A Narrative: Coronavirus, Oxygen Monitors and the FDA

Working flat out to produce possibly unnecessary ventilators         

We learn more all the time about Covid-19 SARS-CoV-2.  Below are some pieces of the puzzle revealed just this month.

1.  From the Emergency Room

 A New York emergency doctor, Richard Levitan, shared his observations about the role of oxygen deprivation in a widely read New York Times piece several weeks ago.  From his discussion:

...(W)hen Covid pneumonia first strikes, patients don’t feel short of breath, even as their oxygen levels fall. And by the time they do, they have alarmingly low oxygen levels and moderate-to-severe pneumonia (as seen on chest X-rays). Normal oxygen saturation for most persons at sea level is 94 to 100 percent; Covid pneumonia patients I saw had oxygen saturations as low as 50 percent.

Patients compensate for the low oxygen in their blood by breathing faster and deeper — and this happens without their realizing it. This silent hypoxia, and the patient’s physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until oxygen levels plummet. In effect, patients are injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.

By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator.

(Note:  The comment that patients compensate for hypoxia by breathing deeper may suggest why cigarette smokers have slightly better outcomes from this disease -- they've had more practice.)


2.  Behold the Oximeter

Dr. Levitan says that oximeters, cheap blood oxygen trackers that have been sold over the counter for decades, can be of great help -- informing people what is wrong when they are in the early or middle stages of this coronavirus.

Before reading his article, I had never heard of oximeters.  I learned only this week that a good friend keeps one by her bed.  She got it when she had pneumonia and after she had gone to the emergency room because she was having a hard time breathing.

Like many others, I am glad finally to know about oximeters now.  I definitely would consider getting one, but I'm pretty sure they are as difficult to find as toilet paper was last month.


3.  A Missed Chance

Curiously, if not for the US Food and Drug Administration and its tender concerns for our health, oximeters could have been available to many millions of people worldwide.

The agent of this availability would have been a surprising one: the Apple Watch, which tracks wearers' health information, starting with steps taken each day, to how much time is spent sitting or moving, to pulse rates, to exercise this year v. last year, and so on.

In fact, Apple Watches were designed and built with oximeters inside them, but these have NOT been hooked up for watch owners to use because getting FDA approval for such would have taken too long and delayed getting the products to market.

How this came about and why this is so is revealed in a somewhat cranky article published a few days ago.

Under current FDA regulation, the function is disabled. It’s another example of how federal regulation of the production and distribution of pharmaceuticals and medical devices in the United States is less focused on stopping viruses and other diseases than on blocking private-sector innovators from developing solutions that may not work or might have harmful side effects.

But, cranky or not, the article's point is fair.  Oximeters are time-tested, reliable and effective.  If the owners of Apple Watches were able to make use of those watches' oximeters, much good would have resulted.

Imagine if your grandfather had taken to his bed six weeks ago with a fever and a cough; imagine that you could put your watch on his wrist and, from it, learn that he was seriously oxygen-deprived.  You could have got him help before he needed to be put on a ventilator.  You possibly could have saved his life.

It doesn't take an imagination to grasp that this scenario could have played out in a non-trivial number of situations this year.  It would have helped many people.  At least at the margin, it could have reduced the demand for ventilators and the stress on emergency rooms and intensive care units.

Don't ask me why the FDA would require a lengthy permission and approval process for something so simple and basic.  What harm could it have done?


4.  Other Priorities

 The FDA continued to protect us from other health dangers even this week, when the number of US coronavirus deaths passed the 61,000 mark.

Just last Monday, when the entire economy was all but comatose, the FDA announced that it was sending warning letters to 10 different manufacturers ... of backpacks and sweatshirts.

"The public should really be outraged by these products," said Mitch Zeller, director of the FDA's Center for Tobacco Products, reports yet another article.

The products being targeted by the FDA ... (are) ... designed with stealth pockets to hold and conceal an e-cigarette; vaping products that resemble smartwatches or children's toys such as a portable video game system or fidget spinner; and vaping liquids that imitate packaging for food products that often are marketed and appeal to youth, such as candy, or feature cartoon characters like SpongeBob SquarePants.

Egads! Stealth pockets! Children being tempted by Sponge Bob to take up smokeless nicotine!  Where would we be without the FDA to protect us?

In fact, governments are all over the vapes industry.  Flavored vapes, apparently pitched to children, have been banned at the federal level and are being more extensively banned in various states.  A number of states' attorneys general are cuing up a great big civil suit, rather like the one that shook down the tobacco companies.  The biggest vape maker, Juul, also seems to be under financial stress.

Good to know the FDA is all over the fashion/toy end of the e-cigarette matter. 


