CR: COVID-19 --Political Talk

[Mrs Whiggins 13050]

58 minutes ago, Hugo Stiglitz said:

Seems like they’re doing as much as possible to set up a brutal second wave.

 

35 minutes ago, 4th&Five said:

That’s assuming we’ll ever get past the first wave. 

I'm going to get smote, but I am afraid it will be a tsunami of biblical proportions. The European strain appears to be dominating so best hope is that some of the early treatments begin to coalesce much like Tamiflu did for the flu. Spouse has a colleague who contracted the virus a month ago (in the 40-50 year age group, non smoker, not obese, no pre-existings) and she is still not back to health yet. That is the part that gets underestimated by many people. Even healthy people can get some long term recovery issues.

[RPM 26333]

14 minutes ago, ChiTownDoc said:

Denver.  Lol.  Vocal minority?  Maybe?

 

If dipshits tweeting were an accurate gauge for anything we’d have Bernie in the WH already.  

We already have a dipshit in the WH that tweets. Does that count?

[Message Board User 12395]

 

[ChiTownDoc 21154]

55 minutes ago, Pancho said:

 

Shit.  They’re already in training...

[Mrs Whiggins 13050]

Daaaang, even got the hornets.

Listening to the doctor reminds me of the King of the Hill episode with the line: "I'm addicted to placebos."

[Jhawkmvp 1489]

1 hour ago, Hugo Stiglitz said:

Seems like they’re doing as much as possible to set up a brutal second wave.

It makes sense if the plan is to try to suspend elections in November, due to pandemic part 2, if Trump's polling remains in the toilet.

[workswithseed 2109]

10 minutes ago, Jhawkmvp said:

It makes sense if the plan is to try to suspend elections in November, due to pandemic part 2, if Trump's polling remains in the toilet.

Is this before or after he confiscates guns away?

[Mrs Whiggins 13050]

1 hour ago, Pancho said:

 

I went to the news station and read the article. What a mess. The health department referenced in the article serves three counties. The threatening email was sent to the receptionist and noted that "I know you're the receptionist and not responsible for these edicts... but tell the 9 petty tyrants who want to keep locking most of Colorado down to F--- OFF." The 'tyrants' to whom the email refers are the 9 directors that have medical expertise and are appointed by the county commissioners. 

It gets worse. The building has been vandalized four times recently--windows broken, graffiti, etc. and despite several Republican state senators and reps testing positive for the virus in the area, they urged local commissioners to break away from this health department and form their own health department to "stand for the Constitution." Since the city of Aurora occupies a portion of the three counties, it has made it difficult for the health department as case counts vary by county.

As I said, what a mess.

 

Edit to add--why would the state senators not work on a bipartisan guideline for how the populace can best move about the community on a limited basis until they get their case counts to where they need to be? This all or nothing approach makes little sense to me. Work with each other people.

Edited May 7, 2020 by Mrs Whiggins
addition

[Hugo Stiglitz 23367]

 

[Mrs Whiggins 13050]

1 minute ago, Hugo Stiglitz said:

 

 

[Jhawkmvp 1489]

Just now, workswithseed said:

Is this before or after he confiscates guns away?

Where the fuck did the guns thing come from? Americans on both sides of the aisle are too fat and generally well off for things to come to armed uprisings over something temporary like that.  Besides he would shoot himself in the foot doing that, as I know some gun lovers who vote R no matter what, to keep their guns. They might love Trump but they love their guns more.

Trump is going to be desperate in the fall if he remains underwater like he is now. He might try to suspend the election, if that is the case, until the pandemic passes to give him more time to right the ship. He would lose in court, but if he does it right before the election it would give him a few more weeks or months, likely before the courts sort it out. He is not going to be able to stay in office indefinitely, but he can buy himself more time if he goes that route.

He might look at opening the economy as win/win. If the economy recovers and deaths are not too bad, he can crow about it on the election trail. If deaths continue to climb and the economy flat lines into the fall, he can try the temporary suspension route to give him more time in office. One thing with Trump is he will try and say anything to deflect blame or make himself look better and losing the election as a sitting president will be a blow his ego will not be able to handle.

[Mrs Whiggins 13050]

4 minutes ago, Jhawkmvp said:

 

Or he could have a Sudafed blowout and save us all the trouble.

