TRUMP SURRENDERS IN US CIVIL WAR II

Donald Trump declared US Civil War II last week by exhorting his cult to "liberate" three key swing States which have Blue Governors. By so doing he called his people to “take up arms” as “The cure was worse than the disease”. The large signboard at his briefings featured the central thrust of his policy which was “ReOpen America”. Trump’s objective was clear - restore the economy at the expense of life - to enhance his re - election to the Presidency.  Ignoring for the moment that the President is becoming more and more unhinged by the day, there is a need to examine whether or not his strategy has any hope of success. 

The President’s electoral strategy is based on a number of false assumptions. It was transparent that he, like Senate leader McConnell, believed that the only “losers” would be in the Blue states if the country is re opened. To this day they are still sticking to the fairy tale that the virus is a Blue virus and will not spread to the Red or Purple states. What was verbalized as well as being manifested by the demographic that was dying was that the “losers” in the Blue States would be predominantly the elderly. 

Choosing the economy over “life” has been Trump’s preference from the get go. None of the faithful have contradicted the many expressions of this utilitarian mantra to effect what is rationalized to be the greatest good for the most. The clearest expression of this philosophy was articulated by the seventy year old Lieutenant Governor of the great state of Texas. He indicated a willingness as he said, many others were as well, “To sacrifice our lives for the good of the country”. He then implied that the geriatrics shouldn’t really have a choice, “Texas should not shut down because a few people are dying”. 

Another rationale behind the lifting of mitigation strategies is that the sparsely populated rural areas and less densely inhabited inner country States, both decidedly Red, have to date not the same prevalences of the plague.  

Finally, as there were only a few right wing outfits and a few Red Governors that were gung ho to follow his “ReOpen America” Trump needed a spontaneous uprising from the masses to bolster his coalition. They would be his troops in Civil War II.

THE COALITION SUPPORTING TRUMP

Besides the initial eight Red Governors who were holding the line on instituting mitigation, three additional Red Governors immediately signed up  - Georgia, South Carolina and Florida. The former obliged by announcing he would open the whole of his State, which Trump initially, privately and publicly endorsed and then publicly condemned, thereby throwing the Georgian Governor under the bus  Both Georgia and Florida were opening up beaches where the cheerful dippers congregate on top of one another.

Iowa and South Dakota had previously obliged the Trump mantra by ignoring the peril that hundreds of positive meat workers might have on the manifestation of the disease in their Red states. For the most part the majority of the Red Governors exhibited no suicidal displays rather they issued careful statements about decreasing the mitigation instructions as circumstances allowed. Some Republican State Legislators were prominent in support of the protests. However there was no outpouring of support from Congressional Republican Legislators who were hiding in their basements unavailable for comment.

With regard to the anticipated angry populace there has been no spontaneous storming of the State Legislatures. Tiny protests of between a hundred and a thousand are evident. Their guns, confederate flags and red MAGA caps make it clear that they belong to the usual fringe groups who come out on these occasions.

Behind the “spontaneous uprisings” is big money some of which is being utilized to flood the social media. According to the Washington Post an initiative called the “Convention of States” which is funded by right wing Republican mega donors such as the Mercer Family is synchronising the "uprisings". The well greased Koch brothers' “Citizens for Self Governance”, is the key organization behind the “Convention of States”. The Koch statement on the debate reiterated the common misperception that this was a Blue problem - “To shut down the rural counties because of what is going on in New York or even Milwaukee is draconian”. The Tea Party and Freedom Works groups have joined the struggle as well. 

There is little doubt that these groups will muster further demonstrations but staring them in the face in every poll is an overwhelming support for stay at home policies with up to seventy percent in favor. 

Of course the key element in the Trump cabal is the feedback loop between Fox News and the POTUS which undoubtedly is the strongest link in his coalition. John Oliver, in an HBO expose, showed how heavily Donald relied on the policy suggestions emanating from his echo chamber which often were tweeted out by him within minutes of being broadcast. 

All in all not a formidable coalition to rally to the President’s call to arms.

THE “EXPENDABLE” GERIATRICS ARE NOT ONLY BLUE

It is acknowledged that the most vicious manifestations of the disease are reserved for those with preconditions and who are over sixty - five years of age.  Even with the death total at over fifty thousand the irrational perception is that the impact on the Trump supporters will be minimal because the Red geriatrics are supposedly hidden away in unaffected Red States and rural areas. Anyway as Bill O’Reilly, a Trump groupie, has opined the dying are “those who are already on the way out”.

