Luke Ford

From Michael Lewis’s superb 2021 book, The Premonition: A Pandemic Story:

* Charity had taken away other lessons from Dr. [Stephen] Hosea.
The simplest explanation is usually the best. If the patient turns up with two separate symptoms—say, a fever and a rash—the cause is more likely than not a single underlying disease.
If there is the faintest possibility of a catastrophic disease, you should treat it as being a lot more likely than it seems. If your differential diagnosis leads to a list of ten possibilities, for instance, and the tenth and least likely thing on the list is Ebola, you should treat the patient as if she has Ebola, because the consequences of not doing so can be calamitous.
When something doesn’t quite seem right about your diagnosis, respect the feeling, even if you can’t quite put your finger on why the diagnosis might be wrong. A lot of people had died because doctors had allowed their minds to come to rest before they should.
A doctor needed to be a detective for the patient: that was Dr. Hosea’s big message. Charity had grafted it onto her job as health officer. Her patient was Santa Barbara County. To keep it healthy, she needed to think about it the way Stephen Hosea thought about his patients. She needed to keep her hands on it. To be its detective.

* She watched Dr. [Charity] Dean tell this important doctor, on the spot, that she was issuing a health order to shut him down.

* At which point Charity needed to let the California Department of Public Health and the Centers for Disease Control in Atlanta know what she’d done. That was the moment she sensed just how far out on a limb she had climbed. “The CDC was aghast,” she said. “They were aghast that I hadn’t asked their opinion. They said no local health officer in the history of local health officers has ever issued an order to close down a doctor’s office based on a suspicion.” They tried to argue that, as a mere local health officer, she lacked the authority to close a doctor’s practice. Charity didn’t understand, first, that the CDC could not know just how broad her authority was—but then she too had only just learned that the power in most of the rest of the United States resided with the state health officer rather than the local ones. California was unusual in having conferred on its county health officers the same powers that, say, Texas and Mississippi reserved for their state health officers. Yet even after the CDC people conceded her authority, they refused to condone how she’d used it. “They told me that if I’m wrong I’m going to get fired,” she said.
That threat actually wasn’t all that original. As Kat DeBurgh, head of the Health Officers Association of California, put it, “To do the job of local public-health officer, you basically always need to be willing to lose your job.” To be a public-health officer—to really own the role—you needed to be prepared for your only appearance on the front page of the local newspaper to be in a story about a call you got wrong. That might be the only time anyone ever looked up and noticed who you were: the moment they chopped off your head.
Apart from the uninsured poor she treated in the clinics and homeless shelters, few citizens had any clue what Charity did—until she did something that infuriated them. “Rich white people would look at me like I was a relic from the past when I explained my role,” she said. “Like they’d stumbled across a candelabra from the Titanic . How lovely—but what does one need it for today?” The illness you prevented, and the lives you saved, went unnoticed by the people sitting on top of society. That’s why her role was, every year, less well funded than the year before. The fax machine was the new tech in the office that still kept its records on paper and filed the paper in red manila envelopes. “If I wanted to send a letter, I needed to fill out a form, and the form had to be approved—all to use a county-funded stamp,” said Charity. “I was the county health officer, and I wasn’t allowed to use a stamp. But that’s okay! I learned to live within the system.”
That system was the front line of defense against disease, not just in the county but in the whole country. Seventy percent of Santa Barbara’s cases of communicable disease came through one of its five public-health clinics, overseen by the health officer. The math was the same everywhere. But because people who had health insurance thought it had nothing to do with them—that it was just government —the society had starved the system of resources. “People don’t realize what it is until something bad happens,” said Charity. “It’s protecting the entire society, the whole economy.” The economy, for its part, understood her role only in its own narrow financial terms. “I learned the way to make the argument to elected officials for money for disease control was not ‘It is the right thing to do to take care of the most vulnerable in our community,’ ” she said. “Rather, make the case of the dollar return on investment to prevent the disease from spilling over into the rest of the community.” Yet even then—even after she showed a return—the investment often went unmade. It had taken years to get the money to buy a machine that allowed her to test quickly for tuberculosis, and to prevent some number of new cases. “The cost of a single TB case is between thirty and a hundred thousand dollars,” she said. “Higher if it is drug-resistant TB. So why are we haggling over a seventy-two-thousand-dollar machine?”

* Charity expected the state medical board to dig deeper. They never did. “I called them and said, ‘We thought you were launching an investigation.’ They said, ‘We are. But it consists of you telling us what you’ve found.’ ” The subsequent report by the Medical Board of California explained that Dr. Thomashefsky had violated a great many standard operating procedures. The state of California stripped him of his license to practice medicine, and he eventually was asked to close his practice in Oregon. With that, his career in medicine ended.
By then Charity Dean knew that, in her quest to stop the spread of disease, she was more or less on her own. She had her friends and allies. The public-health nurses, for example, who were among the more impressive human beings she had ever known. She was also growing to adore Santa Barbara’s chief counsel, who kept handing her enough rope to hang herself, by confirming that, yes, the law allowed her to do whatever the hell she thought needed doing to protect the public. She felt a deep connection to the fifty-seven other California county health officers—though they were, she had to admit, a mixed bag. Some were ancient doctors who viewed the job as a sinecure; some were part-timers who didn’t even seem all that interested in the job. “There’s no defined career path to becoming a public-health officer, and that’s a problem,” she said. “You get the retired anesthesiologist who is spending most of his time as a professional dog breeder.” But some of her fellow local health officers, like Charity herself, were so deeply committed to the job that they experienced it more as a mission. These people she loved best. But their needs and issues were too diverse for them to function as a single, powerful unit. And they weren’t in a position to have her back in a crisis.
The larger apparatus of American public health was very different on the inside from how Charity had imagined it from the outside. The Centers for Disease Control, the apex authority, wasn’t of much practical use to her. The distance they had put between themselves and her when she closed Thomashefsky’s clinic was of a piece with their general behavior. She’d repeatedly seen the tendency to flee when conflict arose.

* Charity instructed the Santa Barbara medical community to test any young person who turned up with a low-grade fever. “It’s not those people with mild symptoms you worry about,” she said. “It’s the people they infect, and the exponential growth.” As the CDC dithered, three more UCSB students tested positive for meningococcal disease. Each case presented differently. One student, with only a rash, had been diagnosed initially with chicken pox; the other two had slight fevers and had been initially misdiagnosed as having nothing special. “None of them lived together,” recalled Dr. Ferris, UCSB’s medical director. “It was really sort of hard to understand why we had these random cases.” Within days the school had set up hotlines to field calls from panicked parents, along with complaints from citizens of Santa Barbara who thought that the school’s twenty thousand students should be confined to their rooms.
Charity stayed up nights staring at the whiteboards in her office, on which she had charted the social relationships of the infected UCSB students. At the top of the board she had written “Cross-Pollination,” a term of art she’d picked up from Dr. Hosea. “It’s when you don’t want to say ‘he had sex with her’ and what kind of sex they had,” she said. “But I was basically trying to figure out who had shared saliva with whom, and where they’d shared it.” All signs pointed to the Greek system. She decided to shut down the college sororities and fraternities and give the twelve hundred students in them a prophylactic drug.
“With meningitis B you have a very narrow window to give the prophylaxis,” she explained, “and it was a weekend. You had to do it fast and all at once, or else the pathogen just keeps circulating.”
She got on the phone with the main guy at the CDC and his silent crowd. The guy strongly disagreed with her doing anything. “What he actually said,” recalled Charity, “was, ‘That decision is not supported by the data.’ I said, ‘Oh, really—there is no data.’ ” She outlined a plan she’d created: thin out the dorms by moving some of the students into hotel rooms; shut down the intramural sports teams; and administer a vaccine that had been approved in Europe but that the FDA had not yet signed off on. “The CDC guy said, ‘We’re not going to do any of that, and if you do that, we’re going to put it in writing that it was your decision and we disagreed with it,’ ” Charity recalled.
There followed other calls with the CDC, each more dismissive of her than the last. After one of them, Paige Batson turned to her boss and said, “Dr. Dean, I’ve never heard anyone at the CDC speak to someone like that!” But in the end the campus ignored the CDC and did everything Dr. Dean recommended. “It was kind of a stern order,” said Dr. Ferris, “and it had never been done before. But after she stopped all the parties and administered the prophylaxis, we had no more cases.” From start to finish, what Dr. Ferris and everyone noticed was that, as Dr. Ferris put it, “the CDC wasn’t pleased with her. The CDC kept saying, ‘There is no evidence to back it up.’ They didn’t have any evidence, because there is only one case every four years.”
The root of the CDC’s behavior was simple: fear. They didn’t want to take any action for which they might later be blamed. “The message they send is, We’re better than you and smarter than you, but we’re letting you stick your neck out to take the risk,” said Charity. “They would argue with me about how kids behave in fraternities and sororities. And I had been president of Kappa Delta!” In the middle of the crisis, Charity figured out what it would take to appease the nation’s highest authority on infectious disease. “It was when they said, ‘If any of this works, you won’t know which one worked,’ ” she recalled. “They said, ‘You need to do these things one at a time and gather evidence.’ They wanted to learn from this meningitis outbreak, and I wanted to stop it. My goal was to stop it, and that was not their goal. They wanted to observe it as if it were a science experiment on how meningitis moves through a college campus. And I was like, ‘Are you kidding me: a kid just lost his feet.’ ”
Charity never would know which of the measures she took had controlled the disease; she knew only that all of them together had. To her, all that really mattered was that the disease had been contained. The job of the public-health officer—or at least her job as the public-health officer—was a series of intense firefights. There was no standard operating procedure for many of the situations in which she found herself: usually, they were sufficiently different from anything that had ever before happened. If she waited until she had enough evidence to publish in a scientific journal, the battle would be over, and she’d have lost. Kids would lose limbs, or die. The decisions she was forced to make were less like, say, those made by a card counter at a blackjack table, and more like the ones made by a platoon leader in combat. She never had all the data she wanted or needed when making her decisions—enough so that afterward she could defend them by saying, “I just did what the numbers told me to do.”
The hard truth was that there was never time to wait for more data. The moment an infectious disease appeared, decisions cried out to be made. The longer you waited, the more likely it was that people would die waiting for you to decide—or waiting for you to gather the data you needed to cover your ass if your decisions proved wrong.
Two years after the UCSB meningitis outbreak, the CDC finally published a report on how to deal with a meningitis outbreak on a college campus. On its list of best practices were most of the things Charity had done at UCSB. After that, from time to time, someone would call her from the CDC and ask her if she’d please get on the phone with some college health officer somewhere in the United States and describe how she handled the UCSB outbreak. But by then Charity had washed her hands of the CDC. “I banned their officers from my investigations,” she said. The CDC did many things. It published learned papers on health crises, after the fact. It managed, very carefully, public perception of itself. But when the shooting started, it leapt into the nearest hole, while others took fire. “In the end I was like, ‘Fuck you,’ ” said Charity. “I was mad they were such pansies. I was mad that the man behind the curtain ended up being so disappointing.”
In theory, the CDC sat atop the system of infectious-disease management in the United States. In practice, the system had configured itself to foist the political risk onto a character who had no social power. It required a local health officer to take the risk and responsibility, as no one else wanted to. Charity could see that the CDC’s strategy was politically shrewd. People were far less likely to blame a health officer for what she didn’t do than what she did. Sins of commission got you fired. Sins of omission you could get away with, but they left people dead. The health officer’s job was to choose, all by herself, the direction in which to err: do too much, or too little? “I did not sign up to be that kind of brave,” said Charity. “That wasn’t my plan. I was always saying to the CDC, ‘This is your job! Do your job!’ But after the UCSB outbreak, my motto was, ‘Stop waiting for someone to come and save you. Because no one is coming to save you.’”

