"The whole aim of practical politics is to keep the populace alarmed by menacing it with an endless series of hobgoblins, most of them imaginary." ~ HL Mencken
I just paid him $1,000. I lost the bet fair and square because implicit in the bet was that we would use conventional metrics of covid deaths, such as those of the Center for Disease Control (CDC) or the World Health Organization (WHO). I have been following the CDC, and while one page reports 244k, it will pass 250k soon; another page on their site reports 265k. Even if I take the minimum, the result is inevitable. In hindsight, my error was not anticipating that covid would become politicized. Robin was right for the wrong reason (covid deaths are inflated, it is not comparable to the Spanish Flu), but that often happens in bets.
The SARS Effect
In January, China reported the first death from the new covid virus, and by mid-month, the WHO published a comprehensive of guidance documents on this new disease. In a prelude to the panic, the CDC, following the WHO's lead, was confident that a new pandemic was at hand. The WHO's initial January report specifically referenced the 2003 SARS, the highly lethal respiratory disease that formed the basis for many new Crisis Response Protocols developed by the health care bureaucracy. Covid was the pandemic that our experts had extensively planned for, which proved disastrous.
In the 2003 SARS pandemic many healthcare workers became infected, and hospital transmission was the primary accelerator of SARS infections, accounting for 72% of cases in Toronto and 55% of probable cases in Taiwan. This pattern is so common and terrifying that there is a special word for this: nosocomial, which means transmitted in a healthcare facility. While conventionally SARS refers specifically to the 2003 pandemic, it is also a generalized term (Severe Acute Respiratory Syndrom), and our current virus is considered in the same clade as the 2003 SARS virus. It is the SARS-CoV-2 virus that causes COVID-19 disease (hereafter, covid). Over the past 17 years, health care institutions created hundreds of detailed guides about how to quarantine, report, and control the next SARS outbreak, with hospital protocols the first line of defense.
Reviews of the SARS experience noted the importance of a detailed protocol for dealing with such diseases. In Toronto, infected health care workers all reported that they had worn the recommended protective equipment, including gowns, gloves, specialized masks, and goggles, each time they entered the patient's room. However, the workers had not been fit-tested for their masks, and one nurse admitted his mask didn't fit well. It was also noted that some of the workers might not have followed the correct sequence in removing their protective equipment (i.e., gloves first, then mask and goggles).
The emphasis on small details created a bureaucratic mindset that ignored common sense because the motivation was preventing not merely the next SARS, but the next worst-case-scenario SARS (see The Andromeda Strain or the latest Planet of the Apes series). The focus was on health care workers at the expense of patients, which seems simply self-serving, but it makes sense if your vision of a pandemic comes from dystopic science-fiction movies. If all health care providers die first, everyone else is sure to die next because, without health experts, health experts expect society to revert to Medieval life expectancies. Thus the priority was not so much healing the sick but getting them out of circulation. When the objective is to prevent an existential threat to humanity, virtually any extreme measure with large present costs is justified.
At the beginning of the covid crisis, the CDC recommended health care workers don full Personal Protective Equipment (PPE) for each patient encounter, consisting of the following:
- A disposable N95 respirator face mask that achieves a seal around the mouth and nose
- Eye protection
- Disposable gown
- Intermittent rather than continuous patient monitoring to reduce contact
- Rapid ventilation to minimize aerosol generation (Rapid Sequence Intubation)
- Aggressively suppress patient cough through sedation strategies (fentanyl, ketamine, propofol).
- Reduced suctioning
- Reduced visitors, and then only with PPE
Early in the crisis, there was a focus on the number of ventilators as a hospital capacity metric. There were calls for transitioning defense contractors to ventilators' production, which are tangible cures for clueless politicians and journalists, similar to how Mao emphasized steel production. In fact, more people would be alive today if there was a shortage, and its aggressive and negligent application killed tens of thousands. Usually, 40% of patients with severe respiratory distress die while on ventilators, as these are emergency tactics for the very sick (classic selection bias). Yet in the March covid disaster in New York City, 85% of coronavirus patients placed on the machines died, including 97% of ventilated patients over 65 (see here). As many were placed on ventilators that otherwise would not have been, the implications for excess deaths are fairly direct.
The problems with intubation are known as VALI: Ventilator Association Lung Injury. For example, the absolute pressures used in order to ventilate lungs, and shearing forces associated with rapid changes in gas velocity can traumatize lung tissue. It increases the risk of pneumonia because the tube that allows patients to breathe can introduce bacteria into the lungs. Pressure and oxygen levels need to be individualized because too much or too little of either damage lungs, requiring frequent monitoring and adjustment. People were put on ventilators at a higher-than-normal rate and monitored infrequently. As their family members were absent, no one could call for a nurse when a patient was in obvious distress.
Drugging patients and putting them on ventilators reduced the risk they would infect health care workers. Additionally, there were reports that some covid patients had a rapid decline of oxygenation levels, and so in anticipation of this, a ventilator first strategy was seen as proactive. A review of experiences in Italy stated that "invasive ventilation is associated with reduced aerosolization and is thus safer for staff and other patients," but also admitted that "it might also be associated with hypoxia, hemodynamic failure, and cardiac arrest during tracheal intubation."
Financial incentives aggravated the overuse of ventilators. In the United States, the government pays approximately $13,000 for a regular COVID-19 patient, but $39,000 for an intubated patient. A ventilator is a cash cow for medical facilities. Given the CDC's official recommendations, no one could second-guess them for being overly aggressive, especially when their aim was to prevent an existential threat. [Left-wing fact-checker Snopes rated this payment factoid as 'mixed,' employing the casuistry that while correct as an approximation, actual payments are not exactly $13k or $39k in every case]
When covid exploded in Italy the WHO had already implemented an unprecedented policy to count all deaths 'with covid' as deaths 'from covid.' The policy was immediately adopted in the US as well, as Illinois' Public Health Director Ngozi Ezike stated, "even if you died of a clear alternative cause, but you had covid at the same time, it's still listed as a covid death." Early in the pandemic, when there was little data on how virulent this pandemic would be, the CDC emphasized how important it was to label anything plausibly related to covid as a COVID-19 death to "appropriately direct [the] public health response." This is a clear indication that they were interested in maximizing covid deaths from the outset. As Marx advised, the purpose of intellectuals is not merely to interpret history, but to change it.
As you die, your immune system shuts down, allowing many viruses to thrive as one nears death. These are opportunistic collateral infections, not the cause of death. Pneumonia was often referred to as 'old man's friend' because it was the immediate cause of death for most old people, whether the real reason was renal failure, cardiovascular disease, or cancer. Measuring for the appearance of a particular virus, regardless of these co-morbidities, is misleading, and why historically, no one has ever used the "died with" protocol for attributing the underlying cause of death (UCOD).
Further, a covid diagnosis is very lenient. The CDC not only allows a presumptive diagnosis but before any significant data on this new virus, confidently recommended applying covid to any death remotely plausible: "it is likely that it will be the UCOD, as it can lead to various life-threatening conditions, such as pneumonia ... in these cases, COVID–19 should be reported." Thus in April, when New York City breached 10k deaths, this included 3,700 who were presumed to have died of covid but never tested.
The US authorized $150B for covid relief in March, including a 20% add-on to the standard rate for patients diagnosed with covid. If you have been to a hospital out-of-network recently, you learn how much extra you are charged without insurance, the 'standard rate' as defined by 'diagnosis-related groups.' These rates are benchmarks that allow insurers to show you how much you are saving with them. They are also high rates because they have low collection rates, and hospitals are obligated to service an ill person regardless of insurance. Many patients leave and are untraceable, so those who pay subsidize those who do not, a hidden redistributive tax within our health care. A covid diagnosis generates the standard rate, which is a premium rate, and adds a 20% bonus.
If you run a long-term care facility where many patients are at the end of their life, and final days usually entail expensive treatments, it would be financially prudent and entirely legal to diagnose as many decedents as covid as possible. Further, this petty cash grab would avoid media moral censure, as many eager to inflate the death count would consider this a cost worth paying.
While no testing is required for a covid diagnosis at death, the tests themselves are biased. A virus with a low load is often inactive, passive, non-threatening. This phenomenon is the basis for HIV antiretroviral therapy, in that when a person has a sufficiently low viral load, they not only do not get sick, they do not transmit the disease.
A critical threshold (Ct) for 'cycles' in PCR tests is an important cause of false positives. Each cycle doubles the amount of the virus fragments, so as 35 cycles is 10 more than 25 cycles, this implies it generates 1024 times (2^10) of the viral fragments in the final solution. A recent covid study found that 70% of samples with Ct values of 25 or below could be cultured, indicating an active infection, compared with less than 3% of the cases with Ct values above 35. Yet, the CDC states Ct values should not be used to determine a patient's viral load because the correlation between Ct values and viral load is imperfect. This objection would obviate just about every health metric if not all of statistics: is high blood pressure a useless signal because some people with high blood pressure live to 100? PCR provides an argument by authority--they reference peer-reviewed science--but if one does not simply defer to their credentials and understands the logic they present, it exposes their complete lack of credibility. Science as a method is rational and objective; science as an institution is as corrupt as the Medieval church.
For the media to portray Cordero as having no underlying health conditions merely because this described him before hospitalization is not just misleading, but intentionally so. The litany of life-threatening complications before his first positive covid test made him one of the least healthy people on the planet. There is clearly a higher truth for the media in his story. It would be interesting to know to what degree the aggressive intubation protocols at his time of admittance factored in his death. It is quite likely he was rapidly intubated and neglected, per SARS protocols, a classic case of iatrogenesis, when medical care harms the patient.
Declines in Elective Surgery and Regular Doctor Visits
To reduce infectious risk to providers and conserve critical resources, most states in the US enacted a temporary ban on elective surgery from March through May 2020. Various discouragements have continued. Elective surgical cases fall somewhere between vital preventative measures (e.g., screening colonoscopy) and essential surgery (e.g., cataract removal). These surgeries plummeted 60% in April, but have subsequently rebounded, though are still well below last year. Similarly, outpatient visits fell by 50% initially and are still well below previous levels (see here and here).
The effects of healthcare visits and elective surgery on mortality, let alone and quality of life, are speculative. Yet, many papers supported Obama's Affordable Care Act, noting that increased access to such care had significant effects. Estimates of how much more health care access people had due to Obamacare range from 1 to 5%, and the consequences range from 10k to 50k deaths avoided per year. Given an initial 50% reduction and a subsequent reduction of 10-20% over the rest of the year, a 100k increase in deaths would be a reasonable estimate given this literature.
Obamacare supporters generally also support the lockdown. They insist a small increase in access to healthcare saved tens of thousands via Obamacare, while this year's radically sharp decline in access to healthcare had no effect worth mentioning when discussing the lockdowns.
People are social, which is why one of the worst punishments in Roman times was exile. Solitary confinement cuts people off from the types of activity that bring meaning and purpose to their life, communal activities, and face-to-face social interactions. To suggest taking this away from people, especially the elderly, is not worth estimating in this pandemic is absurd to anyone who thinks life is about quality as well as quantity.
Yet even if we just focus on quantity, social isolation is a risk factor. Social isolation is associated with functional decline and death. For example, loneliness among heart failure patients nearly quadruples their risk of death, and it increases their risk of hospitalization by 68%. A meta-study on the effects of social isolation found significant mortality effects, where people in the 'loneliest quintiles had 30% higher all-cause mortality rates.
Suicide deaths are a relevant metric, but national data has a couple-year lag. We know that in 2018 there were 48,000 deaths from suicide and at least 1.4 million attempts, and in 2019, almost 71,000 people died from drug overdoses, many of which were suicide-related. There have been anecdotal reports that suicides are up, and it's concerning that the Social Justice Warriors are quick to lobby Twitter to censor these reports as if any information or even discussion of the costs of the lockdown is dangerous. Our uber-rational elite sees no value in debating the costs and benefits of our extreme response, just like the state-run media in one-party states.