Without social distancing the death toll was modeled at between one hundred and two hundred and fifty thousand. Thus far up to eight out of ten deaths in the USA have been in patients over sixty - five years of age while they only represent sixteen percent of the population.  

Now one wonders why the ever practical Trump does not realize that the older demographic is the only one which favored him in 2016. In fact they tipped the balance in the key states.  He can ill afford to lose these voters both from the virus itself and because of the cavalier way they are being cast aside. There are also some crucial workers in or around that demographic - twenty percent of farmers are nearing sixty, while one third of physicians are over that age and a large chunk of nurses are nearing retirement. Is he not worried too about the American Association of Retired Persons, (AARP), the most powerful entity in the country weighing in, big time?

THE RED STATES AND THE BLUE STATES, COUNTIES, RURAL AREAS, NURSING HOMES AND THE ELDERLY

The central misperception, to labor the point, is that the geriatrics are mainly in the Blue states. One quarter of those in the Social Security age group are in California, Florida and Texas, (two out of three in Red, with Florida having the highest number by far) and another quarter are in Georgia, New York, Ohio, Michigan, Illinois, North Carolina (Four of seven Red). 

There is no misperception about the rural areas they are blood Red.

According to the Kaiser Health Foundation more than half the counties in the USA have no Intensive Care Beds, (ICU). In those counties, nearly all rural, there are close on twenty million over the age of sixty. Even counties in the top ten percent of available health care facilities there is only one ICU bed per four hundred and fifty. Hilton Head in South Carolina, a popular retirement destination, has one ICU bed for every three thousand nine hundred vulnerable patents. 

Nearly all of the Counties that have no ICU beds are in rural areas where ninety - five hospitals have closed in the past decade. If, or rather when, the virus penetrates any of these areas whether it be via a long care term facility or meat packing plants or even by personal contact there will be an even higher mortality of this age group than in the cities and towns, like "New York and Milwaukee” where the hospitals are concentrated and can provide care. 

Also the petrie dishes of nursing homes are evenly spread all over the show as are concentrations of elderly retirement homes.These are also understandably situated where property is far cheaper and supportive facilities particularly health care are far and few between.  Nursing homes are manned by personnel that live in the surrounding areas. The staff become infected and will increase the prevalence of the disease as they return to their communities after their shifts. There are nearly sixteen hundred nursing homes with a capacity for one million seven hundred thousand elderly in the country. When they are hit by the virus it spreads through the institution like wild fire. Major hotspots have been the latter and Kirkland Nursing Home in Washington State was the first to shock the nation. Well over a quarter of New York's nearly twelve thousand deaths were nursing home residents.

So much for the cynical belief that this a Blue disease. 

SCIENTIFIC COMMUNITY AND “REOPEN AMERICA”

It is fair comment to maintain that if human life must be preserved as far as possible science is not assisting the Trump position to “Reopen America”. The POTUS, while recognizing that it would be untenable to proceed without at least having some medical scientists hanging around, has nevertheless been arguing against them from day one. 

The first scientific victim of the Commander in Chief’s wrath was Dr. Nancy Messonier, the Center for Disease Control’s, (CDC), Director for Immunization and Respiratory Disease. Dr. Messonier on February 25, 2020 in a WhiteHouse Press briefing, warned that the Coronavirus infection’s everyday disruption might be severe. Trump heard the warning en route back from India where he and Premier Modi were holding a mutual admiration jamboree. Trump blew a fuse. That was her last WhiteHouse appearance. However at a CDC briefing in early March she spelt out the danger to those at high risk advising them to stock up with groceries, medications and to shelter in place for the foreseeable future. She predicted that the problem would persist till 2021. Her prescient warnings were ignored. There are reports that the POTUS threatened to fire her. She is no longer a visible member of Team Coronavirus.

Dr. Andrew Fauci the country’s foremost authority on infectious diseases and Dr. Deborah Birx, Trump’s appointee to head the Task Force, dance around like cats on a hot tin roof as they struggle to correct his patent nonsense while resisting his desire for them to retract their statements. Trump, one is sure, would certainly like to axe Fauci but he has the highest trustworthy approval on the virus while his own, like on every other issue, is well South of fifty percent. 

Dr. Robert Redfield, head of the CDC, made a rare appearance this cycle where he insisted that there were big problems ahead in the fall when both influenza and Covid virus would rear their fatal heads simultaneously. The subsequent WhiteHouse briefing was characterized by Trump trying to bully Redfield and the rest of his scientific team to agree with him that Covid 19 may not come back in the fall. (He didn’t add that was around about Presidential election time). 