[workswithseed 2109]

13 minutes ago, Jhawkmvp said:

Where the fuck did the guns thing come from? Americans on both sides of the aisle are too fat and generally well off for things to come to armed uprisings over something temporary like that.  Besides he would shoot himself in the foot doing that, as I know some gun lovers who vote R no matter what, to keep their guns. They might love Trump but they love their guns more.

 

Cause if Trump wants to take control of government then that would piss people off, that a tyrant is taking over the US. I believe people would be fucking livid as they are now. If he does delay elections cause of a virus people are already tired of, then guns would be brought to the Whitehouse.

 

[Message Board User 12395]

I don't think anybody predicted an Axl Rose vs Steve Mnuchin twitter war a few months ago.

 

Edited May 7, 2020 by Message Board User

[Irwin F Fletcher 3550]

Cause if Trump wants to take control of government then that would piss people off, that a tyrant is taking over the US. I believe people would be fucking livid as they are now. If he does delay elections cause of a virus people are already tired of, then guns would be brought to the Whitehouse.

 

You and the rest of his supporters would back the idea of Trump postponing the election if the polls showed how far behind Biden he truly is.

 

Trump supporters openly support this notion, hell it wasn't long ago Trump kept joking about remaining in office indefinitely and they ate it up.

 

[workswithseed 2109]

Just now, Irwin F Fletcher said:

You and the rest of his supporters would back the idea of Trump postponing the election if the polls showed how far behind Biden he truly is.

Trump supporters openly support this notion, hell it wasn't long ago Trump kept joking about remaining in office indefinitely and they are it up.

I don't understand your line of thinking. I say it's bad, but you think I said it's good. Maybe you see something that I don't? Do you support Trump when you say you don't?

I want Trump to let Americans vote, if he doesn't then sic semper tyrannis.

 

[Irwin F Fletcher 3550]

I don't understand your line of thinking. I say it's bad, but you think I said it's good. Maybe you see something that I don't? Do you support Trump when you say you don't?
I want Trump to let Americans vote, if he doesn't then sic semper tyrannis.
 

Let me simplify it for you. Which side is more apt to "storm the Capitol" this day in age in militia dress up? If you're not sure go ahead and Google it. Anyone showing up armed with long guns in D.C. will be there because they want to make sure Trump holds onto power at all costs.

If Trump suspends the election for any reason, his supporters aren't going to show up at his front door armed and ready for conflict. Neither will the left, though the left will work through proper channels (ie courts) to block the order.

[Doc Sam Beckett 5797]

28 minutes ago, Message Board User said:

I don't think anybody predicted an Axl Rose vs Steve Mnuchin twitter war a few months ago.

 

Best frontman evaaaaa. Fight me

[Mrs Whiggins 13050]

27 minutes ago, Message Board User said:

I don't think anybody predicted an Axl Rose vs Steve Mnuchin twitter war a few months ago.

 

Did Mnuchin ever pay back the money for all those fancy trips he and his wife took that cost taxpayers over a million bucks? His question is rather obtuse.

[Francisco 2.0 32396]

I have no idea how legit this is, but lulz.

[Brisketexan 105192]

Let me simplify it for you. Which side is more apt to "storm the Capitol" this day in age in militia dress up? If you're not sure go ahead and Google it. Anyone showing up armed with long guns in D.C. will be there because they want to make sure Trump holds onto power at all costs.

If Trump suspends the election for any reason, his supporters aren't going to show up at his front door armed and ready for conflict. Neither will the left, though the left will work through proper channels (ie courts) to block the order.

Let’s be clear. Trump’s term of office ends on January 20th. If he doesn’t leave the White House, he should be removed. By any means necessary.
And for a period of time, we may not even have a president, depending on the operation of the succession act.
It would be so wildly, and unorecedented-ly, illegal, that we’d have no real legal guidance. We would officially be a failed state.

[babysdaddy 2726]

Welp

[Aqua Buddha 14600]

Help me out here.  There's some video from an anti-vaxxer that every fucking loon on my FB feed has posted.  Something about how the virus is a plot from the government or something.  It's like they all took marching orders at once.  I'd post it here but I don't want my computer getting AIDS.

Can someone tell me what's going on here?  Why are the loons all coming out at once?

