ELEMENTAL FAULTS

ELEMENTAL FAULTS...What are these?

Decisions are made from a set of assumptions. Most assumptions are derived from a set of generated hypotheses for driving those decisions, others are based on prior experience and understanding and still, others are based on all three. In the confluence of such adventures one learns new things and generates still newer ideas to create newer paradigms, to change the world. 

The Wrights Brothers had a set of priors from the unpowered flight and the motor vehicle that they applied to the Wrights Brother Flyer. The process of learning was by experimenting with their model aircraft.

Today we have modeling generated by a set of assumptions based on previous assumptions. Untested in the past they become the models for a future. Any future. All such models have a fallacy stored in them. The fallacy of unknowns, unknown being the variables. Since priors are rarely used in certain unique circumstances that do not comport to priors, assumptions are heavily weighted in the direction to where the creating entity wants to divine the potential future. The surface is clear to see, albeit it is quicksand. Further, ascribing virtue to such assumptions, augers complete obedience, a difficult bridge to cross. Crossing that bridge means you are a heretic or a radical rebel without the requisite finesse of understanding.

These elemental faults have long been the bane of human existence ever since such practices began to take hold of “scientific rigor.” And scientists became comfortable in talking about science rather than experimenting in the blind with their hypotheses. Life has become easy for the armchair crowd. Using a set of pre-existing patterns, they plug in the numbers and the computer spits out a set of probabilities that soon through an elaborate web of followers, becomes gospel.  We have endured many such ethereal flows of intellect couched carefully in some dense and difficult scientific papers that over time prove these flows to have failed to hold ground. The quicksand is forever unforgiving.

Common sense has been relegated to idiocy, stupidity, and ignorance by those touting the benefits of their new and shiny models. Models that sometimes, even the creator does not understand, as happened to Neil Ferguson’s graphic depiction from the Imperial College of London regarding the COVID-19. When tinkering did not fix a certain divined prophesy, but a much different one than expected, he, the modeler is known to have said, “that should work.” The old adage “garbage in, garbage out,” seems valid at all times when dealing with numerical assertions based on flawed algorithms, resident in the CPUs. Such manifestations cannot be good. It cannot be bad. If good, then why do I take such venom to them in my own mind. Why does the future, these manifestations predict never comes true? If bad, then why do those with supposed wisdom continue to promote such meaninglessness with abandon? These questions are timeless and recurring and are answered only with silence.

Decisions regarding life and death as are made by physicians in the Emergency Rooms and hospital floors every day, take into considerations the priors and the fund of accumulated knowledge and experience to drive a potential outcome and are a whole different matter. Success is never guaranteed, but the pursuit of success is never in question. Yet some folks who have never seen the light of such burden grow deep, soft, and comfortable armchairs around themselves and pontificate the hypotheticals without an ounce of priors or understanding. A perfectly coined phrase exists for such, it is: “they have no skin in the game.” They seem to look at the future without looking at the past. And that brings into the fore, the question, Is the past worthless for any assessment of the future, as they seem to suggest? The answer that comes to our minds differs based on our own personal priors. Yet the past is the constant and the future is well, an undiscovered ground. History teaches if one wishes to learn.

So, what is to be done about the confusion that unfolds for those of us in the fields of science? Perhaps a breath, a memory of the past, a tincture of silence, a drop of solitude, a fragrance of thought, and a large dollop of reason, might come in handy making decisions for the future. Perhaps?

We need more awareness rather than building an army of guideline-following robots. We need more critical thinking in medicine and science, but especially in medicine. We need reason and logic based on priors and a good deal of basic fundamental knowledge. We need skeptics. We need questioners. We need thinkers. We need real educators. We need teachers that give a damn. And we need real scientists and doctors who desire to ponder, to provoke and to prick the bubble of comfort that endlessly surrounds us!

When we solve this problem that has plagued the very essence of the underpinnings in science and medicine, then and only then can we begin to call our skepticism as “scientific inquiry.” It then becomes a real inquiry into the fundamentals of science and equally into the nature of a patient’s illness. A diagnosis is not a patient, and neither is the patient illness. Until we can reconcile that, we will continue to exist in a carefully crafted bubble of IFTTT (If this then that).

SIGNIFYING NOTHING

“…a poor player
That struts and frets his hour upon the stage
And then is heard no more: it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing. “  -Macbeth by William Shakespeare

And so, begins our tale with that quote from Macbeth, a Shakespearean play. The stage has been lit up with bright lights and much fanfare. The spotlights are aglow and the “poor player” steps on the stage and looks bewildered for a moment, then finds his stride and erupts into a most alluring and mystifying speech for all to hear. The audience is transfixed and motionless, riveted to their seats awaiting the next uttered melodic syllable. The moment passes and lights fade, the “player” dissolves into the darkness, and the audience leaves in single file bewildered and disoriented.

