Covid-19 Diary : Tuesday 24 March 2020

 

It is so quiet.  Now that my state (WA) is under a lockdown, I went outside this morning and consciously listened, something I occasionally do.  Normally, when you actually force yourself to listen, you get to hear all the sounds you generally tune out – cars, trucks, motorbikes, sirens, airplanes overhead, machinery nearby, and so on.

But this morning, what did I hear?  Not the steady rumble of traffic, but instead, an occasional infrequent single vehicle disturbing the silence.  Well, not a complete silence.  I heard birds, some wind in the trees, and in the distance, the laugh and chatter of children at play.  It was idyllic and peaceful, but all things considered, I think I’d be more comfortable hearing the normal noises of everyday ordinary life as it used to be, just a day and a week ago.

Some regrettable milestones passed in the last 24 hours.  The US set a new record, both for itself and for the entire world, with over 10,000 new virus cases in a single day.  No other country has ever “achieved” that.  Italy’s worst day was 6,557, and it seems possible – even probable – that their daily new case count has stopped increasing.  It was still a terribly high 5,249 for today, but compared to 6,557 a few days ago, that’s a very welcome drop.  The best part is seeing the daily case count stabilize rather than relentlessly and exponentially increase.  Maybe Italy’s strong movement restrictions are starting to have an impact.

China’s worst ever day, apart from one anomalous day, was 5,090 new cases.  These days, new cases are under 100 a day and often under 50 a day, and largely from people coming into the country from elsewhere.

The other milestone is total worldwide cases climbed past 400,000.  In the last week, we’ve crossed 200,000 and 300,000, but now, adding another 100,000 cases no longer seems so extraordinary.

We were so pleased to see Dr Fauci back in attendance at the daily Presidential briefing today, standing closest to the President, and being invited to comment on issues.  His absence was becoming a point of concern.  But we wonder how much of that concern was generated by the media – this video clip has Dr Fauci describing his relationship with the President, in his own words as part of a television interview.  I think his own words are a more persuasive statement that anti-Trump commentators trying to create problems where perhaps none exist.

I Am Not a Doctor, But….

I’ve had some people disagree with me on this topic, perhaps because of President Trump’s qualified support for the idea.  But now that Governor Cuomo has also endorsed it, can we take the politics out of the medicine?

If you’re reading this, you’ve already self-selected as being massively more intelligent and thoughtful than the couple who heard a soundbite about Chloroquine, discovered that their fishtank cleaner included chloroquine phosphate as one of its ingredients, and so started taking it by the teaspoon-full, with fatal effects for one person.  The survivor is now blaming her husband’s death on President Trump.

You deserve to be advised of things where value judgments and caution are required.  But please don’t blame either me (or the President) for the consequences of what you do with the information being presented here.

I certainly don’t want to be blamed for any deaths!  But that “any death” door swings both ways.  Yes, for sure, there is a risk of serious side-effects extending even to death if any drug is used inappropriately, or taken in 10/100/however many times greater concentrations than is recommended.  For that matter, there isn’t a thing on this planet, starting with oxygen and water, that doesn’t impact on our body when ingested, in various ways including possibly (some might say invariably and inevitably) negatively.

Which bring me to the other side of the equation.  If there is a drug out there that generally does not harm the people taking it, and which might help people infected with Covid-19, shouldn’t we try and break free of the restrictive grip of the medical monopoly (surely the most “closed shop” of any line of business in the world) and be free to make our own risk assessments and decisions?

It is one thing to be cautious about brand new “super-drugs”.  But if there is an existing drug out there, well-known, well-tested, and free of surprises, one that has been used for other purposes and which may unexpectedly be useful in another role as well, then it seems the downside is minimal and the upside potentially significant.

So, let’s talk some more about chloroquine.  This is not some new controversial discovery.  It is a drug that was discovered in 1934, has been in general use since the 1940s, and is on the WHO Model List of Essential Medicines, a list of its “top” essential medicines, currently featuring about 450 entries in total.