University Data: 0.0007% Case Fatality Rate
While one can re-label a standard pneumonia death as covid, this is not possible for young people who rarely die of pneumonia. Further, given their excellent health, young people do not put themselves in situations to receive iatrogenic medical treatment or feel the effects of restricted access to health providers.
As mentioned, opportunistic infections are common in people near death, and there are strong incentives and easy ability to label a decedent as a covid death, regardless of its relevance. This makes the standard CDC data susceptible to massive inflation. An ideal estimation procedure would test a random sample of people, and then for those who test positive, check if they are alive in a couple of months. This removes many of the above-mentioned biases. Universities have done something close to this. As schools were cautious about the PR debacle if they were a covid-death hot-spot, universities were well equipped to test their students in order to keep them from spreading the virus. They would test those arriving, those with minor symptoms, and those without symptoms who were in contact with someone who tested positive. It is not perfectly random in that they will miss asymptomatic cases that were not in known contact with a covid positive person, but it's the most bias-resistant metric we have.
In contrast, the CDC's total covid deaths by age group show 428 deaths for the 15-24-year-old grouping and 1006 deaths in the 18-29 year-old grouping, which implies a death rate of 0.001% to 0.002% among ALL people in this group. Given the CDC reports that 5% of this demographic has tested positive, this would imply a 0.03% case fatality rate. The case fatality rate for college students who tested positive is about 1/25th of this (0.0007%). Given the large sample size, you can reject the hypothesis that these fatality rates are equal at any conventional significance level.
Avg Age at Covid Death > Avg Age at Death
Paradoxically, a typical plague affects the young more than the old. While the old die at high rates in a plague, they die at high rates anyway, they're old. The increase in excess deaths centers on the more numerous young, who start at a much lower normal mortality rate. For example, in the non-politicized Avian flu, the average age at death was 48, well below the usual average age at death, which is about 75. Ebola and AIDS killed mostly young people. Older people are more immune to viruses of all sorts, which is why kindergarten teachers rarely get colds, while children need to suffer through the process of getting infected to get immunity. Older people are less likely to socialize or wrestle (competitively or amorously). We should see a significant effect of a deadly new virus among young adults and infants who are more exposed and less biologically prepared for a novel virus strain, but we do not.
Below we see the most Spanish Flu deaths were among those under 45 years old, with a peak at 27. Though this chart is for select cities, it was a general pattern (see here, here, or here). In contrast, those under 45 represent 3% of total covid deaths according to the CDC, and covid deaths increase by age group, even though the total population starts to fall at 65.
The CDC warehouses a large amount of data, mostly in categories of no significance, as if their purpose is to hide the truth. I could only find case rate in groupings of 10-19, and deaths in 15-24 (etc.), so I had to do some interpolations. Further, the case data by age was about half of the total cases, so I basically multiplied the case data by 2 to get cases by age group. Using this data we can estimate the case fatality rate for the age group, dividing covid deaths by cases. For those under 45, the mortality rate conditional upon getting covid is less than or equal to the all-cause mortality rate. In other words, if you test positive for covid and are under 45, your risk of dying does not increase. Covid is just a regular cold (coronavirus) for healthy people. I could not find a prior pandemic with an average age at death greater than the all-cause average age at death (75 vs. 73), but suggestions are welcome.
CDC Death and Case Data (see here and here)
|Covid Deaths||All Deaths||Pop(K)||Cases(K)||Covid CFR||Overall Mort Rate|
|< 1 yr||29||14,582||3,783||27||0.11%||0.39%|
|> 85 yrs||74,722||771,228||6,605||418||17.88%||11.68%|
|Avg Age at Death||75.6||73.0|
We have seen an extra 378k deaths this year over the prior 5-year average. It seems reasonable to attribute 50k of that from covid. However, the rest is probably the result of increased isolation, lack of standard care, and medical malpractice.
I failed to appreciate how this virus would become the tool of the Left, not merely to replace Trump, but to implement all sorts of comprehensive government policies. Jane Fonda was honest enough to state that covid was "God's gift to the Left," and the Left now has no shame in saying we should 'never let a crisis go to waste (this tactic was initially attributed to right-wingers by Naomi Klein and considered unethical).'
Asian and African countries do not have Western-style liberal parties. For example, there is no great call for third-world immigration in Japan, and they have a small footprint at Davos. Thus, they have considerably less incentive to inflate covid death counts. They have all passed through this virus the way the US passed through the avian flu, with a cumulative covid death rate as a percent of the population orders of magnitude smaller than in the West. Haiti, South Korea, Cuba, Venezuela, Japan, China, Nigeria, Ethiopia, Congo, Singapore, Zimbabwe, and Vietnam all have trivial covid death rates. These countries vary considerably in economic development, only sharing independence from Western political priorities.
If the covid panickers merely cared about covid and not its broader implications, they would emphasize low-cost, simple correctives, such as recommending vitamins C and D, zinc, aspirin (anti-coagulant), and exercise. They would also not grant legal and moral exemptions for Black Lives Matter gatherings. The higher truth in this farce is that the various emergency responses to the pandemic pave the way for further institutional changes and progressive policies. For example, if one gives up at the first sign of problems, no policy will ever work, no matter how good it is. Thus, leaders of new policies hate criticism, because they are 'all-in,' tied to that policy's success, while outside critics have the luxury of simply saying they should try something else. The net result is that those in charge discourage mentioning discrediting information, why one-party states never have a free press. Currently, many obvious anomalies to the covid narrative are actively suppressed as misinformation that threatens public health. Once suppressing these stories becomes common, it is easier to then also suppress criticisms of global warming, immigration policies, or Title IX expansions.
"We have seen an extra 378k deaths this year over the prior 5-year average. It seems reasonable to attribute 50k of that from covid. However, the rest is probably the result of increased isolation, lack of standard care, and medical malpractice."
There is no empirical evidence with this 50K number whatsoever.
The blog post is rich of wild inferences and aggregates.
"Financial incentives aggravated the overuse of ventilators. In the United States, the government pays approximately $13,000 for a regular COVID-19 patient, but $39,000 for an intubated patient. A ventilator is a cash cow for medical facilities."
Aside from the fact that this statement is unsourced, I would warn against thinking by aggregates. I can tell from direct experience that Mount Sinai Helth Care System, the largest health care provider in the city most affected by COVID, suffers from sever financial shortfall caused by overextension of its ICU facilities in March-June 2020.
The entire post relies on the statement that deaths from COVID were overstated; anecdotes and motive imputations add little. And it relies on the statement 'Measuring for the appearance of a particular virus, regardless of these co-morbidities, is misleading, and why historically, no one has ever used the "died with" protocol for attributing the underlying cause of death (UCOD).' I am not sure about the "no one has ever used" part. A very strong statement, and unsubstantiated.
As per death "with" vs "from" COVID, the idea that at the margin COVID caused the death seems very defensible. In order to be persuasive, you should come up with credible estimates of the ratio LR below. On the population of people with comorbidities, let D=dying, C=contracting COVID; and let !D=not dying, i.e. the complementary event.
P(D|C)/P(!D|C) = P(D)/P(!D)*LR (Bayes theorem in odds form)
LR:=P(C|D)/P(C|!D). The ratio of infection rates among deceased and among non-deceased people with comorbidities matter. I think you can proxy P(C|!D) with 13M/331M = 4% (the infection rate in the US). Now, I believe, but am willing to change my mind given evidence, that P(C|D) >> 4%.
But overall the post is a bit rambling and would benefit from trimming and some editing ("People are social, why the worst one of the worst punishments in Roman times was exile.")
Unsourced? There's a link to an adversarial fact-checker, Snopes. The USA Today fact-checker rated it true.
If we applied the 'dying with' protocol to other coronaviruses using your logic we would see the same result: viral loads for all pathogens increase when a person's immune system shuts down, which often happens just before death. Alas, we have no data on other coronaviruses, or even influenza, because no one thought this method for attributing death was informative.
