of the bunch, claiming that President Biden “stated clearly” in the “60 Minutes” interview that “COVID was still a problem. Feel free to scroll back up and compare/contrast.

What I can tell you is that when the Fall season starts in earnest, and booster shots are sitting on shelves unused, I expect a sudden media freak out to try and encourage boosters for all–especially if it’s an otherwise slow news week, or better yet, can be used to subtly impugn the character of one political tribe or another. And the President’s statement, and the WHO’s statement, will be quietly, temporarily forgotten, or explained away. They may even get lucky, with a small rise in numeric cases off a low, even if very localized to claim that “cases are rising” and thus “the science is changing” from the President’s statement–especially if they can use percentages to show big changes in small numbers out of context.

I know, I know. Perhaps I have just grown cynical these long last couple years. But I think we all now recognize how sadly plausible that kind of scenario could be.

–As for “do I need the booster” questions, you can always go to the CDC’s guidelines, definitely speak to your own physician. If you are high risk, I think the rewards still outweigh the risks. If you are younger, in good health, and low risk for severe COVID… already vaccinated or recovered already from a test positive COVID infection (especially if during an omicron wave)… well, talk to your doctor. I won’t eat your lunch either way you decide after that.

–For those interested, the best estimate I can find of the “true” (prevaccine) IFR, or infection fatality rate, of COVID-19 was published in the Lancet. There has been a model or two adjusting the seroprevalence rate (the denominator in the calculation for how many fatalities per infected cases), such as one recently published in Nature, but no earth-shattering differences from the Lancet publication linked.

The long story short is that IFR depends on your age (no surprise, but higher IFR the older you are), and across the board, the IFR was 0.466% and fell to 0.314% by 01 Jan 2021, as the vaccines started to really roll out.

In the very early days of the pandemic, when estimates were all over, we back of the enveloped a final IFR (or CFR; I have a bad habit of using them a little interchangeably, but I was also referring to asymptomatic cases at the time). We said that when all was said and done, we expected an IFR between flu (pandemic forms have an IFR of about 0.1%) and 1%, and this would look like a very, very deadly form of flu. The data appear to agree with the envelope.

Thus, we can conclude that our luck has grown in proportion to our cynicism…

–You may recall military service members getting booted for refusing vaccines, aspersions cast on professional athletes who have refused the vaccines, and several companies laying off workers who did not comply with a vaccine mandate. Some of the nursing shortages still cropping up across the country are in no small part due to vaccine mandates making a complete COVID vaccination (of various definition) a requirement for employment. Suffice to say, after the President’s “60 Minutes” statement, political calls were already being made to end these mandates. Also suffice to say that several of these examples are already working their way through the courts, and the court is what will likely ultimately decide them.

–Worth mentioning as well that there is a pre-publication paper out there that has reviewed the current IFR and myocarditis complication rate of the omicron cousins still around versus the risk of complication from COVID boosters in young (college age) adults. The authors represent some heavy hitter institutions, so this has made some internet waves. The long and the short of it is that they argue, based on the current data, that boosters may not be necessary in this population. Which, presumably, should also apply to military service members of similar age? Anyways, the authors are much more aggressive in their language about boosters for this age group than I have been in describing this, and you should check out the article here.

Socioeconomic

–Inflation continues to run hot around the globe. Energy supply issues have every nation in a scramble to see to its own interests first still. And every week brings announcements of new closures of businesses ranging from energy intensive industries like aluminum, fertilizer and the like to people’s favorite bakeries that can no longer afford their utility bills across Europe. Part of this is still pandemic related, or at least exacerbated, supply issues. Part is also due to the consequences of multi-year conscious decisions in energy sources, without ensuring the total amount of energy could be supplied at a reasonably predictable price. Again, since the world in which we live depends on a certain amount of energy being available, predictably, and at a predictable price, there will be supply chain implications from all of this. They might begin to show in earnest this winter. Certainly I would expect missing widgets sometime next year. Further, as industrial capacity goes offline in Europe (and occasionally elsewhere around the world), there may not be sufficient slack to replace the supply of those widgets quickly. Which means the price for available widgets will go up, and I would expect a continued inflationary headwind, right up until the -lack- of economic activity because not enough widgets are getting made at an affordable price eventually crushes demand.

Which I’m told is a polite way of saying “severe recession or worse.”

–The bonfire of the credibilities has come for the WHO. Maybe. At the very least, a long list of coauthors on a panel have published the public health policy failures during the pandemic with an eye towards the WHO’s performance. They have found that performance wanting, and have recommendations to strengthen response to the ending COVID-19 pandemic as well as reforms to the WHO they would like to see take place to prevent another one. You can find the entire paper here.

