It is week 20 of the coronavirus lockdown. For a man of my age, between the pandemic, the sometimes illogical/irrational Government response, and the everlasting urban mayhem, this is clearly the most bizarre time period of my entire life.

Here in Pennsylvania, presumably due to a rise in cases in western Pennsylvania, our governor has re-imposed restrictions on bars and restaurants. The first version of this specified that there could be no bar seating, and customers had to buy food if they wanted a drink.

Understandably, many already struggling taverns created inexpensive food items for patrons who wish to have a libation while sitting at a table. Curiously, Governor Cuomo in New York, imposed the same rules on his state. This occurred despite the fact that the number of new cases in that state were minimal.

Apparently, New York bars and restaurants followed the Pennsylvania practice, and soon there were “Cuomo chips” made available to patrons.

For absolutely no discernible reason, other than perhaps pique, both Governors imposed additional rules requiring that A “substantial meal” be served. Andrew Cuomo made it clear that for instance “chicken wings” don’t qualify, undoubtedly endearing him to western New York voters.

All of this is ridiculous. I think of restaurants that I frequent in places like Sullivan County, Pennsylvania (5 confirmed cases), or Hamilton County New York (same statistics) which were forced to stay closed from March to June, only to have restrictions re-imposed once again for no good reason. No wonder that a recent Yelp survey reported that 53% of their member restaurants were closing for good.

I recently visited an establishment where I sometimes go for lunch on my day off. I usually sit at the bar, talk to friends, have a beer, and a single slice of sausage pizza (I love the crispy texture of re-baked crust). The slices are large and it’s more than enough food for me.

My waitress on that day was unfamiliar. I dutifully sat alone at a table, no friends around. I ordered my usual slice of pizza with a beverage and waited.

She came to the table with the pizza and beer and then informed me that although they would honor my order today, the slice of pizza was inadequate to be considered a meal, and they would not do this again. I was also told that I could not have another beer regardless of whether the pizza was finished. The restaurant, often quite busy on a Thursday, was minimally occupied. I can’t imagine why.

What kind of madness is this? Is the state now determining what I eat for lunch? And how does this protect anybody from COVID? Or is it just meant to add to the general misery? You decide.

I would be remiss if I didn’t discuss the surge in cases throughout the southern US. There are likely multiple reasons for this from the parallel surge in Mexico, to the loosening of COVID restrictions. Spring break activities may well have played a role.

The climate may also have something to do with this. While the Northeast in March April and May were “hotspots”, the South had minimal problems with really no “peak” like we experienced in April. It was a cold spring in the North and for most of us, we were trapped indoors, while people in the South presumably spent more time outside.

Now in summer things have reversed themselves, with those in the South, escaping the summer heat indoors with air conditioning, and those of us in the North are enjoying the outdoors. I do wonder whether HVAC systems are helping to spread the virus. There is some emerging interest in this possibility.

So, let’s talk about hydroxychloroquine. I’ve been writing about the pandemic since March 21st. In that first article, I already noted that there was some evidence that hydroxychloroquine, along with azithromycin might have some efficacy. I also noted that a research-based physician such as Dr. Fauci would culturally be uncomfortable recommending a medication without multiple double-blind studies. This is entirely understandable. But Dr. Fauci doesn’t treat anybody. Practicing caregivers in the middle of a pandemic are sometimes forced to innovate for the benefit of the patients.

Even in March, there was in vitro data suggesting that HCQ inhibited coronavirus replication, and since then, we have come to understand that there perhaps for other mechanisms on a cellular level where the drug may prevent viral contents from entering human cells. There were also non-blinded trials strongly suggesting that the drug was useful. In later articles, I discussed other papers that had been published with similar views. Finally, there was the controlled study from Detroit where HCQ halved the mortality rate of hospitalized COVID patients.

Unfortunately, when Donald Trump mentioned the drug in one of his briefings, all hell broke loose. I think I understood what he was trying to do, namely offer some optimism during frightening times. I honestly believe that another president, at another time might have been given the benefit of the doubt. Not in this case. Hydroxychloroquine became “Trump’s drug” and its use must not be allowed.

On Monday, a group of physicians calling themselves America’s Frontline Doctors held a press event in front of the Supreme Court. There they discussed their experiences using hydroxychloroquine in the treatment of COVID. The most prominent and controversial speaker was Dr. Stella Immanuel, who was apparently a pediatrician, born in Cameroon. She also claims to be a minister. She is convinced that hydroxychloroquine is effective having by her account treated 350 patients with it with minimal morbidity and no mortality.

What she seems to believe is that “Big Pharma” is suppressing information on the drug’s efficacy in order to boost profits from drugs such as remdesivir, as well as from vaccines to be developed. Having dealt with pharmaceutical companies for much of my career, I do not find this idea completely fantastic.

