A tale of two doctors

13 Apr

Bewildered? Mistrustful? You should be. Here’s Peter Koenig, writing yesterday for Information Clearing House:

On March 26, in a peer-reviewed article in the highly reputed New England Journal of Medicine (NEJM), Dr. Anthony Fauci, Director of NIAID (National Institute of Allergy and Infectious Diseases), likened COVID19 to a stronger than usual flu:

“If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.

This assessment in the New England Journal of Medicine has not prevented Dr. Fauci from saying the opposite, when interviewed by the mainstream media:

Koenig’s piece links only to the NEJM article, not that Health and Science quote, but the latter does check out.

Was Dr Fauci induced to get with the big boys and girls on this?

*

For those fed up of soundbytes, cherry-picked figures and “my scientist knows more than yours” Facebook know-it-alls, here’s a thoughtful piece by Dr John Lee, a recently retired professor of pathology and former NHS consultant pathologist.

In a witty 1865 worder in the Spectator yesterday under the header, Where is the vigorous debate about our response to Covid? , Dr Lee writes that:

… one particular approach to modelling the Covid-19 epidemic – that of Imperial College – is holding court in the UK. The actions we are taking were based on these modelling results. Barely a day goes by without a politician saying they will be ‘led by the science’. But what we are seeing is not ‘science’ in action. Science involves matching theories with evidence and testing a theory with attempts to falsify it,1 so it can be refined to better match reality. A theory from a group of scientists is just that: a theory. Believing the opinion of that group without critical verification is just that: belief.

The modelling results may be close to the truth, or very far from it. The idea of science is that you can test the data and the assumptions, and find out.

… input data in the run-up to lockdown was extremely poor. For example, it’s highly likely a large majority of Covid-19 cases have not even been detected – and most of those that were identified were in hospitals, hence the most severe. Because of this, the WHO initially suggested a case fatality rate (CFR) of 3.4%, which would have been genuinely awful. But as new evidence comes in the predictions of the models change accordingly. A paper from Imperial on 10 February suggested CFR of 0.9 per cent, a more recent one on 30 March 0.66 per cent (both based on Chinese figures, the reliability of which many doubt). Recent data from a German town suggest a CFR of 0.37 per cent, having found an actual infection rate in the town of about 15 per cent.

From poor quality data2 Dr Lee proceeds to ask about:

… the assumptions of the models? These are many and complex, including, among other things, ideas about virulence, infection rates and population susceptibility, all of which are supported only weakly if at all by directly measured evidence. But to give an example from left field (the sort of thing that destroys predictions): what do the models say about transmission between humans and animals? Apparently a tiger in a zoo has caught Covid-19. But could our cats therefore be susceptible to the disease and could they spread it between us? If true, would that make a difference to the validity of the model? Of course it could. Did the model predict or discuss this? Of course it didn’t.

More surprisingly, the Imperial College paper of 30 March states that ‘Our methods assume that changes in the reproductive number – a measure of transmission – are an immediate response to these interventions being implemented rather than broader gradual changes in behaviour’ (my emphasis). That is to say: in this study, if the virus transmission slows it is ‘assumed’ that this is due to the lockdown and not (for example) that it would have slowed down any way. But this is a key point, one absolutely vital to understanding our whole situation? I may be missing something, but if you are presenting a paper trying to ascertain if the lockdown works, isn’t it a bit of a push to start with an assumption that lockdown works?

Read Dr Lee’s piece in full …

* * *

  1. Dr Lee refers here to an important epistemological principle: that of falsifiability. All knowledge is provisional, and the best we can say of any theory is that it has not yet been proved wrong. We hold scientific knowledge in high regard because its claims – if x plus y then z – take risks. They can in principle be proved wrong, and in practice a competitive scientific community will indeed try to do just that.
  2. One of Professor Bhakdi’s questions to Chancellor Merkel – preceded by him saying he had no desire to “downplay the severity” of covid-19 – was whether Germany was following other European nations in relaxing criteria for writing death certificates. He wanted to know if the causal chain (three or four links) required by law – patient died of X caused by Y caused by Z – was being abandoned. Since the letter was ignored by the media I can’t say whether he had an answer, let alone what it was. But the UK’s Coronavirus Act 2020 does lower the bar. A GP may attribute to CV-19 the death in a care home of a person s/he hasn’t even seen if that’s what s/he suspects. This cannot but exacerbate the problem of very poor data.

8 Replies to “A tale of two doctors

  1. The doctors statement of March 26 is surely correct in the terms laid out. If you assume X than Y could well/may/might be the case.

    It seems reasonable to ask the question less than 1% of what? A guesstimate of people who might have contracted a particular strain of virus rather than an ordinary cold or another strain of flu?