5.  Comparable History

Could the FDA have gone a bit too far?

The FDA arose after the 1906 passage of the Pure Food and Drug Act of 1906.  The idea was to make sure that only pure products -- including cocaine, which was legal at the time -- were sold to American consumers.  (To my knowledge, the FDA has yet to take an interest in quantifying the THC strengths of ever-more-potent marijuana strains.)

In 1920 came the Volstead Act, a Constitutional amendment known as Prohibition, a failed effort to rid the country of alcoholic beverages.  Prohibition ended in 1933 when the state legislature of Utah (Utah!) provided the final vote to repeal it.

Between 1920 and 1933 people innovated to conceal their illegal alcohol.  Among the popular products were slim flasks to carry distilled spirits.  For men there were flasks that fit in the breast pocket of business jackets and hip flasks for the back pockets of trousers.  Some women wore stocking flasks on their legs

At right is an image of men of that period enjoying liquor from a flask in broad daylight.  Can you imagine?

If our current activist FDA existed at that time, there would be investigations and prosecutions of flask manufacturers and, then, demands that pockets be eliminated from men's jackets and trousers.  Just for people's protection, of course.

In fact, the FDA mandate to regulate devices and associated products came long after Prohibition ended.

But just as ridding the world of alcohol flasks and flask pockets would have been widely resented a century ago, inspecting children's clothing in searches for "secret pockets" seems like a bit of a stretch today.


6.  The Sad Legacy

Back to Dr. Levitan, who wrote the commentary at top after 10 days in the emergency room at Bellevue Hospital.  (The piece merits a read in its entirety and is available online even to nonsubscribers.) Toward the end, he has this recommendation:

All patients who have tested positive for the coronavirus should have pulse oximetry monitoring for two weeks, the period during which Covid pneumonia typically develops. All persons with cough, fatigue and fevers should also have pulse oximeter monitoring even if they have not had virus testing, or even if their swab test was negative, because those tests are only about 70 percent accurate. A vast majority of Americans who have been exposed to the virus don’t know it.

If not for an FDA barrier, a serious portion of the world's 100 million Apple Watch wearers would know what an oximeter is.  Those same people could check their oxygen capacity if they fell ill this winter.  They could have shared what they knew, or shared their watches, with friends or relatives who got sick and who, like this writer, never knew that oximeters even existed.   Such information spreads fast, and it is extremely valuable in volatile situations like the current one.

We cannot guess at the numbers of people who would have got earlier treatment, who would not have ended up on ventilators and, yes, who would not have died if they learned in time that they were seriously oxygen-deprived.  All we know is that there are such persons and that having access to a simple health tracker in a wrist watch would have made all the difference to them.

I do not know if the FDA's slow-moving and process-heavy approach to approving a basic health-monitoring device was an error as serious an error as the CDC's slow, bungled and protocol-violating rollout of its failed Covid diagnostic test.  At best it was an opportunity squandered; at worst, it was an enormous blunder whose consequences have been revealed only this year.

MovieMonday: The Graduate

This movie was an unexpected hit in 1967, which itself was an odd moment in US history.  It is the story of Benjamin Braddock (Dustin Hoffman,) an almost-21-year-old college graduate who comes home to his parents' house and is asked continually what he wants to do with his life.

He is unmoved when an older fellow offers a suggestion in the film's most famous scene, below.




The most Benjamin can say about his plans for his adult life is this:  "I want it to be -- different."

He spends his summer staring at exotic fish in a tank in the basement and then becoming a sort of fish himself -- wading into the backyard pool in the scuba outfit that his parents have given him as a graduation present.

A family friend, Mrs. Robinson (Anne Bancroft,) seduces Benjamin, and they embark on a clandestine affair that seems to help him get over his extreme and extremely funny awkwardness, even if he does start smoking cigarettes, as she does.

But then the Robinsons' daughter, Elaine (Katharine Ross,) comes home from college and Benjamin is drawn to her -- against the adamant opposition of her mother.

Finally, he chooses the daughter, the only person near his age in the story.  He comes to life and pursues Elaine with great energy and against considerable odds.

In the end, Benjamin and Elaine choose each other -- effectively deciding not to be their middle-aged parents -- before they have worked out whom they plan to be instead.

The film has much going for it:  a fine screenplay with plenty of humor, excellent acting and Oscar-winning direction by Mike Nichols.

You've probably seen it once, but it's fun to watch again.


Note

The Graduate has remained popular since its release, and there was talk of a remake around the time of its 50th anniversary.  The idea was rejected, and no doubt for good reason. 