The whole issue came to the boil this week when a Director of Biomedical Research, Dr. Rick Bright, who is in the forefront of vaccine research, went public with the accusation that he was fired from his position and demoted because he refused to buy into the Trump hype that hydroxychloroquine was a “game changer”. For whatever reason Trump has been punting that age old antimalarial as the miracle drug that would reverse the tide. 

Almost simultaneously to the Bright bohaai the FDA announced that that drug, due to fatal arrhythmic side effects, should only be administered in the hospital for Covid 19. This followed a publication of preliminary results of a randomized study in the Journal of American Medical Association. The initial report showed no difference in outcome between Trump’s drug and a placebo. It did warn that a number of patients on chlorine sustained heart arryhythmias. Bright according to his lawyers is considering a WhistleBlower action.  

All this adds up to an uphill battle for the “ReOpen America” campaign.

AT THE END OF THE DAY. 

The number of deaths per day from the pandemic is consistently around two thousand. New York’s is decreasing as the virus slowly penetrates the Red interior of America. 

Governor Cuomo is establishing himself as the voice of reason and a brilliant debater as Trump found out and Mitch McConnell has just learned. McConnell stated that no way will he vote for a State bail out, they are all Blue States anyway. Cuomo countered that New York pays more into the Federal Government than it receives while Kentucky, McConnell’s Red State is subsidized annually by the Federal Government, “His State receives a bail out every year”. Again this is not a Red or Blue State matter among the Governors. All fifty Governors voted for a five hundred billion dollar bail out to proportionately cover costs and economic losses sustained during the nationally declared emergency. 

Cuomo went on about McConnell’s unbelievable insensitivity at those who died in New York and his never ending partisanship. He then challenged the Republican Senate leader to introduce legislation allowing States to go bankrupt and see how that would impact American Financial markets which would come crashing down. Legislators in McConnell’s own state of Kentucky criticized him. Like with Trump that is sure to end Moscow Mitch messing with Cuomo. The New York Governor is becoming more and more the country’s figurehead and leader against the fight against the coronavirus.

 Trump has seemingly abandoned his Civil War II leaving his troops and the Governor of Georgia at the tender mercies of their critics. He is now investigating extending the mitigation advisory rather than immediately Reopening America. His Coalition needn’t be too despondent because he can reverse his position tomorrow. 

The POTUS maintains that he was being sarcastic when he suggested administering bleach or intravenous sunlight to treat the virus. His following took him seriously however and every State’s poison center is receiving calls while the manufacturers of the sanitizers are issuing warning statements. 

Politico added a few more States that the Democrats might flip in addition to winning back, Ohio, Michigan, Wisconsin and Pennsylvania. The report rated Florida the most vulnerable followed by North Carolina, Arizona and Georgia. 

What news is even worse for Trump is the Fox Poll of elderly voters in swing states where he won in 2016 because of the senior citizens. In Florida, which he won narrowly he had a seventeen percent plurality in the over sixty - five category. He is now ahead by one percent in the senior population, which will result in a trouncing in 2020. In Michigan and Pennsylvania where he likewise relied on the senior citizens the Fox Poll showed him behind by eighteen and seven points respectively in the senior citizen demographic.

It seems that the utilitarian position of sacrificing the elderly for political expediency would not be such a good plan after all. Trump trooped off the WhiteHouse podium on Friday after twenty minutes, just a hundred minutes short of his usual show time. The white flag was evident but not visible.

Everyone is aware that sooner or later the economy has to get going but the curve at least has to be trending downwards. Post coronavirus it will be a new world even after a vaccine. Everyone is also aware that Trump will never give up.

DESPERATE TEFLON TRUMP TAKES ON CUOMO AND DECLARES CIVIL WAR II

With every positive metric of Trump going South, including the acne like bump in his ratings since the start of the Coronavirus pandemic, he has gone nuclear. Having been thrashed in the 2018 midterms and having lost crucial post 2016 elections, where he personally intervened, in Red States, Alabama, Oklahoma, Louisiana, Kentucky, Michigan, Virginia and Wisconsin and showing no sign of winning back the suburban women, millennials and the Republican intelligentsia, he was relying on the economy to give him another razor thin electoral college victory. And then came the pandemic. 

Having abandoned responsibility, Trumps concerns have exacerbated as he has lost control of the country’s response to the pandemic.  States, Democrat and Republican, have banded together to act in concert in the three most economically powerful areas of the country. In addition, even though a minority of GOP Governors publicly side with him, the fifty strong Governors’ Association are unanimous in demanding fifty - billion dollars to cope with their costs, which Trump has claimed is their responsibility. Then his call to business leaders to back him to open the economy backfired when they demurred demanding testing as well. The final humiliation is that he can get nothing done without the support of Nancy Pelosi who unless she gets the final say no financial package can happen.  It is in this milieu he has called upon his supporters to protest his own administration's regulations and has attacked his current nemesis Governor Andrew Cuomo from New York.

