America the Exceptional

Militia members inside the Michigan Statehouse;
Defending the right of a tattoo parlor to reopen

My husband Alvin and I are flying out tomorrow morning – Oakland, Los Angeles, Paris, Rome – so this is my last, brief blog post from the USA. My apologies for what may be an excess of self-indulgence and speculation. I am a tiny bit afraid of the flight home – three flights and four airports – but I am more fearful of what we will find when we touch down at last in Rome, when we walk into our apartment for the first time in nearly three months.

Treatment Update

Remdesivir: While Anthony Fauci was enthusing about some preliminary trial results on April 29th, I did a double take – “Did he just say what I think he said?” I decided he couldn’t have, and didn’t investigate further. But it turns out I did hear right: the National Institutes of Health have stopped the randomized trial he was describing, on the grounds that it would be unethical to withhold the drug from any COVID-19 patient. For me, as for many experts in the field, this was absurd – the trial’s preliminary data showed only a modest benefit, the drug shortening illness by only a few days and not significantly cutting death rates. Sadly, it looks like those results, now published in The New England Journal of Medicine, are all we’re ever going to get – we’ll probably never know whether remdesivir actually saves lives. There is still a World Health Organization sponsored trial going on, but it is not anywhere near as well designed. Unless there are more randomized studies hiding out there that I don’t know about, we’re left with exactly two trials of remdesivir and COVID-19 mortality, the earlier one negative and this one equivocal. The moral of the story seems to be that science is playing second fiddle to politics: the CDC and the NIH are leaning over backward to give Donald Trump the triumph he craves.

Another remdesivir trial has now been reported in The New England Journal of Medicine, one run by its manufacturer and  comparing five vs. 10 days of treatment in patients with fairly severe COVID-19. Both gave equally good, or equally bad effect – it’s impossible to tell which, since there was no non-treatment control group. A total waste of resources.

One might have hoped that remdesivir might work better – as do most antivirals – if given very early in the course of the disease. Unfortunately it doesn’t seem so. 

Infliximab (Remicade), etanercept (Enbrel), adalimubab (Humira) and other TNF inhibitors: What I consider the biggest COVID-19 treatment news of the week is a bolt from the blue: a study of 1300 COVID-19 patients who also happened to have rheumatoid arthritis or other autoimmune disorders. People who were already taking any of these “biologicals” that block the pro-inflammatory cytokine called tumor necrosis factor did great – they were 60% less likely to need hospitalization. Being on prednisone doubled the risk of hospitalization; hydroxychloroquine did nothing one way or the other. Why do I say “bolt from the blue”? Because until now expert opinion was that these drugs would make COVID-19 worse – even recommending that biologicals be stopped as soon as coronavirus was diagnosed. But there was at least one set of lone voices crying in the wilderness, whose April commentary in The Lancet was titled “Trials of anti-tumour necrosis factor therapy for COVID-19 are urgently needed.” As far as I know that advice was never taken, but surely it will be now.

Enalapril and other ACE-inhibitors: Here too expert opinion has flipped. After first it seemed these might make COVID-19 worse. Now it appears people who are taking them for high blood pressure may actually be protected against severe COVID-19. A new trial is underway, so we’ll see.

The pandemic slogs onward

Where it’s raging

COVID-19 isn’t really rampaging through the Third World yet as many of us had expected, but the scorched-earth campaign has begun. While the epidemic slips down the far side of the curve virtually all over Europe, it’s steadily on the upswing in Latin America: Peru, Mexico, Chile, Argentina, Colombia, Bolivia... and Brazil, which now leads the world in daily deaths. The curves are also scary in Russia, Belarus, Ukraine and especially, because of their population density, in  India and Pakistan – where people are starving to death because of the lockdown. But then even back in the great US of A, 1 in 5 children are going hungry during the COVID-19 crisis.

A shocking proportion of COVID-19 deaths (42% in the USA) have been in nursing homes and other long-care facilities; now that the horses have long since escaped, a few states including California, Delaware, and Connecticut are finally trying to close the barn door by requiring that every person who lives or works in one should be tested and if necessary isolated. The federal government, as usual, is absent.

