Category: Covid-19

The “Gold Standard” of Randomized Clinical Trials “Has Its Own Issues”

(p. R2) . . ., closely held Epic Systems Corp., maker of one of the most widely used electronic health record systems, searched a segment of its database in the spring of 2020 to find that routine breast, colon and cervical cancer screenings in the U.S. had each dropped by more than 85% during the first weeks of the Covid-19 pandemic. The report helped spur efforts to persuade people to make up for missed screenings.

But researchers have a much more ambitious vision for this data: to help guide how doctors treat individual patients in real time.

“The evidence from real-world data is a different and exciting new path,” says Jackie Gerhart, a physician who works with the informatics team at Epic. “You can get a lot of outcomes information from medical records that can help change care for individual patients.”

. . .

To be sure, patient records are observational, and thus subject to confounders and other shortcomings that can undercut their reliability in pointing to treatment options.

But the gold standard has its own issues. Randomized clinical trials, which control for differences in patient health status and other variables, are the preferred evidence to inform patient care. Yet such trials generally exclude an especially common group of patients—those with multiple ailments. Moreover, the elderly, children, women, minority groups and people who live far from medical research centers have long been underrepresented in such studies.

As a result, the highest-quality evidence that medicine produces doesn’t apply to most patients doctors see in daily practice. “There are so many clinical situations where the evidence that is needed does not exist,” says Nigam Shah, professor of medicine and biomedical data science at Stanford University Medical School.

Researchers have believed for at least a half-century that data in patient medical records could help fill the gaps.

. . .

The struggles of International Business Machines Corp.’s Watson raises [a] . . . yellow flag. It had ambitions to develop a tool for cancer doctors that would mine patient health records and thousands of pages of research from the peer-reviewed medical literature for treatment advice. But it hit walls, including accuracy and the complexity of combining data from electronic health records, billing claims and published research to provide a cohesive product. Doctors who used the service rarely changed treatment plans. IBM says it discontinued Watson for Oncology at the end of 2020.

For the full story, see:

Ron Winslow. “Mining the Gold in Patient Records.” The Wall Street Journal (Thursday, December 9, 2021): R2.

(Note: ellipses, and bracketed word, added.)

(Note: the online version of the story has the date December 3, 2021, and has the title “Medical Records Data Offers Doctors Hope of Better Patient Care.” In a couple of passages there are a few extra words in the online version, which is the version quoted above.)

Johan Hultin Self-Funded Trip to Find 1918 Flu Virus in the Permafrost

(p. B9) Dr. Hultin’s quest to find victims of the 1918 flu was sparked in 1950 by an offhand remark over lunch with a University of Iowa microbiologist, William Hale. Dr. Hale mentioned that there was just one way to figure out what caused the 1918 pandemic: finding victims buried in permafrost and isolating the virus from lungs that might be still frozen and preserved.

Dr. Hultin, a medical student in Sweden who was spending six months at the university, immediately realized that he was uniquely positioned to do just that. The previous summer, he and his first wife, Gunvor, spent weeks assisting a German paleontologist, Otto Geist, on a dig in Alaska. Dr. Geist could help him find villages in areas of permafrost that also had good records of deaths from the 1918 flu.

After persuading the university to provide him with a $10,000 stipend, Dr. Hultin set off for Alaska. It was early June 1951.

. . .

He removed still-frozen lung tissue from the victims, closed the grave and took the tissue back to Iowa, keeping it frozen on dry ice in the passenger compartment of a small plane.

Back in the lab, Dr. Hultin tried to grow the virus by injecting the lung tissue into fertilized chicken eggs — the standard way to grow flu viruses. He was caught up in the excitement of his experiment, he said, and had not thought about the possible danger of introducing a deadly virus into the world.

“I remember the sleepless nights,” he said. “I couldn’t wait for morning to come to charge into my lab and look at the eggs.”

But the virus was not growing.

He tried squirting lung tissue into the nostrils of guinea pigs, white mice and ferrets, but again he failed to revive the virus.

“The virus was dead,” he said.

Dr. Hultin never published his results but bided his time, working as a pathologist in private practice in San Francisco and hoping for another opportunity to resurrect that virus.

His chance came in 1997, when, sitting by a pool on vacation with his wife in Costa Rica, he noticed a paper published in Science by Dr. Jeffery K. Taubenberger, now chief of the viral pathogenesis and evolution section at the National Institute of Allergy and Infectious Diseases.