What has happened over the past three months is nothing short of a play orchestrated by a few on the many. A play that may have cost many their livelihood and ultimately their lives. Act one takes us into an office chaired by a be-speckled “scientist” who determined that using outdated software with some tweaks in the codebase, could magisterially predict the future. His determinant may have lacked the necessary tools, yet he soldiered on with his predictions. The predictions were so dire that every lowly mind fell lockstep behind them. The player never ceded to the fact that the computer code might be using a single initial variable that might have been erroneous. A further critical review showed that even using the same parameters and the single variable the computer output showed a wide swath of unrelatable non-conforming results. Nope, he marched on the stage and delivered a powerful soliloquy to the willing, ticket holder audience. His complex model suggested that the reliability of his model was based on a highly accurate deterministic nuanced variable “seed” grounded in reality. He further claimed in these captivating terms, “this has historically been considered acceptable because of the general stochastic nature of the model.” The world was awash with the spellbinding ferocity of his monologue. He discussed the many iterations that he had used with some small non-determinant errors in the scheme of things. To some, the 80,000 predicted deaths were more than “non-determinant,” but not to the epidemiologist “player.” There was no mention of error rates when using parallel computing where errors were magnified when iterations achieved high-speed throughputs, nor the potential of those tiny miscreants called “Heisenbugs” that can make most outputs “signify nothing.” Yet this piper piped, and the music played which soothed the fears of the many in attendance. Alarmed by the horrible future that lay ahead, yet disquietly comforted by the preventative measures of shuttered doors and isolation that would defeat this “plague,” and return their universe to a higher version of harmony.

When the play was over and the “player” had been regaled, destined for greatness, the spotlight disappeared as did he, returning back to the apple of his eye and resigned to his fate as an interloper.

Meanwhile under the shadows of the greatest “Play,” the world had ever seen, the Second Act saw the doors starting to shutter in lockstep with the dictates of the easily distracted policy-makers. Fear spread through societies like volatile fuel ignited by a spark. Nations both under authoritarian rule and democratic rule clamped down on the basic liberties of their citizens. The world was ablaze with news as each new case was glorified in headlines and each new resulting death from the plague as a means for more restrictions on freedom. The standstill in commerce caused a significant decline in the economic activity and bode a serious blow, to the future of each nation harnessed by the dictatorial dictates of the few. Countries with the means paid the citizens to keep the economy moving temporarily, but those without such means saw the policy harm to the youngest in their midst with a rising tide of childhood malnutrition. The policy-makers and their marketing accessories continued to gloat about a restricted shutdown in perpetuity till something was done about the plague. They modeled forecast using similar computer codes as previous with dire circumstances if the people were set free to start their lives again. The predictions of 200,000 cases a day with over 350,000 deaths from the plague if the people were allowed to return to their normal lives were broadcast for all to see and shiver in fear. However, a piece of little-known evidence was glossed over that the people actually contracting this “plague” were those huddled in their homes behind shuttered doors. More evidence suggesting that the in the name of “public good,” some of the plague victims were placed in Nursing Homes for the elderly where the deaths mounted and accounted for a large tragedy in numbers. Some estimated the deaths from those policies/mandates by the governing individuals cost almost 45% of the total deaths from the plague. Further analysis on the shutdown of planned healthcare estimated that 80,000 cancer diagnoses would be missed and 6200 untimely deaths from these diagnoses. Other diseases including, heart disease, high blood pressure, diabetes, kidney disease, and lung disease would suffer a similar fate due to fear of contracting the plague from venturing out into the open. In fact, the fear instilled in the populace was so strong that 3 out of 4 people thought that restrictions on liberty and freedom should continue for fear of the escalating infections and deaths from this plague. The marketers and promoters of this “pandemic” had achieved their version of utopia.

Governors heeded to their new-found power and ejected executive order on a daily basis and disciplined anyone, not in compliance with their edicts. This was the utopia some had secretly yearned for and dreamt. Citizens  were bereft of their ability to make a living for themselves while the ruling class steadied with a steady paycheck clamped down further. Policies with no merit surfaced; you could not give a haircut, go to the beaches or the parks, or golf courses, but you could visit the buildings of large retailers for goods and services. Power being the strongest known aphrodisiac, created nuances to stick to the weak individual at the hem. Goal-posts started to shift: From “Flattening the Curve” to “universal Testing” to “Availability of Vaccine” became the war-cry before liberty would be regranted by these people-servants turned tyrants and before freedom was earned.