 The question remains whether Trump, who appears to have an unconscious desire to catastrophically fail then to rise Phoenix like from the ashes, can defy all the odds and once again triumph. He relishes the challenge. Underlying his value system is never concede a point, never apologize, counter every accusation by a magnified accusation and every litigation by a preposterous counter suit, divert blame and project your own faults onto your opponents. 

TRUMP’S CURRENT M.O. IS THE STORY OF HIS LIFE

Truth be told he has always, throughout his long career, survived with the result that this uncanny salesman has convinced his cult like following that he can walk on water. More significantly his frustrated opponents are silently terrified that they maybe right. One fact that there is no argument about it is that he will do whatever it takes to achieve his ends. He seemingly is unworried about anyone else other than himself. In the process he has gone through his seven decades reaping chaos and destruction in his wake. However the stakes have become magnified on a national and international scale since he has become head of the richest and most powerful nation on earth.

Trump is now facing the greatest challenge in his life - his reelection as President and has upped the ante to where the stakes could involve human lives and could pit one half of America against the other in a war like struggle.

There is a magnificent piece in Politico by Michael Kruse outlining Trump’s audacious bold strokes through out his life which have trained him for this moment. His skills at adapting and turning defeat into victory are legend. In retrospect the reader becomes bemused at the stunning effrontery of his moves which should have been apparent to all but the blind. Just to review one of his stupendous failures, which occurred in the mid 1990’s, and then marvel at his audacious actions to escape the consequences. He survived penury by going public netting hundreds of millions of dollars with his gauche debt ridden casinos and hotels in Atlantic City! Kruse’s article likens him to the great Houdini. It appears that his forty percent electorate following are not his first cult following, there have always been gullible believers of his spin. 

The public has witnessed his involvement with Russia, several of his campaign team criminally indicted, his lawyer in jail for carrying out his instructions to evade campaign finance laws, the Mueller report, the Ukrainian “perfect call”, his “pussy grabbing” Action Hollywood tape, his failure to produce his “audited” tax returns, his rejection of America’s allies, his love affairs with the world’s bloodiest dictators and on and on. (No one really knows the roots of his current wealth and why Deutsche Bank loaned him billions when his credit unworthiness was tattooed on his head).

Yet there he is alive and well facing the coronavirus threat while strutting before the nation surrounded by his flunkies, who are not social distancing nor wearing masks. He is accompanied by uncomfortable scientific experts subtly countering his mumbo jumbo but doing it so expertly so as not to dent his credibility so that they may survive another day to maintain some semblance of sanity in this crisis. Somehow he has comfortably survived his inept, contradictory and mendacious management of the current pandemic.

THE EVOLUTION OF TRUMP’S CHANGING RESPONSE TO THE PANDEMIC

Although the POTUS received intelligence reports and memos warning him about the impending disaster, one according to a report in the Times of Israel as early as November 2019, he went into a denial mode over at least two months. First he just shut up and then his silence morphed into it being a “Democratic hoax - a second impeachment”. Then as more and more news leaked out of the Wuhan mayhem, he claimed over that “his great friend Xi and the WHO had it under control". Then the narrative changed into that there were only five cases in the USA and as the number increased a miracle would occur.  Next it would go away in sunshine April eventually there would only be a hundred thousand deaths. Finally, he gave the appearance of bowing to science while arguing that his hunches would win over their rationale. As the horizon darkened with increased cases and death he knew he could duck reality no longer so he became the voice of the response team.

 Ever resourceful at turning defeat into victory he seized upon the opportunity to deliver two hour daily monologues in Prime Time where he conducted his favorite past time of abusing, humiliating the reporters of the opposition “failing” fake news. However his ratings gradually receded together with his pimple like bump in the polls and the escalating drop of stock market prices - his parameter of economic success, so he looked for other solutions. 

His overall strategy was to take “no responsibility or blame” - this was the States’ burden. However as the press briefings with the self congratulation, contradictory statements, attacks on Obama became less and less newsworthy he shocked everyone by withdrawing finance from the WHO. The latter were the only vehicle to avoid the pandemic reaching Spanish Flu proportions in impoverished Africa, India and South America. Even with the almost universal condemnation of his neutering of the co coordinating body that could prevent the annihilation of the “sh....thole”nations he could not refocus the critics from his almost sabotaging efforts of the  fight against the plague. Everyone knew that  he was as informed about the crisis as was the WHO and they had as much authority over China as they had over him.

