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NIH Stops Remdesivir Study
Inside the NIH's controversial decision to stop its big remdesivir study
By Matthew Herper @matthewherper
The drug maker Gilead Sciences released a bombshell two weeks ago: A study conducted by a U.S. government agency had found that the company's experimental drug, remdesivir, was the first treatment shown to have even a small effect against Covid-19.
Behind that ray of hope, though, was one of the toughest quandaries in medicine: how to balance the need to rigorously test a new medicine for safety and effectiveness with the moral imperative to get patients a treatment that works as quickly as possible. At the heart of the decision about when to end the trial was a process that was — as is often in the case in clinical trials — by turns secretive and bureaucratic.
The National Institute of Allergy and Infectious Diseases has described to STAT in new detail how it made its fateful decision: to start giving remdesivir to patients who had been assigned to receive a placebo in the study, essentially limiting researchers' ability to collect more data about whether the drug saves lives — something the study, called ACTT-1, suggests but does not prove. In the trial, 8% of the participants given remdesivir died, compared with 11.6% of the placebo group, a difference that was not statistically significant.
A top NIAID official said he had no regrets about the decision. "There certainly was unanimity within the institute that this was the right thing to do," said H. Clifford Lane, NIAID's clinical director. "While I think there might've been some discussion, [because] everyone always tries to play devil's advocate in these discussions, I think there was a pretty uniform opinion that this was what we should do."
From the standpoint of the agency, he said, the study had answered the question it was designed to answer: The median time that hospitalized Covid-19 patients on remdesivir took to stop needing oxygen or exit the hospital was, at 11 days, four days shorter than those who were on placebo. "How many patients would we want to put at risk of dying," he asked, for that last little bit of proof? Remdesivir, he noted, was not a home run, but is probably better than nothing.
Steven Nissen, a veteran trialist and cardiologist at the Cleveland Clinic, disagreed that giving placebo patients remdesivir was the right call. "I believe it is in society's best interest to determine whether remdesivir can reduce mortality, and with the release of this information doing a placebo-controlled trial to determine if there is a mortality benefit will be very difficult," he said. "The question is: Was there a route, or is there a route, to determine if the drug can prevent death?" The decision is "a lost opportunity," he said.
Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, agreed with Nissen. "The core understanding of clinical research participation and clinical research conduct is we run the trial rigorously to provide the most accurate information about the right treatment," he said. And that answer, he argued, should ideally have determined whether remdesivir saves lives.
The reason we have shut our whole society down, Bach said, is not to prevent Covid-19 patients from spending a few more days in the hospital. It is to prevent patients from dying. "Mortality is the right endpoint," he said.
Most experts contacted by STAT expressed opinions that fell between Nissen and Lane, believing that the decision was a difficult case, with several defending the NIAID.
"I think it was a really tough call," said Janet Wittes, a prominent statistician and the president of Statistics Collaborative.
When the remdesivir results were announced, the NIH said the data came from an "interim" analysis. This means that a study was stopped early because a drug's benefit was so undeniable that it would be unethical to continue the study. But Lane said this was incorrect. The data come from a preliminary final analysis, a point at which the study would normally end.
With remdesivir, Gilead finds itself at strategic crossroads, with its reputation (and far more) at stake
The ACTT study (short for Adaptive Covid-19 Treatment Trial) began in late February. The first patient dosed in the study was an American repatriated from the Diamond Princess, a British cruise ship where there was an outbreak of more than 800 Covid-19 cases. By the terms of the study, hospitalized patients were randomly assigned to receive either intravenous remdesivir or a placebo. On day 15, the study would score patients on a scale from 1 (dead) to 8 (not hospitalized, with no restrictions on activities).
As results from other Covid-19 studies conducted in China started to trickle in, Lane and his team began to worry that looking at the outcome on only the 15th day could lead the study to fail even if the drug was effective. On March 22, with only 77 patients enrolled in the study, members of the NIAID team had a conference call on which they decided to change the measure that would be used. Instead of measuring patients on an eight-point scale on one day, the study would measure the time until the patients scored one of the best three outcomes on the scale. This decision was finalized on April 2; it was posted to clinicaltrials.gov, a government registry of clinical trials, on April 16.
Ironically, Lane said, the study would still have been positive if the change had not been made. But the change in the study's main goal also changed the way the study would be analyzed. Now, the NIAID decided, the analysis would be calculated when 400 patients out of the 1,063 patients the study enrolled had recovered. If remdesivir turned out to be much more effective than expected, "interim" analyses would be conducted at a third and two-thirds that number.
The job of reviewing these analyses would fall to a committee of outside experts on what is known as an independent data and safety monitoring board, or DSMB. Though they generally go unseen, DSMBs are among the most important and powerful forces in medical research. They are allowed to analyze the data from a trial while it's ongoing, even as drug companies, doctors, and patients are kept from knowing who is getting the medicine and who is getting placebo. These boards have two jobs: to make sure that patients aren't being harmed by the experimental drug, and to ensure that it's not already clear beyond a doubt that a medicine is effective.
Those decisions bring moments of triumph, despair, and, occasionally, confusion.
When Merck decided to withdraw the painkiller Vioxx in 2004, it was because a DSMB had recommended stopping a study of the drug when it became clear the medicine increased the risk of heart attacks and strokes. In 2014, when a study of the cancer immunotherapy Opdivo first proved that drug extended survival in melanoma, it was because a DSMB had found the result incontrovertible and recommended stopping the study.
But the DSMB for the remdesivir study did not ever meet for an interim efficacy analysis, Lane said. All patients had been enrolled by April 20. The data for a DSMB meeting was cut off on April 22. The DSMB met and, on April 27, it made a recommendation to the NIAID.
That recommendation was not about whether the patients on placebo should receive remdesivir. Instead, the DSMB recommended that in the next phase of the study, testing Eli Lilly's arthritis drug Olumiant against remdesivir, there was no need for a placebo-only group.
That decision, Lane said, led the NIAID to conclude that patients who had been given placebo should be offered remdesivir, something that started happening after April 28.
This is where Nissen and Bach disagree. There were 1,063 patients in the study, but only 480 had recovered at the time of the analysis. Researchers could have collected more data, they argue, and perhaps have learned if remdesivir saves lives. They were already close, both note. Results are considered "significant" if a measure called a p-value is less than 0.05; the value for mortality in the preliminary analysis was 0.059. "How many patients would we want to put at risk of dying to get that 0.01 on the p-value," Lane retorted.
Marc Pfeffer, a cardiologist at the Brigham and Women's Hospital in Boston, said he believes NIAID made the right call. He said that he was "very sympathetic" to the fact that researchers were getting this study done during a pandemic. "If you make the decision that remdesivir should be part of everybody's therapy in the next phase, then those volunteers taking the risks in the current trial should be switched to the active therapy now considered effective," he said.
Should this decision have been left to the DSMB, not the NIAID? DSMBs are technically only advisory panels, said Richard Chaisson, a professor at the Johns Hopkins Bloomberg School of Public Health.
Chaisson remembers running an NIH-funded study of a preventative treatment for tuberculosis. The DSMB recommended continuing the trial, but he decided not to, because it was putting patients at too much risk. "The NIH had no problem with me not following the DSMB's advice, and were even relieved I made the decision I did," he said.
Wittes, of Statistics Collaborative, said she is glad she wasn't on this DSMB, adding, "I don't know where I would have come out." And she said that when full results of the study are available, she would be "shocked" if the NIAID had not done things properly.
"I think there are groups of people who you'd really respect who would not have stopped a study like this without a mortality benefit," Wittes said. "And I think you can argue that both ways."
But she also worried that the evidence might not be strong enough to make the decision society is now making: that every new Covid-19 treatment must be given with or compared to remdesivir.
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"The danger is now it's the treatment for everybody," she said. "Now this is the base drug and everything is going to be that plus something or the control. I think we don't know if it's strong enough for it to be the standard of care. I don't think we know who should be treated."
Steven Joffe, an ethics expert at the University of Pennsylvania, said he believes the NIAID likely took the right steps in making its decision to give remdesivir to the placebo patients. But he worries about deciding to use time to improvement, not death, as the measure of success, in the first place.
"I don't find this endpoint very compelling, and to me the real issue is the decision to design the trial around the endpoint of time to recovery defined in the way they defined recovery," Joffe said. "To me, the decisions that are this weighty ought to be based on clinically important endpoints."
All of this would normally wait until the full results were published, at which point the roster of the DSMB may be revealed. (Lane would not share their names.) But what is unusual in this case is that, before the data are even fully analyzed, the FDA has authorized remdesivir's use. A Chinese study, meanwhile, failed to show remdesivir had a benefit. Several more studies of the drug expected to read out soon.