It was her opinion, that if hydroxychloroquine was used more often for prophylaxis and treatment, that no masks or other restrictions would be necessary. She was, to say the least, very fervent in her beliefs.

I saw this video on Monday night. It was interesting, but I’d never heard of the physician group and thus wasn’t sure what to make of it. Nonetheless, if her treatment claims are truthful, it is another data point. I couldn’t really figure an ulterior motive when the drug is off-patent for 40 years.

Tuesday morning, I was perusing Facebook when I noticed that multiple friends of mine had posted the video. They also were reporting that Facebook and YouTube were deleting it. I despise “Big Data” censorship, and thus I shared the video with the comment that I was posting this because it was being removed, but I found the video “interesting”.

I was then beset upon by a young lady of my acquaintance, who works in health sciences who was extremely offended that I would post what she considers to be essentially anti-science. She informed me that either I should take down the post, or undoubtedly Facebook would, as she had already reported the post to their “editors”.

Dr. Immanuel, as it turns out as a somewhat “colorful” online presence and holds some controversial opinions as part of her ministry. Websites like the Daily Beast, eschewing their usual love of diversity, quickly did a “deep dive” in order to debunk her. They claimed that Dr. Immanuel claimed that masks are not necessary, without the qualifier she provided.

Nonetheless, if her claims about her medical practice and her treatment of coronavirus are true, then the information may be useful. Again, it’s information to be processed and then believed or discarded. Information is generally helpful.

Given the significant number of articles that I have quoted in the past, some controlled, some anecdotal, but all supporting hydroxychloroquine as a COVID antiviral (here is a recent one from Newsweek), the virulence of opposition to this video would suggest that there are people who just don’t want to know if the drug works. Logically, it suggests that they may not wish for any chance to see the pandemic brought under control so that the economy can fully reopen. And why would they feel that way? Maybe it has something to do with the presidential election in 3 months or so?

I for one cannot imagine being such a nihilist- so politically driven that I would be willing to discard a potential treatment and prolong people’s physical and economic distress. I do not understand on an interactive forum like Facebook, why people who disagree with a viewpoint, would want to erase it, rather than just to make their case in opposition.

I just want to know what works so I can treat my patients.

And perhaps selfishly… sit at a bar with a beer and eat a piece of pizza.

By my count, it is week 18 of restrictions imposed upon us by the COVID-19 pandemic. It feels like “the new normal” has set in. Here in Pennsylvania, all of the state is in the so-called “green” phase, where the remaining businesses have opened, and we can now go to bars and restaurants albeit with masks and appropriate distancing. Our case numbers per day continue to trend downward except in Allegheny County (Pittsburgh). There the numbers are slowly increasing.

There is been great concern about the surge in new coronavirus cases in multiple states. Florida for instance has seen a significant increase in new cases over the last several weeks. If you look at the long-term graph of cases per day however, this surge looks like the state’s first true peak. Deaths are on the rise there. Interestingly there are reports out of Florida that a significant number of sites had an 80-100% positivity rate (our positivity rate in April was around 27% which is typical). This sounds like there are testing issues in the Sunshine State.

Georgia, which up to now had been fairly quiet, has seen its own increase, but so far deaths are flat. Another hot spot, Texas, new cases, and deaths are continuing to rise at this point. This is mainly centered in the cities and much of Texas remains quiet.

I should point out that the Texas hotspots of Houston, El Paso, and Austin were the site of significant protesting/mayhem in previous weeks. This is also true of Miami, Seattle, and Portland Oregon, where cases are also rising.

My concern about this situation regards the data on which it is based. Because it appears there are serious problems with the acquisition and reporting of COVID testing that could lead to bad decisions down the road.

There have been several interesting articles published in the last several weeks. Several sources I’ve pointed out that state by state, reporting of new cases uses different methodology. The CDC and apparently some states report both positive PCR tests (swab test), and positive antibody tests (blood test) as new cases (I understand this is true in PA). This is problematic.

First off, PCR test, or polymerase chain reaction test looks for pieces of the coronavirus RNA. This RNA can be present on your mucous membranes whether you’ve been merely exposed to the virus but not infected. The test detects segments of RNA that can either represent either intact virus actively spreading, or fragments of virus successfully destroyed by your antibodies or T cells. So, it may report a failed infection as positive.

Also, it is important to remember that we are reporting positive tests, not positive patients. If the patient has a positive PCR test, and weeks later has a repeat study and it remains positive, then that’s counted as another positive test even though it’s on the same person. And again there is the thought that the positive PCR in that situation may reflect the presence of viral debris at the end of the infection. So any way you look at it, it is bad data.

The antibody test, as most people know is geared to discover whether someone has been infected in the past. If we count these positives in the same way we count the PCR, then we can give the false impression of additional viral spread occurring in real time when that is not necessarily a valid conclusion.

Also, the dynamics of testing have changed radically in the last 3 months. It used to be that you needed to have very specific symptoms and be in a high-risk group to obtain a nasal swab test. Now you can essentially obtain testing on a whim. Thus, it is likely that many more asymptomatic patients are being tested.

We do know that the uptick in cases has also involved a roughly 10 years shift in average age downward. This means that the average person exposed is likely much less vulnerable.

 So, if a younger patient tests positive by PCR but has no symptoms is this really an actual infection or an aborted one? These are questions I don’t think we really understand. But we still count them as positives.

So, it would appear that the actual impact of each additional positive coronavirus test in July may be different than one in early April.

Need evidence of this? There is recent data from the University of Pittsburgh suggesting that the recent strain of COVID being encountered is perhaps less virulent than previous sprains. They note that only 2% of people who test positive now require hospitalization. And only 0.2% of cases result in death, far lower than previous statistics. Given the different profile of patients getting tested this might actually have been true all along.

There is another thing to consider. When we locked things down in March, we had little to no knowledge of how to treat these patients. We had shortages of hospital beds, PPE’s and of course ventilators.

Now, 4 months later, the healthcare system has adequate supplies and additional expertise in the care of these patients. We figured out how to reprioritize and add additional patient care units and negative pressure rooms. New discoveries in therapeutics are reducing the severity of illness and shortening the length of admissions. We are far more ready and capable than we were in the spring.

I should mention the hydroxychloroquine study out of Henry Ford Hospital in Detroit. They studied patients hospitalized with COVID. In one leg of the study, the patients were treated with hydroxychloroquine alone. These were compared to patients but did not receive the drug. The mortality rate for those in the treatment arm was 13% as opposed to roughly 26% in the nontreatment arm. There were negligible cardiac difficulties, which is the main concern over the use of the drug. This is a peer-reviewed study, the first significant evidence for use of the drug. So it is likely we can finally add this medication to remdesivir, and dexamethasone in our anti-coronavirus armamentarium.

There is also emerging information that many people may well have had some degree of both antibody and T-cell immunity to this particular coronavirus based on previous exposure to the “common cold” coronavirus that we have all encountered for most of our lives. This virus may not be so “novel” as we have been told.

I guess what I really want to say is this: We need to be careful about how we react to these surges.  In places where the healthcare services start to become strained, then we need to react strongly to avoid further spread. But in places where the numbers merely go up without much impact, then we need to remain vigilant,. We need to protect the vulnerable, but continue to go about our business with precautions in place.

As I am a compliant soul, I will wear my mask and observe the CDC recommendations. I will respect the businesses I visit, and obey the rules so they will not be penalized by the state.

So I wrote the words above between Monday 7/13 and Wednesday afternoon 7/15. I just needed a punchy way to end it.

I get home and turn on the news only to find that his Majesty the Governor has reimposed lockdowns?… on the whole state? He has targeted the bar-restaurant trade which I suspect he views as a more frivolous business and the least defendable (tell that to the owners and employees).

There is no justification for this in the state’s own data. First off, cases were bound to kick up a bit when we went to green several weeks ago. Then there is the fact that the increases are limited to a few counties in the west. Remember the announcement above from UPMC?

So I went to the State’s own COVID Early Warning Dashboard. In Allegheny county, the PCR positivity rate is 7.9%. The percentage of ER visits related to COVID is 0.9%. Pittsburg has multiple very large hospitals. There are 80 patients admitted with COVID, only 9 on ventilators. All of this in the State epicenter.

I’m sorry, but this feels purely political. It is tyranny in the Commonwealth of Pennsylvania.

What do you think…punchy enough?

As I mentioned in my last “Viral Post” two weeks ago, my local mountain laurels were in bloom, which signals to me that very likely they are in bloom elsewhere in the Poconos.

This includes several areas of nearby Hickory Run State Park, where there are areas where the laurels dominate the landscape.  In June the forest there is awash in pinkish-white blossoms as far as the eye can see. I have written about this before.

This is for me, a favorite time of year for photography. The blooming of the laurels is closely followed by the flowering of the closely related rhododendron which is also widespread in that location. In some years they bloom together which is particularly striking.

So, with the camera bag and a tripod on my back, I hiked up the quiet trail where I know from past dealings the display will tend to be lovely.

Unfortunately, perhaps symbolically for this year, this was not to be. For the first time, most of the mountain laurel had not flowered, and those that did had spotty blossoms.

Moreover, I found that the rhododendron was in the same state. I counted literally 4 to 5 flower buds on the whole trail where there would’ve been literally hundreds of thousands.

Not sure why this has happened. Perhaps the unnaturally cool spring we experienced is responsible.

There were blossoms elsewhere in the park, near to the brand-new park headquarters, but these were underwhelming and located on the border of newly cleared land, where the light was harsh and unflattering.

So a small event that I look forward to each year as once again failed to happen.

Whats next?

I’m thinking Murder Hornets