But as all things real and fictional reveal themselves, so did this plague. Locking down seemed to harm more. The despair form job loss, the abuse from depression, the turmoil from lost wages, the foreclosures, the bankruptcies, the destruction of the economies had a larger price. One that had started to unfold before the seeing eyes. 

Meanwhile, some states in the United States decided to forgo the warnings and maintained their functioning economies and freedoms. As William Briggs showed, the States listed below have a substantially diminished number of deaths from this plague: In deaths (XXX) per million (5/7/2020) “using the COVID Tracking Project’s numbers): Iowa (111), Oklahoma (73), Nebraska (64), North Dakota (56), South Dakota (50), Arkansas (32), Utah (25), and Wyoming (14).” While the States with the strictest clamped down restrictions: “California (83), Illinois (330), Michigan (490), New York (1162), New Jersey (1166)” were a runaway-disasters!

When this “Play” is ultimately analyzed and the dust settles, it should give us pause. The belief in modeling based on faulty premises and inadequate tools or even with adequate tools should be countered with well-reasoned thoughts. Perhaps the Insurance Actuaries are better at forecasting the future of pandemics than self-appointed experts and epidemiologists playing with computer codes.

Plagues and Pandemics have a short shelf-life. They create havoc for a few weeks or months and then they are gone. It is the nonsensical policies of the grifted, the power-hungry, and the least intelligent amongst us that make human disasters out of natural events. A sane policy would have been sheltering the high-risk population and allow the rest to create herd-immunity for the benefit of all. In this case, the vulnerable were subjected to direct harm by locking them in with the asymptomatic or mildly symptomatic individuals while everyone was sheltered to increase the chance of injury to those that could be harmed.

Economies take a long time to wind up and deliver the promise of wealth and security, but they can wind down suddenly and lay waste to nations and hurl havoc on their citizenry. Decisions made through the eyes of a select few with blinders must be tempered by the many who face the daily turmoil of survival. The future is still us. The future is still tomorrow. Perhaps we will learn a hard lesson and be stronger for it. 

I pray so.

LOGICAL FALLACY

"False equivalence is a logical fallacy in which an equivalence is drawn between two subjects based on flawed or false reasoning. This fallacy is categorized as a fallacy of inconsistency. A colloquial expression of false equivalency is "comparing apples and oranges"

Apples 

 Oranges

are not the same...

There is a powerful force in humans that drives their destinies. This force asserts itself in the form of Liberty. In the Declaration of Independence, the statement “Life, Liberty, and the Pursuit of Happiness,” is the most powerful of liberating words written. The absence of subjugation to power and the right to act, speak, or think as one wants, are the tenets of what makes us all Americans. When these basic rights are threatened the ire of freedom-loving people is raised.

The current COVID-19 pandemic seems to have roiled the tranquil waters. In this chaos, many a voice seems to invoke falsehoods and render them as truths. There is a false equivalency between disparate ideas that rule the minds of the policymakers for ruling the minds of the citizens. 

Let us look at the past 6 weeks and gather reality from this recent past. As the pandemic broke across the Pacific and Atlantic shores simultaneously there was a sense of urgency and panic. The urgency was implied by some very poor models that were based on hypotheticals that overtime failed to materialize. The pandemic continues to march through the country from both the coasts into the middle taking down thousands of lives in its wake. The tally of the infections and deaths has become the daily mantra of the experts. In fact, some seem to thrive in reporting such numbers and take delight in the fact that the worse is yet to come. Even in the face of a slow and steady decline, these experts continue to feed the beast of fear. Caught in the trap are politicians that have lesser of a sense of what is real. The louder the drumbeat, the more deference is given to the experts. Policies are made to counter this beast of an epidemic. No one seems to pause and reflect for a moment as to what is at stake with each policy or mandate, they conjure. No one! 

One such policy is the “lockdown” of the private commerce in its many forms. Closure of hotels, airline travel, shops, and even short-distance travel is frowned upon. So much so that drones have been utilized by various police precincts to usher an era of command and control through virtual means. In a Texas city, the SWAT Team was called upon to close down a bar. The loudest voices seem to be repeating the phrase, “We must flatten the curve.” By that, they mean that by distancing from one another and “shelter at home” the spread of the virus will be contained, and the healthcare system will not be overburdened. Meanwhile dubious policies are in effect; releasing prisoners, arresting law-abiding citizens walking with their children. Yet given the information from recent events, when large quantities of beds were made available and larger numbers of ventilators were built to respond to the need, the threat never materialized. Most of the beds remained empty and as far as the ventilators they are being sent to other countries to handle their respective crises.

But within this “shelter in place” and other such terms is a sinister mechanism that has raised its ugly head and seems to hover over us as the Damocles Sword. The thinking goes that if the private business is opened too soon then we will have many hundreds of thousands of more deaths. That specter shakes the core of any human being. But time is passing, and more and more information is being revealed. The virus seems to not like living under sunlight and moist air. Yet even armed with this knowledge, the powerful governing forces have shut down parks and beaches, albeit a few have been reluctantly opened due to people pressure. Small businesses still are forced to remain closed. Among small businesses include the physician offices that are having a deleterious effect on the medical care of the infirmed and ailing fellow citizens. There are estimates of over 6,000 early deaths just among cancer patients. Other specialties are also seeing fewer patients with heart disease, diabetes, lung disease, and kidney disease. All these patients have been furloughed from healthcare due to fears of hospitalization and close contact with others for fear of contracting COVID-19. How many people will die from such an action will probably scale the number of COVID deaths.

The false equivalency exists between the control of the virus and the shelter in place concept. Although shelter in place may have flattened the curve, that still remains in dispute given the data from Sweden and the U.S. and other parts of the world, where shelter in place was not undertaken by the government. The essence of this virus suggests that it will find “parity” with its surroundings and eventually die off. “Parity,” here means herd immunity. Scientists have since the beginning said that it will take 70% or greater infected populations for the virus to finally die off. But some epidemiologists have models that suggest only 25-30% of the infected population shuts the virus down. Further evidence from other countries including, Sweden, France, and others including the United States suggests that between 40% to as much as 65% of the deaths were from Nursing Home patients. In fact, the Swedish Health Minister stated as such that the increased deaths in Sweden were from the Nursing Home due to poor Infection Control. The incomprehensibility of some enforced policies of moving COVID patients into the Nursing Homes in New York, New Jersey and California are counterfactual to scientific reality. It would, therefore, be prudent to allow the country to open for business and people over 65 years of age with co-morbidities might continue social distancing as preventative measures against the virus. The younger population meanwhile can begin the process of normal living with recommended good hygiene standards. The herd will get itself immunized and the virus will become a distant memory.

While Aristotle suggested that desire can be subjugated to reason and Plato stated that all desire must be postponed for a higher ideal, the current ideal seems to threaten the economic welfare of everyday workers in every country as the economic collapse continues from these unbridled restrictions. Socrates meanwhile argued, “that happiness and personal growths were a major purpose of life and a central goal of education.” If that is true, and it is, then the current actions by some governors are a direct assault in human liberty and freedom to pursue happiness.

It is therefore imperative that Governors exerting an undue force of their incomprehensible logic should undo their dictates and open the civil activities of daily life so that for the time being those aged 18 to 60 years of age can work and provide for their families. Government subsidies cannot sustain life as has been evidenced through history by a top-down movement. The United States Constitution states, ““Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof, or abridging the freedom of speech, or of the press, or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.”

As the New Hampshire automobile license moniker states, “Live Free or Die,” let us continue to live under that banner of liberty.

IMPALPABLE SUSTENANCE

There are moments of clarity that in their tempestuous presence, far exceed in gains than the comprehension, prolonged excruciating and time-robbing pensive deliberations, when nothing moves or advances. These eureka moments arise indifferent to time or space. Like the zephyr filling the sails of a sloop on a quiet lake. 

Judgment inquires, about experience and knowledge in the same breath. It is not about theorizing movements, or ordaining trajectories of arrows in flight with indifference to wind or a gathering storm. Judgment requires a spate of intuition boiled in a vat of reality. 

Taking a certain object away from a child to prevent harm, is based on the past experiences of others under similar circumstances. Rubberizing a sharp edge has equal protective value for an infant. In the adult world of aviation, a preflight is meant to prevent the potential of a catastrophe. Checking the free movements of the control surfaces, draining the fuel or checking the oil before takeoff heed to the same convention of prevention. All stem from the experiences of others and self, about using the correct conduct prior to a flight. I remember upon embarking in an airliner, my son upon looking into the cockpit asked, why the pilot and the copilot had their pilot operating handbooks on their lap. “Are they learning how to fly the plane?” He asked with incredulity.

In medicine, judgment is an important determinant of a physician’s management of any illness. True care of a patient is not a repetitive mantra of this for that. It is not the guideline metric of “Less is More,” or “Choosing Wisely,” as envisioned by the wisdom of the ones who ordain the trajectories of their version of the medical discipline. It is as Rebecca Elson put it, 

“And purpose is a momentary silhouette

Backlit by a blue anthropic flash,
A storm on the horizon.”