Millions – perhaps even billions – of people have been taking it over the past eight decades, primarily as an anti-malarial drug, but also for other purposes such as lupus and rheumatoid arthritis.  Like every medicine, there are some side-effects, and possible combination reactions if taking with other drugs at the same time.

In the US, in 2017 in the hydroxychloroquine form, it was the 128th most prescribed medicine in the US, with more than 5.6 million prescriptions being written for it.

We’re not going to say the drug is 100% safe.  It clearly isn’t, and there is, among other side-effects, an alarming potential for permanent eye damage as a side effect.  But it is a common ordinary drug in widespread use in the US and many other countries at present, although it can only be obtained via prescription, not over-the-counter.  The only way to obtain the drug without a prescription is to go to one of the off-shore pharmacies and buy from them (see below).

It is primarily the hydroxychloroquine form that is being investigated as a possible treatment for Covid-19 infections.  Initial results appear positive.  They’re not 100%, nor are they sudden and miraculous.  But they are encouraging.

Tests have been done using this drug in combination with a moderately common antibiotic, Azithromycin.  It seems that combining the two has a stronger beneficial effect than using the hydroxychloroquine by itself.

If you decide you want to at least have a supply on hand – maybe just to have in the event of shortages later (hydroxychloroquine is already becoming scarce and rationed in US pharmacies because doctors are rushing to grab some for themselves, which is, itself, a significant thing to consider).  This would mean that if you’re diagnosed with Covid-19, and it becomes impactful/severe rather than inconsequential, you can at least discuss the option with the heathcare professionals caring for you, and if they say “Well, yes, we’d prescribe this for you in an instant, but there’s none available” you can then disclose you actually have some already.

We do not recommend you should take this daily as a preventative.

If you decide you might want to do have some of this drug on hand in case of future need, we suggest you do your own due diligence about dosage and also check to see if you’re in a category of people who should not use it, and check to see if it might react with any other medications you are currently taking.  Useful sources include medscape.com, healthline.com, rxlist.com, and others.  A quick search on Google can get you to plenty of professional reference sites.

We’re not being unhelpful, we just don’t want to get in trouble by giving medical advice.  We certainly found the information readily ourselves, and perhaps you should consider this a qualifying test – if you can develop a reasonable understanding about the dosage, the frequency of dosing, the duration of the course of medicine, and understand the side-effects and other issues, then perhaps you can become your own doctor.

If you decide to get some, then you can try asking your doctor for a “just in case” prescription.  Alternatively, you can order online through one of the off-shore companies.  A reader reports having had consistent good results with https://allinonerxmarket.com/ over a number of years, and I’ve just placed an order with http://www.canadian-pharmacy-24.com/ (which is not at all Canadian!) and will let you know how that works out, too.  I’ve never used them before, and ended up selecting them more or less as a coin toss, there are a number of other potential choices too.

There is always a danger that packages of medicines sent from overseas might be intercepted and seized by US Customs.  That has never happened to me or anyone else I know, but who knows what will happen next time.  The order I placed today included an “insurance” option – if your package doesn’t make it to you, they’ll reship it a second time for free.

I ordered some other medicines too.  I am keen to avoid doctors’ offices at present – it is hard to think of places where the coronavirus is more likely to be concentrated than a doctor’s office!  Plus, who only knows how hard/easy it will be to get an appointment as our entire healthcare system gets more and more overloaded by Covid-19 patients.

So I asked myself “What are all the prescription medicines I have had in the past and foreseeably might need again in the next couple of years”?  Fortunately for me, that is a simple short list, so I added a general antibiotic in case of a strep throat or various other type bacterial infection, and some Tamsulosin in case of (sadly, I should say “when”) I next get another kidney stone attack, declined the free sample drugs the company was keen to give me, and now am hoping to get the order delivered sometime in the next 3 – 8 days.