The most controversial element was the call for an independent, unbiased commission to fully investigate zoonotic versus “research-related” origin of COVID-19. One of the co-authors is also the co-author of a paper we mentioned recently calling on greater transparency of NIH records as a means to investigate an accidental lab leak of a virus at the Wuhan Virology Institute where the gain of function studies funded indirectly by NIH via a contractor with debatable oversight was being conducted.

That probably shouldn’t be controversial. If it was research related, there are important lessons to be learned on how that escape might have happened, despite the biosafety level rating of the laboratory. There may be updates and new best practices for appropriate measures to minimize risks to laboratory staff and of accidental release, particularly for agents of higher biosafety levels with significant public health risk. There is also an excellent case to be made that if COVID-19 was directly, or indirectly, the result of gain of function research, you know have good empiric evidence for why this kind of research is such a bad idea, and cannot be conducted safely over a long enough time period. We have already covered the math that suggests that no matter how minimal you make the risks, so long as there is ANY non-zero risk, over a long enough timeline, escape of a gain of function mutant is inevitable.

–Yes, Hypothetical Reader, I do recognize that there is undoubtedly several strong currents of counterpressure that do NOT want the question about possible research related origin of COVID-19 investigated, because of what the answer could be. One, as we have mentioned before, is pure nationalism and perception of international reputation management. The other, of course, is from a segment of the research community that does and believes in gain of function testing–they will not want an answer that suggests greater danger from this research than they currently believe exists.

–Otherwise, the suggestions are pretty much par for the course for anything related to the United Nations: transfers of resources and technology from the have to the have not countries, creation of new panels and UN (WHO in this case) oversight, all the member states through the World Health Assembly (where each country sends a health minister and provides oversight of the WHO) to write and sign and bind themselves to a new pandemic agreement, and of course, expansion of the budget.

Of course, a major part of the WHO’s ineffectiveness is, as we mentioned before, that the WHO is effectively beholden to whomever is paying its bills. By increasing the budget, you increase the dependence of the WHO on those from whom the gold is coming–and of course, there is the golden rule which states “those who have the gold, make the rules.” The WHO could not compel co-operation from China earlier. There is little it could do about Trump (or Biden, if Biden decided to obstinate). Further, the WHO already had to try to declare monkeypox a global health emergency because of wealthy country hoarding of available vaccines, just to try to free resources for poorer nations with their own cases. That’s disappointing considering the castigation the WHO has, to its credit, consistently applied to wealthy nations which pretty much bought up all the COVID-19 vaccine and treatments as soon as they were available. The desired brotherhood of man has not appeared where the called for transfers of resources and technology are likely to happen–let alone in the current environment of inflation and “every country for their own energy supply” you are seeing play out in real time right now. We can safely assume any pandemic agreement will be cover for some very expensive dinners and breakout sessions for the negotiating team, and promptly forgotten, as the International Health Regulations 2005 agreement (prompted specifically because of SARS) pretty much was already.

And of course a panel of experts who work on these kind of panels for these kind of bureaucracies believe there should be more panels of their expertise, and greater budget.

The men and women with a hammer have seen a nail, dear readers…

And my concern is not only that, but the selection pressure that is now picking the experts who will be on this panel, and, in truth, has formed the author list here. There are two good quotes you should see on changes and trends which I was worried I was among the few to be observing with some alarm across scientific academic publishing. The first is here, and you should read the entire thread (and I have heard similar to this before). The second I will have to quote from the Doomberg substack, as the article is behind a paywall:

“To understand how broken US academic research has become in many fields – but especially in the comparatively lucrative commodity, materials, and chemical sectors – it is important to appreciate the incentive structures at play. In an ideal world, professors would allocate their time roughly equally across three priorities: teaching introductory science to undergraduates, training the next generation of future professional scientists (i.e., majors and graduate students), and performing original scientific research. Only one of those three activities brings in incremental money to fund the giant bureaucratic monster that many university campuses have become.

When a professor wins a grant – either from a government agency, an industrial sponsor (Braskem, in Singh’s case), or even a private donor – a large portion of the money never actually finds its way to the professor’s laboratory. Much of it is siphoned off by the university for general purposes. At many large campuses, this overhead tax can run over 50%! We discussed the issue with a research professor at a well-known Ivy League school who estimates that as much as 60% of the grant money he brings in is used to fund the bloated and ever-growing administrative cancer that is overwhelming his institution.

