By Dr. John M. Livingston | Medical Policy Adviser
I am having a difficult time matching what the experts have told us and reconciling what is happening worldwide on the ground. As I have mentioned in earlier posts, I am a contrarian and a skeptic. I never mean to imply that a certain group of people don't care, but rather that the premise of their caring and the premise of their recommendations can be the result of their real world experiences.
I have been encouraged to see that many of our public health specialists at the White House presentations have their specialty boards in internal medicine and infectious disease. This is not true of the majority of experts that are providing inputs to their analysis and recommendations.
We all see life through the lens of our own expertise. An expertise that is developed through our own life's experience and our individual application of the skills that we have developed. We are all jealous of our own knowledge sets and the little corners of our world that we share with people that share these unique areas of knowledge. Unfortunately as the division of labor becomes more specialized, many people who are experts in their own little corner of the world have a very skewed view of the overall world.
During the course of my 44-year medical career I have interacted with specialists, all who feel they are special, especially in my own field of surgery. I have seldom, however, dealt with a specialty group who felt they were more special than the group in public health and preventive medicine. Part of the problem, I believe, is that this particular group seldom personally interacts with sick patients. They deal almost exclusively in the world of statistics. Their modeling is theoretical in nature and as such is subject to prospective and retrospective manipulation.
When a clinician makes a bad decision, his or her patient suffers and they directly participate in the bad outcome. I do not mean to imply that these public health specialists don't care or don't feel the pain of a bad decision. The difference is shown by a statement reportedly made by Stalin: "The death of one man is a tragedy, the death of millions is a statistic.” Clinicians feel each death one at a time.
So there are some interesting statistics that are just coming out and they give me pause and stimulate my contrarian instincts.
The same COVID-19 Virus is causing patterns of morbidity and mortality that are very different in different locals and within different demographics. Why?
In California, where they have twice the population of New York state, they are seeing one-tenth of the death rate. This time last year, California was averaging 776 deaths per day in a state with 40 million people.
The last two weeks, California has been averaging 780 deaths per day — four more people per day. That’s an increase of .00001%. Why? Is this number worth shutting down the world's fourth-largest economy? Are there other mitigating interventions that would be more appropriate, not to mention more efficacious. Clinicians need to have a say in these decisions. Maybe using Hydroxychloroquine and Z-Packs would be wise at this point?
Are people in California living differently than people in New York? Are they more disciplined in applying population isolation techniques? California has more than 8,000 people per day flying from the Far East directly into hub cities like Los Angeles and San Francisco.
That's twice as many people as New York and New Jersey each day. Just maybe the statisticians will tell us years from now that Californians had been exposed very early on in the epidemic and a form of herd immunity was established earlier than we had been led to believe. This is exactly what happened in smallpox and measles epidemics in the past.
The same types of numbers are being revealed from South Korea, where deaths and incidence rates dropped off quickly.
In Israel, another interesting experiment is proceeding before our eyes. The incidence rates and death estimates are low across all the country except in certain isolated demographic groups who refuse to self-isolate — Hasidic Jews and fundamentalist Muslims. In these groups, incidence and death rates are more like New York City than those of South Korea and California.
All modeling — financial or public health — uses retrospective data to predict future events. As such inputs that skew the overall data can cause large shifts in the validity of our predictions. People who live in these worlds of statistics — with the exception of many insurance actuaries — fail to recognize the limitations of their models. The closer they get to the problem, the more they view the future through a diaphanous veil.
When these numbers validate their own importance, the more they fail to confess publicly their own limitations. One of my great mentors, arguably the greatest surgeon of the 20th century, Dr. Robert Zollinger, once confided in me, "I know what I know and I know what I don't know, and part of what I know is what I don't know." These are words of wisdom for clinicians and public health statisticians alike.
The real questions to be answered years from now will be: Why did the people at the Center for Disease Control and the National Institutes for Health fail to understand and prepare for the COVID-19 epidemic? Was it because China didn't let them in? Did the World Health Organization fail to do its job of surveillance and warning?
And the big question for me is this: Was the virus here weeks or months earlier than we have thought? If so, how does this skew our numbers and the flattening of the curves?
The people who will be in charge of answering these questions are the people advising our president today. I do believe they will be honest and forthright moving forward recognizing that "they don't know what they don't know."
Seasonal flu takes between 20,000-80,000 lives a year in our country. I believe that as we move forward and as the epidemiological models evolve, the loss of life in our country will be less than double that upper number.
I just don't know.
If businessmen and entrepreneurs and doctors and scientists always assumed worse case scenarios, then startup companies, many cancer patient treatments, and moon shots would never get off the ground. Plato warned of arguments of the extreme. An assessment of risk is not an analysis of the risk. We have been told the risks about COVID-19. We've yet to receive a proper analysis.
Note: Dr. Livingston added a few more thoughts after the initial publication. Find those below:
An addendum to this discussion is provided in the April 5 edition of the Wall Street Journal in an article by the economist Vernon Smith. He relates a theory of "agency" found in Adam Smith's first treatise "The Theory of Moral Sentiments."
Compassionate people have a sense of "fellow-feeling" which is a sense different than empathy, compassion or sympathy, but rather is a sense of literally putting yourself in the place of your fellow man. In this regard Adam Smith refers to the asymmetry between joy and sorrow Our distress is far greater when we fall from a better situation (social or financial) to a worse one when compared to the limited joy we have rising from worse to better. We, therefore, seek security in our choices, situations and in the case of public health officials reputations---hence their propensity to making worse case scenarios. My college football coach called this "The Black Curse." If a team wins 30 games in a row and then loses, there is much anguish. When they are 0-30 and win there is just a little bit of joy. I hope the people advising our president and the president himself understand this concept, because if they don't it may delay our return to economic normalcy.