As the total number of cases of COVID-19 diagnosed worldwide continues to creep towards 3 million, little has changed over the last few days. Only South Korea, Taiwan, and Japan seem to have avoided major outbreaks of the disease. Singapore seems to be seeing a resurgence in the number of cases.

The curve may be bending in Italy. The peak in the number of new cases took place on March 21 and that seems to be holding although new cases continue to be accumulating. I can’t distinguish whether the measures the Italians have put in place are succeeding or the epidemic is just running its course there.

Here in the U. S. the health care system hasn’t been overwhelmed but I see few signs that we’re “bending the curve”, either. The New York metropolitan area still has about a third of all cases of COVID-19 diagnosed in the U. S. and about half of the deaths. There are some reports that pressures on ICUs in that area are decreasing. The situation seems to be worsening in the Washington, DC area.

The number of cases per million population in Florida, Texas, and California are 10% their number in New York State. Maybe those states are being protected by heat or sunshine. Population density would appear to be a more significant factor. Minnesota has a rather low prevalence and morbidity and the state is not known for heat or sunshine.

I wanted to share the information above from the Illinois Department of Public Health. Illinois has been under a statewide “stay at home” directive for almost six weeks now. I would think that if there were any “curve-bending” going on we would see evidence of it by now. There’s more info at the IDPH site. Based on what they show there is still substantial available capacity in every sector of the state. The City of Chicago itself is tightest, as you might expect. That Chicago is in the middle of a shooting spree that began the week after the governor announced the “stay at home” directive might have something to do with that.

I suppose one might make the argument that the fact that Illinois’s ICUs are not stretched to capacity is proof positive that the “stay at home” directive is having the desired effect. As I’ve said before that strikes me as a “tiger repellent” argument. It also does not disaggregate the effects of the “stay at home” directive with any changes in treatment protocols that may have taken place over the same period. Are treating physicians still as likely to put people presenting with the symptoms of COVID-19 on ventilators as they were six weeks ago? I have no idea.

According to NPR the National Institutes of Health is raining on the HCQ parade:

A panel of experts convened by the National Institute of Allergy and Infectious Diseases recommends against doctors using a combination of hydroxychloroquine and azithromycin for the treatment of COVID-19 patients because of potential toxicities.

“The combination of hydroxychloroquine and azithromycin was associated with QTc prolongation in patients with COVID-19,” the panel said.

QTc prolongation increases the risk of sudden cardiac death.

The recommendation against their combined use would seem to fly in the face of comments made by President Trump suggesting the combination might be helpful. On March 21, for example, the president described them in a tweet as having a “real chance to be one of the biggest game changers in the history of medicine.”

There are also some other treatments they recommend against:

But occasionally, there are recommendations explicitly against certain therapies. For example, the panel recommended against using Lopinavir/ritonavir or other HIV protease inhibitors because of negative clinical trial data. It also recommended against using interferon because it seemed to make patients with SARS and MERS worse. Those diseases are caused by a coronavirus related to the one causing COVID-19.

“It’s all based on the data,” said panel member Dr. Susan Swindells, a professor in the department of internal medicine at the University of Nebraska College of Medine. “We just plowed through everything that was, and apart from supportive care, there wasn’t anything that was working terribly well.”

The panel also concluded that there was insufficient evidence to recommend any kind of treatment either to prevent infection with the coronavirus or to prevent the progression of symptoms in those who are already infectious. That recommendation could change based on clinical trials presently underway.

I don’t have any ox to get gored in this discussion but I wonder how the NIH explains the experience in South Korea? Or are they just discounting it completely?

Just to pass along a little gossip I heard according to one doc I’ve spoken with South Korea’s strategy for handling their COVID-19 outbreak made it impossible for other countries to follow its lead, at least in the near term which was when it would have been necessary. The country had already sucked up all of the necessary supplies. Just gossip, as I say.