* Inside Casa Dorinda, Charity had thirty minutes. “I knew what I had to do,” she said. “I didn’t want to do it. I was asking myself: Is there any way out of this?” The answer came back: no. She looked around and found that the fire sprinklers didn’t work—and that alone, she told the medical director, was grounds for shutting the place down. “I told them, ‘We can do this the easy way or the hard way,’ ” said Charity. “They were very upset, but they decided to do it voluntarily. Sure enough, there were seven deaths. Their medical director sent me a scathing email saying, ‘Their deaths are on you.’ He was right.” The second mudslide never came.

* The most disorienting aspect of the job by far was her new boss. Charity had assumed that she herself would replace her old boss, Dr. Karen Smith, whenever Dr. Smith stepped down. That’s why Dr. Smith had brought her in in the first place. Dr. Smith had left in June 2019, and for the next few months Charity had filled her shoes—but then, in October, she was returned to her original position. The new governor, Gavin Newsom, broke with the tradition of naming a former local California health officer to run the state when he instead brought in Sonia Angell, a former CDC employee in the agency’s Noncommunicable Disease Unit. Angell had experience in neither California nor communicable disease. Her most recent job had been working on heart disease in New York City’s health department. Only later, in August 2020, at the press conference where he announced Angell’s abrupt resignation—without going into why she was resigning so abruptly—would Newsom explain why, in part, she’d been recruited by his administration: her work in righting racial injustice in health care. Charity was later told that she herself had never been a serious candidate. “It was an optics problem,” says a senior official in the Department of Health and Human Services. “Charity was too young, too blond, too Barbie. They wanted a person of color.” Sonia Angell identified as Latina.

One thing that intrigued me from a deep Google search of Julius Ruechel is that nobody has bothered to critique his work. How important is it if nobody has bothered to push against it?

A friend sent me this link to Ruechel’s 115 page expose.

Julius writes: “Having a severe pre-existing health condition or a severely compromised immune system are necessary pre-requisites before you have cause to worry.”

That does not seem to square with this Feb. 18, 2021 Nature magazine study showing the average Covid death costs 16 years of life.

I find the Nature report more compelling. It strikes me as judicious while Ruechel’s style is hyperbolic.

Julius writes: “a full 97% of outbreak-related deaths are in long-term care & hospitals/healthcare!”

He doesn’t footnote the claim. It does not jive with other things we know about Covid deaths, including the Nature study.

Julius writes: “The pie chart demonstrates that this is a crisis that affects people with extremely serious pre-existing health conditions and compromised immune systems. And almost no-one else.”

That does not seem to square with this Feb. 18, 2021 Nature magazine study showing the average Covid death costs 16 years of life. Somebody is wrong here.

Julius writes: “Which means that, despite all the shaming about our desire to have a BBQ in our backyards with our friends, 98.6% of outbreak-linked deaths are from infections caught and spread inside the walls of tightly controlled institutional environments, not out in the community.”

He is on to something here as we have no evidence of substantial Covid transmission outside.

I find Ruechel’s rhetorical style too shouty to endure for long.

“When you overstate, readers will be instantly on guard, and everything that has preceded your overstatement as well as everything that follows it will be suspect in their minds because they have lost confidence in your judgment or your poise. Overstatement is one of the common faults. A single overstatement, wherever or however it occurs, diminishes the whole, and a single carefree superlative has the power to destroy, for readers, the object of your enthusiasm.” (Strunk & White)

Julius writes: “98.6% of all outbreak-linked deaths are the result of infections caught inside these institutional barriers. Only 1.4% are linked to outbreaks in the community at large.”

I’m skeptical. Where’s the footnote for this claim?

Julius writes that “many COVID deaths are deaths with but not from COVID.”

As soon as I hear this argument, my brain shuts off because I know I’m dealing with someone who doesn’t know much on the topic and does not think clearly with the little knowledge they do have. When I compare Julius’s arguments with Dr. David Gorski’s arguments on this matter, I find the surgeon more convincing. A pandemic that kills people at a median length of time of 18 days seems likely to be the underlying cause of death for most people who die with Covid. Covid, like AIDS, is never the proximate cause of death. Instead it will be something like organ shutdown or respiratory failure.

I don’t have the energy right now to survey the literature on the utility of face masks and social distancing to reduce an influenza pandemic. On the other hand, to me, just because some politicians and health officers used the justification of “two weeks [of lockdown] to flatten the curve” is not strong evidence that lockdowns don’t provide benefits that might outweigh the costs in some circumstances. Also, just because politicians and health officers reversed themselves quickly on the efficacy of face masks to reduce the spread of an influenza pandemic is not strong evidence that face masks are not useful in some contexts.

It makes sense to me that leaders would want to reduce the Rt (a measure of how quickly the virus is spreading), and when it goes above 1, they would have incentives to promote social distancing and when it goes well below 1, they might ease up on social distancing.

I just read Michael Lewis’s superb 2021 book, The Premonition: A Pandemic Story.

He writes:

* The problem, as he [Richard Hatchett in 2005] framed it for the Pentagon, was how to slow the spread of a communicable disease until you can produce a vaccine. As communicable disease spreads through social networks, Richard reasoned, you had to find ways to disrupt those networks. And the easiest way to do that was to move people physically farther apart from each other. “Increasing Effective Social Distance as a Strategy,” he called it. “Social distance” had been used by anthropologists to describe kinship, but he didn’t know that at the time, and so he thought he was giving birth to a phrase. (“But I don’t think I turned it into a gerund,” he’d later say.) What he also didn’t realize was that he was giving new life, to a dead idea: that apart from isolating people who were ill, you needed to do anything you could to slow the spread of a disease before you had drugs to help. “I was this emergency room doctor,” he said. “I didn’t know that people said all this stuff had been tried in 1918 and it hadn’t worked. I wasn’t rejecting anything. I just didn’t know any better.”

* There was, most importantly, a passage that suggested what the federal government might do, at the start of a pandemic, before a vaccine was available. It would, they’d written, “provide guidance, including decision criteria and tools, to all levels of government on the range of options for infection control and containment, including those circumstances where social distancing measures, limitations on gatherings or quarantine authority may be an appropriate public health intervention.”
It was hard to imagine anyone wading into that passage voluntarily, much less giving it a second thought. The words mattered less for what they said than for what they could be made to say. Like the words in the Holy Bible or the U.S. Constitution, they invited the problem of how they might be interpreted, and by whom, and for what purposes. As read by Richard Hatchett and Carter Mecher, those words gave them cover to answer the most important medical question they’d ever faced: How do you save lives in a pandemic before you have the drugs and vaccines to do it?