We do apply the 'dying with' logic to HIV...but that's the CDC, and it's just as misleading.
What is unsourced is the statement "A ventilator is a cash cow for medical facilities". The reimbursement difference means very little because it does not prove that hospital systems receive higher profits by moving patients to ICUs. My experience is very much the opposite.
No, I completely disagree with the statement that "If we applied the 'dying with' protocol to other coronaviruses using your logic we would see the same result". I am not an expert on the subject, and neither are you, I surmise. But at least I proposed an evidentiary standard. There are different ones (and more rigorous); for example, one could apply the "do" calculus of J.Pearl to this problem. I am fine with discussing and checking the evidence under any of them. My point is that your post doesn't even have one. It's a bunch of disorganized observations and anecdotes that aren't even wrong. The 250K may be somewhat incorrect, but this post doesn't help me identify neither the size nor the sign of the error. Other readers' mileage may vary.
I think you lost the bet fair and square and the excess mortality being reported in the USA is not primarily due to increased isolation, lack of standard care, or medical malpractice.
My primary reason to believe this is the case is the lack of excess mortality in Australia and New Zealand, which have implemented severe lockdowns and had very significant disruptions to standard care (cancellation of elective surgeries, remote telehealth), but have reported increased mortality only in line with coronavirus positive cases. In the case of NZ, the number of cases was so low there was no excess mortality. I am based in Australia but a New Zealand citizen so I am familiar with the situation in both of these countries.
I largely agree with your interesting points regarding mortality early in the epidemic (March April 2020) being probably associated with excessive use of ventilators, and the MERS / SARS mortality rates driving hospital protocols early, but I think you are mistaken that this is quantitatively the major driver of the excess mortality. I see the current (Dec 2020) mortality rates of 2,500 USA deaths per day, even where medical treatment protocols have improved and evolved, as being important counter evidence.
Finally, your assessment of the mortality increase by age being suspiciously different to other pandemics, and substantially different from the 1918 influenza pandemic: Yes I agree the age based mortality rates are different, but I don't think that is enough to conclude that the mortality of COVID-19 is therefore largely iatrogenic. The 1918 pattern was driven by a historical circumstances around that pandemic, where a previous pandemic in 1890 became the dominant strain initially infecting everyone born between 1890 and 1918. That initial infection drove their immune system away from developing immunity to the 1918 pandemic. People born before 1890 had an initial infection with influenza strains that were more likely to generate cross-reactivity to the 1918 strain, which is why you see the interesting mortality pattern in the 1918 pandemic. Pre-existing immunity is an interesting mix of genetic background and previous exposure, it's complicated. I have a particular interest in this because of the New Zealand history of breaking quarantine on the Cook Islands in 1918, so I've done a bit of reading around the historical situation.
Hope you can accept these alternate viewpoints.
Australia and New Zealand are relatively immune from the excess death spike, though they do have strict lockdowns. Thus, I agree that lockdowns themselves are not iatrogenic. The policies often associated with them, however, are highly suspect. Standard health care is down significantly (25-50%), and old people are isolated from their families in facilities that also discourage human interaction of all sorts. This is a recipe for death, and pneumonia is the common mechanism for this in old people. Our health care experts are focused on a vaccine, and say nothing about simple things like exercise, vitamin D, etc., which I find frustrating as if their goal is to make sure the people understand they can only be saved by things they cannot do themselves.
I haven't yet seen a plague where the age of death for the virus was greater than the normal age of death. See https://bit.ly/3mELa14 for an example of some data. There was Legionnaire's disease (1977), but the etiology of that is highly disputed (it broke out at a convention of old people, and could be selection bias). Note that older people should have much more familiarity with coronaviruses of all sorts, and so, like 1890 to 1918, there are good reasons to expect older people to suffer less. Given this age peculiarity and the absence of this disease in countries like Haiti, I'm inclined to think this is a big nothing, a world-wide panic over a novel cold virus, that hit the 2003 SARS template.
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