Category: Health & Medicine

Adieu to the felon Trump

A last chance for commenters to let off steam.

The loyal remnant of RBC readers deserve one last chance to let off steam about Donald Trump.

Your budget foreign soothsayer predicts:

1. Based on current polls: Joe Biden will be elected President in November, quite comfortably (high probability, strong evidence, as the IPCC would say). Democrats will get a thin majority in the Senate (medium probability, weak evidence) and hold their 2018 gains in the House.

2. “In one year many things can happen. I may die. The king may die. And perchance the horse will learn to sing.”  Biden, Trump and Murdoch are all old men, living like me through a dangerous pandemic. Life insurance salesmen are not queuing at our doors. There is a significant chance the election will not be between Biden and Trump. Suppose it’s a contest between Abrams and Hawley? The best you can say is that Ms Generic Democrat beats Mr Generic Republican. Fox News either stays the same or implodes; the upside is all for the Democrats.

3. Current polls do not reflect the full impact of the coronavirus disaster. Trump’s increasingly unhinged behaviour (injecting disinfectant? WTF?) suggests his lizard brain fears the worst, and it’s right to do so.

Cumulative US deaths today are 50,000, about at the peak daily rate. The total death toll will therefore be at least 100,000. Check: Spain today, well past the peak, is at 22,000. Say ultimate toll of 25,000. Scale up to the USA by population (x 7.6) and you get 190,000. Spain, after a poor start, now has a well-enforced national lockdown, credible plans for a phased exit, and a decent income support safety net. The poor US safety net is leading to a chaotic and premature lockdown exit, giving the pandemic a long tail and ensuring an anaemic economic recovery. These predictions are pretty safe. Together they could easily lead to a wave election defeat for Trump and his party, on a par with 1932.

  •     *     *     *     *     *

On behalf of all us bloggers, a heartfelt thank you to all our readers and commenters over the years.

The coronavirus disaster in Brazil

Brazil should take the Imperial College models seriously.

This post is mainly intended for my Brazilian family and friends, since it’s too long for a Facebook post. Others may find it a change from their local tragedies.

Imagine a big country with an unqualified populist elected as President who compares the Covid-19 virus to the flu, has accused the media of hyping the risk for underhand political motives, challenges death statistics, picks a fight with the governor of the most populous state including its largest city, talks frequently of an early return to work, and disregards social distancing rules himself? Not the USA but Brazil under Jair Bolsonaro. See also Wikipedia. Meanwhile the plague advances as desperate state governors declare uncoordinated lockdowns, and health care professionals complain of a shortage of masks and ventilators, well before any peak. Some drug kingpins are enforcing lockdown in their favela fiefdoms at gunpoint.

Remember that sickening moment on 9/11 when you realized that the collapsing skyscrapers were not from a disaster movie, but the horrifyingly real thing? That’s Brazil today.

Into this chaos step the high-minded foreign experts. On March 26, the industrious mathematical epidemiologists at Imperial College (Walker, Whittaker et multi) released their Report 12 (pdf) extending their scenarios from the UK and the USA, as in report 9, to 102 countries. The O Globo newspaper got hold of the data spreadsheet (xls here; extract for Brazil only by me here) and published what looks like an accurate summary. Judging by the Facebook posts of my Brazilian acquaintances, this was greeted with widespread incredulity. Let me try to persuade them to take it seriously.

To recap, the Imperial team modelled three main mitigation scenarios for this country of 212 million inhabitants. They put in various values of R from 2.4 to 3.3, and assumed social distancing would be about 40% effective . They define R thus: “R0 : Basic Reproduction number (average number of secondary infections by a typical infection in an unconstrained epidemic and wholly susceptible population).”

A – no mitigation at all:

  • total ultimate infections             183m – 188m
  • total deaths                                       908,000 – 1,152,000,
  • total critical hospitalizations    1,466,000
  • peak critical bed demand            470,000

B – social distancing (40%) only for the elderly:

  • total ultimate infections             92m- 121m
  • total deaths                                       271,000 – 530,000
  • total critical hospitalizations    359,000 – 703,000

C - social distancing (40%) for the entire population:

  • total ultimate infections             95m- 122m
  • total deaths                                       452,000 - 627,000
  • total critical hospitalizations   600,000 – 831,000

What to think of this?