Cautionary note, restated :  I am not a doctor, and probably you are not one, either.  There are reasons why prescription medicines require a physician’s approval.  Of course, not all countries agree as to which medicines can and can’t be dispensed over the counter, so while our authorities believe certain drugs are “ethical” – ie, can only be dispensed by accredited physicians – that is not a universally held truth.

If nothing else, if you’re able to at least conversationally ask your regular doctor if there are any specific concerns that apply to you in particular regarding the medicines you are mail-ordering, that might be helpful.  But if you don’t have a good relationship with your doctor, they’ll probably not answer your questions and just give you the standard lecture about how you shouldn’t do any of this.

Statistics

Several changes on our top case rate list today (which I’ve now allowed to grow to seven countries), including the return of Vatican City, which had dropped off the list yesterday.  The new top countries in terms of infection density are

    • San Marino/187 cases/the equivalent of 5,511 cases per million people (no increase from yesterday)
    • Vatican City/4/4,994 (they had three new cases today which skyrocketed them back up the list)
    • Faero Islands/122/2,497
    • Andorra/164/2,123
    • Iceland/648/1,899
    • Luxembourg/1,099/1,765
    • Liechtenstein/51/1,338 (no increase from yesterday)

Worldometers has now started tracking another relevant statistic.  They’ve of course been tracking total deaths per country right from the start, but they’ve now added another column to express deaths in proportion per million of population.  This is a meaningful measure, so here are the top five countries, showing death rates per million.

    • San Marino/21 total deaths/the equivalent of 619 deaths per million
    • Italy/6,820 deaths/113 per million
    • Span/2,808/60
    • Iran/1,934/23
    • France/1,100/17

To put those numbers into context, the death rates per million in US/UK/Canada are 2/6/0.7.

For major countries and/or outbreaks, and in general :

Same Day
Last Week
YesterdayToday
Total Cases197,766378,394417,676
Total Deaths/Percent of all Resolved Cases7,954/8.9%16,491/14.0%18,605/14.7%
Active Cases (ie not yet died or cured)108,121260,319290,759
US Cases/Deaths/Case rate per million6,211/102/18.843,449/545/13152,996/685/160
UK Cases/Deaths/Case rate per million1,950/71/28.76,650/335/988,077/422/119
Canada Cases/Deaths/Case rate per million479/5/12.72,091/23/552,590/25/69
Worst affected major country/case rateItaly/521Italy/1057Italy/1144
Second worst country affectedSwitzerland/317Switzerland/1016Switzerland/1141
Third worstNorway/271Spain/751Spain/853
FourthSpain/254Austria/497Austria/587
FifthIran/193Norway/483Norway/513

If trends continue, tomorrow will see Switzerland with more cases per head of population than Italy.  On the other hand, it has a much lower death rate (14 compared to 113 per million).

Talking about death rates, the closed case fatality rate inexplicably continues to grow.  The percent of severe/critical cases to current cases continues to reduce and now is 4.5%, but the death rate has climbed further to 14.7%.  How/why is this happening?  Why is it not trending down, as every analyst and prediction is suggesting?  And, most of all, each day gives us more data from more sources, meaning that this figure is becoming more meaningful and statistically significant.

We’d love to see a medical professional’s take on this.  The only thing we can say is perhaps it takes longer for a survivor to be finally cleared and declared a closed case than it takes for someone who dies.  But if that was so, we’d still expect this timing discrepancy to reduce in significance as the total time series extends.  That had been what we initially observed, but then it inexplicably turned around and the death rate has been growing ever since, as you can clearly see from the chart above.

It is several days since I showed my chart that details the comparative rate of cumulative death numbers for different countries.  I’ve slightly changed the assumptions from the previous chart (I think it was shown on Saturday or Sunday), moving the data series for the UK forward one day to match its data more closely to the other countries.

I’ll just show the “overview” chart today, which is interesting for perhaps two reasons :

  • Iran’s continued very slow increase in deaths, almost exactly matching that of China
  •  Spain’s growth in deaths is happening faster than in Italy

Who Should Pay?