Ethan Weiss, a cardiologist at the University of California, San Francisco, who traveled to New York two weeks ago to treat Covid-19 patients, said that he does worry that we have missed "a fleeting opportunity" to understand how well remdesivir works. "It is sad to me that we're not going to get a complete answer about it." But he said he also thinks the issue is "inside baseball." Remdesivir, as several experts have pointed out, is not a game changer.
The real problem, Weiss said, is not the handling of this particular study but that there aren't more like it. He said he wished the U.S. had built the infrastructure needed to do more studies like this when the pandemic in New York was at its height. He wished there were more studies, with more DSMBs.
"We've squandered an incredible opportunity to do good science," Weiss said. "If we could ever go back and do something all over, it would be the infrastructure to actually learn something. Because we're not learning enough."
Matthew Herper has covered medical innovation ––––for two decades chronicling the rise of genetic medicine and the ballooning cost of new drugs. Along the way he profiled major figures from Martin Shkreli to Bill Gates. From 2000 to 2018, he covered science and medicine for Forbes, writing 17 covers and building the Forbes Healthcare Summit into an industry leading event.
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US-China Confrontation Will Define Global Order
Friday, May 8th, 2020
China is the source of COVID-19 that is presently destroying our world. China is America's most serious enemy both economically and militarily. Somehow, after the VIRUS are gone, we will need to deal with the Chinese. Victor Davis Hanson lays out some interesting ideas.
Victor Davis Hanson: US-China Confrontation Will Define Global Order
Hoover Institution, Stanford University
The United States is at a crossroads with an increasingly aggressive China, which could define America's security and the international order for decades to come, Hoover scholar Victor Davis Hanson says.
Hanson, the Martin and Illie Anderson Senior Fellow at the Hoover Institution, studies military history and the classics. Last year, Hanson won the Edmund Burke Award, which honors people who have made major contributions to the defense of Western civilization. He is the author of the 2019 book The Case for Trump, and 2017's The Second World Wars. He was recently interviewed on US policy toward China:
What is the Trump strategy behind these tariffs, short term and long term?
Hanson: Short term, Trump feels that he can take the hit of reciprocal Chinese tariffs, given that quietly his opposition, the Democrats, have been raging about Chinese cheating for decades, and, second, that the US economy is so huge and diverse that China simply cannot cause serious damage.
Remember the United States is a country one-third the size of China that produces over double China's annual gross domestic product and fields a military far more formidable with far more allies—while enjoying a far more influential global culture and a far more sophisticated system of higher education and technological innovation. China's Asian neighbors and our own European Union allies quietly are hoping Trump can check and roll back Chinese mercantilism, while publicly and pro forma chiding or even condemning Trump's brinksmanship and his resort to fossilized strategies such as tariffs and loud jawboning.
Long term, Trump believes that if present trends are not reversed, China could in theory catch and surpass the US. And as an authoritarian, anti-democratic superpower, China's global dominance would not be analogous to the American-led postwar order, but would be one in which China follows one set of rules and imposes a quite different set on everyone else—perhaps one day similar to the system imposed on its own people within China.
Is China a more formidable rival now than Russia was during the Cold War, and if so, why?
Hanson: Yes. Its population is five times greater than that of even the old Soviet Empire's. Its economy is well over twenty times larger, and over a million Chinese students and business people are in European and American universities and colleges and posted abroad with Chinese companies. So, unlike the old Soviet Union, China is integrated within the West, culturally, economically, and politically. The Soviets—like Maoist China—never leased Western ports, or battled Hollywood over unflattering pictures, or posed as credible defenders of Asian values or owned large shares of Western companies or piled up huge trade surpluses with Western nations. Soviet propaganda and espionage were crude compared to current Chinese efforts.
What is China doing in terms of cheating on trade and intellectual property as the Trump administration says, and how can the United States stop this behavior?
Hanson: China does not honor patents and copyright laws. It still exports knock-off and counterfeit products. It steals research and development investment through a vast array of espionage rings. It manipulates its currency.
Its government companies export goods at below the cost of production to grab market share. It requires foreign companies to hand over technology as a price of doing business in China. And, most importantly, it assumes, even demands, that Western nations do not emulate its own international roguery—or else.
The result is a strange paradox in which the United States and Europe assume that China is an international commercial outlaw, but the remedy is deemed worse than the disease. So, many Western firms make enormous profits in China through joint projects, and so many academic institutions depend on China students, and so many financial institutions are invested in China, that to question its mercantilism is to be derided as a quaint nationalist, or a dangerous protectionist, or a veritable racist. China is an astute student of the Western science of victimology and always poses as a target of Western vindictiveness, racism, or puerile jealousy.
Remedies? First, we must give up the 40-year fantasies that the richer China gets, the more Western and liberal it will become; or that the more China becomes familiar with the West, the greater its admiration and respect for Western values; or that China has so many internal problems that it cannot possibly pose a threat to the West; or that Western magnanimity in foreign policy and trade relations will be appreciated and returned in kind. Instead, the better paradigm is imperial Japan between 1930 and 1941, when Tokyo absorbed Asian allies; had sent a quarter-million students and attachés to the West to learn or steal technology and doctrine; rapidly Westernized; declared Western colonial powers and the US as tired and spent, and without any legitimate business in the Pacific; and considered its own authoritarianism a far better partner to free market capitalism than the supposedly messy and clumsy democracies of the West.
How is China able now to leverage its arguably less powerful military to confront the United States globally?
Hanson: Global naval dominance is not in the Chinese near future. Its naval strategy is more reminiscent of the German Kriegsmarine of 1939 to 1941, which sought to deny the vastly superior Royal Navy access at strategic points without matching its global reach. China is carving out areas where shore batteries and coastal fleets can send showers of missiles to take out a multibillion-dollar American carrier. And its leasing of 50 and more strategically located ports might serve in times of global tensions as transit foci for armed merchant ships. But for now they do not have the capabilities of the American carrier or submarine fleet or expeditionary Marine forces—so the point is to deny America reach, not to emulate its extent.
Why are the current administration policies different than those in the past in confronting China on many different fronts and levels?
Hanson: Trump believes that economic power is the key to global influence and clout. Without it, a military wilts on the vine. A country with GDP growth at a 3 percent annual clip, energy independence, full employment, and increasing labor productivity and trade symmetry can renegotiate Chinese mercantilism and reassure China's Asian neighbors that they need not appease its aggression. Past administrations might have agreed that China violated copyright and patent laws, dumped subsidized goods, appropriated technology, and ran a massive global espionage apparatus, but they considered remedies either impossible or dangerous and so essentially negotiated a slowing of the supposed predestined Chinese global hegemony. Trump was willing to confront China to achieve fair rather than free trade and take the ensuing heat that he was some sort of tariff-slapping Neanderthal.
Any other thoughts?
Hanson: I think Secretary of State Mike Pompeo's State Department is the first to openly question the idea that China will eventually rule the world and has offered a strategic plan to check its trade and political agendas. In this regard, a number of Hoover Institution scholars, currently working with Hoover fellow Kiron Skinner, director of policy planning at the US Department of State, are offering alternatives to orthodox American approaches of the past, with the caveat that the most dangerous era in interstate relations is the transition from de facto appeasement to symmetry—given that the abnormalities of the past had become considered "normal," and the quite normal efforts of a nation to recalibrate to a balanced relationship are damned as dangerously "abnormal."
Victor Davis Hanson is also the chairman of the Role of Military History in Contemporary Conflict Working Group at the Hoover Institution.
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The "New Normal": Thoughts about the Shape of Things to Come in the Post-Pandemic World
Sunday, May 3rd, 2020
Here is a very interesting and insightful essay on what the future now holds after COVID – 19. It is disturbing, but certainly quite possible.
by Nicholas Eberstadt
Nicholas Eberstadt
Nicholas Eberstadt holds the Henry Wendt Chair at the American Enterprise Institute in Washington, D.C., and is a Senior Advisor to the National Bureau of Asian Research.He is Senior Advisor, The National Bureau of Asian Researc Nicholas Eberstadt offers insights into the challenges to U.S. leadership in a post-pandemic world. This is the inaugural essay in the series "The New Normal in Asia," which explores ways in which the Covid-19 pandemic might adjust, shape, or reorder the world across multiple dimensions.
Though we are as yet barely weeks into the Covid-19 pandemic, what should already be apparent is that it has precipitated the deepest and most fundamental crisis for Pax Americana that this set of global economic and security arrangements has faced in the past three postwar generations.