As the inept and contradictory Federal management became more and more embarrassing he decided, as the President he had “absolute power”, to instruct the Governors to call the mitigation actions off and “Open America Again”. As he had delegated the shutting of America to the Governors there was no way he could constitutionally or by the gravitas of his Office open it. In addition the Governors’ approval ratings were sky high while his were wilting back to the hard core. Andrew Cuomo, Governor of New York, had become the iconic figure in providing comfort to those at home. His daily morning briefing, marked by transparency and hope was drawing far better ratings then Trump’s Prime Time disingenuous and abusive monologues were and this was increasingly getting on the POTUS’S goat. 

The time had come to declare war. He elected to start it during a Cuomo briefing where the latter was annoyingly not taking him on but stating that New York’s phased opening depended on testing which the Federal Government had to co - ordinate and subsidize.  Trump had repeatedly instructed the States to fend for themselves in all matters Coronavirus which found them in a bidding was against one another. To add insult to injury the Federal Government bid against them. There was no better time then in the middle of a Cuomo briefing to issue a series of tweets that would grab the limelight and start Civil War II.

@REAL DONALD TRUMP  ATTACKS CUOMO DURING THE GOVERNOR’S PRESS CONFERENCE

Trump spouted out four tweets during Cuomo’s Press briefing that indicated the newest phase in his attempt at winning the 2020 election. The first tweet was a criticism of Cuomo who had become the leader of reason as opposed to his scatterbrained response to the coronavirus. The next three were calls to the street mobs to challenge the stay at home policies of Democratic Governors’ in crucial states in the 2020 Presidential Election.

Cuomo’s daily Press Conference has become the balm of the nation. New York State being in the eye of the storm, having a half of the nation’s death toll, Cuomo exuded credibility with his systematic and comprehensive management of the crisis. “New York”, he eloquently argued, “is the canary in the coal mine”. The Governor was a repository of facts, transparency, lucidity, humility and empathy treating his audience as adults. He shared personal stories on how he had grown in this crisis. He also emphasized the need for Federal leadership and resources.

Up to then Cuomo had studiously avoided any major confrontation with President Trump but he was ready for the latter’s bomb throwing perpetrated while he exuded gravitas and a historical perspective - “This is the gravest crisis America has faced since the second world war”, while acknowledging society’s anger and fear for their personal and economic future.  

Trump tweeted that Cuomo ”should spend more time doing and less time complaining. Get out there and get the job done. Stop talking. We built you thousands of hospital beds that you didn’t need or use, gave you large numbers of ventilators that you should have had and helped with testing that you should be doing……we never hear a thanks ….your numbers are not good. Less talk and more action”.

The New York Governor finally rose to the bait and gave Trump a devastating mouthful lasting twenty minutes that held the seasoned journalists in the room spellbound. 

CUOMO SHUTS @REAL DONALD TRUMP UP IN REAL TIME

Our fearless President had believed that before starting Civil War II he needed to discredit the de facto leader of the safe return to work faction. Trump could not have dreamed that in real time, with a national audience being broadcast live on several channels, he would receive a comprehensive point by point rejoinder accompanied by audiovisuals, to his childish admonition. To the “lack of action” criticism the Governor snapped back, “If Trump is watching this televised press event, maybe he should get up and work”. 

Harking back to Trump’s reversal of his position that he, the President, had absolute authority to instruct the State Governors and subsequently condescendingly accepting that they could decide how to re open their states, Cuomo was derisive, maintaining that the President had done “a graceful one hundred and eight degrees… (but) by the way it was always up to the States, what are you going to grant me what the Constitution gave me before you were born. I don’t need the President of the United States to tell me the powers of a state”.  

President Trump’s insulting reference to Cuomo’s requesting far more beds and ventilators than he needed, was met by an audiovisual indicating that the numbers were derived from the President’s administration which he apparently appeared clueless about. Cuomo sarcastically continued, “Whose projections were wrong? Head of the CDC, Peter Navarro and the Head of the Coronavirus Task Force? Fire them”. Turning to the jaw dropped audience -“You know that show the President did - Fire them all. The only mistake was following your number your projections. I don’t know what, am I supposed to send a bouquet of flowers?”. Repeatedly he mockingly thanked Trump for the providing the extra beds and added that was his job. 

Cuomo returned to his central narrative that the Federal Government needed to provide the States with the where withal to do the testing that was needed to open up the economy. He pointed out the obvious that it was everyone’s objective to return to work. Earlier in the presentation he had outlined in detail why this was necessarily a Federal function as only they had the resources to do this complicated international transaction and co ordinate the disposal through the States. He epitomized the Trump approach to put the blame and responsibility on the Governors while putting himself in the position to take the credit if there was a successful outcome,  “Don’t pass the buck without passing the bucks”.

The expected Trump tweet storm in response never materialized nor did the POTUS allude to the interlude at his daily Press Conference/Campaign Rally Meeting that evening. He had met his match, at least for the moment. But Trump had another string his bow that morning - turning to his cult mob when all else fails.

TRUMP DECLARES CIVIL WAR 11 EXHORTING ANARCHY

Trump in his original tweet storm immediately following his attack on Cuomo gave a call to arms to his supporters who have been starved of his rallies exhorting them  to “liberate” Minnesota, Michigan and Virginia. These were crucial to his re election. He claimed at a Press briefing that the protestors were “responsible people”. No sooner had the word gone out, a maskless mob ignoring social distancing stormed the streets some with Federalist flags and red MAGA caps. Albeit there were only small groups they garnered media coverage and the diversion Trump had desired to deflect attention for his gross mismanagement materialized. 

Trump was also responding to a section of his supporters like disgraced Fox News commentator Bill O’Reilly, who reckoned that those were dying were on the way out anyway. There were others, including a few Republican legislators that articulated that the risk of deaths to save the economy was well worth it. The cynics noted that by and large the victims also came from demographics that didn’t support the Republicans any way.

AT THE END OF THE DAY

Trump is taking a huge risk with this strategy but what’s new? It could be the final one, one way or another, in his lifelong game of chicken. 

The eight Republican Governors who have been with him for the ride all along who hope that his theory that the virus only attacks blue states should resign from the cult now. In tiny South Dakota they have already have over fifteen hundred cases with close on six hundred workers positive from a meat factory who have spread into the community. The Mayor of Sioux Falls has begged the Governor to close down at least his City but the Governor is ad idem with her leader Donald, right or wrong. The Iowa Governor stands firm as well even in the face of outbreaks at meat processing plants.

On May 15 the Supreme Court are finally taking up the numerous cases where lower courts have ruled that Trump’s financial records should be revealed. Don’t hold your breath.

One outcome is for sure. Trump is like the liver of the little old lady who took liver pills every day of her life and when she died at age of ninety - six they had to beat her liver to death.

TRUMP, THE CORONAVIRUS, MEDICINE, RESEARCH AND BELIEF

The POTUS Donald Trump has daily punted, in his own inimitable style, a management for the coronavirus, a medicine called hydroxychloroquine, (Trade name, Plaquenil). Plaquenil has been one of the many medications that have been hopefully and empirically administered, without scientific testing, in the current world wide pandemic, These interventions have been advocated in attempts to, prevent, cure and/or ameliorate the disease caused by Covid 19.  

Trump’s dogmatic emphatic endorsement has resulted in the widespread demand and usage for the drug by patients, doctors and hospitals to the extent that there is now a national shortage. In his enthusiasm he has been openly contradicted by scientific experts that deny his recommendation has been proven, that it has deleterious side effects and will cause shortages for patients that are on the treatment for registered indications. The POTUS’S phlegmatic counter is “What can you loose?”. 

Before Jay H. Ell can examine the basis of all the above claims it is essential to understand the basis of research in medicine and the roles anecdotal results and belief play in our decision making process. 

HISTORY OF RESEARCH INTO DISEASE IN ORDER TO EFFECT ITS MANAGEMENT.

In trying to find a cure or treatment there has to be the knowledge of the course of the disease, its complications, whom it may target and its outcomes. In medical terminology all the latter is termed the natural history. What is thus needed is research into the natural history of the diseases and interventions to prevent, ameliorate or cure them. 

With regard to natural history epidemiological research is the most powerful tool. That involves disciplined observations and measurements of a patients for the duration of the illness. These can be long term in chronic disease and short term in acute illnesses.The most famous of these epidemiological studies is the Framingham Study that documented and made observations of the natural history of Coronary Artery Heart Disease and its major risk factors. They were the first to identify high blood pressure, raised cholesterol and cigarette smoking as the causative factors. A whole range of therapeutic interventions followed for the risk factors as well as the complications.

Then there are observations of catastrophic outcomes that through the ages that have necessitated immediate intervention or death would occur. For example it did not take army surgeons treating many cases of gangrene of a limb to note that death followed unless the offending limb was amputated. Today emergency surgical management of a burst appendix, a ruptured ectopic pregnancy or a bleeding aortic aneurysm is mandatory. No decades long observational studies are needed for these management decisions.   

It stands to reason that the natural history of acute illness is of a shorter duration. Influenza, for example, is responsible for mortality in the very old and extremely sick. Before venturing into the researching of management or treatment into acute infectious disease such as the coronavirus it is crucial to recognize that what appears to be obvious or intuitively certain is often wrong. Below are a few of the commonest mistakes in making decisions on causation and treatment of disease.

CAUTION IN RESEARCH - ASSOCIATION OR CORRELATION DOES NOT NECESSARILY MEAN FACT

Observational or epidemiological studies - unless they are rigorously designed and conducted can be subject to all manner of false conclusions and biases. 

The commonest of these misapprehensions is a conclusion based on a what appears to be a logical association or correlation. This assumption results in an initiation of a management intervention. One example was the hypothesis or belief that women would maintain their premenopausal lower rates of cardiovascular disease if given hormone replacement therapy after menopause. The basis of this assumption was the differing natural histories of coronary heart disease in men and women. A scientifically designed multi center national study was conducted to test this hypothesis. It produced catastrophic results. Those on hormones suffered far more complications such as an increased risk of cancer and thrombotic episodes. The trial had to be stopped prematurely. 

The initial basis for the hormonal replacement study had been reinforced by earlier smaller observational studies which showed that women taking these postmenopausal hormone therapies had lower cardiovascular events rates than those that didn’t. However this causality or association was negated by the fact when the data was relooked at those that had taken the therapy were wealthier more educated and were more likely to be on dietary and exercise regimens as well. The confounding variables by the designers of the earlier studies had not been properly addressed.

There is yet another powerful variable that dictates management - belief and or fear.

BELIEF AS A MOTIVATING FACTOR IN DISEASE CAUSATION AND MANAGEMENT

With the evolution of more sophisticated diagnostic equipment there was a belief that earlier diagnoses could be made and therefore treatment instituted would prevent mortality. Annual routine mammography became the standard of care in all women from forty years of age. Careful epidemiological studies decades later showed that all routine mammography performed before fifty years caused far more harm than good. There were unnecessary biopsies anxiety and even more radical managements instituted with no improvement of the death rate from breast cancer. The new recommendation by the professional societies was that routine imaging start after the fifth decade. This raised an uproar which resulted in Congress passing a law that insurance companies still had to pay for those done after forty years! Fear ruled.

Not a dissimilar situation occurred in the male world with regard to prostate cancer. A test known as the prostatic antigen test (PSA) was introduced. A raised level of the latter was thought to be indicative of cancer and it was generally prescribed as a routine screening test. However not very soon afterwards the scene was flooded with false positives and false negatives. The picture became even more murkier when further studies were made available which were correlated with earlier post mortem studies, which showed a high percentage of men dying with prostate cancer not of it. So the danger was that the raised PSA would result in unnecessary prostate operations on very slow growing cancers. The muddied waters became muddier when it was realized that the death from the more fast growing prostate cancers were unlikely to be influenced one way or another by detection via the screening test. 

Several patients, particularly the anxious ones still desire the screen. The newest professional thinking on PSA screening is to offer the patient an “informed” choice as whether they wish to do one or not.

All the medications advised for the coronavirus at this stage would fall under the rubric of anecdotal or belief. 

FEDERAL DRUG AGENCY - OVERSEER OF SAFETY AND EFFICACY OF MEDICATIONS AND ITS APPLICATION TO CORONAVIRUS TREATMENTS.

Over the last century and a quarter the Federal Drug and Food Agency, (FDA), has grown into a gigantic organization entrusted to oversee, among other responsibilities, the safety and efficacy of all prescription medications. They have instituted an elaborate program whereby sanction is finally afforded for a medications to be prescribed by licensed health care providers. There are a number of phases that are designated from naught to four. This takes a medicine through from the creation of the molecule to animal testing, to volunteers for safety concerns, to administration for very serious conditions where everything else has failed and then finally to the crucial third phase highly scientific studies where the new medicine is tested against a standard of care or a placebo. Every drug has risk so that even when marketed the medicine is surveyed for safety, (Phase four). 

In the definitive third phase comparative studies neither the doctor or the patient know whether or not they are receiving the medicine being evaluated for effectivity and safety. The reasons for this are many. Firstly there is the placebo effect where the patient getting the non active drug Improves. This can either be attributed to patient belief that the medicine is “working” or the positivity exuded by a doctor in her desire for the resolution of the disease. An equally important basis for this type of study is to ascertain whether the patient would have become better whether or not they were administered the active drug. 

