April 11 2020
Disclosure: Dr. Why voted Republican for the last 3 election cycles.
The mounting pressure on politicians and healthcare administrators to outline the plan for “restarting the country”, or just give an approximate time frame for doing so, failed to extract any specifics.
Waive after waive of questions from all corners of the society, including some of the POTUS closest proponents such as Mr. Mark Levin, hits a “waive breaker” of incompetence and inability of his advisors to accept responsibility for their own mistakes.
One of the most notorious propaganda bulldogs - Mr. Hannity, who interviewed Mr. Mark Levin day before yesterday, started his segment stating to an effect that “questioning doctors competence by MSNBC promotes conspiracy theories” only to watch Mr. Mark Levin asking all of the right questions and having nothing else to say other than to thank Mr. Levin at the end. I not a fan of MSNBC of course, FOX is my channel of choice, but I am fortunate to be vaccinated by Soviet propaganda (and BCG)!
It was painful to watch when Dr. F and Dr. B could not defend their own doomsday mortality projections , which continue spectacular (and very fortunate!) drop from millions of victims to <100,000 number extracted from the POTUS today.
In the interview with Mrs. MacCallum, Dr. F admitted yesterday that he is not a “modeler” and that modeling is inherently imperfect science. Earlier in the day, Dr. B spent her time during the press briefing to sing praises to “public health administrators” around the country, while refusing to answer “modeling” questions.
The pinnacle of the day was an announcement that there will be second task force for “reopening economy”. I am curious, if this “force” will be comprised of the same geniuses who shut down the economy, their nemeses, or the mix of the two.
What is shocking is that everything we need to know was outlined in February of 2007 when CDC published “Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States — Early, Targeted, Layered Use of Nonpharmaceutical Interventions (NPI)”. Of note, I did not find “the final” or “updated” guidance, but this one makes a lot of sense.
If only our “task force” could read it, we would not end up where we are now to begin with! The guidance clearly indicates that NPI shall be staged in accordance with pandemic severity in order to determine possible benefit vs. harm of such measures.
“The possible benefit to be derived from implementation of these measures weighed against the cascading second- and third-order consequences that may arise from their use. Cascading second- and third-order consequences are chains of effects that may arise because of the intervention and may require additional planning and intervention to mitigate. The term generally refers to foreseeable unintended consequences of intervention. For example, dismissal of students from school may lead to the second order effect of workplace absenteeism for child minding. Subsequent workplace absenteeism and loss of household income could be especially problematic for individuals and families living at or near subsistence levels. Workplace absenteeism could also lead to disruption of the delivery of goods and services essential to the viability of the community.”
The first mistake or miscalculation was made when faulty models predicted Category 5 (out of 5) severity of the pandemic based on projected case fatality ratio of = or >2% and = or > 1,800,000 deaths in the USA. The calculation assumes 30% illness rate and Unmitigated Pandemic Without Interventions. In fact, we ended up with Category 1 severity based on projected <0.1% case fatality rate and <90,000 deaths.
The mischaracterization (miscalculation) of category of severity led to disproportional NPI: appropriate for category 4 or 5, but not appropriate (‘overkill”) for categories 1-3. This is well reflected in tables from the same document.
It is clear that even under more recent, downgraded projections, which could have characterized this pandemic as Category 2 or 3, community strategies ONLY recommend “Voluntary isolation of ill at home and treatment, if available”, while other measures - child social distancing and workplace/community adult social distancing could be considered with duration of = or < 4 weeks. Based on this guidance, the country can be safety “restarted” on Monday, the 13th of April.
Further, if we agree that, at this point, pandemic severity is arguably Category 1, the one and only recommended measure is “Voluntary isolation of ill at home and treatment, if available”, while other measures “Generally NOT recommended”. Please note, the even under Categories 4-5, the lengthy (= or <12 weeks) NPI was only recommended for child social distancing.
It is remarkable that when discussing Duration of Implementation of Nonpharmaceutical Interventions the reference is made to infamous 1918 pandemic, which, in relative terms was in pre-historic time and before the first virus was identified.
Nevertheless, the document states that “Stopping or limiting the intensity of interventions while pandemic virus was still circulating within the community was temporally associated with recrudescent increases in mortality due to pneumonia and influenza in some communities. Total duration of implementation for the measures specified in this guidance will depend on the severity of the pandemic and the total duration of the pandemic wave in the community, which may average about 6-8 weeks in individual communities. However, because early implementation of pandemic mitigation interventions may reduce the virus’s basic reproductive number, a mitigated pandemic wave may have lower amplitude but longer wavelength than an unmitigated pandemic wave. Communities should therefore be prepared to maintain these measures for up to 12 weeks in a Category 4 or 5 pandemic”.
An interesting article titled Novel Framework for Assessing Epidemiologic Effects of Influenza Epidemics and Pandemics published by CDC scientists in January of 2013 contains further illustrations to the interim guidance.
Figure 1. Estimates of influenza deaths in the 2010 United States population (308,745,538 persons) across varying values of case-fatality ratio and the cumulative incidence of infection in the population. Selected estimated numbers of deaths are indicated with a black line, across each relevant combination of case-fatality ratio and cumulative incidence. In addition, the background color transitions from blue to yellow to red as the estimated absolute number of deaths increases.
Figure 2. Framework for the refined assessment of the effects of an influenza pandemic, with scaled examples of past pandemics and past influenza seasons. Color scheme included to represent corresponding estimates of influenza deaths in the 2010 US population as shown in Figure 1.
Figure 3. Framework for the refined assessment of the effects of an influenza pandemic, stratified by age group with scaled examples from the 2009 pandemic. Color scheme included to represent corresponding estimates of influenza deaths in the 2010 US population as shown in Figure 1.
Whypinion:
It is time to admit mistakes made in assessment of pandemic severity, which led to disproportional and destructive measures affecting the USA and, by consequence, triggering the worldwide economic crisis, before it became a catalyst for a political crisis;
The country must be restarted at once and without further delay;
The practical lessons must be drawn from this debacle and become a part of mandatory curriculum in medical, public health, and governance educational institutions;
The medical and public health curriculum must include in-depth study of rules for determining and reporting the cause of death;
The administrators who made mistakes and gave bad advice to the POTUS must resign and be held accountable in civil and, when appropriate, criminal proceedings;
Our great country will never allow any form of authoritarian government, but we shall remember words by Joseph Stalin from the Address Delivered in the Kremlin Palace to the Graduates of the Red Army Academies on May 4 of 1935: “Cadres decide everything”!