The movie is understood best as an icon of its moment.  Benjamin, who often wears a jacket and tie, looks like his parents and is cordial toward their friends.  But his restlessness suggests the discomfort that was rising among the first wave of Baby Boomers who were coming of age about the time the film hit theaters. 

John F. Kennedy was assassinated during Benjamin's first college semester.  When he and Elaine ran away, their generation had begun to agitate against the Vietnam War.  The following year came the assassinations of Martin Luther King Jr. and Robert Kennedy.   The early-60s Beatles pop music they had enjoyed as teenagers gave way to Woodstock and  the rock- and drug-inflected Easy Rider movie of 1969.  The Beatles broke up in 1970.

The movie doesn't go into the generational differences between Ben and his parents, but that probably wasn't necessary in 1967.  Mr. and Mrs. Braddock's early years were marked by the stresses of the Depression and World War II.  By the time they got around to having a family, life must have looked better than anything they had seen before.  The GI Bill made college affordable, and nearly 20 years of pent-up demand fueled a period of prosperity that continued into the 1970s. 

No wonder Ben's parents were expecting great things for him.   No wonder he didn't understand why they were so optimistic.

-----

For all its light moments, The Graduate has an undertone of what Woody Allen used to call "heaviosity."   Its music, from Simon and Garfunkel, is folky and melodious, but the song that starts and ends the film, "The Sounds of Silence," has a tone and lyrics that are downright ominous.  

The song was written by Paul Simon when he was 21 and worried about totalitarian government, and perhaps when he was like Benjamin Braddock and unsure of himself but more articulate than Ben himself.  

Testing NOW

 Marko Djurica/Reuters

The United States has a restless population straining against limitations on social meetings ranging
from family gatherings to public education to basic transportation to business operations to public elections to religious observances to restaurant meals to sports events and musical concerts.

That it came to us from China reflects badly on that country.

That we cannot rally a sufficient and timely response reflects badly on us.

What is worst is that we cannot ramp up two basic testing programs that would be the most effective ways to start digging ourselves out of this hole.


Testing for Antibodies

Three interesting but isolated news items were released this week.

1) All the residents of a homeless shelter in South Boston were tested for Covid-19.  Among the 397 men tested, 146, or more than a third, were experiencing coronavirus.  None had any symptoms.

2) A small-scale serological blood test for Covid-19 antibodies in Santa Clara, California, suggested that many, many more than the number of residents reported sick with the illness already had been infected and were done with it.
         (Experts are pissing all over this test based on who was sampled and statistical grounds, but in general, false positives are far less common on antibody tests than false negatives.)

3) A random testing of 200 persons in Chelsea, a dense Boston suburb, found that one-third had Covid antibodies and, again, no previously reported symptoms.

Tests like these are anecdotal and, yes, too limited.  BUT they suggest that what researchers long have suspected:  A significant portion of persons who become infected with Covid-19, perhaps one-third, experience no symptoms.  (I heard this most recently from a friend who is a professor of pharmacology.) Another number of those infected, also uncounted, have mild symptoms and take care of themselves at home.

In Southern California, word is that doctors and nurses (and, one hopes, other workers in medical facilities) are being given serological blood tests only now.

Antibody tests require less intensive production and analysis than tests for active infections.  Why not make them broadly available, starting in the hot spots like New York, northern New Jersey and Boston?

If you had antibodies to Covid-19, wouldn't you like to know?  Wouldn't you want to help your relatives with shopping or home schooling?  Wouldn't you like to get back to work at some job, even if your old one had been eliminated for the duration of this period?


Testing for Infection

At present, the US is doing more testing for Covid-19 than ever:  about 150,000 tests per day.

Also at present, unless you are symptomatic, you cannot get a Covid test unless you are an NBA player or some kind of celebrity influencer.

"Experts" tell us we need 500,000 to 700,000 tests per day to better manage the situation.

I say the experts are wrong. We need millions of tests per day, starting three weeks ago.

Here is why:  People are agitating for a lifting of some of the quarantine restrictions.

In some states, they are demonstrating in crowds that don't do social distancing.

In Southern California, the resistance is milder -- a tripling of road and pedestrian traffic in recent weeks, but with social distancing maintained -- but every park has been closed and fenced off.  The parking lots by the beach have been closed. People who walk on the all-but-empty beach boardwalks are yelled at by police bullhorns and threatened with $1,000 citations.   Last week I saw a police helicopter hover for 10 minutes over two sailboats to hector the sailors back to port.

I'm sure the enforcement is well-intentioned, but it is reaching a straining point. There is no way we can keep 327 million people and most of the economy shut down until autumn 2021, the most hopeful date for an approved vaccine and broad-scale immunizations.