We are still very much in the "fog of war" phase of the calamity. The novel coronavirus and its worldwide carnage have come as a strategic surprise to thought leaders and political decision-makers alike. Indeed, it appears to be the intellectual equivalent of an unexpected asteroid strike for almost all who must cope in these unfamiliar new surroundings. Few had seriously considered the contingency that the world economy might be shaken to its foundations by a communicable disease. And even now that this has happened, many remain trapped in the mental coordinates of a world that no longer exists.
Such "prewar" thinking is evident everywhere right now in the earliest phase of what may turn out to be a grave and protracted crisis. Here in the United States, we watch, week by week, as highly regarded financial analysts from Wall Street and economists from the academy misestimate the depths of the damage we can expect—always erring on the side of optimism.
After the March lockdown of the country to "flatten the curve," the boldest voices dared to venture that the United States might hit 10% unemployment before the worst was over. Four weekly jobless claims reports and 22 million unemployment insurance applications later, U.S. unemployment is already above the 15% mark: north of 1931 levels, in other words. By the end of April, we could well reach or break the 20% threshold, bringing us to 1935 levels, and 1933 levels (25%) no longer sound fantastical. Even so, political and financial leaders talk of a rapid "V-shaped recovery" commencing in the summer, bringing us back to economic normalcy within months. This is prewar thinking, and it is looking increasingly like the economic equivalent of talk in earlier times about how "the boys will be home by Christmas."
This is moreover a global crisis, and vision has not yet focused on the new realities in other leading powers and major economies. If we try to take an unflinching measure of the impact globally, we can see both good news and bad news—although the two are by no means equally balanced.
The good news is that policymakers the world over have learned from the prewar Great Depression and are unlikely to repeat its exact mistakes. Instead of reducing the money supply and forcing bank collapses, the U.S. Federal Reserve this time is flooding the world with liquidity. Likewise, U.S. fiscal policy, far from attempting to impose further austerity on an already imploding economy through balancing budgets, is embracing Keynesianism with an abandon that might have startled Keynes himself. Given the "stimulus" packages already passed in the last month, this year's U.S. budget deficit to GDP ratio is already certain to be of World War II scale. And, at least so far, no emanations of Smoot-Hawley-like impulses are on the policy horizon. Last time around, protectionism had devastating reverberations on an already severely stressed international trade and financial system. Confidence in U.S. and international economic management of the current crisis, at least for the time being, is reflected inter alia in the surprisingly sanguine valuations of the stock indices both in the United States and abroad.
The bad news, on the other hand, lies in the nature of the virus itself and in its implications for human life and socioeconomic arrangements. Covid-19 is an extremely contagious virus with high lethality for those exposed to it, and it can be transmitted by asymptomatic "super spreaders." Further, since this disease is zoonotic (contracted from another species) and novel (our species has no preexisting immunity), the pandemic will roam the world in search of human quarry until an effective vaccine is invented and mass-produced—or until so many people are infected that herd immunity is conferred.
A Darwinian experiment to invite global herd immunity is unthinkable because it could entail untold millions of deaths. New vaccines, for their part, typically take many years to develop. Barring some miracle, even a crash program to perfect a vaccine is currently expected to take at least a year, and it could be a year and a half or longer before a serviceable serum is generally available to the public. Reports now emanating from South Korea, moreover, suggest that survivors might also be susceptible to reinfection. If so, the quest to come up with a lasting inoculation against Covid-19 may be all that much more daunting.
Consequently, societies the world over face the prospect of rolling lockdowns and quarantines until such time as a technological breakthrough rescues them from this condition. This would seem to mean that not just a single national lockdown of a country's population and economy is in store to fend off mass contagion but rather quite possibly a succession of them—not just one mother-of-all-economic-shocks but an ongoing crisis that presses economic performance severely in countries all around the world simultaneously.
The potential downside of this crisis looks dire enough for affluent societies: even with excellent economic management, they may be in for gruesome recessions, both painful and prolonged. But the situation for the populations of low-income countries—and for least-developed, fragile states—could prove positively catastrophic. Not only are governments in these locales much less capable of responding to pandemics, but malnourished and health-compromised people are much more likely to succumb to them. Even apart from the humanitarian disasters that may result directly from raging outbreaks in poor countries, terrible indirect consequences may also lie in wait for these vulnerable societies. The collapse of economic activity, including demand for commodities, such as minerals and energy, will mean that export earnings and international remittances to poor countries are set to crash in the months ahead and remain low for an indefinite period. Entirely apart from contagion and lockdowns, this can only mean an unavoidable explosion of desperate need—and under governments least equipped to deal with this. While we can hope for the best, the worst could be much, much worse than most observers currently imagine.
Eventually, of course, we will emerge from the current crisis. Envisioning the post-crisis "new normal" is extraordinarily difficult at this early juncture—not that much less demanding, perhaps, than imagining what the postwar world would look like from the vantage point of, say, autumn 1939. Lacking clairvoyance, we can only peer through the glass darkly at what may be the shape of things to come in the post-pandemic order. Yet it is not too soon to offer one safe prediction about that coming order, and to identify three critical but as yet unanswerable questions, the answers to which promise to shape it decisively.
The safe prediction is that the Indo-Pacific, then as now, will be the locus of global economic, political, and military power—and will remain so for at least the coming generation, possibly much longer. Currently, countries belonging to the Asia-Pacific Economic Cooperation (APEC) account for as much as 60% of the world's estimated GDP and close to half of global trade. If we add India, which is not an APEC member, to that roster, the economic predominance of the region looks even more overwhelming. APEC plus India likewise accounts for much—perhaps most—of the ongoing knowledge production in the world today. By such necessarily imprecise measures as publications in peer-reviewed scientific journals, authors from the APEC-plus-India region are responsible for about three-fifths of current global output. The only state with truly global military capabilities (the United States) is part of this region, as are the only other two governments entertaining global strategic ambitions (China and Russia). In addition to these countries, India and (alas) North Korea are nuclear weapons states. For the moment, the combined nuclear potential of all nuclear powers outside the APEC-plus-India region (France, Britain, Pakistan, and Israel) is dwarfed by the atomic arsenals within it.
Barring a catastrophe of truly biblical proportion (a formulation that may admittedly seem to be tempting fate, given current circumstances) it is impossible to see what configuration of states or regions could displace the Indo-Pacific as the epicenter of world power anytime soon. Someday Africa might in theory become a contender for geopolitical dominance, but that date looks so distant that such scenarios for now are perhaps best narrated by science fiction writers.
"Will the Covid-19 pandemic bring a brutal end to the second age of globalization that began in 1945, just as World War I heralded the cataclysmic death of the first globalization (1870–1914)?"
As for the questions that stand decisively to shape the coming global order, the first concerns the scope and character of what we have been calling "globalization" in the years and decades ahead. Will the Covid-19 pandemic bring a brutal end to the second age of globalization that began in 1945, just as World War I heralded the cataclysmic death of the first globalization (1870–1914)?
At this early point in the crisis, it would take a brave (or foolish) soul to assert confidently that an end to our current far-reaching arrangements for world economic integration simply could not happen. That said, at least for now, it would look as if a lot of things that have not yet gone wrong would have to go wrong, and at the same time sweep away the foundations (and memory plastic) for the networks of trade, finance, communications, technology, culture, and more that have come to deeply connect societies all around the world today. Not much less than a continuing, cascading, and unabated series of worldwide political blunders—not excluding military adventures—would be required to burn this edifice to the ground.
On the other hand, it is also hard to see how a post-pandemic world will pick itself up and carry on with commerce, finance, and global governance as if nothing much happened around the year 2020. Even under the optimistic assumptions—i.e., the assumptions wherein the second age of globalization survives Covid-19's heavy blow—much will need to be dramatically different. Until the advent of some biometric, post-privacy future, the more or less free movement of peoples across national borders will be a nonstarter. "Davos" stands to become a quaint word, somewhat like "Esperanto," as national interests and economic nationalism come roaring back. International supply chains will tend to be resourced domestically, notwithstanding the immediate apparent cost in terms of production and profits. At the same time, today's crisis may explode and wipe out old inefficient business models that had already outlived their usefulness: the "big box" store and retail malls, the unproductive (but sociologically alluring) office, the law firm (with its Soviet-style valuations of its services on the basis of inputs rather than outputs), perhaps the cartelized, price-fixing university as well, and more.
