Archive for the ‘Health’ Category

The Wuhan virus and common sense

July 26, 2020

Common sense went on vacation sometime in March 2020.

It seems to be an extended vacation and it is not certain when it will return.

Virus sense

Lockdowns seem to be counterproductive. They solve nothing. Instead they extend the life of the virus and prolong the pandemic. They could have maximized the global death toll. The only positive is that they may reduce the load on the hospitals.

The two areas where Sweden got it wrong were:

  • they did not restrict infection sources from reaching the care homes, and
  • they locked up the elderly in their “infected prisons”

But all the rest they did right.


 

Epidemiology is still more art than science and sometimes just speculation

July 24, 2020

The Wuhan virus, after 6 months, is still not under control.

I have grown a little tired of being told by all kinds of people that they are just following the science in the fight against the Wuhan virus. What science? There is a widespread delusion that epidemiology is a “settled science”. Epidemiology is, in reality, a mix of science and art and of “social science” (which is always a politicized view of behaviour). It is about “the frequency and pattern of health events in a population”. With a little known virus, as in this case, epidemiology relies on models and speculation. When the speculation is garbage, the model results are also, necessarily, garbage. The model results have ranged from the ridiculously complacent to the grotesquely alarmist, but what they all have in common is that they are/were wrong. Nothing surprising in that. That is the nature of modelling. A mathematical model is nothing more than a crystal ball and model results are always forecasts of the future. The problem lies in the delusion that epidemiology is an exact science and that model results give a sound and certain basis for public policy.

In the absence of a vaccine we are being led (or misled) by politicians blindly following the epidemiologists’ speculations about both the characteristics of the unknown virus and about social behaviour. In the space of 4 months the “best” epidemiologists at the WHO have changed their view of the Wuhan virus from being “non communicable between humans”, to “communicable by liquid droplets between humans”, to now be of “air borne transmission”. The experts have been divided whether transmission is from the symptomatic or from the asymptomatic. There are as many speculative views about when herd immunity can be achieved as there are epidemiologists. No one really knows. Art not science. Herds are always moving and herd immunity depends upon leaving the weak behind. Public policy is floundering as it staggers from lockdowns to no lockdowns to social distancing, from masks to no masks to some masks to masks for some, and from testing those with symptoms to restricted testing to mass testing. There is no certainty about whether testing is to be for the virus or for antibodies to the virus.

The Center for Disease Control has this definition of epidemiology:

Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.

But then they go on:

…. the practice of epidemiology is both a science and an art.

The reliance on speculation and the resulting weaknesses of epidemiology are well known and there are many scientific articles about spurious but statistically significant epidemiological forecasts. This article in the BMJ from 2004 is just an example.

The scandal of poor epidemiological research

Something surely must be wrong with epidemiology when the new editors of a leading journal in the field entitle their inaugural offering, “Epidemiology—is it time to call it a day?” Observational epidemiology has not had a good press in recent years. Conflicting results from epidemiological studies of the risks of daily life, such as coffee, hair dye, or hormones, are frequently and eagerly reported in the popular press, providing a constant source of anxiety for the public.  In many cases deeply held beliefs, given credibility by numerous observational studies over long periods of time, are challenged only when contradicted by randomised trials. In the most recent example, a Cochrane review of randomised trials shows that antioxidant vitamins do not prevent gastrointestinal cancer and may even increase all cause mortality. 
Now Pocock et al describe the quality and the litany of problems of 73 epidemiological studies published in January 2001 in general medical and specialist journals. …… Worryingly, Pocock et al find that the rationale behind the choice of confounders is usually unclear, and that the extent of adjustment varies greatly. They also confirm that observational studies often consider several exposures, outcomes, and subgroups. This results in multiple statistical tests of hypotheses and a high probability of finding associations that are statistically significant but spurious. 

Modern epidemiology starting from – say – the 1854 London cholera outbreak has vastly improved public health. But it is not just a science and it is certainly not a “settled science”. The Wuhan virus is not under control. The various public policy interventions (lockdowns of various kinds and the deselection of the old for treatment) have prolonged, rather than shortened, the outbreak. The lockdowns may have protected health systems while maximizing the number of deaths. In fact, politicians have often abdicated responsibility for public policy to epidemiologists and bureaucrats who have not been best-suited to make political decisions. In other cases public policy has exploited epidemiology to protect the system rather than protecting people.

