Hey everybody. Dylan here. Writing another community-oriented COVID-19 post for you here. Where I’m sitting, in Lubbock Texas, isn’t as high in cases as we’d expected a few days ago when the numbers started to jump. These trends aren’t necessarily linear, but as I wait for the situation to deteriorate further, I can’t help but wonder if it actually will or not.
Writing philosophy has taught me that sometimes the right question is more important than any answer — in this article, I’ll walk you through seven unresolved questions on my mind and show you a few of the resources that have helped to shape my views on this, among other things.
1. The outbreak seems to be spreading at a slower rate than it might have been. Did we do well at controlling the outbreak or did we do poorly at testing? Both?
In the case of testing, the US Government repeatedly lied to its citizens and sat on its hands. A Trump travel ban in late January had no effect upon the most potentially harmful passengers it was enacted to prevent from entering the US, and efforts to procure and distribute PPE to the nation’s hospitals to protect doctors and nurses so that they can protect the rest of us have come up more or less emptyhanded. 3D printing is surging in popularity as individual people take responsibility for meeting this need on their own.
In addition, we’ve set records for how badly our tests are working in practice as well as how slowly testing was implemented. The fact of the matter is that nobody has any idea how many cases there are in the United States — we’ve never known, this whole time, not for a minute. There’s a funny sort of cognitive bias that creeps up when you’re hearing numbers reported each day; we begin to assign meaning to them. In this case, that meaning is flat out wrong. The inadequacy of testing ensures that 4 to 7 out of ten tests will come back negative, regardless of the fact that the subject being tested is COVID-19 positive.
I’ve heard of multiple cases of people I know — one man’s wife is ill with this disease, but they refused to test him or their infant daughter. That’s 2/3 of the cases in that household which went completely unreported, due to the scarcity of the test. While it is completely sensible to withhold tests in cases where it would not inform care, we need to remember that the numbers being reported at the national level have absolutely no bearing on the number of cases which exist in the wild. Though many of these cases are not severe, New York City is reporting a surge in at-home deaths which almost certainly has to be linked to the COVID-19 outbreak, which it will begin to report as suspected COVID-19 deaths.
2. Reinfection. Is this still a thing?
Early reports from China suggested that an elderly man was released from the hospital after beating COVID-19, but readmitted a few days later — for another COVID-19 infection. We still do not have much information about how or why this occurs. See this article from the New York Times if you’re interested in infecting yourself to get this over with. HINT: Don’t do it! We still do not know whether this disease is something the body is able to develop immunity to. Herpes, for example, is a life-long infection once it is contracted.
The biggest concern here is how our society will change if we determine that immunity is impossible or unlikely with SARS-CoV-2, the virus that causes COVID-19. There was only one strain of the virus in late 2019, but now, as people around the world have been infected, it has mutated into at least eight different strains. If more than one of these is active in an area, it could be that the virus is a normal virus but there are multiple versions. This would explain the reinfections seen, for example, in the Shenzen children who were studied. Still, it would appear that reinfection does not occur in monkeys, and this likely rules out the Herpes-like dormancy/outbreak model. So what we’re left with is two possibilities: false negatives from testing, which are widespread and well-documented, and multiple strains of the virus which are somewhat less known. Have a look at this article if you’re interested in this thread of the discussion.
A quick edit: Antibody levels have been found to be low after infection in people who recovered. It looks like the body has a hard time developing immunity to COVID-19 for this reason.
3. Hydroxychloroquine. Help or harm?
Hydroxychloroquine is manufactured by a company with financial ties to the US President, leading to ethics concerns about his interest in the drug. While doctors everywhere will quickly point out that it is not, in fact, a wonder drug that is able to eliminate COVID-19 from the body, and human trials on active cases have shown a similar mortality rate to other treatment measures, it is becoming more difficult to have an opinion on this treatment method, despite the fact that the Chinese are reporting excellent results with this medication.
The general use of the drug seems to be to shorten the duration of the hospital stay, which helps to flatten the curve and allows more patients to be treated who would have died without lifesaving intervention — but the intervention in question is certainly the ventilator, the IV fluids, and the general bright spots of modern medicine, not so much an untested drug just now undergoing its first major American clinical trial in New York City.
4. Drugs to avoid: ibuprofen, Tylenol (?), other NSAIDs?
People are still avoiding ibuprofen after the WHO recommended against it and later walked back its recommendation last month. As this article discusses, the debate raged for a few days and was ultimately more or less tabled without resolution. As a former researcher who looked into the deleterious effects of common pain medications, I was particularly susceptible to this debate — and I still know the gist of it better than most of the people writing about it.
The worry is that all of these drugs function as COX-2 inhibitors. COX-2 is an inflammation pathway that is downstream of ACE2, which researchers believe is a major cellular entry point for SARS-CoV-2. So taking a COX-2 inhibitor, which turns off the COX-2 pathway — and I haven’t found anything particularly conclusive on this, which is mildly frustrating — seems likely to relieve inflammatory symptoms precisely by upregulating ACE2, whose role is to regulate oxidative stress and mitigate damage when blood pressure increases.
As the Louisiana outbreak continues, data are rolling in which support the thesis that the most dangerous comorbid condition to have in a COVID-19 outbreak is hypertension. Blood pressure is regulated by the renin-angiotensin system, which I don’t have time to explain here, but the upshot is that ACE2 is part of this system, which maxes itself out in hypertensive conditions. ANG is the hormone which leads to increased blood pressure, and as ANG levels increase, ACE2 levels also increase. Maddeningly, there is still very little conclusive data on the COVID-19 pandemic and hypertension, but I suppose one day we’ll look back and know all of the details.
5. The economy: it’s all bad.
A few people the past few days have reached out, some about billing and cashflows in this crisis — I believe the hospitals are actually furloughing a lot of workers who are involved in nonessential services. The economy is taking a huge hit and New York, among other states, is cutting the budget to match.
At every stage of this crisis, the naysayers have really rapidly seized upon this narrative of “just let people die, then! It won’t be so bad! Don’t wreck the economy for this!” and frankly, there’s a grain of truth to this statement: 300 million people broke or starving in the US would NOT be a pretty sight — especially given the number of guns we have here.
That said, it isn’t really a choice between the economy and the lives of a few random seniors — this is a disease that kills indiscriminately, and at a high enough rate to scare the hell out of anyone with half a clue, whether they’re 20 or 89. Additionally, it’s a debilitating disease that can leave lasting damage to the lungs and heart. A lot of what people value about their lives is centered in their bodies, so the prospect of a life with a new handicap is something people want to avoid as well.
What I’m saying is that the economy is going to tank regardless of what the government does to slow or stop the spread of the disease. More small businesses will fail, lay off workers, and stop seeing customers. Regardless of what else happens. So the question then becomes whether or not the government is able to step up to help citizens manage this pandemic, which, overwhelmingly, it has yet to accomplish.
6. Social fallout?
About two weeks ago, social unrest memes circulated in Italy, speculating that such would be the case for the US in about 3 weeks. I do not see much evidence to support this conclusion — the number of US cases has dwarfed the Italian outbreak and does not show much sign of slowing or stopping even in New York City, which has been ravaged for weeks now.
That said, any time the system suffers a partial collapse such as the present one there is bound to be some social unrest that goes along with that. Reports of muggings over groceries and unpaid rents are merely the tip of the iceberg on this, as the economy will likely continue to languish as long as the disease rampages through the streets.
Workers who aren’t working aren’t getting paid, aside from a small tax credit and a bump in the unemployment insurance program. Still, governments around the world have done far better for their citizens than the US Government, which seems intent only on enriching the family of Donald Trump at the moment. People are extremely angry about this state of affairs in many parts of the country, but it is difficult to say what their options are. Donald Trump has already been impeached, and is facing many federal felony charges when and if he leaves office, but somehow the US Government has forgotten how to remove a president from power and US Attorneys agree that it is unlawful to even prosecute one.
7. Duration of Shelter in Place?
Lastly, the ultimate question: how long will Shelter in Place continue? Some states, no doubt, will attempt to lift Shelter in Place guidance sooner than others. The abdication of the duty of managing this by the federal government has led to a dramatic series of controversies between governors, putting many of them into difficult positions as they work to appease the religious right who put them in office while avoiding the potential to harm their constituents.
In many Southern states the old Trumpian narrative of “it’s the flu” or “it’s not going to be that bad here” still echoes around the smaller towns, even as more cautious citizens of these same areas take precautions themselves such as wearing face masks in public. The unfortunate truth for us all is that we’re in this together, and the sooner we figure out how to respond to the threat together, the sooner we’ll be done with it — but there is no consensus as there is little or no certain knowledge to base such a consensus upon.
The anxiety we all feel, locked in our houses and apartments throughout this nation, is a real one. It is caused by actual events. We can’t know how long it will go on for, or whether it will change everything for us, time and time again. We can only muddle through as best we can, make sense of the situation where and when that becomes possible, and ultimately strive to find joy and happiness where the current sets us down eventually.