Too Big To Be Allowed To Exist

I see that the editors of the New York Times are now worried about something I’ve warned about since the “stay at home” directives first began to be issued:

Unfortunately, the federal $2 trillion coronavirus stimulus package does little to mitigate retailers’ woes, despite their executives’ pleas for relief, though the Federal Reserve is working to ensure that larger companies have continued access to credit markets. The aid plan gives tax relief for prior property improvements, and it establishes a $350 billion fund for small-business loans that could help those firms maintain payroll and rent, but little else.

Though the cracks in bricks-and-mortar retail began forming years ago, the widening coronavirus outbreak stands to hasten physical retail’s decline and strengthen the monopoly hold of Amazon and other online giants. Such a consolidation of power among just a few retailers threatens to leave consumers with higher prices and less choice.

During the pandemic, reliable delivery of essentials like milk, eggs, toilet paper and cleaning supplies has been a lifeline for those who are reluctant or unable to venture outside their homes — Amazon-branded trucks have remained a familiar sight in residential neighborhoods. The competitive advantages of Amazon’s meticulously constructed worldwide logistics network, built to shuttle nearly every imaginable item to customers in as little as an hour, are especially evident in this crisis.

While many other traditional retailers are struggling with falling demand, Amazon has pledged to hire 100,000 temporary workers to keep up with it. Several other retail giants, including Walmart and Target, have kept pace with coronavirus quarantine demands by keeping physical stores open and leaning on their own delivery networks for grocery shipments and other necessary items. Walmart plans to hire 150,000 new workers.

and

Even in less frantic times, Amazon has been criticized for its workplace culture and its heavy-handed tactics with sellers. Last year, The Wall Street Journal contended that Amazon may be losing control of its own marketplace, allowing dangerous counterfeits to appear on its virtual shelves that would never pass muster at traditional retailers. Both Walmart and Amazon have quashed unionization efforts.

Amazon and Walmart have offered critical delivery services during this crisis, but regulators and elected officials should not lose sight of the dangers of monopoly power falling into the hands of the fortunate few that survive the coronavirus fallout.

My beloved Happy Foods continues to offer home delivery. It always has but that has increased substantially during Illinois’s “stay at home” directive. Indeed, the panic-buying of a week or so ago has gone a long way to redressing the damage that the city did to it over the last couple of years. Both Jewel and Mariano’s both now offer home delivery. At least in Chicago people don’t need Amazon to get “milk, eggs, toilet paper and cleaning supplies” without walking into a store. Is it different in other places?

Amazon’s real competitive advantage resides in its ability to sell and deliver clothing and everything else that people buy. My first suggestion was that Amazon be prohibited from selling anything other than essentials during the crisis.

My second suggestion was that it, along with Google and Facebook, be made so busy with the “war effort” that they wouldn’t have the resources to expand their monopolies. That’s what happened during World War II. IBM became IBM because it didn’t participate in the war effort and its much larger competitors were too busy manufacturing machine guns to introduce new products. My last suggestion was that, once the crisis is over, the Federal Trade Commission start working overtime in breaking up monopolies.

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You Are Here

I have reservations about the rest of the this Wall Street Journal editorial but I find their conclusion a pretty good summary of where we stand:

April is going to be a brutal month for America, and the next two weeks especially. But as the bad news arrives, it’s important to understand that the worst-case-scenarios that many in the media trumpet are far from a certain fate.

Right now, this minute, the death toll from COVID-19 of those who have contracted the disease is less than 2%. Here in Illinois it’s 1.44%. IMO it’s a pretty good assumption that, as the number of people who’ve been tested and the velocity of testing both increase, that percentage will actually decline since right now the sickest are being tested. A little back-of-the-envelope calculation tells you that a couple of hundred thousand people may well die. That’s awful—a multiple of those who die every year from the seasonal flu. But it’s not the Black Death. It isn’t even the Spanish Flu.