* The graph illustrated the effects on a disease of various crude strategies: isolating the ill; quarantining entire households when they had a sick person in them; socially distancing adults; giving people antiviral drugs; and so on. Each of the crude strategies had some slight effect, but none by itself made much of a dent, and certainly none had the ability to halt the pandemic by driving the disease’s reproductive rate below 1. One intervention was not like the others, however: when you closed schools and put social distance between kids, the flu-like disease fell off a cliff. (The model defined “social distance” not as zero contact but as a 60 percent reduction in kids’ social interaction.) “I said, ‘Holy shit!’ ” said Carter. “Nothing big happens until you close the schools. It’s not like anything else. It’s like a phase change. It’s nonlinear. It’s like when water temperature goes from thirty-three to thirty-two. When it goes from thirty-four to thirty-three, it’s no big deal; one degree colder and it turns to ice.”

* In the end he plotted both the deaths [in the 1918 Spanish Flu] and the restrictions imposed to prevent them, and saw that the earlier the restrictions imposed in any given outbreak, the fewer the deaths. In the case of Philadelphia, he wrote, “the closing of schools and churches, banning of public meetings, and banning of large public gatherings occurred relatively late into the epidemic”—nearly one month after the outbreak began and just a week before its peak. He wondered if other cities had reacted more quickly, and if their specific reactions might explain the huge variation in the death rates from city to city.

…“Others use the stories in Barry’s book to support the position that the infection control and social distancing measures would probably be ineffective,” he wrote. “On the flight back to Atlanta I went thru Barry’s book carefully and tried to reconstruct the events in a particularly hard hit city—Philadelphia . . . The bottom line is that anyone using the 1918 Philadelphia experience to argue that infection control and social distancing measures would be of little help needs to recognize how ineffective the overall response was in Philadelphia and how late the measures were instituted (within one week of the epidemic peak and after tens of thousands and perhaps hundreds of thousands were already ill).”

* It took just a few months for them to piece together what had actually happened in 1918. Their paper appeared in the May 2007 issue of the Proceedings of the National Academy of Sciences . A coauthor and friend, the Harvard epidemiologist Marc Lipsitch, did the statistical work and the other stuff that made it seem as if it were written by proper scholars. § Titled “Public Health Interventions and Epidemic Intensity during the 1918 Influenza Pandemic,” the piece revealed, for the first time, the life-or-death importance of timing in the outcomes of 1918. Cities that intervened immediately after the arrival of the virus experienced far less disease and death. The first reported flu cases in Philadelphia had been on September 17. The first case wasn’t spotted in St. Louis until October 5—which also happened to be the day the United States surgeon general, Rupert Blue, finally acknowledged the severity of the disease and recommended that local leaders take action. The death rate in St. Louis was half that of Philadelphia because St. Louis’s leaders used the cover provided by the federal government to distance its citizens from one another.
That didn’t mean that everyone in St. Louis appreciated what had happened. “We’re reading the newspapers in St. Louis,” said Richard, “and they know for a fact that they are having a better experience than other cities, and they still couldn’t keep their interventions in place for more than four to six weeks.” The paper analyzed the effects of that inability, and showed that American cities that caved to pressure from business interests to relax their social distancing rules experienced big second waves of disease. American cities that didn’t did not. The paper offered a real-world confirmation of what Bob Glass and the other mathematical modelers had discovered in their fake worlds. However you felt about the strategy of Targeted Layered Containment, you could no longer say there was no data to show that it had any effect. “Until then, the people who hated our ideas could throw up smoke screens about modeling,” said Richard. “They couldn’t throw up smoke screens about what had happened in 1918.”
The paper’s more subtle message appeared between its lines: people have a very hard time getting their minds around pandemics. Why was it still possible, in 2006, to say something original and important about the events of 1918? Why had it taken nearly a century to see a simple truth about the single most deadly pandemic in human history? Only after three amateur historians studied the various interventions, and the various death tolls in individual American cities, did the importance of timing became obvious. Carter wondered why this had been so hard to see. A big part of the answer, he decided, was in the nature of pandemics. They were exponential processes. If you took a penny and doubled it every day for thirty days, you’d have more than five million dollars: people couldn’t imagine disease spread any better than they could imagine a penny growing like that. “I think it’s because of the way our brains are wired,” said Carter. “Take a piece of paper and fold it in half, then fold it in half again, for a total of 50 times folding it in half. If a piece of paper is 0.004 inches thick to begin with, by the time you fold it 50 times, it is more than 70 million miles thick.” Again, it feels impossible. The same mental glitch that leads people to not realize the power of compound interest blinds them to the importance of intervening before a pathogen explodes.
It was seven months before the United States public-health system fully bought into the power of social distancing. The story of those months was dear to Lisa Koonin. She saved every email and every version of the fifty or more presentations she and Carter made—to everyone from the Department of Education to state and local public-health officers who filled hotel ballrooms. She thought she might one day write a book about it.
The big theme of her book would be the power of storytelling. It had taken Lisa, Richard, and Carter some time to see that they were in a war of competing narratives, and that whoever had the best narrative would win. Public-health people who did not actually know all that much about the subject, for instance, would insist that if you closed schools, all sorts of bad things would happen: crime would rise with kids on the streets; the thirty million kids in the school-lunch program would lack nutrition; parents wouldn’t be able to go to work; and so on. American society now leaned on schools to care for children in a way that would have bewildered Americans of an earlier age, as that other institution, the family, was failing at the job. “The sub-rosa conversation was that families weren’t safe places for children,” said Lisa.
To refute knee-jerk arguments about the costs of social distancing, Carter had marshaled so much data from so many corners of the U.S. government that a senior public-health official who passed through the White House called him Rain Man. He’d show his critics that crime rates actually fell on weekends, for instance, when kids were out of school. The FBI keeps all these stats, he’d say. Juvenile crime peaks at 3:30 p.m. on weekdays. Because they’ve been cooped up all day and they’re just going nuts. He’d show his critics exactly how many households would need help minding their children—and it was not nearly as many as they had assumed. During the summers, only 2.6 million kids used the school-lunch program: Did that not suggest that the number of kids without access to proper nutrition was far smaller than the number of kids using the program? He showed them a survey that Lisa Koonin commissioned, of parents with children who used it: just one in seven, or 2.8 million, said they’d have trouble feeding their children if schools could not. If schools were closed, Carter concluded, the problem was not 30 million kids but fewer than 3 million; they could be fed with supplemental food stamps.

* Carter sat at a desk and, consulting with Richard over the phone, wrote the CDC’s new policy, which called for social distancing in the event of any pandemic. The nature of the interventions would depend on the severity of the disease, of course. The CDC recommended that schools close, for instance, only when some new communicable disease was projected to kill more than 450,000 Americans. But school closure and social distancing of kids and bans on mass gatherings and other interventions would be central to the future pandemic strategy of the United States—and not just the United States. “The CDC was the world’s leading health agency,” said Lisa. “When the CDC publishes something, it is not just the CDC talking to the U.S. but to the entire world.”

* Two months after the CDC published its new pandemic strategy, Laura Glass, now sixteen years old, returned to Washington, DC, for her final science competition. The Young Epidemiology Scholars Competition, this new contest was called. Her mom had somehow found out about it and suggested she enter her science fair project and make a trip of it. On her giant foam boards, she’d honed her mission statement. “Could the oldest of strategies, social distancing, be designed to target specific age groups and zones of high infectious contact within a social contact network and thus limit the spread of disease?” she’d written. On her boards, she walked the science fair judges through all the work she had done. She explained the computer model she had helped to build, the surveys she’d done of the citizens of Albuquerque, New Mexico, and the insights that her work had led to, with the help of the model. “I found that if schools are closed AND preschoolers, children and teens are restricted to the home epidemics that would have infected 65% of the population COULD BE REDUCED BY NEARLY 80%,” she wrote. “If adults also restrict their contacts within non-essential work environments epidemics from such highly infective strains can be ENTIRELY THWARTED!”

Dr. Jeremy Samuel Faust writes April 28, 2020 for Scientific American:

When reports about the novel coronavirus SARS-CoV-2 began circulating earlier this year and questions were being raised about how the illness it causes, COVID-19, compared to the flu, it occurred to me that, in four years of emergency medicine residency and over three and a half years as an attending physician, I had almost never seen anyone die of the flu. I could only remember one tragic pediatric case.

Based on the CDC numbers though, I should have seen many, many more. In 2018, over 46,000 Americans died from opioid overdoses. Over 36,500 died in traffic accidents. Nearly 40,000 died from gun violence. I see those deaths all the time. Was I alone in noticing this discrepancy?

I decided to call colleagues around the country who work in other emergency departments and in intensive care units to ask a simple question: how many patients could they remember dying from the flu? Most of the physicians I surveyed couldn’t remember a single one over their careers. Some said they recalled a few. All of them seemed to be having the same light bulb moment I had already experienced: For too long, we have blindly accepted a statistic that does not match our clinical experience.

The 25,000 to 69,000 numbers that Trump cited do not represent counted flu deaths per year; they are estimates that the CDC produces by multiplying the number of flu death counts reported by various coefficients produced through complicated algorithms. These coefficients are based on assumptions of how many cases, hospitalizations, and deaths they believe went unreported. In the last six flu seasons, the CDC’s reported number of actual confirmed flu deaths—that is, counting flu deaths the way we are currently counting deaths from the coronavirus—has ranged from 3,448 to 15,620, which far lower than the numbers commonly repeated by public officials and even public health experts.

There is some logic behind the CDC’s methods. There are, of course, some flu deaths that are missed, because not everyone who contracts the flu gets a flu test. But there are little data to support the CDC’s assumption that the number of people who die of flu each year is on average six times greater than the number of flu deaths that are actually confirmed. In fact, in the fine print, the CDC’s flu numbers also include pneumonia deaths.

Nature magazine published this article February 18, 2021:

* We find that over 20.5 million years of life have been lost to COVID-19 globally. As of January 6, 2021, YLL in heavily affected countries are 2–9 times the average seasonal influenza; three quarters of the YLL result from deaths in ages below 75 and almost a third from deaths below 55; and men have lost 45% more life years than women. The results confirm the large mortality impact of COVID-19 among the elderly. They also call for heightened awareness in devising policies that protect vulnerable demographics losing the largest number of life-years.

* The average years of life lost per death is 16 years.

* We find that in heavily impacted highly developed countries, COVID-19 is 2–9 times that of the common seasonal influenza (as compared to a median flu year for the same country), between 2 and 8 times traffic related YLL (years of life lost) rates, between a quarter and a half of the YLL rates attributable to heart conditions in countries (with rates as high as parity to twice that of heart conditions in Latin America).

* A noted problem in attributing deaths to COVID-19 has been systematic undercounting of deaths due to COVID-19, as official death counts may reflect limitations in testing as well as difficulties in counting in out-of-hospital contexts… Our results support the claim that the true mortality burden of COVID-19 is likely to be substantially higher. Comparisons of COVID-19 attributable deaths and excess deaths approaches to calculating YLL suggests that the former on average may underestimate YLL by a factor of 3 [meaning, multiply the covid death toll by three to get a more accurate number].

* This study’s sample presents an average age-at-death of 72.9 years; yet only a fraction of the YLL can be attributed to the individuals in the oldest age brackets. Globally, 44.9% of the total YLL can be attributed to the deaths of individuals between 55 and 75 years old, 30.2% to younger than 55, and 25% to those older than 75. That is, the average figure of 16 YLL includes the years lost from individuals close to the end of their expected lives, but the majority of those years are from individuals with significant remaining life expectancy.

* These results must be understood in the context of an as-of-yet ongoing pandemic and after the implementation of unprecedented policy measures. Existing estimates on the counterfactual of no policy response suggest much higher death tolls and, consequently, YLL. Our calculations based on the projections by8 yield a total impact several orders of magnitude higher, especially considering projections based on a complete absence of interventions (see Supplementary Information for details on projections). This is in line with further evidence of the life-saving impacts of lockdowns and social distancing measures15.

There are two key sources of potential bias to our results, and these biases operate in different directions. First, COVID-19 deaths may not be accurately recorded, and most of the evidence suggests that on the aggregate level, they may be an undercount of the total death toll. As a result, our YLL estimates may be underestimates as well. We compare our YLL estimates to estimates based on excess death approaches that require more modeling assumptions but are robust to missclassification of deaths. The results of this comparison suggest that on average across countries, we might underestimate COVID-19 YLL rates by a factor of 3.

Second, those dying from COVID-19 may be an at-risk population whose remaining life expectancy is shorter than the average person’s remaining life expectancy16,17,18. This methodological concern is likely to be valid, and consequently our estimate of the total YLL due to COVID-19 may be an overestimate.

On May 28, 2021, I published this blog post:

Why Are Ethicists Usually Late To The Party?

Philosopher A tells me: “They tend to pick up social science stuff much later, and deploy it in their own feuds. They prefer reasoning by intuition. But when someone forces them out of it they respond. Moral psychology is a big thing now, but in the past it was just something that someone like Rawls had but didn’t defend.”

Philosopher B tells me: “Philosophy–particularly ethics–attracts people who, even if they’re intelligent, prefer to reason by intuition. They’re not good at critically analyzing empirical work. They usually just accept whatever studies jibe with their intuitions.”

I notice that many people, not just ethicists and moral philosophers, begin their analyses of public policy from the unshakable and unimpeachable foundation of their feelings and then, to the extent that they have any interest in data at all, they only welcome the data that confirms their feelings.

Many of my responses in the following dialogue (about 38 total emails so far) have been rewritten from the time I originally emailed them (so they now may sound more impressive and documented than when my friend received them and responded to them) and many of our emails are not responding to the email directly posted above in the following dialogue, but to some previous email. Also, my friend did not get the opportunity that I took to polish his emails prior to publication here. So this dialogue as I present it is not fair to him. Like many of my blog entries, this post started out as an email correspondence and then I chose to publish parts of it.

My friend the philosopher says to me today:

I want to question your position on Covid a little. My view is that the illness is basically similar to a moderately bad flu for anyone except a few small groups (e.g. very old people, people with serious co-morbidities, the obese). There is no significant change in overall mortality in many countries and regions, which is what you’d expect under this hypothesis. Where there are significant “extra” deaths, this often seems to be due largely to factors other than the intrinsic lethality of the illness (e.g. “treating” people with ventilators that end up killing them, or Cuomo’s decision to put infected people into nursing homes, people not getting normal health care as a result of the Covid response). It might be too early to judge, but I don’t see much strong evidence for any of the official claims about the illness.

So basically I think it’s a (very probably) a real illness that did require some kind of policy response from governments, but also that the danger has been wildly exaggerated; governments and media have been irrationally fixated on this one moderate risk to the exclusion of other more serious problems.

I’d be curious what you think of this guy’s critique, if you have time to check it out. It’s about the Canadian situation but most of it seems translatable to the States. I haven’t tried to verify all of his claims but much of it seems worth considering at least.

Luke:

I don’t think I have a position on Covid beyond an impatience for idiocy. I don’t automatically side with either dissidents or the MSM. I read both views. I don’t have many more specific positions.

Some public policy to limit Covid has been idiotic. For example, restricting people’s outdoor activities are a bad way of limiting the spread of Covid. We don’t have evidence for substantial outdoor transmission of Covid. Also, wearing a mask while out for a walk or when you are driving alone is bonkers.

You write: “My view is that the illness is basically similar to a moderately bad flu.”

“There is no significant change in overall mortality in many countries and regions”

These assertions are obviously false. Perhaps that is why you did not care to substantiate them beyond a link to the amateur analyst Julius Ruechel. I have previously posted links and articles about the dramatic decrease in American life span due to Covid, how the average Covid death cost about 16 years of life, and how Covid is about 40x more deadly than the 2019-2020 flu. We have more than four million worldwide deaths from Covid. Death certificates are something that industrialized nations take very seriously.

I’m curious who are public intellectuals who you tend to take seriously. For example, I generally respect Steve Sailer and Stephen Turner. During confusing times, I turn for help from people like these thinkers.

I Googled Julius Ruechel and I couldn’t find any reason why he would have expertise in anything aside from perhaps farming, which does not mean he’s wrong on Covid, it just means that the odds are at least 1000 to 1 he’s not adding anything.

There are stories that come along where I feel that I have something special to add. I’ve rarely if ever felt that with regard to Covid. I think compared to any pundit I know, I’ve been more diffident. I’ve rarely railed about Covid in any direction, it’s only when I hear something that is obviously wrong that I say something strongly.

With voter fraud, I knew nothing beyond the conventional Republican talking points until I did a deep dive after the 2020 election and realized Republican talking points were bogus.

PHILOSOPHER:

So it seems we might disagree about too many things here for a useful debate–at least for the moment. In order to have a good conversation we’d have to first set up some agreed working assumptions. Backing off from the covid issue for a moment, I’ll just mention two points of disagreement.

(1) You say that this Julius guy lacks relevant expertise and so he’s very unlikely to be right (when disagreeing with authorities). We could debate this issue for a start. Here’s my thinking.

I defer to expert opinion in many situations but not all. Suppose that on a given topic T, we have all these conditions: public opinions about T aren’t tied up with political or moral controversies; public opinions about T aren’t linked to social status and signaling; public opinions about T aren’t likely to be influenced by funding or special interests; T is clearly a subject requiring expert knowledge; there are experts regarding T; and there is clearly a long-standing expert consensus on T.

When some or all of those conditions fail, I’m less likely to defer to the opinions of experts (even if it seems like many are in agreement). So, for example, if the topic is racial differences or gender identity, I don’t defer. Instead, I just do my best to sort through the evidence–bearing in my mind that my own thinking could well be wrong since I’m not an expert myself. When I checked the figures in Julius’ essay they generally seemed correct, and his reasoning seemed plausible to me. I wouldn’t distrust my assessment in this case.

And I’d say that covid is a topic where many of those conditions fail. As far as I can tell, there are many reasons for thinking that mainstream “expert” opinion is influenced by politics, money, special interests, etc. There seem to be many experts who dissent, and their views are never directly challenged or refuted by government-appointed experts; this is suspicious to me. I’m also skeptical that epidemiological modelling is a properly scientific field. (It appears that predictions are generally false or unfalsifiable, for example.) Finally, the people presented to me as experts on the topic don’t seem to be. Here in Canada our “top doctor” who’s constantly pronouncing on covid is a Chinese pediatrician. She seems to have no real expertise on most of the topics that are relevant here. I’ve also communicated with public health officials in Toronto who admitted–in private–that they don’t really have any strong evidence for their policies. So I don’t think this is a case where I should defer.

(2) It does seem that there is significant excess mortality in the US, at least according to some people who’ve studied this. But is it obviously empirically false to suggest that much of the excess is not due to the virus itself, but mainly to poor decisions by political leaders and health authorities? I don’t have a strong opinion about this, but it seems to me that many people have made a strong case. (There are some published studies on this, for example.) You mention death certificates, but it seems that in many jurisdictions these have been recorded in an unusual way–counting deaths “with” covid as deaths primarily caused by covid, even when the empirical evidence for this conclusion seems lacking. This was a policy decision. For various reasons, then, the mere fact that a large number of deaths globally have been attributed to covid is not strong evidence that covid itself is highly lethal. We need to know more about the true causes of any excess deaths in a particular country or region; it’s not obvious (to me) that none of these are due to the pandemic response rather than the virus.

