Wednesday, May 20, 2020

The Near-Irrelevance of Drs. Birx and Fauci

Not being a creature of Washington, it's entirely possible that I'm too hopelessly unaware of the insider baseball that regularly gets played at the highest level in the nation's capital, and I'm simply too much a rube to see when someone's outmaneuvering someone else in, say, the corridors of the Rayburn Building. So perhaps I'm just being obtuse when I note how ridiculous I think this political analysis by Jonathan Swan of Axios is.

Swan's point is that it is Deborah Birx, and not Anthony Fauci, who is the real wear-the-pants doctor on the coronavirus task force, and therefore is the one who's gotten things done. "Don't be fooled by the grandmotherly demeanor and whimsical scarf collection," Swan crows. "Administration officials say they've been taken aback by Deborah Birx's masterful political skills — including a preternatural ability to get what she wants while telling people what they want to hear." According to Swan, Birx has been "far more adept at influencing the president and shaping the administration's response to the global coronavirus pandemic."

Well, if that's so, what a bang-up job you've done, Doctor Birx!

Amazingly--astonishingly, jaw-droppingly astonishingly--Swan offers recent back-room gossip surrounding discussions about the World Health Organization as evidence of Birx's savvy compared to Fauci's blundering. Weeks ago, Trump asked Birx, Fauci, and CDC Director Robert Redfield their thoughts on WHO. "Birx was very critical of the WHO and its relationship with China. She said the institution badly needed reform," the article notes, while "Fauci was more ambivalent in the Situation Room meeting. He started out by saying the WHO is an imperfect organization...[and the Director General of WHO] has a China problem."

Based on that, and presumably other conversations, Dr. Birx can therefore receive credit...for Trump holding WHO hostage in the middle of a pandemic. Or how about her allowing the President to sway tens millions of millions of Americans on the almost-certainly false hope of hydroxychloroquine as a panacea, even as of this late hour in mid-May, weeks after it became clear that this drug's promise was built on the sale of snake oil from an egomaniacal French doctor. What great public health work! That must be worthy of a marble statue somewhere!

The premise upon which this analysis is built is notably described here, in a prescient analysis of Game of Thrones, as "the pop culture fixation on heroic leaders rather than institutions [that] reinforces a dangerous tendency of real-world politics." The notion of Birx being more adept than Fauci is of a piece with someone admiring a well-played scheme of Tyrion Lannister's. It also contains zero information on the World Health Organization and the work that it does in the world. Which, given that we're in this thing called a "pandemic," and "World Health" is in their title, might be something at least as important to explore, right?

Nor does this article make even the slightest attempt to explain the complicated relationship that WHO has with China at the very root of the discussion, or even make a nod to past issues with the structure of WHO and how that has affected prior responses, such as during the West African Ebola Outbreak.

No, Jonathan Swan's fixation is on Dr. Birx versus Dr. Fauci and their attempts to get the ear of Nero. Meanwhile, Swan himself seems to be blithely unaware that Rome is burning, and that its leader is trying to hamstring the efforts of the Fire Department by taking away its trucks and hoses, fiddling as he goes.


PS. Disclosure: I have served as a consultant for WHO. Proudly.

Thursday, May 7, 2020

COVID: Trump's Next Target Will Be Organized Medicine Itself

As has been obvious to anyone paying attention to politics for about the past thirty years, the Republican Party has been escalating a war on science and expertise. In order to keep their evangelical wing on the same page, they've tried to demonstrate hostility to the concept of evolution, at first by championing the pseudoscientific gobbledygook of intelligent design, and then in more recent years by simply denying the truth of Darwin's insight. Even more importantly, they have long tried to obfuscate the truth about global warming once a scientific consensus emerged, initially responding by evasions and sophistry, but accelerated to outright denial in the past few years. In recent years they've even made tentative inroads toward the antivaccine movement, though that has traditionally been the happy hunting ground for the fringe left. We could list more examples, but we'll assume that these examples will suffice.

And perhaps before moving forward, it's worth briefly addressing the inevitable harrumphs of those who worship at the altar of false equivalence and insist that since the Republican Party has what amounts to an official policy of hostility to science, the same must be true of the Democratic Party. In short: no. Yes, it's true that there are some left wing movements that incorporate a vague kind of disregard for scientific expertise, principally the antivaccine movement (although as noted above, this has developed a bipartisan fringe tinge), and the opposition to genetically modified foods is generally rooted in progressivism (and while much of this opposition is based on total nonsense, at the Billy Rubin Blog, we think some aspects GMO skepticism, particularly when it comes to issues regarding biodiversity, is not entirely without scientific merit).