Santa Clara County, California has reported a death due to COVID-19 that took place weeks before what had previously been presumed to be the first death due to the disease here in the U. S.:

Santa Clara County, CA – The County of Santa Clara Medical Examiner-Coroner has identified three individuals who died with COVID-19 in Santa Clara County before the COVID-19 associated death on March 9, 2020, originally thought to be the first death associated with COVID-19 in the county.

The Medical Examiner-Coroner performed autopsies on two individuals who died at home on February 6, 2020 and February 17, 2020. Samples from the two individuals were sent to the Centers for Disease Control and Prevention. Today, the Medical Examiner-Coroner received confirmation from the CDC that tissue samples from both cases are positive for SARS-CoV-2 (the virus that causes COVID-19).

Additionally, the Medical Examiner-Coroner has also confirmed that an individual who died in the county on March 6 died of COVID-19.

February 6 is three weeks earlier than what had thought to be the first death due to SARS-CoV-2. That is additional confirmation of the point I have been making for some time. Without China’s being much more forthcoming weeks earlier than they actually were any prospect for avoiding an outbreak of COVID-19 here in the states depends on assumptions unrealistic in the extreme.

I think that “unrealistic assumptions” will be the story of the handling of this pandemic from end to end, not limited to the United States. The word I’m getting now is that India, which issued a countywide “stay at home” directive several weeks ago, is about to surrender and just let the disease run its course.

So, what next? I would think that the experience of Florida, which initiated “stay at home” directives much later than in other jurisdictions and the incidence and mortality due to COVID-19 are an order of magnitude lower than in New York, suggests that whatever is happening in the U. S., it cannot be attributed to “stay at home” directives alone.

I found this op-ed at USA Today from virologists Konstantin Chumakov and Robert Gallo pretty interesting. In addition to searching for a specific vaccine for SARS-CoV-2, why not deploy a vaccine that’s been in our arsenal for a long time and, coincidentally, has already been approved by the FDA?

Ultimate control over COVID-19 will be possible only after a large part of the world population becomes immune. This can happen either after a large fraction of the world population gets infected or by prophylactic vaccination. Efforts are underway to accelerate the development of safe and effective vaccines. However, vaccines can be used for mass immunization only if they prove to be safe and effective by thorough clinical evaluation. Given the time this requires, vaccines specific to COVID-19 are likely to remain unavailable for mass immunization during the current pandemic.

In the meantime, we propose an approach to mitigate the SARS-CoV-2 pandemic through the use of existing attenuated live viral vaccines. In particular, oral polio vaccine has been documented to induce protection against a number of viral and bacterial infections. OPV, developed by Albert Sabin, consists of attenuated (weakened) poliovirus and has been used with great success in worldwide efforts to eradicate poliomyelitis.

In addition to protecting against polio by inducing antibodies that kill the virus, OPV activates other protective mechanisms, including an innate immune system, thus making people resistant to infections caused by other viruses and bacteria. For example, in large scale multicenter clinical trials conducted in the 1970s during outbreaks of seasonal influenza, OPV protected more people from influenza than most flu vaccines do. Furthermore, observational studies in many countries suggested that the hospitalization rate and the overall mortality among children immunized with OPV were consistently lower compared with unimmunized children, even in the absence of poliovirus in communities.

Related studies revealed that similar nonspecific protection can be induced by immunizing people with measles vaccine, tuberculosis vaccine (BCG) and some other live attenuated vaccines. These observations suggest that the nonspecific protective effects are a result of boosting innate immunity that is our body’s front-line defense against infectious agents. This protection would last for a period of several weeks or months preventing or reducing the severity of disease in immunized individuals and slowing down the spread of COVID-19.

An idea so crazy it might just work. It’s at least worth experimenting with on a limited trial basis.