    That seems reasonable if the same set of variables are going to apply to the model being compared against – normal flu.

    With normal flu it also seems reasonable to assume there will be a number of “asymptomatic or minimally symptomatic cases” . And if that is the basis of the criteria which gives a case fatality rate of less than 1% than in theory the comparison is reasonable.

    However, this is all built on assumptions and guesswork in which data collection is abysmal and which suggest many fatality cases are being under reported . As of today’s figures the UK percentage of fatalities to cases is 12.78% based only on hospital cases.

    Those cases being based on numbers tested. On that aspect I’ve only seen two sets of figures (over a week ago) in regard to the percentage number of positively tested cases to the number actually tested. Both were withing three days of one another. The first was around 19.5% the second about 22.3%.

    Consequently, if it is reasonable to make an assumption that there is an unspecified high number of “asymptomatic or minimally symptomatic cases” to arrive at an assumed mortality rate close to normal seasonal flu it might well be argued that it is also reasonable to make an assumption of an unspecified number of higher than reported mortality cases based on both releases of cases back into the community to free up hospital beds and all those cases who don’t make the points for scarce ventilators and other treatment triage system reported in the press.

    And the observation about different experts with different interpretations, models and assumptions is surely pertinent.

    Because the only relevant experts are, as with most other things, those on the front line dealing with a situation.

    If front line health service workers are saying there is an out of the ordinary problem risking their capacity to deal with real time cases being presented leading to:

    – risks of high levels of and actual mortality more than normal
    – a requirement to make choices on who gets life saving treatment or not

    the choice seems to come down to either untested and unverifiable assumptions and incomplete models based on guesswork from miles behind the line or what those dealing with a situation on and from the front line are reporting both in the UK and elsewhere.

    • … the only relevant experts are, as with most other things, those on the front line dealing with a situation. If front line health service workers are saying there is an out of the ordinary problem risking their capacity to deal with real time cases being presented leading to …

      – risks of high levels of and actual mortality more than normal
      – a requirement to make choices on who gets life saving treatment or not

      … the choice seems to come down to either untested and unverifiable assumptions and incomplete models based on guesswork from miles behind the line or what those dealing with a situation on and from the front line are reporting both in the UK and elsewhere.

      I wouldn’t go quite so far as you, Dave, in saying frontline carers are the only relevant experts. We do also need thinkers and strategists with the big picture. But I must say, your point is nonetheless a powerful one. It comes days after a friend in Barcelona, his thirty-something daughter a frontline health worker in the city’s biggest hospital, called me – apropos Bhakdi’s open letter, linked above in footnote 2 – to say even her oldest and most seasoned colleagues have experienced nothing like this.

      Call to anyone with first hand experience. Please share it with us!

  2. Cheers for the link to this article Phil.

    Dr Lee presents a very calm, lucid and fair case, particularly on the topic of the contested nature of much biological ‘knowledge’. Interesting he doesn’t mention the problems with the current ‘test’ though. From what I’ve read it is almost useless in the sense of being able to accurately and consistently detect the presence of C 19. Of course as you point out, it isn’t even needed to certify death as C 19 related.

    M.

    • Dr Lee presents a very calm, lucid and fair case …

      Yes, and he’s highly readable with it. This is off-topic, I know, but good thinkers are often good writers too. This one writes simply of things more often served up as polysyllabic soup. Good thinkers also often have a keen sense of humour, irony especially.

      For all these reasons Dr Lee deserves the widest possible read. Please share!

  3. Fair point Phil.

    I’m looking forward, for example, to seeing some comparable figures presented from previous years of the number of qualified front line doctors, nurses and other health staff who have died from ordinary flu whilst treating patients for normal flu?

    Not that that is the only question I’m not going to be holding my breath waiting to be asked never mind answered in this pissing contest of experts along with their “media” megaphones and amplifiers all pushing their assumptions as conclusions.

    I’m also looking forward to the question, which surely arises, as to why it is most of the world’s health systems cannot cope or are struggling to cope with what is being claimed as the statistical equivalent of a normal bout of flu?

    Depending of course on whatever convenient assumptions are made to make the model fit the pre-arrived at/pre-chosen straight out of the microwave pet theory. Even experts in the sciences have egos and like to compete with other experts for attention. At least in the West where competition rather than co-operation has been elevated to be status of Holy Writ.

    Not to mention why it is front line medical and health professionals are jumping up and down screaming blue murder for hazmat suits (I have a recent photograph sent to me last week of a relation of a former work friend suitably togged up) and other PPE as well medical ventilators etc over what is presented as nothing more lethal as bog standard flu?

    Statistically speaking of course.