I was astonished to see Congress trying to attach various provisions to the “Save the Country from the Virus” spending bill currently being debated, to provide money for things as varied as studying airplane effects viz a viz “global warming” and/or possibly setting new emission standards on airlines (these things are changing all the time); tax credits for solar and wind energy (yet again – why no tax credits for the cleanest and cheapest form of power of all, nuclear?); mandatory voting; $300 million for migrant and refugee assistance, $35 million to the Kennedy Center, and a requirement for diversity reporting in corporations.

The list goes on and on and on.  Why do our politicians never see any spending bill without reflexively seeking to add to it, in any unrelated way they feel they can slip in.

Timings And Numbers

An interesting study was released today by a group at Oxford University in the UK.  If their assumptions are correct, then perhaps half the UK population has already been infected by the virus, and in large part, has already recovered from it.  Unfortunately, they start off their complicated research with a huge assumption – that many people will get the virus and not be hospitalized, and then in a somewhat self-referential manner, end up more or less saying “if our assumption is correct, then these numbers prove that the assumption is correct”.

That’s a meaningless statement to make.  Their conclusion is we need to be testing a large random sample of people, and testing to see not just if they have the virus at present, but if they have had it in the past too.  Those results will give validity to their assumption, or contradict it.

Their paper, which I’ve uploaded to my site and you can access here, is complex and dense for the non-statisticians among us.  But even the thought it might be true is extremely uplifting.  Don’t go giving away all your spare toilet paper just yet, but they end up saying that meaningful testing of their analysis should be possible to a degree that would reasonably confirm or contradict their analysis in the next few days – perhaps even by the end of the week.

WHO has now declared that the US has become a potential epicenter for the virus.  This article, reporting on their rather obvious statement, says that now 17 of our states have lock-down orders in effect.  How long for the other 33 to follow?

Talking about lockdowns, enormous India has a mere 519 cases and very slow growth in new cases.  But that hasn’t stopped it from also instituting a national “total lockdown” for 21 days, to ensure the virus doesn’t get out of hand.  It seems that India truly does understand the exponential curse of the virus.

They’ll probably continue to report growing cases for the next week or even two, but then as the lockdown effects start to take over, we should see them return back to a very low level of new infections.

India is definitely doing the right thing.  Why can’t our other 33 states do the same thing?

Closings

There are further collapses in air travel.  Yesterday, the TSA reported screening a mere 331,000 flyers, which is a mere 14% of the same day last year when there were 2.4 million flyers.  So we expect to see further massive cuts to airline schedules.

I heard from a friend in the Denver area.  He went to Costco early today during its one hour “for the over-60s” special opening, and saw a long line wrapped at least halfway around the building.  He also noticed a lot of “very young looking 60+ year old folk”.  I wonder if Costco – and other retailers with similar policies – asks for proof of age during their special opening hours.

He chose not to wait, and went back to it in the afternoon during ordinary hours.  At that time there was no line or crowd inside the store at all, and most of what he wanted was available for purchase.  It would be interesting to know if that experience is being repeated elsewhere, too.

Shortages

I had expressed concern yesterday that the predicted ongoing reduction in airline flights would create a crunch for commercial freight shipping.  Perhaps that was an unnecessary worry – airlines (most notably AA) are responding to the opportunity by now scheduling cargo only flights.  Good for them.

Here’s a great example of how the business community is coming together to address the desperate needs for more respirators, ventilators, and other medical gear.

Logic?  What Logic?

The idiocy of people still disappoints and dismays us.

Virus?  What Virus?

Medical

Here is a great video that shows what happens when you cough, and how far your cough impacts.

Of particular note is that most masks (ie non-respirator type masks) do not stop a cough.  They greatly reduce it, but they’re not a magical cure-all invincible shield.

