Thursday, 26 March 2020

Covid-19 – Friends, Survival of the Fittest, Focus on Reality and Forget about PC

Replacing the EU Flag with the Chinese Flag in Italy

In times of crisis people often find out who their friends really are.  In Northern Italy teams of doctors and equipment arrived from China, Russia and Cuba.  The citizens of a town in Italy have taken down the blue EU flag and replaced it with a red Chinese one.

Some Americans on social media think it is a "photoshop job".  Where we live Chinese doctors have also arrived, along with donated ventilators and other equipment.  The Chinese flag is fluttering on many video/digital billboards.

We should note that Italy sent aid to China, when Covid-19 first appeared. 
In most countries treatment guidelines have been published to determine how to treat patients and how to ration the limited available medical resources.  There is nothing new in rationing medical resources, it happens every day.

In terms of therapy, the note linked to below (in English), is very good.  It includes both chloroquine and hydroxychloroquine, mentioned in my initial post.  Note the dosage is tapered, as I suggested in my post.  In the case of hydroxychloroquine, you only need 12 tablets; so a standard pack can treat 5 adults.  Time for emergency production to start? Or we have to wait for the Chinese to do that for us?

Note that these drugs may have side effects, in particular QT prolongation of your heart beat.  This is a possible side effect of many drugs,  You would not want to combine multiple drugs that prolong QT. The QT interval is measured by ECG.

I am pretty sure I took chloroquine many years ago when travelling in a malaria infected area and never had an ECG.  It is clearly a case of balancing risks.  

Back to triage 

In the Napoleonic wars the French came up with the word triage and by the time of the World War One they had fine-tuned it. Those collecting the injured had to categorize patients into one of three groups:-

·         Those who are likely to live, regardless of what care they receive
·         Those who are unlikely to live, regardless of what care they receive
·         Those for whom immediate care might make a positive difference in outcome

In the current Covid-19 outbreak patients are first split into two groups: -

·        At-risk group, based on age and existing medical conditions 
·        Not in an at-risk group, based on age and existing medical conditions

Severity of the Disease

·        Mild to moderate, the case for most people (no pneumonia or oxygen required)
·        Severe, breathing difficulties requiring oxygen
·        Critical, ARDS (Acute Respiratory Distress Syndrome), Sepsis, Multi organ failure.  The people with critical severity require mechanical ventilation and intensive care

Frailty assessment

The clinical frailty scale (CFS) is used to give a rating from 1 (very fit) to 9 (terminally ill).  Each patient is given a CFS score when it is necessary to ration care.

People with a disability obviously do not want to get a black mark in the frailty assessment.

When overwhelmed with sick people, those working in hospital are not going to be able to devote time to people who are disruptive (aggression, self-injury etc) or those who need a family member at their bedside.

Another issue is where to put disabled people after treatment, so they do not block hospital beds needed for others.  In Italy hotels have been taken over to house people who are still infectious, but not seriously ill.

People who have intellectual disability (ID/MR) are not so easy to house, as this recent article highlights.

Developmentally Disabled New Yorkers Stuck in Hospital After COVID-19 Recovery
According to AABR ( Association for Advancement of Blind and Retarded), a non-profit with a New York State contract to house roughly 200 adults with developmental disabilities, their staff does not have enough necessary masks and gowns to safely retrieve 12 autistic and developmentally disabled residents who are ready for discharge after being treated for coronavirus.

Nine of those patients tested positive and six more hospitalized are awaiting test results. The 12 patients no longer require hospitalization, but are still considered contagious.  

“We have twelve individuals who have been hospitalized who are ready for discharge and isolation at home, but we don’t have a safe plan to bring them home,” said Libby Traynor, executive director of AABR, which used to be known as the Association for Advancement of Blind and Retarded, an 80-year-old organization that runs 22 group homes in the five boroughs.  Residents in six of those group homes have tested positive for COVID-19. 

Because of their intellectual disabilities, many of the AABR clients are unable to speak, let alone comprehend and follow safe social distancing and isolation rules, and the virus appears to be spreading rapidly within their facilities.

"It’s a pretty big ask to ask folks to take care of individuals, and they don’t have the protective equipment that they need,” Traynor said.

Survival of the Fittest

People affected by disabling conditions are worried that they might suffer from the rationing of hospital resources.  In times of crisis political correctness goes out of the window and it is back to survival of the fittest.  Younger healthier people get priority because they have more potential future years ahead of them and they recover faster and make space for the next patient.
Complaining that it is not fair is not going to help you.  Assigning ventilators by lottery, as some suggested, is just deluded. Fortunately, rationing life-saving treatment is nothing new and systems are in place to maximize the public good.