The problem with even the most limited opening now is that it will be accompanied by a new rise of infections, one that probably will be smaller but that could be ameliorated by making tests much more broadly available.

It's time to test people who don't have symptoms.  Infected people can spread the disease before they get sick; identifying even a few of those BEFORE they get sick or acquire antibodies would prevent further infections.

Anyone who wants to be tested should be able to get tested, period.

This must be done sooner and not later.


Why

My first argument for testing is that a nation that can commit $2.2 trillion for subsistence payments to people and small businesses -- more than $8,000 for every single person in the US -- should damn well be able to provide infection AND antibody tests for every one of those persons.

But, pathetically, the problem is not one of cost.

Unfortunately, we do not have the manufacturing or staffing capacity to administer such tests.  Rich as we are, we have insufficient "supply chains."

Shame on us.

The limits we face at this moment are hinted at in this part of a broader commentary by Marc Andreeson.  I recommend reading the whole piece.

Part of the problem is clearly foresight, a failure of imagination. But the other part of the problem is what we didn’t *do* in advance, and what we’re failing to do now. And that is a failure of action, and specifically our widespread inability to *build*.

We see this today with the things we urgently need but don’t have. We don’t have enough coronavirus tests, or test materials — including, amazingly, cotton swabs and common reagents. We don’t have enough ventilators, negative pressure rooms, and ICU beds. And we don’t have enough surgical masks, eye shields, and medical gowns — as I write this, New York City has put out a desperate call for rain ponchos to be used as medical gowns. Rain ponchos! In 2020! In America!

We also don’t have therapies or a vaccine — despite, again, years of advance warning about bat-borne coronaviruses. Our scientists will hopefully invent therapies and a vaccine, but then we may not have the manufacturing factories required to scale their production. And even then, we’ll see if we can deploy therapies or a vaccine fast enough to matter — it took scientists 5 years to get regulatory testing approval for the new Ebola vaccine after that scourge’s 2014 outbreak, at the cost of many lives.

Movie Monday: Doctor Zhivago

In a moment when hundreds of millions of us are quarantining ourselves for the greater good, this isn't the worst movie to give a look.

Its title character is an honorable person who does his best, but whose fate is determined more by a world war and national strife on either end of that war.  It perhaps will help us put our current sacrifices into perspective.

The setting is Russia, where Yuri Zhivago is adopted by his uncle after his mother's death.  Yuri (Omar Shariff) grows up and trains to be a doctor, marries a good woman, meets another good woman who works as a nurse when he ministers to Russian soldiers in World War I, loses his wife and then is caught between the White and Red armies after the 1917 Revolution replaces the Czarist government with a new and less predictable reign of chaos.

The story comes from a novel by Boris Pasternak, who survived the same history, no mean achievement.  His book was published in 1958 in Italy, then other countries and, finally, in the still-USSR in 1987.

David Lean, the maker of two Best Picture Oscar-winning films -- The Bridge on the River Kwai(1957) and Lawrence of Arabia(1962) -- released Dr. Zhivago in 1965.

There are many things to like about this film.  Its cinematography shows us the violent attacks on unarmed marchers in the first Russian Revolution of 1905, the honest anger of Russian soldiers at the end of World War I and the desperation of starving Russians fleeing for the provinces after 1917.

In addition, it gives us more complex characters, among them Pasha (Tom Courtney,) a sincere Marxist who turns into a Red Army enforcer and Komarovsky (Rod Steiger,) a callous and opportunist lawyer who seems to survive all.

I have read much Russian literature and will not read Dr. Zhivago until I have finished The Brothers Karamazov.  But what little I know of Pasternak's magnum opus suggests this movie does not -- cannot -- do it justice, even at its length of three hours and 20 minutes.

Besides the necessary plot compression, there are other weak links:  Julie Christie, playing beautiful heroine Lara, is unbelievable as a 17-year-old in the film's early scenes; the syrupy "Lara's Theme" song punctuating the whole film isn't supported by what remains of the plot's trajectory; the loopy ending that aims to link the whole story together is weak, etc.

 A multi-part television series of Zhivago was released about 15 years ago in Russia.  I will not be surprised if the producers of our current binge-watch favorites (Tiger King, anyone?) rediscover this story and try to come up with a substantial project. 


Note

The visual content available when streaming old movies frustrates those who favor actual film over video.  This is because streaming is rendered in a digital format, typically HD.  The Idiosyncratist was particularly disappointed with the less subtle but more jarring literal translation of North by Northwest several weeks ago.

To convert 35mm film to digital and display all the nuance of 35mm requires more resolution than is generally available on HD today, which typically tops out, alas, at 1080p.  Films that are converted to digital at 4K look substantially better.