That same insatiable, unproductive bureaucracy is presently empowered to decide who gets tenure, who is allocated valuable lab space, and countless other career-critical adjudications. Worse still, those who have the courage to insist on reality with such authorities are marginalized or canceled. The social pressures to conform to the “correct” thinking – regardless of what the underlying science dictates – is overwhelming. It’s no wonder that untenured professors like Singh are forced to feed the ESG beast. It’s an untenable situation: either you play the game to attract the associated grant money or suffer the career-crippling embarrassment of having been denied tenure despite a solid track record of doing and teaching great science.”

This is also 100% true, and not unique to commodities, materials and chemicals. It permeates biology and biochemistry as well, and is stock and trade for many biotech start ups that get venture funding on a story, no matter how scientifically implausible, that gets sold to hit lucrative “exits” over and over again.

That 50% overhead tax for any grant, public or private, taken by the University administration? Totally true as well, no matter the size of the institution. I’ve found that “tax” runs from 30-60%. And it wasn’t even an Ivy League institution with the highest quote I ever heard, either.

But it those playing these games, selected to these exact, well, less than honest, narrative focused selection pressures that have survived and thrived to be the recognized “experts” with the fanciest titles and name recognition. These two pressures are selecting not only for the people who will form the commissions to write this kind of paper on how to reform the WHO in response to the bonfire of credibility, but will populate the expert panel to oversee those reforms that they propose as solution. That’s not to say that all, or even some, of the authors of this Lancet paper or the experts that might be put on the panel they suggest (if adopted) are guilty of these kinds of behaviors. But because this is the selection pressure for academic promotion now, it greatly increases the likelihood that the people writing these papers, making these judgments, and becoming recognized for their expertise are formed by it. And thus their expertise is in the kind of narrative management, self-censoring, and promotion of ideas that fit broader political or personal goals but won’t actually work in the real world, that those two threads describe. That is not the kind of character and expertise that will function well in the crucible of pandemic, or other serious global health threat in the future. Nor is it the kind of character and expertise likely to undertake and be effective in the reforms necessary to restore credibility to the WHO and other major health organizations.

Really, how do you feel about the more-of-the-same-only-bigger “reforms” they are proposing here to correct the manifest-to-all failings of the WHO in the exact kind of situation it was created for? Credibility restored? High confidence this will lead to the necessary changes to prevent more pandemics, and function in the way you thought the WHO functioned, or was supposed to?

I know, I know. I’m being cynical again.

–Permit me to extend that cynicism a bit, dear reader. Stepping aside from the very real question of “how will we select the right people to lead these institutions, and the right experts,” let’s look at the necessary conditions for the solutions they propose here. They call for a new era of co-operation among nations, a new family of humankind, even as they list all the ways that failed, and even as the global order appears to be devolving back into multi-polarity, which has been the historical norm.

When there is a severe physical threat like a deadly illness or widespread deadly force, isn’t “everyone for themselves” tribalism the expected result? Isn’t human history replete with examples of that? When resources are shared among others in such times, how often is it because of firm belief in our shared humanity, followed by clear action in support of that belief–and how often is “sharing” a compulsory response to the tangible threat of greater and more immediate physical harm and danger? How often have the vulnerabilities of low and middle income populations, be they within a nation or other low and middle nations -ever- been protected in these kind of situations?

Don’t we admire saints as much for their rarity as their virtue?

What we need is solution for the world we have, not the world we want.

We all agree our better natures should guide our behaviors more often.  From the personal scale to the public scale. But the family of humankind, recognizing we are all brothers and sisters in the same human race preached as this Lancet Commission’s gospel as well as in the actual Gospel, is a shockingly difficult choice to make at scale.  If it was as easy as saying we should do that, we would already be doing it, and would not need to say it.  Put another way, if humanity was actually good at this, God would never have had to send Jesus Christ, and His gospel would have been widely adopted and in current practice since the first hearing of it.

Sadly, merely look around you.

The change the Lancet panel seeks is needed and noble. It is the nation level equivalent of “love your neighbor as yourself.” But another horse we have flogged is that solutions at one level do not always scale to other levels. We cannot have the success this proposal needs without first making the changes at a local level. And I would argue that the solution for a multi-polar world is best achieved at the local or regional level, not with a massive global bureaucracy that only gets bigger. Solutions that work for the wealthy financier countries will always be favored in the WHO, because that is the political reality of the WHO. Those will not be solutions for smaller countries, and they should have the freedom to regulate and plan for themselves, or band together as regions, without the pressure and regulations of a global entity.