He, too, asked the Department of Health and Human Services to take action to stop rationing.
The letter, dated March 18, asked the department to "quickly issue a notice to physicians and hospitals specifying the applicability of non-discrimination requirements" of federal disability civil rights law.
Romano says he got a response from Roger Severino, who heads the HHS Office for Civil Rights and that he's now been talking to officials there about taking action.
"We're working very, very closely and very hard to make sure that we get some form of guidance out to the medical community as soon as possible," Romano says.
It's still unclear. If the federal government will respond. And if so: How forcefully.

If you are at high risk, self-isolate.  It is up to you if you want to self-treat, but it is wise to know what you are doing.

An Arizona man has died and his wife is in critical condition after they ingested chloroquine phosphate - an aquarium cleaning product similar to drugs that have been named by US President Donald Trump as a potential treatment for coronavirus infection.
The couple, in their 60s, experienced immediate distress after swallowing the drug, an additive used at aquariums to clean fish tanks, according to Banner Health Hospital in Phoenix.
Chloroquine phosphate shares the same active ingredient as malaria drugs that Trump has touted as possibly effective against Covid-19, the potentially life-threatening disease caused by the coronavirus.

According to the CDC’s at-risk list, people with Classic/ Kanner’s/ Severe autism are at elevated risk from Covid-19.  I have my doubts that young people in this group are at any elevated risk, if they are in good general heath.  Admitting a child with this level of autism to hospital for several days, alone, might cause problems (for the child and the hospital).

Missed Chemotherapy

Many medical procedures have been cancelled.

People are complaining that the delay disembarking from their cruise ship is affecting their chemotherapy. 

They might want to skip the article below from an oncologist.

In the above article the oncologist is brutally frank about the benefit of chemotherapy in most cases.

In effect, she is saying not to worry if you have to stop your chemotherapy.  The positive results in trials do not reflect the real world, where people have comorbidities etc. She says that “Patients are often astonished to hear that common therapies offer less than 5% benefit. The more lines of chemotherapy, the less the chance of success. Hand in hand with benefit goes harm.”

You do wonder why the bar is set so low for not very effective cancer therapy and yet so high for autism therapy. One pill is supposed to works for hundreds of different autism variants. All avenues are pursued to treat a person with cancer, but no avenues are pursued for someone with autism and intellectual disability. 

The same is actually true with dementia drugs, which are pretty much a placebo for the family members, rather than an effective therapy.


The currently recommended Chinese solution is mass testing to identify all those carrying the virus, most of whom have minor symptoms or no symptoms and then isolate them, so they cannot infect their family members and others.

My solution would be mass treatment of healthy people (no people with abnormal ECGs) with prophylactic doses of Chloroquine, to stop the virus spreading.  The drug is very cheap and it is much easier to make more of this drug than millions of ventilators. Once you take the drug the effect will last for weeks (the half-life is one month), so you could treat whole cities, one by one.  Many old people with arthritis take chloroquine or hydroxychloroquine every day, so I think the QT risk can be managed. 

Chinese doctors found that treating health workers with prophylactic doses of Chloroquine gave them protection from catching the virus from their patients.  15% of those with confirmed Covid-19 in Spain are health workers, so a little advice from China might be in order.   A trial in the UK is planned.

Chloroquine Prevention of Coronavirus Disease (COVID-19) in the Healthcare Setting (COPCOV)

Once hospitals get over-loaded, as they now are in Italy and parts of Spain, there are inevitably people who do not get fully treated.

If you are in the CDC’s at-risk group, it would seem smart to start treatment at home, when the symptoms start, and hopefully avoid the need for triage and “frailty” assessment a few days later.

Anti-viral therapy is most effective when taken early on and in later stages, not surprisingly, has little benefit.

Fish tank cleaner will kill you rather than the virus, but the pharmaceuticals proposed in the medical guidance note from Belgium are saving lives.


  1. I am in the United States, and it feels like the vast majority of us have lost their mind as we are too spoiled to make objective choices anymore.

    The case fatality rate numbers from the Diamond Princess cruise ship have been known for some time which is the only really decent metric we have in judging the upper and lower bounds of how bad Covid-19 could be as a killer. And the numbers and demographics suggest Covid-19 is worse than anything people are used to at the moment, but it is not that bad in historical context. Not bad enough you should destroy your economy over.

    Unfortunately in a crisis, democratic debate tends to give way to group-think and authoritarianism where contrarian viewpoints are shouted down by those who use appeals to authority to justify their knee-jerk actions and if the short-term and hyperbolic thinking is not pushed back on by leadership, it will inevitably lead to a domino effect of bad decision after bad decision plus plenty of partisan back and forth blaming .

    At the moment, the United States and likely many other western nations have effectively decided to permanently impoverish the continually shrinking pool of young people being born thanks to abysmal and unsustainable low birth rates that will only get worse from the disastrous martial-law like decisions, just so some older people who have had lives better than any other generation in human history can live a few more years.

    Well-paid doctors and other like-minded professionals in their social bubble naively believe everyone can telecommute to work for an indefinite period of time and everything will just be fine economically after a little bit of pain they won't actually have to feel financially. I personally will take being exposed to Covid-19 over having my kids starve as would most people, but doctors in this country don't seem to understand this because they cannot comprehend a Venezuela like collapse happening in the United States. Politicians and economists believe that handing people free money is the right solution, when the problem will actually be that we will soon have severe supply shortages, both from domestic factory production being shuttered, as well as international trade (especially with China) being disrupted or even ended in some cases. This will cause a yo-yo effect and a price war for basic goods which will inevitably cause rationing and then a cycle of even more decreases in productivity as everyone worries about fighting for basic goods, rather than producing them since factory know-how and employment will be severely dislocated or destroyed and it won't be coming back since these are specialized skills with strong teams that require predictable levels of capital to keep together. On top of that, we are giving out unemployment insurance that pays you as much to sit on your butt as to go back to work which will achieve the same result as the shelter-in place orders and continue to striking decreases in economic production.

    Economic pundits on TV predict we will be at 2.1% economic growth by the end of the year which is absolute bonkers because they believe you can just reboot the economy like you can reboot the brain of a human being after they have been dead for several hours. Modern economies just don't work that way. If modern economies did work that way, Argentina would still have a top 10 economy in the world after rebooting itself from disastrous economic policies of past leaders.

    And with respect to autism, I expect all formal research into autism to end worldwide (or at least in North America and Europe), as budget priorities will keep going to try and engineer a fix to the last engineered crisis ad nauseum as nobody cares about doing research when you have 30% unemployment and require a war to force the elites in countries around the world to start making intelligent and pragmatic decisions for their own survival, unfortunately, at the expense of the poor people who end up dying for them.

    1. Tyler, I think your President is on your side of this argument.

      The problem I foresee is what happens when the initial wave of Covid-19 fades later in spring, things start to go back to "normal", but in December the virus returns again, before any vaccine has been released. I do not see a second global shutdown; then the economy probably will be the priority.

      I think people are unduly worried about disaster in refugee camps, because they are not full of old people with comorbidities, they have already passed on. The same applies to poor countries in Africa. The better your healthcare system the more people you have with comorbidities.

      We are very lucky the death rate among those with the virus is likely 1-2% and many die with the virus, rather than from the virus. It is widely agreed that the real number of infections is 10X the figure of positive tests. Unless you are a member of a Royal Family you cannot get a test.

      The Spanish flu killed about 5% of the population, but they were mainly young people with 40 years of life ahead of them.

    2. The death rate is likely well below 1-2% as well as that is just the case fatality rate. My wife's grandfather about 10 years ago passed away from pneumonia, but he was 90 years old and recently had a heart attack. Saying he died of pneumonia might be technically true, but really a more honest post-mortem is that he just died from a malfunctioning immune system due to old age.

      Furthermore, our health care system is grossly inefficient and before the coronavirus situation, health care costs were already increasing consistently above inflation and wage increase levels for a long, long time. Simply put, if you destroy your economy, you will find that quality health care will only be available to the rich and connected because nobody else will be able to afford it. Better to just let nature run its course and deal with the aftermath as fast as possible rather than drag things out and diminish economic output so much that people start dying en masse from all kinds of other things because we can no longer afford medicine or to pay doctors who will refuse to take a pay cut in the midst of all of this. Sadly, our political leadership does not seem to want to make any hard decisions now which dramatically increases the chances of total economic collapse. The mayor of New York is suggesting quarantines through May which is causing people to all leave New York and spread coronavirus around the country at a faster rate, which as far as I am concerned is a good thing since I have little confidence a vaccine will be ready anytime soon.

      Also, Americans by and large are also are not dealing with the reality in that an enormous amount of our basic medical supplies as well as medicines and components of medicines are manufactured in other countries, and especially in China. Europe has similar problems as they are finding out how unwise it now is to have Asia and now Africa be employed in all of the dirty industry in the world because westerners take their relatively clean air for granted. Of course, nobody likes pollution but an economy needs to have some sort of balance and the idea of extreme national specialization in neoliberal economic thinking where rich countries just do high-level jobs in tech and finance, and everybody else does the hard labor is proving to be a very unwise line of thinking now. Unfortunately, we don't have a skilled work force like the Chinese have as robotics have not become ubiquitous enough to do those kind of jobs yet, plus we won't have the capital to invest anymore if we destroy America's wealth to the extent we start having major endemic shortages of medical supplies and eventually food as well, even though the oil to ship stuff around is at negative prices.

      You also know how the American Medical Association artificially reduces the number of doctors in the United States to keep wages sky high and

  2. And now to add another layer of pesimissm and problems: My husband and I are, in usual times, very concerned with state overreaching and privacy issues (not email privacy more like body privacy which is being infringed upon more and more). Europe has always been a place where you get the most freedom in the world (whatever Americans might have heard from their propaganda machines, this is the truth) and the european governments find the taste of totalitarian oversight over their citizens way to sweet for my liking. When will the measures end? There have been interesting things slipped into the stimulus package in the US and I can see articles everywhere, in all languages, with the same title: social distancing is here to stay. Doesn’t look good and seems our decision to move to a small island in the next 2 years is not a second to early.

    1. This is one of the main problems with authoritarianism in that bad decisions are covered up by even worse decisions vis-a-vis with China's early handling of coronavirus so that the regime can save face. You have the same problem now in the United States and many other nations in Europe where you have a bunch of clueless leaders taking advice from all the wrong people and then making the case that will be in a perpetual war with Eurasia (1984 reference so as not to confuse people) until a vaccine is found.

      It is pretty convenient that nobody can protest anymore when you have martial law under the pretext of saving lives from a novel virus that we don't have a lot of good scientific evidence about to justify the draconian policy decisions of western governments around the world who saw China locking up an entire province of people and then saying to themselves "well we can do better than that, we can shut down our entire nation indefinitely".

  3. New hydroxychloroquine/azithromycin study from Marseille (in English)
    "Given the urgent therapeutic need to manage this disease with effective and safe drugs and given the negligible cost of both hydroxychloroquine and azithromycin, we believe that other teams should urgently evaluate this therapeutic strategy both to avoid the spread of the disease and to treat patients before severe irreversible respiratory complications take hold."

    1. Here is the home made recipe to prevent/mitigate infection:
      "2 cups of Green Tea & a 10mg Zinc tablet a day"
      Seems harmless enough to be worth a try. Effective? IDK

  4. how many deaths are needed to save economy? in italy we have 10.000 deaths until now

    1. Well considering Italy has among the lowest and most unsustainable birth rates in the world, anything that harms your economy and makes it even tougher for young people to start families needs to be seriously weighed against the deaths of even a substantial number of older people who will no longer reproduce. The Roman elites could not make those forward thinking calculations about investing in their young and look what happened to them in 410 AD when they could no longer defend themselves.

      A high school friend of my mother's who married an Italian and moved to Italy many years ago, has two grown children. One of them had to move to Japan because there were no jobs in Italy (he has advanced degrees in the humanities), and the other who also has advanced degrees finally had her first child in her very late 30's or early 40's (not 100% sure) after putting off that aspect of her life for similar reasons. She is likely too old to have any other children at this point.

      Whether it be Japan, South Korea, or even most of western Europe it is extremely sad to see those nations commit auto-genocide, and now with coronavirus, things will likely just get accelerated in that direction with the economic shocks to come that you cannot dig out of if you have an upside down economy where the old people eat the seed corn that is supposed to be saved for the next generation of people.

      The United States has similar problems with the birth rate at about 1.5 per woman and without immigration both legal and illegal, it would be comparable to Italy's low birth rates as self-identified non-Hispanic white women in the United States have only about 1.1 children each now. Regardless of your political position on immigration, things will likely change a lot on this issue which will only seriously exacerbate the birth rate crisis due to reduced immigration and a zombie economy. This is a crisis since the 2008 recession few are willing to talk about, even though this crisis has existed in Europe for some time as they have tried to solve it with mass immigration leading to a lot of social problems and an existential crisis in many nations as to what national identity means causing more social strife that makes solving political decisions all the more intractable.

      On top of this, the ineptitude in long-term cost benefit analysis with policy making as it concerns coronavirus will inevitably lead to the fall of neoliberal governments in charge around most of the industrialized world and cause the rise of extremist ideologies on both the left and the right where you end up with a bunch of demagogues pursuing the exact policies of Hitler and Stalin while at the same time constantly saying to their populace how those policies are not those of Hitler or Stalin.

      Which future sounds worse to you?

    2. in italy people know how to till the soil and kitchen gardev and feed need of killing grandparents

  5. I tried to reach the Mimaki pharmacy to order Ibudilast, but their webserver has been down for quite some time now. Anyone who knows anything about it?


    1. Anyone tried Looks a bit shady...
      They do list Ketas (=Ibudilast).

    2. For completeness: I tried this site, and it worked even though there was some corona-related hassle with delivery from Japan.


  6. For people ordering drugs through online pharmacy covid 19 and the travel restrictions Have basically meant it's hard to order any drugs at all. I know can't get my hands bumetanide and this is across a lot of the pharmacies particular India no longer producing and shipping generics has had a big impact on these online sites. If anyone knows ways or sites still operating don't have have delays any info posted here would be appreciated

  7. Anyone who can explain why I feel so extremely hungry after taking allergy drugs? Makes me feel like a carbohydrate addict. 3 months on prescribed meds and I am a always a couple of kilos heavier, and stopping them also makes my whole body ache. I'd say I'd be better off, if it wasn't that I can't breathe without them. :-/
    Someone recently posted about a link to depletion of B vitamins, but I have never heard of that before. I'd be interested in ways to ameliorate side effects.


  8. Leflunomide, maybe useful for some mitochondrial autism too?

    "A growing number of pathologies are associated with alterations in mitochondrial dynamics. In this regard, a reduction in mitochondrial fusion proteins is linked to metabolic disorders, neurodegeneration, and cardiovascular diseases in mouse models. In humans, mutations in genes encoding mitochondrial fusion proteins cause Charcot-Marie-Tooth 2A neuropathy, autosomal dominant optic atrophy (ADOA),
    and parkinsonism. In addition the expression of mitochondrial fusion proteins have been found to be decreased in obesity, type 2 diabetes, and aging. In consequence, the identification of activators of mitochondrial fusion amenable for pharmacological intervention could be beneficial in the treatment of different disorders. In this regard, by using a phenotype-based high-throughput screening using an FDA-approved library of 1,120 compounds, we have identified leflunomide as an activator of mitofusin expression and mitochondrial fusion"

    "In the case of leflunomide, it would be interesting to test it in preclinical trials against diseases where mitochondrial fission is aberrant"


  9. Great post Peter, although not easy.

    Here is the conclusion from WHO international mission to China from late Feb. It comes to my mind whenever I hear the European/US news or see some odd comments on the pandemic:

    “Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans. Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and
    immediate case isolation, rigorous tracking and quarantine of close contacts, and an exceptionally high degree of population understanding and acceptance of these measures.”

    Time will tell, but I think Serbia is lucky with regard to help from China.
    A pity that Chinese doctors did not share the details on chloroquine treatment nor published any data on prophylaxis. Officially, we have no evidence.

    PC may go out of the window in crisis, but there is also medical ethics and I don’t intend to sound exalted here. Beneficence, non-maleficence, respect for autonomy and equity may still work even if resources are scarce. The Italian Society of Anesthesia, Analgesia and Intensive Care published their guidelines for resources allocation as first country affected in Europe and it is about the chances of survival, but not about literal counting frailty scale score as in the NICE guidelines. I hope other countries will follow Italy and Switzerland rather than the UK or ideas to consider social usefulness. The sad truth is that the outcome of COVID-19 patients requiring ventilator is poor anyway, with survival rates as low as 3% reported in China. Actually it's not about increasing access to ventilators.

    This all sounds scary, on the other hand the virus is novel, but its transmission is quite well understood and so is prevention. Personally, I wouldn’t underestimate simple, but rigorous behavioral preventive measures during the outbreak peak for the whole family if a child belongs to risk group. ~80% cases in China were household infections.
    I would also discuss safety plans in advance with family and friends as unusual situations may happen and would not be easy for children with autism:

    At least COVID-19 clinical research is progressing faster than autism research.
    Here is another useful summary of treatments or drug concerns in COVID-19 which seems to be updated every few days:

    Probably I happen to be one of few physicians professionally involved both in autism treatment and COVID-19, so in case this could be of help for any reader here, feel free to email me: covid19@attempto-clinic.

    For the US based readers, a trial of hydroxychloroquine for post exposure prophylaxis has started at the University of Minnesota
    Persons living with someone who has been diagnosed with COVID-19 are asked to email and U of M declares to provide the medicine (or placebo) overnight.

    Don’t mistake the two emails and stay safe :-)

  10. Regarding our mood problems with Zoloft, they became very obvious (always between 11am and 5 pm regardless of what we supplement in the morning). We decided to cut it out and see - mood was great, 0 issues. I loved the very visible effects. We will try giving it every 3 days to see if we can produce the same effects but without the mood problems.



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