If your home screen cannot accommodate 4K, you can improve what you see by switching the viewing mode from Vivid (which highlights brightness and contrast) to Cinema (which reduces those things and creates a more tonal mood).  This capability is available on almost all current HD television screens.

MovieMonday: Bringing Up Baby

This 1938 movie is known now as one of the best screwball comedies of its period, a time marked by the second blow of the Depression, a recession that had started a year earlier.  It was a moment when people were eager for humorous distractions.

This movie set out to fill that need, and, funny as it is, it was a flop that almost killed Katharine Hepburn's career.  After its release she moved back to New York, starred in a hot new Broadway play called The Philadelphia Story and returned to Hollywood to star in its smash movie version in 1940.  (Cary Grant costarred in all three productions.)

Since 1938, film students and audiences have changed their minds about Bringing Up Baby.  Its director, Howard Hawks, acknowledged years later that, yes, it was pretty wacky and none of the characters was believable.  But as light entertainments go, it is very, very fun.

The story involves a romance between two opposites.  Cary Grant plays Dr. David Huxley, an uptight, bespectacled paleontologist who collects old bones to recreate a brontosaurus skeleton.  His milieu is a stuffy museum, which suits him well.

He is coaxed out into the natural world to play a golf game with a lawyer who perhaps can help him raise money for his museum. 

Whom does he meet on the links?  Susan Vance (Hepburn) an impulsive and flighty heiress who is a better golfer and who steals his golf ball and then his car.  They meet up later at a nightclub, where David is still pursuing that museum donation and where Susan, besmitten, pursues David, over his adamant protests.

The next day, she takes him farther out in the world, to her wealthy aunt's Connecticut farm.  He carries with him a dinosaur bone, his most recent prize, and she takes a leopard named Baby, a recent gift from brother in South America.  (Get it?  David has/is a fossil and Susan has/is a minimally restrained wild animal.)

From there it's off to the races.  Naturally, the farm dog, George, gets hold of the dinosaur bone and, as dogs will, buries it for later enjoyment.  This requires David and Susan to follow George, hoping he will reveal where the bone, technically an "intercostal clavicle," is buried.  Meanwhile, Baby is let out of the barn by the drunken field hand.  Susan, her aunt and a big game hunter share stories over dinner with David while he darts out to follow George every time the dog leaves the room.

By the end of the evening, the whole bunch end up in the local jail, where their interactions with the befuddled constable call to mind an extended Marx Brothers scene, and where, of course, a second, less tame leopard makes an appearance.

David, while initially angry with Susan, admits intermittently that he's actually coming to enjoy being with her, at least some of the time. 

And so it goes.

Notes

In this film,  Grant and Hepburn play out of type, or at least out of the types that were more emblematic of their later careers.  Turns out Grant could do awkward, physical humor.  Seeing Hepburn as an impetuous wild child of a woman is a little disorienting, but she threw herself into the role just as Susan threw herself at David.

The script moves at rocket speed.  There is so much spoken dialog -- much, much more than I can recall in any recent film --  that one is tempted to wonder whether the screenwriters were paid by the word.  But the dialog, like the action, provides many laugh-out-loud moments.

It's difficult to think of a modern comedy that would compare to this.  Yes, the 2009 Hangover movie had a tiger, but it and its female follow-ons like The Bridesmaids involve a level of vulgarity that would have been unthinkable in the early part of the last century.  Who knew that the squares of those older generations could be so funny?

Dead-End Testing

It’s the type of inertia that clearly frustrates Romer.  He calls the $2 trillion legislation passed by Congress “palliative care” for the economy. 

If you took $100 billion and put it into testing, 
he says, we would “be far better off.”

MIT Technology Review, April 8 2020

The article cited above makes more sense than almost anything else I have read about Covid-19 this year.  The quote is from NYU economist Paul Romer, who deserves more attention than our bumbling public health experts.

Here's the point:  If U.S. coronavirus testing had been handled better, fewer people would have died, many people would have been spared a miserable illness and the national economy might not be careening into what looks like a very deep, very expensive recession.  (More about the economy another day.)

So let's talk about testing, starting on January 20 of this year.

We all remember January 20.  That was the day the World Health Organization and China acknowledged, at long last, that Covid-19 was a contagious virus that was passed from person to person.  (This had been understood in China by December 6, 2019, and by everyone else not much later.)

Also on January 20, the United States and South Korea announced the diagnoses of their first Covid-19 patients.

The differences between the two countries' reactions -- specifically, their testing rollouts -- is worth a closer look.


South Korea

On January 27, when South Korea had a total of four patients, the South Korean Center for Disease Control sent an SOS to Korean medical labs, promising streamlined approvals for Covid detection tests.

The first test was approved on February 4, and a second one on the 12th.  By March 15, when a fifth test was approved, the country was testing 20,000 persons daily.  Daily diagnoses peaked at 909 on February 29, then dropped to 93 by March 18 and since then have rumbled at a very low level even as testing has continued, as seen below.

South Korean testers also contacted and tested the friends and neighbors of those who had tested positive, and almost every single member of a large church where hundreds of congregants had tested positive.  Because the tests had been given quick approval, their results were cross-checked against each other as the rollout continued, to assure validity.

In the world of disease prevention, these activities are known as Public Health 101.  South Korea now is manufacturing and providing Covid tests for many other countries.


United States

In the U.S., the CDC preferred initially to design and release its own test, starting February 4.  Four days later, reports began to surface about the test's unreliable results.

Another problem was the lack of tests.  Curiously, Kaiser Health News reports, the CDC distributed its first batch of tests in equal numbers to every one of the 50 states.  Sounds wacky to me, but, hey, I wasn't there.

On February 27, California's governor said the state had identified 33 persons with Covid-19 and was monitoring another 8,400 persons who had Covid-like symptoms.  Testing was going slowly, he said, because the state had only 200 CDC tests on hand. 

(NB: California is home to 40 million people, about 80 percent as many as live in South Korea.)

On February 29, the Food and Drug Administration gave its first go-ahead for non-CDC tests developed by pharmaceutical companies, universities and medical laboratories.

One week later, the U.S. had conducted 2,000 tests and South Korea 80,000.

There were other problems.  Because U.S. tests still were scarce, the CDC recommended testing only for people who had been to Wuhan or who had met people from Wuhan or who had Covid-type symptoms.

This approach did nothing to seek out people who had been in contact with sick Americans.  It did nothing to identify infected persons who were pre-symptomatic and contagious, let alone to tell such persons to isolate themselves.  Later, state by state, almost the entire U.S. population was ordered to quarantine, an edict with no end date in sight.

The US version of the Korean chart, above, mostly tells us how much later testing started here.  Its fast-rising trend line almost certainly reflects only the increasing numbers of tests performed; the inference that infections may have peaked in the last week (five weeks after the peak in South Korea) may be true or may indicate a lull in the daily availability of tests.

Worst, it tells us nothing about the number of infected persons in the country, because, again, testing was reserved for symptomatic people who were lucky enough to get access to tests (plus a good sampling of politicians, celebrities and tigers in a zoo; one of the last group was heard coughing and so six were tested "out of an abundance of caution.")   One hopes medical workers were given broad access to testing, but news reports suggest that may this may not have been the case.

In one perhaps typical case, the state of New Jersey, a domestic hot zone for the virus, set up a drive-through test site in late March.  When it opened at 8 a.m., the line of idling cars was miles long.  After 35 minutes, the line was closed because there were not enough tests for all the drivers who were waiting.  Testing stopped by noon.
           Last week, about six drive-through test days were announced in one New Jersey county, and persons with high temperatures and Covid symptoms were invited to make appointments for the limited number of tests available, roughly 100 to 250 per day.  The available appointments filled quickly, and 5,000 requests were denied.  Maybe in a couple weeks, or maybe in May ....

A friend shared the story of a Pennsylvania family man in his early 40s who ran a fever for two weeks and then got a Covid test whose results were promised four days later.  After two in-patient stints for major pulmonary interventions and after his second hospital discharge, he got his test result -- yes, he did have coronavirus.  Good to know, huh?

You can read more about these matters in articles from Reuters and the increasingly valuable Kaiser Health News.

-----

The conclusion here is this: After a late, slow start, the U.S. has piles of test results that reveal very little in the way of useful information.   We still have no idea how many people in the U.S. were infected, or are infected or might develop symptoms.  We never will know how many of this season's "flu deaths" were actually Covid-19 deaths.  If we have flattened the curve, it was by curtailing the movements of everyone for a period of time whose end we cannot forecast.

"The system is not really geared to what we need right now," the estimable and understated Dr. Anthony Fauci told a Congressional committee in March.

"That is a failing. Let's admit it."

-----

Given the cynicism engendered by the original testing program, it might sound odd to say this, but here goes:  The best hope for minimizing Covid damage in the U.S. is more tests.  

The new testing would be for antibodies.  Testing for such, done with pinprick blood samples, could identify people who are Covid-19 survivors and who have developed immunity to the virus.

Theoretically (and I do mean theoretically, given recent history) many of these tests could be done fast and yield answers within hours.  

The people who test positive for antibodies could go back to work and help start the revival of our comatose economy.  They could staff grocery stores, drive delivery vans, plow and harvest food crops and give medical workers some deserved relief.  They also could donate their plasma, which in very early testing has seemed to benefit seriously ill Covid patients.

This would NOT end basic coronavirus testing, however.  Those with no antibodies would need to be tested, probably repeatedly, for Covid infection and/or would need to remain quarantined until those slowpokes at the Department of Health and Human Services approve a Covid vaccine and get it to those who need it.  In a perverse way, those lucky enough to avoid infection will have to limit their movements until immunization provides their get-out-of-jail-free cards.

(In my dark imaginings, HHS will deploy Google to monitor the compliance of those without antibodies or immunizations by tracking them using data from their cellphones.  This capacity was revealed in recent weeks when residents of some cities were admonished for walking or driving too far from their houses and -- theoretically, again -- endangering others.  It doesn't take a Constitutional lawyer to wonder whether this isn't a Fourth Amendment violation.)

In any event, no immunization is expected to gain FDA approval for at least 18 months.  The restriction on movement during that period will be less popular than the proverbial ants at a picnic.


Note

Another upside to antibody tests -- again, IF we can organize and administer them -- would be establishing how many persons, if any, acquired antibodies without experiencing a traditional case of Covid-19.  The hope is that there are many of these people, but, again, we don't have the facts.  

Such tests also would answer a nagging question in the American West:  whether many Americans caught minor cases of Covid-19 and, with it, acquired immunity last winter.  There is a developing belief that minor Covid exposures lead to less serious cases, and the cases at issue arose and were resolved before very sick people began clogging hospitals, at least in New York, in mid February.   

This writer is one who would like the question answered.  I flew to California at the end of December and then coughed continually starting shortly afterward and for almost a month.  If what I had was a cold, it was a strange one (no stuffy nose, no fever) and my first in almost 20 years.  One of my siblings, in another state, had the same bug.  Another sibling flew out of a small town that later saw many Covid cases and arrived home with other odd symptoms.

For the record, if I do have coronavirus antibodies, I will be happy to donate as much plasma as I am able.   

MovieMonday: North by Northwest

Since movie theaters are closed I've spent recent weeks streaming classic movies on the big screen in the living room.

This is one I'm always happy to watch again.  It involves a New York advertising executive caught in a case of mistaken identity that goes horribly wrong.

I'd seen this movie several times, but it was only this time that I saw how the lead character, advertising executive Roger Thornhill (Cary Grant,) comes to be mistaken for a CIA spy named George Kaplan.  (My previous viewings of this film were in theaters, and so it is entirely possible that I was getting popcorn during this early scene, to my regret.)

Anyway, here it is.  Thornhill meets friends in the bar at the Plaza and realizes he needs to send a telegram.  Listen to what the bellhop is saying as Thornhill tries to get his attention.




Aha!

The film is a 1959 period piece, and not just for the telegram business or the old cars with tail fins.  Its Cold War premise is that a team of spies, presumably from the Communist Bloc, are willing to do anything to get some purloined microfilm out of the country.

First they try to kill George Kaplan/Roger Thornhill by pouring a bottle of bourbon down his throat and putting him behind the wheel of a car aimed into Hempstead Bay, which gets him arrested for car theft and drunk driving.  Then Thornhill tracks down the UN official who Thornhill believes has set him up, and alas, the official is stabbed and the police take out after Thornhill for the murder.  Thornhill eludes capture and meets a mysterious blonde, Eve Kendall (Eva Marie Saint,) on a train.

And things just keep going from there.

Arguably the film is over-plotted, with some notable rabbits pulled out of hats and with an unusual dose of pre-Vietnam cynicism toward the CIA, whose officials understand Thornhill's problem but care more about frustrating the other team's spies.

Cary Grant is great in this one, and not least because of the way he rocks a fine gray suit.  He manages get to himself out of one jam after another, sometimes with Kendall's help and sometimes not. The plot takes him to Chicago, to an art auction, to a Midwestern cornfield (the famous crop duster scene) and, finally, to South Dakota.  The final resolution occurs, of course, on Mount Rushmore.

Through it all, Thornhill/Grant has lighter moments of humor that don't interrupt the action.

If you haven't seen it, cue it up now.  If you have seen it, cue it up again.


Notes

Alfred Hitchcock often made cameo appearances in his films.  In this one, he is seen missing a bus on Madison Avenue as Thornhill steps out of his office building.

-----

Hitchcock had a real thing for icy blonde actresses -- Eva Marie Saint here, Janet Leigh in Psycho, Tippi Hedren in The Birds, Kim Novak in Vertigo and Grace Kelly in Rear Window.  

