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Another New Book Available: States of the Union, The History of the United States through Presidential Addresses, 1789-2023

Mount Greylock Books LLC has published States of the Union: The History of the United States through Presidential Addresses, 1789-2023.   St...

Sunday, March 29, 2020

The Epidemic and its Consequences

Prince Max of Baden, born in 1867, was a trained lawyer and a one-time general in the Prussian Army.   He had left the army by the time of the First World War, and during that war, he became active in contacts with Germany's enemies to secure better treatment for prisoners of war.  In early 1918, he wrote one of the most brilliant strategic appreciations that I have ever seen, a plea to the highest German authorities to abandon hopes of total military victory and offer a generous peace at a moment when the Germans had once again secured a military advantage.  The government ignored his advance, and the great German offensive of March 1918 stalled in the summer, having wrecked the German Army.  By September Germany was clearly losing the war, and Prince Max suddenly became Chancellor, charged with putting through liberal reforms to the German constitution and seeking a negotiated peace with President Wilson.  By late mid-October, he was becoming convinced that the Emperor William II would have to abdicate to secure that peace.  Meanwhile, the influenza pandemic was raging, killing many thousands in Germany, where years of hunger had weakened the population.  On October 22, he came down with influenza himself.  He continued his delicate negotiations among all the German parties, as he described in his extraordinary memoirs, until November 1.  "I had not yet got over my attack of influenza," he wrote years later.  "The pressure of owrk of the last few days had utterly exhausted me, and I had a serious relapse.  The doctor was called and wanted above all things to ensure me rest. He administered a drug which in my weakened state had a stronger effect than had been intended, and put me into a deep sleep. For thirty-six hours all attempts to wake me were in vain."

The German Empire, as it turned out, had only 8 more days to live, but Prince Max survived to write his memoirs.  That is one lesson I am trying to keep in mind as I watch our own epidemic spread:  the vast majority even of those of us who have become infected will survive, even as many die.  Yet in another parallel, our political system as we know it may also face critical threats.

The fear that hangs over us all now has put some things in perspective for me.  We have temporarily lost many parts of our lives: visits to the gym, to restaurants, and the movies; professional sports; social gatherings.  Millions of us are losing their jobs, and traditional education has come to a halt.  We need to revive some of these activities as soon as we can, but some of them--such as the gym--are emerging as luxuries within a very well-off society.  Another luxury, I am convinced, are the political attitudes that have come to dominate various sectors of our society, and which never would have become so popular had we had more real problems to deal with.

Worst among those is the largely Republican belief in the superiority of free markets and the supremacy of private interests.  Fifty years ago we had an expensive, but necessary public sector, paid for in part by high marginal personal and corporate income taxes.  Now transfer payments make up the bulk of the federal budget and the discretionary part of it that provides critical public goods is proportionally much smaller. The situation seems to me much worse at the state and local level, where pension commitments, I suspect, have continually crowded out money for education and infrastructure at an increasing rate.  We now have to find extraordinary resources to deal with the economic crisis that goes along with the medical one, and this will challenge a very stressed system--especially in red states.

That is not all.  On the Democratic side of the fence, which has become the party of the economic and political status quo, what the government does has increasingly become less important than who exactly does it.  The party's key constituencies have focused more and more on the identity of its candidates, and the need to reduce the number of straight white males among them has become something of an obsession.  This year none of the minority, female or gay candidates managed to win over a sufficient portion of the Democratic electorate to contend, but Joe Biden, the presumptive nominee, has made a guarded promise to put a woman on the ticket.   Meanwhile, despite eight years of Barack Obama (b. 1961) in the White House, the Democratic Party has failed to create any new national political figures of stature under 70.  During the crisis, Andrew Cuomo (b. 1957) has emerged as the most impressive leader that we have seen in some time, demonstrating a quick intelligence, an ability to lay out the essentials of a complex problem quickly, and the administrative ability to get solutions going  Nearly everyone I know seems to wish that he could become the Democratic candidate--even some New Yorkers who have not been smitten with him during his decade as governor.  Our nominating system, however, now lacks the flexibility that in earlier decades enabled parties to select a suitable candidate at the last minute.  Barring unforeseen events in Joe Biden's campaign, Biden seems sure to be nominated--even if the Convention has to be held virtually, instead of in Milwaukee as planned.

