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On COVID, NPIs, and “Human” Data Points

24 Tuesday Nov 2020

Posted by pnoetx in Lockdowns, Pandemic, Public Health

≈ 1 Comment

Tags

Alzheimer's, Anthony Fauci, Asymptomatic Carriers, Cancer, CDC, Centers for Disease Control, Covid-19, Dementia, Domestic Abuse, Education, HIV, Human Costs, Journal of the American Medical Association, Lancet, Lockdowns, Malaria, Malignant Neoplasms, Mandates, Masks, Public Health, Robert Redfield, SAAAD, SARS-CoV-2, Starvation, Suicide, The Ethical Skeptic, Tuberculoosis, Tyler Cowen, United Nations, Vitamin D

The other day a friend told me “your data points always seem to miss the people points.” He imagines a failure on my part to appreciate the human cost of the coronavirus. Evidently, he feels that I treat data on cases, hospitalizations, and deaths as mere accounting issues, all while emphasizing the negative aspects of government interventions.

This fellow reads my posts very selectively, hampered in part by his own mood affiliation. Indeed, he seems to lack an appreciation for the nuance and zeitgeist of my body of blogging on the topic… my oeuvre! This despite his past comments on the very things he claims I haven’t mentioned. His responses usually rely on anecdotes relayed to him by nurses or doctors he knows. Anecdotes can be important, of course. But I know nurses and doctors too, and they are not of the same mind as his nurses and doctors. Anecdotes! We’re talking about the determination of optimal policy here, and you know what Dr. Fauci says about relying on anecdotes!

Incremental Costs and Benefits

My friend must first understand that my views are based on an economic argument, one emphasizing the benefits and costs of particular actions, including human costs. COVID is dangerous, but primarily to the elderly, and no approach to managing the virus is free. Here are two rather disparate choices:

  1. Mandated minimization of economic and social interactions throughout society over some time interval in the hope of reducing the spread of the virus;
  2. Laissez faire for the general population while minimizing dangers to high-risk individuals, subject to free choice for mentally competent, high-risk individuals.

To be clear, #2 entails all voluntary actions taken by individuals to mitigate risks. Therefore, #1 implies a set of incremental binding restrictions on behavior beyond those voluntary actions. However, I also include in #1 the behavioral effects of scare mongering by public officials, who regularly issue pronouncements having no empirical basis.

The first option above entails so-called non-pharmaceutical interventions (NPIs) by government. These are the elements of so-called lockdowns, such as quarantines and other restrictions on mobility, business and consumer activity, social activities, health care activities, school closures, and mask mandates. NPIs carry costs that are increasing in the severity of constraints they impose on society.

And before I proceed, remember this: tallying all fatal COVID cases is really irrelevant to the policy exercise. Nothing we do, or could have done, would save all those lives. We should compare what lives can be saved from COVID via lockdowns, if any, with the cost of those lockdowns in terms of human life and human misery, including economic costs.

Economic Losses

NPIs involve a loss of economic output that can never be recovered… it is gone forever, and a loss is likely to continue for some time to come. That sounds so very anodyne, despite the tremendous magnitude of the loss involved. But let’s stay with it for just a second. The loss of U.S. output in 2020 due to COVID has been estimated at $2.5 trillion. As Don Boudreaux and Tyler Cowen have noted, what we normally spend on safety and precautionary measures (willingness-to-pay), together with the probabilities of losses, implies that we value our lives at less than $4 million on average. Let’s say the COVID death toll reaches 300,000 by year-end (that’s incremental in this case— but it might be a bit high). That equates to a total loss of $1.2 trillion in life-value if we ignore distinctions in life-years lost. Now ask this: if our $2.5 trillion output loss could have saved every one of those 300,000 lives, would it have been worth it? Not even close, and the truth is that the sacrifice will not have saved even a small fraction of those lives. I grant, however, that the economic losses are partly attributable to voluntary decisions, but goaded to a great extent by the alarmist commentary of public health officials.

