Friday, April 24, 2020

Oh, those …

… from the New England Journal of Medicine: The Untold Toll — The Pandemic’s Effects on Patients without Covid-19 | NEJM. (Hat tip, Dave Lull)

As the coronavirus pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for people with non–Covid-related disease? For some, new risks may warrant reconsideration of usual standards of care. For others, the need to protect caregivers and preserve critical care capacity may factor into decisions. And for everyone, radical transformation of the health care system will affect our ability to maintain high-quality care. As Michael Grossbard, chief of hematology at New York University’s Langone Hospital, told me, “Our practice of medicine has changed more in 1 week than in my previous 28 years combined.”

 See also: The forgotten patients of the coronavirus lockdown. (Hat tip, Dave Lull.)
I suspect when the modeling was undertaken and the government was being quoted various possible and undoubtedly horrific death tolls, a lockdown policy which — in the view of mathematicians and epidemiologists — would significantly mitigate this was received with open arms. But was the cost in terms of people already ill or about to become ill with other conditions taken into account? I have no doubt serious illnesses and diagnoses will be delayed and missed as a result of measures preventing people from being infected by COVID-19. Has anyone actually asked the people we are supposed to be ‘protecting’ about this?


  1. Jeff Mauvais2:36 PM

    All true, but to present a balanced picture, you should provide links to articles which examine the continued lack of PPE for health care workers, and the colossal, ongoing bungling by the Federal government of testing. Abundant PPE and sufficient testing capacity would eliminate some of the issues described in the NEJM article.

    Right now, there are acute shortages of the DNA primers required to run the viral PCR test, and swabs to collect the samples. States and hospitals have been forced into eBay-like bidding wars for the trickle of PPE arriving from China, still the primary producer of masks, gowns, face shields, etc. A competent administration would have established adequate testing and PPE capacity as the twin foundations of our early response.

    Tens off millions of Americans with diabetes use simple, ubiquitous test kits to check their blood glucose five or six times a day. A partnership between the CDC and private industry, with the goal of having equivalent testing for COVID-19 within a year, should have been established weeks ago, with the backing and leadership of the president. Why involve the government? Because that's where infectious disease expertise resides. The pharmaceutical and medical device industries are great at scaling up lab bench science into mass-manufactured, quality-controlled products. But they employ very few infectious disease specialists, because there is little money to be made in that area. What do you think would be more lucrative: a ten-day course of antibiotics, or an arthritis drug which might be taken daily for 30 years. Pharma companies are focused almost entirely on chronic diseases that affect tens of millions: diabetes, arthritis, depression, high cholesterol and blood pressure. Commitment to the goal I outlined would require federal government leadership and expertise.

    As Lee says, you (and apparently Dave) seem intent on providing only a sliver of the whole picture. My occasional comments are intended to provide a semblance of balance.

  2. Jeff Mauvais2:57 PM

    It's also worth noting that not all of the COVID-19 changes to our health care system have been negative. One of the biggest drivers of the high cost of health care in this country is the widespread habit of millions to use hospital emergency departments as primary care providers. These people show up at emergency rooms for treatment of everything from colds to constipation. The cost of examining a kid with an upset stomach is 10X higher in an ER than at the office of a primary care physician. Not surprisingly, this phenomenon has waned substantially with the arrival of COVID-19. Perhaps an extended viral outbreak will finally end this practice.

  3. Hi Jeff,
    The view that you feel the need to defend seems to me to be the more or less official view, which is abundantly on display in newspapers and on television. So one hardly needs me to bring it to anyone's attention. As a fervent disciple of Brian of Nazareth, I believe that we are all individuals and can think for ourselves. We can hardly do that very effectively, though, if we are confined to only accepted viewpoints. Moreover, many of the sources I have cited are quite respectable— the Lancet, the British Medical Journal, The New England Journal of Medicine, Nature are all well-regarded. No reason to take them at their word either, though, so I welcome your dissent to mine. But even the official view has changed from what it was at the start. And rather serious policy decisions have been based upon it, decisions that have adversely affected many people's lives. It is best we know the whole story from every angle, and not just a single Party line. It's good to know, to give just one example, that to die with COVID-19 is not the same as to die from it. Accuracy and precision are essential to clear thinking. As that fellow Einstein said, "Don't listen to the person who has the answers; listen to the person who has the questions."

  4. Oh, and there's this from Aquinas: “Locus ab auctoritate est infirmissimus“ — the argument from authority is the weakest. Of course, he immediately cited Boethius as an authority in support of this view (proving, I think, that he had a sense of humor.)

  5. Jeff Mauvais2:17 PM

    Do not accuse me of defending the "Party view". Nothing is more insulting than mischaracterizing your readers' views. Understood? (That's a question, by the way.) In virtually every comment, I have simply urged you and your readers to think through the implications of the article to which you have linked, to reason using the data presented by the experts you quote. In fact, my comments have been full of questions, which you dismiss as "putting on airs" and then ignore. Don't you find your quoting of Einstein a bit hypocritical in light of your non-response to my many earlier questions? (Another question, by the way.)

    For example, the Swedish model accepts as a given that 6,000 to 12,000 people will die out of a population of 10 million. The country's head epidemiologist is OK with that. Will the Swedish people be OK with it? (A question.) I also find it ironic to see someone like you who rails against big government praising a policy which allows no dissent or variance at the regional or local level. How do you reconcile those views? (Question.)

    The Swedish model itself predicts 198,000 to 396,000 deaths in the U.S. if the herd immunity approach is adopted. Will the American public be able to sustain such losses? (That's another question, not an assertion.)

    You want questions. Here are several more: With other coronaviruses, personal immunity fades to non-existence within a year or two, sooner in some people. Can you provide any evidence that this particular coronavirus is different? Is enduring repeated waves of serious illness and death fueled by waning immunity a good way to manage this epidemic until a vaccine is available? (Questions.)

    I don't have the answers to these questions, but at least I have the sense to ask them. Will you ignore them, as you have in the past, because they disrupt your internal narrative? (Question.)

  6. Jeff Mauvais4:09 PM

    What about your prediction that U.S. deaths would not reach 30,000 until early September? (Question). At the beginning of April, when we had accumulated 5,000 deaths during the previous month, you stated that your math suggested it would take five more months to reach 30,000. I tried to explain the distinction between linear and exponential growth, but you dismissed me. A little over three weeks later, the U.S. has accumulated 53,000 deaths. No doubt you will respond that failing to distinguish between "dying of" and "dying with" leads to an overcount. It does. On the other hand, anyone who dies of the virus before being tested (at home, in the streets, in an ambulance or ER) is not counted because there is no post-mortem testing. That leads to an undercount. But whatever the inaccuracies in death attribution, the methods have remained consistent over the past two months, meaning that it's still valid to compare your prediction with measured outcome.

  7. Jeff Mauvais4:38 PM

    I'll close with a quote as well, not from Aquinas or Yogi Berra, but from myself: Knee-jerk contrarianism is no different from any other reflex. It uses neural circuits that completely bypass the cerebral cortex.

    Skepticism is great. I've always striven to be a skeptic. If I remember correctly, the word is derived from a Greek root meaning "to search or examine". Searching and examining require work, time, diligence, intellectual honesty. Thinking, not just linking.

    Contrarianism, on the other hand, is lazy and reflexive. It's critical in this situation to stay on the right side of the line that separates the two.

  8. Hi Jeff,
    You concluded your initial comment by noting that "As Lee says, you … seem intent on providing only a sliver of the whole picture. My occasional comments are intended to provide a semblance of balance." A reader sent me an email wondering "where would Mr Mauvais and Lee get these dissenting views in any detail if they weren’t reading your blog? My family, friends, former colleagues, and just about everyone I encounter have almost no knowledge, and certainly no detailed knowledge, of these dissenting views … They all receive the points Mr Mauvais attempts to make everywhere they turn."
    So there does seem to be a market for the things I have been linking to. And the others — shall I call them the orthodox views? — seem to be getting around without any help from me.
    Those dissenting views are also written by persons thought to possess some expertise.
    I did not predict that the mortality rate would be 30,000. I said that if the numbers held steady, the mortality rate could end up in the middle range of this past season's flu epidemic (between 20,000 and 63,000). Given the controversy over the the mortality statistics — dying with COVID-19 is not same as dying from it — that may still be the case. But even if the numbers are in the range of the flu mortality rate, the question remains as to whether the reaction to the problem was an over-reaction. I have objected to the dictatorial manner of the governments in all this (so my anti-government, anti-authoritarian bona fides have actually been on display all along), and will continue to be. As for the points of view you say I am neglecting, send along articles you admire. You can be sure I will post links to them. Let's get as much information out there as we can. This is, after all, the information age (though information, of course, is not the same as knowledge).

  9. Frank, let me answer that email correspondent: I try to get dissenting views by reading widely, and particularly not just American publications. It's also a good idea to turn to people who actually understand statistics, and how modelling works (and what it can and can't do).

    I'm all for intelligent dissent -- the emphasis being on *intelligent*. Where I do agree with Jeff is that most of your links till now do not give the impression of an attempt to provide a balance, but rather underline that we, your readers, are fools for falling for the orthodox view(s). And some of these articles are a short step away from propaganda, if I'm being frank. At least you're admitting that your 'anti-government, anti-authoritarian bona fides' are behind your choice of reading material. And if you're prepared to provide a better balance going forward, I for one will be grateful.

  10. In other words, Frank, we are all subject to confirmation bias.

    'So there does seem to be a market for the things I have been linking to', you wrote. Indeed. There's evidently a market for all manner of stuff. In my mind, this is precisely the reason why someone with a large readership needs to blog responsibly.

  11. Just to muddy the waters regarding mortality rate: