On the menu today: The head of research for a top-ten U.S. hospital offers an update on the state of the fight against the coronavirus; the World Health Organization muddles the answers about the contagiousness of the virus again; an expression of gratitude; and a lament about our ongoing Civil War of Stupidity.
A Top Medical Researcher: ‘If You Have a Loved One in a Nursing Home, Watch Them Like a Hawk’
I had a chance to check in with my reader who is the head of research for a top-ten hospital in this country, getting a sense of where the country stands as we head into summer. This director has been briefing high-level decision makers since the coronavirus epidemic began. He prefers to not to be quoted by name, lest his assessments cause headaches for his institution. (He has not yet said to me, “dammit, Jim, I’m a doctor, not a corporate spokesman.”)
This director’s view is that hospital cases are the best measure of the impact of the pandemic; as death statistics can look higher or lower by how narrowly or loosely authorities define the cause of death, and total number of cases is driven in part by how aggressively a state is testing asymptomatic people — testing that he concludes the country is doing a much better job on now.
The Washington Post noted yesterday that “14 states and Puerto Rico have recorded their highest-ever seven-day average of new coronavirus cases since the pandemic began.” But as observed above, an infection is not necessarily a serious problem, particularly if the patient is asymptomatic. (More on that below.)
This director’s medical center and his home city’s health department have been aggressively going into the nursing homes and testing, so the spread of infection in nursing homes is way down. “The authorities are working smarter, finally. If you have a family member or other loved one in a nursing home or rehabilitation center, I’d still be watching them like a hawk and making sure the staff there are taking upmost precautions every single day, because we know from sad experience that this is where the impact of COVID-19 is going to be most severe.”
This researcher’s home city, one of the country’s larger ones, has seen “a nice steady decline” in hospital cases since hitting a peak or plateau the last week of April and the first week of May. “We’re now below 40 percent of the number of cases we had at the peak, we no longer need the surge facilities, and my hospital is working on resolving the backlog in procedures that are formally considered elective, but laypeople wouldn’t call elective, like cancer surgery. I’m very grateful we can take care of those patients again.”
He notes that he saw an uptick in cases last week in his county and statewide following the Memorial Day holiday. “Small, but real. It didn’t spark any kind of crisis, and it was over three or four days later, but it is evidence that social distancing still is necessary.”
This researcher believes that America’s more rural states will experience a pattern similar to the more rural parts of his state on the East Coast. “They had very few cases in March and early April while the cities were getting hammered, and then you see comparatively large jumps at various times in late April and throughout May. They look big because the baseline is low, but they’re consistent with a little outbreak in one community or nursing home that isn’t spreading any further. In fact, if you track the hospital data, these jumps last around a week, which is about the average length of stay for our hospitalized COVID-19 cases. It’s going to be a long slow burn out there instead of the short-term, and eventually the proportional number of cases in rural areas will be equal to or higher than the city figures. That’s not proof that the blue state governors were right to lock their states down, it’s just basic epidemiology.”
This director acknowledges the advice from CDC has been confusing often and contradictory at times. “They’re being pushed and pulled in all directions. In part it’s political winds, and in part it’s the normal thing that happens when we have to make decisions based on really weak data. People seize upon the most recent data and overreact to it, rather than adding it to the body of evidence and steering a steadier course. Good reason to spend less time with the shouting and overreactions endemic to Facebook and Twitter.”
This director’s advice to others is, “continue to take sensible precautions as you try and resume something like a normal life. Set a good example for your neighbors, and for heaven’s sake, don’t try to make a political statement by disobeying mask and social distancing requests or by calling out your neighbors for going for walks together or playing in the street.”
[Did you get that, Karen?]
He continues, “there will be a few setbacks as the pandemic wanes, but I’m cautiously optimistic we will not see a terrifying second wave. If we continue to act sensibly, the government nannies will look more and more foolish by comparison, and then we can make the case to the swing voters that the American people can and should be trusted with liberty instead of being ruled over by their betters.”
I asked him whether there was a way to determine if any discernible increase was driven by the protests or by the reopening in businesses, or both.
“My sense is that right now is a little too early to see effects in hospital cases,” he replied. “Most of the protestors and virtually all of the rioters are the relatively young and healthy persons who will be outpatient cases if they suffer a coronavirus infection. However, a lot of them go home to parents who are more likely to have one or more conditions that could exacerbate the disease. Allowing for a few days latency from the initial infection to the time the disease becomes symptomatic, we should know in the next few days what the impact of the protests will be (aside from the effect on public trust in institutions, my peers in public health, the media, and elected officials) . . . Separating the effect of protests from the effect of loosened restrictions on businesses won’t be possible in areas where the two coincided, but there ought to be ample data for a natural experiment comparing the disease incidence in cities where restrictions were lifted earlier, cities where restrictions were lifted right around the time of large demonstrations, and cities where the restrictions haven’t been formally lifted yet.”
He concludes the regression analysis to get an answer about the rate of virus spread from protests is simple, but a separate question is how much a researcher is risking a career by reporting the results.
Way to Go, WHO. Way to Go.
Thank you, Dr. Maria Van Kerkhove, head of WHO’s emerging diseases and zoonosis unit, for adding to public confusion by declaring Monday, “from the data we have, it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual. It’s very rare.” The original headline on CNBC drew a sweeping conclusion: “Asymptomatic coronavirus patients aren’t spreading new infections.”
The problem is the doctor’s statement sounds like if you don’t have symptoms, you’re not contagious. That is not the case. Asymptomatic — infected, but showing no symptoms — is not pre-symptomatic, which is infected, but not showing symptoms yet. If you don’t have symptoms, you may not have the virus, or you may be asymptomatic, or you may be pre-symptomatic. Your only way of knowing is if you take a test. (And that depends upon the test being reliable, and the test can only tell you your condition at the time of testing. You could catch the virus in between the testing and getting the results!)
Doctors warn that a patient’s self-assessment of being asymptomatic may be genuinely asymptomatic, or the patient may be ignoring or downplaying minor symptoms. Doctors and medical researchers sometimes have difficulty measuring the difference between the indisputably asymptomatic and those with exceedingly minor symptoms! And some doctors aren’t even sure that the WHO assessment is as rare as they make it sound, as the studies they’re citing have fairly small samples. One used just 63 people.
Less than a week ago, a different group of researchers published a paper contending that at least 30 percent of coronavirus cases are driven by asymptomatic carriers, and perhaps as many as 40 to 45 percent. Time magazine’s headline declared, “Nearly Half of Coronavirus Spread May Be Traced to People Without Any Symptoms.”
The news, and in particular, medical news during a serious pandemic, is not supposed to be choose-your-own-adventure. (“If you think masks are necessary, turn to page 34. If you think the coronavirus is being spread by 5G towers, turn to page 17.”)
ADDENDA: Our webathon is a tremendous success. If you are one of the more than a thousand donors to NR, thank you, thank you, a thousand times, thank you . . .
. . .You may have heard some people discussing America’s political divide as a “Civil Cold War.” Over on the home page, I see it differently. It feels like every day, we awaken to a new furious skirmish in our Civil War of Stupidity, where every problem is greeted by the two loudest and dumbest hot-take responses, and reverberating waves of outrage echoing between those sides.