But it doesn't take a Kissinger to observe that these groups are relegated to the fringe of the party, and in fact are mostly outside the Democratic tent pissing in, demonstrating how little power they really have. When fringe third-party presidential candidate (and former physician) Jill Stein ran as the nominee of the Green Party in 2016, she sounded some antivax dog whistles to her constituency to mollify them. For her troubles, she got verbally flayed by the solidly left Huffington Post and the center/wonky left Vox, among other outlets. And you can't find one US Senator from the Democratic Party who would champion this or other similarly nonsensical beliefs, but demonstrating contempt for the scientific process is worn as a badge of honor by many of the most powerful Republicans.

As I said, this is no recent innovation within the Republican Party structure, but without any question Trump has turbocharged the activation of the pitchfork brigade. His embrace of climate denial is, like everything else about him, not done by half-measures. Previously, forked-tongued Republicans dealt with the subject by acknowledging that "climate change" is occurring, but would minimize the impact and point to other causes. Not so with Trump, who simply disregards the evidence. Since he lies to advance his personal interests, he assumes that everyone else does, too.

Which brings us to COVID. We could link you to about a thousand well-written articles now documenting the various missteps of the Trump administration, from the early hours of the outbreak up until five minutes ago; we assume you're already aware of the glaring incompetence of the man and his underlings. Moreover, you're almost certainly equally aware of his desperate embrace of medications that never looked promising, and his more unhinged pronouncements on disinfectants and ultraviolet light.

Yet the virus marches on, despite Trump's attempts to distract and distort. And as the bodies continue to pile up, Trump is likely to become even more unhinged in his public statements, if that's even possible. But supposing it is, one very straightforward way is to capitalize on those decades of the Republican Party program to nurture a hatred for the (liberal), elite, educated classes so smug in their coastal enclaves, is to deny the reality of the situation itself. 70,000 deaths? That's just fake news. You would think that in a sane and prosperous society, this would be an impossible gambit. But there's already a whiff in the air that this strategy is coming any day now, if it hasn't already. After all, since disregarding solid evidence is not precisely a new strategy for Trump, and a kind of barely-contained rage at experts is a feature of his administration, why should COVID mortality statistics be sacred?

I'll go out on a limb here and make a prediction that that's only the beginning, and denying the reality of the size and scope of the epidemic is only going to be the first move in a more active campaign against the medical establishment itself. Medicare is offering twenty percent bonuses for the care of COVID patients; this is being done so that these hospitals, which are hemorrhaging money both by decreased revenue and by purchasing all the equipment required for COVID care, can stay financially solvent.

But don't color me surprised that in Trumpland, this will provide the basis for accusations of fraud. Where it goes from there, we don't know, although it is safe to say that tens of millions of people will continue to buy what he's selling. But the finger's about to get pointed at us, and I would not be surprised to see a local hospital somewhere be on the receiving end of the kinds of death threats aimed at Dr. Fauci should Trump whip them up. As Trump himself notes, he does not take responsibility for anything, especially something like COVID, so with each passing day, a new target is required.


Sunday, May 3, 2020

COVID: The Dunning-Kruger Effect In Epidemiology

My most recent blog entry was, by my assessment, fairly mild in its assertions: I simply attempted to show two graphics to make two specific points about COVID: namely, that the "official" state counts that only include those who were PCR positive for COVID represents an undercount; and that there is now mounting evidence that people spread the disease before their symptoms begin, which makes containment via contact tracing much more difficult.

Inherent in those two messages is a theme I've written about at length previously, namely, that data in medicine has an essential fuzziness to it, and one shouldn't get too caught up in thinking that a number represents a precise, mathematical reality in the same way a physics equation does. Though maybe physicists might indicate that they have the same issues with interpreting data as we do in medicine. Hopefully mechanical engineers are more precise.