It is a collective experiential reference based on knowledge and with that instructive modicum of intuition.

Ask any physician in the throes of a busy Emergency Room work-day, how he or she is able to keep the collective mob of ailing people from inundating their decision and judgment on the singular patient they are tending to? “I refocus on each one as I go along,” most will reply. But, how do you know what medicine or therapeutic option to offer? “I look at them and my knowledge and experience come into play, each time,” they respond. Exasperated, with these equivocations, you ask, “But how do you know what the right thing is to do. Do you follow some guidelines?” They stare back at you and then shake their head and head to the next patient moaning for their help. Is it intuition or judgment or an inkling? A fair question.

Walt Whitman squares this argument thus, “impalpable sustenance of me from all things at all hours of the day.” There is a flow of an ethereal transfer of information between humans, the kind that unifies us as humans. This flow ebbs and flows to the beat of human desire. Intuition, judgment and inkling are all words that imbue the essence of that “impalpable sustenance.”

Another example where such judgment comes to the forefront is in piloting an aircraft. The virtue of experience and knowledge is compacted into that tiny moment of decision-making when things go silent and fear shakes the bones. When the engines shuddered, while ingesting geese and the aluminum behemoth becomes a glider. Sullenberger, the pilot using his “impalpable sustenance” was able to glide the US Airways Flight #1549 an Airbus 320 into the Hudson River, NY and saved all the lives on board. Even second-guessing by armchair experts, of his decision, could not achieve the same fate.

A not dissimilar event happened in 1989 on a United Flight 292 under the command of Captain Al Haynes. The DC-10 aircraft experienced a catastrophic engine failure in its rear engine, which triggered a loss of hydraulic fluid. That loss of hydraulic fluid caused all control surfaces (rudder, flaps, ailerons) to malfunction. The flight was diverted to Sioux City, IA and after judiciously manipulating the two engines still operating and using thrust vectoring for directional control, he was able to crash land the aircraft and save 189 lives. 55 test pilots given the same scenario in simulators failed to achieve similar results. You may call it “experience” or “intuition” or “judgment” in those critical moments, but surely it transcended all written words in some manual!

As recently as yesterday a report from the COVID19 frontlines brought forth another example of human ingenuity and good judgment in an attempt to save a life, that has won over many other physicians. A patient developed severe shortness of breath after being infected by COVID19. Ventilatory support did not offer much help as the patient’s life continued to ooze away. The physician considering the possibility of multiple clots as the reason for the sudden shortness of breath gave an anticoagulant as a form of therapy. That therapy stabilized the patient for a short while, but she succumbed. However, the physician’s insight has led to a new therapeutic option for other severely ill patients with similar complicating features of COVID19.

One cannot always relegate human intuition/judgment/inclination to the back seat or to the written word from academic experts. There is a blossom of colors in the minds of each physician-scientist who faces extraordinary charges and must be allowed without the nitpicking of retrospective legalism, to use that kernel of “impalpable sustenance” however implausible it might seem in face of unparalleled adversity. To any future charges, the physician-scientist must also be able to answer such questions to the best of his or her ability as to why such actions were taken. Suppressing such “impalpable sustenance” would lead us all into the ocean of mediocrity and stagnation and soon that sustenance will wilt and die, leaving us as nothing more than a non-thinking collective, what Star Trek called the “Borg.”

And I, being you, “Just as you feel when you look on the river and sky, so I felt,
Just as any of you is one of a living crowd, I was one of a crowd,
Just as you are refresh’d by the gladness of the river and the bright flow, I was refresh’d,
Just as you stand and lean on the rail, yet hurry with the swift current, I stood yet was hurried,” (Walt Whitman stated), we all rush to the same shore but each with a different voice and understanding.

It is fitting, therefore, to leave you with this short Walt Whitman poem:

WHEN I HEARD THE LEARN’D ASTRONOMER
When I heard the learn’d astronomer,
When the proofs, the figures, were ranged in columns before me,
When I was shown the charts and diagrams, to add, divide, and measure them,
When I sitting heard the astronomer where he lectured with much applause in the lecture-room,
How soon unaccountable I became tired and sick,
Till rising and gliding out I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.

COVID19 SHUTDOWN & its COSTS

In all post-war aftermaths, a reckoning is inevitable. Even though we are still in the midst of this pandemic, there are certain corollaries that seem to fill in some of the blanks. These are the blanks that wake us up in the dark of night with a thought that cannot be easily reconciled; A scratch that cannot be itched. 

