Northern Lights in a Time of COVID

After 26 years, 9 months and 13 days in the Washington, DC, metro area, the Phantom announced he was moving to New Hampshire, leaving his friends and neighbors bewildered and aghast. "Why would you move to New Hampshire? It has a primary every four years, but what happens up there in between?"

Portsmouth, NH

Which says something of the mindset of those suffering from Potomac fever, where important jobs, impressive offices and titles are the raison d'etre. 

And it was true, the Phantom had not ever lived in Northern New England. The closest he came was six years in Rhode Island and two in Connecticut, but that was enough to convince him that New England is where the real people live. Not the enclaves in university towns, but the townies themselves, who he remembered as irreverent, grounded and fundamentally decent.

And there were the mountains, the lakes and, in the case of Hampton, the seacoast.

Exploration of Portsmouth was edifying: dodging into the Portsmouth Brewery on a snowy evening, already dark at 4 PM, the first thing the Phantom saw, mounted on a brick wall across from the bar was that iconic Shepard Fairey poster of Obama, unexpected, boldly displayed, and this was January, 2008, before anyone thought Obama could win New Hampshire. 

"Oh, that?" the waitress said, "I think someone from the Leftist Marching Band gave it to the owner and he liked it, so there it is on the wall. Wasn't easy mounting that thing on brick."

Yes, Portsmouth, New Hampshire does have a Leftist Marching Band. 

And, it turned out, the Phantom's inklings about the people he might live among were underestimates. 

North Hampton, NH 

Consider his underground soul mate, with whom he canvases Hampton neighborhoods, searching out voters to cajole, trying to convince them to vote Blue.

Recently, she and her daughter got fever, chills, headache, cough, headache and their strep and  influenza swabs were negative, so the smart money is on COVID, although the tests are still incubating. Awaiting the results, she has been thrown into solitary confinement in one bedroom, her daughter in another and her husband slides food trays in front of the doors and collect the remains in classic prison style.

Exeter Road, Hampton, NH

The Phantom, consolingly, suggested she consider writing a Solzhenitsyn inspired novel, not "Cancer Ward," but "COVID Ward" to occupy herself during the long week of her discombobulation. 

Her response:

A novel, what a great idea....."COVID Ward"--"the harrowing tale of one woman's descent into madness after being locked away in her room with nothing but paper and scissors and a growing need to cut out chains of paper dolls... and name them.." ...So what do you think darling, are we talking a best seller?

Now, I ask you, drooling reader, where else but New Hampshire are you going to find a woman like that? 

Fearful Symmetry: Failing to Ask the Question

 Tyger Tyger, burning bright, 

In the forests of the night; 

What immortal hand or eye, 

Could frame thy fearful symmetry?

In what distant deeps or skies. 

Burnt the fire of thine eyes?

On what wings dare he aspire?

What the hand, dare seize the fire?

And what shoulder, & what art,

Could twist the sinews of thy heart?

And when thy heart began to beat,

What dread hand? & what dread feet?

What the hammer? what the chain, 

In what furnace was thy brain?

What the anvil? what dread grasp, 

Dare its deadly terrors clasp! 

When the stars threw down their spears 

And water'd heaven with their tears: 

Did he smile his work to see?

Did he who made the Lamb make thee?

Tyger Tyger burning bright, 

In the forests of the night: 

What immortal hand or eye,

Dare frame thy fearful symmetry?

55 years ago--seems like last year--the Phantom found himself dissecting a frog in his freshman biology class at university, staring down at the heart he had just flayed open, at the spiral valve of the amphibian heart, which allowed oxygenated blood to be separated from unoxygenated blood, which sent oxygen rich blood to the aorta and on to the brain and kidneys and muscles, while the unoxygenated blood shunted off to the lungs where it could get oxygen. What dazzling engineering! O what immortal hand or eye could frame that symmetry?

Beholding that tiny, breath-taking valve, perfect in form and symmetry, the words of Blake's poem rang in the Phantom's ears. He had just read that poem that very morning, and later in the day would attend a symposium on that poem and it seems like Kismet.

As a fledgling student of science, the Phantom was being steeped in evolutionary theory, the explanation for the immense variations in anatomy and physiology throughout the plant and animal kingdoms.  Environmental demands impinging on genetic variation, selecting out those organisms who happened to carry forth advantages wrought by that Santa's bag of genes, from which a vast array of possibilities were plucked and released to find a niche in the world.

But looking at that spiral valve, it was difficult for the Phantom to imagine that shape, that delicate, perfect, swirling thing occurred by chance: Its perfection looked like mute testimony to design, and by implication a creator and not some blind watchmaker, someone who knew exactly what he was doing.

