Things we've learned about the coronavirus

We've learned a lot about the coronavirus these past seven(!) months. But keeping current has taken much effort, and I'm finding that persons I know are often unaware of many of the details that I regard as important to staying safe and healthy. Maybe you'll find them important too, because they could inform how you think about your own actions as we make our way through this trying time. I intend to cover some of them here.

Before we begin, I'll take note of where we stand. If you want to get right to the meat of the post, skip the commentary that follows in the next several paragraphs and go straight to the sections below that are headed in bold.

Coronivirus  (a.k.a., SARS-CoV-2, a.k.a. COVID-19, but see the "note on terminology" below) is now the third leading cause of death in the U.S., behind cancer and heart disease. As I write this more 190,000 persons have died of the virus in the U.S. since the beginning of the pandemic. We have been plateaued at about 40,000 new cases and 1,000 deaths per day—a staggering toll. Epidemologists are on the lookout for a possible post-Labor Day surge. Most public health experts expect a difficult winter. There have been more than 6.5 million confirmed cases in the U.S., which understates the true infection rate by many multiples. A frequently-cited model from the University of Washington projects a mind-blowing 415,000 deaths by January 1.

Many schools and universities have been opening, which will continue to seed new outbreaks—something that's happening even as I write this. To cite just one example, nine fraternities and sororities are under quarantine at the University of Kansas, in my home state, and cases are surging in the city of Lawrence. It's the same story, and sometimes a lot worse, around the country.

[Update 09/17/20 - Yesterday the Big Ten athletic conference reversed itself and announced it will play a fall football schedule.]

Unlike other parts of the world, the U.S. seemingly has no ability nor obvious intention to contain disease spread. Dr. Anthony Fauci, the country's top infectious disease expert, says he'd like to see a baseline of 10,000 new cases per day, and preferably less, in order to bring the spread under control. At the current high baseline levels control is not possible.

There is no national policy to achieve control, and no immediate prospect that anything will change. If anything, policy is moving in the wrong direction, as indicated by the appointment of the shockingly unqualified Scott Atlas to the White House coronavirus task force. Dr. Atlas, who is neither an epidemiologist nor a public health expert (he's a radiologist whose prime qualification is appearances on Fox News), says it's a mistake to isolate lower-risk persons because, he argues, this just delays the buildup of immunity in the larger population. In response, former CDC director Dr. Tom Frieden said that "trying to get to herd immunity other than with a vaccine isn’t a strategy. It’s a catastrophe." Perhaps you can see why it's good to have experts in positions that require expertise.

[Update 09/17/20 -  In an open letter, former colleagues and researchers at Standford Medical School, where Dr. Atlas once held a position, repudiated the "falsehoods and misrepresentations of science recently fostered by Dr. Scott Atlas," saying, among much else, that "encouraging herd immunity through unchecked community transmission is not a safe public health strategy. In fact, this approach would do the opposite, causing a significant increase in preventable cases, suffering and deaths, especially among vulnerable populations, such as older individuals and essential workers."]

Meanwhile there have been growing indications that the CDC, that most venerable of public health institutions, has been succumbing to political pressure from the White House. The CDC recently announced new testing guidelines that have drawn widespread rebuke from epidemiologists. The CDC now says that persons who have been closely exposed to infected individuals need not get tested themselves, despite the fact that asymptomatic spread of the disease is one of its important features. This new guidance meshes closely with President Trump's long and repeated insistence that he wants less testing, not more, in contradiction to his medical advisers and public health experts. And indeed, the country is now doing less testing than at its peak, at a time when epidemiologists continue to warn that more is needed.

[Update 09/18/20 - The New York Times broke the story that the much disparaged "CDC" guidance on testing was not written by the CDC, and was published on the agency's web site over the objection of CDC scientists. This never happens. Now it has. The politicization of the CDC and other national public health agencies has been stunning.]

[Update 09/19/20 - The CDC, reversing its previous guidance, said yesterday that anyone exposed to an infected person for more than 15 minutes should get tested.]

Perhaps most alarming of all, a Trump political appointee has been interfering with the CDC's "Morbidity and Mortality Weekly Reports," which have been referred to as the "Holiest of the Holy" agency communications. That political appointee, Michael Caputo, thinks CDC scientists are trying to make the president look bad. In our present dysfunctional political environment, our nation's most hallowed public health institutions have been hampered, muzzled, and at times have performed poorly.