And last but not least, a real threat looms over the electoral process.  For the time being we are giving up much of our lives and shutting down much of our economy to save tens or perhaps hundreds of thousands of lives.  I do not think that this can continue indefinitely, although it could be, if the epidemic can be brought under control as in China, that lockdowns and shutdowns will become local events in response to small outbreaks instead of national ones until, somehow or other, the epidemic ends.  We would however have great difficulty, it seems to me, holding a national election under today's conditions.  We need planning right now to make sure that the election takes place on schedule, and in a manner that will command the nation's confidence in its results.  Having held elections during the Civil War and the Second World War, we can certainly carry on with this one--but we made need adjustments.  We can certainly survive even the worst case scenarios for deaths from the epidemic.  Surviving a complete collapse of our democracy would be much more difficult.

Sunday, March 22, 2020

Drug treatments for COVID-19?

I have decided to use today's post to pass on some research I've done (via google) about the possibility that a combination of two drugs, Hydroxychloroquine & Azithromycin, might be effective against the COVID-19 virus.  This is a confusing story which I have already done a tiny bit to spread on facebook.  It has several dimensions, and at this point, I do not know what to think about it, but I think I can shed some light on what is going on.

To begin with, a team of French doctors has written and is about to publish a study arguing that a small sample trial showed effectiveness for these drugs.  I quote from their summary.

"French Confirmed COVID-19 patients were included in a single arm protocol from early March to March 16th, to receive 600mg of hydroxychloroquine daily and their viral load in nasopharyngeal swabs was tested daily in a hospital setting. Depending on their clinical presentation, azithromycin was added to the treatment. Untreated patients from another center and cases refusing the protocol were included as negative controls. Presence and absence of virus at Day6-post inclusion was considered the end point.

"Six patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms.

"Twenty cases were treated in this study and showed a significant reduction of the viral carriage at D6-post inclusion compared to controls, and much lower average carrying duration than reported of untreated patients in the literature. Azithromycin added to hydroxychloroquine was significantly more efficient for virus elimination.

"Despite its small sample size our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin."

The study lists 18 different authors with French names (including two with Vietnamese or Arab roots) and I checked some of them to verify that they are indeed French doctors and medical scientists.  The study also includes some caution about the use of these drugs.  They have side effects and can be serious for patients with certain pre-existing conditions--which are, of course, exactly the patients most at risk from COVID-19. 

Now the CDC has posted comments about the use of these drugs for treatment.  Here is what it says:

"Hydroxychloroquine and Chloroquine
"Hydroxychloroquine and chloroquine are oral prescription drugs that have been used for treatment of malaria and certain inflammatory conditions. Chloroquine has been used for malaria treatment and chemoprophylaxis, and hydroxychloroquine is used for treatment of rheumatoid arthritis, systemic lupus erythematosus and porphyria cutanea tarda. Both drugs have in-vitro activity against SARS-CoV, SARS-CoV-2, and other coronaviruses, with hydroxychloroquine having relatively higher potency against SARS-CoV-2 [1,4,5]. A study in China reported that chloroquine treatment of COVID-19 patients had clinical and virologic benefit versus a comparison group, and chloroquine was added as a recommended antiviral for treatment of COVID-19 in China [6]. Based upon limited in-vitro and anecdotal data, chloroquine or hydroxychloroquine are currently recommended for treatment of hospitalized COVID-19 patients in several countries. Both chloroquine and hydroxychloroquine have known safety profiles with the main concerns being cardiotoxicity (prolonged QT syndrome) with prolonged use in patients with hepatic or renal dysfunction and immunosuppression but have been reportedly well-tolerated in COVID-19 patients.

"Due to higher in-vitro activity against SARS-CoV-2 and its wider availability in the United States compared with chloroquine, hydroxychloroquine has been administered to hospitalized COVID-19 patients on an uncontrolled basis in multiple countries, including in the United States. One small study reported that hydroxychloroquine alone or in combination with azithromycin reduced detection of SARS-CoV-2 RNA in upper respiratory tract specimens compared with a non-randomized control group but did not assess clinical benefit [7].   [The footnote cites  the French study, above.] Hydroxychloroquine and azithromycin are associated with QT prolongation and caution is advised when considering these drugs in patients with chronic medical conditions (e.g. renal failure, hepatic disease) or who are receiving medications that might interact to cause arrythmias.