And so the Phantom became a secret apostate, a doubter, a heretic.  He did not bring that heart to his professor and ask how such a perfectly wrought thing could have occurred by chance, and while he learned evolutionary theory, he, at some level, never really believed it. Had his professor been Professor Condit, the Phantom could have approached him, because Dr. Condit is approachable and would likely have not been offended, but intrigued, and then noted spirals are common in nature. But in those days, at the first of the Ivy League institutions through which the Phantom slogged, such questions were an invitation to disaster, or so the Phantom thought at the time.

He did, occasionally, challenge an evolutionary explanation, as when an instructor insisted white skin was an adaptation to low sunlight but for the most part, the Phantom just let it slide. Like some figure in Boris Pasternak's "Doctor Zhivago" he went along with the party line, and recited the gospel when required, but he always clung to his doubts and his poetry.

But then, listening to an episode of "This Week in Virology" that lovely podcast which now claims 3 hours of the Phantom's week every week, one of his favorite cast members, Rich Condit, remarked, off handedly as Dr. Condit so often does, casting out pearls non chalantly , as he does, "The spiral: it's amazing how often that occurs in nature."

And a 5 decade wall off abscess surfaced:  The Phantom Googled and found Dr. Condit's remark had wide and deep support. And the Phantom realized, swirling winds, swirling fluids often form spirals and it was just possible, over eons, that spiral valve was just another beautiful splash of paint in the evolutionary story and in some way, that set the Phantom's mind at ease and he could think of evolution again as something he could believe in. 

Henrietta Lacks and Inappropriate Outrage

 

A woman named Henrietta Lacks visited Johns Hopkins medical center in 1951 because of vaginal bleeding.  The source turned out to be a particularly aggressive and invulnerable malignant tumor which killed her within the year. 

Since then, she has become a symbol of many things, the inspiration--if one may call what followed "inspired"-- for a book, an Oprah Winfrey movie, and lawsuits.

Scientists at Hopkins took cells from Ms. Lacks's tumor and grew them in a laboratory, using them as a source for human cells which had not been possible to grow before: the relentless vigor with which these cells divided and reproduced was unconstrained by the usual genetic programs which make cells wither and die. Normal cells are programmed, genetically, to die, but some cancer cells do not die, which is what allows them to grow, invade, overgrow the garden and choke it out. The cells from Ms. Lacks's tumor were robust and would not wither in the petri dishes and die, but they could be used for breakthroughs in polio vaccine, for studies into which agents could be used to kill cancer. 

Ms. Lacks's misfortune became a hugely fortunate source which benefited public health, helped vanquish polio, helped save lives of cancer patients for generations after her.

Enter the author, the TV stars, the lawyers.

Ms. Lacks was Black. 

Any ethical analysis must begin with the facts, and the Phantom admits outright, he has not read the book, "The Immortal Life of Henrietta Lacks" and does not intend to.

Ms. Lacks was Black and a connection--an entirely bogus connection--was made to  Black patients who were used as subjects so white doctors could study syphilis at Tuskegee. Of course, in the case of those infamous Tuskegee experiments, the unsuspecting Black "subjects" were not treated with penicillin by the "scientists." When the study began, in 1932, there was no treatment, but by 1947 there was a treatment and yet none of the "subjects" were treated. The disease was allowed to progress so the scientists could study it, without regard to the harm it did the "subjects." 

In Ms. Lacks's case every treatment known to man was given her, to no avail. She surely did not "miss" the cancer cells they removed from her. 

But the commonality was they were Black and the Tuskegee men were not asked for "informed consent" and neither was Ms. Lacks. But even in the age of "informed consent" the purpose is ordinarily to be sure a patient is aware of the risks of treatment, and of no treatment. Informed consent is not ordinarily concerned with what happens with discarded tissue or cells.

Actually, one might argue nothing was done "to" Ms. Lacks's body--something was done to cells removed from her body, and what was done to those cells was done to them when they were no longer part of her.

It goes beyond saying that Ms. Lacks's cells were valuable not because of anything Ms. Lacks did or did not do but because of the brain power of the men who used them. Of course, you could say if Ms. Lacks's home sat atop an oilfield, then the White men who wanted to possess that land would have had to pay her for her property and then they could use their technology to profit from it, even though she had no idea how to drill for oil or extract it, so the fact she did not know how to use her property does not mean she has no right to profit from it. 