We need to do a lot more testing, especially epidemiological testing and serological testing. Let’s abandon any thoughts of putting the measures the Chinese did into place. According to the reports I’ve heard everybody has received a QR code for their phones that identifies them and tells what the results of their latest COVID-19 test was. They’re only allowed out if they’re negative for COVID-19 (that’s from the wife of a colleague whose family is in Shanghai).

But I’m also skeptical of China’s reports. There are those who are not bat-**** who say that China’s total cases and death toll may be an order of magnitude or more than they’ve acknowledged. I have more faith in South Korea than that.

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Is Central Control What We Really Need?

The editors of the Washington Post have their own ideas about what should be done next:

There is no room for a patchwork response. Without restrictions in place, what’s happening in New York City today will be in Miami, Detroit or Chicago tomorrow. A few irresponsible politicians can undermine recovery for everyone. The only way to break the chains of coronavirus transmission is for the entire country to engage in physical distancing until the pandemic abates or an effective vaccine or therapy is ready. A piecemeal approach invites a raging, rolling pandemic.

While I agree that the federal government should restrict interstate travel temporarily (that is within its power), otherwise I think that a patchwork response is exactly what we need. Centrally controlling the production of a new test for COVID-19 is precisely what put us behind the 8-ball where we find ourselves. Why repeat or continue that mistake? What is necessary for New York City is probably not needed in Marfa, Texas.

The federal government should focus its efforts on the areas of its legitimate authority. It will have enough to do there. Governors and local officials need to step up to the plate, too. Under our system of government the states are where the action is. Simply because COVID-19 can infect anybody and everybody will not change that.

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Coming Back

I both agree and disagree with the editors of the New York Times in their prescription for “reopening” America. For example, I agree that contrasting the need to preserve life with the need to keep the economy afloat is a false dichotomy:

This is a false choice. While policymakers must sometimes make trade-offs between life and money, this is not such a moment. The American economy needs to be shut down in order to preserve both human life and long-term prosperity. During the 1918 influenza pandemic, communities that quickly imposed stringent measures not only saved lives but experienced stronger economic rebounds, according to a new study. The message is clear: Coronavirus is a danger to life and prosperity; a strong public health response is the needed corrective.

but I disagree with their strategy. Keeping the economy shut down too long will kill people much more surely than COVID-19 will. The economy of 2020 is not the economy of 1920. Farming is not as important to the economy as a whole as it was then. There has been enormous consolidation—there are fewer companies per million population than there were then. Banks and the whole financial sector comprises a much large portion of the economy.

Offhand I’d say that a one month shutdown will lead to 10% of companies declaring bankruptcy and a three month shutdown will lead to 30% of companies declaring bankrtuptcy with longer shutdowns doing even more damage. After a year-long shutdown there would be little economy to reopen. I can think of no surer method of returning to the economy of 1918 than than acting as if it were still 1918.

It increasingly appears necessary that for the next eight weeks, and possibly for longer, all nonessential businesses should be closed, domestic travel restricted and the “shelter-in-place” measures being employed by some parts of the country extended to the rest. Such a shutdown will be enormously expensive in the short term, likely requiring fresh rounds of federal aid on top of the $2.2 trillion Congress approved on Friday. But scientists say that based on what they’ve learned from Europe and Asia, that’s the only way to get the virus, which is spreading like wildfire across the country, under control.

Quite to the contrary the too-slowly increasing testing should be exploited to allow us to selectively end the mass shutdowns in favor of much more targeted shutdowns. People who are provably, testably non-infected should go back to work with all due haste. It may be that very densely-populated areas like New York City and San Francisco should remain locked down for a protracted period. I agree with them, however, that foreign and domestic travel should be restricted, including American citizens. IMO one of the biggest mistakes in the early days of the pandemic was not quarantining everybody returning from international travel.

I agree with them that we will need to do a lot of testing on an ongoing basis. I disagree that the method for doing so should be by beefing up public health:

To build such capacity, the federal government will have to invest in the nation’s undervalued and deeply strained public health system: more funding will be crucial, but it will not be enough. State and federal leaders should work together, now, to create a public works corps to assist epidemiologists with contact tracing, to erect thousands of drive-through testing sites, and to do the work of infection control in nursing homes and homeless shelters. Some states are already doing this on their own, but others will need federal funding — perhaps in the form of block grants.