It reported a remarkable discovery. Dr. Taubenberger had searched a federal repository of pathology samples dating to the 1860s and found fragments of the 1918 virus in snippets of lung tissue from two soldiers who had died in that pandemic. The tissue had been removed at autopsy, wrapped in paraffin and stored in the warehouse.

Dr. Hultin immediately wrote to Dr. Taubenberger, telling him about his trip to Alaska. He offered to return to Brevig to see if he could find more flu victims.

“I remember getting that letter and thinking: ‘Gosh. This is really incredible. This is amazing,’” Dr. Taubenberger said in an interview this week. He thought the next step would be to apply for a grant for Dr. Hultin to return to Brevig. If all went well, Dr. Hultin might go back in a year or two.

Dr. Hultin had a different idea.

“I can’t go this week, but maybe I can go next week,” he told Dr. Taubenberger.

He added that he would go alone and pay for the trip himself so that there would be no objections from funding agencies, no delays, no ethics committees and no publicity.

. . .

Using the tissue Dr. Hultin provided, Dr. Taubenberger’s group published a paper that provided the genetic sequence of a crucial gene, hemagglutinin, which the virus had used to enter cells. The group subsequently used that tissue to determine the complete sequence of all eight of the virus’s genes.

. . .

Before results from the study of the Brevig woman’s virus were published, Dr. Hultin asked the villagers if they wanted the village to be identified in a news release and a journal article. They might be besieged by media. “Maybe you won’t like that,” he warned them.

The Brevig residents came to a consensus: Publish the paper and identify the village. Dr. Hultin was listed as a co-author.

For the full obituary, see:

Gina Kolata. “Dr. Johan Hultin, 97, Whose Work Helped Map 1918 Pandemic, Dies.” The New York Times (Friday, January 28, 2022): B9.

(Note: ellipses added.)

(Note: the online version of the obituary was updated January 28, 2022, and has the title “Johan Hultin, Who Found Frozen Clues to 1918 Virus, Dies at 97.”)

Gina Kolata devotes a chapter to Hultin’s search for the 1918 flu virus in her book:

Kolata, Gina. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It. New York: Farrar, Straus & Giroux, Inc., 1999.

Instead of Centralizing With C.D.C., the Need for Speed Requires “Clinical and Commercial Labs to Create and Deploy Tests”

(p. A22) The faulty coronavirus testing kits developed by the Centers for Disease Control and Prevention in the early weeks of the pandemic were not only contaminated but had a basic design flaw, according to an internal review by the agency.

Health officials had already acknowledged that the test kits were contaminated, but the internal report, whose findings were published in PLOS ONE on Wednesday, also documented a design error that caused false positives.

. . .

The C.D.C.’s test was designed to detect three distinct regions, or target sequences, of the virus’s genetic material. The test kits contain a set of what are known as primers, which bind to and make copies of the target sequences, and probes, which produce a fluorescent signal when these copies are made, indicating that genetic material from the virus is present.

The primers and probes need to be carefully designed so that they bind to the target sequences and not to each other. In this case, that did not happen. One of the probes in the kit sometimes bound to one of the primers, producing the fluorescent signal and generating a false positive.

“It’s something that should have been caught in the design phase,” said Susan Butler-Wu, a clinical microbiologist at the Keck School of Medicine of the University of Southern California. “That’s one thing that you check for.”

. . .

The bigger lesson, Dr. Butler-Wu said, is that the responsibility for developing diagnostic tests should be distributed more widely during a public health emergency. Rather than relying on the C.D.C. to be the sole test developer, officials could also enlist clinical and commercial labs to create and deploy tests.

“It’s great that there’s all these additional checks in place, but what are you going to do when there’s a new emerging pathogen and we need to respond quickly?” she said. “I don’t think that’s a viable model for responding to a pandemic.”

For the full story, see:

Emily Anthes. “C.D.C. Finds Design Error In Testing Kits It Distributed.” The New York Times Thursday, December 16, 2021): A22.

(Note: ellipses added.)

(Note: the online version of the story has the date Dec. 15, 2021, and has the title “C.D.C. Virus Tests Were Contaminated and Poorly Designed, Agency Says.”)