    On which subject I’m also waiting with non bated breath for someone to ask the question why it is we have suddenly jettisoned the lessons of lies, damned lies and statistics in favour of dying in a ditch over statistical models based on the notion of “if we assume this, and assign a big number to something it doesn’t look too bad/it looks horrendous”?

    After that we could move on to some of the more pertinent questions conveniently being buried under an avalanche of competing assumptions about whose got the biggest, bestest and baddest model.

    Like why is it that we don’t have the capacity to deal with what is statistically claimed to be a normal bout of flu never mind a pandemic?

    Why we’re we – everywhere – so unprepared?

    It’s not like no be ever modelled such scenarios:

    These US intel reports ACCURATELY PREDICTED pandemic years ago. Why was NOTHING done? https://www.rt.com/news/485718-experts-warned-pandemic-years/

    Why don’t we have sufficient stocks of PPE, ventilators, Critical care facilities etc to deal with a pandemic, or should that be just a normal bout of statistical flu?

    Why is that the number of people officially recovered in the UK is probably the lowest on the planet? So much so that yesterday that figure (334 on Sunday) was not even reported. No number just N/A!

    Why is our health system so under resourced we are having to recruit retired medics and nurses to come back for what is argued to be, in one set of assumptions based on figures conveniently plucked out of thin air, to be nothing more than a seasonal bout of statistical flu?

    Why are people being sent DNR letters for a statistical bout of flu?

    Why are we seeing official guidance to health professionals based on a points system for life saving treatment? With criteria based on gender, age, health condition (including disabled and learning difficulties), physical fitness and so on.

    All of course for what is argued to be nothing more than a stistical bout of flu.

    Why, if we are supposed to be under house arrest or whatever term is deemed politically accurate and everything is in lockdown are flights still coming into Heathrow with no checks?

    Why is public transport packed with people crushed together? Where are the systems to ensure things keep running whilst enabling safe distancing etc?

    Here’s a couple I’d be particularly interested in hearing both question and answer:

    You don’t think the Government are actually still operating a herd immunity policy by stealth?

    You don’t think they are culling the vulnerable, the poor, the elderly, the sick, the disabled, and anyone considered to be “economically inactive”? Do you?

    At any other time in any other context such questions would be so numerous we would be literally drowning in them.

    You would not be able to move without seeing or hearing a narrative shouting out at the top of its voice about eugenics, about the run down of the NHS and other systems necessary to maintain a civilised society, about failure to provide practical transport and other systems for ensuring safe distancing etc to keep things running (this lot cannot even do an effective lockdown), about lack of contingency planning and a thousand and one othe practical questions.

    But right now it’s tumbleweed time. Statistical roulette with real people’s lives.

    Just like when I was at work where the statistical productivity models assumed it was possible to get from A (Sheffield) to B (Royston/Adwick/Wingerworth/and probably the dark side of the soddin’ moon for all we knew) instantaneously without taking time in traffic to and from jobs.

    Just like on Star Trek.

    Or that all buildings were the same. Meaning all jobs took the same length of statistically assumed time and it was possible to do X + whatever number was plucked out of thin air by moving variable assumptions around a spreadsheet in an alloted time.

    And those who came up with this bollox would look at you as though you were from another planet when you asked these kinds of practical questions or raised such issues.

    Because this is where we seem to be wherever you look during waking hours:

    In the beginning was The Plan.
    And then came the assumptions.
    And the assumptions were without form.
    And the plan was without substance.

    And darkness came upon the face of the workers.
    And they spoke amongst themselves saying:
    “It is a crock, and it stinketh mightily.”

    And the workers went unto their Supervisors and said,
    “It is a pail of dung, and none may abide the odor therefore.”
    And the Supervisors went unto their Managers saying,
    “It is a container of excrement, and it is very strong,
    such that none may abide by it.”

    And the Managers went unto their Directors saying,
    “It is a vessel for fertilizer, and none can abide by its strength.”
    And the Directors spoke amongst themselves, saying to one another,
    “It contains that which aids plant growth, and is very strong.”
    And the Directors went unto the Vice Presidents saying,
    “It promotes growth, and it is very powerful.”

    And the Vice Presidents went unto the President saying unto him,
    “This new plan will actively promote the growth and vigor
    of the company, with very powerful effects.”

    And the President looked upon The Plan and saw that it was good.
    And the Plan became Policy.

    This is how (SH-)IT happens.

    And considering those questions and issues above it doesn’t even matter if they are asked, or even answered, in a witty and amusing way or not.

    While I’m waiting I’ll just go and pop down to the beer off. to stock up on what is likely to be a long wait. I know it’s open because HS1 works there and it’s apparently still open as its considered and “essential service”.