On the positive side, the creative destruction the crisis will unleash will eventually offer immense opportunities for innovation and dynamic improvements in productivity, so long as resources from inefficient or bankrupt undertakings are reallocated to more promising new purposes. To give just one example, the returns on remote communications will likely be high, incentivizing impressive breakthroughs. Post-pandemic economies around the world will need all the productivity surges they can squeeze out of technological and organizational innovation, too—for they will almost certainly be saddled with a far higher burden of public debt than today. Moreover, given current demographic trends and the prospect of significantly less immigration, the shrinking of labor forces and the pronounced aging of national populations may be characteristic of a growing number of economies in the APEC-plus-India region and the rest of the world, and not just in high-income settings. Japan may become a model here, but not in a good way: avoiding "Japanification" could become a preoccupation of policymakers, pundits, and populaces in an epoch of diminished expectations for globalization.
A second huge question for the post-pandemic world concerns China: more specifically, how will the rest of the international community treat this increasingly powerful but intrinsically problematic state?
The world has yet to conduct the authoritative blue-ribbon scientific inquiry into the origins of the coronavirus pandemic that is obviously and urgently needed. However, there is little doubt that heavy responsibility for the global health and economic crisis we are now coping with falls on the Chinese Communist Party (CCP)—and to a lesser but by no means negligible degree, on China's collaborators within the World Health Organization. Had the CCP placed its population's health above its own—had it behaved like an open society or followed international transparency norms—there is no question that the global toll from the Covid-19 pandemic would only be a fraction of what has been exacted to date. Epidemiologists from the University of Southampton in the United Kingdom have suggested that the damage might have been contained to just 5% of what we have thus far suffered with an expeditious (and honest) response to the Wuhan outbreak. If that estimate is overly precise, it nonetheless gives a sense of the price the world has paid for the CCP's priorities and standard operating procedure. We also already know of the complicity of the World Health Organization at its highest levels in buying time for Beijing as the regime figured out how to spin the story of what happened in Hubei Province.
"…the post-pandemic world will have no choice but to contend at last with a problem long in the making: the awful dilemma of global integration without solidarity."
It would be one thing if this crisis were a one-off—dreadful as the tragedy would be. The problem, unfortunately, is that it is not a one-off, and in fact cannot be. At the heart of the tragedy is an uncomfortable but unavoidable truth: the CCP simply does not share the same interests and norms as the international community into which it has been so momentously and thoroughly integrated. Moreover, there is scant evidence that integration into the world economy and global governance has been "reforming" the Chinese regime, in the sense of bringing its politics and behavior into closer alignment with those acceptable to Western populations. Quite the contrary: in the Xi Jinping era, China's politics have manifestly been moving away from convergence as the regime has concentrated on perfecting a surveillance state policed by "market totalitarianism" (a social credit system powered by big data, artificial intelligence, and more).
Thus, the post-pandemic world will have no choice but to contend at last with a problem long in the making: the awful dilemma of global integration without solidarity. China is deeply interlinked with every APEC-plus-India economy and with those of the rest of the world as well. Chinese interests are likewise deeply embedded in much of the institutional apparatus that has evolved to facilitate international cooperation. How will the rest of the countries in the international community manage to protect their interests (including health security interests, but by no means limited to this alone) in such a world? Will it be possible to accurately identify and carefully isolate all the areas in which win-win transactions with the CCP are genuinely possible and cordon off everything else? Or will the CCP's authoritarian influence compromise, corrupt, and degrade these same institutions, and likewise constrain or poison opportunities for truly free international economic cooperation and development after the Covid-19 pandemic?
Last, but by no means least important, there is the question of the United States' disposition in a post-pandemic world.
Even before the Covid-19 crisis, it was not exactly a secret that the United States—which is to say, Americans—was becoming increasingly reluctant to shoulder responsibility for world leadership in the global order that Washington had been instrumental in creating and that U.S. power was indispensable in supporting. The skepticism and disfavor with which American proponents of internationalism were increasingly greeted at home, however, was not entirely explained by the deep historical roots of isolationism in our country. Nor can it be dismissively described as yet another paroxysm of paranoia and anti-intellectualism on the part of the yahoos, as would-be Hofstadters from today's chattering classes would like to have it.
Such discontent with our nation's considerable international obligations skews strongly with socioeconomic status. For those in the bottom half of the country, grievances with the status quo (which not so incidentally includes a strong political commitment to Pax Americana) are by no means delusional. Over the past two generations, the American escalator has broken down for many. Just before the Covid-19 crisis, at the supposed peak of a business cycle, work rates for prime-age American men (the 25–54 age group) were slightly lower than they had been in 1939, near the end of the Great Depression. It is hardly reassuring that this alarming situation has attracted relatively little attention from the talking and deciding classes (many of whom are shielded from personal familiarity with how the other half lives by Charles Murray's famous bubble).
Scarcely less disconcerting than the work rates for American men are the dismal trends in wealth formation for the less well to do. According to estimates by the Federal Reserve, the mean real net worth for the bottom half of households in the United States was lower in 2019 than it had been in 1989 when the Berlin Wall fell. By these estimates, in fact, the net worth of such households was about a third lower in 2019 than it had been three decades before. Voters from these households might be excused if they were prompted to ask what the fabled "end of the Cold War" had done for them. Recall that these same Americans witnessed a decline in net household worth in a period when overall nominal net worth in the United States soared by almost $80 trillion—an average of almost $250,000 for every man, woman, and child in our country today. Since the arrival of Covid-19 on our shores, the net worth of the bottom half of Americans has dropped still further, as their indebtedness has risen and the value of their assets (mainly homes) declined. It could be quite some time before the balance sheets of those homes look as "favorable" as they did in 2019.
In the United States, the constitutional duty to obtain the consent of the governed obtains for the little people, too, even if they happen to comprise a majority of voters. And in a post-pandemic world, it may be even more difficult to convince a working majority that the globalized economy and other international entanglements actually work in their favor.
If U.S. leaders wanted to generate broad-based domestic support for Pax Americana, they need to devise a formula for generating prosperity for all. Such an agenda, of course, would win on its own merits, with or without an eye toward international security. Absent such a credible agenda, popular support for U.S. international leadership could prove increasingly open to question in the post-pandemic United States. The peril that declining domestic U.S. support poses to the current global order should not be minimized. If or when Pax Americana is destroyed, its demise may be due not to threats from without but rather to pressures from within.
Nicholas Eberstadt holds the Henry Wendt Chair at the American Enterprise Institute in Washington, D.C., and is a Senior Advisor to the National Bureau of Asian Research.
Posted in American and International Economies, American Economy, ecomomics, Foreign Policy, History, New Ideas, Politics | No Comments »
Clovid-19 and China's Responsibility
It is clear that Clovid-19 came from China. And the Chinese did not inform the rest of the world concerning many facts of how this coronavirus was released out of a laboratory in the city of Wuhan, and the nature of the virus's capabilities for death and distraction. The following commentary by the Heritage Foundation provides an interesting approach to China now that Clovid-19 has destroyed the world as we know it.
Commentary By
Riley Walters
Riley Walters is a policy analyst in the Davis Institute for National Security and Foreign Policy at The Heritage Foundation.
Dean Cheng
Dean Cheng brings detailed knowledge of China's military and space capabilities to bear as The Heritage Foundation's research fellow on Chinese political and security affairs.
Americans are understandably upset. Businesses are closed, and people's lives and livelihoods are at stake.
It makes sense that people would demand the government take action against those responsible for the spread of the COVID-19 pandemic once we've made it through.
Here's how—and how not—to hold China accountable for the new coronavirus.
>>> When can America reopen? The National Coronavirus Recovery Commission, a project of The Heritage Foundation, is gathering America's top thinkers together to figure that out.
As of right now, for very good reason, the Chinese Communist Party is culprit No. 1. However, it won't be so easy getting it to fork over restitution.
There's the reality that nations are generally not able to be sued, under the concept of "sovereign immunity." While there are some exceptions, it would require the construction of a very tight case, in this case against the Chinese Communist Party.
In these trying times, we must turn to the greatest document in the history of the world to promise freedom and opportunity to its citizens for guidance.
To build such a case, policymakers would need to answer three important questions:
Who exactly is responsible for the COVID-19 outbreak? Meaning, who in the Chinese Communist Party is responsible for suppressing the information that heroes such as Dr. Li Wenliang tried to share with the world before COVID-19 grew rampant?
What exactly are they guilty of? Meaning, is the Chinese Communist Party simply guilty of the suppression of information? Are they also guilty of not acting soon enough? What else, exactly?
How do we even begin to calculate the restitution owed to the U.S.? Some estimates suggest that the coronavirus has generated losses of as much as $4 trillion. That's roughly one-third of China's economy.
Perhaps because of the complications with a legal case, folks are talking about ways to make China "pay" in other ways. Many of the ideas are lacking a dose of reality.
Here's how we should not hold China accountable:
Refuse to pay Chinese holders of U.S. debt. As of January, Chinese investors held $1.1 trillion worth of U.S. Treasury securities (debt). Chinese holders of U.S. debt (both private and government entities) account for more than 15% of total foreign holders of U.S. debt, but only a fraction of total public debt.
If there is one thing that would destroy the credibility of the American dollar and the American financial system, it would be to raise any doubts about the American commitment to meeting its financial obligations.
Such a threat would shatter the faith of every holder of American debt, not just the Chinese.
After all, if the U.S. could suddenly decide not to pay Chinese holders of American debt, what would keep us from doing the same to the Saudis? Or the Japanese? And that, in turn, would effectively end the role of the American dollar as the global reserve currency. This is truly one case where the cure would be worse than the disease.
Get U.S. companies to leave China and come home. Some suggest COVID-19 is a great opportunity to bring U.S. companies back from China. The problem is that while some companies might leave China (and there could be incentives to encourage them to do so), few would then relocate back to the U.S.
Companies went to China in pursuit of cheaper costs, and COVID-19 doesn't change that. Most of the companies that are leaving China won't be coming to the U.S. They'll more likely be going to Vietnam or Mexico, or many other places.
Kick out all Chinese news reporters. This has little to do with China's suppression of information about the COVID-19 virus, and more to do with China's overall suppression of a free press.
After all, it wasn't Chinese reporters in the U.S. that failed to report on COVID-19 developments in China.
Kicking China's reporters out of the U.S. would simply justify China's ejection of American journalists, to little effect on the pandemic (other than limiting what unrestricted information is available).
Decouple entirely from the Chinese economy. Some suggest the U.S. should have no business with China whatsoever. But China was our fourth-largest trading partner in 2019, with $560 billion worth of traded goods.
Historically, U.S. and Chinese investors have directly invested more than $150 billion in each other (about twice as much U.S. direct investment in China than vice versa). Subsidiaries of U.S. companies sell hundreds of billions of dollars of goods in China every year on top of what they export there from the U.S.
These benefits would be hard to give up. Are there costs of doing business in China? Yes. But businesses are there because there are also benefits.
There are more realistic ways to put the Chinese Communist Party's feet to the fire and hold it accountable.
A human rights approach. Sanctioning specific individuals for specific rights violations can be more successful than trying to punish a nation of 1.4 billion people.
An international approach with allies. This includes taking international legal action as another possibility. Legal scholar James Kraska has laid out one such approach. But litigation could take years and still lack the desired effect Americans might want to see this year.
Public diplomacy. It will take some patience and not have the visibility of legal action. That is to say, legal action would feel good up front, but would take years to maybe reach results, and then only if accompanied by painstaking diplomatic work.
Diplomacy includes keeping the spotlight on the Chinese Communist Party and the nefarious impact it has on the world. Results may vary, but doing this and letting people and governments around the world take matters into their own hands will have a lasting effect.
The truth is that this virus has given the Chinese Communist Party a big black eye and right now the Chinese are doing all they can to shift the blame or obfuscate the truth.
The Trump administration is likely to continue pushing back against China's efforts to reshape the international narrative, much like we've seen the U.S.-China competition across the international arena.
But the outbreak of COVID-19 doesn't change that the People's Republic of China will be our most persistent and consequential U.S. foreign-policy challenge for the next several decades.
There might be right ways to hold the Chinese Communist Party accountable for the COVID-19 outbreak and its other misdeeds. But there are also wrong ideas that undermine U.S. long-term interests.
Let's not mix those up.
Posted in ecomomics, Foreign Policy, New Ideas, Politics | No Comments »
As I already have indicated, I believe that the world is in one of its most deadly times, a truly enormous cascade of events that have changed human lives forever. Indeed, we are living through what might well be considered a tale of horror. My close friend, Doctor Stephen Dubel, has recently dissected Poe's great poem of revulsion and terror, and here it is :
Ah, yes. Nevermore, nevermore, shall we see our world as it once was. It shall be different, it will seem strange. And all around us, nevermore!
Posted in Favorite Authors and Books, Literature, New Ideas, Sci-fi/Horror | No Comments »


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23 TV Moments From This Week That We Can't Stop Talking About
Orange Is the New Black, Jane the Virgin, Andi Mack, and iZombie all ended.
🚨Obviously MASSIVE spoilers ahead!🚨
1. First, the Jane the Virgin series finale featured Jane and Rafael's wedding and Jane revealed the ending of her novel.
2. Also on Jane the Virgin, Petra and J.R. got back together after Rafael called J.R. and told her Petra still loved her.
3. And, Jane the Virgin FINALLY revealed that Mateo has been the Narrator the entire time — honestly, it was a flawless series finale.
4. The Andi Mack series finale featured T.J. and Cyrus becoming a couple, which makes them Disney Channel's first openly gay teen couple.
Earlier this year, Cyrus became the first Disney Channel character to say the words "I'm gay."
5. The final season of Orange Is the New Black started streaming and featured a heartbreaking storyline involving an I.C.E. detention center.
6. Also on Orange Is the New Black, we have to give a shoutout to Danielle Brooks and Natasha Lyonne, who gave heartbreaking performances as Taystee and Nicky.
During the final season, Taystee contemplated attempting suicide while Nicky dealt with Red's dementia and Lorna's mental illness.
7. And, Orange Is the New Black ended with the return of some beloved characters when Alex was transferred to a prison in Ohio.
8. The 100 said goodbye to an original character when Abby was killed in order to resurrect Simone, one of the Primes.
9. The Handmaid's Tale was shockingly uplifting when Fred was arrested after he crossed over into Canada in an attempt to get Nichole. What was even sweeter was that Serena Joy set him up. Praise be.
10. Also on The Handmaid's Tale, June killed Commander Winslow after he attempted to rape her while she was at Jezebels.
11. On Agents of S.H.I.E.L.D., Daisy learned that as Sarge's powers increase each time he's killed, more of Coulson's memories return.
12. On the iZombie series finale, Liv, Ravi, Clive, Major, and Peyton succeeded in finally getting a zombie cure to the people of New Seattle.
Ravi and Peyton, who was turned into the zombie during the finale after being fatally shot, both took the cure along with most of the zombies in Seattle.
13. Also, iZombie ended with a 10-year time jump where we learned that Liv miraculously survived an explosion at the morgue and reunited with Major. Meanwhile, Ravi, Peyton, and Clive moved out of Seattle and kept Liv and Major's survival a secret.
Liv and Major remained zombies and finally made Zombie Island a reality. They live there with the orphans Liv took in during the final season. A perfect happy family.
14. On Euphoria, after Rue realized that Nate was Tyler, she wanted Fez to threaten him. Fez confronted Nate, which led to Nate calling the cops on him.
Basically, Nate continues to be THE WORST.
15. Also on Euphoria, Cassie learned that she's pregnant and heartbreakingly told McKay.
16. On Good Trouble, Davia confessed to Alice that she loves Dennis and I'm very emotional about it.
17. Also on Good Trouble, Gael learned that Jamie was the one who purchased his painting and confronted Callie about it — this sets up next week's summer finale.
18. Mindy Kaling's TV adaptation of Four Weddings and a Funeral started streaming on Hulu. The pilot alone was filled with numerous classic rom-com references.
19. Also on Four Weddings and a Funeral, Andie MacDowell guest starred as Ainsley's mother — of course, Andie starred in the original 1994 movie.
Hulu, Rank Film Distributors
20. The Boys started streaming on Amazon this week. The new series is based on comic books of the same name and follows a group of vigilantes who set out to take down corrupt superheroes who abuse their superpowers.
The series stars Karl Urban, Jack Quaid, Chace Crawford, and Karen Fukuhara.
21. On Younger, Enzo proposed to Diana, who happily accepted.
22. On Pose, Angel and Lil Papi's romance finally kicked it into gear after Angel booked a modeling gig.
23. And finally, on Grown-ish, Aaron continued his "Black Minds Matter" movement by hosting an amazing gala that featured an appearance by Joey Bada$$.
Also in the episode, Doug and Sky adorably said "I love you" for the first time.
What were your favorite TV moments this week? Tell us in the comments below!
Obsessed with all things TV and movies? Check out all of our TV & Movies coverage here!

redpajama_set_name: RedPajamaCommonCrawl


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Calum Best
Calum Best on why he's 'still f*****g single' but refuses to say he's unlucky in love
EXCLUSIVE: The reality TV regular says he's looking to find the one on Celebrity Ex On The Beach - and won't give up until he does
Vicki NewmanSenior Celebrity Reporter
Keep in touch with news on your show faves and when Love Island is back with our weekly newsletter
Calum Best says he signed up for Celebrity Ex On The Beach because he's "still f*****g single".