The PLOS ONE article mentioned above is:

Lee, Justin S., Jason M. Goldstein, Jonathan L. Moon, Owen Herzegh, Dennis A. Bagarozzi, Jr., M. Steven Oberste, Heather Hughes, Kanwar Bedi, Dorothie Gerard, Brenique Cameron, Christopher Benton, Asiya Chida, Ausaf Ahmad, David J. Petway, Jr., Xiaoling Tang, Nicky Sulaiman, Dawit Teklu, Dhwani Batra, Dakota Howard, Mili Sheth, Wendi Kuhnert, Stephanie R. Bialek, Christina L. Hutson, Jan Pohl, and Darin S. Carroll. “Analysis of the Initial Lot of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel.” PLOS ONE 16, no. 12 (Dec. 15, 2021). DOI: 10.1371/journal.pone.0260487.

Due to B Cells, Covid-19 Infection Creates Longer-Lasting Immunity than Does Just Vaccination

(p. D4) . . . among the vaccinated and boosted, getting infected with the Omicron variant also appears to be contributing to a psychological shift, as people realize they have probably gained at least a short-term natural boost to their immune system. Scientists call it “hybrid immunity,” which results from the combined protection of pre-existing vaccine antibodies and natural antibodies from a breakthrough infection.

. . .

A recent study showed that vaccinated health care workers with breakthrough infections had significantly higher levels of antibodies compared to a vaccinated control group that had not had natural infections. Fikadu Tafesse, an immunologist at Oregon Health & Science University who helped conduct the research, said that although the study was done before the Omicron wave, the findings suggest a drastically elevated level of protection after a breakthrough infection.

“Super immunity is maybe an overreach, but we know the most recent studies show there’s hybrid immunity, really due to immune players known as memory B cells,” said Anita Gupta, an adjunct assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. “When some of the short-lived immune cells go away, these memory B cells are going to last a while.”

For the full story, see:

Dani Blum. “Your New ‘Hybrid Immunity’ Isn’t a Superpower.” The New York Times (Thursday, January 27, 2022): D4.

(Note: ellipses added.)

(Note: the online version of the story was updated Jan. 21, 2022, and has the title “I Had Breakthrough Covid. Can I Start Living Like It’s 2019?”)

The “recent study” mentioned above is:

Bates, Timothy A., Savannah K. McBride, Bradie Winders, Devin Schoen, Lydie Trautmann, Marcel E. Curlin, and Fikadu G. Tafesse. “Antibody Response and Variant Cross-Neutralization after Sars-Cov-2 Breakthrough Infection.” JAMA 327, no. 2 (Jan. 11, 2022): 179-81.

Surgical Masks Provide Wearer Modest Protection Against Infection from Covid-19

(p. A17) The first large randomized community-level study, published last month in Science, found that while generic surgical masks provided a modest (about 10%) reduction in the risk of infection from Delta, cloth masks didn’t significantly reduce risk. Masks may be even less protective against an extremely contagious variant like Omicron.

For the full commentary, see:

Daniel Halperin. “Omicron Is Spreading. Resistance Is Futile.” The Wall Street Journal (Tuesday, January 25, 2022): A17.

(Note: the online version of the commentary has the date Jan. 24, 2022, and has the same title as the print version.)

The article in Science mentioned above is:

Abaluck, Jason, Laura H. Kwong, Ashley Styczynski, Ashraful Haque, Md. Alamgir Kabir, Ellen Bates-Jefferys, Emily Crawford, Jade Benjamin-Chung, Shabib Raihan, Shadman Rahman, Salim Benhachmi, Neeti Zaman Bintee, Peter J. Winch, Maqsud Hossain, Hasan Mahmud Reza, Abdullah All Jaber, Shawkee Gulshan Momen, Aura Rahman, Faika Laz Banti, Tahrima Saiha Huq, Stephen P. Luby, and Ahmed Mushfiq Mobarak. “Impact of Community Masking on Covid-19: A Cluster-Randomized Trial in Bangladesh.” Science 375, no. 6577 (Jan. 14, 2022). DOI: 10.1126/science.abi9069.

FDA Takes “Several Months” to Approve Manufacturers’ “Rapid” Test Applications

(p. A1) As rising Covid-19 infections stoked demand for tests across the U.S. in December, California-based LumiQuick Diagnostics Inc. shipped 100,000 rapid tests to a hospital customer—in Germany.