The full depth of losses is far worse than the dollars and cents comparison above might sound. Output losses are always matched by (and, in value, are exactly the same as) income losses. That involves lost jobs, lost hours, failed businesses, and destroyed careers. Ah, now we’re getting a bit more “human”, aren’t we! It’s nothing short of callous to discount these costs. Unfortunately, the burden falls disproportionately on low-income workers. Our elites can mostly stay home and do their jobs remotely, and earn handsome incomes. The working poor spend their time in line at food banks.

Yes, government checks can help those with a loss of income compete with elites for the available supply of goods, but of course that doesn’t replace the lost supply of goods! Government aid of this kind is a palliative measure; it doesn’t offset the real losses during a suspension of economic activity.

Decimated Public Health

The strain of the losses has been massive in the U.S. and nearly everywhere in the world. People are struggling financially, making do with less on the table, depleting their savings, and seeking forbearance on debts. The emotional strains are no less real. Anxiety is rampant, drug overdoses have increased, calls to suicide hotlines have exploded, and the permanence of the economic losses may add to suicide rates for some time to come. Dr. Robert Redfield of the CDC says more teenagers will commit suicide this year than will die from COVID (also see here). There’s also been a terrifying escalation in domestic abuse during the pandemic, including domestic homicide. The despair caused by economic losses is all too real and should be viewed as a multiplier on the total cost of severe NPIs.

More on human costs: a health care disaster has befallen locked-down populations, including avoidance of care on account of panic fomented by so-called public health experts, the media, and government. Some of the consequences are listed here. But to name just a few, we have huge numbers of delayed cancer diagnoses, which sharply decrease survival time; mass avoidance of emergency room visits, including undiagnosed heart attacks and strokes; and unacceptable delays in cardiac treatments. Moreover, lockdowns worldwide have severely damaged efforts to deal with scourges like HIV, tuberculosis, and malaria.

The CDC reports that excess mortality among 25-44 year-olds this year was up more than 26%, and the vast bulk of these were non-COVID deaths. A Lancet study indicates that a measles outbreak is likely in 2021 due to skipped vaccinations caused by lockdowns. The WHO estimates that 130,000,000 people are starving worldwide due to lockdowns. That is roughly the population of the U.S. east coast. Again, the callousness with which people willfully ignore these repercussions is stunning, selfish and inhumane, or just stupid.

Excess Deaths

Can we quantify all this? Yes we can, as a matter of fact. I’ve offered estimates in the past, and I already mentioned that excess deaths, COVID and non-COVID, are reported on the CDC’s web site. The Ethical Skeptic (TES) does a good job of summarizing these statistics, though the last full set of estimates was from October 31. Here is the graphic from the TES Twitter feed:

Note particularly the huge number of excess deaths attributable to SAAAD (Suicide, Addiction Abandonment, Abuse and Despair): over 50,000! The estimate of life-years lost due to non-COVID excess deaths is almost double that of COVID deaths because of the difference in the age distributions of those deaths.

Here are a few supporting charts on selected categories of excess deaths, though they are a week behind the counts from above. The first is all non-COVID, natural-cause excess deaths (the vertical gap between the two lines), followed by excess deaths from Alzheimer’s and dementia, other respiratory diseases, and malignant neoplasms (cancer):

The clearest visual gap in these charts is the excess Alzheimer’s and dementia deaths. Note the increase corresponding to the start of the pandemic, when these patients were suddenly shut off from loved ones and the company of other patients. I also believe some of these deaths were (and are) due to overwhelmed staff at care homes struck by COVID, but even discounting this category of excess deaths leaves us with a huge number of non-COVD deaths that could have been avoided without lockdowns. This represents a human cost over and above those tied to the economic losses discussed earlier.

Degraded Education and Health

Lockdowns have also been destructive to the education of children. The United Nations has estimated that 24 million children may drop out of school permanently as a result of lockdowns and school closures. This a burden that falls disproportionately on impoverished children. This article in the Journal of the American Medical Association Network notes the destructive impact of primary school closures on educational attainment. Its conclusions should make advocates of school closures reconsider their position, but it won’t:

“… missed instruction during 2020 could be associated with an estimated 5.53 million years of life lost. This loss in life expectancy was likely to be greater than would have been observed if leaving primary schools open had led to an expansion of the first wave of the pandemic.“