In many American prisons, virtually all the inmates have antibodies against COVID-19, and huge numbers are getting sick. Fortunately “only” 462 are known to have died nationwide – undoubtedly an undercount – partly because prisoners tend to be younger than the general population.

And the scandal of American meatpacking plants hasn’t abated: as the number of COVID-19 cases continues to expand, probably to over 10,000, with dozens of deaths among workers and 4 among the FDA officials sent to inspect the plants, the Occupational Safety and Health Administration and the Centers for Disease Control and Prevention have demoted their safety standards from mandatory orders to mere suggestions, and North Carolina has joined Nebraska in deciding to pretend the problem doesn’t exist.

One place it ain’t

When the pandemic started it seemed people living with HIV, the ultimate immune-suppressing disease, would be particularly vulnerable to COVID-19. More recently the word on the street has been that they’re particularly invulnerable, and that if they get the bug they do particularly well. Because they’re being extra careful? Because their HIV meds work against the novel coronavirus too? Unfortunately, as so often, the word on the street is wrong. The HIV meds are duds against COVID-19, and a careful recent review concluded that HIV patients don’t get COVID-19 any more or any less than other people, and that once they have it they don’t do any better or any worse.

We’re the Top, We’re the Colosseum (thank you Cole Porter)

In their heart of hearts, most Americans believe that whatever rules govern the rest of the world don’t apply here. And they think that’s as it should be, because we are a superior country that breeds the “best and brightest innovators” and is destined to lead the world. In its arrogance, American Exceptionalism beats the Chosen People’s self-regard hands down. 

Odd though it may seem, the United States is barely a country at all. Unlike France, Germany, Italy, Japan, etc., the federal government is a declawed institution that lies lightly on top of a conglomeration of the 50 individual states where real power abides. Small aspects of power: Arizona lets you drive with 20/70 vision, while all four of its neighbors require 20/40. Medium aspects of power: a physician licensed in New York can’t practice in California. And gigantic aspects of power: the Peculiar Institution of the Electoral College, which decides presidential elections, gives people who live in thinly populated states a vastly outsized voice. 

Beginning with its foundation tales – the pioneers, the Gold Rush – the United States has been the world center of rugged individualism. After sixshooters got traded in for assault rifles, the land of the Frontier became the land of the Branch Davidians in Waco who preferred to die rather than surrender their arsenal; of Timothy McVeigh, who blew up the Federal Building in Oklahoma City with a bomb concocted from agricultural fertilizer and diesel fuel; of  the Bundys in Nevada, whose insistence on grazing their cattle on federal land led to an armed standoff in 2014; of the Hammonds in Oregon (right-wing arsonists pardoned by Donald Trump in 2018); and of today’s vast array of “sovereign citizens” who dismiss the very idea of government. Now there’s even a judiciary to back them up – the Supreme Court of the State of Wisconsin has overturned the governor's stay-at-home order against COVID-19, one judge writing: “This comprehensive claim to control virtually every aspect of a person’s life is something we normally associate with a prison, not a free society governed by the rule of law.”

In my radical youth, “States’ Rights” was the battle cry of our nemesis: the Southern racists who stood up in defiance of federal integration laws. But in the time of COVID-19 I’m not the only one to notice how, paradoxically, the weakness of the United States federal government and the hegemony of individual states turns out to have its strong points. With a void at the center, American states have been free to trailblaze their own responses to the pandemic, leaving many of us grateful to rediscover how much power sits in the hands of governors such as Andrew Cuomo of New York, Gretchen Whitmer of Michigan, and Gavin Newsom of California. And glad that however much the Trump-Pence gang may bluster about blasting the economy open it has no power to order it.

Could my title photos, of militia members inside the Michigan Statehouse and a vigilante shielding an illegally reopening tattoo salon, have been shot anywhere else in the world? There have been a few right-wing anti-lockdown demonstrations around Europe, but armed resistance would be unthinkable.