The reality TV regular, 38, has appeared on a host of dating shows, including Celebrity Love Island and Celebs Go Dating.
Now, he's taking part in his 44th reality series in the hope of finding true love at last.
But despite his string of failed relationships, the hunky son of late footballer George Best refuses to describe himself as unlucky in love.
During an exclusive chat with Mirror Online, Calum explained why he decided to take part in MTV's new all-star version of its hit show.
Calum is heading into Celebrity Ex On The Beach (Image: Instagram)
Why Ellie Brown turned down Geordie Shore and her secret connection to Sophie Kasaei
Michael Griffiths almost turned down Celebrity Ex On The Beach over bad boy Love Island image
He told us: "I'm doing it because I'm still f*****g single and in the hope of finding someone and the hope that this might be the one.
"The thing is, if I can't find a f*****g Mrs in my private life then I'm going to try elsewhere. I remember I was once told, if opportunities come your way take them and if they're opportunities that are with the best intentions then go for it and this came about.
"I hadn't worked with MTV for about 15 years and I decided to do it for two reasons, I thought hopefully I can find someone or I could rekindle something with somebody, but I also thought entertainment wise that Love Island were looking to do a celebrity version and fans wanted it but they weren't going to do it and MTV decided to do it in their own style and I'm all over it."
The cast of Celebrity Ex On The beach (Image: MTV)
During his time on the show, Calum came face to face with his ex Marissa Jade.
His run in with the former Mob Wives and Celebrity Big Brother star is said to have been an explosive one.
He said: "Well you can imagine. So I knew with my track record and my past reputation that it could go one way.
"I was the last person to walk in and I walked round the corner and the first person to make eye contact with me was Marissa, and I was like, 'Oh my God, from day one I'm in here with an ex and I've got four weeks in this place'.
"But she's a grown woman, she knows how to handle it and is a pro in TV and she's a good girl but there was a lot of awkwardness between us. We squashed it and we're good friends, I've got a lot of time for her."
Love Island's Michael Griffiths admits he doesn't regret what he did to Amber Gill
Caulm wants to find Mrs Right (Image: Instagram)
Calum admitted that having so many exes left him in a tricky situation more than once, with him being sent down to the beach by the Tablet of Terror to meet a mystery arrival more than anyone else on the show.
But he said despite all of his failed romances, he refuses to say he's unlucky in love.
He told us: "I don't think I'm unlucky in love. The thing is for me, I've been single for so long but it's by choice and I don't want to settle unless it's right.
"I'm at an age now and I've dated so much in my past like in my f*****g 20s I was all over the place, but now unless it ticks all the boxes, without being a diva about it, then I'm going to stay single until it's right.
He comes face to face with ex Marissa Jade (Image: Rex Features)
"I know there's a Mrs Right for me, there's got to be, and I'm willing to try a few more situations until it works.
"I still enjoy being single, there are things about it that I really love like getting to do these shows but at the same time I've got a lot to give and when you go into a show like this you're looking for love even if people say that's not what you should do.
"But I've tried nightclubs, I've tried Wholefoods, I've done the gym, so you're like what can MTV bring to the table? Let me see what they can do that I've not been able to do."
* Celebrity Ex On The Beach starts at 10pm on January 21 on MTV
Do you have a story to sell? Get in touch with us at webtv@trinitymirror.com or call us direct 0207 29 33033


This is part 4 of 5 additional posts to the original idea.
Ability to easily email/upload videos from cell phone, email, or web browser. (Make the videos with your cell phone, webcam, camera, or video camera).
Videos converted into multiple formats – ability to post on your website/blog/MySpace Profile; send to your cell phone, send to your friend's cell phone, send by email, download to your iPod Video player, or compile a bunch in a playlist on our site and get them in a format ready for burning to a DVDR. Also have ability to do all of the above with videos by others on our website, because every video on our website is public.
Each video will have the audio extracted, turning those into custom ringtones. Thus if you see a video with great audio, then you could send that to your cell phone as a ringtone, free!
Ability to easily record video on your cell phone and then email to us, then we send you an AOL Instant Message instantly with the HTML code for posting it in your MySpace profile, or as a comment to someone's MySpace profile.
Our Community — Tons of current topics to give your video opinion about, such as – What did you think of King Kong the movie? What did you think of that NCAA championship football game last night? What do you think about the new XBOX 360? If you were going to buy a digital camera, what would you suggest? Who serves the best pizza in your city?
Specific daily themes — everyone has 24 hours to create a video related to the same subject/theme. The next day, everyone rates the videos, and on the third day winners are announced and prizes awarded! You don't have to be a great film producer, you just need to be a bit creative — and everyone has the same amount of time, so it's a leveled playing field!
Purchase misspelled domains of MySpace, VidiLife, YouTube; redirect traffic to us.
Target Google AdWords campaigns to site-specific (do search for 'myspace', 'youtube', 'video hosting' and other phrases, find websites that get high ranking and purchase advertising on them). Also see what other ad networks these websites that relate to our website are using and try to get our ad on them — such as www.bigoo.ws, this caters to MySpace users looking for editors, graphics, etc.
Hire savvy college students to plow through MySpace, Friendster, etc, profiles and find users that have 200+ friends ("social influencers") or are using video. Have our employees invite these "social influencers" to be the first users of our website, and allow them to hand-out exclusive invites to their friends. Those that have the most friends sign-up and/or most videos getting posted by themselves and friends, will win prizes — daily!
3a) Once we contact these "social influencers" (in MySpace, Friendster, etc), then we tell them they are a VIP to our service (yes, because they have tons of friends in MySpace and we respect that) and that if they post 10 video commentaries per week for next 4 weeks (get them to keep coming back to the site and becoming involved) relating to our "video opinion subjects", then we'll give them X. (X might be magazine subscriptions, iTunes gift certificate, etc) Maybe we also entice them to invite their friends (or maybe just through our system, but tell them that we're hoping they'll tell their friends, but not going to force them to; we think our website is great and you'll want to get your friends involved).
Create Flash-based ads that can be automatically updated daily on websites that display the ads, and have the new "daily video contest theme" in the ad, with quick info on what it is and how the browser can participate in it (and our website).
Gimmicks to get in the Press — align with a music superstar, or a bunch of them (maybe create a monthly theme for creating the next music video for that band). Align with a movie house (New Line Cinema) to help promote one of their movies, in exchange for a press release and free PR. Get music videos posted on our site. Get exclusive video posted — team up with NBC, ABC, or CBS in regards to a popular show (or even a popular "indie" show that isn't on the major networks). Team up with established online sources — such as some website that reviews movies and Oscars; get a counter promotion going ("you guys promote our site for allowing your visitors to post their own video comments on nominees and results, and we'll promote you as the source for the Oscars" or for a sports website, or for a poker website, etc).
e a video displays, it has our branding through-out the video, as well as at the end of the video (a 3-second branding clip). Comment videos in MySpace will allow viewers to then submit their own comment on top of that video comment by easily sending their video comment to a specified email address in the video comment they just viewed. This continues, allowing tons of people to keep commenting on something. Becomes viral.
Google AdSense (or Overture PPC ads) — as we get specific webpages relating to specific topics (i.e. "Where's the best pizza in Boston?" or "What did you think of the 40-year Old Virgin movie?" or "What do you think of the new Kanye West album, Late Registration?"), then there will be more specific PPC ads relating to those subjects, resulting in higher CPC revenues.
Sponsorships — if the video theme daily contests take off, then we'll be able to charge Coca-Cola to have their brand or a product utilized as the daily theme.


There is a common misconception that, because of their belief in equality, most Quakers assisted fugitive slaves and involved themselves in civil rights activism. While there were Friends committed to ending enslavement and post-enslavement injustices, this study of Quaker history reveals that racism has been as insidious, complex, and pervasive among Friends as it has been generally among people of European descent. The book documents the spiritual and practical impacts of discrimination in the Religious Society of Friends in the expectation that understanding the truth of our past is vital to achieving a diverse, inclusive community in the future.


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GUNASH
GUNASH was born in 2003 from an idea by singer/guitarist Ivano L. Zorgniotti alias "Zor" and drummer/percussionist Danilo Abaldo alias "Pannico" as a cover band with different name and staff, little by little it tended towards an Alternative Rock influenced by grunge, stoner, punk, metal and prog (Nirvana, Soundgarden, Queen Of The Stone Age, Faith No More, Foo Fighters, King Crimson, etc…) and inspired by Seattle Sound in their musical compositions and styles.
At the end of 2005, Gunash published a homonymous album for the Italian Label New LM Records (Crotalo Edizioni Musicali) from Ravenna, which is followed by an activity of Live concerts and composing new original songs.
Since 2008 the line-up has been consisted of singer/guitarist Ivano L. Zorgniotti alias "Zor", who busies himself with figurative art too, of solid bassist Mauro Ippolito alias "Marlo" and of drummer/percussionist Danilo Abaldo alias "Pannico". Occasionally, violoncellist Marco Allocco, experienced musician who played in the Pavarotti's Orchestra, joins it.
In 2012 Gunash come again in Studio for the production of the second album, titled
"Same Old Nightmare", a concept album with 12 original songs and with the extraordinary contribution of the American musician RAMI JAFFEE, keyboardist of Foo Fighters, founder with Jacob Dylan of The Wallflowers and involved in recording projects winners of several Grammy Awards.Rami recorded at his Fonogenic Studio in Los Angeles and his colorful Hammond B3 has enriched the sound of Gunash.
In 2014 the album "Same Old Nightmare" is published and distributed by the prestigious independent Record Label Go Down Recordsand then the Gunash begin the promotional tour "Same Old Nightmare Tour," during which the Gunash participate in numerous Festivals, including the "Home Festival" in Treviso (Italy), along with international artists in the line-up.
The album starts playing on European Radios, but also on American College Radios, thanks to the collaboration of the band with the Planetary Group from Los Angeles and in n 2015 Gunash continue "Same Old Nightmare Tour" with several concerts in Italy, Spain, France, Switzerland and the United States, and a mention for the Show like headliner at the legendary Whisky a Go Go in Los Angeles.During the American Tour Gunash record 3 singles for the third album with the featuring of Rami Jaffee, at the Fonogenic Studios in Los Angeles and they release the video for the single "Need To Bleed", video recorded during the Whisky a Go Go show in Los Angeles with the collaboration of the famous Californian photo agency TourBusLive.
In 2016 the band finished the recording of the third album "Great Expectations" at the Go Down Records Studio in Savignano sul Rubicone (FC - Italy) with Rami Jaffee like keyboardist, but also like Artistic Producer.
The third album is released for Go Down Records the 1st April 2017.During the August 2016 Gunash published with Go Down Records the EP "SuperHeroes In Town", which contains the 3 singles recorded in Los Angeles, at the Fonogenic Studios of Rami Jaffee and Ran Pink, then Gunash and Rami played some shows in Italy.
Meanwhile, after months of work and with the involvement of more than 80 people, the Band and Rami Jaffee realised, with the video productions label Babylon Film, The Official videoclip of the single "Death Comes". The new videoclip is released in International Premiere the 20th February 2017.
The third album for Go Down Records released in April 2017 in CD, Classic Vinyl, Limited Edition white Vinyl and Digital format.
From April 2017 the Gunash launches with the "Great Expectations Tour", with the first release date and Release Party in the historical Mezzago (MB - Italy) Bloom Concert Hall. In ten months of Tour the band has realized 45 dates.
"Great Expectations" is greeted enthusiastically by the specialized press and major magazine and Rock websites expressing flattering judgments and excellent reviews on the quality of the new studio work with the artistic production of Rami Jaffee of Foo Fighters. The single "Death Comes" includes numerous radio passes, exceeding one million radio plays (certified data Radio Airplay Italy v2) and the Band participates in several interviews in radio music programs at national and international level.In June 2018 the Gunash and Rami Jaffee come out on the famous ROLLING STONE France magazine with the album "Great Expectations" and the videoclip of the single "Death Comes".
The album "Great Expectations" is getting great reviews from the specialized press and numerous Radio passes (currently the single "Death Comes" almost 1,000,000 of Radio plays) and some North Italy's Fans founded the Gunash Fan Club which currently has more than 500 members.In July 2018 Gunash began the collaboration with the new bass player Luca Negro (Temperance, Even Flow, Rockin'1000), a musician of great experience and professionalism, who goes on to define the new line-up in the Gunash Power Trio.In the summer of 2018 the Gunash made the "Great Expectations Electro-Acoustic Summer Tour" and on August 6th 2018 they played in Treviso (Italy) with the legendary bassist NICK OLIVERI (Queen of the Stone Age, Kyuss, Mondo Generator), for his "Death Acoustic Summer Tour", with the collaboration of the Heavy Psych Sounds Records.
After the success of the album and of the tour, the Band decided to continue the "Great Expectations Tour", after more than 80 shows in the last two years and in the 2019 Gunash played w/ JOHN CORABI (Motley Crue, The Dead Daises) and toured in Italy with the American musician from Los Angeles, legend of the rock/folk music, JONNY KAPLAN and with Rami Jaffee of Foo Fighters too. In 2020 Gunash continue their Shows and their collaboration with NICK OLIVERI. In February on the same year they share the stage with Nick's band Mondo Generator at the historic live club "Brin de Zinc" in Barberaz (France). During the show, Gunash and Nick Oliveri present an exclusive Live preview of the single from the new album with Nick.
Currently the Gunash are working on the production of the fourth album, which will always be recorded with the collaboration of Rami Jaffee of Foo Fighters and Nick Oliveri. For the new album the Band has signed with the prestigious first class independent Record Label Golden Robot Records (GRR Entertainment Group) and always with the support of Go Down Records, in order to create a successful international cooperation.
The band's name is a pun between Ganesh (the Indian divinity with elephant head, god of knowledge and patron of letters and arts), Gunas, that are the four phases of the transforming matter for the Indian Alchemy and the fusion of the English words Gun and Ash; after all, a mix of spirituality and esotericism with the gloomy contradiction given by the two Anglo-Saxon terms, as to intend to show that every concept implies its opposite.
Ivano "Zor" Zorgniotti | lead singer, guitars
Danny Abaldo "Pannico" | drums, percussions, sampler, scream
Luca Negro | bass, backing vocals
feat. Rami Jaffee (Foo Fighters) | keyboards
feat. Nick Oliveri (Queens of the Stone Age) | vocals
Great Expectations - Gunash (Golden Robot Records - Album)
Same Old Nightmare (feat. Rami Jaffee) - Gunash (Golden Robot Records - Album)
Gunash - Gunash (Golden Robot Records - EP)


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 Book Hotel La Casa Rosa (Santa Cruz la Laguna) - 2019 PRICES FROM $76!
Located in a beautiful garden, in the shores of the Atitlan Lake, Hotel La Casa Rosa has attractive rooms and bungalows that offer a splendid view to the lake, the volcanoes or the mountains that surround the place. Some of the attractive activities you can have here are fishing, hiking or yoga. Guest may also relax with a soothing massage or with the sauna. In the main building you can find the restaurant that will provide its guests with local, international and Asian food. The colorful rooms have traditional and rustic-style furniture and beamed ceilings. Guests can only access to La Casa Rosa by boat, which they can take from Tzanjuyú dock in the Panajachel area. The travel will take about 20 minutes until you reach the hotel dock.
Guests may arrive by boat only, which they can take from Tzanjuyú dock in the Panajachel area. They will arrive into the Santa Cruz dock, located 164 feet away from the hotel. Please inform Hotel La Casa Rosa of your expected arrival time in advance. You can use the Special Requests box when booking, or contact the property directly using the contact details in your confirmation. Payment before arrival by bank transfer is required. The property will contact you after you book to provide instructions.


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Grace Your Home with an Antique Game Table
Today when someone talks about getting a game table, they are often referring to pool, ping pong, air hockey or foosball. But most of these types of games have not been around for very long, and some are as new as the 1970's! But you can find antique game tables, and they are very nice, stylish and collectible. But they cannot be used for table tennis, hockey or foosball!
Most antique game tables are smaller than what we think of today, and are made of wood. Some were also quite ingenious. One I found was a beautiful mother of pearl and ebony table made in China in the mid 19th century. It was wonderfully inlayed with detailed oriental scenery and figures. This game table had a single, three footed leg, though most I found had the traditional four legs! The sides of the table curved inwards and the corners were rounded and fancy. The center of the table had a removable chess board on one side, and the table design on the other. When the chess board was removed, a recessed backgammon board was revealed on the inside of the table, and there was also a small drawer for storing game pieces.
The idea of a removable chess board with a recessed backgammon board underneath was not unique. Another game table I found was similar, but had some other unique features. This second table is round, made out of hardwood with a light finish and a beautiful inlay design. It has two drawers and, more unusual, four drink holders that pull out from the sides. This style table is heavily reproduced.
Many square or rectangular tables opened up to reveal a felt playing surface underneath, perfect for cards. Though a game table like this was similar in function to many others, they did come in many different styles. With a bit of searching, I found one from the French Napoleon III period from the 1860's with a black lacquer and gilt bronze finish. Another one I found was a rare English table made of solid walnut with a burl finish. Not as fancy, but still elegant.