The FDA has provisions for fast track registration of drugs particularly in life or death situations such was utilized in the AIDS epidemic and are often set into motion for oncological conditions.  

 For any medication that has been approved for other conditions to be given the go ahead for a new indication they have to undergo rigorous scientific testing in third phase studies as to prove efficacy and safety in the new situation. The widespread usage of these medications in the current crisis have been "allowed” under the provision they can be administered if all other therapies have been attempted with no success. This provision has been liberally interpreted by the health care workers and widespread usage of particularly hydroxycloroquine, has been reported. 

One word of caution, results in double blind randomized trials are sometimes not clear cut. Statistical significance is essential in interpreting the results to eliminate chance as being responsible for the results. The participants characteristics have to be carefully analyzed to make sure the randomization resulted in apples being compared with apples. 

Thus too date there are no treatments or vaccines that have been registered by the FDA for the treatment of the coronavirus. 

MEDICATIONS THAT HAVE BEEN USED FOR TREATMENT OF CORONAVIRUS UNDER SPECIAL FDA PERMISSION PRINCIPLES

As outlined above with the lack of a defined treatment for this circumstance has resulted in the FDA liberally allowing medications that have been registered for other conditions to be used. The most commonly used medication utilized in this fashion is hydroxycloroquine, (Plaquenil), which has gained FDA sanction for the conditions of malaria, rheumatoid arthritis and systemic lupus. Hydroxycloroquinol has been found to have potent antiviral activity. 

The study quoted most for hydroxycloroquine usage is a tiny French study where it was combined with  azithromycin, (Zithromax). On analysis it was obvious that the study was far too small to come to any conclusion and if any thing it should be viewed as highly cautionary for the administration of this cocktail. The Journal in which it was published has issued an apology for its publication implying that it did not pass appropriate peer review standards as it was written by the editor.

 The medical scientists have been emphatic that all results quoted of treatment to date merely provide anecdotal knowledge. No one has a clue whether, hydoxycloroquine is effective  or not. In France as a result of arrhythmic deaths the utilization of this medication has been put on hold. The American Heart Association has also warned against the usage for the same reason. In addition lupus and rheumatoid arthritis patients have been unable to have their prescriptions filled because of the shortage evoked by the pandemic.

Another medication used on a widespread basis is Remdesvir an antiviral AIDS medicine which has shown strong activity in laboratory situations against coronaviruses and in mice experiments.

The Chinese experience, in particular, would indicate that a wide variety of modalities were tried such as generalized treatments such as vitamins and metals especially zinc. antivirals, Chinese medicines and monoclonal antibodies.

THE CORONAVIRUS AND WHERE WE ARE TODAY

On the immediate horizon the only known effective empirical treatment is isolation, the more draconian the better. The experiences of Singapore, Taiwan and South Korea versus those of Italy, Spain, and America are obvious glaring examples. Sweden’s attempt tp create herd immunity with only isolating the most vulnerable is about to get an answer and the earliest indications are not positive. South Africa and India who have large numbers of highly susceptible citizenry by acting early and even using the army to maintain lockdown have thus far had remarkable results.

The reason for total lockdowns being the only successful management thus far is because there is a large knowledge gap in the natural history of coronavirus. Nobody knows how many citizens have the condition asymptomatically or with minimal symptoms. If there was widespread testing this could be ascertained. In addition the approach is necessary to identify those to make an early diagnosis as those who are admitted to hospital have a far worse prognosis than  influenza patients. Besides the high rates of respiratory failure there is the startling statistic that that one out of ten middle aged patients admitted to hospital die. There would be a far better basis as to whom to quarantine and who to let back to work if testing were instituted. This knowledge is central to management and restarting the economy. 

There are a six hundred scientific trials in process at the moment with a broad spectrum of approaches from hydroxyclorquine to monoclonal antibodies to anti virals by the ton. These might yield results soon as some were started in February in China. To see the light of day in respected journals they will need to have been conducted under stringent conditions.

 Companies have claimed that their vaccines will be ready before the eighteen month predicted period. 

One fact is for sure that it is highly irresponsible on the basis of the anecdotal non scientific knowledge to recommend any of these managements as a “game changer”. More so if you are the President of the United States with tens of million followers on Twitter, a forty percent devoted following and a two hour daily exposure to the public on television. 

PS: Jay H. Ell’s anecdotal belief is that one of the children’s vaccines, probably for measles, is effective. Basis of belief is the fact that young children after starting on the vaccine regimen appear to be immune. The reason for the manifestation in older ages, he is arguing, is that the immunity has worn off. Maybe somebody will do a real study! Till that happens don’t run around vaccinating your grandparents.