Lockdown Inefficacy

Lockdowns just don’t work. There was never any scientific evidence that they did. For one thing, they are difficult to enforce and compliance is not a given. Of course, Sweden offers a prime example that draconian lockdowns are unnecessary, and deaths remain low there. This Lancet study, published in July, found no association between lockdowns and country mortality, though early border closures were associated with lower COVID caseloads. A French research paper concludes that public decisions had no impact on COVID mortality across 188 countries, U.S. states, and Chinese states. A paper by a group of Irish physicians and scientists stated the following:

“Lockdown has not previously been employed as a strategy in pandemic management, in fact it was ruled out in 2019 WHO and Irish pandemic guidelines, and as expected, it has proven a poor mitigator of morbidity and mortality.”

One of the chief arguments in favor of lockdowns is the fear that asymptomatic individuals circulating in the community (and there are many) would spread the virus. However, there is no evidence that they do. In part, that’s because the window during which an individual with the virus is infectious is narrow, but tests may detect tiny fragments of the virus over a much longer span of time. And there is even some evidence that lockdown measures may increase the spread of the virus!

Lockdown decisions are invariably arbitrary in their impact as well. The crackdown on gyms is one noteworthy example, but gyms are safe. Restaurants don’t turn up in many contact traces either, and yet restaurants have been repeatedly implicated as danger zones. And think of the many small retailers shut down by government, while giant competitors like Wal-Mart continue to operate with little restriction. This is manifest corporatism!

Then there is the matter of mask mandates. As readers of this blog know, I think masks probably help reduce transmission from droplets issued by a carrier, that is, at close range. However, this recent Danish study in the Annals of Internal Medicine found that cloth masks are ineffective in protecting the wearer. They do not stop aerosols, which seem to be the primary source of transmission. They might reduce viral loads, at least if worn properly and either cleaned often or replaced. Those are big “ifs”.

To the extent that masks offer any protection, I’m happy to wear them within indoor public accommodations, at least for the time being. To the extent that people are “scared”, I’m happy to observe the courtesy of wearing a mask, but not outside in uncrowded conditions. To the extent that masks are required under private “house rules”, of course I comply. Public mask mandates outside of government buildings are over the line, however. The evidence that those mandates work is too tenuous and our liberties are too precious too allow that kind of coercion. And private facilities should be subject to private rules only.

QED

So my poor friend is quite correct that COVID is especially deadly to certain cohorts and challenging for the health care community. But he must come to grips with a few realities:

  • The virus won’t be defeated with NPIs; they don’t work!
  • NPIs inflict massive harm to human well-being.
  • Lockdowns or NPIs are little or no gain, high-pain propositions.

The rejection of NPI’s, or lockdowns, is based on compelling “human” data points. As Don Boudreaux says:

“The lockdowns and other restrictions on economic and social activities are astronomically costly – in a direct economic sense, in an emotional and spiritual sense, and in a ‘what-the-hell-do-these-arbitrary-diktats-portend-for-our-freedom?’ sense.” 

This doctor has a message for the those denizens of social media with an honest wish to dispense helpful public health advice:

“Americans have admitted that they will meet for Thanksgiving. Scolding and shaming them for wanting this is unlikely to slow the spread of SARS-CoV-2, though it may earn you likes and retweets. Starting with compassion, and thinking of ways they can meet, but as safely as possible, is the task of real public health. Now is the time to save public health from social media.”

And take some Vitamin D!

The Favored Cause of Death

19 Monday Oct 2020

Posted by pnoetx in Coronavirus, Public Health

≈ Leave a comment

Tags

All-Cause Mortality, Andrew Bostom, Andrew Cuomo, Cause of Death, Centers for Disease Control, Clinical Events, Coronavirus, Death Certificate, False Positives, Florida House of Representatives, Hospice Deaths, Justin Hart, Lockdown Deaths, Non-COVID Deaths. Co-Morbidities, PCR Tests, Specificity, Testing

The CDC changed its guidelines on completion of death certificates on April 5th of this year, and only for COVID-19 (C19), just as infections and presumed C19 deaths were ramping up. The substance of the change was to broaden the definition under which death should be attributed to C19. This ran counter to CDC guidelines followed over the previous 17 years, and the change not only makes the C19 death counts suspect: it also makes comparisons of C19 deaths to other causes of death unreliable, since only C19 is subject to the new CDC guidance. That’s true for concurrent and historical comparisons. The distortions are especially bad relative to other respiratory diseases, but also relative to other conditions that are common in mortality data.