[Grade of D as in David 13253]

3 minutes ago, Aqua Buddha said:

Help me out here.  There's some video from an anti-vaxxer that every fucking loon on my FB feed has posted.  Something about how the virus is a plot from the government or something.  It's like they all took marching orders at once.  I'd post it here but I don't want my computer getting AIDS.

Can someone tell me what's going on here?  Why are the loons all coming out at once?

Because hair and nails

[Woland 741]

Help me out here.  There's some video from an anti-vaxxer that every fucking loon on my FB feed has posted.  Something about how the virus is a plot from the government or something.  It's like they all took marching orders at once.  I'd post it here but I don't want my computer getting AIDS.

Can someone tell me what's going on here?  Why are the loons all coming out at once?

The plandemic conspiracy? Susceptible users of FB are already catalogued through the shit they follow and share...easy enough to push more crap on the people who will spread it around the internet.

[otisdog 365]

2 hours ago, Mrs Whiggins said:

 

 Spouse has a colleague who contracted the virus a month ago (in the 40-50 year age group, non smoker, not obese, no pre-existings) and she is still not back to health yet. 

Pics?

[4th&Five 41573]

 

[Mrs Whiggins 13050]

8 minutes ago, otisdog said:

Pics?

Haha, she is well known in her field, so I’m not going to land in hot water for that I’m afraid. 

[GRHorn 105]

22 hours ago, Irieguy said:

1,111 divided by 3,195 = 35%. If you need further explanation, let me know. 
 

I’m aware of the math. Didn’t understand the point of it. 

[gmr548 16590]

Nobody has done this, as far as I know, but if you look at the number of patients dying in battle ground states and their demographics...orange fuckstain is losing a disproportionate number of votes.  It would only be fitting if he literally kills his chances to win.  I mean, not as fitting as his fat non-mask wearing ass dying of corona, but I'll take it...
 
Edit: I know it's disproportionately hitting minorities but the overall numbers dying are still skewed towards old white people...this isn't the tard thread so I hope I don't have to explain this. 

Source? Honestly I've seen very little beyond old, unhealthy, and men as far as who this virus prefers to kill. I know it's hitting black people really hard, probably due to underlying health problems, but I've never seen any numbers.

[GRHorn 105]

20 hours ago, Bama Chick said:

Ooooh, sexist and stupid!

Here’s some histrionics for you - you’re the worst kind of moron. A moron who doesn’t know they’re a moron but still feels the compulsion to contaminate everyone else with their stupidity. You’re mean, you’re clueless, you’re selfish, you’re incurious, and you’re boring. No woman worth a damn would ever willingly want to have sex with you for pleasure. They only do it out of pity, for a transaction, or to have a story to tell their friends about the dumb mean half-man they suffered through.

You’re the absolute perfect Trumpkin. You’re sure to take that as a compliment but know that, as usual, you will be wrong.

So take this message with a the histrionic effort I can muster - fuck you, eat shit, and go read a book.

Adj- overly theatrical or melodramatic in character or style. 

Not sure what that has to do with your gender. Had more to do with your style of posting, of which you provided a fine example.

You need to calm down. 

 

[gmr548 16590]

Is the economy in a recession?
50% R; 89% D

Wait....WTF....that's a question of math, not opinion.

Uh, yeah, two consecutive quarters of contraction. We got Q1. We know where Q2 is going to end up. 50 percent of Republicans and 11 percent of Democrats are stupid.

[gmr548 16590]

Where the fuck did the guns thing come from?... They might love Trump but they love their guns more.

Pretty sure he was joking... lol no.

I wouldn't be surprised at all if Trump tried to stop the election. He can't though. The date of federal elections is explicitly defined by statute. He can't do shit without Congress. House will obviously tell him to get fucked.

Elections are administered at the state level too. States with Democratic executives plus popular NE Republicans, which is all your blue states, plus WI, MI, PA, and NC, would vote and Trump would get smooth buttfucked in the EC. Like not a single vote.

[TexArcher 37998]

12 minutes ago, GRHorn said:

Adj- overly theatrical or melodramatic in character or style. 

Not sure what that has to do with your gender. Had more to do with your style of posting, of which you provided a fine example.

You need to calm down. 

 

And that's why you're a virgin.  That right there.