Before we go hunting for the culprit of this current pandemic, let us visit the age-old annual irritant to our existence. The Influenza virus. There is something quite sinister in this micro-beast. The Influenza virus rears its ugly head every year to raise Cain among the young and the old. The virus has developed an art form in its sneaky attacks. Winter brings with it the cold. With the cold, everyone cordons themselves to the indoors. The virus starts the breeding process in schools where young children congregate. From there it gains access to the parents and thence to the commercial tracks across the world. 

INFLUENZA...

Influenza is a very contagious illness. It affects approximately 9% of the population infecting roughly 1 billion people annually. Of those around 30%-50% develop fairly significant illness requiring some form of therapy and management. And of those around 10% die as a result of the illness. The Case Fatality Rate is 0.15% for the Influenza illness. The numbers are staggering and this happens every year, but no specter of “the world is coming to an end” is in the daily news broadcast. If we are to look strictly at the United States population, 15-20% of the population is affected each year or 50 million people in all are infected by the Flu virus. Of those 250,000 are hospitalized and around 10-20% succumb to the illness. The variations in the severity of the illness and the fatality rate depend on the mutational features in the Hemagglutinin and Neuraminidase surface antigens of the virus and the efficacy of the vaccine. If the antigenic drift (Antigenic drift results from the accumulation of point mutations in the Hemagglutinin (HA) and Neuraminidase (NA) genes) is significant (and not anticipated by the vaccine producers) then the infection rate and the fatality rate is fairly extensive as evidenced by the H1N1 viral infection of 2008-2009 period. According to CDC estimates, between 43 million and 89 million cases of novel influenza A (H1N1) occurred from April 2009 to April 2010. Between 195,000 and 403,000 individuals were hospitalized, and between 8,870 and 18,300 people died. Of those patients who died, 90% had underlying medical conditions. Given the vulnerability of the elderly population with multiple comorbidities such as Diabetes, Hypertension, COPD, Kidney disease and Heart Disease, the elderly makeup almost 15% of the U.S. population but represent 65% of the hospitalizations and 90% of the deaths associated with influenza. (1,2,3)

ECONOMIC BURDEN OF INFLUENZA

In regards, the economic burden of the Influenza infections specifically in 2003 alone was the estimated economic burden of influenza totaled $87.1 billion, with $10.4 billion spent in direct medical costs. Most of the costs were directly related to the care of the 65 years and older patients. (10,12)

FATALITY RISKS FROM INFLUENZA

The mortality from the Influenza virus is enhanced by comorbid states such as COPD after making adjustments for age, sex and risk status. Any person with a history of hospital admission three years prior, or a chronic condition such as cirrhosis, Heart disease, pulmonary disease, kidney disease, Immuno-deficiency, HIV infection, and long-term residence in an Extended Care Facility (Nursing Home) were considered high risk for the Influenza. (4,5)

COVID-19, SARS COV-2, CHINESE CORONAVIRUS

Now let us turn our attention to the current miscreant; the SARS Cov-2 or COVID-19 or the Chinese Corona virus. The current data on this virus as of this writing today suggests that a total of 1.48 million people across the world have been infected and 87,444 people have succumbed to the disease. In the United States the estimates are that 1 in 994 people are infected with different regions showing different penetrance. In February 12, 2020, 4,226 COVID-19 cases were reported in the United States; 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths occurred among adults aged ≥65 years with the highest percentage of severe outcomes among persons aged ≥85 years. (6). The incubation period of 2-14 days makes the exact number infected (diagnosed) difficult unless testing for IgG and IgM antibodies is done. Although the number prevalent in this discourse, based on China data, is that an estimated 81% of the population is asymptomatic, this number is probably much higher (86-90%) given the nature of illness in asymptomatic people. The difference of the severity of infection in the Hubei Province and other parts of the world is discussed in this article at length.

“One of the most perplexing questions regarding the current COVID-19 coronavirus epidemic is the discrepancy between the severity of cases observed in the Hubei province of China and those occurring elsewhere in the world. One possible answer is an antibody-dependent enhancement (ADE) of SARS-CoV-2 due to prior exposure to other coronaviruses. ADE modulates the immune response and can elicit sustained inflammation, lymphopenia, and/or cytokine storm, one or all of which have been documented in severe cases and deaths. ADE also requires prior exposure to similar antigenic epitopes, presumably circulating in local viruses, making it a possible explanation for the observed geographic limitation of severe cases and deaths.”

Furthermore, data from Wuhan presented in the journal Science, “This estimate reveals a very high rate of undocumented infections: 86%. This finding is independently corroborated by the infection rate among foreign nationals evacuated from Wuhan.