The change in the CDC guidelines was noted in a recent report prepared for the Florida House of Representatives. It was brought to my attention by a retweet by Justin Hart linked to this piece on Andrew Bostom’s site. Death certificates are divided into two parts: Part 1 provides four lines in which causes of death are listed in reverse clinical order of events leading to death. Thus, the first line is the final clinical condition precipitating death. Prior clinical events are to be listed below that. The example shown above indicates that an auto accident, listed on the fourth line, initiated the sequence of events. Part 2 of the certificate is available for physicians or examiners to list contributing factors that might have played a role in the death that were not part of the sequence of clinical events leading to death.

The CDC’s change in guidelines for C19, and C19 only, made the criteria for inclusion in Part 1 less specific, and it essentially eliminated the distinction between Parts 1 and 2. The following appears under “Vital Records Criteria”:

“A death certificate that lists COVID-19 disease or SARS-CoV-2 as a cause of death or a significant condition contributing to death.”

How much difference does this make? For one thing, it opens the door to C19-attributed deaths in cases of false-positive PCR tests. When large cohorts are subject to testing — for example, all patients admitted to hospitals — there will always be a significant number of false positives even when test specificity is as high as 98 – 99%.

The elimination of any distinction between Parts 1 and 2 causes other distortions. A review of the Florida report is illustrative. The House staff reviewed almost 14,000 certificates for C19-19 attributed deaths. Over 9% of those did not list C19 among the clinical conditions leading to death. Instead, in those cases, C19 was listed as a contributing factor. Under the CDC’s previous guidelines, those would not have been counted as C19 deaths. The Florida House report is conservative in concluding that the new CDC guidelines inflated C19 deaths by only those 9% of the records examined.

There are reasons to think that the exaggeration was much greater, however. First, the Florida House report noted that nearly 60% of the certificates contained information “recorded in a manner inconsistent with state and national guidance”. In addition, almost another 10% of the fatalities were among patients already in hospice! Do we really believe the deaths of all those patients whose diseases had reached such an advanced stage should be classified as C19 fatalities? And another 1-2% listed non-C19 conditions as the immediate and underlying causes.

Finally, more than 20% of the certificates listed C19 alone as a cause of death despite a range of other contributing conditions or co-morbidities. This in itself may have been prompted by the change in the CDC’s guidelines, as the normal standards often involve a “comorbidity” as the initial reason for hospitalization — in that case a clinical event ordinarily listed in Part 1. The high rate of errors and the fact that roughly two-thirds of the deaths reviewed occurred in the hospital, where patients are all tested and often multiple times, raises the specter that up to 20% more of the C19 deaths were either erroneous and/or misclassified due to false positives.

(An exception may have occurred in New York, where an order issued in March by Governor Andrew Cuomo to return C19-positive residents of nursing homes (including suspected C19 cases) back to those homes, The order was made before the change in CDC guidelines and wasn’t rescinded until later in April. There is reason to believe that some of the C19 deaths among nursing home residents in New York were undercounted.)

All told, in the Florida data we have potential misclassification of deaths of 9% + 9% + 2% + 20% = 40%, or inflation relative to actual C19 deaths of up to 40%/60% = 67%! I strongly doubt it’s that high, but I would not consider a range of 25% – 50% exaggeration to be unreasonable.

We know that reports of C19 deaths lag actual dates of death by anywhere from 1 to 8 weeks, sometimes even more. This is misleading when no effort is made to explain that difference, which I’ve never heard out of a single journalist. We also know that false positive tests inflate C19 deaths. The Florida report gives us a sense of how large that exaggeration might be. In addition, the Florida data show that the CDC guidelines inflate C19 deaths in other ways: as a mere contributing factor, it can now be listed as the cause of death, unlike the treatment of pneumonia as a contributing factor, for instance. The same kind of distortion occurs when patients contract C19 (or have a false positive test) while in hospice.