Do you think these arguments are also clearly wrong?

I don’t know that there are too many public intellectuals I rely on. I do like Steve Sailer, but on some topics I wouldn’t trust his judgment. Definitely I do check in with him to check myself. Even when I don’t agree he usually gets me thinking and he can make a good case for an opposing view.

With something like covid, I’m more likely to trust in the judgment of non-public intellectuals. So, for example, when I read stuff by Sukharit Bakdhi–who’s now apparently considered a nutcase–his reasoning seemed convincing. He’s an emeritus professor of immunology or something. (I can’t remember.) Anyway, presumably a real expert on many relevant topics. If it turns out that a majority of similarly qualified people disagree with him, but I just find that their reasoning is less convincing, I’ll tend to go with my own assessment. And I might then trust his judgment in other related areas where I can’t assess.

Here’s one thing that made me skeptical when I first started looking into the topic. The government told us that “growing evidence” indicates that masks prevent transmission. I wrote to various government agencies asking for their evidence, and eventually they responded. The evidence reviews they sent to me all​ said that the existing evidence was “poor”. In fact there was stronger evidence that masks do not​ have any benefit; there had already been many randomized controlled trials that found no effect, and the only supporting evidence was lower-quality “observational studies”. So it seemed that “growing evidence” really just meant “a little more evidence than before”; they weren’t telling us the whole truth, that on balance the existing evidence seemed to show that mask mandates would have no effect. When I wrote back to the public health people to ask about this, they just said things like “That’s not in our area” or “I’ll see if there’s someone who can answer your questions”. Eventually they just stopped responding. Wouldn’t you say that’s pretty suspicious? If “the science” really supports their policies, why can’t they share it with the public?

LUKE:

Disagreeing with people who have expertise is not the same thing as authorities. There’s no connection between authority and expertise. Sometimes those with no expertise are right and the experts are wrong, but that is relatively rare. What are some prominent examples akin to Covid where those with no expertise have been shown to be right? I love the skeptical work of Stephen Turner regarding expertise (link). The case of oophorectomy vs bloggers seems to be a good example of the non-experts being more right than the experts. Also, as a blogger, there have been stories where I was more right than the MSM (for a while).

“As far as I can tell, there are many reasons for thinking that mainstream “expert” opinion is influenced by politics, money, special interests, etc.”

True!

“There seem to be many experts who dissent, and their views are never directly challenged or refuted by government-appointed experts; this is suspicious to me.”

I’m primarily interested in the stats and how valid are they regarding Covid, rather than opinions. I am able to find a robust debate on Covid, not in the MSM, but elsewhere online, so who are the dissident thinkers (PhDs, profs) regarding Covid who have not been challenged by experts?

“I’m also skeptical that epidemiological modelling is a properly scientific field.”

I’m sure there are situations where it is and situations where it isn’t. Generally speaking, epidemiology does not attract our best and brightest.

“Finally, the people presented to me as experts on the topic don’t seem to be.”

Agreed. The talking heads on TV aka Fauci are not impressive.

“It does seem that there is significant excess mortality in the US, at least according to some people who’ve studied this. But is it obviously empirically false to suggest that much of the excess is not due to the virus itself, but mainly to poor decisions by political leaders and health authorities?”

I’m unaware of any evidence of this, or studies supporting this?

“You mention death certificates, but it seems that in many jurisdictions these have been recorded in an unusual way–counting deaths “with” covid as deaths primarily caused by covid, even when the empirical evidence for this conclusion seems lacking.”

I don’t believe this is true.

“For various reasons, then, the mere fact that a large number of deaths globally have been attributed to covid is strong evidence that covid itself is highly lethal. We need to know more about the true causes of any excess deaths in a particular country or region; it’s not obvious (to me) that none of these are due to the pandemic response rather than the virus.”

Well, the word “none” is a bit much. Are there significant errors overstating Covid deaths in industrialized nations? I haven’t read any compelling case for that. Industrialized nations take death certificates seriously.

PHILOSOPHER:

I agree that the following talking point was dumb: “Only 6% had no co-morbidities; therefore, only 6% died of covid”. Clearly that doesn’t follow. The fact that 94% had other conditions doesn’t mean that other conditions caused their deaths. But the more important point, which I didn’t see addressed in MSM “fact checks” was this: If 94% had co-morbidities and​ CDC recommendations are highly liberal with respect to “underlying cause of death”, the fact that 100% had covid​ doesn’t mean that 100% died because of covid. In other words, the CDC data raises the possibility that in some​ of the remaining 94% percent covid was not the most likely cause. And since people were being advised to mark down “covid” even when other serious morbidities were present, and even when covid was merely “presumed” or likely, it becomes plausible that many​ of the 94% were not really covid deaths.

LUKE:

If someone has lived with comorbidities for decades and then they suddenly die with Covid, yes, it makes sense that they likely died from covid. It seems that for 99% plus of people dying with Covid, they did die from Covid.

Death certificates are not taken trivially in industrialized nations…and before they are dismissed, one has to invest the work (20 minutes of reading) to understand how death certificates work.

PHILOSOPHER:

I appreciate that you dissent from the dissenters about as often as you agree. It shows independence. So while we disagree on this I do respect that (I think) you’re just thinking it through dispassionately and not falling in line with a faction.

Here’s one example of a dissenting expert [John Ioannides] whose views seem to make little difference to the public discourse. I mean, what would Faucci say to this guy? Has he ever tried to refute these arguments? I don’t know that Ioannidis is right, but it does seem to me that these arguments have been largely ignored by policy makers and experts with influence.

LUKE:

There are so many published critiques of John P.A. Ioannidis’s with regard to Covid (Greg Cochran). There’s hardly been silence. John P.A. Ioannidis is a buffoon with regard to Covid, he said there wouldn’t be more than 10,000 deaths.

I don’t even consider anyone akin to Fauci, any public health officer (unless compelling reason to do so) seriously because by definition their job prioritizes other values aside from truth. I don’t know if we could even have someone more truth-seeking in Fauci’s position because to climb that greasy pole, you have to put politics before truth.

“If someone is 92 years old, has three serious illnesses, then dies within a month or two of contracting the flu, is it clear that she died from the flu? I don’t think so.”

I agree. People who died from Covid, however, don’t usually have Covid for a month or two. They die much quicker (on average 18 days). If you’ve been overweight all your life, or some other comorbidity, and you get Covid and die at 52, you likely died from covid.

“it’s important that covid is not likely to lead to life-threatening conditions unless the dead person belongs to one of a few special categories.”

Yes. 80% of Covid deaths in the USA are for people over 65. There are very few Covid deaths under 60 for people without comorbidities.

PHILOSOPHER:

Here it seems to me you’re applying a double standard. The experts whose claims were the basis for governments’ covid response have also been wildly​ wrong in their predictions. Ferguson’s Imperial College model predicting over 2 million US deaths, for example, or the initial WHO claim of 3.4% lethality. Trump was ridiculed for estimating less than 1% but it turns out that was far closer to the truth. Ferguson has repeatedly predicted mega-death from various illnesses over decades and been wildly wrong.

Maybe Ionnadis is a buffoon on this stuff. But if he is, shouldn’t we say that almost all the experts are buffoons? I wouldn’t disagree, but this is why I’d generally not trust any expert opinions on the topic.

LUKE:

As I never praised any of the buffoons you mentioned, I don’t think I am using a double standard. I have never praised Neil Ferguson or WHO trumpeting 3.4% lethality or any of the hysterical modeling (I did not criticize it at the time either, I just didn’t feel I knew anything). I don’t think Trump was awful or good regarding Covid. The MSM was a mess (lack of comparison of the US to other industrialized western nations was a major defect in their blaming of Trump for what they alleged was America’s unique awfulness in combating the pandemic when America Covid toll was right in line with other western industrialized nations). Epidemiologists were often horrible.

“shouldn’t we say that almost all the experts are buffoons?”

It depends on which experts in which situations.

Science now depends upon major bureaucratic funding and can’t police itself and often gives distorted findings to please funders.

The WHO has been awful re Covid. Even an academic lefty friend of mine who works for the WHO has confided this. Also ridiculous that social media lets WHO and CCP determine what we can say on social media about covid.

I don’t think the death of a 70yo from Covid is as wrenching and sad as the death of a 20yo (which happened more with the Spanish Flu). So that covid primarily kills the old and those with comorbidities make it less serious to me than if it were primarily killing healthy 20 somethings. Still, those studies saying each covid death took
about ten years of life means it is moderately serious.

No evidence for substantial outdoor transmission of Covid.

PHILOSOPHER:

“If you’ve been overweight all your life, or some other comorbidity, and you get Covid and die at 52, you likely died from covid…”

It’s “likely” enough, sure. Is it less likely that the other morbidity was the cause? That may depend on further facts. (What kind of condition? What’s your life expectancy with that condition? What happened physiologically to bring about death?)

But in any case, how many of the official covid deaths were like this? We agree that the vast majority of deaths are people over 65. The highest number is among those over 80. So let’s just think about those, ignoring the far less common case where the person is 52.