That is simply not how our government operates in the 21st century. What could happen is that the federal and state governments could let contracts to private organizations, for profit and non-profit. Such a process is guaranteed to be far too time-consuming, will only let contracts to preferred organizations, and will, ultimately, be a license to steal. How could they possibly know there are no “shovel-ready projects”? Much more needs to be done by local governments and the private sector. In many (but not all) cases the best role for the federal and state governments will be to get the heck out of the way. People, both as individuals and in the form of companies are eager to do what they can to aid in this “war effort” just as they were during World War II. Unfortunately, just as then, too, some are eager to profit from it. Dealing with that is a legitimate activity for the state and federal governments.

I’m not opposed to this:

Public health authorities also should oversee the creation of temperature checkpoints outside of factories and office buildings, and in other close-packed or high-traffic places — and those measures should be increased anytime disease detectives find the hint of a brewing outbreak. This will take a combination of state-level mandates and aggressive public advertising campaigns. People hate being told what to do, never more so than when it comes to their own bodies; clear and consistent messages will help mitigate the predictable pushback.

This is nonsense:

Some scientists are working to rectify that problem — to create the apps and websites that such a crisis demands. But those efforts will only be useful if they are brought to scale quickly. That, too, will take federal oversight and financial support.

Have they not learned their lesson yet? The federal governments is incapable of creating or overseeing the creation of solid, functional web sites and apps in a short time frame. Do you know who can do that? Google, Amazon, Facebook and a handful of other companies. They should be shamed into producing these sites and apps as their part in the “war effort”. To do otherwise will push their development into a future after the need is over, to be developed by a qualified vendor, i.e. one with political connections.

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Small Steps

USA Today reports that the Food and Drug Administration has approved Abbott’s 5-minute COVID-19 test:

CHICAGO – A five-minute, point-of-care coronavirus test could be coming to urgent care clinics next week, and experts say it could be “game-changing.”

The U.S. Food and Drug Administration issued Emergency Use Authorization to Illinois-based medical device maker Abbott Labs on Friday for a coronavirus test that delivers positive results in as little as five minutes and negative results in 13 minutes, the company said.

The company expects the tests to be available next week and expects to ramp up manufacturing to deliver 50,000 tests per day.

“I am pleased that the FDA authorized Abbott’s point-of-care test yesterday. This is big news and will help get more of these tests out in the field rapidly,” FDA Commissioner Steve Hahn said in a statement. “We know how important it is to get point-of-care tests out in the field quickly. These tests that can give results quickly can be a game changer in diagnosing COVID-19.”

Scott Gottlieb, former FDA commissioner, echoed Hahn’s comments on Twitter, calling the development a “game changer.” Gottlieb also said it’s “very likely” that we’ll see additional approvals of point-of-care diagnostics behind this one, extending testing to doctor offices across the U.S.

Physically the tests are small cartridges that are used by Abbott’s ID NOW benchtop instrument. There are presently 18,000 of these units installed around the country. I suspect we can expect Abbott to start producing more of them.

Also, USA Today reports that the limitations the FDA had imposed on Battelle’s using its facemask sterilization process have been lifted:

COLUMBUS, Ohio – After a day of pressure from Ohio Gov. Mike DeWine, the U.S. Food and Drug Administration late Sunday rewrote rules to allow full application of a potentially game-changing Battelle technology to sterilize protective masks worn by those treating coronavirus victims.

The agency ruled that upgrading its emergency use authorization from partial to full “is appropriate to protect the public health or safety.”

DeWine said Sunday night that he and Lt. Gov. Jon Husted “just had a very productive call” with the Food and Drug Administration. “I anticipate a positive announcement soon. We must do all we can to protect our front-line workers.”

Husted tweeted: “This Ohio-driven solution has the potential to save lives now and in the future across the United States.”

I suspect these are just two of many new tests and processes that will be deployed in the coming days. 50,000 tests a week and 80,000 masks sterilized per day are fractions of the need but these are steps in the right direction. They won’t be the last.

Update

And yet another small step. The Hill reports that the FDA has issued an emergency use authorization for the use of hydroxychloroquine (HC) and chloroquine in treating COVID-19:

The Food and Drug Administration (FDA) on Sunday issued an emergency-use authorization for a pair of anti-malaria drugs as health officials work to combat the rapid spread of the novel coronavirus.

The Department of Health and Human Services (HHS) said in a statement that the authorization would allow 30 million doses of hydroxychloroquine sulfate and 1 million doses of chloroquine phosphate to be donated to the Strategic National Stockpile. The doses of hydroxychloroquine sulfate were donated by Sandoz, while the chloroquine phosphate was developed by Bayer Pharmaceuticals.

Hopefully, this move will motivate more physicians to start giving these drugs to their patients with COVID-19, possibly in combination with azithromycin, as was used in South Korea.

Use of HC will probably cause some problems, too. The drug is presently used to treat other diseases including rheumatoid arthritis and shortages will probably develop rapidly. We need to produce all of the pharmaceuticals domestically and some emergency grants for doing just that should be approved by the Congress.

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Make a Better Argument

At Genetic Literacy Project Ricki Lewis argues that we need to be cautious about COVID-19 treatments:

At ClinicalTrials.gov since last week, new registered studies have gone beyond China, with many from Italy and Spain, but also Egypt, Jordan, the UK, Canada, France, Germany, Denmark, Romania, Israel, and the US. In addition to more repurposing candidates are a sprinkling of studies on the social manifestations and consequences of the pandemic, such as “social media effect on knowledge dissemination.”

[…]

Pharmaceuticals aren’t like noodles, flung against a wall to see what sticks.

But even though the “RCT” – a randomized controlled clinical trial – is widely recognized as the gold standard, many researchers, Dr. Fauci said, are uneasy at the prospect of giving a placebo in a study, even if it is an existing treatment. Is doing so a betrayal of their oath to “do no harm?”

Fortunately, a novel clinical trial strategy, called an adaptive design, may help speed the drug approval process. Dr. Kalil describes it in his Viewpoint. It allows a clinical trial to test more than one treatment. That’s what the National Institutes of Health is doing in a trial of Remdesivir, which has been much talked about and is already through phase 2 to treat HIV/AIDS. It is an intravenous infusion.

In the end I think that Dr. Lewis fails in her argument. It amounts to “it isn’t good science”. So stipulated. Neither is issuing “stay at home” directives in the largest states in the country. When pharmaceuticals have been approved by the Food and Drug Administration for treating other conditions including conditions that are not “100% fatal”, and there is some clinical evidence and copious field experience albeit not in the U. S. it seems to me that resorting to something that isn’t pristine science is the lesser evil.

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The Second Punch

In another Wall Street Journal op-ed Jeff Colyer reports on the progress in the second punch in the one-two punch I mentioned above—the search for an effective treatment beyond supportive care for people with COVID-19:

What is the treatment?

Physicians are using two drugs in combination—hydroxychloroquine and azithromycin, which I’ll abbreviate HC and AZ—to treat patients with advanced Covid-19 symptoms. We use a regimen reported in a recent open-label trial in Marseille, France, which was updated March 26, and which doctors may modify in any given case.

What is the evidence?

For HC, two bodies of evidence support its potential in treating Covid-19: in vitro (test tube) studies and initial clinical reports from the field. After the 2002-03 global outbreak of SARS, a coronavirus related to the one that causes Covid-19, an in vitro study conducted by doctors from the Centers for Disease Control and Prevention identified chloroquine (a relative of HC) as an attractive option for prevention and treatment. If added before the virus was introduced, the drug was highly effective in preventing cellular infection. Even later application markedly inhibited infection. Another contemporaneous study showed similar results. As for Covid, a Chinese study published March 9 showed HC has excellent in vitro effects. Other recent information suggests potential antiviral mechanisms of HC and chloroquine.