This is not so much to criticize epidemiology as to criticize the manner in which public policy has misused epidemiology. Epidemiology can only be an input for determining public policy. It cannot replace common sense. And it is not a convenient shelter for politicians to hide behind.


 

Has “flattening the curve” maximized the number of Wuhan virus deaths?

July 22, 2020

I am beginning to think that the international lockdowns may have been a colossal mistake.

The primary objective of “flattening the curve” was to protect health services, not to minimize deaths.

In theory, flattening the curve should have given the same number of deaths but over a longer period of time. In practice, the flattened curve has kept the pandemic alive for much longer than necessary. The lockdowns have ensured that no general immunity has been achieved anywhere. The total number of deaths could well have been lower with a more intense but short-lived pandemic.

 

“Flattening the curve” Theory

“Flattening the curve” Actual?

The assumption that the curve can be flattened without affecting the area under the curve is speculative and unjustified. The two curves cannot be equated. The reality is that extending the tail of the curve by attempting to flatten the peak may have done more damage than good.

Have the lockdowns actually saved any lives?

Or have they extended the pandemic such that more lives have been lost than if there had been no lockdowns. And at the cost of a global economic shutdown. Fewer lives lost per day but for a very, very long time as opposed to many lives lost per day over a much shorter period of time.

Flattening the curve may well have maximized the number of deaths.

The Chief Minister of Karnataka State in India actually made some sense yesterday when he said:

“There will be no lockdown in Bengaluru from tomorrow. However, I humbly request the people of Karnataka — with folded hands — to wear masks and to practice social distancing. This is the only way to combat COVID-19, at least till a vaccine is found,  …….. People can resume work and businesses as usual, outside containment zones. A stable economy is essential for the state to combat the coronavirus pandemic effectively.” 

Indeed. Protecting a health service in a collapsed economy is not possible.


 

So what exactly have the lockdowns achieved?

July 20, 2020

The Wuhan virus continues to lay waste.

Cases are on the rise again.

Deaths are also rising globally.

The pandemic is now expected to continue into 2021.

There will be no reliable vaccine at least until spring 2021.

So, what exactly have the lockdowns and economic disruption achieved?

If anything?

But one thing is certain. The lockdowns have extended the life of the pandemic.

Without any lockdowns there may well have been a sharper peak.

But it could possibly all have been over by now.

The WHO is clueless. It went from “no person-to-person transmission” to “transmission by fluids only” and is now on to “air-borne transmission”.

Alarmist models don’t make for settled science.


 

 

 

All the Chinese viruses from the Spanish flu to the Wuhan coronavirus

July 10, 2020

This is the Wuhan virus and it did come from China. 

Trying to be politically correct is more misleading and probably the cause of more disinformation and self-delusion than any other. Political correctness applied to the scientific process is particularly destructive and gives us the burgeoning levels of fake science. Results are determined before the investigations have begun. For the WHO it is servility to Chinese interests which has prevented the Wuhan coronavirus from being named the Wuhan virus.

It now seems highly probable that even the Spanish flu of 1918 originated from China.

National Geographic:

 The deadly “Spanish flu” claimed more lives than World War I, which ended the same year the pandemic struck. Now, new research is placing the flu’s emergence in a forgotten episode of World War I: the shipment of Chinese laborers across Canada in sealed train cars.

Historian Mark Humphries of Canada’s Memorial University of Newfoundland says that newly unearthed records confirm that one of the side stories of the war—the mobilization of 96,000 Chinese laborers to work behind the British and French lines on World War I’s Western Front—may have been the source of the pandemic. …..

…. The 1918 flu pandemic struck in three waves across the globe, starting in the spring of that year, and is tied to a strain of H1N1 influenza ancestral to ones still virulent today.

There is little doubt that the current pandemic originated from Wuhan though, every so often, some journalist or “scientist” who is part of the China lobby will cast doubt on that. 

RealClearScience:

The Asian Flu in 1956 killed between one and four million people worldwide. SARS in 2002 infected 8,098 and killed 774 in seventeen counties. H7N9 emerged ten years later to strike at least 1,223 people and kill four out of every ten of them. Now, the milder, yet more infectious COVID-19 has sickened more than 70,000 across the globe, resulting in 1,771 deaths.
All of these outbreaks originated in China, but why? Why is China such a hotspot for novel diseases?

“It’s not a big mystery why this is happening… lots of concentrated population, with intimate contact with lots of species of animals that are potential reservoirs, and they don’t have great hygiene required. It’s a recipe for spitting out these kinds of viruses,” Dr. Steven Novella recently opined on an episode of the Skeptics’ Guide to the Universe.