"Hydroxychloroquine is currently under investigation in clinical trials for pre-exposure or post-exposure prophylaxis of SARS-CoV-2 infection, and treatment of patients with mild, moderate, and severe COVID-19. In the United States, several clinical trials of hydroxychloroquine for prophylaxis or treatment of SARS-CoV-2 infection are planned or will be enrolling soon.  More information on trials can be found at:  https://clinicaltrials.gov/external icon."

Thus, medical scientists in two different countries--China and France--have reported, based on relatively limited evidence, that these drugs have been effective, and broader trials are underway here to test them further.  I do not know exactly why Dr. Anthony Fauci, in yesterday's press conference, described the evidence for their effectiveness as "anecdotal." I am not a scientist myself, and "anecdotal" might be a word frequently used to describe the results of very small clinical trials.  I will allow the above evidence to speak for itself, and wait for evidence from the additional trials that are going on.

Meanwhile, however, something else is happening.

The Huffington Post now reports that two men are waging a public relations campaign on behalf of this treatment: Michael Coudrey, a Las Vegas marketer with ties to Republican politicians, and Gregory Rigano, who claims to be an adviser to Stanford Medical School, but isn't.  Tucker Carlson of Fox News has interviewed Coudrey about this.  That's probably how President Trump heard about the drug, and he has plugged the idea that it might be a cure in his last two press conferences, while Dr. Anthony Fauci has replied that any evidence is anecdotal..  Trump is also retweeting Coudrey's tweets about this.   Coudrey's and Rigano's motives are unclear.

There is already a run on Hydroxycholoroqine as people beg their doctors to prescribe it, and arthritis and other patients who already relied on it are having trouble getting it.  In this as in so many other issues of public policy, we obviously need to proceed cautiously on the basis of real science, while looking for answers as thoroughly and quickly as we can.  With Donald Trump at the helm--a man who seizes upon the answers most convenient to him and refuses to study any data--this is not easy.  Now, more than ever, we have to try to read beyond headlines and use the tools available to us all to check important information out. That is what I have tried to day.  Best wishes to all in these difficult times.

Sunday, March 15, 2020

The Prospects for November, and what they mean

The corona virus has struck us at a critical moment in our politics, and there is every reason to believe that it will exacerbate trends already in progress.  It has drastically altered our national life at the very moment that Joe Biden's nomination as the Democratic candidate has become almost assured.  We have a long way to go to November, but as things look to me now, Biden will probably defeat Donald Trump by a significant majority.  That would put an end to a disastrous episode in American history--but it will not change the fundamental direction of the country or the outcome of the great crisis that may finally be nearing its end.

Donald Trump so dominates the news cycle, and so completely enjoys the abject devotion of the Republican Party in general and its Senate majority in particular, that we easily forget how unpopular he remained in the country even before the current crisis began.  The current poll averages at realclearpolitics.com show him with 52% disapproval and 44% approval and they have never shown him with more than 50% approval.  More to the point, a similar poll average shows Joe Biden leading him in trial heats by a full 6 percentage points, 50.7 to 44.4.  (Bernie Sanders, by the way, leads by almost as much.)  Biden, meanwhile, came out of nowhere after the Iowa caucuses and the New Hampshire primary to demonstrate real enthusiasm among very broad segments of the Democratic Party--every segment, as it happens, except voters under 40, who did not vote in sufficiently large numbers to make a difference.  (Age, by the way, trumped race: younger black voters, like their white contemporaries, favored Sanders in exit poll after exit poll.)  Because Biden is well known thanks to 8 years as Vice President, he evidently inspires confidence.  That, clearly, is going to be Trump's biggest problem.

For a long time, it seems to me, both sides of our political spectrum have been practicing different kinds of vanity politics.  The nation works, to the extent that it still does, because of the institutions that earlier generations put in place in the middle decades of the last century, and both sides have been undermining the institutions they control both for monetary benefit and personal satisfaction.  Both the tightly regulated and heavily taxed economy of 1940-80 and the remarkable educational system that grew up in the same period have become extraordinarily rich and powerful institutions that principally benefit only the people who run them, corporate executives and university administrators.  Meanwhile, both parties use buzzwords to rally their base.  The system survived even the shock of the 2008 crash, largely because a Democratic President accepted the premise that it remained fundamentally sound.  The George W. Bush Administration had used the favorable situation it inherited to embark on useless, destructive, extraordinarily expensive crusades in the Middle East, because it had talked itself into the idea of a great crusade [sic] to keep the US supreme in the world.  By the 2010s, however, the political system was paying a price for its vanity.  Donald Trump in 2016 showed that the Republican Party had totally lost touch with its voters.  This year, it looked for a while as if Bernie Sanders might make the same point about the Democrats.

Sanders' fall from front runner status was the first signal of where things were going.  Several factors played a role, but one cannot ignore the absolute panic among nearly all of our punditry during the month of February over the possibility that he might actually be nominated.  That panic was only partly based on the fear that he might lose (a fear that had no support whatever from polling data that showed him beating Trump), or that his candidacy might hurt down-ballot Democrats.  It also reflected a terror that the Democratic Party might actually nominated a candidate who felt that economic inequality was a serious danger that required direct, determined steps to do something about it.  He drew heat, among other things, from the very reasonable statement (in  my opinion) that billionaires should not exist.  Several commentators cringed at the thought of a world without the philanthropic Bill Gates and Michael Bloomberg, forgetting that we cannot have those few exceptions without the Koch brothers, the Scaifes, and the many other corporate giants who now dominate our politics.  It has become fashionable, by the way, to claim that sexism doomed Elizabeth Warren, but she faced the same onslaught of centrist panic when she seemed likely to become the front runner--and made the mistake, in my view, of backing away from Medicare for all in response.  In centrist mythology, private insurance--the reason that we have an increasingly unaffordable health care system, which doctors have told me we cannot sustain--has become something that millions of Americans love.  Biden's candidacy will reassure the health insurance industry and Wall Street--which is important, sadly, since it means they won't be tempted to vote for Trump, whom they already trust to allow their wealth to keep growing faster than the economy as a whole.

Trump, meanwhile, faces a real domestic crisis for the first time, and it is bringing out the worst in him.  He is trying to use it the same way he uses everything else: to make himself look like an innocent genius in a world full of guilty idiots.  He has already made absurd claims to give himself an aura of omnipotence and omniscience. It now turns out that the google website that will allow sick people to get tested--which he promised within a few days--hadn't gotten beyond the stage of a few conversations between Jared Kushner and a google subsidiary called Verily.  The president's bizarre claims have prompted Google to try to make them come true, but Verily had in mind only a pilot program in the San Francisco and Seattle areas.  Meanwhile, the virus has crashed the stock market, depriving the President of his favorite talking point. 

These two major developments point towards a Biden victory, followed by a return to the Obama-era status quo.  That means on the one hand that we will once again have a federal government led by men and women who believe in its mission and respect facts and science.  Given Biden's age, and the unlikelihood of him seeking a second term, he will also be less beholden to politics and less likely to be dominated by spin.  He can also try to restore  our stature in the world and arrest the drift towards war with Iran--although I doubt that our allies will ever have the same degree of trust in us again. He will get us, at least rhetorically, back on the right side of the climate change issue.  But I do not think that Biden and the Congress can be expected to make any fundamental attack on the direction of our economy.  Rather than try to dismantle our oligarchy, his administration will try to diversify it.  And even Democratic policies on social issues will face lots of opposition from the federal courts, now effectively packed by Trump and McConnell.  Those courts will exercise their enormous power--which they developed from the 1950s through the 1970s in pursuit of liberal goals--for conservative ones.  That marks a return to the traditional role of the courts in American history, from 1789 until about 1938.

I have said many times that we do not live in a heroic age.  Inequality, and the decline of state authority, define our era.  I will be having more to say about that after I read Thomas Piketty's new book, now on its way to me.  Under the circumstances I am grateful for any step away from disaster. That is what Biden's election would mean.  True progress, however, will fall to subsequent generations, some of them not yet born.