But in this case, the "property" has no intrinsic worth to anyone other than that scientist in the lab. It was his special knowledge which made it valuable. Those cells were not like oil or gold, which anyone could exploit, but they became valuable only because of what the Hopkins scientist, Dr. Gey, noticed about them and what he was able to do with them. Does the Mona Lisa claim the fortune from the sale of her portrait? It the value of that painting inherent in her face, or in the genius of the artist?

But this is a legal, not an ethical argument. 

In some ways this argument is more like the claim someone might make that a photograph taken of her and used to sell some product or another should profit her, even though she did not take the photograph. Models, after all, are paid for their photographs. Can that nurse who was photographed being kissed by an exuberant sailor in Times Square on VE Day claim a share of profits Life Magazine made using her likeness?

It should also be noted that at Hopkins that same day almost certainly, some White patient had an appendix removed and that piece of her  was handled without her permission after it was removed. Women, on another ward, gave birth that same day, elsewhere in the same hospital, and their placentas were hauled off and they were never told what happened to that part of them. For that matter, stools were removed from patients, deposited in bedpans and flushed down toilets without written permission from the patients. 

On the other hand, one could argue, suppose a patient had a tattoo and after his death that skin was used to make a lampshade without his permission? But then there is a certain aspect of ghoulishness and one can imagine the dead person would be horrified to learn, if he were looking down from Heaven, of the use his skin had been put to. 

Ms. Lacks, one imagines would look down from Heaven and say, "Hallelujah!" about the use to which her cells were put.

There is that wonderful scene in "O Brother, Where Art Thou" when the escaped (White) convicts give a ride to a Black man they pick up along a road, who mentions he has sold his soul to the devil for a brand new guitar.  This horrifies one of his new friends, who expostulates, "Oh, how could you sell your soul for a guitar?"

And the man shrugs and replies, "Well, I wasn't using it any way."

And that is true for Henrietta Lacks: she was not using those tumor cells. Had she been asked, had she been able to fathom the explanation from the lab guy, Dr. Gey, what he hoped to do with those cells, how he hoped to grow them in his lab dishes, is there any doubt that she would have said, "Of, course!"?

How many times has the phantom heard a cancer patient say, "Well, if they can learn something from my disease to help others, I'd feel better."?

The fact is, this is not a moral tale. This at best, is a tale of procedure, of propriety, maybe of good manners, or even respect, but even the act of asking, in a practical sense, would make the average patient grow suspicious and ask, "Why would they feel they have to ask?" They don't ask when they take your gall bladder out what you want done with it.

And then, there is the money angle. In our society money poisons many things.

A poor Black family is told a bunch of  White doctors grew rich selling the cell line they made from Henrietta's cells to other rich White doctors in labs around the world. What are they supposed to think? We got robbed! Deal us in!

The Phantom does not blame Ms. Lacks's family. 

But he does blame Ophrah Winfrey and all those who sought to sanctimoniously enrich themselves by exploiting the false allegations of this story as one that had anything to do with racism.  Had this woman been White, there would have been no story.

Well, that's not exactly true. There would have been the story of a poor woman who had a nasty, lethal tumor, who sought help at Johns Hopkins, where they were unable to help her but where they were smart enough to use her misfortune to benefit millions of future patients: kids who would have got polio, adults who would have died from various sorts of cancer. 

It's the sort of story that gives liberalism a bad name. 

Down And Out in the Meritocracy

 

Whenever I am feeling particularly maschositic...

Or whenever I am seized by a deep sense of resentment that I was never chosen for the best college or the leadership of a major corporation or as the main script writer for a classic TV series...

I bring myself down to earth by opening up whatever New Yorker magazine I may have at hand, turn to the final page and examine the Cartoon Caption contest.

It is there I can feel fully cognizant of just how average, ordinary, how undistinguished and unworthy of the idea of "first rate" I truly am.

Displayed there is a single, caption-less cartoon for my consideration and I usually draw a complete blank, struggle to offer some utterly prosaic uninspired idea and then collapse in a puddle of self aware self rebuke.

Then, to really twist the blade in that space between my ribs, I read over the "finalists" suggestion from the contest the week before and am at once dazzled by their brilliance--"brilliant" that word so overused as to be almost meaningless now, but the best description of what I find there. And in the face of the three extraordinary offerings from my fellow citizens, I sink to the bottom of my own well of collapsed self regard and gasp.

The only salutatory part is once I am at rock bottom, I have achieved getting to the point where everything else has got to be up from there. 

When I was in middle school (then called "junior high") in Montgomery County, Maryland in some capricious lark, no doubt launched by a bored bureaucrat in the depths of the Department of Education, they administered an examination to some unsuspecting cohort of students, who were spared English class that day, sat at their desks and presented with an SAT like test booklet. Breaking that seal with your #2 pencil that day unleashed a different experience from what we usually expected. The questions were not multiple choice but required essays, handwritten in those days, which presented its own special sort of bias, but there you have it. 