Even granting for the sake of argument that most die within one month of infection, how many were very old and seriously ill with other conditions that are often lethal?

In most places the average age of “covid death” is more than a year over than the average life expectancy. So, for many of these people, it was already pretty likely they’d die around the time that they did. There’s a lot to take into consideration, but I don’t think we can safely assume in all these cases that covid was the cause of death.

Let’s say that in half the cases, there was already something else present which was also quite “likely” to kill the person around the same time. In the absence of hard evidence regarding what happened physiologically, I don’t see why we should think covid is more likely than the other condition. I’d guess that in a fair number of these cases, covid was present or was a merely contributory cause–not the underlying cause. But CDC advises that covid may be recorded as the underlying cause (for the bad reason that covid can cause life-threatening conditions). To me this seems like a recipe for over-counting.

LUKE:

If you’ve lived with various comorbidities such as obesity and high blood pressure and type 2 diabetes for decades, and then you catch covid and die within 48 hours, it seems reasonable to say you died from covid. I don’t see what’s terribly complicated about that. Sure, there will be exceptional circumstances where this might not be accurate, but they will be few and far between.

You write: “Is it less likely that the other morbidity was the cause?  That may depend on further facts.  (What kind of condition?  What’s your life expectancy with that condition?  What happened physiologically to bring about death?)”

A condition that you have lived with for decades, and your life expectancy with the condition is for at least another decade (average covid death costs ten years of life), and what happened physiologically fits in with the Covid, yes, it sure seems like covid killed you.

Dr. David Gorski: “Part I of the death certificate includes the proximal cause of death, or what directly caused the death, and Part II lists conditions that contributed to the death.”

“For example, if a patient dies of respiratory failure due to acute respiratory distress syndrome (ARDS), which was the result of pneumonia, which was the result of COVID-19, the proximal cause of death was the respiratory failure, but contributing causes were ARDS and COVID-19, with the one farthest up the chain being the underlying cause of death under Part I. If the patient had hypertension or asthma, that would go under Part II.”

You write: “In most places the average age of “covid death” is more than a year over than the average life expectancy.  So, for many of these people, it was already pretty likely they’d die around the time that they did. There’s a lot to take into consideration, but I don’t think we can safely assume in all these cases that covid was the cause of death.”

According to this study in Nature magazine, a prestigious journal, “The average years of life lost per [covid] death is 16 years.”

I would say that it is worth taking some strong public health measures (I don’t know which are most effective after vaccines, prior to vaccines wearing masks indoors around other people seems at least as prudent as it is with any influenza) to reduce the occurrences of this type of disease. Sixteen years per death is an enormous toll.

So, no, contrary to what you repeatedly allege, the overwhelming number of Covid deaths were not of people about to die anyway.

You love to use absolute language to make your points as if one anecdote discredits established statistics and policies. You write: “I don’t think we can safely assume in all these cases that covid was the cause of death.” Nobody assumes perfection in any human activity, including the writing of death certificates. If one in ten thousand death certificates inaccurately lists Covid as a cause of death, so what?

PHILOSOPHER:

David Gorski: “These are contributory factors, but if you have one or more of these conditions when you contract COVID-19 and later die, it’ll very likely be the COVID-19, not your underlying health condition, that killed you.”

Why is this “very likely”? Why wouldn’t that depend on the specific other conditions present, any one of which has its own likelihood of being lethal? Again, when CDC has recommended that covid be recorded as the UCOD simply because it can be “life-threatening”, that would make it likely that other (equally life-threatening) conditions are sometimes or maybe regularly being dismissed out of hand. CDC does not make this recommendation for influenza.

There’s also this embedded quotation, which makes no sense to me: “Regardless of where covid is listed on the certificate–underlying or contributing–it was a CAUSE of death. Ergo, people die of covid, not with covid.” By this reasoning any one of those 94% of deaths “of covid” can just as correctly be called deaths “of” or “from” one or two or three other conditions. However, they were not​ recorded as deaths from those other conditions; they were recorded as covid deaths. Why? It seems arbitrary.

If covid was not justifiably deemed the underlying​ cause of death, but the death is counted as a “covid death” regardless, that implies that covid deaths are not counted in the same way as other deaths. Someone who dies from condition C with influenza as a contributory cause is not counted as an influenza death, as far as I know. (Is that what they do for influenza? If so, how do they avoid double-counting? Every death with two co-morbidities would count as three deaths…?)

Here’s why I say the article seems question-begging. The objection I’m making has to do with policies for writing death certificates. I’m saying there seems to be evidence that they’re not being filled out in a normal, rational way. The article seems to just assume that they are being filled out normally and rationally. So it seems to assume the very thing I’m questioning.

LUKE:

You write: “Why wouldn’t that depend on the specific other conditions present, any one of which has its own likelihood of being lethal?”

If you have lived with a comorbidity for decades and your life expectancy with this comorbidity is at least another decade of life, and then you catch covid and die within 48 hours, it seems obvious to me that it would not be surprising to see covid listed as the UCOD.

You write: “when CDC has recommended that covid be recorded as the UCOD simply because it can be “life-threatening”, that would make it likely that other (equally life-threatening) conditions are sometimes or maybe regularly being dismissed out of hand.”

Where do you come up with the idea that death certificates dismiss other causes of death out of hand when someone died with Covid? You just made that up. You invented it. You fantasized it and it was real to you. It seemed like a stunning argument to you even though it was pure delusion.

As explained in detail in the referenced article, other underlying factors are listed in a death certificate. A death certificate does not always just list one cause of death. Did you read referenced article with any comprehension or did you just blank out anything inconvenient to your desired beliefs? To repeat a quote: “For example, if a patient dies of respiratory failure due to acute respiratory distress syndrome (ARDS), which was the result of pneumonia, which was the result of COVID-19, the proximal cause of death was the respiratory failure, but contributing causes were ARDS and COVID-19, with the one farthest up the chain being the underlying cause of death under Part I. If the patient had hypertension or asthma, that would go under Part II.” Oh, so it is stating here that contributing causes are listed, not just Covid. So where on earth, aside from your desire to not understand basic English because it is inconvenient to your agenda, do you get the idea that the CDC wants to dismiss other causes of death out of hand? You don’t want to understand the most basic facts if they are inconvenient to your desire to be outraged. 

Any death certificate that solely lists Covid as a cause of death is an improperly filled out death certificate. From Dr. Gorski’s article: “There should be zero death certificates that list COVID-19 alone. The CDC report basically tells us that 6% of death certificates were incorrectly completed.”

“Part I of the death certificate includes the proximal cause of death, or what directly caused the death, and Part II lists conditions that contributed to the death…”

“Part I lists a single UNDERLYING cause, which lead to another cause, which lead to another cause, and so on, until the final cause which immediately caused the death. Part II may list zero or more additional CONTRIBUTING causes. Sometimes called “multiple causes”.”

“For example, if a patient dies of respiratory failure due to acute respiratory distress syndrome (ARDS), which was the result of pneumonia, which was the result of COVID-19, the proximal cause of death was the respiratory failure, but contributing causes were ARDS and COVID-19, with the one farthest up the chain being the underlying cause of death under Part I. If the patient had hypertension or asthma, that would go under Part II. As I like to say, if you suffer a cardiac arrest due to blood loss after being shot, the cardiac arrest might have been the proximal cause of death, but you still died of a gunshot wound.”

“Sometimes these underlying causes contribute to the death. For example, if you have hemophilia and suffer a stab wound that leads you to bleed out and die when someone with normal blood clotting probably would have survived, then you still died of a stab wound, but the hemophilia was a contributing cause of death.”

“In the end, the final causes of death are always one of a few things, the underlying cause, however, is what matters.”

PHILOSOPHER:

I can only say that when I asked the government for their evidence they sent me (reluctantly) some evidence reviews conceding that the highest quality studies were inconclusive at best. I could look up those documents if you’re interested. But here’s something else that seems important: We’ve had mask mandates in lots of places for a long time now, and also lots of places without them. As far as I know there’s no pattern whatsoever. There seems to be no difference in terms of “case” numbers or hospitalizations or deaths. If masks in public settings work, why don’t we find any pattern?

I agree it seems like common sense, but if common sense is relevant here we should probably reject most of what we’re told about covid. It’s also common sense (for me) that masks and lockdowns aren’t going to eliminate the flu but not covid. It’s common sense that lockdowns will only delay the spread of the virus, possibly making it worse. As soon as people start going out again, it starts spreading again; so then we have another lockdown. What’s the point of this behavior? But that’s what we’ve been doing up here for a year and a half.

LUKE:

“Well, I can only say that when I asked the government for their evidence they sent me (reluctantly) some evidence reviews conceding that the highest quality studies were inconclusive at best.  I could look up those documents if you’re interested.”

No, you can’t only say this. You are perfectly capable of investigating the matter beyond what some bureaucrats or politicians deign to email you. Why would you not Google this? Why not look up studies? Why depend on what others feed you?

“We’ve had mask mandates in lots of places for a long time now, and also lots of places without them.  As far as I know there’s no pattern whatsoever.”

How much effort have you put in, aside from contacting the government, to see the evidence for lockdowns and mask mandates as useful tools in some circumstances to reduce the transmission of covid?

“It’s common sense that lockdowns will only delay the spread of the virus, possibly making it worse.  As soon as people start going out again, it starts spreading again; so then we have another lockdown.  What’s the point of this behavior?  But that’s what we’ve been doing up here for a year and a half.”