There is no doubt that C19 led to “excess deaths” relative to all-cause mortality. However, many of these fatalities are misclassified, and it’s likely that a large share were and are lockdown deaths as opposed to C19 deaths. That’s tragic. The CDC has done the country a massive disservice by creating “special rules” for attributing cause-of-death to C19. If reported C19 fatality rates reflected the same rules applied to other conditions, our approach to managing the pandemic surely would have inflicted far less damage to health and economic well being.

CDC Sows Covid Case-Fatality Confusion

15 Wednesday Apr 2020

Posted by pnoetx in Data Integrity, Pandemic

≈ Leave a comment

Tags

Case Fatality Rate, Centers for Disease Control, Co-Morbidities, Coronavirus, Covid "Hot Spots", Covid-119, Crisis Management, Data Integrity, Death Toll, Excess Deaths, Government Accounting, Influenza, New York Deaths, Probable Deaths, Respiratory Disease, Testing Guidelines

The Centers for Disease Control has formally decided to inflate statistics on coronavirus deaths by adding so-called “probable” cases to the toll. This news follows the announcement yesterday that New York decided to add, in one day, about 4,000 deaths from over the past month to its now “probable” Covid-19 death toll. So much for clean accounting! We have a confirmed death toll up to April 14th. We have a probable death toll after. The error in timing alone introduced by this abrupt adjustment impairs efforts to track patterns of change. Case fatality rates are rendered meaningless. Data integrity, which was already weak, has been thrown out the window by our public heath authorities.

It’s no longer necessary for a deceased patient to have tested positive for Covid-19:

“A probable case or death is defined as one that meets clinical criteria such as symptoms and evidence of the disease with no lab test confirming Covid-19. It can also be classified as a probable case if there are death or other vital records listing coronavirus as a cause. A third way to classify it is through presumptive laboratory evidence and either clinical criteria or evidence of the disease.”

Consider the following:

  • to date, more than 80% of patients presenting symptoms sufficient to meet testing guidelines have tested negative for Covid-19;
  • the most severe cases of Covid-19 and other respiratory diseases are coincident with significant co-morbidities;
  • “probable” cases appear to be concentrated among the elderly and infirm, whose regular mortality rate is high.

Deaths involving mere symptoms, or mere symptoms and co-morbidities, and even deaths of undetermined cause, are now more likely to be over-counted as Covid-19 deaths. This is certain to distort, and I believe overcount, Covid-19 deaths. Of course, this was already happening in some states, as I mentioned last week in “Coronavirus Controversies“.

One of the charts I’ve presented in my Continue%20reading Coronavirus “Framing” posts tracks Covid-19 deaths. The change in these cause-of-death guidelines will make continued tracking into something of a farce. I’d be tempted to deduct the one-day distortion caused by the New York decision, but then the count will still be distorted going forward by the broader definition of Covid-19 death.

The only possible rationale for these decisions by New York and the CDC is that testing is still subject to severe rationing. I have my doubts, as the number of daily tests has stabilized. On the other hand, I have heard anecdotes about hospitals with large numbers of respiratory patients who have not been tested! And they are intermingling all of these patients?? I’m not sure I can reconcile these reports. Surely the patients meet the guidelines for testing. Perhaps the CDC’s decision is associated with an effort to spread testing capacity by allowing only new patients to be tested, counting those already hospitalized as presumptively Covid-infected. And if they aren’t already, they will be! A decision to count deaths within that group as “probable” Covid deaths  would fit conveniently into that approach, but that would be wildly misguided and perverse.

I’m obviously cynical about the motives here. I don’t trust government accounting when it bears on the credit or blame for crisis management. Who stands to gain from a higher Covid death toll? The CDC? State health authorities? “Hot spots” vying for federal resources?

A consistent approach to attributing cause of death would have been more useful for gauging the direction of the pandemic, but as I’ve said, there will always be uncertainty about the true Covid-19 death toll. Ultimately, the best estimates will have to rely on calculations of “excess deaths” in 2020 compared to a “normal” level from a larger set of causes. In fact, even that comparison will be suspect because the flu season leading up to the Covid outbreak was harsh. Was it really the flu later in the season?