[Update 09/17/20 - Mr. Caputo, who has apparently suffered a severe meltdown these past several days, announced yesterday that he's taking a 60-day leave of absence.]

A note on terminology. Correctly understood, SARS-CoV-2 is the name of the virus, whereas COVID-19 is the name of the disease that it causes. SARS-CoV-2 is closely related to an earlier coronavirus, SARS-CoV,  which was identified in 2003 and which caused the SARS epidemic back then.

In the discussion here we'll not distinguish closely between the disease and the virus, and we'll refer to both variously as COVID-19, COVID, or just the coronavirus. My purpose here is to describe important features of the virus and the disease that often aren't well understood by the general public, and which when better understood might change how we organize our lives during these challenging times, with the objective of being around this time next year to evaluate our circumstances.

An important disclaimer is that I am not an expert, and you should take what I say accordingly. On the other hand, I've tried to document much of what I've said by referring you to authoritative sources. Let's get started.

 

Many people don't have symptoms, or have misleading symptoms. A large proportion of persons infected with COVID-19 are asymptomatic or are only mildly symptomatic. By some estimates the actual number of infections could exceed the official case count by a factor of 10. That's in part because it's mostly sick people who get tested. That so many people infected with the virus don't develop significant symptoms may at first blush seem to be positive, but there are reasons why it isn't. Some are described below, and in sections that follow.

The classic symptomatic presentation of COVID involves a dry hacking cough, fever, and then progression to lung involvement including pneumonia. But early on emergency room physicians began seeing peculiarities. Some patients presented to the ER with cardiac symptoms, with subsequent testing showing a COVID infection. It's likely that a number of early deaths, and perhaps some later ones, were attributed to heart attacks when the true cause of death was COVID.

Some persons develop serious pneumonia even before experiencing the labored breathing that one would expect from such a condition. Dr. Richard Levitan, an internationally known airway specialist and emergency physician, was volunteering at New York's Bellvue Hospital ER early in the pandemic. "Even patients without respiratory complaints had Covid pneumonia," Dr. Levitan wrote. "The patient stabbed in the shoulder, whom we X-rayed because we worried he had a collapsed lung, actually had Covid pneumonia. In patients on whom we did CT scans because they were injured in falls, we coincidentally found Covid pneumonia. Elderly patients who had passed out for unknown reasons and a number of diabetic patients were found to have it."

"And here is what really surprised us," Dr. Levitan continued. "These patients did not report any sensation of breathing problems, even though their chest X-rays showed diffuse pneumonia and their oxygen was below normal."

Dr. Levitan seemed amazed: "A vast majority of Covid pneumonia patients I met had remarkably low oxygen saturations at triage — seemingly incompatible with life — but they were using their cellphones as we put them on monitors. Although breathing fast, they had relatively minimal apparent distress, despite dangerously low oxygen levels and terrible pneumonia on chest X-rays." [my emphasis -mb]

Dr. Levitan calls this initial stage, where blood oxygen saturation drops dangerously while breathing remains substantially unlabored, "silent hypoxia." It's worth noting here that individuals can easily monitor their own blood oxygen levels with an inexpensive device called a pulse oximeter. You can buy one at your pharmacy, or on Amazon. It's an easy to use device that could help with early detection of pre-symptomatic COVID pneumonia. Persons who have been exposed or who have tested positive might consider purchasing one and using it a few times per day. Not, mind you, that you should be taking medical advice from me.

According to Dr. Levitan, patients who had serious pneumonia even before developing breathing difficulties typically did feel sick in other ways after becoming infected. But as described below, it's shockingly common for young adults to incur lung damage while having essentially no symptoms. This suggests there could be a large amount of hidden damage, perhaps lifelong, that might not become apparent until much later. It's a good bet that we have been substantially underestimating the risk to young adults. Every time I hear acquaintances recount with a shrug how they or their kids had the disease and it was no big deal, I worry that the true toll is yet to be revealed. With many universities now back in session and experiencing widespread outbreaks, it's likely that unexpectedly high numbers of young people are sustaining lung damage without being aware of it. See the section on young people below for more on this.