Additionally, Michael Farzan, co‐chair of the Department of Immunology and Microbiology at Scripps Research, states, “once a vaccine for COVID-19 is developed, it would not need regular updates, unlike seasonal influenza vaccines” Those infected and recovered have active immunity and are firewalled against future infections as well. The British Medical Journal states that the COVID appears less mutable than expected. The Case Fatality Rate for the COVID-19 is between 0.15%-1% with an average of 0.6% based on results from across the world vs. SARS or MERS, which have had case fatality rates of 9 to 10% and 36%. 

Most countries are already showing a “flattening of the curve.” (By “flattening” we mean that the rate of infection and recovery equalizes and then as the rate of infection falls, the curve turns downwards) In some of the countries, the flattening of the curve has occurred spontaneously preceding the Social Distancing, while in others it has followed. Several questions arise as a consequence of this finding and need further elucidation. Remember the estimates of infection rates and death rates are based on an arbitrary multiplier as done for the Swine Flu previously and was grossly overestimated. “We estimate that the total number of pandemic (H1N1) 2009 cases in the United States during April–July 2009 may have been up to 140× greater than the reported number of laboratory-confirmed cases.” The worst aspect of all this “estimated scientific data” is what most Journalists sensationalize to get their ratings and cause fear and panic among the laity for the sake of viewership and some busy experts feed off the journalists to get more exposure on television as well. Experts like journalists are, after all, human. The R0 or Reproducible Rate of the virus has also become an issue. The common flu R0 is 1.28 while the COVID-19 was estimated at 2.2. The difference is of significance because the +0.92 difference is the difference between an epidemic and a pandemic. Hence the deployment of the “Shelter in Place” mandates. However, if one considers this a bit further, a conundrum becomes evident. The advocated “Social Distancing” does limit exposure but might it prevent the youth from getting the asymptomatic infections and thus restrict enlarging the herd immunity pool and thereby because of this prevention might inadvertently later be exposing the risk to the vulnerable elderly and thereby cause a secondary peak?

OBFUSCATION

The management of the present COVID19 virus has been of serious concern from the beginning. In China, the real data from the Communist country remains hidden. The issues related to suppressing information and delaying the transmission of pertinent information from the Chinese Authorities and the World Health Organization are in discussion presently. Both are being questioned for disinforming the virulence of COVID19, the actual number of cases and its easy transmissibility between humans. Why this obfuscation was attempted, will need to be reconciled in the near future.

LIES, DAMNED LIES, AND STATISTICS

Another more interesting but likely dubious statistical modeling data done by the Imperial College of London by Neal Ferguson suggested that the deaths from this virus would amount in the millions globally. That initial model became the benchmark for all countries and threw everyone into a tailspin. No one, no leader or otherwise would ever want such a debacle on their hands. Experts clogged the television and Radio waves to highlight the Armageddon that was upon us. “Shut everything down,” they cried, and the leaders listened. The initial impact of the virus on humans was a cause for concern, accented with the statistical modeling. The dye was cast. The world would pay a huge price if it did not listen to these sages of science. The initial event can be traced down to the Hubei Province and Wuhan in particular on Chinese soil. Images of the shutdown of the Province from the rest of China, while simultaneously allowing world travel by millions of the Wuhan citizens came to pass. Images of Street spraying and lock-down and citizens forcefully separated from their families played out on the Western media daily. At the same time, the virus was being carried to points far and wide, WHO Director Tedros Adhanom maintained that the virus only was transmitted from animal to human and there was no evidence of human to human transmission. Simultaneously WHO’s Tedros and some other politicians suggested that any restriction on incoming travel from China would be considered xenophobic. The rest of the world let their guard down because of these assurances and collectively with political correctness the journalists cast the net of confusion. The influx of the infected Wuhan citizens into the world community gathered steam and intensity without a question. 

Once the virus had taken hold in a country, the images of the Wuhan lock-down and street spraying, social distancing, shelter in the home became the call from the experts. Focusing on the population needs based on the IHME modeling and other such experts, estimates of the devices, including ventilators, hospital beds, and PPEs appeared grossly below the needs. Calls for the government to take action rose in unison by the political crowd. “We need more!” Yet in a mere period of 2 weeks, they needed less!