1. It’s state-of-the-art professional modelling. The parameters are put in from the latest data, especially Chinese. Put in different parameters, and you get different results. But you can’t just make up your own parameters, you need a reason. A bigger number of asymptomatic carriers? Maybe; it lowers the total of infections in Scenario A, as you hit herd immunity sooner, but the higher pace of infection exacerbates the peak load on hospitals. Wishful thinking in the Trump/Bolsonaro style does not hack it.

2. The least reliable scenario is A, the disaster one in which no action is taken. This won’t happen, anywhere, for two opposite reasons. One: even if central governments fail, as in the USA, Mexico and Brazil, lower levels of government step in – less effectively, but they will act. If the worst comes to the worst, people will just self-isolate, as Isaac Newton did in the London bubonic plague of 1665. (Incidentally, this is why the “economy vs. public health” opposition is a false one. The economy tanks sooner or later, whatever the government does.) Two: a reason, this time on the bad side, for distrusting scenario A is that it does not allow for hospital collapse, which would be inevitable. Death rates would rocket, unpredictably. The model is benchmarked on the Chinese health care system which never faced such extreme loads.

3. The key conclusion of the Imperial reports is that mitigation isn’t enough, you have to go for energetic suppression to keep the health system from collapsing. Even the lowest Imperial mitigation scenario has over 2m hospitalisations in Brazil, 360,000 of them critical ones. Brazil has 415,000 hospital beds, just adequate for normal times. Any mitigation scenario leads to hospital collapse. Unfortunately they do not offer suppression scenarios, impossible for so many countries at once. So the Brazilian government has to put some work into this to avoid the catastrophe.

Stepping outside the report, there are now plenty of examples of successful suppression strategies.

Gold medal: Taiwan, silver medal: South Korea. These have not SFIK relied on fancy models at all but on the trusty Epidemics 101 playbook: test, track, isolate. The playbook was it seems first worked out for animal diseases before WWI. The part about “slaughter all the infected animals, dump the carcasses in a big pit, and burn the animal sheds” has been toned down for humans, but the take-no-prisoners attitude survives. One quarantine violator in Taiwan was fined $33,000. The Vice-President is an epidemiologist. I doubt if Brazil has the administrative capacity or social cohesion for this, and anyway it’s too late.

Second best is Europe. After a late start, most countries adopted strict lockdowns to drive R below 1 quickly. They are working. In Spain where I live, a state of emergency and national lockdown was declared on March 15. New deaths peaked on April 1. Cumulative deaths on that date stood at 10,003. Assume the curve is symmetrical, and total deaths will end up around 20,000. Scale that to Brazil, and you would get 99,000.

That would be a decent second-best outcome starting from now (cases 20,247, deaths 1,090). I’m afraid I don’t believe it. Spain has a competent and rational government and civil service, a first-world healthcare system, and a surprisingly deep reserve of social solidarity in spite of political divisions. Brazil has much lower levels of trust in government, very high inequality, and a healthcare system overstretched in normal times. In addition to these structural handicaps, it has, like the USA, unwisely elected an erratic and irrational President incapable of offering the example of steadiness and discipline required by the situation*, The country will IMHO be lucky to escape with under 200,000 deaths. It could easily be worse.

* Epidemic management is a Roman dictatorship of public health experts. What political leaders have to do is hand over the keys and make frequent sober and statesmanlike statements. A good number of quite ordinary politicians have shown themselves up to this: Xi Jinping, Moon Jae-in, Merkel, Conte, Sanchez, Cuomo, Newsom, even Matt Hancock, the previously unimpressive British Health Secretary. The failures are striking: Trump, Obrador, Bolsonaro, Abe.

Anglo-Saxon thought for the day

From The Battle of Maldon.

Dedicated to the exhausted army of doctors, nurses, and ancillary workers who have woken up in many countries to another endless day of struggle against a faceless epidemic. And particularly to those who relax reading Anglo-Saxon poetry.

From The Battle of Maldon, ca. 1000 CE. The Saxon war-leader Byrhtnoth has been killed and his band is losing the battle to the Viking invaders; some Saxons have run away. His old retainer Byrhtwold speaks to the remnant standing fast. Try reading it aloud to catch the alliteration. The letter þ is a voiced “th”. [Update: sound file on YouTube.]

Hige sceal þē heardra, heorte þē cēnre,
mōd sceal þē māre, þē ūre mægen lytlað.

Thought shall be the harder, heart the keener,
Mood [mind, courage] the more, as our might lessens [lit: littles.].