Why some people don't develop symptoms is an open question. It might be because of some inherent or acquired immunity, or that their immune system doesn't overreact in ways that can cause severe damage. Such immune system overreaction is involved in the most severe cases. Or it might be that they weren't exposed to high enough levels of the virus to get very sick. There's a suggestion that our tests are too sensitive, because the gold-standard PCR test can detect extremely low levels of virus. The test goes through a number of "amplification cycles" to find the virus, and lower viral loads require more cycles. It could be helpful if the "cycle threshold"—the number of cycles that were required to detect the virus's genetic material—was reported in the results, but it typically isn't. Were it available, the cycle threshold might be a useful proxy for viral load. It's reasonable to assume that persons with low viral loads aren't very infectious, but it seems we still have things to learn.

None of this argues for less testing; quite the opposite. As epidemiologist Michael Mina says, "we should be ramping up testing of all different people, but we have to do it through whole different mechanisms." Dr. Mina says "the decision not to test asymptomatic people [per the latest CDC guidelines, which are apparently now politicized, and which continue to change -mb] is just really backward."

 [Update 09/19/20 - The CDC, reversing its previous guidance, said yesterday that anyone exposed to an infected person for more than 15 minutes should get tested.]

Because the virus is still spreading out of control, and because we are still learning new things about it, my own position tends toward caution, which means more testing. Perversely, it seems, we are currently doing less than even our previously inadequate levels. It is unclear to what extent reduced testing is reducing the number of confirmed cases being reported in the daily statistics.

Asymptomatic spread is common. In at least two noteworthy respects, lack of symptoms does not mean a person is not infectious, which is one of the most insidious features of this disease. Persons can and do spread the disease without having symptoms.

In particular, even persons who do become strongly symptomatic are believed to be at their most infectious a day or two before symptoms appear. It is therefore not possible to rely on the presence of symptoms, or on temperature checks, to gauge whether an individual is safe to be in the presence of others.

A study in South Korea published August 6 found that "many individuals with SARS-CoV-2 infection remained asymptomatic for a prolonged period, and viral load was similar to that in symptomatic patients; therefore, isolation of infected persons should be performed regardless of symptoms." A related story in the New York Times said the study "offers more definitive proof that people without symptoms carry just as much virus in their nose, throat and lungs as those with symptoms, and for almost as long."

Young people get it too. A common misconception is that young people don't get the disease. That is a dangerous falsehood, for a number of important reasons.

Health experts have been aware almost from the beginning that a small number of children were afflicted with a COVID-related condition that's referred to as multisystem inflammation syndrome (MIS-C). The condition, which involves the heart and other organs, is similar but not identical to a rare childhood syndrome called Kawasaki disease. As of the end of June, two research groups found nearly 300 cases of the syndrome. 80% of the involved children required intensive care, 20% required mechanical ventilation, and 2% died. As of very recently, the CDC received reports of 694 confirmed cases, with 11 deaths. Most have occurred in children between 1 and 14 years of age. See this, this, and this.

Children are something of an enigma. They get the disease at about one third the rate of adults, and typically have few symptoms. Yet children often have much higher viral loads in their airways compared to even very sick adults. Even so, children under the age of 10 are currently thought to be relatively inefficient spreaders of the disease, whereas older children spread it as readily as adults. Children with very high viral loads might be more infectious, but it seems we still have more to learn.

[Update 10/04/20 - A very large study in India published in the journal Science found that children are readily infected and readily spread the virus to other children. The study's discussion says that "social interactions among children may be conducive to transmission" in settings such as schools. See also this from NPR.]

Young adults are likewise cause for concern. Based on outward symptoms, they fare much better than older adults. But outward symptoms don't tell the whole story.

Whereas the initial phase of the outbreak occurred in older adults, the country's second coronavirus case surge, in early summer, was driven by young persons who were contracting and spreading the virus. According to Dr. Aileen Marty, Professor of Infectious Disease at Florida International University, although they were ostensibly asymptomatic, many were sustaining lung damage that could have long term consequences.

"In our hospitals, we're seeing the largest portion of our hospital patients are in their 30s, and younger," said Dr. Marty on July 7. "They're asymptomatic as far as they can tell. But when we do chest X-rays on these people, 67 percent show lung damage. So they may feel great; they're not great. And the truth is, they're having scar tissue forming in their lungs that may have implications for their future. So even the young people, even the children, when you do films, we see the damage. These are people we don't hospitalize."