Anyway, I didn't think I was making an especially debatable point, and in the first half of the blog, the part about the relationship between the official count and the true count, I certainly didn't think I made any statements that could be construed as political (the end of the blog tosses in a typically Billy Rubenesque political potshot). Keep in mind I made no confident pronouncement about the exact total: I just pointed out that the real number of deaths from COVID is somewhere between the official count and the total number of deaths in a given county or state. Let me be clear: that's not controversial. Any epidemiologist could tell you this is true. Here, for instance, is a CDC document explaining this very phenomenon for influenza.

So imagine my surprise when a reader writes back to tell me--politely but forcefully--that I was full of shit:

We "know" that's an undercount. 
What you "know" ain't exactly "so". Compare 2019 deaths 
from 2020 deaths for NY. What we actually know 
is that there is a high degree of uncertainty. Sloppy thinking.

As I wrote, we do know that the official COVID mortality total is an undercount--though again, nobody knows by how much. Which is to say, there is a degree of uncertainty, and I don't think I ever said that wasn't the case. But I was informed that what I know ain't exactly so, and was told to compare 2019 from 2020 deaths for NY.

No link was provided so I can't be sure what the reader was referring to, but here is the CDC's rolling estimates of total deaths by month in New York dating to 2017:

Spot the one part of the graphic that's different? So while there is some uncertainty about the precise number of deaths, there's no debating that COVID mortality is quite substantial. You can also break it down by including known COVID cases, and even including that, you still end up with a huge number of deaths above recent historical averages, which strongly suggests missed COVID diagnoses (you want to look at the lime-green bars above the average):

The reader then goes on to imply that epidemiologists must suffer from some kind of rain-is-falling-everywhere bias with what certainly reads like a sneer about the perceived snobbery of coastal elites:

People keep saying that covid is coming to my area 
of flyover country, but our new infections have been flat 
for a month and our random swab sample showed almost 4% infections. 
I figure we're at 16% who have or have had covid. 
Herd immunity by end of June.

Why and how this reader from "flyover country" figures "we're at 16 percent" is not made fully clear, nor is it clear whether he is qualified to pronounce with confidence that his community, wherever it is in flyover country, will have herd immunity by the end of June. (We'll assume for a second that we're dealing with a he, given the whiff of testosterone ambient in the I'm-splainin'-to-you-you-pointy-headed-professor commentary.) The fact that this reader has previously gravitated toward embracing what amounts to folk remedies for COVID, touted by people too ignorant to understand their own limitations as they conduct what they mistakenly believe are "clinical trials," might suggest that they regard assertions made with bravado to have high truth value, regardless of the expertise of the person making those assertions.

I simply don't know what motivates these declarations, although I am confident that his confidence is overblown, given that virtually every qualified epidemiologist thinks we are far from the finish line of this pandemic. What does our reader know that every PhD steeped in epidemiology, virology, and biostatistics does not? Or is this just denial masquerading as swagger? I have an opinion on this; I'll let you guess at it.

Wherever his section of flyover country might be, it is curious that he might assert everything is hunky and dory in rural or less urban America. Take a look at this graphic from WaPo displaying the ten counties in the US with the highest rate of deaths, adjusted for population:

In short, half of the ten counties with the highest rate of deaths are in less populated, non-urban settings: four counties in southwest Georgia and a suburbanish community outside of New Orleans. That would strongly suggest that this virus will spare no area, and supposing that it has a predilection strictly for urban centers is wishful thinking.

Why has our reader's area been spared? Nobody knows. Japan has the oldest population in the world, and so they should be experiencing a level of misery on par with Italy. So far, they're not. Most countries from warm-weather climates aren't seeing much death; not so for Ecuador and Brazil, which are getting hammered. But one reasonable interpretation is that, in the words of Kim Carpenter, we've only just begun, and over time we're going to see these numbers even out if people return to their normal habits. Russia, for instance, was fine until it wasn't. (Though skepticism of official Russian statistics, given its political structure, is probably warranted, especially as news stories of strange "accidents" befall Russian doctors. Given Trump's warm regard for Putin, Anthony Fauci should watch his back.)

As with hydroxychloroquine and clinical trials, on the topic of armchair epidemiology, it might be best to follow the simple, but lifesaving, dictum: don't try this at home.

I grew up in flyover country, by the way. I have never forgotten where I have come from.


(Postscript: we note, with embarrassment, that the great Ms. Carpenter's first name was, of course, Karen and not Kim. Anonymous below in the comments has decided we're not worthy as a consequence, and we find it hard to argue the point, as we'd say the same thing. Some things are not worthy of mercy.)