–Further, the major -political- change is not that governments need to consider themselves -more- beholden and -more- obligated to experts, especially ones whose expertise did not measure up in the time of crisis. Their expertise expected prescriptions to scale at all levels, and were surprised when they did not. For example, the documented public health ineffectiveness of mask requirements at the macro scale, even as studies did show a consistent risk reduction in mask use on the individual scale. Again, no one is requesting their surgeons to NOT wear masks in the operating room because masks were ineffective at a national level in reducing the Ro of a pandemic coronavirus.

No, there are other more obvious political changes that are both more necessary and more achievable. For example, the message in times of crisis like this needs to change.  Emphasizing fear and worst consequences to -compel- behavior, as was often done during the pandemic, needs to stop. There are many examples of this. We covered a lot of them. Among the most egregious were the CDC withholding data for political and messaging concerns (hence their announced systematic reforms), and UK media deliberately cherry picking the most dire statistical models (none of which were likely to match reality and did not). But that’s just top of my head. You can think of your own examples I’m sure.

However, the decision to emphasize fear to compel desired behaviors by the leadership and media, as we have seen, is a poor choice.  If you scare people, the natural reaction is to make sure they and their family and their tribe are protected –first– and foremost. And in approximately that order.

That becomes the genesis for political pressure to have every country act in its own self interest–its people and leaders become motivated by that fear.

Better messaging is to acknowledge the threat realistically but emphasize and frame it as a chance to show personal and national courage.  “Yes, the threat is real and serious.  Crisis calls for courage and character, and we will show our national courage and our character through this crisis. Here is how we will meet the challenge to keep ourselves as safe as possible….  Here is how we will show ourselves and the world who we really are, when we do X, Y and Z to help the most vulnerable among us AND other nations and people we know are vulnerable too.  Because we are people who can, and have, persevered and triumphed in adversity, and will do so again, by action, now…”

At no time, and under the “leadership” of -either- of the US political tribes, was that -ever- the dominant message.  I don’t believe it was a message from any major international leader or institution. If I am mistaken, readers, and that was a message you heard during the pandemic, by all means send it along. That kind of leadership and messaging needs to become the new standard.

Instead, the messages I heard here in the US were fear and appeal to tribalism. It was schismogenesis ratcheted to new levels, at the worst possible time. This deserved a pox and a plague on both houses, and sadly, that is exactly what they, and we, got. If there was ever an appeal to the angels of our better natures, it was often corrupted–presented as an opportunity for tangible demonstration of your tribal affiliation, and smug knowledge that your action was clear evidence how much better your tribe was than the others. No more clear example of this is the vaccination campaign debacle, where you were as likely to immediately get the yelled lecture of “independent critical thinking” for refusing vaccines and masks from a proud member of one tribe as you were to be accosted for literally killing others as an anti-science troglodyte through the triple N95s with an “I Got My Booster” sticker on them from a dedicated member of the other tribe.

And before you start, Tribally Steaming Hypothetical Reader, I have heard from my fellow physicians of nearly instant, and intense, accosting along either of those lines from their patients. Often before the physician even got a word out, sometimes from different patients in the same day, and regardless of the tribal lean of the actual physician involved. The general malaise of tribal and personal isolation that we have discussed, the simmering feeling of loss and being on edge all the time–it is a pox and plague that has affected both houses.

And it is one we can cure, fortunately. We need to have the courage to start with ourselves.

–Saw some Tweets the past couple weeks asserting that the most patriotic thing one can do right now is find common ground with someone from the other political tribe you disagree with. I tend to agree with that.

–That said, I was disheartened to read some of the comments under those tweets, which were pointless accusations between the tribes that no, no, the other was clearly a threat to democracy. (Hint: It’s that shared belief by the two tribes that is the real threat to democracy here, for how can one side in power now, in good conscience, relinquish that power if it loses an election if it believes the other will use political power to end all elections in the future?)

But then I remembered this was Twitter. And if were oh, say, Russia or China, or both, and could create and manage thousands to millions of bot accounts, those are exactly the comments I would spam to useful messages of unity in the United States right now. If I were clever, I would even have bots made for both sides, so readers could see two clear sides fighting one another. Misery loves company, and Russia and China are pretty miserable at the moment between a war going horribly wrong and Zero COVID and economic policies coming home to roost.

–Anyone who is not preaching that gospel, that the most patriotic and useful thing you can do right now is find common ground among those you disagree with, is not helping, and not meeting the many challenges of this moment. This is a decade where a century will happen…

“Crisis calls for courage and character, and we will show our national courage and our character through this crisis. Here is how we will meet the challenge…”

–Your chances of coronavirus and monkeypox this week certainly still exist. They’re about as good as the chances that the socioeconomic section deserved a more formal essay, but alas, time constraints…

<Paladin>