This is a sobering realization at a time when many colleges are reopening and some football schedules are going forward. Outbreaks have been flaring up on university campuses around the country, with anecdotal reports of 80 percent infection rates in some fraternity houses. Because the concern of hidden lung damage in asymptomatic young persons seems to have been largely overlooked in our public discourse, I was curious about whether Dr. Marty stands by her earlier claims from back in July. She does.

In private correspondence, Dr. Marty told me that "a large proportion of infected people do not develop detectable symptoms, or symptoms are mild, or at worst a walking-pneumonia-like syndrome, not requiring special medical attention. Studies of asymptomatic persons indicate that nearly 30% show ground-glass opacities on chest computed tomography and about 67% have abnormal radiological findings in at least one lung."  [Computed tomography is the formal name for CT scans. Ground-glass opacity refers to "the hazy, white-flecked pattern seen on lung CT scans." -mb] See also: this.

Not just the lungs. We continue to learn how COVID-19 can be a multi-system disease, and not all individuals experience it the same way. As we have previously seen, some patients were presenting early in the pandemic with apparent cardiac problems that had an underlying COVID cause. More recently, Dr. Haider Warraich wrote about how "Covid-19 Is Creating a Wave of Heart Disease." Dr. Haider is a cardiologist and researcher at the Veterans Affairs Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School.

Dr. Haider noted that whereas we previously believed COVID primarily affected the lungs, "now we know there is barely a part of the body this infection spares. And emerging data show that some of the virus’s most potent damage is inflicted on the heart."

Add to all the other emerging syndromes a new condition called "COVID-19-associated myocarditis," which is an inflammation of the heart muscle. Dr. Haider describes a study from Germany where "researchers studied 100 individuals, with a median age of just 49, who had recovered from Covid-19. Most were asymptomatic or had mild symptoms. An average of two months after they received the diagnosis, the researchers performed M.R.I. scans of their hearts and made some alarming discoveries: Nearly 80 percent had persistent abnormalities and 60 percent had evidence of myocarditis. The degree of myocarditis was not explained by the severity of the initial illness." [my emphasis -mb]

"Though the study has some flaws," Dr. Haider wrote, "and the generalizability and significance of its findings not fully known, it makes clear that in young patients who had seemingly overcome SARS-CoV-2 it’s fairly common for the heart to be affected. We may be seeing only the beginning of the damage."

Other people have difficulty kicking disease, with a baffling array of symptoms persisting for many months, even if their symptoms were mild initially. Previous evidence from other, related, diseases indicates that persons can experience a post-viral syndrome with symptoms that manifest as chronic fatigue syndrome.

Dr. Margot Gage, a professor of epidomiology, and herself a sufferer, said that "a lot of COVID long-haulers are reporting that their nails are growing really long, but our hair is falling out. Other symptoms—for example, I have ringing in my ears that I never had before." Also vision issues. Strange rash-like skin issues. Sensitivity to the sun.

As a personal aside, an 87-year-old woman whom I know well, and who tested positive for COVID but seemingly (and amazingly) had no significant symptoms, was experiencing some mild but persistent coughing many weeks later. As we were talking, she—completely unprompted by me—look at her fingernails and remarked that they were growing faster than normal. I had heard the NPR report of this bizarre symptom just a few days earlier.

Some severely ill COVID patients inexplicably remain in comas after coming off the ventilator, prompting questions about whether they will ever wake up, and whether to remove life support.

Dr. Brian Edlow, a critical care neurologist at Mass General in Boston, says that "because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it's going to take any individual patient to recover  consciousness." Dr. Edlow observed dozens of patients lingering in this state. A research group at New York's Columbia Medical Center is trying to determine how many COVID patients end up in this condition.

There's a concern that hospitals overwhelmed with COVID patients are not giving ventilator patients enough time to wake up before discussing ending life support. In the midst of the crisis, some patients have surely died because overwhelmed hospitals could not devote sufficient time and resources to individual patients in that condition.

Hydroxychloroquine doesn't help. Anecdotal claims of benefit from hydroxychloroquine surfaced in the early part of the outbreak. Early small, inconclusive studies were reported in China and France. Large, well-designed studies were then commenced under the oversight of the World Health Organization, the National Institutes of Health, and others.

WHO ended its "Solidarity Trial" in early July when it became clear that the drug had no mortality benefit, and that there were "some associated safety signals in the clinical laboratory findings." The NIH ended its trial in late June after its data monitoring and safety board overseeing the trial concluded (after its fourth interim analysis) that the drug was unlikely to be beneficial to hospitalized patients. The NIH study was blinded, randomized, and placebo controlled. Another large, randomized, high-quality study, the UK RECOVERY Trial, reached the same conclusion.

One outlier study was conducted by the Henry Ford Health System, a network of hospitals in the Detroit area. The study seemed to show a significant benefit from hydroxychloroquine, but it had multiple significant flaws that have been well publicized. One of the most befuddling was that patients treated with hydroxychloroquine were also more frequently administered steroids. Administering steroids (particularly dexamethasone) to seriously ill patients is one of the major advances in COVID treatment to emerge in recent months.

If hydroxychloroquine is unlikely to benefit hospitalized patients—a conclusion that's becoming increasingly definitive—what about using it for prophylaxis? A large number of trials to investigate whether pre- or post-exposure use of hydroxychloroquine to prevent disease has benefit have been launched, but results are maddeningly (to me) inconclusive or incomplete. One study of postexposure phrophylaxis involving 821 health care workers did not show that hydroxychloroquine prevents illness. A long and rambling commentary suggested we should not yet rule out benefit, but did not demonstrate any conclusively.

The safety profile of hydroxychloroquine is also debated, and where one comes down seems at least in part to depend on whether or not he is a devotee—in a non-expert sense—of the drug. Unfortunately, this has become a politically fraught discussion, and needlessly so. On the one hand, experts conducting carefully designed studies find no benefit. On the other, non-experts, including the U.S. president, hype anecdotal claims. If you believe the claims, then potential safety issues seem a small price to pay. But if the drug truly has no benefit, then widespread use in the general population is reckless.

Hydroxychloroquine has a long list of possible and possibly dangerous side effects. Yet it has been used more or less safely for decades for the treatment of malaria and autoimmune conditions. Surely the layman is in no position to exercise judgement on how to resolve this question. Nor, for that matter, is the president. Fortunately, we have experts who are tasked with making these very determinations. But un-fortunately, in the current politicized environment, those experts are often disparaged and denigrated. Throughout this epidemic, the politicization of the public health system has been as harmful and unfortunate as it has been unprecedented.

According to The American College of Cardiology, "known harms of chloroquine in patients without COVID-19 include (but are not limited to): cardiovascular (cardiomyopathy, electrocardiographic changes); hematologic (aplastic anemia, thrombocytopenia); nervous system (seizures, psychosis, extrapyramidal disorders); and ophthalmic macular degeneration." The ACC said on July 27 that "we should not use chloroquine or hydroxychloroquine alone or in combination with azithromycin as prophylaxis against COVID-19 due to known harms and no available evidence of benefits in the general population." The ACC recommends against using the drugs both as prophylaxis and as a treatment.

The Food and Drug Administration's mandate is to assess the crucial balance between drug safety and efficacy. On June 15, the FDA revoked the emergency use authorization (EUA) that had been granted on March 28 for hydroxychloroquine in the treatment of COVID. "In light of ongoing serious cardiac adverse events and other potential serious side effects," said the FDA, "the known and potential benefits of chloroquine and hydroxychloroquine no longer outweigh the known and potential risks for the authorized use. This is the statutory standard for issuance of an EUA."

This was not an arbitrary determination. The FDA said it was "aware of reports of serious heart rhythm problems in patients with COVID-19 treated with hydroxychloroquine or chloroquine, often in combination with azithromycin and other QT prolonging medicines." It also said that it had "determined that the legal criteria for issuing an EUA are no longer met."

"Hydroxychloroquine and chloroquine can cause abnormal heart rhythms such as QT interval prolongation and a dangerously rapid heart rate called ventricular tachycardia," said the FDA. "These risks may increase when these medicines are combined with other medicines known to prolong the QT interval, including the antibiotic azithromycin, which is also being used in some COVID-19 patients without FDA approval for this condition. Patients who also have other health issues such as heart and kidney disease are likely to be at increased risk of these heart problems when receiving these medicines."

The FDA said that its "actions will be guided by science."

"Recent results from a large randomized clinical trial in hospitalized patients, a population similar to the population for which chloroquine and hydroxychloroquine were authorized for emergency use, demonstrated that hydroxychloroquine showed no benefit on mortality or in speeding recovery. This outcome was consistent with other new data," said the agency. The FDA's detailed safety review (pdf) is here.