Each question was shown below a picture, a photo, a painting and the student was asked to comment on its meaning, to write a paragraph or two about the image.

One frame was left blank. The classic blank canvas, and this was a particularly important question. Some students simply wrote there must be some error here because there was no image on the copy of the test the student had been provided. (These students, we were later told, tended to be the students who scored highest later on the Princeton Scholastic Aptitude Test--the SAT. These students could see the game and prepare effectively for those concrete, there-is-always-the-answer-right-in-front-of- you type tests, but give them a blank page, not so much.)

Some students, confronted with the page wrote wonderful stories about a snowstorm with white out conditions. Others ruminated on what sort of state occurs before we are born. Others wrote about what comes after death. Some got so carried away by the blank page, they continued their answers on the back of the answer sheet. 

So, this experimental test was a game about creativity, imagination, the ability to express one's ideas using a pencil in hand.

You had to get the game, of course, and some of the straight A students with the high college boards, most of them actually, apparently did not get the game or if they did, they did not have that sort of intelligence or energy. These high SAT students got the game of the SAT, which required some learned concepts in math, some cunning to see the traps in the questions, some memory prowess and, in the case of syllogisms some feel for the variations in meaning in words or in difference between words like "to want" and "to need." 

But the rules for this test were different. A different game. 

I thought I did pretty well on that test, but, of course, never heard what anyone else, much less the test makers, thought. No scores were ever reported. Certainly, nobody from Harvard or Yale ever called saying they had read my exam and wanted me to come up and visit the campus. 

But now, looking at those blank spots for the captions in the New Yorker, I could appreciate the depths of my own unworthiness. 

Consider the #730 contest. Just look at that cartoon. For me, the important detail is in the expression on the lab rat's face, and that makes me choose the first answer below, but I would have been happy to come up with any of the finalist answers. Never could. My mind is just not that rich. Each of these answers is a reference to some social/cultural issue, and the last one is a jibe at that line about continuing a family tradition in the workplace. Each is beyond clever. Not me. 

But, there is a whiff of hope:  In a nation where at least half of the people find Donald Trump inspiring, there is some intelligent life buried under the red dust, and all you have to do to know it's there is to put a cartoon on the last page of The New Yorker and ask for suggested captions, and this life sprouts out, like photosynthesizing organisms reaching for the sun.

“I bet you also had to be twice as smart as the men.”

Eva Hess, Davis, Calif.

“And, when you get hungry, the cafeteria is to your right, left, left, right, left, straight, right, straight, left, and then you push on the big lever.”

Michael Moran, Evanston, Ill.

“They tell me your family has been doing lab work for generations.”

William Howard, New Fairfield, Conn.

The Great American Tune Out

 Sitting at a restaurant table in Washington, DC, Jimmy McNulty of "The Wire" a Baltimore policeman, chats over wine with Teresa Dagastino, a woman who grew up in Baltimore, but now makes a rich living in Washington, as a political consultant. 

The two have been enjoying each other carnally for a few weeks but hardly know each other, and Jimmy eventually insists that they actually have a conversation, go out to a restaurant, get to know each other a little. "I feel like I'm just a breathing machine for my penis," he says. So Teresa agrees to go out to dinner. 

She asks who he voted for in the last election, but McNulty is only vaguely aware who was even running for President, to Teresa's stupefaction. Politics is what she lives and breathes, after sex, she turns on TV news and comments about the on screen politicians.

She cannot believe McNulty is so indifferent to who is in the White House, much less who is in Congress.

He says none of them look much different to him, and in fact, whoever is in the White House at the moment would not know where Baltimore is, unless Air Force One had to crash land on Eutaw street.  From the perspective of a Baltimore City cop, living on the streets, the nuances of the State of the Union speech mean exactly nothing.

It's not exactly the point of view of any of the characters on West Wing, who agonize over every wrong word choice, who talk about "destroying" their opposition, by which they mean outwitting them or verbally besting them. 

The Phantom asked his assistant at work if she had voted. She is the mother of a ten year old, and she is Hispanic, married to a tatoo artist.  She had absently said she would vote days earlier, but never made it, and finally she  explained she didn't follow politics enough to really know who to vote for. This, is after many months of office chatter which revealed how foolish she thought Trump is. But for her, voting did not rank as more important than picking up take out after work, and going home to relieve her husband from day care duty.

Neither she nor her husband voted.

Martin Luther King noted "we cannot be satisfied as long as the Negro in Mississippi cannot vote and the Negro in New York believes he has nothing for which to vote."

Well, now the Negro in Mississippi can vote, and the Hispanic in Massachusetts can vote, but sees no reason to vote. Washington is an abstraction, not a reality for these young parents. Their right to vote has been hard won, back in the 60's and 70's before they were born, and freedom riders died for it, but it means nothing much to them now. Voting is something other people do.

On the Trump side, the Phantom imagines, there were likely lots of people like his assistant, for whom voting meant nothing in their lives--until Trump started giving rallies where he sounded just like them, and like the people on Fox News and talk radio. He stirred the smoldering resentful underclasses into life and brought them out to the polls as a sort of after rally party. 

These folks have never watched West Wing. They watch zombie movies, and car chase and explosion movies. They could not say what the three branches of government are, or why the Supreme Court might be important, beyond maybe something to do with abortion. They have read on the internet that metformin causes cancer, and do not know that what that story was about was a batch of contaminated drug made in a single factory which had a carcinogen in it and was recalled. So metformin, the drug, causes cancer. For them, Breibart News, Fox News, CNN and PBS are all the same: They are just news, none more reliable than another. Well, except they have never watched PBS or listened to NPR. 

The Phantom's assistant tried listening to NPR once, at his suggestion, but she said it was boring, all about people who lived in Africa or Europe or South America and she would never go any of those places. Her husband had never been on an airplane and only once had traveled out of New England. 

On the other side, are the clinically depressed college grads who consider Trump an intimate member of their world, who regard him as that horrible frat boy they cannot avoid in the hallway or the cafeteria, who is not in their classes, but who lurks around at the parties every Friday night and gets drunk and smirks and drags off a girl to a bedroom whenever he can. He's an intruder they cannot avoid.

But, of course, they can avoid him. They can avoid him but they can simply not stop obsessing about him. He is not the thug they have to confront; he is simply the thug they cannot ignore.

He brings the rabble out onto the street, but not the streets the West Wing crowd typically frequent. He makes White Power marches by Proud Boys socially acceptable, among those who are so inclined. But there is plenty of denigration of those KKK wannabes.

We'll know, eventually, maybe by the end of this weekend, who the various secretaries of state declare the winner of the election. And then, if it's not Trump, there will be the law suits. If Trump wins, the Democrats will meekly accept it and make brave, inspiring speeches and there will be women's marches with pink knit hats and chatter on Twitter and Facebook and people complaining how vulnerable they feel, and how they feel like crying. 

And then they will have to face the coming storm of the return of COVID19.

This America, man.

Rumor and Authority: What I Learned At Journal Club

Every month I go over New England Journal of Medicine Articles with a group of colleagues who range from internists to orthopedists to oncologists in a hospital based journal club.

They are a bright group, brighter than me, who have great command of statistical analysis and who bring rigorous thought to examining the flaws in studies which often look pretty good to me until they begin to dissect them out.

But tonight they asked me to summarize what I hear from "This Week in Virology," since I'm the only one in the group who listens religiously to all 4 hours of TWiV every week.

And then things went south in a hurry.

One, a doctor who has traveled the world extensively, asserted that SARS COV-2 had originated in the wet markets of China, which he has seen, where bats are kept in cages, which provoked another to assert that the virus came out of the Wuhan laboratory, neighboring the wet market,  where it was made and the Wuhan facility had to be shut down because all the lab folks there died and that American scientists had be withdrawn from that facility years ago because it was so sloppy. * Another said the dose of inoculation of SARS COVID 2 is what's important and that's why the New York City outbreak was so bad, because of the subways. Another said that once you have had COVID 19 if you are exposed again, you'll have a milder version, so herd immunity will be the answer.

Of course, all these things have been repeatedly and meticulously addressed by the virologists and immunologists on TWiV. 

So here's what I remember from TWiV--

I have no journal articles to refer to, although I suppose I could comb back through the "bullet points" on the TWiV website, but here's just from memory:

1. SARS COV-2 AS A CHINESE PLOT: 

This virus was not manufactured in the Wuhan laboratory. As every virologist has said, no virologist or group of virologist is  smart enough or capable of creating such a virus.

Conspiracy rants that the Wuhan lab was shut down when all the workers died or that it was the source of SARS COV-2 have been a Breibart horror movie tale, but now even otherwise erudite physicians are picking this up in their politically groomed nasal hairs and it's getting transmitted to their brains and broadcast to unsuspecting colleagues.

Some version of SARS COV-2 may have been circulating in bats for some time, years even, before it "spilled over" into human beings.

Even before the wet market event, cases of COVID 19 had been described.

Bats pooping on pig feed on farms may be as much a problem as wet markets, so the idea you can simply close the wet markets to prevent the next epidemic is wishful thinking. Wet markets are so repugnant to Western eyes, it's easy to believe they would be a source of pestilence and they may well be, but they may not be the source of this particular outbreak and to say so is to leap from an emotional reaction to a conclusion which needs to be proven with actual science. 

This would be an easy solution--"just" close the wet markets, when what is really needed is in the field sampling world wide, which would cost money and substantial effort over years to maintain surveillance over emerging viruses, and no government official wants to even think about paying a bunch of virologist hunters to do this.

2. THE DOSE OF INOCULUM: 

This is a concept which goes back to medical school.  It stands to reason, if you get a whopping big dose of millions of living viruses directed into your nose and throat you'd be a lot more likely to get sick unto death than if you got just a few. In fact, the initial experience in New York was that doctors who intubated patients in the ICU were much more likely to get seriously ill seemed to suggest this inoculum effect. But Vincent Racaniello has repeatedly said he's seen no persuasive articles to support this. It's almost impossible to know what the "dose of inoculum" was in any given case. 

 The fact is, the patient who gets a small dose, with the wrong immune system may be overwhelmed by the rapidly reproducing virus which can generate millions of particles over just a few days, so whether you start with 300 particles or 300,000 particles may not matter if the virus is energetic enough in its reproduction. A match can light a fire big enough to bring down a house; even a Molotov cocktail may not do that, if it lands in a swimming pool.

Of course, the whole concept of Michael Mina's infectivity argument is that people go through a phase in which they are just stoking up production in their nasopharynx, maybe have 100,000 virions day 1, but by day three, they've got 3 million and by day 6 back down to 100,000. He has argued the patient is only infectious at the 3 million stage, so the dose he spews out might matter. But that is not an argument that the guy who gets sick is the guy who gets the big dose; it's an argument that the big dose may be needed to gain a toe hold in the nasopharynx  in the first place; what happens after that may depend more on the host than the dose of inoculum. (Whether the match lands on the gas range or in the swimming pool.)

Of course, the next idea is that it's not free virions in the air that matter so much as droplets carrying millions of viruses which provide enough virus to infect, so maybe it's the package which delivers that  matters.

Masks likely work by shielding from droplet borne infection and in some ways you might argue that they reduce the dose of viruses but this is unsettled. Again, this is more important to whether the virus can gain a foothold, not what happens once it's dug in.

3. HERD IMMUNITY:

 May not be possible from natural infection with SARS COV-2. 

Corona virus elicits "sloppy immunity" and in the case of the two coronaviruses which have caused the common cold, reinfections with genetically identical viruses happen two or three times during a single season. This is what has made a vaccine for "the common cold" so difficult. Patients with reinfection with the same genetically identifiable SARS COV-2 isolate have been documented. I don't recall how many, but some case reports at least have accumulated suggesting the second exposure to SARS COV-2  does not always result in a milder case.

This discussion led Brianne Barker, the TWiV immunologist, to say that given the brief duration of immunity, which is not sterilizing (killing virus) but only neutralizing, herd immunity from naturally acquired infections is not at all a given. She hastened to add that the immunity from vaccines against the spike protein may confer longer immunity and more durable immunity. Immunity from vaccine may be better than what you get from having the disease.

The consensus among the panelists and their guests has been this coronavirus, like other conronaviruses, will never leave human populations: There will be no small pox vaccine for it. We'll have it with us for the foreseeable future, hopefully controlled like influenza, with annual vaccinations. 

So that's my, possibly faulty, recall of TWiV wisdom acquired over the past few months as these topics have been raised, discussed, rehashed multiple times.

If I'm far off, I don't think I'm very far off.

* I was very proud for my restraint when I heard that. I did not say, "Oh, you know what I heard? It wasn't actually the Chinese in that Wuhan lab. It was those aliens they are keeping in Area 51 who made that virus! Good grief, stop listening to Breitbart and Rush and Aryan Nation Speaks and tune into This Week in Virology."

Reading Andrei Codrescu in New Hampshire

 Arguably the best thing about my time in Washington, D.C. was driving to work and listening to Andrei Codrescu and David Sedaris on NPR. Until I moved to WDC, I hadn't been aware of NPR, having lived in parts of New England which were then apparently not considered to be enough a part of the nation for National Public Radio to bother with, or in New York City, where I never listened to the radio because I was never in a car. 