Brian Doherty has published a good post at Reason, the thesis of which is that posing the debate between “Openers” and “Closers” as one between “idiot death-worshippers” and “unnecessarily frightened tyrants” is counter-productive:

Beyond its devastating effect on the health of hundreds of thousands and the livelihood of millions, the COVID-19 crisis is a harshly vivid example of Americans’ inability to understand, fruitfully communicate with, or show a hint of respect for those seen to be on other side of an ideological line.

Americans are divided about the best way to proceed from here, three months since the first case was diagnosed in the U.S. The division is more vivid and harsh on social networks than in the polls, where a vast majority of Americans still think strong lockdowns are the best idea moving forward. Such Americans think the economy needs to stay shut down by law until a vaccine or some effective treatment is developed that ensures no more, or a very tiny number of, people will be seriously harmed or killed by COVID-19.

On the other hand, some Americans think, on balance, the country’s overall quality of life demands we start letting people and businesses make their own decisions about whether it is safe to go out in public or conduct business openly, especially given access to simple prophylactic measures such as gloves and masks.

Read the whole thing. It isn’t terribly long.

I’d like to offer some scattershot reactions. My first reaction is that dehumanizing your opponents isn’t supposed to be productive. It’s some combination of kneejerk reaction and battlespace preparation. It makes it easier simply to dismiss them rather than treating their concerns as legitimate.

A second reaction comes from one of my oldest blogging correspondents, Wretchard of The Belmont Club: “The cost of politicizing the disease is it locks people into positions. In fact dealing with an epidemic is an exercise in adaptation.” We don’t know “the facts” and may never know them completely but a famous response of the economist John Maynard Keynes’s seems appropriate: “When my information changes, I alter my conclusions. What do you do, sir?” When altering your conclusions in response to new revelations is seen as some sort of moral failing, we have a basic problem.

Finally, I think the political incentives are presently completely disregulated. IMO the “stay at home” directives will remain in place until they become impossible to maintain or serious recall and/or impeachment proceedings begin. Then they will be lifted in an excessive rush.

I’ve got to admit that the logic of Illinois’s public officials’ policies and public statements eludes me. The Chicago Tribune reports:

Gov. J.B. Pritzker on Tuesday said models are now predicting the new coronavirus won’t peak in Illinois until mid-May, weeks later than previously projected.

During an interview on The Washington Post Live, Pritzker noted that Illinois was the second state to issue a stay-at-home order and that because people have been abiding by it, “for the most part,” the anticipated peak of the outbreak in mid-to-late April has changed.

Meanwhile, Chicago Mayor Lori Lightfoot said on a conference call with reporters that she expects Pritzker’s stay-at-home order could extend into June.

State officials reported 1,551 new known COVID-19 cases on Tuesday, as the total number of known infections reached 33,059. There were also 119 additional deaths reported, bringing the toll since the start of the outbreak to 1,468.

I simply don’t understand. Is the policy succeeding, failing, or will it continue whether it succeeds or fails?

The number of new cases and new deaths in Illinois continue to increase. To the extent that there is any trend, it is up. It looks to me as though the actual changes are smaller than irregularities in reporting. They are not declining.

As I have been for several weeks now I was reviewing the global COVID-19 data and I noticed something I wanted to share with you. Only a handful of countries south of 23° North have death rates per million due to COVID-19 above 20: Ecuador (29), Dominican Republic (22), Panama (32), Bahamas (23), St. Martin (52), Antigua & Barbuda (31), and Turks & Caicos (26). With the exception of Ecuador a prospective explanation for those would be that they reflect cases imported from the U. S., Canada, or Europe. I don’t know enough about Ecuador to venture a guess.

In most of those countries the death rate per million is extremely low—frequently less than 5.

That could reflect the relative disconnection of the “Global South” from what we perhaps over-generously call the “world economy”. Or it could be climate, demographics, maybe their recordkeeping is poor, or they have other things to worry about or any number of other possibilities. As the seasons in the Southern Hemisphere change from fall to winter, it will provide a test of sorts.