LumiQuick didn’t receive authorization from the Food and Drug Administration to sell Covid-19 tests domestically after waiting several months for a decision.

Some public-health experts said the relatively strict review process is part of a broader failure by U.S. officials and manufacturers to make and distribute enough rapid tests to track the pandemic adequately. Nearly two years into the pandemic, people have struggled to find tests during the holiday season as infections surge again, fueled by the highly infectious Omicron variant.

. . .

(p. A4) “We’ve never gotten the testing situation well instituted in our country,” said Ezekiel Emanuel, co-director of the Healthcare Transformation Institute at the University of Pennsylvania, and a former member of the Biden administration’s disbanded coronavirus advisory board.

. . .

Some U.S. manufacturers said the FDA’s slow review of new rapid tests discouraged them from making products that they weren’t sure they would be able to sell in the U.S. “Without approval we cannot commit,” said Frank Wang, chief executive officer of BioMedomics Inc., a North Carolina manufacturer that applied for authorization in March. The company has sold some tests outside the U.S.

Another test maker, Kaya17 Inc., said it has been waiting on FDA approval for months. “The FDA has to up their game and move faster,” said Sulatha Dwarakanath, the company’s CEO.

For the full story, see:

Austen Hufford and Brianna Abbott. “Slow Test Approvals Blamed for Shortage.” The Wall Street Journal (Friday, Dec. 31, 2021): A1 & A4.

(Note: ellipses added.)

(Note: the online version of the story has the date December 30, 2021, and has the title “Covid-19 Rapid Test Shortages Tied to Slow Federal Action.” The online version says that the title of the print version is “Tests in Short Supply as Approvals Lag.” But my print version (probably the Central Edition) has the title “Slow Test Approvals Blamed for Shortage.”)

COVID-19 Vaccines Were Built on “Decades-Long Efforts to Create Other Vaccines”

Gregory Zuckerman’s The Frackers was a great deep dive into the lives of important non-Silicon Valley entrepreneurs. So far I am also enjoying Zuckerman’s new book, reviewed in the brief passages quoted below.

(p. 26) Zuckerman answers a question still circulating among both vaccine fans and skeptics: How could scientists develop the Covid-19 vaccines so quickly?

The answer is that they didn’t. The Covid-19 vaccines were built on the backs of decades-long efforts to create other vaccines, like one for the Zika virus and, in particular, several failures to develop a useful H.I.V. vaccine.

For the full, but short, review, see:

Eve Fairbanks. “THE SHORTLIST; Covid.” The New York Times Book Review (Sunday, January 9, 2022): 26.

(Note: the online version of the review has the date Dec. 29, 2021, and has the title “THE SHORTLIST; New Books Explore the Many Ways Covid Has Altered Our Lives.”)

The book under review is:

Zuckerman, Gregory. A Shot to Save the World: The inside Story of the Life-or-Death Race for a Covid-19. New York: Portfolio/Penguin, 2021.

Tesla Could Switch Chips By Internally Modifying Software Code that Other Car Companies Had Outsourced

(p. 1) For much of last year, established automakers like General Motors and Ford Motor operated in a different reality from Tesla, the electric car company.

G.M. and Ford closed one factory after another — sometimes for months on end — because of a shortage of computer chips, leaving dealer lots bare and sending car prices zooming. Yet Tesla racked up record sales quarter after quarter and ended the year having sold nearly twice as many vehicles as it did in 2020 unhindered by an industrywide crisis.

Tesla’s ability to conjure up critical components has a greater significance than one year’s car sales. It suggests that the company, and possibly other young electric car businesses, could threaten the dominance of giants like Volkswagen and G.M. sooner and more forcefully than most industry executives and policymakers realize. . . .

Tesla and its enigmatic chief executive, Elon Musk, have said little about how the carmaker ran circles around the rest of the auto industry. Now it’s becoming clear that the company simply had a superior command of technology and its own supply chain. Tesla appeared to better forecast demand than businesses that produce many more cars than it does. Other automakers were surprised by how quickly the car market recovered from a steep drop early in the pandemic and had simply not ordered enough chips and parts (p. 12) fast enough.

When Tesla couldn’t get the chips it had counted on, it took the ones that were available and rewrote the software that operated them to suit its needs. Larger auto companies couldn’t do that because they relied on outside suppliers for much of their software and computing expertise. In many cases, automakers also relied on these suppliers to deal with chip manufacturers. When the crisis hit, the automakers lacked bargaining clout.

Just a few years ago, analysts saw Mr. Musk’s insistence on having Tesla do more things on its own as one of the main reasons the company was struggling to increase production. Now, his strategy appears to have been vindicated.

. . .

“Tesla, born in Silicon Valley, never outsourced their software — they write their own code,” said Morris Cohen, a professor emeritus at the Wharton School of the University of Pennsylvania who specializes in manufacturing and logistics. “They rewrote the software so they could replace chips in short supply with chips not in short supply. The other carmakers were not able to do that.”

“Tesla controlled its destiny,” Professor Cohen added.

. . .

Doing more on its own also helps explain why Tesla avoided shortages of batteries, which have limited companies like Ford and G.M. from selling lots of electric cars. In 2014, when most carmakers were still debating whether electric vehicles would ever amount to anything, Tesla broke ground on what it called a gigafactory outside Reno, Nev., to produce batteries with its partner, Panasonic. Now, that factory helps ensure a reliable supply.

“It was a big risk,” said Ryan Melsert, a former Tesla executive who was involved in construction of the Nevada plant. “But because they have made decisions early on to bring things in house, they have much more control over their own fate.”

As Professor Cohen of Wharton pointed out, Tesla’s approach is in many ways a throwback to the early days of the automobile, when Ford owned its own steel plants and rubber plantations. In recent decades, the conventional auto wisdom had it that manufacturers should concentrate on design and final assembly and farm out the rest to suppliers. That strategy helped reduce how much money big players tied up in factories, but left them vulnerable to supply chain turmoil.

For the full story, see:

Jack Ewing. “Tesla’s Edge in Pandemic: Superior Command of Supply Chain.” The New York Times, First Section (Sunday, January 9, 2022): 1 & 12.

(Note: ellipses added.)

(Note: the online version of the story has the date Jan. 8, 2022, and has the title “Why Tesla Soared as Other Automakers Struggled to Make Cars.”

After Escaping Communism, Karikó Achieved “Critical Breakthrough” on Covid-19 Vaccine

(p. C8) “Infectious” is a chronicle of the “ongoing arms race between host and infection,” as Mr. Tregoning puts it, as well as the astounding medical progress in the past 100 years that has tipped this struggle in favor of humanity.

. . .

Before the pandemic, many doubted that vaccines based on messenger RNA would work at all, as the technique had a reputation for being finicky and unstable. That these new technologies have thus far outperformed traditional vaccines is an upset akin to Buster Douglas’s 1990 knockout of Mike Tyson. According to Mr. Tregoning, a large share of the credit belongs to the biochemist Katalin Karikó, who had a critical breakthrough that “massively improved the potency of the vaccine.” Ms. Karikó, “who fled Communist Hungary in 1985 with $1,200 hidden in a teddy bear,” was able to stabilize messenger RNA by studding it with methyl groups. This enabled the RNA to survive in the body just long enough to produce viral proteins for the immune system to target.

For the full review, see:

John J. Ross. “The Battle Inside Your Body.” The Wall Street Journal (Saturday, Dec. 11, 2021): C8.

(Note: ellipsis added.)

(Note: the online version of the review has the date December 10, 2021, and has the title “The Defenders: Three Books on the Science of Immunity.”)

The book under review in the passages quoted above is:

Tregoning, John S. Infectious. London, UK: Oneworld, 2021.

During Pandemic, Conditions and Information Constantly Change, Making Decision-Making Stressful and Exhausting

(p. A14) What should you wear today? What to eat for lunch? If life’s daily questions are getting harder to answer nearly two years into the Covid-19 pandemic, you aren’t alone, according to a new survey.

The survey, conducted by the Harris Poll on behalf of the American Psychological Association, found that 32% of American adults were sometimes so stressed about the pandemic that making basic decisions was tough.

. . .

“For many, the pandemic has imposed the need for constant risk assessment, with routines upended and once trivial tasks recast,” the study said. “When the factors influencing a person’s decisions are constantly changing, no decision is routine. And this is proving to be exhausting.”

For the full story, see:

Allison Prang. “Can’t Decide? It Could Be Pandemic Stress.” The Wall Street Journal (Thursday, Oct. 27, 2021): A14.