The bedrock of all infectious medicine, from developing treatments for specific infections to treating individual patients, is in vitro laboratory testing and patient trials. Covid-19 is no exception. Current laboratory data suggest that HC should work.

Clinical information has also emerged from Covid treatment. During the initial Chinese outbreak, Wuhan doctors observed that patients with lupus—a disease for which HC is a common treatment—did not seem to develop Covid-19. Of 178 hospital patients who tested positive, none had lupus and none were on HC. None of this Wuhan hospital’s dermatology department’s 80 lupus patients were infected with the novel coronavirus. The Wuhan doctors hypothesized that this may be due to long-term use of HC. They treated 20 Covid-19 patients with HC. Their result: “Clinical symptoms improve significantly in 1 to 2 days. After five days of chest CT examination, 19 cases showed significant absorption improvement.”

Second, consider AZ—the antibiotic marketed as Z-Pak—combined with HC. The French study showed that 57% of 14 Covid-19 patients receiving HC without AZ tested negative for the virus on a nasal swab on day six. But 100% of the six patients who received both HC and AZ tested negative on day six. Compare that with 16 infected patients at another hospital who didn’t receive either treatment: only 12% tested negative on day six. These are small samples, but significant.

HC has been approved by the FDA and in use since 1955 and Z-Pak since 1988. Given the field experience in South Korea in using the two in combination to treat COVID-19, I’m not sure why American physicians would be reluctant.

Finding an effective treatment for COVID-19 is the sine qua non for stemming the epidemic. As long as people continue to contract the disease which in my opinion is likely to be forever, new cases will continue to threaten the health care system with collapse.

It should be carefully noted that HC+Z-Pak or any other treatment will not be prophylactic and will not be a substitute for limiting the spread of the disease. Testing will need to be increased by several orders of magnitude, especially epidemiological testing and serological testing.

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The First Punch

I think this prescription by Scott Gottlieb and Lauren Silvis in an op-ed at the Wall Street Journal makes sense:

How do we crack the current outbreak, develop a plan to return to normal life, and ensure that the virus never poses the same threat again? That will require a system that can detect when the virus is spreading. The system would have three components:

First, a sentinel surveillance system, which collects high-quality data from specific locations and can test a statistically representative sample of patients to detect where and when the virus may be spreading. Such a system could help find small pockets of infection before they multiply into larger outbreaks.

Second, rapid and reliable diagnostic tools. Insurance coverage should be mandatory, and the Centers for Disease Control and Prevention should give flexible guidance that encourages doctors to test liberally. If you have any signs or symptoms of Covid-19, you get a test right away with no out-of-pocket payment.

Third, coronavirus serology tests, which screen blood for the antibodies that confer immunity after exposure to a pathogen. This is essential for tailoring interventions to stop local spread. If you know that a large percentage of people have been exposed and developed some immunity, it may allow for less-restrictive measures. These tests can be added to routine blood draws with no additional hassle for the patient.

This should be implemented with all due haste and whatever can be done to expedite the process should be done. That’s the first punch in the one-two punch that will enable all of these “stay at home” directives to be lifted prudently.

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Father of the Year

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COVID-19 + Power Failure = Double Disaster

Paul Steidler is right in his piece at Inside Sources. COVID-19-induced power failure is a “double disaster” we really need to avoid:

The electric grid is essential for all aspects of modern life — including hospital care, food preservation, computer operations (i.e., many people’s ability to work), and at-home medical devices for the sick, elderly and disabled.

When countries attack one another, there is an excellent reason the grid is typically a top target. By knocking out electric power, an adversary is thrown into disarray.

To make sure our grid stays up, we need to make sure the people managing the grid stay healthy. Indeed, this must be a priority.

The highly-skilled, hard-to-replace and experienced professionals in the energy profession seldom can work from home. In fact, there is no record of a power line ever having been replaced remotely.

There are also significant limits to “social distancing” in power production. Line workers often must be near one another.

The engineers and other professionals in the control rooms of power plants and transmission facilities must be able to communicate immediately, directly and close to one another.

Think things are tough now? Imagine being trapped in your house with your kids for a week without electricity.

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