The editors of the Chicago Tribune have noticed that Gov. Pritzker and his pals in Illinois’s legislature are not letting the present crisis go to waste and are proceeding to beg for a bailout from the federal government using COVID-19 as a pretext:

It is not surprising an Illinois politician finally put in writing what economists and financial watchdogs have been warning for years: That elected officials who failed to take seriously decades of fiscal warning bells in this state eventually would seek a bailout from the federal government.

What is beyond galling is using the coronavirus as an excuse. But that’s what Illinois Senate President Don Harmon, D-Oak Park, did last week in a letter circulated among Illinois’ congressional delegation and obtained by The New York Times. Harmon requested more than $41.6 billion in bailout aid as part of the next coronavirus relief package, including $10 billion for Illinois pensions, due to economic collapse from the virus.

Even by this state’s low standards, asking federal taxpayers from California to North Carolina, from North Dakota to Texas — farmers, small business owners, teachers, nurses, bus drivers, bartenders — to help dig Illinois out of its pre-coronavirus, self-inflicted, financial hellhole is astonishingly brazen. Every member of Congress should carefully scrutinize pleas from states whose unbalanced budgets, embarrassing credit ratings and vastly underfunded pension systems predated virus outbreak.

“I realize I’ve asked for a lot, but this is an unprecedented situation, and we face the reality that there likely will be additional, unanticipated costs that could result in future requests for assistance,” Harmon, who has been in office since 2003, wrote in the letter.

SARS-CoV-2 did not create a fiscal crisis in Illinois. Illinois was already in the midst of a fiscal crisis before the virus existed. Illinois has the lowest credit rating of any state in the Union—teetering on the verge of junk status which would render the state unable to borrow at all. Its population is shrinking faster than any other state. Its tax base is eroding. Housing values in the city of Chicago have not recovered the values they had in 2006 and there is little prospect of their doing so. That has not stopped property taxes from rising. Property taxes are reaching confiscatory levels. Chicago’s retail sales tax is already the highest of any major city. City fees have risen just about as high as they can.

Under the circumstances asking for a bailout from the federal government is not merely brazen it is ghoulish. It is asking people suffering more greatly than we are from COVID-19 to bear the costs of decades of Illinois’s politicians’ misfeasance, nonfeasance, and malfeasance.

Illinois’s request should be rejected out of hand. The only conditions under which Illinois should receive money from the federal government are in exchange for some serious terms. There are many, many compelling reasons for that not the least of which is moral hazard.

I have read several proposals for such terms. Everything I have read so far punishes the innocent right along with the guilty while rewarding the guilty, will accomplish the opposite of what I presume their authors’ intent to be, or both.

For example, demanding that Illinois be split into two state—downstate and the Chicago environs—would actually reward Illinois’s incompetent political class while ruining downstate Illinois. The erstwhile Illinois would be given two additional senators along with a stack of cash. Converting the erstwhile Illinois to a territory and taking it into a sort of receivership would disenfranchise those who’ve been voting against Illinois’s prodigality right along with those who voted for it.

Here’s my modest proposal.

• Illinois’s state constitution should be amended to allow the state’s legislature to renegotiate pension agreements of state public employees.
• The state’s constitution should be amended to ban defined benefit pensions from being paid to any present state employee.
• Its constitution should be amended to prohibit paying any form of pension to elected officials, present or past.
• Its constitution should be amended to prohibit public employees’ unions in the state from lobbying officials or striking for pay.
• Its constitution should be amended to bar any present holder of statewide office or member of the state legislature from seeking re-election or holding statewide office or serving in its legislature in the future. That is similar to the provisions of the 14th Amendment and is completely appropriate under the circumstances.
• State payrolls should be cut until the state is in sound fiscal shape.
• A freeze on state taxes for at least five years.
• If, after five years of belt-tightening, the state continues to be unable to come into sound fiscal shape, only then will it be able to seek additional revenue via a gradated income tax.