Left’s Pandemic Response: Politics As Usual

17 Tuesday Mar 2020

Posted by pnoetx in Health Care, Pandemic, Regulation

≈ 2 Comments

Tags

Biodefense, Breitbart.com, CDC, Centers for Disease Control, Coronavirus, ebola, FDA, Glenn Reynolds, Infectious Diseases, John Bolton, Legal Insurrection, Leslie Eastman, Nancy Pelosi, National Biodefense Strategy, National Security Council, NSC, Pandemic Response Team, Richard Goldberg, Ronald Bailey, Ronna McDaniel, Tim Morrison

The Left asserts that President Trump dismissed and dismantled the nation’s Pandemic Response Team. That’s bullshit. So is the claim that the CDC was defunded. The news media and certain pundits have helped to feed this narrative. Or, as Glenn Reynolds calls those pundits, “Democrat operatives with bylines”.

First of all, the team in question was not at the CDC, a fact that hasn’t always been clear from the commentary on this issue. It was a team of White House overseers at the National Security Council’s “Directorate for Global Health Security and Biodefense”. What happened was this: the senior director of that team resigned after John Bolton was appointed to head the NSC. Bolton might have wanted him out, but what we know is the director resigned. Subsequently, that team was folded into another directorate as part of an long-overdue consolidation. Health experts from the team remain on the NSC staff today. Yet Sen. Sherrod Brown (D-OH)—and many others since—had the temerity to charge that Trump had fired “the entire Whilte House pandemic team”. Well, at least he didn’t imply that it was the CDC.

Tim Morrison wrote the following in the Washington Post yesterday:

“Because I led the very directorate assigned that mission, the counterproliferation and biodefense office, for a year and then handed it off to another official who still holds the post, I know the charge is specious. …

When I joined the National Security Council staff in 2018, I inherited a strong and skilled staff in the counterproliferation and biodefense directorate. This team of national experts together drafted the National Biodefense Strategy of 2018 and an accompanying national security presidential memorandum to implement it; an executive order to modernize influenza vaccines; and coordinated the United States’ response to the Ebola epidemic in Congo, which was ultimately defeated in 2020.”

This assessment at Brietbart.com quotes former senior NSC official Richard Goldberg:

“Weird. A year later I was inside the NSC working with talented global health/biodefense professionals who coordinated an incredibly effective response to Ebola. They’re still there. Working hard. On #Covid_19.”

It’s true that Bolton sought to eliminate red tape, duplication, and bureaucracy within the NSC, and that was wholly justified. According to Morrison, the NSC staff quadrupled from the 1990s through the second Obama term. Pandemics are supposed to be the CDC’s purview, but the proliferation of administrative layers is what happens as government grows uncontrollably. Leslie Eastman at Legal Insurrection questions whether the U.S. needs a permanent “Pandemic Response Team” in the White House. She quotes GOP Chairwoman Ronna McDaniel:

“JAN 7: CDC established a coronavirus incident management system, two days before China announced the outbreak. … Pelosi began Week 3 of withholding her sham impeachment articles. 

JAN 21: The CDC activated its emergency operations center to provide ongoing support to confront coronavirus. …What were Congressional Democrats focused on? Writing their opening arguments for their bogus impeachment trial.”

Well, bully for the CDC. As for “defunding the CDC”, the facts are this: the proposed budget submitted to Congress by the Trump Administration in February, but never passed, did indeed include cuts to the CDC’s budget, which has grown over the years as it expanded its mission from fighting infectious diseases to matters like obesity, racism, and questions of social justice. The cuts proposed by Trump, however, were primarily to state grants. Actually, the proposal called for increased CDC staffing, and it funded all programs related to infectious diseases. But no matter, because that proposal is unlikely to become part of any appropriations bill that would pass Congress.

True to form, the Left plays politics in the middle of a national crisis. When the Trump Administration told airlines that it was considering banning flights from China in late January, it was called racist. Now, of course, he hasn’t done enough. A huge irony, however, is that Trump’s biggest mistake was in trusting the FDA and the CDC’s authority to develop and regulate testing for the coronavirus. They botched it. In a classic case of over-regulation, they prohibited hospitals and labs from conducting tests developed privately or by academic researchers, insisting that everyone wait for the “approved” test to be distributed. Then, the test they released in early February was flawed, costing additional weeks before testing was available.

 

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