Although bad haircuts are a widespread side effect of the current pandemic, it is not hard to recognize this guy even with a mask on.

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That of course is a guy who is famous for three things (besides his hair). The third is being prime minister of the UK and the second is being a famous Brexit wanker. But his most famous fame is being one of the most notorious victims of COVID-19. Whatever your feelings about him, I think we can all agree that Boris Johnson was hospitalized in mid-April because of a severe case of COVID-19. So here’s what I want to know.

Why is he wearing a mask now?

Besides privacy/anonymity, masks can have two functional objectives. The first one, the normal and obvious one, is to keep bad stuff away from you, like when you’re sanding fiberglass. Interestingly, in pandemic times, this is not why masks are encouraged. For airborne disease control the idea of masks is a second objective, keeping the wearer from expelling and spreading infectious particles.

Are we worried that The Right Honourable Mr Johnson is a threat to our health? Are we worried that he will spread some infectious agent that will inflame the pandemic? Do we think that two months after suffering the most unambiguous case of COVID-19 possible that he is still an infectious threat?

Or, is Mr. Johnson looking to the first function of protective masks and trying to keep himself from getting infected again with C19? Either way, I would suggest that if this strategic thinking is valid, we are into some serious zombie apocalypse scenario.

Of course I bring this famous case up to highlight one of the most obscure cases of COVID-19 — mine. It turns out that I’m not too fond of wearing masks even when sanding fiberglass (though I do my best to do so). But having to wear a mask in the limited public outings I’ve had in the last 4 months has been especially tiresome. Why? Because it impedes breathing. Not a problem for a high volume athletic oxygen furnace like me, right? Not so much these days.

I’m still cycling about 100km a week but I can feel the damage. I had mentioned reduced circulation in my shins but that was really just the most noticeable problem. I’ve done a lot of work to strengthen my shins and they feel ok today but still not full strength. But as in December there has been a wave of problems targeting many different subsystems, just much more mild. Right now my thighs are covered in bruises, both left and right — I have no idea why. Last week I had unnatural leg muscle pain for no explainable reason. When I wake up in the morning my arms tingle with paresthesia (aka limbs "falling asleep"). I also have an ear infection, just like I did at the end of my illness previously, but other ear now; the second ear infection of my life. And my breathing is not at full strength. I can become winded just climbing the stairs. When riding I can feel the loss of capacity. I’ve been saying that it feels like I’m living at 2000m or 3000m, depending on the day — about the altitude of HAPE, a mountaineering sickness, which has some very similar symptoms to C19. It’s all pretty tiring.

Is this weakness half a year later scarring of some kind? Nerve damage? Vasculature damage? Immune system weakened? More live C19 virus attack? Reinfection? Hard to say.

My current guess about COVID-19, from personal experience, is most closely aligned with the thinking in this article which is well worth a read: Coronavirus May Be a Blood Vessel Disease, Which Explains Everything. I think that kind of idea is sinking in finally and I’m now seeing others pursue this possibility: It’s not just the lungs: The Covid-19 virus attacks like no other respiratory infection.

That’s my current situation — there are indeed long term effects. What can we do about it? Probably nothing for me personally, but for humans in general there are many different strategic approaches to defeating this disease. Let’s review my tiny opinions about each of them.

The first is a vaccine. To which I say good fucking luck. You can have no more than two of the following: developed soon; works; safe. This sensible article from a former CDC epidemiologist calls out all kinds of problems with the hope for a magic cure any time soon. It highlights a phenomenon known as antibody-dependent enhancement which

…causes some vaccine recipients, who nevertheless become infected by exposure to a pathogen, paradoxically to have more severe illness than if they had not been vaccinated at all. ADE has been observed for coronavirus vaccines in monkeys, pigs, cats, and in cultured human cells. It was also observed in children after a trial of a respiratory syncytial virus vaccine and after a mass campaign of a licensed dengue virus vaccine given to 830,000 children in the Philippines, resulting in withdrawal of the vaccine."

I just can’t help but think that the vaccine hope is a form of wishful thinking similar to "pharma is not predatory and these magic beans will magically cure my lifetime of poor lifestyle choices".

At this point C19 is a real pain in the ass, but so is HIV and ebola (actually now has a brand new vaccine after only 44 years!) and a lot of other diseases; why not come up with cures for them too? Because it is very hard to do and considerable luck is required.

What about "contact tracing"? Good idea, right? I side with Bruce Schneier who says correctly it is "just plain dumb". And he’s not even introducing any privacy concerns to the discussion. I like this barb at gormless Silicon Valley tech bros for their typical banality when solving any problem (Ans: a telephone app?). "To me, it’s just techies doing techie things because they don’t know what else to do." Australia’s experience is what I would expect: How did the Covidsafe app go from being vital to almost irrelevant?

What’s sad to me is that contact tracing is close to the right answer. This pandemic is not really a medical problem any more. It is an industrial engineering problem. Unfortunately the world’s industrial engineers are restrained in obscurity thanks to a terrible name for their profession. It has been extremely frustrating to see the terrible ad hoc industrial engineering popping up everywhere in response to The Virus. Suffering the virus itself was only slightly more demoralizing than the constant stream of fatuous reports featuring numbers of new cases lacking base rates! But a sensible application of some serious industrial engineering could cure this pandemic in a few weeks. Because very few people understand this, it will not happen. (I am delighted with the I.E. consolation prize — that this virus forced major grocery store chains to use single feeder lines. Yay! Should have done that decades ago!)