[GRHorn 105]

5 hours ago, Mrs Whiggins said:

SIAP

 

Counterpoint 

I know just a comment/note in the Lancet, but not from a nobody. 

https://en.m.wikipedia.org/wiki/Johan_Giesecke

 

Another column here that outlines some valid points imo 

https://www.drjohnm.org/2020/05/can-we-discuss-flatten-the-curve-in-covid19-my-eight-assertions/

Spoiler

On Telehealth, an older couple asked me a tough question about COVID19. They asked whether this virus would either be gone or less dangerous in 6 months to a year.

It was a curious question. I replied, Why do you ask?

Doc, we have a big family with many children and grandchildren, most of whom live nearby. We miss them. We’ve been isolating, but it’s hard; we did it for 6 weeks. Doing it for a year or more would be miserable.

We saw on the news today that the battle with the virus would be long. A man called it a cruel new normal. 

So doc, if you tell me the the virus will be gone in a year or it will be less dangerous to get infected later, then it makes sense for us to keep isolating. But if the situation will not be much different a year from now, we would just as soon see our family and take the risk. Of course, doc, we would still be sensible. We’d not visit if someone was sick; we would wash our hands and wear masks.

Indeed my patient was correct. Dr. Scott Gottlieb writing in the WSJ, did not mince words:

Hospitals and public-health systems will have to contend with persistent disease and death.

In essence, my couple asks whether flatten-the-curve policies save lives. Buried in that question are three other questions: namely, in one year, will the virus be 1) gone, or 2) less contagious, or 3) less deadly? If any of those three are true, then my couple could rationally decide to stay lonely for a year or more. 

I study this new virus and this once-in-a-lifetime-situation every day.

I don’t think flatten-the-curve policies will change any of those issues. Let me explain my reasoning. I may be wrong; tell me if you disagree in the comments.

Flatten-the-Curve Purpose

You now know the famous curves–one with an early surge of disease, and the other flatter curve that spreads the infections over time. The y-axis is number of COVID19 cases.

In early March the COVID19 narratives were from Wuhan, Iran, Lombardy and Spain, places where surges overwhelmed hospitals. In the US, COVID cases spiked in NYC. 

Early COVID19 surges were over-running some big-city hospitals. This was bad because it caused excess or preventable death–people who could have been saved were not saved because of shortages of ICU beds, dialysis equipment, staff and ventilators. 

Social distancing policies and postponement of elective medical care were necessary to stop the excess deaths. These policies allowed time for hospitals to prepare for COVID19 cases and for doctors to learn how best to treat these patients. Exhibit A: not intubating patients early. 

Social distancing worked. The number of cases slowed and the US got into the blue part of the curve. But now, months later, the narrative has changed.

Change in Flatten-the-Curve Narrative

What was once flatten the curve to prevent over-running hospitals has changed to flatten the curve to save lives. Some likened moderation of social distancing to human sacrifice. 

That change in framing, I believe, is misleading. I will argue that the cumulative deaths from COVID19 will not be reduced significantly by flatten-the-curve policies. And that this virus will be as dangerous to vulnerable patients in 6 months to a year. We should be allowed to debate this.

My case has eight assertions.

First: the virus will not be contained. The chance for containment has long passed. The virus transmits before people know they have it and many patients never develop symptoms. It will be with us until an effective vaccine is both widely available and widely used. (See #6) 

Second: Tests will under-perform. The high rate of asymptomatic disease, the low sensitivity of PCR tests (false negatives), imperfect specificity of antibody tests (false positives) and concerns over privacy mean that we should expect less from test and trace–even if proposed by a Nobel Laureate. Carl Bergstrom and others writepersuasively on major barriers to contact tracing in the US. 

Third: US hospitals are now prepared and in little danger of being over-whelmed. In fact, many hospitals are so dormant they are nearing financial ruin. Healthcare workers have been furloughed due to postponement of elective work. I’ve talked to numerous colleagues in the US and the message is clear: hospitals are under-capacity and prepared for a “persistent” number of COVID19 cases during the coming months/years. Hospitals now have COVID response teams. 

Fourth: Americans are not stupid. Before governors enacted lockdowns, economic activity and travel slowed, the NBA, MBL, NHL stopped their seasons and medical meetings were cancelled. People socially distance not because police are bearing down on them, but because it makes sense. The pictures of spring-breakers in Florida and crazies-with-guns in state capitals bring clicks to news organizations but belie the majority of sensible people in this country. 

Fifth: Public-health surveillance has improved. Tests may underperform but they will not be useless. Tests will help signal coming hot spots and that will allow communities to act locally. Other technologies may emerge that help prevent surges. One cool example isthe use of resting heart rate apps that might signal health officials early on. 

Sixth: (I need a few paragraphs):Social distancing will not lower the infection fatality rate or IFR. Remember the red and blue curves? The y-axis of that graph is number of infections. Due to the contagion of this virus, the area under these curves is likely to be the same at the end of two years. Ok, then, if the number of cases is similar at two years, then the number of people who cumulatively die will not likely change either. 

The only way fewer people die from COVID19 over time is if the IFR declines. Here is where American exceptionalism misleads people. Politicians have a strong bias to pump up optimism on any potential medical advance–no matter how dubious. (Exhibit B- hydroxychloroquine.)

That is not how Medicine works. History is replete with examples showing that drug development is super hard. But leaving aside the challenge of developing new drugs against a new virus, the basic math of COVID19 creates a huge barrier for success: already, more than 99% of people infected with this virus survive. A therapy that has a massive 50% reduction in death from a disease with 1% mortality (high estimate) delivers only a 0.5% absolute risk reduction.

What about Remdesivir? This antiviral may help a little. But even if you believe its ≈ 3% reduction of death was not due to chance (p = 0.06), the death rate in the remdesivir arm in that trial was 8%. Remdesivir is no game-changer. 

COVID19 vaccine development is sobering. Most experts say a safe and effective vaccine is at least 18 months away. Again, the 99% survivability erects a huge safety barrier for vaccine makers. (I get that from Dr. Paul Offit.) Given society’s tension over vaccines, it would take only a tiny signal of harm to derail a coronavirus vaccine.

A slight hedge on the sixth assertion that IFR remains constant: some smart people say that getting the virus later may be better because doctors will be a little better at treating this disease. For instance, a year from now we may better understand how to use drugs that block clotting; we may have better vent protocols. These are big ifs. They may drive the IFR down a little but IFR is already low. Another benefit of infection in a year would be that most hospitals will likely allow family visitors. 

Seventh: The more we test, the lower the IFR goes. Early estimates had it at 3%. Then it was revised downward to about 1%. Now most people put it at 0.1-0.5%. But that is still quite serious. You’ve probably read that 0.1% is similar to flu mortality. That is likely wrong. Dr. Jeremy Faust points out that flu mortality is grossly overestimatedand is probably much lower than 0.1%. 

Eighth: I wrote a piece on Medscapeabout the harms from COVID19 interventions. One of the points I made is that right now we count only deaths from COVID19. We stay riveted on day-to-day numbers. But the endpoint of this crisis is not next month but in 1-2 years. And when we get there, we have to count people who died from COVID19 and those who died from other causes. 

This preprint from prominent researchers suggests a substantial proportion of excess deaths observed during the pandemic are not attributed to COVID19 and may represent an excess of deaths due to other causes.

In my column I cited an older study by Raj Chetty and co-workers that finds a strong association of lower income and lower survival. And that is the rub with COVID19 interventions: they make poor people even poorer. The rich just work from home. It is possible, therefore, that our social interventions will be especially hard on the disadvantaged. 

I realize that no person overtlydismisses the harm from economic shutdowns. My friend Dr. Dan Morgan expresses my frustrations well in this thread. Why can one safely critique a drug for COVID19 but not massive public health interventions? 

Dan Morgan@dr_dmorgan

 

 

1/ It is strange being an epidemiologist, liberal, scientist who feels like we are making mistakes with absolutism of shutdowns. (and being lumped with antivaxxers, Trump etc. by my own people)
Many people out of work→ anxiety & depression & social discord → @VPrasadMDMPH

 

292

7:46 AM - May 4, 2020

Twitter Ads info and privacy

 

97 people are talking about this

 

 

 

Conclusion:

I did not have a clear answer for my couple. But after thinking and writing about this question it seems that the most reasonable approach in this crisis is transparent information–no matter how stark. And, crucially, we must have space for public debate. 