Suitably, the text is incomplete, and breaks off before the battle ends. We don’t know who wins - then or now.

Warriors:

Then

 

Now

 

Ambroise Paré’s COVID advice

Look at emergency home nursing.

The surgeon to François Ier of France, Ambroise Paré, gave this classic statement of the doctor’s mission:

Guérir parfois, soulager souvent, consoler toujours.

In his day, there were few hospitals. Most people were born, went to their beds when they fell sick, recovered a few times, and finally died, all in their own homes. It wasn’t much different in 50,000 BC. Hospitals were for the few mobile categories: soldiers, seamen, merchants, pilgrims. Paré would have done most of his surgery in tents in the rear of the battlefield.

Florence Nightingale at Scutari - Shutterstock

The hospital, as a temple of scientific medicine, is a 19th-century invention. The Dr. House TV series offers an exaggerated but basically fair image of its ethos. The model is badly adapted to a massive epidemic of nearly identical cases. In parts of Lombardy, hospitals have been overwhelmed, and resorted to triage. The older arrivals with preexisting conditions have reportedly sometimes been left in corridors to die with minimal palliative care. Ethically, this is not really problematic; in human terms, it is horrific. The same is very likely to happen in many other countries, including the UK and the USA (here, report 9).

I am 73 with asthma. I therefore have a personal stake in this problem, which has started to arise in Madrid. The army are setting up large improvised field hospitals. This fixes the bed shortage, and I trust that crash programmes are under way to make respirators and masks, but you can’t create qualified nurses in a few weeks.

So you enlist unqualified ones. Go back to the 18th century, and ask family members to care for the sick at home. Patients who fail the hospital triage would be sent home with a Happy Care package, including an army or airline-issue respirator, a bottle of oxygen, a box of antibiotics and opioids, a bedpan, a one-page guide, and a Skype helpline.

Every medical professional from Florence Nightingale to Geoffrey House will be shocked by this unprofessional atavism. But the objections are readily answered.

1. Half or more will die! Sure. The basis of comparison is not best or even average hospital practice, but the horrid reality of the triage corridor. At the very least, the sick will die with more dignity and human warmth.

2. The potential carers have to go out to work. Not just now they don’t.

3. The patients will infect the carers. They are already infected.

4. Not every patient has potential home carers physically and mentally fit enough to do the job. Absolutely. Home nursing is only part of the solution. That’s why we also need the army field hospitals. I can’t guess the relative numbers here.

An additional twist to this plan is that there is a rapidly expanding cohort of asymptomatic or recovered people with immunity, who are potentially available to support others, though home nursing assistance among other ways. In Veneto province in Italy, which has tested heavily, about 8% of the population tests positive, two-thirds without symptoms or nearly so.

If it comes to such a choice for me, I would take the home solution over the corridor. I don’t know what Lu thinks.

I really would like to know what the heirs of Florence and Ambroise make of this. If  anything on these lines is the way forward, or even a last-ditch fallback, it has to be planned for.

De Long is wrong on coronavirus

If you are going to quarantine, do it soon.

It’s not often one gets the chance and obligation to say this. Brad DeLong :

Note to Self: Is there anything wrong with this analysis? With 14 deaths in the U.S., a 1% death rate, and 4 weeks between infection and death, that means that as of Feb 8 there were 1400 coronavirus cases in the United States. If it is doubling every seven days, then now about 22,000 people have and in the next week about 44,000 people in the U.S. will catch coronavirus. These numbers could be five times too big. These numbers could be five times too small. But with only 1 in 10,000 currently affected, it seems 4 or 5 weeks early to start imposing serious geographical quarantines …

No, no, no. R is not a function of the number of cases. It is only a function of herd immunity and the individual chance of transmission.

The condition for the decline and fall of the epidemic is lowering R below 1. There are two paths to this. Call them the Trump policy and the Xi policy.

Under the Trump policy of malign neglect, the virus spreads until most of the potential transmittees of the virus have recovered from it and are immune. Meanwhile, the cemeteries have filled up with those who didn’t recover. 200,000? 480,000? 1.7 million, if the hospitals collapse and the treatment is back to Black Death standards? The epidemic expires from satiety.