    In a “lockdown” being sold as the equivalent of Marshall Law/Police State/Fascist takeover (I thought they were supposed to be efficient?) etc.

    Yeah! Reyt!

    If that risk to him goes belly up I’ll be moving rapidly up the gears way beyond sarcasm.

    • I’m looking forward, for example, to seeing some comparable figures presented from previous years of the number of qualified front line doctors, nurses and other health staff who have died from ordinary flu whilst treating patients for normal flu?

      Me too Dave. Also, and again, to hearing the war stories of doctors, nurses and other frontline health givers both in the West and across the world. I’m not finding these easy to track down through online searches.

      See also bevin’s comment.

  4. “..The Covid-19 crisis took the world by surprise, and the world (Sweden excepted) has reacted in roughly the same way: with lockdowns. In the rush, the usual checks and balances have not been applied..”
    Actually this is not the case. There have been and still are a wide variety of responses and the immediacy of the reactions has also varied greatly. In the US the government was extremely slow to respond and for two months insisted that what they wee dealing with was no worse than ‘flu. In China the response was speedy, after an initial denial from local bureaucrats, and the measures taken exhaustive.

    And then there is the question of whether, for example, the UK government has ever been serious in its quarantine policies- to this day people pour into the airports and are neither tested, interviewed or monitored before they mingle with the population. And are the tubes still running? And are people cheek by jowl in other public transport? I suspect that the answer to both questions is affirmative. If so this is clear evidence that the quarantine is more for show than to stop the virus in its tracks, in order to treat all testing positive and then pursue the virus back to its original carriers.

    The ruling class is itching to get back to ‘normalcy’ and that will mean curtailing the quarantine regimes before they have had a chance to work. By then the most vulnerable, including thousands of old folk living in ‘care’ homes will have died, so the weekly figures will be malleable enough to argue that ‘the worst is over’ and that it is time to get back to work. And despite Dr Lee what this will confirm is that, apart from the theatrics, the policy of herd immunity remains that of the government.
    :Luckily for the Tories I cannot imagine HM’s Opposition quarreling with it either.
    By the way this is a good article in Counterpunch:
    https://www.counterpunch.org/2020/04/13/how-to-convince-the-recalcitrant-that-this-time-really-is-different/

    • ‘..The Covid-19 crisis took the world by surprise, and the world (Sweden excepted) has reacted in roughly the same way: with lockdowns. In the rush, the usual checks and balances have not been applied..’

      Actually this is not the case. There have been and still are a wide variety of responses and the immediacy of the reactions has also varied greatly.

      You too make a fair point, bevin. In a highly uncertain situation, I’m trying hard to stand in a place of Not Knowing. It is not a comfortable place at any time, and in this situation incurs the wrath of those – libertarian CV-19 downplayers on the one hand, many if not most socialists on the other – who want me to place myself firmly in their camp. They might say I’m hedging my bets. I say it’s just plain stupid to call this while the jury is out.

      There are bigger considerations at stake here than my discomfort, of course. I mention it only as one measure of the uncertainty.

      The ruling class is itching to get back to ‘normalcy’ and that will mean curtailing the quarantine regimes before they have had a chance to work. By then the most vulnerable, including thousands of old folk living in ‘care’ homes will have died, so the weekly figures will be malleable enough to argue that ‘the worst is over’ and that it is time to get back to work.

      I agree in part, and in a recent post said so in respect of a WSWS piece of April 6. But while I acknowledge the truth of what WSWS (and you) say, I add that appropriation of an idea for self serving ends neither negates nor affirms its truth. There seem to me good arguments for herd immunity by allowing the least vulnerable to spread the virus while protecting the most vulnerable. But even Professor Wittkowski says optimal approach depends in part on where we are in the pandemic cycle. And thanks to poor data, we don’t seem to know.

      (Not only are all sides cherry picking which experts to cite. Some are also cherry-picking what even their chosen experts say. Those insisting libertarian values trump all else tend to downplay the severity of CV-19. To this end some will cite Professor Bhakdi’s open letter to Merkel, which raises valid questions, without saying he begins by expressly saying he does not wish to downplay the dangers posed by the virus. Similarly, Wittkowski is quoted as though herd immunity and social distancing were not only mutually exclusive (see previous para) but articles of religious faith. When I watch the video (linked in previous para) I see a mildly eccentric but ultimately pragmatic man.)

      I’ll check out the CounterPunch piece. I’m working on a post about the rush to embrace the illusion of certainty, and the epistemological naivety – I’m being kind here – of those who say “the science proves” their particular stance.

      Meanwhile, Dr Lee makes good points about the nature of knowledge.

Leave a Reply

Your email address will not be published.