I seriously considered watching that last movie the other day, but then I thought that the story of a guy confined to his apartment -- not for social distance but with a broken leg -- just didn't sound all that appealing.

Rethinking Face Masks

A month ago in Prague

I'm so old I can remember when Covid 19 (which recently was renamed Covid-19) was not such a big deal.

First we were told not to gather in groups of 500 or more, then in groups of 250, then 50 and then 10.  Finally, we were ordered to go home and stay there.

(Meanwhile, the amusingly named Centers for Disease Control was applying its not-invented-here mistrust of South Korea and major pharmaceutical companies and developing its very own Covid-19 test -- which didn't work and wasted weeks while the virus spread.  Great bunch, that CDC.)

Now our public health bureaucracy is in the middle of a similar evolution on the matter of face masks.

As we know, a month ago the word was:  Don't get a face mask!  First responders need them more!  Don't be selfish!

As long as we kept to ourselves, we were told, the biggest danger was touching surfaces that had been touched previously by infected persons, including ones who were not yet symptomatic.  The things to do were to stay in the house and wash our hands many, many times each day.

So I didn't even try to get a face mask.

(I even read an article about a company that proposed to make a big batch of N95 masks, the kind that first responders need and that are still in very short supply.  The apparatchiks at the CDC or FDA responded thusly:  It will take us at least 45 days -- and possibly 90 days -- to evaluate and approve your design before you can start manufacturing masks.  I remember thinking:  Are these bureaucrats too busy to put a rush order on something that seems kinda important?  Do they want more masks, or do they want to shut down their work-from-home computers at 4:30 p.m. every single day?)

Even as a non-expert, I thought the no-masks-for-the-general-public drumbeat sounded off.  If Covid-19 afflicted the lungs, which it does, why not limit the degree to which people breathe on each other in public -- just to be careful?

Among Asian immigrants, I had noticed a practice of wearing masks occasionally in public (not N95 masks, just basic paper ones.)  When I asked a friend why, she explained that masks were worn when people didn't feel well and didn't want to make other people sick.  Seemed like a nice idea.

While Americans were being told not to hog the face mask supply, people in the Czech Republic (or Czechia; hard to keep up) also were being told to stay home and, if they had to go out, to cover their mouths and noses.  The innovative Czechs donned masks and antifa-style gaiters and head scarves.  Shockingly, this seemed to reduce the spread of the coronavirus. 

After a few weeks, Americans got wind of this strange new innovation.  The quilting community, particularly, began sewing masks by the hundreds.  If you want to make some yourself, YouTube has many patterns and ideas for how to go about it.

But then, as happened with toilet paper, the 1/4-inch elastic used to secure such masks behind the ears soon became scarce.  Perhaps it was because the stores that sell sewing accessories had been deemed non-essential and were closed for the duration.  Or perhaps some seamsters were hoarding.  I do not pretend to know.

Anyway.  Here is a perfectly satisfactory mask recipe  for those who own tee shirts, which I am pretty sure is just about all of us.   If you make one for yourself, I recommend wearing it with a hat, to cover the not entirely attractive top knot.  (OTOH, the top knot might accessorize nicely with a man bun; just saying.)

You're welcome.


Another Covid-19 Evolution

In the early days of Covid, we were told not to hug or shake hands with other persons, and also not to get too close to them.  We were given a new name for this: social distance.

Initially, social distance was defined as one meter (a tad more than three feet for those still on the English system) between persons.  Then the perimeter was pushed out to five feet, then six feet.

All fine.  Those in my household obeyed when walking on the street and when waiting on stretched-out lines to buy groceries or prescriptions.  Around here, we pride ourselves on compliance.

Then, earlier this week, an egghead at MIT said that we were Doing It All Wrong.  The appropriate social distance, said the expert, was 27 feet.  This had something to do with the potential for explosive, possibly meteoric, nose explosions.

Then Dr. Anthony Fauci, the most trustworthy source we have at this moment, said no, there was no need to adopt the new guideline.  Turns out we do not need to limit our conversations to people who live in other counties.

Here is a helpful example of the kind of sneeze Dr. Fauci regards as not requiring wary vigilance.  It comes from the comic oeuvre and involves Tom employing a pepper shaker to get himself out of a tight spot.





Note

Across the country, mayors and governors and important public health officials have begun rethinking their advice, again.  Some now are saying, maybe we should begin requiring people to cover their noses and mouths when they go out.

As usual, these chuckleheads are late to the party.  I went to a farmers market last Sunday, and just about everyone in the place had covered his or her mouth and nose with a mask or scarf.

And, of course, when this new edict is announced it will include yet another stern warning for all us stupid people:  Don't even THINK of hoarding N92 masks!