Under the Xi policy (also now the Moon, Conte, Sanchez, and Merkel policy), the state cuts the opportunities for transmission, including quarantines as well as contact tracing and mass preventive screening. The cost of this, direct and indirect, is fixed and independent of the number of cases. Imagine a perfect lockdown in which everybody stays in their house or flat, living out of tins by candlelight, for a fortnight: end of epidemic. This can’t be done perfectly of course, so real outcomes are a risk distribution, but you can get pretty close, as Singapore and Taiwan have shown. The death toll is still 1% or 1.6% or whatever of those infected.

It is lower the earlier you start the policy. Starting when the diagnosed cases are in the thousands, as seems to be the political trigger, looks as if it might limit ultimate deaths also to the thousands or tens of thousands. QED.

Lego clone army

A more picturesque way of looking at this is from the point of view of the virus. It’s a clone army of dumb replicants with no leader and a single mission: reproduce. For the Virus Army as a whole, a pandemic is a death ride. At the end of it they will all be dead, apart from the small source population living quietly in non-fatal parasitism with its animal hosts. The fun part is how many non-standard hosts they can kill along the way.

No zoom in on the virus commando that has infiltrated a single human host, you. The commando is doomed. In 14 days, either you are dead (end of viruses) or your immune system has destroyed them all and you are recovered (end of viruses). Their only hope for reproduction is for some members of the commando to jump ship and invade another disarmed host. The jumping ship is nearly always fatal, as the viruses can only survive a few hours outside a host. They have no independent motility and are dependent on cooperation by the hosts: handshakes, kisses, cough aerosols, unwiped door handles. Reduce that cooperation, and the survival odds for SEAL Team Virus drop to almost nothing. That, in essence, is the Xi policy: and it works.

U.S. Prescription Opioid Consumption Still Leads the World

I frequently hear the claim that “doctors have just stopped prescribing opioids”. The truth is that U.S. doctors prescribe fewer opioids than they did 5 years ago, but the U.S. still dwarfs the world in its per capita prescribing even among the heaviest prescribing nations. For details, see my latest piece at The Washington Monthly.

Feline asthma

Cat asthma as a political argument to Republican pet owners.

This is about public policy, promise.

My elderly cat Hobbes now has a respiratory problem, as I do. It’s probably feline asthma. Cats get asthma like humans, while dogs don’t. One cause, say vets, is air pollution.

Credit: MeowValet on YouTube

The literature seems stronger on indoor air pollution than outdoor. Second-hand tobacco smoke is a culprit, as are wood fires and incense. I found a serious controlled Taiwanese study on indoor pollution making the link. The effect of outdoor pollution has been less studied for animals. One Mexican study creepily found similar lesions in the brains of big-city dogs to those found in humans with Alzheimer’s.

It seems safer just to rely on the parallelism in the symptoms and mechanisms of cat and human asthma, and the massive literature connecting the human form to air pollution, to conclude that all air pollution is bad for cats too. The effect is reinforced by the height difference: cats and dogs breathe in air at car exhaust level.

This hypothesis suggests a political strategy. In the USA, there are said to be 49.2 million households with a cat. There are 50.4 million with children under 18. That’s 39% each. I couldn’t find a combined breakdown, but let’s assume that the two are independent. That would give 30 million childless households with a cat. The real total will be different, but it’s still a very large number.

This demographic skews old, white and therefore Republican. It cares for its cats. It strikes me as a good argument to make to this group in favour of the energy transition and the GND that the policy will protect the health of their pets.

Some will say: this is ridiculous. Are there really a non-trivial number of voters who will be swayed by the health of cats but not the health of children? If there are, surely they are either “low-information voters” - idiots – or moral imbeciles, and lost causes in either case?

My answers are (a) quite likely and (b) no.

Let me make the case for the defence. The questions are linked by the broader issue of moral myopia.

Continue reading “Feline asthma”

Percentages and the pastrami panic…

the hot dog horror, and the salami scare. This story in the NYT quotes a source:

 “We see a 4 percent increase in the risk of cancer even at 15 grams a day, which is a single slice of ham on a sandwich,” said Dr. Nigel Brockton, director of research for the American Institute for Cancer Research.  
Eating a more typical serving of 50 grams of processed meat a day would increase the risk of colorectal cancer by 18 percent, a 2011 review of studies found.