While we are variously hoping and even weakly being promised cures and vaccines for this virus, here’s an important article that puts things in a more realistic context.

Money

The Dow soared today, rising 11.4% and closing back over 20,000, at 20,705.

But when you look at the last month, and in particular, since the beginning of March, occasional rallies are not unusual and the total amount lost is much greater than the recovery today.  We had been at over 27,000 before the plunge started.

Rumors

Other

This is an interesting example of what we need to be doing – monitoring everyone in the country through their cell phones and close to real-time, matching our whereabouts with those of people thought to be infected and alerting us of this.

Yes, that is ultra-invasive of our privacy.  No two ways about it.  But that privacy invasion might be an acceptable trade-off if it allows us greater freedom of movement, and simultaneously reduces the spread of new infections through our communities.

And if you think it would be impossible to monitor almost 350 million people simultaneously, well, there’s at least one three letter agency that could contradict you.

Please stay happy and healthy; all going well, I’ll be back again tomorrow.

 

Please click here for a listing of all our Covid-19 articles.

5 thoughts on “Covid-19 Diary : Tuesday 24 March 2020”

  1. David,

    I have been enjoying your daily Covid-19 articles, especially your interpretations of some of the data. However today you definitely disappointed me with your “I am not a doctor, but… ” recommendations to your readers.

    First of all, the French study was done on only 20 patients, and was not a randomized study. As a statistician, you should know that 20 is not a large enough number to give us any real statistical evidence – especially when it was not randomized, nor blind, and not all patients even had their virus load measured after taking the drug! Until there is a real study done on the use, we don’t know if it is helpful or even hurtful to patients with Covid-19.

    Secondly, IF it is indeed helpful, then rather than urging readers to go out and get some, should we not let doctors be the ones to decide who needs it most? By suggesting your readers order these drugs, you are contributing to possible misuse which could prove harmful or even deadly to your readers. Even worse, you are helping create a shortage of a medicine that possibly could help patients in need. Neither of these situations is good.

    Lastly: I would really like to have you clarify what you mean by “shouldn’t we try and break free of the restrictive grip of the medical monopoly”. Are you referring to pharmaceutical companies? Physicians? Medical insurance? Please do clarify.

    I’ll look forward to reading more of your updates, but personally am going to avoid your medical suggestions and recommendations and rely on a “real” doctor for my medical advice.

    1. Hi, Mary

      Thank you for your polite and well written note.

      I was not recommending anything to readers in the section about hydroxychloroquine and other medicines. I was attempting to dispassionately disclose information, and encouraged – indeed, required – readers to then go and make their own decisions based on their assessment of the evidence.

      As a statistician, I actually do know that you can learn a great deal from a group of 20 responses, and sometimes to surprisingly high confidence levels. Besides which, how much confidence do you need when told “Here’s a drug, used billions of times over 80 years, one of the most common drugs in the world, which might also help reduce the effect of the coronavirus. It will cost you $25 for a course of treatment.”

      If you were told “There is 90% chance it will help” would you spend the $25? Now, what say you were told “There is a 10% chance it will help”? Would you still buy the $25 treatment? I sure know I would.

      But, notwithstanding the comments above, that isn’t the point I was making. I did not say there was a French study that proves the value of this drug. I did say the drug is widely used with what are deemed to be no more than acceptable side effects for most people, most of the time, in other situations, and that while there were no guarantees, on balance it seemed to be a case of probably won’t do harm and might actually do good.

      I totally do not accept the canard of “contributing to possible misuse which could prove harmful or even deadly”. Rather, I’m attempting to assist with better more informed choices – who among my readers is likely to now rush to buy fish tank cleaner and then consume it in vast quantities?

      Creating a shortage of medicine? So the 30 tablets I ordered from a mail order pharmacy in India (population 1.3 billion) is going to materially impact on the global supply of this drug? Remember that probably 6 million prescriptions and who knows how many refills for it were written in the US alone in the last year – this is not a drug in desperately short supply, other than due to the standard practice of pharmacies doing “just in time” stocking and never carrying more than a few days inventory in house. They make the pills in batches of many millions.