I hate this virus. I wish it never came. But we can make it worse by avoiding hard discussions on tradeoffs, the limits of modern medicine and risk. 

JMM

P.S. I am very interested in your rebuttals to any of my assertions but will block vitriol and politicized nonsense.

 

 

[TheRealRonWeaver? 1258]

2 minutes ago, gmr548 said:

I wouldn't be surprised at all if Trump tried to stop the election. He can't though. The date of federal elections is explicitly defined by statute. He can't do shit without Congress.

greenshirtguylaughing.gif

[gmr548 16590]

greenshirtguylaughing.gif

That'll be me if he does and gets secsecsec to postpone elections, because he'll get fucking Mondale'ed

 

[TheRealRonWeaver? 1258]

2 minutes ago, gmr548 said:

That'll be me if he does and gets secsecsec to postpone elections, because he'll get fucking Mondale'ed

 

He doesn't need to postpone shit. He just needs the red states in danger of flipping blue to have the legislatures select his presidential electors.

[Anastasis 23481]

27 minutes ago, GRHorn said:

Adj- overly theatrical or melodramatic in character or style. 

Not sure what that has to do with your gender. Had more to do with your style of posting, of which you provided a fine example.

You need to calm down. 

She probably confused histrionic with hysterical, which has a built in etymology to the uterus.  

[GRHorn 105]

13 minutes ago, TexArcher said:

And that's why you're a virgin.  That right there.

Appreciate your response. I can now safely disregard any and all of your posts without the worry of missing any mature or useful content. 

[achooloco 1072]

38 minutes ago, 4th&Five said:

 

Thats her at 102? God damn.

[washparkhorn 9939]

5 minutes ago, TheRealRonWeaver? said:

He doesn't need to postpone shit. He just needs the red states in danger of flipping blue to have the legislatures select his presidential electors.

1868 (Florida) and 1876 (Colorado) was the last time that was used - because there wasn't time and/or money available to hold an election. It was contemplated in 2000 by Florida - to settle the hanging chad election. Andrew Jackson would have won in 1824, but state legislatures overturned that election by choosing their own electors to vote against Jackson. Finally, there was talk of it in 2016. 

[gmr548 16590]

He doesn't need to postpone shit. He just needs the red states in danger of flipping blue to have the legislatures select his presidential electors.

At that point we'd have to look in to whether these states have any statutes on thre books, but I concede that's a theoretically possible workaround.

[Al Bundy's Napoleon Hand 13586]

6 minutes ago, Anastasis said:

She probably confused histrionic with hysterical, which has a built in etymology to the uterus.  

I'll take Douchebag Mouth Fart for a hundred, Alex.

[Mrs Whiggins 13050]

11 minutes ago, GRHorn said:

Counterpoint 

I know just a comment/note in the Lancet, but not from a nobody. 

https://en.m.wikipedia.org/wiki/Johan_Giesecke

 

Another column here that outlines some valid points imo 

https://www.drjohnm.org/2020/05/can-we-discuss-flatten-the-curve-in-covid19-my-eight-assertions/

  Reveal hidden contents

On Telehealth, an older couple asked me a tough question about COVID19. They asked whether this virus would either be gone or less dangerous in 6 months to a year.

It was a curious question. I replied, Why do you ask?

Doc, we have a big family with many children and grandchildren, most of whom live nearby. We miss them. We’ve been isolating, but it’s hard; we did it for 6 weeks. Doing it for a year or more would be miserable.

We saw on the news today that the battle with the virus would be long. A man called it a cruel new normal. 

So doc, if you tell me the the virus will be gone in a year or it will be less dangerous to get infected later, then it makes sense for us to keep isolating. But if the situation will not be much different a year from now, we would just as soon see our family and take the risk. Of course, doc, we would still be sensible. We’d not visit if someone was sick; we would wash our hands and wear masks.

Indeed my patient was correct. Dr. Scott Gottlieb writing in the WSJ, did not mince words:

Hospitals and public-health systems will have to contend with persistent disease and death.

In essence, my couple asks whether flatten-the-curve policies save lives. Buried in that question are three other questions: namely, in one year, will the virus be 1) gone, or 2) less contagious, or 3) less deadly? If any of those three are true, then my couple could rationally decide to stay lonely for a year or more. 