What does this really mean? Lifetime risk of colorectal cancer is about 1 in 23, or a little over 4%.  Now, does that slice of ham double your risk (4% to 8%), or merely increase it from 4.3% to (1.04*.043 = .045), 4.5%? Do a full fifth (18 + 4 = 22) of the 50-gram noshers get these specific cancers? Of course not. The quote, and the story, are completely ambiguous, but if you follow the link, you find that the data are relative risk values, which is the second interpretation. 50 grams a day entails about a 1% extra risk, and that’s not even counting all the people already in the 4.3% who eat deli meat and get cancer. If you do, and you stop, your risk of these cancers goes down from about 4% to…a little more than 3%. Perhaps Zabar’s should sue the Times over this alarmism.

Eating a reasonable amount of these exceptionally yummy foods seems to me a good deal, at the price of being 1% more likely to get this type of cancer before I get one of the other kinds or a heart attack. YMMV, of course. Everyone dies of something, so a much more useful statistic would be the average number of [quality adjusted ?] life years I’m putting at risk from a ham habit, and from an occasional indulgence.

The lesson here is that any statistics involving percentages have to be stated carefully to make it clear whether an increase adds to an existing rate or multiplies it, and “X% added risk” simply doesn’t cut it. Dr. Brockton and the reporter are equally at fault here, along with the Times copy editor. Students and colleagues: don’t make this mistake, especially when you’re explaining science to the public. What Dr. Brockton meant to say is that “the 15g pigout habit raises your lifetime risk from 4 to 5%”. There’s no escaping the additional words. Or reporting base rates: something that “quadruples your risk of contracting the gleeps” is not a big deal if the incidence of gleeps is a fraction of a percent.

Evidence-based catfighting

Lessons of the great row in the Cochrane collaboration.

Want a change from watching the turds circle the drain in the Kavanaugh confirmation circus? Let me bring you a nasty academic spat between high-minded medical researchers. This is how learned gentlemen stab each other in the back! With a couple of serious morals. Everybody named below is a highly credentialed professional; I leave the titles out to avoid repetition.

The milieu is the Cochrane collaboration. Inspired by and named after the  epidemiologist Archibald Cochrane  (d. 1988), the Cochrane people promote evidence-based medicine through meta-analyses of randomised clinical research trials using methods as rigorous and objective as they can make them. (Our own Keith Humphries has been a Cochrane reviewer.) [Update] The very solid proposition is that if you can analyse correctly a handful of properly conducted trials, you are in effect adding the sample sizes, so you can draw much more statistically reliable conclusions than by cherry-picking one. There is of course a lot of art here behind “correctly”, “properly”, and “in effect’. [/update] They are not the only researchers carrying out meta-analyses, but a Cochrane review is widely regarded as the gold standard. Depressingly often, the answer is “we don’t know”.

One recent Cochrane review (lead author Marc Arbyn) was on vaccines against human papilloma virus (HPV), which causes much cervical cancer among women and lesser numbers of anal and penile cancers in men. This is not a trivial health issue. Fortunately there are vaccines sold by Merck (Gardasil) and GSK (Cervarix). Do these work? Short answer: yes. Are they dangerous? Short answer: no. (Please DO NOT quote me, read and cite the report, they do provide a summary for dummies.)

So far so routine. But then an article was published in the journal BMJ - Evidence-Based Medicine by Lars Jørgensen, Peter Gøtzsche, and Tom Jefferson, alleging that the vaccine review was sloppy on several counts and hinting that it was influenced by pressures from the Big Pharma vaccine vendors. (Note that while they argue that the side-effects are greater than the review says, the critique does not recommend stopping or curtailing vaccination programmes.) This naturally provoked a rebuttal from the Cochrane management (David Tovey and Karla Soares-Weiser), saying the criticism is wrong on all counts.

It did not stop there. Gøtzsche is, or rather was, a member of the Cochrane board, indeed a founder member of the organisation. He could presumably have raised his concerns there first rather than publicly. After a presumably furious board meeting, Gøtzsche was expelled and four other board members quit. The great collaboration is now in existential danger. Will donors, including the Gates Foundation, keep the funding flowing? Will Gøtzsche set up a breakaway fitzCochrane, applying his own higher standards? Will anti-vaxxers and misogynists exploit the row to attack the vaccination campaign? Only 27 % of American men under 26 are vaccinated.

It’s important that the crisis be resolved quickly and the collaboration continue. There’s not much outsiders can do to help this in the short term, and I am quite unqualified to take sides. I have though one reflection and one suggestion for the future. Continue reading “Evidence-based catfighting”