Treatment gets more effective over time. Also, over time, the virus will mutate out of lethality. The Spanish Flu burned out in two  years. Now we have vaccines that are highly effective at saving lives. So, yes, delaying the transmission of covid seems to have some solid arguments in its favor. 

PHILOSOPHER:

How do we know that in all or even most of the 94% of cases this​ is what happened? For example, in how many cases did the person died of respiratory failure (and didn’t have a co-morbidity that also often causes respiratory failure)? We don’t know that. And we have reason to suspect that’s not what’s happening in at least some of the 94% because of the CDC recommendation I mentioned (and similar guidance in other countries).

LUKE:

We know that all industrialized nations take death certificates seriously. So unless you have evidence that there’s massive incompetence in the execution of death certificates in industrialized nations, I think we have to go with the notion that death certificates bear a strong relationship to reality.

You write: “I think it’s plausible that the covid response was more lethal than the virus would have been had it been treated like a regular flu.”

I am curious if there is anyone who makes that case strongly? It’s such a compelling matter that I would not think we would have to rely on those with no expertise. Surely somebody with a PhD in a related field has investigated this and reported back?

Philosopher:

Many of your comments are gratuitously insulting. I don’t think I’ve said anything similar to you, so I’m not sure what it is that you’re responding to. Does this style of communication serve you? Do you think it’s ethical, or enlightening? If you want to continue debating the issue, that’s great, but I do expect basic respect and charity. No one learns anything from condescension and insults. And it’s bad for the soul.

LUKE:

You are right. I slipped my leash and I am sorry for that. I’ve spent the day thinking about how I would act differently in future situations of similar frustration and have decided that when I feel like I am not able to contribute on a discussion like we’ve had, to pause until such a time and situation when I feel like I can be useful. When I get upset, there’s something wrong with me, there’s some part of reality I am not accepting.

These situations have often come up for me and I don’t like how I have handled them. Sometimes, I addictively keep trying to make a point and I get out of alignment and shouty and accuse the other person of cognitive shortcomings. Neither approach has been good for me, let alone others.

PHILOSOPHER:

I watched some of your livestream and now I’m pretty sure you’ve misunderstood what I was saying. Of course, I agree with this: “Just because covid isn’t the proximate cause doesn’t mean it’s not the underlying cause.” You seemed to be saying that I don’t grasp this obvious point. But I never made the argument you’re refuting.

In the first email I wrote to you on this issue, I said that the following inference is dumb: “Only 6% had no co-morbidities, therefore co-morbidity was the underlying cause in the other 94%.” The mere fact that covid was the proximate cause in only 6% doesn’t mean that covid was not the underlying cause 100% (or 90% or 85% or whatever). It could be that covid was the underlying cause in all or most cases where co-morbidities were present.

In other words, the first thing I said about this was exactly what you think I fail to understand.

What I’ve been saying is this: (i) When covid was one contributory cause among others, it’s possible that covid was not the underlying cause; (ii) When covid was merely present, it’s possible that covid was not even a contributory cause; (iii) some of the guidelines for recording covid deaths seem to imply that merely being one contributory cause or merely being a condition present at death is sufficient for being an underlying cause. And that’s enough for me to be skeptical regarding the official numbers.

There are two ways to directly attack this reasoning. You could dispute the logical part. For example, you could argue that being a contributory cause or merely being a condition present at death is a sufficient condition for being an underlying cause. But then you’d be misunderstanding causal concepts. Or you could dispute the empirical part. For example, you could deny that these guidelines mean what I claim, or you could argue that the guidelines have no significant influence on how deaths are recorded. But as far as I can tell, your objection is just that “we know that industrialized nations take death certificates very seriously”. That could be true, but in this context it begs the question: The argument is that, given (i)-(iii), we have reason for doubting that industrialized nations are producing correct death certificates where covid is involved.

Sometimes it’s reasonable to reject an argument just because its conclusion seems obviously false. If someone argues that Biden is Chinese I’m going reject the argument even if I don’t know what exactly is wrong with it. Maybe you think it’s just absurd to imagine that death certificates are being filled out incorrectly–so absurd that any argument to the contrary can be dismissed without identifying the mistake. That’s fine. We just have very different background assumptions in that case. But then the disagreement has nothing to do with whether an underlying cause may not be the proximate cause.

You’re also lumping me in with people “denying covid”. On the contrary, I said at the beginning that I think it’s a somewhat serious illness (and very serious for some groups) and some kind of response was justified. I just don’t think that the actual response was justified or effective. (I think in many cases it made things worse.)

You say you’re sharing real scientific findings, while people like me simply ignore the research. But I’ve been reading that stuff too. Of course, you can find studies or articles supporting the mainstream narrative about covid–16 years of life lost, etc. I can find studies that support the skeptical narrative. For example:
https://onlinelibrary.wiley.com/doi/full/10.1111/eci.13484 ; https://www.nature.com/articles/s41586-020-3025-y What follows? Maybe nothing much. It’s normal that scientists disagree, that there is no definite consensus for non-experts to just accept. You appeal to one or two studies as evidence that skeptics are wrong on a given point–e.g. how serious covid is. When I mention other studies that support skepticism–RCTs indicating that masks in community settings have no effect–you just say that it’s “common sense” that masks would help. On the blog you say that while you haven’t checked out the research on masks or lockdowns, it just “makes sense” to you that these measures would help. I have no problem with this response. Life is short and we have to rely on intuitions or common sense. But how is this different from what I’m doing? We just have different intuitions or assumptions.

You write on the blog: “just because politicians and health officers reversed themselves quickly on the efficacy of face masks to reduce the spread of an influenza pandemic is not strong evidence that face masks are not useful in some contexts.”

I agree. But who ever said this was “strong evidence” for that conclusion? The evidence is the RCTs, along with comparisons we can now make between regions where masks were mandated and others where they weren’t. Maybe the evidence isn’t strong enough to draw any firm conclusions. I don’t know.

Overall, it seems to me that you’ve been reacting to things I never said. You seem to have preconceived ideas about how “covid skeptics” think and you project these beliefs and arguments on to me.

But I’m glad you’re rethinking your approach. People can reasonably disagree about this topic. There are so many different issues involved that no one is really an expert on the topic. It’s not just immunology or epidemiology but also psychology and politics and economics and ethics, etc.

You think any religious belief depends on a leap of faith. There’s no ultimate rational basis, but when people take the same leap they can reason within shared assumptions. I agree. But I think every topic is like that. Your basic orientation on covid is centrist, and that determines which sources you’re willing to take seriously, which topics you’ll investigate, which claims just “make sense” and don’t need to be rigorously tested against scientific studies. My orientation is more suspicious, so I approach things differently. There’s no objective rational basis for either orientation. Any argument you can come up with (or I can come up with) is ultimately going to be circular. It’s going to rest on presuppositions that won’t be plausible for someone whose basic orientation–faith–is different.

I didn’t say that there’s been no excess mortality but rather that (a) in some places there’s been none, and (b) in places where there’s been significant excess mortality it’s likely that the pandemic response is a significant factor, possibly more important than the virus. In Ontario, we’ve had over 200k delayed surgeries and 1 million missed cancer screenings, for example. Then there are all the extra suicides and drug overdoses. So in some regions it seems likely (at least) that excess mortality isn’t tracking covid accurately. But I definitely don’t deny that covid has produced some excess mortality.

More importantly, I don’t base any of these claims on feelings. Yes, in moral philosophy that’s standard practice; there isn’t really any other method available. But no sane moral philosopher would use that method in trying to figure out facts about epidemiology or excess mortality! My basis for these claims is simply what I’ve been reading about excess mortality: various different StatsCan reports, some published studies about Canada and other countries, stuff I find in the news, etc.

Feelings come into this at a deeper level. For example, if I come across government statistics that seem intuitively weird or incompatible with my experience, my suspicion toward government is strong enough that I’d be ready to suspect they’re lying or incompetent. Though that depends a lot on the topic and situation.

LUKE:

Live streams are not exact or as precise as writing, particularly when I’m riffing.

As I understand it, Covid like AIDS is never the proximate cause of death.

” (i) When covid was one contributory cause among others, it’s possible that covid was not the underlying cause; (ii) When covid was merely present, it’s possible that covid was not even a contributory cause; (iii) some of the guidelines for recording covid deaths seem to imply that merely being one contributory cause or merely being a condition present at death is sufficient for being an underlying cause. And that’s enough for me to be skeptical regarding the official numbers.”

Yes, it is possible that covid is not a contributory cause. Given what I have read, however, it seems to me that our Covid death toll overall is dramatically understated, but yet, there are some grounds to argue it is overstated, and yes, it is possible that government responses killed more than did Covid itself (though I don’t find this a strong possibility overall, but maybe in some times and places it is true).

“The argument is that, given (i)-(iii), we have reason for doubting that industrialized nations are producing correct death certificates where covid is involved.”

Yes, industrialized nations take death certificates seriously, and yet like all human endeavors they will inevitably be filled with errors and biases and reactions to incentives.

Neither of us is an expert in death certificates. Here is a case where I would be 1000 times more interested in what those with expertise in death certificates have to say about your arguments than what anyone without specialized knowledge has to say on this. I know nothing beyond 30 minutes of reading.