But then I moved to DC and acquired a car with a radio and I was intrigued by this guy with his Transylvanian accent brightening my day in 60 seconds and I thought, "Hey, maybe Washington won't be so bad, after all."

I was wrong about Washington, but Codrescu remains a find.

Some time ago, I was deeply saddened to learn Mr. Codrescu had died, but Googling him today, I find this announcement was premature, which brightened my day once again, even though I have not heard from him for years. 

I wondered how that rumor got started, but then I remembered Codrescu has edited a journal called "The Exquisite Corpse" and that may have had something to do with it.

The reason all this came to mind is a copy of "Raised by Puppets: Only to be Killed by Research" surfaced as I was rearranging my bookshelves.

I was rearranging my bookshelves because watching PBS News Hour I realized everyone is now judged by their bookshelves and I wanted to be sure mine displayed my better points to advantage.

Hampton Falls, New Hampshire

Here is just one little riff from Codrescu which may give a sense of the man:

"Downriver"

"The world's not good from downriver. It's no fun waiting for that big mess from Ohio to float down to us. How long will it take? Three weeks? Four months? However long, it doesn't change the universal law: we folks downriver are forever waiting for whatever folks upriver will send us. Every glass of water in New Orleans, goes the old saw, has already been drunk six times. Of course, the trouble's not all from upriver. We do our best to poison our own water: we dump radioactive runoff from gypsum into it, too. An overworked filter is supposed to take out all the bad chemicals. But then--radioactivity isn't a chemical. Every few months a new report tells us how vile our water is. As if the highest rates of liver and pancreas cancer weren't enough.

No Louisianan in his right mind drinks the river water, unless he's poor, and the poor are, obviously, not in their right minds since they are poor...Nevertheless, there comes that time in the middle of the night when you stumble into the kitchen to fetch yourself a glass from the faucet before you're thinking clearly. You hold it in your sleepy hand, and just as you're about to bring it to your lips, it begins to glow--and hum! Mutated microorganism come to life with an eerie luminescence while trace minerals from every discarded chemical by product start singing softly.  A cobalt blue radioactive light of indefinite source plays softly over the whole show. 'Drink us,' the horrors croon, looking quite beautiful in their man-begotten glow, 'and you can be just like us!' And you do, because it's late, and you're thirsty, and you think it's all a bad dream. But it's not: it's the middle of the night three months from now and the mess from Ohio has finally arrived!"

I missed many a turn on the way to the office, listening to Codrescu.

Auvers, France

Now, I can sit on my porch in New Hampshire and read him.

He had to live in New Orleans. No place else in America is odd enough for him.

Hampton, New Hampshire

Indian Summer in Northern New England and Grace Metalious

 "In Northern New England, Indian summer puts up a scarlet-tipped hand to hold winter back for a little while. 

She brings with her the time of the last warm spell, an uncharted season which lives until Winter moves in with its backbone of ice and accoutrements of leafless trees and hard frozen ground. 

Those grown old, who have had the youth bled from them by the jagged edged winds of winter, know sorrowfully that Indian summer is a sham to be met with hard-eyed cynicism. 

Starr Island from North Hampton

But the young wait anxiously, scanning the chill autumn skies for a sign of her coming. 

And sometimes the old, against all the warnings of better judgment, wait with the young and hopeful, their tired, winter eyes turned heavenward to seek the first traces of a false softening."

Hampton, NH

--Grace Metalious

Obadiah Youngblood

Peyton Place

The Truth This Week, from TWiV

TWiV #654 brings not so much news, as revisions of news and critical assessment of news.

Here is the link for those who have 2 1/2 hours:
https://www.microbe.tv/twiv/twiv-654/



Some salient points:
1/ Post COVID 19 lymphoma is not yet  a documented complication of SARS COv-2, but there are a few case reports and this same phenomenon has been seen in other viruses, namely HIV and Burkett's Lymphoma

2/ Viral droplet  spread prevention by masks: studies on this are surprisingly difficult to find, at least good studies. But thus far, the evidence and mostly the theory suggests masks are important. Controlled studies (with controls who do not wear masks) will not be done for ethical reasons. (The parachute effect: You cannot do control studies on people jumping out of planes without parachutes as controls.)

3/ An Op Ed in the NYT by a pediatrician suggesting children are not playing much of a role in the spread  is a bewildering position, which is likely flat out wrong. Children, whether or not they get symptomatic, likely do bring virus home and out into the community. 

4/ Postural Hypotension and Tachycardia is a syndrome seen in some patients.

5/ Return of taste and smell after the anosmia of COVID may herald recovery from the virus.

6/ "Long haulers" --patients who continue to be symptomatic with fatigue, weakness for months following the acute phase.

7/ Convalescent sera with IgG antibodies studies have been a mess, because so many other therapies are given at the same time so it's difficult to know which therapy helped or even if any of them helped. The TWiV faculty continues to say the idea of anti viral therapy making a difference is hard to fathom because it's not the phase of the disease when the virus is replicating that gets people sick--it's the cytokine storm following that brief phase that kills people. 

8/ Testing is improving in the sense that turn around time is diminishing, but the only real strategy which might work is the salivary quick tests.
Many doctors are still saying "the tests are inaccurate" and when you say they are not inaccurate the doctors say, "But what about false negatives?" 
This means too many doctors have remain ignorant on this point.
What you want in a screening test is a test which captures infectious patients, not infected patients.
If the test misses an infected patient who is not infectious that is fine.
Patients are likely only infectious briefly, when they have millions to billions of virions in their noses and throats. During that phase, the Michael Mina mentioned quick saliva test will be reliably positive. 
You could pump out these simple antigen salivary tests which work like home pregnancy tests and use these to keep home infected school children, factory workers and others.

9/ Rules for testing accuracy during a pandemic should be different from when there is not a pandemic.

10/ The Russian vaccine is not ready for prime time. "They were Rushing all right."
It's an adenovirus vector vaccine--and as TWiV has discussed before, if you attach a vaccine to an adenovirus and lots of people have antibodies to that adenovirus, the vaccine may be ineffective.  Even so, the Russian vaccine will not be available to the general population until January 2021 and the manufacturer will be only to make only 1 million doses a year. So it will not be a solution. 

12/ Vaccines may well not provide long term (years) protection because coronaviruses typically do not elicit that, even from native disease. Likely a few months or maybe a year, if we're lucky, but hopefully recurrent infections will be milder.  Vaccines under development are mostly to the spike protein and this is a gamble, and we need vaccines to other parts of the virus. 

Cliff's Notes for COVID 19 or Virilogy for Dummies

The Phantom has been told his blogs are too long, digressive and require too much of the reader.
So here's his boiled down version of TWiV #645:

Michael Mina, MD, PhD

We can get out of this pandemic thing before the vaccines become available if we believe certain assertions which are likely true, but are as yet unproved:

#1 SARS COV-2 is only infectious briefly.  Michale Mina, MD PhD has said this on a couple of TWiV episodes:  He tells us who have the virus in their noses, throats and lungs are likely infectious to others for only a few days, like 3-7 days. 
During this infectious period they can be super spreaders or just ordinary spreaders and they make millions upon millions of infectious virus units (virions).
But once they pass through this phase, they are no risk to anyone else. They may make virions but only in the thousands which is not enough to infect most contacts.

#2. Detecting the patient who is breathing out millions of virions is best done with a low sensitivity test, which is sensitive enough to catch the big load of virus in the saliva but will miss the patient who only has thousands of virions in his mouth.  You really don't want to know about the non infectious patient: He can go to school or to the bar or fly on the airplane. You only want to know about the infectious guy who spreads the disease.

Why would you not care about the asymptomatic or pre-symptomatic person? Because if he does not become sick, it doesn't matter to him or to the rest of us, as long as he doesn't spread virus.  If he becomes sick, then you can use other more sensitive tests to confirm he is sick with COVID 19 if he seeks medical attention.

#3 We have on the shelf different versions of a test strip which can be used at home like a pregnancy test with results from saliva in 10 minutes.
According to  Mina, you could print these strips by the millions almost as easily as photocopying. 
Imagine if you could test kids at home or when they arrive at school each day with a cheap, 10 minute test and you send home or keep home the kids who are infectious but then move on with your day without masks, without contact tracing. 
You don't need contact tracing if you can test virtually everyone daily at home.

If all these things are true, then Mina is talking about a game changing approach.
If he is right, he should be talking to the powers that be.

So far Democratic Senators and Congressmen and Republican governors have ignored him or simply not heard of him.  

The system for making the bureaucracy aware of scientific advances or changes in thinking is apparently imperfect. 

The science and details are summarized by the excellent Medcram youtube:
https://www.youtube.com/watch?v=h7Sv_pS8MgQ&t=9s

There is a long form version now in the Atlantic:
https://www.theatlantic.com/health/archive/2020/08/how-to-test-every-american-for-covid-19-every-day/615217/?utm_source=newsletter&utm_medium=email&utm_campaign=atlantic-daily-newsletter&utm_content=20200814&silverid-ref=NjYzNDQ4NjU4MDY2S0