(Note: ellipsis added.)

(Note: the online version of the story was updated Oct. 26, 2021, and has the title “Can’t Decide What to Wear? It May Be Pandemic Stress.”)

The survey mentioned above is reported in detail in:

Association, American Psychological. “Stress in America™ 2021: Stress and Decision-Making During the Pandemic.” Washington, D.C., 2021.

Identifying as “Taiwanese,” They “Love the Freedom”

(p. A1) CHIAYI, Taiwan — When Li Yuan-hsin, a 36-year-old high school teacher, travels abroad, people often assume she is Chinese.

No, she tells them. She is Taiwanese.

To her, the distinction is important. China may be the land of her ancestors, but Taiwan is where she was born and raised, a home she defines as much by its verdant mountains and bustling night markets as by its robust democracy. In high school, she had planted a little blue flag on her desk to show support for her preferred political candidate; since then, she has voted in every presidential election.

“I love this island,” Ms. Li said in an interview. “I love the freedom here.”

Well over 90 percent of Taiwan’s people trace their roots to mainland China, but more than ever, they are embracing an identity that is distinct from that of their Communist-ruled neighbor. Beijing’s strident authoritarianism — and its claim over Taiwan — has only solidified the island’s identity, now central to a dispute that has turned the Taiwan Strait into one of Asia’s biggest potential flash points.

. . .

(p. A8) When nearby Hong Kong erupted in anti-government protests in 2019, Ms. Li, the schoolteacher, followed the news every day. She saw Beijing’s crackdown there and its destruction of civil liberties as evidence that the party could not be trusted to keep its promise to preserve Taiwan’s autonomy if the sides unified.

Ms. Li’s wariness has only grown with the pandemic. Beijing continues to block Taiwan from international groups, such as the World Health Organization, a clear sign to her that the Communist Party values politics above people. Taiwan’s success in combating the coronavirus, despite these challenges, had filled her with pride.

. . .

“We are Taiwanese in our thinking,” she said. “We do not need to declare independence because we already are essentially independent.”

That emerging confidence has now come to define Taiwan’s contemporary individuality, along with the island’s firm embrace of democracy. To many young people in Taiwan, to call yourself Taiwanese is increasingly to take a stand for democratic values — to not, in other words, be a part of Communist-ruled China.

Under its current president, Tsai Ing-wen, the Taiwan government has positioned the island as a Chinese society that is democratic and tolerant, unlike the colossus across the strait. As Beijing has ramped up its oppression of ethnic minorities in the name of national unity, the Taiwan government has sought to embrace the island’s Indigenous groups and other minorities.

Taiwan “represents at once an affront to the narrative and an impediment to the regional ambitions of the Chinese Communist Party,” Ms. Tsai said last year.

. . .

Growing up in the 1980s, Ms. Li was faintly aware of the divide between the Taiwanese and mainlanders. She knew that going to her “mainlander” grandparents’ house after school meant getting to eat pork buns and chive dumplings — heavier, saltier food than the Taiwanese palate of her maternal grandparents, who fed her fried rice noodles and sautéed bitter melon.

Such distinctions became less evident over time. Many of Taiwan’s residents are now proud of their island’s culinary offerings, whether it is the classic beef noodle soup — a mix of mainland influences unique to Taiwan — or bubble milk tea, a modern invention.

. . .

Ms. Li points to Beijing controls on speech and dissent as antithetical to Taiwan.

She compares Tiananmen Square in Beijing, which she visited in 2005 as a university student, with public spaces in Taipei. In the Chinese capital, surveillance cameras loomed in every direction while armed police watched the crowds. Her government-approved guide made no mention of the Communist Party’s brutal crackdown in 1989 on pro-democracy protesters that she had learned about as a middle school student in Taiwan.

She thought of Liberty Square in Taipei, by comparison, a vast plaza where people often gather to play music, dance, exercise and protest.

“After that trip, I cherished Taiwan so much more,” Ms. Li said.

For the full story, see:

Amy Qin and Amy Chang Chien. “‘We Are Taiwanese’: A Rising National Identity.” The New York Times (Wednesday, January 19, 2022): A1 & A8.

(Note: ellipses added.)

(Note: the online version of the story has the same date as the print version, and has the title “‘We Are Taiwanese’: China’s Growing Menace Hardens Island’s Identity.”)