“Maybe you think it’s just absurd to imagine that death certificates are being filled out incorrectly–so absurd that any argument to the contrary can be dismissed without identifying the mistake.”

I would want evidence (logical argument is not evidence, but it can help the search for evidence) before I questioned the general accuracy of death certificates in the US and other industrialized nations.

“You’re also lumping me in with people “denying covid”. On the contrary, I said at the beginning that I think it’s a somewhat serious illness (and very serious for some groups) and some kind of response was justified. I just don’t think that the actual response was justified or effective. (I think in many cases it made things worse.)”

I was sloppy.

“You say you’re sharing real scientific findings, while people like me simply ignore the research. But I’ve been reading that stuff too. Of course, you can find studies or articles supporting the mainstream narrative about covid–16 years of life lost, etc. I can find studies that support the skeptical narrative. For example:
https://onlinelibrary.wiley.com/doi/full/10.1111/eci.13484 ;
https://www.nature.com/articles/s41586-020-3025-y

What follows? Maybe nothing much. It’s normal that scientists disagree, that there is no definite consensus for non-experts to just accept. You appeal to one or two studies as evidence that skeptics are wrong on a given point–e.g. how serious covid is. When I mention other studies that support skepticism–RCTs indicating that masks in community settings have no effect–you just say that it’s “common sense” that masks would help. On the blog you say that while you haven’t checked out the research on masks or lockdowns, it just “makes sense” to you that these measures would help. I have no problem with this response. Life is short and we have to rely on intuitions or common sense. But how is this different from what I’m doing? We just have different intuitions or assumptions.”

If you go back to your first email on this topic, you are starting out with your feelings about reality (for example, that there has not been excessive mortality, which seems to me obviously wrong) and then it seems to me you are logically reasoning from your feelings about reality and seeking out evidence to support your intuition. This is how ethicists and moral philosophers generally work (I have been told by philosophers). I am not aware of starting with any strong feeling or intuition about government responses to Covid (aside from reading Paul Barry’s book on the 1918 Spanish Flu early on and thereby being open to strong governmental response including restrictions on freedom), which is why I had few strong opinions until recently. I
went more than a year without staking out any position, and after more than a year of reading different things, some things have become clear to me lately, I think.

In my spontaneous videos, I am reacting to a caricature of your thinking, and I am often imprecise and unfair to your views. In my defense, I am somewhat the same way with myself in these videos.

So how is my approach different from yours in that we are both relying on limited evidence? I feel like I am starting with the evidence I’ve read and it seems like you are starting with your intuition. You are reasoning like a moral philosopher and I am operating like a bloke who wants to be data driven but is lazy, sloppy and not so sharp with data.

When anyone says or writes anything, it is important to ask — what is he reacting to? I am reacting to my audience which is disproportionately covid-skeptical. I am not primarily reacting to you even when I am ostensibly reacting to you. That’s why I’ve misrepresented your views because in my videos, I am not primarily talking to you, I am primarily talking to my audience that is dominated by covid skeptics and our dialogue is just an excuse or stimulus for me to engage again with my audience. Making a video takes tremendous energy, and a good source of energy is when I want to react to an ongoing irritant (not you, but my covid skeptic audience).

“You think any religious belief depends on a leap of faith. There’s no ultimate rational basis, but when people take the same leap they can reason within shared assumptions. I agree. But I think every topic is like that. Your basic orientation on covid is centrist, and that determines which sources you’re willing to take seriously, which topics you’ll investigate, which claims just “make sense” and don’t need to be rigorously tested against scientific studies. My orientation is more suspicious, so I approach things differently. There’s no objective rational basis for either orientation. Any argument you can come up with (or I can come up with) is ultimately going to be circular. It’s going to rest on presuppositions that won’t be plausible for someone whose basic orientation–faith–is different.”

I agree.

My perception is that I change my mind more than anybody I know. I’m a bit of an intellectual gigolo — falling in love with every comely idea that comes along and ultimately staying loyal to none.

I often make my own psyche the achimedian point for analyzing the world, which is not data driven of me.

Much of my audience thinks elites are sinister. I think elites are just like you and me only they are elite and that they are no more inherently sinister or good than we are.

So I don’t begin with the suspicion that elite directed covid lockdowns are any more sinister than how I conduct myself when I have some power. Sometimes I’m a jerk, sometimes decent, and often a mix and usually I am just doing the best I can in sometime difficult circumstances. I don’t think governors Cuomo and Newsome are evil, just flawed like me. I used to bang as many chicks as I could because that was the best tool I had at the time to meet my needs (does not mean I don’t need to make amends, but I don’t beat myself down for my promiscuous past).

I also don’t think there’s an overall moral difference between individuals on the left and right. People are different and experience the world differently and we’re all doing the best we can.

I have no patience for the view that any race or religion or social class is sinister (more than the average human) or that people who live in cities are useless or that people who live in Cleveland are losers. I find these views widespread in my audience.

When I read the news or watch a movie, I assume the characters are just as flawed as I am, just in different ways and facing different situations than I’ve faced. I can empathize with anyone, even Hitler, Stalin, Mao.

PHILOSOPHER:

From my perspective, people who refused to wear masks might just be people adequately informed about the very poor evidence that wearing masks has any effect on the spread of the virus. No doubt some are also jackasses. But then I’ve had a lot of experience by now with “maskers” being jackasses. Or just being very weird. I find it disturbing that I regularly see people alone in a car with a mask on. This is weird behavior. One of the biggest problems that the covid thing has brought to the surface is the profound lack of trust and respect between “citizens”. People who can’t seem to find tolerable ways to navigate basic daily life–shopping or lining up at the bank or sharing a sidewalk. Almost anything can become a moralistic showdown, with each faction treating the other as if they were complete morons or demons.

It’s reasonable for many people to refuse the vaccine. There are so many reasons, but the most obvious one is just that if you’re young and healthy the very low risk of covid may not be worth the presently unknown long-term risks of vaccination. There might be some obligation to protect others, but that’s very complicated. The obligation might be cancelled if the risk to most others is low, or if there are many other ways for them to protect themselves just as effectively, or if there’s some basic principle of autonomy at stake, etc. People will assess things differently. The ones who presently don’t want the vaccine are not all “jackasses”. It’s a simple-minded and arrogant point of view.

One reason there’s probably no obligation to others is that the vaccines may have no effect on transmission. If those others want protection, they should just vaccinate themselves.

And on that issue, the authors write:

“That the ‘science’ keeps changing is unsurprising. We only know what we know when we know it. It’s what makes a “novel coronavirus” novel.”

But this was always likely. Anyone who read past the headlines was aware that the vaccine trials weren’t designed to provide any evidence regarding infection or transmission. That’s why people like me were frustrated by the government and media “messaging” to the effect that once enough people were vaccinated things could “get back to normal”. How could they know that? At most, they might reasonably hope that vaccinating a majority of people would result in fewer deaths and hospitalizations. But then mass vaccination would be pointless. Just vaccinate those in high-risk groups.

Something is very wrong when a non-expert, like me, ends up being right about this stuff more often than Faucci or Biden or Trudeau. Or the CDC. I’ve been called a science hater and conspiracy theorist (etc) for making this rather obvious point. (The next big idea that may eventually make it into the mainstream: the variants might be due to the vaccines.)

So this doesn’t seem very insightful to me. Maybe covid is “novel” in some respects, but that’s irrelevant; if you don’t even test for X, don’t just assume that your product will have an effect on X. From my perspective this piece has an air of rationalization. I get the sense they invested too much in the establishment’s unscientific narrative, and now they want to minimize how badly this has turned out. The reason people are angry is not that “science keeps changing” but that the leaders and pseudo-experts they trusted to design policies based on science were apparently just making things up. What was the point of the massive campaign to persuade and pressure us to get vaccinated? Why did they insist for months on end that the vaccines were “effective”? They must have known that “effective” strongly suggests “effective in reducing transmission”, that most people were not going to read the fine print.

It’s not just that the messaging has been bad, though it has. The problem is that there seems to have been no coherent rational plan behind the messaging. Maybe people should all be wearing masks again (granting for the sake of argument that it helps). But why were they ever told they wouldn’t need masks after vaccination? It should have been obvious to the authorities that there was no reason for thinking vaccinated people wouldn’t be spreading the virus, or even that they’d be less likely to spread it. Again and again, they ignored the real state of the evidence.

A doctor emails about Covid death accuracy:

The ultimate determinate of Covid-19 mortality will be a detailed look at excess mortality. Given the way that these “probable” deaths are to be certified, if they are done correctly, one should be able to get a sense of how many “non-tested” COVID deaths there were. In addition, COVID-19 testing is tracked by public health departments. For example in Connecticut, anyone with a COVID-19 positive test gets reported to the DPH. Comparisons are made with test results, fatalities, and death certificates to correlate these factors and to ensure we are capturing the appropriate deaths. This process may vary in other jurisdictions but by comparing the death certificates and the test results, one should be able to get a sense of how many deaths were certified as covid-19 but did and did not have a positive test. There are literally thousands and thousands of different physicians and nurse practitioners who were and are certifying these deaths. There are some physicians who will only certify a death as covid-19 if there is a positive test. Plus there may be out of hospital covid-19 deaths that are missed. No system is perfect but when one is seeing hundreds of thousands of deaths that have occurred in hospitals with extensive testing, what is the “big picture” effect of any imperfect system? Once testing ramped up, it was unusual to have any hospital or nursing home death that did not already have a COVID test.