"Hydroxychloroquine is the most disappointing, disavowed drug that researchers keep studying for COVID-19," writes one reporter. "Can We Just Stop Wasting Time on Hydroxychloroquine," asks a peer-reviewed post in REBEL EM, a clinical blog focusing on research appraisal. And in Science News: "Hydroxychloroquine can't stop COVID-19. It's time to move on, scientists say."

So we shall.

 

The virus is spread primarily through the air. Our understanding of the likely modes of viral spread has changed a lot over the months. Early on, it was believed that very close contact and touching surfaces ("fomites") was a principle means of exposure. Officials even advised against mask wearing in the early going, although this seems at least in part because there was such a severe mask shortage that recommending masks would have been pointless, and would have made it harder for health workers and first responders to obtain the protective equipment they desperately needed.

Later it was thought that the virus was also transmitted in large droplets, such as during coughing. Such droplets are so heavy that they fall to the ground quickly, and therefore don't travel very far. Thus the 6-foot separation recommendation you've heard so much about. Officials soon began to reverse themselves on masks, and the CDC even recommended simple cloth face coverings as better than nothing. Such coverings arrest at least some amount of expelled virus, and helpfully blunt the shape and trajectory of what gets through.

It was not until early July that more than 200 scientists wrote an open letter (pdf) to the World Health Organization arguing that the virus spreads through the air not just in heavy droplets but also in aerosols. There had been some resistance inside WHO regarding this route, but WHO soon got on board, and the plausibility and even likelihood of the aerosol route of transmission has become increasingly accepted.

Aerosols are minute, very light particles that can remain aloft for a long time—even hours—and which can potentially be circulated by air-handling systems in buildings. Confined indoor spaces are especially problematic, especially areas where large numbers of people congregate, such as bars, casinos, churches, prisons, meat packing plants, and Trump rallies. Importantly, 6-foot spacing is much less relevant to aerosol spread than to large droplet spread, because aerosols can travel greater distances while remaining airborne.

All forms of airborne transmission are far less likely outdoors than in, so you're much safer outside. Better ventilation indoors (such as by opening windows) also reduces risk. Indoor activities where people congregate should be moved outdoors whenever possible.

It's now presumed that airborne spread is the most frequent route of exposure, although touching surfaces remains a possible route. Hand washing, and refraining from touching your face, is still recommended. Because spread is largely through the air, mask wearing is particularly important.

I should add that the amount of virus to which you're exposed can affect the likelihood of getting sick. Longer contact with infected persons, and remaining longer in high risk areas, increases your risk. 

Don't ingest bleach. Or alcohol. Or disinfectants. Yes, I'm being facetious. But really, don't. And work to elect a president who won't spew such stream-of-consciousness nonsense that might cause persons less bright than you to harm themselves.

Conclusions. The most important takeaways are these. The virus can be spread asymptomatically, which is why physical distancing, mask wearing, and careful hygiene are so important. Absent testing, you just can't know whether you or somebody else is infectious. The virus spreads primarily through the air, but touching surfaces might also be dangerous. All age groups participate in the disease in one way or another, either by spreading it, by being harmed by it, or both. More people are affected and harmed than is generally understood, and the presence of symptoms is not a reliable indication of harm. Very young children seem the least likely to be harmed, but a very small fraction experience extremely dangerous organ inflammation. Young children also seem to be the least contagious, but can carry enormous viral loads that should give us pause. Young adults absolutely do get infected and readily spread the disease, and they also might be incurring long term lung damage even in the absence of symptoms. And there's increasing evidence that COVID damages not just the lungs, but other organs too, particularly the heart. Quite a disease, all in all.

Much more could have been said here, such as what relief we can expect from a vaccine, and how our lives are likely to unfold over the next year or two. Vaccine development is crucially important, but for a variety of reasons will not be a game changer in the short to mid term. Maybe more on that in a later post.

Much of our understanding has, unsurprisingly, evolved over time. So it's reasonable to assume there are still things to learn. Because of this, and because the disease's effects are distributed much more widely than we often realize, caution in all things, as a default stance, is warranted—even though it isn't practiced nearly enough. My advice, for what little it seems to be worth to the people I interact with personally, is to keep yourself alive and unharmed, and live to fight another day.

Copyright (C) 2020 James Michael Brennan, All Rights Reserved

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