We’re the Exception to Every Rule

Pick your poison

I’ve taken dictation watching drug ads on American TV:

-       Severe liver problems, some fatal

-       Unusual changes in behavior

-       Increased risk of death or stroke

-       Coma or death

-       Aggressiveness, agitation, hallucinations, or confusion

-       Impairment in judgement

-       Tuberculosis

-       High fevers

-       Suicidal thoughts or actions

-       Uncontrollable muscle movements

-       Cancers, including lymphoma

-       Heart attack or stroke, which can lead to death

-       Heart failure

-       Fatal bleeding

-       Increased risk of prostate cancer

-       Blood clots in the legs

-       Increases  risk of death in people with asthma

-       Heart valve problems

-       Kidney problems and kidney failure

That’s from voiceovers that hurry to cover some of what their chosen drug can do to you. There are more ads for prescription drugs than for cars, painkillers, or anything else. Only in America (well, actually not only – New Zealand allows this madness too).

You pays your money and you takes your choice

Elsewhere in the world drugs cost what they cost, the price is the same in any pharmacy, and it’s always a tiny fraction of what it would be in the USA. People on their national health service pay if anything a tiny fraction of that tiny fraction. Alvin and I take thankfully few medications and pay zero for them – except for one. It’s not covered by the Italian National Health Service so I have to pay the price that’s printed on the box, about $11 per month, which I have always considered obscenely expensive. 

Until, that is, I became a coronavirus refugee in the very exceptional United States of America. I had no difficult getting a physician friend to call in our prescriptions to the local CVS, or  strolling over in mask and gloves. But once there I got told by the pharmacist that my pill, made by the same company and with the same brand name, would set me back $228 for a month’s supply. More than 20 times the already exorbitant Italian price.

I have Medicare Parts A and B but not the drug coverage in Part D, so that $228 is what I would have handed over. If, that is to say, the kindly pharmacist hadn’t taken pity on my furriner ignorance and tipped me off to a website called GoodRx. There I learned that the “list price” of my pills varied, among the eight pharmacies within range of North Berkeley, from $204 to a dizzying $268 a month. And that GoodRx, out of the pure goodness of its heart, would award me discount certificates that would bring all those prices down by about 15%. As if that weren’t bewildering enough, I eventually figured out at the same site that there were multiple generic versions of the same substance, some labelled with their own brand names and some not, each of them with its own array of list and discounted prices. After balancing off price and distance from the drug store, I wound up paying only 47 bucks.

Here for your edification I’ve graphed all the prices I found at GoodRx. 

If I hadn’t had a doctor friend to write me a prescription, by the way, the GoodRx website offered an alternative: “Need a [Zoloft/Viagra/Cipro/Humira] prescription? Start a private online doctor visit now.” It was hard to restrain myself from clicking out of curiosity on the convenient “Start Visit” button alongside.

It is my impression that all of this, from the peddling of dangerous medications on TV, to the Wild West of drug prices, to the docs prescribing those dangerous drugs online, seems perfectly normal to Americans. It’s crept up on them so gradually that they can barely comprehend how bizarre it seems to me, or to anybody else who’s ever lived outside the Exceptional Country.

Coda

Farewell, Berkeley! You’ve been the loveliest refugee camp ever! On Sunday it will surely feel great to reach our Rome home, but I confess there’s a lot we will miss from here in California: those one-of-a-kind, one-more-charming-than-the-next houses; those wild front gardens; the Black Lives Matter signs; the “leave one or take one” book boxes; the hiking trails in Tilden, Huckleberry, Sobrante, Sibley, Claremont Canyon; the sensuous smoothness of the manzanita; the Berkeley Bowl where we’ve scored not only mangos, apples, and pecan pie but spigola, broccolo romano, and even – once – fresh porcini.

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FYI, a selection from my Californian COVID-19 blog posts has been published by the venerable Rome expat magazine, Wanted in Rome, under the title “Notes From a Coronavirus Refugee.” Click on their May issue and go to page 14. And a stripped-down version of one post was republished on KevinMD.com, the number 1 medical blog, as "Don’t drink the COVID conspiracy Kool-Aid” (already shared by 148 people).