South Central China is a noted “mixing vessel” for viruses, Dr. Peter Daszak, President of EcoHealth Alliance, told PBS in 2016. There’s lots of livestock farming, particularly poultry and pigs, with limited sanitation and lax oversight. Farmers often bring their livestock to “wet markets” where they can come into contact with all sorts of exotic animals. The various birds, mammals, and reptiles host viruses that can jump species and rapidly mutate, even potentially infecting humans. Experts are pretty sure this is precisely what happened with the current COVID-19 coronavirus, which is why, on January 30th, China issued a temporary ban on the trade of wild animals. ………

….. China is also notorious for its misinformation, secrecy, and censorship, which raises the chances that new diseases will fester and spread. Back in early January, Chinese government officials told the public that the new infection’s spread had been effectively halted. This was not true. At the same time, the authoritarian regime bullied health experts who attempted to sound alarm. The young doctor Li Wenliang attempted to warn others about the new coronavirus. He was ‘rewarded’ with a threatening reprimand by police. Li subsequently caught COVID-19 and succumbed to the disease the first week of February.

It may be called the Covid-19 virus but it is the Wuhan coronavirus pandemic


 

The great success and the great betrayal of the Swedish coronavirus strategy

July 3, 2020

The Swedish lockdown has been more voluntary than enforced. The over 70’s were told to quarantine themselves to protect the health system. Since the compliance with the voluntary social distancing requirements has been quite high, the spread of infection has not been much worse than in many countries enforcing very strict lockdowns. In total number of deaths due to the Chinese virus, Sweden sticks out among its Scandinavian neighbors who enforced much stricter lockdowns. But Sweden is not an outlier among other European countries. Economically, Sweden will probably be among the countries which recover fastest.

The Swedish strategy has been both a great success and a great failure. The numbers tell the tale.

source: worldometers

There is no right or wrong to the various strategies applied by different countries. Decisions have probably been made in good faith though these have been dominated by the culture of fear and risk aversion that permeates the world today. The fear of alarmist, imaginary crises has meant the world was totally unprepared for a real crisis. The impotence of a politicized WHO and the duplicity of a terrified Chinese bureaucracy has not helped. The stupidity of relying on imperfect and alarmist mathematical models was very evident.

But diving into the Swedish statistics also shows great successes among some very great betrayals.

Only 10% of the deaths have been of those under 70. Based on the National Board of Health and Welfare (Socialstyrelsen) criterion of “expected remaining life”, the loss of expected remaining life has been kept to a minimum. The 90% of deaths of those above 70 do not contribute much to “expected remaining life”. Among the “productive” population the loss of life has been kept down to about 50/million of population. That is the great success. 

Also among the successes have been:

  • intensive care places were more than doubled in a very short time
  • intensive care places were never overwhelmed
  • restarting the economy is well under way, and
  • herd immunity may not yet have been achieved but the risk of infection to the general population under 70 is greatly reduced. (Effectively, Swedish policy excludes the +70s from the herd).

But the cost has been the betrayal of the elderly. The unvoiced, undercurrent of opinion is that “but they were going to die soon anyway”. Care homes became virtual prisons for their inmates. Following the Socialstyrelsen’s publishing of their criteria for prioritizing lives based on “expected remaining life”, there were cases of those infected in care homes being denied oxygen and respirators. There have been cases where they have been put directly onto palliative care (sometimes a euphemism for a self-fulfilling, end-of-life care). The Swedish government through up its hands and abdicated its responsibilities to the bureaucracy of the Public Health Agency (Folkhälsomyndigheten) and of the National Board of Health and Welfare (Socialstyrelsen). The Public Health Agency were, I think the heroes, at least for honesty and fidelity and for stepping-up, if not always for compassion. The Health Services were also among the heroes. The bureaucrats of the Socialstyrelsen were hypocritical, mealy-mouthed and less than impressive. The reality, which is the opposite of what they often voiced, is that the elderly are second, or even third, class citizens in Sweden. The Swedish herd has protected itself by excluding the elderly from the herd.

I am over 70 and may be a trifle biased. But the villains of this pandemic internationally are the Chinese bureaucracy, the Alarmist Brigade and the WHO. Within Sweden, the villains are the government and the National Board of Health and Welfare (Socialstyrelsen).

And even if herd immunity is achieved, the over 70’s will remain at great risk until such time as a vaccine is developed. Every herd protects itself by sacrificing the weak and the sick. And the old.


 

“Covid 19: We need neither vaccine nor herd immunity”

May 28, 2020

Reblogging this article from https://milindwatve.home.blog/

Both interesting and a refreshing change from the usual.


Covid 19: We need neither vaccine nor herd immunity

Posted on

I had said in an earlier blog article that the SARS Cov-2 virus responsible for the current pandemic is likely to evolve rapidly towards reduced virulence. The reason why I expect this is that on the one hand, almost all countries are implementing strict quarantine measures for all detected positive cases. But on the other hand, we cannot afford to do mass testing, leading to many undetected asymptomatic cases roaming around and spreading the virus. The virus reaches huge populations and also has a high mutation rate, so all possible variants will keep on arising. A virulent strain is most likely to cause severe infection which will invite testing and ultimately quarantine. A mild variant, on the other hand is more likely to lead to asymptomatic or mild symptomatic infections which are more likely to escape screening followed by quarantine and therefore keep on spreading. In several generations of the virus, which is a short time for us, natural selection will favour the mild variants.

While all research on the virus is engaged in developing vaccine, studying pathogenic mechanisms or suggesting treatments, nobody seems to talk about evolution of the virus. This is for two reasons. One is that people in medicine are never trained to think of evolution. The other is that virulence is difficult to quantify. It is easier to sequence the virus, study its proteins, look for antibodies in the host etc. Researchers typically do what is easy to do rather than what is scientifically more relevant. Since one cannot measure a change in virulence easily, nobody will even talk about any hypothesis related to it. This is what I call “evidence bias” in science. If it is difficult to find evidence to either falsify or support a hypothesis, people will avoid talking about the hypothesis because it cannot make a paper. Whether the hypothesis is relevant to public health is not an important issue, whether you can publish a paper is.

But in the epidemiological trend at the global as well as the Indian scene, there are definite signs of reduction in virulence. Although the infection is growing, the death rate is consistently reducing with time. Look at the patterns. From mid-April, although the total number of new cases per day has been increasing, the total reported deaths per day is decreasing.

The same is happening in India too. In fact, the case fatality rate in India was always low and it is decreasing further, although the absolute number of deaths per day has not started decreasing yet.

Data from: https://ourworldindata.org/mortality-risk-covid

I plotted the time trend in the ratio of daily reported positive cases to daily reported deaths starting from the day the new death count exceeded 50. Although there are expected daily chance fluctuations, there is a clear decreasing trend.

Data from https://www.covid19india.org

Now if we make a simplistic assumption that the linear trend continues, then we can come out with a prediction that in India in about 35 days, Covid 19 will remain only as dangerous as any seasonal flu. The assumption of linearity is of course an oversimplification, the slope may not remain the same throughout. The second caveat is that case fatality rate cannot be exactly equated to mortality rate. In a growing epidemic, case fatality rate is an underestimate or mortality. But that need not affect the trend. The estimate of 35 days might be too optimistic. It may take somewhat longer. But the direction is assuring. Anecdotally I heard from some of my clinician friends that the proportion of patients needing critical care is already low.

The vaccine trial and mass production is going to take many months and may not immediately become available or affordable to the masses. For the huge population of India, acquiring herd immunity is a huge task and will not happen for a year or two. But much before either of the two becomes useful for public health, evolution would have taken care of the deadliness of the virus. We need to continue quarantine and good medical care of symptomatic cases, but not be fussy about the asymptomatic ones. Because they are going to be the saviours. Let us wait for a couple of months to see whether the prophecy turns out to be true qualitatively or quantitatively. If it does, it has a long term lesson for medicine. Virulence management strategies should become an integral part of public health planning. This is not the last time that a new virus arises. This will keep on happening. Understanding of evolutionary dynamics is certainly required to manage public health.


 

Has the world overreacted?

April 17, 2020

As countries now begin to, or plan to, relax their lockdowns and struggle to restart their economies, I have a niggling suspicion at the back of my brain that the world reaction may have involved more of panic and less of rationality. That the world may have overreacted in a fearful chain reaction may be understandable but was the chosen solution actually worse than the problem?

” ….. the spread of COVID-19 peaks after about 40 days and declines to almost zero after 70 days — no matter where it strikes, and no matter what measures governments impose to try to thwart it”.

This is from Prof Isaac Ben-Israel, head of the Security Studies program in Tel Aviv University, Chairman of the National Council for Research and Development and Head of Israel’s Space Agency.

A case perhaps of a kind of Mass hysteria?

A prominent Israeli mathematician, analyst and former general claims simple statistical analysis demonstrates that the spread of COVID-19 peaks after about 40 days and declines to almost zero after 70 days — no matter where it strikes, and no matter what measures governments impose to try to thwart it.

Prof Isaac Ben-Israel, head of the Security Studies program in Tel Aviv University and the chairman of the National Council for Research and Development, told Israel’s Channel 12 (Hebrew) Monday night that research he conducted with a fellow professor, analyzing the growth and decline of new cases in countries around the world, showed repeatedly that “there’s a set pattern” and “the numbers speak for themselves.”

……..

Asked to explain the phenomenon, Ben-Israel, who also heads Israel’s Space Agency, later said: “I have no explanation. There are all kinds of speculations. Maybe it’s related to climate, or the virus has a life-span of its own.” He said the policy of lockdowns and closures was a case of “mass hysteria.” Simple social distancing would be sufficient, he said. If the lockdowns instituted in Israel and elsewhere were not causing such immense economic havoc, there wouldn’t be a problem with them, he said. “But you shouldn’t be closing down the entire country when most of the population is not at high risk.”

Asked to explain why the virus had caused such a high death toll in countries such as Italy, he said the Italian health service was already overwhelmed. “It collapsed in 2017 because of the flu,” he said.


 

Fatality League: Without the 70+ deaths, Sweden would be doing very well

April 14, 2020

The pandemic is far from over, but as some countries contemplate or begin to relax their lockdowns, it is not too early to begin to look at some of the emerging data.

With its 10.1 million population Sweden has suffered over 1,000 deaths due to Covid-19. In the fatality league (deaths/million of population), Sweden has by far the worst numbers in Scandinavia and lies among the worst 10 globally (and in Europe) as of 14th April 2020. (Countries with fewer than 100 deaths are not included). Almost 90% of the fatalities in Sweden are of those over 70. Without these included, Sweden would have a fatality rate just one tenth of that observed.

I merely observe that in a mathematical model which gives little value to the lives of those over 70, Sweden would be doing very well indeed.

The questions are accumulating but any attempt at answers will have to wait at least a year.

Death League (as of 14th April 2020)

Some of the questions that will have to be addressed in Sweden at some time are:

  • Most countries have used “worst case” models (which are always ridiculously alarmist) but Sweden has used, it seems, “best case” models. Why?
  • Do the mathematical models give a lower “value” to the lives of the 70+?
  • Policy has been to restrict the movement of those over 70 to reduce load on the health service in case they are infected. However the infection carriers are the young and the mobile. Has the policy led to more of the 70+ being infected or less?
  • How much of the spread of infection was initiated/due to returning, asymptomatic tourists from the Alps who were neither tested nor quarantined?
  • Almost 90% of the dead in Sweden are 70+. Was this modeled at all?
  • How many of the 70+ were “prisoners” to infection in their care homes?
  • Was the main source of infection in the care homes through infected but asymptomatic staff?
  • Sweden has more than doubled Intensive Care Places in the last month. By establishing “priorities” for intensive care, Sweden has succeeded in ensuring that they have not been full to the limit. How many of the 70+ were denied Intensive Care due to the “priorities” established by the Social Welfare Board? (Priority is based on “expected life remaining”).
  • Was it optimal that unlike in other countries, leadership was abdicated by politicians in favour of the officials of the National Health Board.
  • …….
  • ….

 

 

In Sweden, coronavirus deaths are almost invisible among average daily deaths

April 12, 2020

In response to great demand Sweden’s Statistics Central Bureau (SCB) has published daily deaths (all causes) data for 2015 – 2020.

For the month of March 2020, the daily total deaths do not appear much different than the average for 2015-2019. The average daily death toll is about 250 (+/- 30). The coronavirus has been responsible (so far) for about 30 fatalities per day but there is some probable offset due to reduction of deaths from some other causes. During March there is no visible spike in total daily deaths that can be attributed to the coronavirus.

Daily Deaths March 2020 compared to average 2015-2019

We can never know what it would have been without a lockdown. What is visible during March is that with the voluntary lockdown in place, fatalities by all causes have not increased significantly.

In a few months, when the outbreak has been brought under control, I will not be surprised if we will be asking if the level of economic disruption was worth it.


 


%d bloggers like this: