The Honest Man of American Medical Research weighs in on coronaplague

by philg

“Coronavirus disease 2019: the harms of exaggerated information and non‐evidence‐based measures,” a March 19, 2020 peer-reviewed article by John Ioannidis, best-known for “Why Most Published Research Findings Are False”, cites a few issues:

  • Even major peer-reviewed journals have already published wrong, sensationalist items
  • Early estimates of case fatality rate may be markedly exaggerated
  • Reported epidemic curves are largely affected by the change in availability of test kits and the willingness to test for the virus over time

This guy is such a contrarian that Donald Trump is not mentioned even once as a cause for American and worldwide woes!

Some of his theories:

  • China data are more compatible with close contact rather than wide community spread being the main mode of transmission
  • Plain hygienic measures have the strongest evidence. Frequent hand washing and staying at home and avoiding contacts when sick are probably very useful. Their routine endorsement may save many lives. Most lives saved may actually be due to reduced transmission of influenza rather than coronavirus. [How about reduced driving-related deaths? Tough to get killed in a car accident when there is nowhere to go]
  • if only part of resources mobilized to implement extreme measures for COVID-19 had been invested towards enhancing influenza vaccination uptake, tens of thousands of influenza deaths might have been averted. Only 1-2% of the population in China is vaccinated against influenza.
  • Closure of borders may serve policies focused on limiting immigration. [He’s not a complete contrarian after all. When you’re a Bay Area Stanford-employed elite, you don’t want to stem the tide of asylum-seekers coming over the Southern Border and helping to make your fellow elites $500 billion richer each year!]
  • Leading figures insist that the current situation is a once-in-a-century pandemic. … Leaving the well-known and highly lethal SARS and MERS coronaviruses aside, other coronaviruses probably have infected millions of people and have killed thousands. However, it is only this year that every single case and every single death gets red alert broadcasting in the news.
  • Some fear an analogy to the 1918 influenza pandemic that killed 20-40 million people. Retrospective data from that pandemic suggest that early adoption of social distancing measures were associated with lower peak death rates. However, these data are sparse, retrospective, and pathogen-specific. Moreover, total deaths were eventually little affected by early social distancing: people just died several weeks later. Importantly, this year we are dealing with thousands, not tens of millions deaths.

Meanwhile, here in Massachusetts, the governor has ordered every “non-essential” business to close as of tomorrow at noon (marijuana retail is considered “essential” as well as “liquor stores”; people can be stoned and drunk while at home waiting for their government, alimony, and/or child support checks). We have no idea how widespread the infection is because the only people who get tested are hospital inpatients or medical personnel (i.e., the “new cases” figures out of Massachusetts are actually “people newly hospitalized and who test positive”).

One thing that seems to be too hot for any politician to handle is putting a price on human life. The FAA does this routinely in deciding whether to impose a new regulation. It was only $650,000 back in 1985 says the New York Times, with the average agency using $1-2 million and the EPA using the highest numbers. The Department of Transportation uses closer to $10 million today (2016 guidance). Heather Mac Donald in The Spectator:

Around 40,000 Americans die each year in traffic deaths. We could save not just one life but tens of thousands by lowering the speed limit to 25 miles per hour on all highways and roads. We tolerate the highway carnage because we value the time saved from driving fast more.

(One positive of coronaplague: For the first time in years, here in Massachusetts we have regularly been able to drive more than 25 miles per hour!)

Maybe right now the answer is “each additional day that a human can live, regardless of that person’s age and health status, is worth $infinite”? So we shut down society if there is any chance that any person sick with coronavirus won’t get the complete range of medical services that would have been available in December 2019? But we also have to make sure that everyone else who has a different medical issue also gets the complete range of services that would have been available in December 2019, e.g., a second liver transplant for an IV drug user, $2 million in cancer therapy for an imprisoned felon, weeks in the ICU billed to Medicare for a 95-year-old, etc. Therefore, if human life is truly priceless, we have to shut down whenever 10% of the hospital beds are occupied by coronavirus patients?

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24 thoughts on “The Honest Man of American Medical Research weighs in on coronaplague”

  2. These are good questions. One that’s crossed my mind is, has anyone seen the term QUALY employed in reports of the coronaplague? Or if not the term, the concept?

    Consider saving an ill 80 year old so he can live one more (uncomfortable) year, versus helping an 18 old live another fifty years in good health. From the prevailing hysteria, it seem these are given exactly equivalent value. Reports like this are making no noticeable impression.

    Another aspect receiving little attention is the virus’s preference for killing men (from that previous link, “All of Italy’s victims under 40 have been males”). In the era of female supremacism maybe that’s considered a feature not a bug.

  3. I read this. Didn’t learn much. Basically, the author points out there is uncertainty.

    Time will tell, but better safe than sorry. We are under shelter-in-place in NCAL, and I think this should be nationwide, for at least a month, until we figure out where we are at with this threat.

  4. One good reason to shut down the entire city is to save it from bankruptcy later on when the surviving citizens sue the Mayor and the City Hall and demand punitive damages for indecent exposure (https://statelaws.findlaw.com/new-york-law/new-york-indecent-exposure-laws.html) to the #TrumpVirus.
    And that’s even before the suits start piling up claiming that our Mayor has committed treason by not providing enough dried pasta and hand sanitizer. And he could probably defend himself by saying that he demanded lots of stuff from the Trump Administration and publicly warned that people would die otherwise.

  5. There’s a hypothesis that aspirin intoxication played some role in 1918 pandemic deaths.

    “In 1918 Pandemic, Another Possible Killer: Aspirin”, https://www.nytimes.com/2009/10/13/health/13aspirin.html

    Original paper and discussion:

    “Salicylates and Pandemic Influenza Mortality, 1918–1919 Pharmacology, Pathology, and Historic Evidence”, https://academic.oup.com/cid/article/49/9/1405/301441

    “Questioning the Salicylates and Influenza Pandemic Mortality Hypothesis in 1918–1919”, https://academic.oup.com/cid/article/50/8/1203/451446

    “Reply to Noymer et”, https://academic.oup.com/cid/article/50/8/1203/451457

  6. Funny corobservation of the day. Spaghetti aisle still bare everything else has reasonable selection. I don’t think people are still panic buying pasta, I think it is the only thing people know how to cook. Forget MCAS kids should need to pass a couple years of home ec to graduate high school.

  7. “weeks in the ICU billed to Medicare for a 95-year-old”

    My 68 y/o mom spent 4 weeks in ICU after a stroke, then 30 days in a rehab facility, then two years at an ALF before she passed at the age of 70. Fortunately, her LTC insurance paid 80% of the ALF bill, and Medicare paid for the ICU and rehab.

  8. Philip, it looks like Trump reads your blog! (Or more realistically, his advisors are reading the same sources you are.) Washington Post: Trump signals growing weariness with social distancing and other steps advocated by health officials.

    Why this is so dangerous: there’s a delay of 10 days or more between infection and diagnosis, so the number of confirmed cases today reflects the number of infections 10 days ago. If the US has 43,000 confirmed cases today, and the doubling time is three days, that suggests that the actual number of cases is more like 300,000. Most of those people don’t feel sick yet. The invisible part of the problem is much larger than the visible part, and if it’s growing at 20%, the rate of new cases is increasing every day.

    If you’re willing to appeal to authority, the Imperial College COVID-19 Response Team’s Report 9 makes for sobering reading. Basically, half-measures like quarantining people who are obviously sick are not going to be sufficient to prevent mass deaths. Only general social distancing (i.e. shelter in place) is going to do it.

    If I can make a more philosophical point, Philip, a while back someone commented that the US two-party system has resulted in a two-party epistemology: that is. progressives and conservatives now disagree not just on values, but on facts. Changing your mind is very difficult: people tend to latch onto things which strengthen their existing beliefs. Once you’ve decided that people are overreacting, and after you’ve spent a couple months making fun of these people and their hysteria over coronaplague, it’s not easy to change your mind. Essays like Aaron Ginn’s will seem much more plausible to you than the Imperial College report. (It amazes me that you find his per-capita argument plausible.)

    This is human nature. William James commented on this more than 100 years ago:

    The observable process which Schiller and Dewey particularly singled out for generalization is the familiar one by which any individual settles into new opinions. The process here is always the same. The individual has a stock of old opinions already, but he meets a new experience that puts them to a strain. Somebody contradicts them; or in a reflective moment he discovers that they contradict each other; or he hears of facts with which they are incompatible; or desires arise in him which they cease to satisfy. The result is an inward trouble to which his mind till then had been a stranger, and from which he seeks to escape by modifying his previous mass of opinions. He saves as much of it as he can, for in this matter of belief we are all extreme conservatives. So he tries to change first this opinion, and then that (for they resist change very variously), until at last some new idea comes up which he can graft upon the ancient stock with a minimum of disturbance of the latter, some idea that mediates between the stock and the new experience and runs them into one another most felicitously and expediently.

    … Loyalty to [existing beliefs] is the first principle – in most cases it is the only principle; for by far the most usual way of handling phenomena so novel that they would make for a serious rearrangement of our preconceptions is to ignore them altogether, or to abuse those who bear witness for them.

    • I hope that I didn’t cast doubt on the Imperial College report. I linked to it the day it was published. https://philip.greenspun.com/blog/2020/03/17/more-from-the-british-on-coronavirus/

      I don’t think that Ioannidis and the Imperial College authors are saying anything inconsistent or disagreeing about “facts”. The Imperial College report itself describes most of its assumptions as “uncertainties”. If two people disagree on whether to shut down a society/economy based on an “uncertainty” that is not a scientific disagreement.

      Nor did I say that shutting down the U.S. economy was the wrong decision. If we agree that every day additional that every human (even Harvey Weinstein and similar convicted felons) can live has an infinite value then we are doing more or less the right thing. That’s implicitly been our assumption in the U.S. health care system, especially Medicare, for the last 50 years or so. What’s different about COVID-19 is that maintaining this philosophy might cost us closer to 50% of what’s left of our GDP rather than only the 17% that we’ve been spending. (50% of GDP means that every other day that an American works it will be to support the health care system, instead of 1 out of 5 that is the current ratio)

    • The Imperial College report is incomplete, I think, in a significant way. It assumes that the supply of care remains constant and that the therapies available remain constant. Both assumptions may end up being correct, but, if not, the “we have to be shut down for most of the next 1-2 years” conclusion won’t be right.

      One hint that these assumptions aren’t correct in the U.S.: “U.S. hospitals have something like 62,000 up-to-date machines immediately available, plus another 99,000 obsolete units that could be pulled out of storage in an emergency, says the Society of Critical Care Medicine.” https://www.forbes.com/sites/baldwin/2020/03/14/ventilator-maker-we-can-ramp-up-production-five-fold/#60c288c85e9a

      If the pessimistic forecasts of transmission and severity turn out to be correct, we still might not see health care services overwhelmed because they might have expanded by the time the Imperial College forecasted peak arrives (early summer 2020).

    • Finally, if things get truly bad the U.S. might abandon its commitment to unlimited health care services to the super old, the undocumented, the imprisoned. Will we let taxpayers die so that a prison inmate who needs gender reassignment surgery can get it? https://www.nbcnews.com/feature/nbc-out/idaho-must-provide-sex-reassignment-surgery-trans-inmate-court-rules-n1046501

      How about a convicted child molester who is an undocumented immigrant? Give him the $1 million in cancer treatment that he needs, depriving a legal resident of the U.S. of a life-saving hospital bed, and then deport him? Or deport him to Mexico and let the Mexican taxpayer fund his cancer treatment (maybe equal quality at a tiny fraction of the cost!)? https://www.sltrib.com/news/politics/2018/07/26/utah-county-inmate-was/

      Medevac the 90-year-old from a community hospital to a big city super hospital to take a 5% $500,000 shot at postponing death by 6-12 months?

    • “I don’t think that Ioannidis and the Imperial College authors are saying anything inconsistent or disagreeing about ‘facts’.”

      I would respectfully disagree. For example, how contagious is Covid-19? The two reports have very different estimates. Who’s closer to the truth?

      Based on fits to the early growth-rate of the epidemic in Wuhan, we make a baseline assumption that R0=2.4 but examine values between 2.0 and 2.6.

      Ioannidis:

      Early estimates of the basic reproduction number (how many people get infected by each infected person) have varied widely, from 1.3 to 6.5. … The fact that containment measures do seem to work, means that the basic reproduction number is probably in the lower bound of the 1.3-6.5 range….

      How dangerous is it? How many of those infected will require hospitalization? How many will require critical care? How many will die?

      Analyses of data from China as well as data from those returning on repatriation flights suggest that 40-50% of infections were not identified as cases. This may include asymptomatic infections, mild disease and a level of under-ascertainment. We therefore assume that two-thirds of cases are sufficiently symptomatic to self-isolate (if required by policy) within 1 day of symptom onset, and a mean delay from onset of symptoms to hospitalisation of 5 days. The age-stratified proportion of infections that require hospitalisation and the infection fatality ratio (IFR) were obtained from an analysis of a subset of cases from China. These estimates were corrected for non-uniform attack rates by age and when applied to the GB population result in an IFR of 0.9% with 4.4% of infections hospitalised (Table 1). We assume that 30% of those that are hospitalised will require critical care (invasive mechanical ventilation or ECMO) based on early reports from COVID-19 cases in the UK, China and Italy (Professor Nicholas Hart, personal communication). Based on expert clinical opinion, we assume that 50% of those in critical care will die and an age-dependent proportion of those that do not require critical care die (calculated to match the overall IFR).

      Ioannidis:

      Exaggerated case fatality rate (CFR): Early reported CFR figures also seem exaggerated. The most widely quoted CFR has been 3.4%, reported by WHO dividing the number of deaths by documented cases in early March.7 This ignores undetected infections and the strong age-dependence of CFR. The most complete data come from Diamond Princess passengers, with CFR=1% observed in an elderly cohort; thus, CFR may be much lower than 1% in the general population; probably higher than seasonal flu (CFR=0.1%), but not much so.

      Observed crude CFR in South Korea and in Germany, the countries with most extensive testing, is 0.9% and 0.2%, respectively as of March 14 and crude CFR in Scandinavian countries is about 0.1%. Some deaths of infected, seriously ill people will occur later, and these deaths have not been counted yet. However even in these countries many infections probably remain undiagnosed. Therefore, CFR may be even lower rather than higher than these crude estimates.

      The Imperial College report is saying that lockdown for several weeks, and ongoing measures after that, are required to avoid mass deaths. The Ioannidis report is saying that the Covid-19 pandemic isn’t that serious, and that extreme measures like lockdown are not justified. I don’t see how you can say that they’re consistent with each other. They can’t both be right.

    • “Nor did I say that shutting down the U.S. economy was the wrong decision. If we agree that every day additional that every human (even Harvey Weinstein and similar convicted felons) can live has an infinite value then we are doing more or less the right thing.”

      This seems like a reductio ad absurdum. It’s unreasonable to put an infinite value on every additional day that someone lives. I wouldn’t even put an infinite value on every additional day that I live! It’s reasonable to apply cost-benefit analysis to health care.

      The argument from public health specialists is that temporarily shutting down a large chunk of the economy for several weeks, in order to prevent the spread of a highly contagious virus that will result in many people (not just the elderly) requiring intensive care, does meet that cost-benefit test.

    • Russil: It is not “reductio ad absurdum”. It is how the current U.S. system works. There are no death panels. There is no rationing of care. There is no https://en.wikipedia.org/wiki/Quality-adjusted_life_year being considered as in the U.K.

      If a patient, in the opinion of a physician who is going to get paid to do the procedure (and as long as it is not completely inconsistent with some standard of care), could conceivably benefit from the procedure, the procedure will be done and then billed to Medicare, Medicaid, or private “insurance” (in reality, the employer who is “self-insured”). There is an implicit assumption that life has infinite value.

      If your child can benefit from Brineura at $486,000 per year (Medicaid discount price) starting at age 3 and continuing through age 103, nobody is going to say “I don’t know if your child is worth $50 million in tax money given that you’ve never worked and the tendency to collect welfare is heritable.” https://www.chemdiv.com/fda-approves-biomarins-batten-disease-drug-cost-per-year-702000/ (13 out of 23 patients experienced no improvement after getting $2.5 million worth of this drug)

      Here’s a story about 90-year-olds getting $500,000+ cancer treatments: https://www.scientificamerican.com/article/never-too-old-to-fight-cancer/
      Cost is not the primary part of the analysis: “people in their ninth and 10th decades of life were seen as too fragile for treatment. Their cancers were often believed to be so slow-growing that something else might kill them first; it made little sense to put them through the ordeal and cost of treatment.”

    • “It is not ‘reductio ad absurdum’. It is how the current U.S. system works.”

      It’s both. It’s how the current US system works, and it’s absurd.

  9. I figured out how to flatten the curve. Close the hospitals. Open everything else. Have everyone go back to living. If you get sick self quarantine until recovered or dead. Don’t let a little fear overwhelm what is best for civilization.

  11. Did Trump really just say that he wants to end social distancing by Easter, against the advice of health officials?

    Twitter thread by Tom Inglesby of Johns Hopkins: “In last 24 hrs there’ve been prominent US voices calling for a stop to social distancing, citing rationale that they’re worse than impact of COVID itself. It’s worth looking very closely at that claim, where we are in US COVID epidemic and what happens if we stop. “

  12. https://westhunt.wordpress.com/2020/03/20/john-ioannidis/

    Gregory Cochran’s takedown of this. Cochran is another contrarian. Battle of the contrarians!

    “He emphasizes the cruise ship ( why ignore other whole countries?) and he distorts that example. Most never caught it: of those that did, all had excellent medical care. That’s no longer possible when many millions get infected – resources are limited.”

    And he goes on from there.

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