I study this new virus and this once-in-a-lifetime-situation every day.

I don’t think flatten-the-curve policies will change any of those issues. Let me explain my reasoning. I may be wrong; tell me if you disagree in the comments.

Flatten-the-Curve Purpose

You now know the famous curves–one with an early surge of disease, and the other flatter curve that spreads the infections over time. The y-axis is number of COVID19 cases.

In early March the COVID19 narratives were from Wuhan, Iran, Lombardy and Spain, places where surges overwhelmed hospitals. In the US, COVID cases spiked in NYC. 

Early COVID19 surges were over-running some big-city hospitals. This was bad because it caused excess or preventable death–people who could have been saved were not saved because of shortages of ICU beds, dialysis equipment, staff and ventilators. 

Social distancing policies and postponement of elective medical care were necessary to stop the excess deaths. These policies allowed time for hospitals to prepare for COVID19 cases and for doctors to learn how best to treat these patients. Exhibit A: not intubating patients early. 

Social distancing worked. The number of cases slowed and the US got into the blue part of the curve. But now, months later, the narrative has changed.

Change in Flatten-the-Curve Narrative

What was once flatten the curve to prevent over-running hospitals has changed to flatten the curve to save lives. Some likened moderation of social distancing to human sacrifice. 

That change in framing, I believe, is misleading. I will argue that the cumulative deaths from COVID19 will not be reduced significantly by flatten-the-curve policies. And that this virus will be as dangerous to vulnerable patients in 6 months to a year. We should be allowed to debate this.

My case has eight assertions.

First: the virus will not be contained. The chance for containment has long passed. The virus transmits before people know they have it and many patients never develop symptoms. It will be with us until an effective vaccine is both widely available and widely used. (See #6) 

Second: Tests will under-perform. The high rate of asymptomatic disease, the low sensitivity of PCR tests (false negatives), imperfect specificity of antibody tests (false positives) and concerns over privacy mean that we should expect less from test and trace–even if proposed by a Nobel Laureate. Carl Bergstrom and others writepersuasively on major barriers to contact tracing in the US. 

Third: US hospitals are now prepared and in little danger of being over-whelmed. In fact, many hospitals are so dormant they are nearing financial ruin. Healthcare workers have been furloughed due to postponement of elective work. I’ve talked to numerous colleagues in the US and the message is clear: hospitals are under-capacity and prepared for a “persistent” number of COVID19 cases during the coming months/years. Hospitals now have COVID response teams. 

Fourth: Americans are not stupid. Before governors enacted lockdowns, economic activity and travel slowed, the NBA, MBL, NHL stopped their seasons and medical meetings were cancelled. People socially distance not because police are bearing down on them, but because it makes sense. The pictures of spring-breakers in Florida and crazies-with-guns in state capitals bring clicks to news organizations but belie the majority of sensible people in this country. 

Fifth: Public-health surveillance has improved. Tests may underperform but they will not be useless. Tests will help signal coming hot spots and that will allow communities to act locally. Other technologies may emerge that help prevent surges. One cool example isthe use of resting heart rate apps that might signal health officials early on. 

Sixth: (I need a few paragraphs):Social distancing will not lower the infection fatality rate or IFR. Remember the red and blue curves? The y-axis of that graph is number of infections. Due to the contagion of this virus, the area under these curves is likely to be the same at the end of two years. Ok, then, if the number of cases is similar at two years, then the number of people who cumulatively die will not likely change either. 

The only way fewer people die from COVID19 over time is if the IFR declines. Here is where American exceptionalism misleads people. Politicians have a strong bias to pump up optimism on any potential medical advance–no matter how dubious. (Exhibit B- hydroxychloroquine.)

That is not how Medicine works. History is replete with examples showing that drug development is super hard. But leaving aside the challenge of developing new drugs against a new virus, the basic math of COVID19 creates a huge barrier for success: already, more than 99% of people infected with this virus survive. A therapy that has a massive 50% reduction in death from a disease with 1% mortality (high estimate) delivers only a 0.5% absolute risk reduction.

What about Remdesivir? This antiviral may help a little. But even if you believe its ≈ 3% reduction of death was not due to chance (p = 0.06), the death rate in the remdesivir arm in that trial was 8%. Remdesivir is no game-changer. 

COVID19 vaccine development is sobering. Most experts say a safe and effective vaccine is at least 18 months away. Again, the 99% survivability erects a huge safety barrier for vaccine makers. (I get that from Dr. Paul Offit.) Given society’s tension over vaccines, it would take only a tiny signal of harm to derail a coronavirus vaccine.

A slight hedge on the sixth assertion that IFR remains constant: some smart people say that getting the virus later may be better because doctors will be a little better at treating this disease. For instance, a year from now we may better understand how to use drugs that block clotting; we may have better vent protocols. These are big ifs. They may drive the IFR down a little but IFR is already low. Another benefit of infection in a year would be that most hospitals will likely allow family visitors. 

Seventh: The more we test, the lower the IFR goes. Early estimates had it at 3%. Then it was revised downward to about 1%. Now most people put it at 0.1-0.5%. But that is still quite serious. You’ve probably read that 0.1% is similar to flu mortality. That is likely wrong. Dr. Jeremy Faust points out that flu mortality is grossly overestimatedand is probably much lower than 0.1%. 

Eighth: I wrote a piece on Medscapeabout the harms from COVID19 interventions. One of the points I made is that right now we count only deaths from COVID19. We stay riveted on day-to-day numbers. But the endpoint of this crisis is not next month but in 1-2 years. And when we get there, we have to count people who died from COVID19 and those who died from other causes. 

This preprint from prominent researchers suggests a substantial proportion of excess deaths observed during the pandemic are not attributed to COVID19 and may represent an excess of deaths due to other causes.

In my column I cited an older study by Raj Chetty and co-workers that finds a strong association of lower income and lower survival. And that is the rub with COVID19 interventions: they make poor people even poorer. The rich just work from home. It is possible, therefore, that our social interventions will be especially hard on the disadvantaged. 

I realize that no person overtlydismisses the harm from economic shutdowns. My friend Dr. Dan Morgan expresses my frustrations well in this thread. Why can one safely critique a drug for COVID19 but not massive public health interventions? 

Dan Morgan@dr_dmorgan

 

 

1/ It is strange being an epidemiologist, liberal, scientist who feels like we are making mistakes with absolutism of shutdowns. (and being lumped with antivaxxers, Trump etc. by my own people)
Many people out of work→ anxiety & depression & social discord → @VPrasadMDMPH

 

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7:46 AM - May 4, 2020

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Conclusion:

I did not have a clear answer for my couple. But after thinking and writing about this question it seems that the most reasonable approach in this crisis is transparent information–no matter how stark. And, crucially, we must have space for public debate. 

I hate this virus. I wish it never came. But we can make it worse by avoiding hard discussions on tradeoffs, the limits of modern medicine and risk. 

JMM

P.S. I am very interested in your rebuttals to any of my assertions but will block vitriol and politicized nonsense.

 

 

One of your examples isn’t showing up for me for some reason—gray box. But I read the longer spoilered one and it is a counterpoint and a discussion that would be nice to have. I do think that we (the country) needs to continue a process of lifting restrictions but openly and honestly. What the positive and negative implications will be, what safeguards will be implemented (if any), and what recourse there will be should everything go south. For example, the case in Utah where the two businesses told their employees to return to work even though they were sick resulting in more than 68 cases. Were those employees provided with health care? Sick leave? The rules for liability have been changing during this pandemic, so will anyone be upfront and honest enough to state “you’re on your own?”

It (the various local, state, and especially  fed response) is too checkerboard, too obfuscated, and too poorly managed at the moment to have a sense of, “okay, this sucks but we will get through it” right now. We probably will, but the phrase ‘attitude reflects leadership,’ isn’t helping inspire confidence if you know what I mean. 

[Anastasis 23481]

4 minutes ago, Al Bundy's Napoleon Hand said:

I'll take Douchebag Mouth Fart for a hundred, Alex.

[Al Bundy's Napoleon Hand 13586]

Not really.

[Al Bundy's Napoleon Hand 13586]

What are you doing?

[Anastasis 23481]

1 minute ago, Al Bundy's Napoleon Hand said:

Not really.

There is more than enough uterus to go around in this world. 

[Anastasis 23481]

1 minute ago, Al Bundy's Napoleon Hand said:

What are you doing?

You tell me what you are doing?