      Now, most importantly, we absolutely should not let doctors decide our future. Oh my goodness me, what a terrible thing that would be; the way it used to be 100 years ago, when doctors wouldn’t even tell patients what was wrong with them.

      Do you have no desire to live? Do you really think that a harried doctor, having worked double shifts for the last some weeks struggling with the Covid-19 pandemic, and probably seeing you for the first time, for five minutes, before rushing on to the next patient, is going to make a careful and wise adjudication as to if you should live or die?

      Call me selfish, or possibly call me sensible, but I have already made that decision, so as to spare the doctor. I’ve decided to survive, and to live. I am leading my life as best I can to optimize my chances of doing so.

      I’m not going to answer your rhetorical question at the end, other than to suggest that “all of the above” would not be a wrong answer.

  2. David – I agree completely with Mary on this. Apart the merits or otherwise of the drug in question, ordering from random internet sources is extremely risky. Regarding your comment about “harried doctors” — it’s irrelevant. When I need a prescription drug, I’m not simply relying on my own GP. I’m relying on a series of institutions and agencies set up to try to protect me and people like me who are not knowledgable enough to judge the risks. It’s irresponsible to advocate an end run on this system at a time like this. Whether or not it’s a monopoly — or oligopoly — is arguable, but at another time and in calmer circumstances.

    1. Hi, Fred

      Yes, buying medications online may be risky. There are occasional stories of fake medicine being sold online, although I’ve no idea if the prevalence of this is 50%, 5%, or 0.005%. I take encouragement from the reader who referred one such site and said his medicine has been “real” for some many years so far.

      On the other hand, guess what. Covid-19 is also risky, particularly for people in our age ranges. It is a case of balancing risk. Are we knowledgeable enough to make those decisions ourselves, or should we – as you advocate – rely on a shadowy series of institutions and agencies set up to protect us?

      Should we rely on what WHO tells us – surely the agency at the top of that pyramid? You know, the agency that was telling us there is no evidence of human to human transmission, even though they’d been advised several weeks prior of convincing credible evidence of exactly that? The agency that was telling us there was no need to screen people arriving into countries, and no need to worry about China?

      At a more national and local level, should we rely on the same agencies/organizations that have failed to anticipate and respond to the general and specific threat of this pandemic? The same ones that failed to adequately maintain stocks of PPE, masks and ventilators in case of such events, who allowed inventories to drop in 2009 and never replenished them? In what exact way have these agencies earned our trust other than telling us “I’m from the government and I’m here to help you”?

      And how exactly do these agencies translate down to that critical flash five minute exposure in front of a doctor? He’s going to run through the agencies’ official checklist of who to treat and who to leave to die outside the door. We’re both in the “too old” category that Italy is now using. If you’re over 60, you’re out of luck. So are you just going to “take it like a man” and go home to quietly die?

      I’m not. Surely the ultimate freedom we have is the freedom to control our own life and outcomes. I’m exercising that freedom as I see fit and as I believe best for me, in my particular circumstances. After all, I’m the person who most gets to benefit or suffer from the decisions made about me – I’d like to be able to participate in those decisions, not accept what people from shadowy institutions and agencies decide.

      Most of all, here’s the thing : I’m not arguing at all that you must take control of your own life and future. By all means passively trust that the government agencies know best. I’m simply saying that we all should have the right to choose what we do and how we do it.

  3. WHO? Seriously? A strawman argument if I ever saw one. WHO does not regulate pharmaceuticals or the medical profession. In your case that would be the FDA and Washington’s state licensing commission. I’m not sure I would refer them as “shadowy institutions and agencies” but if that’s how you regard them I guess you can get politically involved and try to cause them to change instead of going rogue and sourcing your meds and screengrabbing (or conveying) advice from unregulated sources.

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David.