Another French table that I found was a mahogany table from the Jacob period of the early 19th century. This game table appeared to be a small writing desk with a gold-embossed leather writing surface. But the top could be flipped over to expose a green felt card playing table, or the top could be completely removed and inside was found an ebony and ivory inlaid backgammon board. This great table also still had the original white and green tinted ivory playing pieces.
Though, I would have to say that the most deluxe and versatile table I found was from 19th century Paris. At first glance, this table looks like an ordinary side table, measuring 31" wide by 26" deep, with beautifully carved legs with casters and leg supports. But the table conceals multiple playing boards for backgammon and chess or checkers, as well as a pull out roulette wheel! But that is not all, this game table has more. The legs pull out to extend the table to a full 93", what appears to be a decorative part of the legs becomes the middle leg support. The table top then unfolds to a long, rectangular felt top, which I believe is for a form or carrom or billiards. This is a really cool table!
So, if you are in the market for a game table, perhaps you need the modern version that invites rowdy game play for the whole family. But perhaps your life has quieted down and you mainly enjoy cards and some board games with friends. Then perhaps you should look around for an antique game table to grace your home and impress your friends.
Fun And Functional Decorative Fire Pits View Entry
Interior Design Magazines - Very Useful!


"It has passed for eight years. However, you are still brilliant. I love you, Michael, forever. From Japan, Noriko.
This entry was posted on Saturday, June 24th, 2017 at 5:49 pm. You can follow any responses to this entry through the RSS 2.0 feed.


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She's back.For the two years she's been away at boarding school, there was no word from her. Back when we lived in the same house, she used to cut me down during the day and then leave her door open for me at night.
I'm back.Two years and I can tell he still wants me, even if he acts like he's better than me.
But I won't be scared away. Or pushed down. I'll call his bluff and fight back. That's what he wants, right? As long as I keep my guard up, he'll never know how much he affects me….
Natasha's Experience:The Fall Away Series never fails to test me. I get so conflicted when reading because on one hand, hello bullying is a major no-no for me, but on the other, I'm so far gone for this person that I'm kind of allowing it??? Do you see my dilemma?
BULLY did that to me the entire time and I managed to fall head over heels in love with it. Completely adored every single word that Penelope Douglas put together to form that story.
Now RIVAL? I'm a goner. Utterly lost my mind somewhere between Madoc's antics and Fallon's crazy-intense love/hate relationship with him.
The story progresses perfectly and I really liked how the timing wasn't rushed at all. This really gave me a chance to get connected to Fallon and Madoc and let me feel like I was actually in the book. I loved that Jared and Tate, the two main characters from BULLY, were more than just secondary characters in Madoc and Fallon's story. They added so much to this book and I loved seeing them from a different POV.
Fallon is incredible. I love her character. She's strong as hell and fights back just enough. I also love how vulnerable she is and how even she knows her limits and eventually does what's best for herself.
My heart is already hurting and can't wait to read FALLING AWAY, the third book in this series. I've got to mentally prepare myself for that one, I can tell.


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Hearing loss is being partly or totally unable to hear sound in one or both ears.
Symptoms of hearing loss may include:
Certain sounds seem overly loud in one ear
Difficulty following conversations when two or more people are talking
Difficulty hearing in noisy areas
Trouble telling high-pitched sounds (such as "s" or "th") from one another
Less trouble hearing men's voices than women's voices
Hearing voices as mumbled or slurred
Feeling of being off-balance or dizzy (more common with Ménière disease and acoustic neuroma)
Feeling of pressure in the ear (in the fluid behind the eardrum)
Ringing or buzzing sound in the ears (tinnitus)
Conductive hearing loss (CHL) occurs because of a mechanical problem in the outer or middle ear. This may be because:
The 3 tiny bones of the ear (ossicles) are not conducting sound properly.
The eardrum is not vibrating in response to sound.
Causes of conductive hearing loss can often be treated. They include:
Buildup of wax in the ear canal
Damage to the very small bones (ossicles) that are right behind the eardrum
Fluid remaining in the ear after an ear infection
Foreign object that is stuck in the ear canal
Hole in the eardrum
Scar on the eardrum from repeated infections
Sensorineural hearing loss (SNHL) occurs when the tiny hair cells (nerve endings) that detect sound in the ear are injured, diseased, do not work correctly, or have died. This type of hearing loss often cannot be reversed.
Sensorineural hearing loss is commonly caused by:
Childhood infections, such as meningitis, mumps, scarlet fever, and measles
Ménière' disease
Regular exposure to loud noises (such as from work or recreation)
Use of certain medicines
Hearing loss may be present at birth (congenital) and can be due to:
Birth defects that cause changes in the ear structures
Genetic conditions (more than 400 are known)
Infections the mother passes to her baby in the womb (such as toxoplasmosis, rubella, or herpes
The ear can also be injured by:
Pressure differences between the inside and outside of the eardrum, often from scuba diving
Skull fractures (can damage the structures or nerves of the ear)
Trauma from explosions, fireworks, gunfire, rock concerts, and earphones
You can often flush wax buildup out of the ear (gently) with ear syringes (available in drug stores) and warm water. Wax softeners (like Cerumenex) may be needed if the wax is hard and stuck in the ear.
Take care when removing foreign objects from the ear. Unless it is easy to get to, have your health care provider remove the object. Don't use sharp instruments to remove foreign objects.
See your provider for any other hearing loss.
Call your provider if:
Hearing problems interfere with your lifestyle.
Hearing problems do not go away or become worse.
The hearing is worse in one ear than the other.
You have sudden, severe hearing loss or ringing in the ears (tinnitus).
You have other symptoms, such as ear pain, along with hearing problems.
You have new headaches, weakness, or numbness anywhere on your body.
What to Expect at Your Office Visit
The provider will take your medical history and do a physical exam.
Tests that may be done include:
Audiometric testing (hearing tests used to check the type and amount of hearing loss)
CT or MRI scan of the head (if a tumor or fracture is suspected)
The following surgeries may help some types of hearing loss:
Eardrum repair
Placing tubes in the eardrums to remove fluid
Repair of the small bones in the middle ear (ossiculoplasty)
The following may help with long-term hearing loss:
Safety and alert systems for your home
Learning techniques to help you communicate
Sign language (for those with severe hearing loss)
Cochlear implants are only used in people who have lost too much hearing to benefit from a hearing aid.
Decreased hearing; Deafness; Loss of hearing; Conductive hearing loss; Sensorineural hearing loss; Presbycusis
Ear anatomy
Arts HA. Sensorineural hearing loss in adults. In: Flint PW, Haughey BH, Lund V, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 150.
Baloh RW, Jen JC. Hearing and equilibrium. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 428.
Bauer CA, Jenkins HA. Otologic symptoms and syndromes. In: Flint PW, Haughey BH, Lund V, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 156.
Eggermont JJ. Types of hearing loss. In: Eggermont JJ, ed. Hearing Loss. Cambridge, MA: Elsevier Academic Press; 2017:chap 5.
Lonsbury-Martin BL, Martin GK. Noise-induced hearing loss. In: Flint PW, Haughey BH, Lund V, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 152.
National Foundation for the Deaf website. Helpful resources. www.nfd.org.nz/hearing-matters. Accessed October 23, 2018.
Shibata SB, Shearer AE, Smith RJH. Genetic sensorineural hearing loss. In: Flint PW, Haughey BH, Lund V, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 148.
Updated by: Josef Shargorodsky, MD, MPH, Johns Hopkins University School of Medicine, Baltimore, MD. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team. Editorial update 10/23/2018.
Hearing Disorders and DeafnessRead more


Favorite Places in Paris | One quality, the finest.
All the phone numbers here are in the French format. If you are calling from outside of France, add the country code and drop the first 0. For the United States, for instance, the country code is 33.
Tea Room at the Musée Jacquemart-André 158 bd. Haussmann, 75008 Tel.: 01 01 45 62 11 59 Hours: 11:45 AM to 5:30 PM (lunch from 11:45 AM to 3 PM and snacks from 3 PM to 5.30 PM). Brunch is served each Saturday and Sunday from 11 AM to 3 PM. Late night opening on Mondays and Saturdays until 7 PM during exhibitions.
Musée Jacquemart-André 158 blvd. Haussmann, 75008 Tel.: 01 01 45 62 11 59 Hours: every day from 10 AM to 6 PM. Late night opening on Mondays and Saturdays until 8:30 PM during exhibitions.
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You forgot to state that the delicious dessert pictured at the top of the article is from the Polidor.