One problem that severely impacts the aforementioned industrial engineering cure is testing. Testing, if quick, accurate, and effective enough would itself essentially be a cure without fancy industrial engineering heroics. But it’s neither fast nor accurate, and thus not effective. People keep asking me, "Don’t you want to know if you have it?" Well, my symptoms were enough of a red flag positive test for me, but of course I’d love for some simplistic magic test to tell me something useful about this disease. But I have no faith in such things. I’ve seen all kinds of health security theater going on and these tests seem fraught with complexity. This resource is very expansive and hints at the diverse problems someone taking "testing" seriously will encounter. Tack onto that living in the medical third world and I’m not too keen to try my luck — you only need to read the title of this article to appreciate my misgivings: Two Friends in Texas Were Tested for Coronavirus. One Bill Was $199. The Other? $6,408.

Earlier some people were thinking that the warmer weather would tamp down the virus. That’s obviously not actually happening. People are out more, the dumb ones at political rallies even. Even if hot weather was helpful, it’s looking pretty strongly like air conditioning is not great for controlling the virus. When the AC industry lobby is worried about that we probably all should be.

How will this pandemic end? Consider the difference between these two scenarios: A. The disease is running amok and no one realizes there’s a problem. B. People are aware there is a virulent disease that is quite deadly to a certain demographic. It is possible that all the reduction we’re seeing is because we once had A and now we have B. I think that has been the single biggest factor in controlling things. My money is still on luck mysteriously causing this to simply go away for reasons that medical research will be too underfunded to understand. Like previous pandemics! At some point we will run out of susceptible potential victims.

One final interesting therapeutic approach is transfusions of antibody-rich blood plasma from COVID-19 survivors to inoculate against the disease. This article claims it is promising but mired in regulatory friction. I can’t say if that’s a sensible idea or not. But it does make me wonder… Who knows, maybe it might be smart for uninfected people to inhale deeply in the unmasked presence of strong antiviral producers like Boris Johnson. And me.

UPDATE 2020-07-19

In summary, progress since January 2020 has been impressive, but there is still so much more to learn. Are T cells protective and if so which are the key antigens and and cytokine effector programs to focus on? Are all T cell responses beneficial, or are some contributory to immunopathology and to be avoided? If it is indeed the case that antibodies are transient and T cell memory is more durable (though, how durable?), what can we learn about anomalies of T follicular helper-B cell interactions in germinal centers? In the short to medium term, we need to ensure that all of this T cell toolkit and knowledge is brought to bear on robust, comparative evaluation of the different vaccine platforms, their immunogenicity, efficacy and safety. Entering the next part of the battle, there are many thousands of people suffering the chronic aftermath of infection posed by chronic, so-called long-COVID cases, characterized by diverse symptoms including fatigue, joint pain and dyspnea. A more detailed understanding of the T cell immunology will be valuable in deciphering this pathogenesis.

At the start of the pandemic, a key mantra was that we needed the game-changer of antibody data to understand who had been infected and how many were protected. As we have learnt more about this challenging infection, it’s time to admit that we really need the T cell data too.

I’m citing this paper as a thoughtful excellent contribution to the topic. It is basically saying that simplistic thinking about the immune system is wrong. And I believe that sentiment is absolutely correct. But note the "and and" [sic] in the second sentence. My writing isn’t grammatical perfection but I’m not published in fancy scientific journals, i.e. peer reviewed and professionally edited. I don’t mean to carp but rather point out that we humans are fallible and even in the field of immunology, mistakes are made. Perhaps especially in that field? My point is that if we get a miracle cure it will indeed be a miracle.

UPDATE 2020-07-19

Some industrial engineering heroics finally shambling into action. It’s been very painful for me to watch this not happen for so long. Trump admin allows group Covid-19 testing.

UPDATE 2020-07-28

This short article asks, Can you get the coronavirus twice? They seem to conclude that it is possible but unlikely. They correctly make the logical conclusions echoing my concerns about the topic.

If [reinfection] can occur, that could undermine the idea of "immunity passports" for returning back to workplaces. And it would not bode well for hopes of getting a long-lasting vaccine.

Again, to summarize - either I have nothing to worry about personally or we’re all screwed.

UPDATE 2020-08-03

Still unclear about what an industrial engineering solution looks like? Here’s an example of the kind of thing that seems obvious to me but which has been clumsily avoided throughout this ordeal.

We construct network measures of nursing home connectedness and estimate that nursing homes have, on average, connections with 15 other facilities. Controlling for demographic and other factors, a home’s staff-network connections and its centrality within the greater network strongly predict COVID-19 cases.

UPDATE 2020-08-06

The ever excellent Ed Yong writes another superb piece.

This is about as gentle of an introduction to practical immunology as it gets and clearly addresses things I’ve been wondering about. In one sentence he hits upon the conundrum I’ve highlighted.

…concerns that people could be infected repeatedly, or even that a vaccine — many of which work by readying neutralizing antibodies — won’t provide long-term protection.

In other words, either people can’t get reinfected (well, easily anyway) or vaccines are not as useful as people imagine — one of the two, pick one. While that simple analysis is simple and not completely invalid, Yong does rightly spend the majority of the article correctly emphasizing that when it comes to immunology, it’s complicated.