THE ECONOMIC DEBACLE

Meanwhile, the economic engine of the world, the economy of the United States was brought to a standstill by a select few individuals. The economy that produced $21 Trillion a year shut down. The US government was forced to pay the companies and individuals a total of $2.5 Trillion (at last count). The money was shepherded to keep the economic engine on life support and workers on the payroll. From an $80 billion loss for the Flu to a staggering $2.5 Trillion and counting loss for the COVID-19. But there were some dishonest and shameful politicians who wanted to secure a fiefdom by giving freebies to their constituents and wanted more. Together, the damage was done across the world and especially to the most productive nation on the globe. But the experts were not done yet. They promised that this virus was going to be rearing its ugly head annually, (contrary to known information that this particular RNA virus’s virulence via the spike was immutable and that a potential vaccine would mitigate that risk entirely), therefore we must get used to “social distancing” as a way of life and just to add fuel to their rhetoric they advocated the need for “Contact Tracing” as a means to contain the spread. The fix was in and the population could be controlled easily under the guise of “public good.” Meanwhile, the technocrats at Google, Facebook, Apple, and others were busy working overtime to make this happen. These technocrats already know what your next desire is, why not know where you are or where you are going to be every second of the day. 

Liberty seems to be on a ventilator these days.

But getting back to the illness-related loss of human life from the COVID19, seemed to mimic that of the annual Influenza but the death rate was higher by a factor of 6-10 of an average Flu season but similar to a highly evolved Flu virus with a larger antigenic drift. The Economic loss however as a consequence of the shutdown is and will be astronomical. It might contract the greatest economy into a Recession. The experts continue their rant to keep everything shut down. One such “expert” wants the shut-down to last for 18 months. Perhaps these fanatics believe their rhetoric, perhaps their need for self-importance exceeds their capacity to understand or tell the truth, but there is a willingness to obfuscate reality in the United States equal to that what happened in China. Only in the US that obfuscation comes from biased modeling, fear-mongering, while in China it comes from Authoritarianism and Control. An important study  from John Ionnadis, MD., “People less than 65 years old have very small risks of COVID-19 death even in the hotbeds of the pandemic and deaths for people less than 65 years without underlying predisposing conditions are remarkably uncommon. Strategies focusing specifically on protecting high-risk elderly individuals should be considered in managing the pandemic.” The study suggests that selective high-risk group distancing is the more appropriate measure.

Meanwhile, did I mention that the “Wet Market” where supposedly the virus originated is now open for business? The previously safety-breached Wuhan Level IV Biosafety Lab (the other possible source) remains shut down for the present as far as the world knows.

WHAT IS THE VIRUS TO DO?

All of this begs the question, “What is this virus going to do?” In answer, one can only say with the most humility that it will do what viruses do. It will infect humans as many as it can to propagate itself. When a certain number are infected and attain a degree of immunity to it, one of three things will happen: 

1. The Selection pressures from the immunity will slow the virus down both as the temperature rises and people start to stay outdoors with pockets of infection scattered intermittently. 

2. The virus mutates, and that antigenic drift creates a more benign version that behaves like the common flu. 

3. The virus mutates with a significant drift that creates another monster. 

The current Social Distancing has had an impact. Perhaps only selective distancing measures for the vulnerable with comorbidities going forward might be appropriate and not the entire country. The economy needs to rev up again so a further loss of life from starvation, depression, and suicide does not engulf us in the future. 

Vaccine innovation against the COVID19 is in full bloom( 13). Meanwhile, mitigation strategies including the cheapest therapeutic version of Hydroxychloroquine and Azithromycin plus Zinc are being used with some success, but simultaneously being derided by the experts. Newer drugs probably at much higher prices are being touted as potentials, including Remdesivir (anti-viral agent) and EIDD-2801 as a prophylactic. Time exposes everything from the antisepsis of the sun. 

This time too, it will tell a tale, worthy to learn from.

 References:

1. Estimates of deaths associated with seasonal influenza—the United States, 1976–2007. Morb Mortal Wkly Rep. 2010;59:1057–1062. 

2. Girard MP, Cherian T, Pervikov Y, Kieny MP. A review of vaccine research and development: Human acute respiratory infections. Vaccine. 2005;23:5708–5724. 

3. Lambert LC, Fauci AS. Influenza vaccines for the future. N Engl J Med. 2010;363:2036–2044

4. Simonsen L, Clarke MJ, Williamson GD, et al. Impact of influenza epidemics on mortality: introducing a severity index. Am J Public Health. 1997;87:1944–1950. [

5. Simonsen L, Fukuda K, Schonberger LB, Cox NJ. Impact of influenza epidemics on hospitalizations. J Infect Dis. 2000;181:831–837. 

6. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333–1340. 

7. Centers for Disease Control and Prevention (CDC) In: Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed. Atkinson W, Wolfe S, Hamborsky J, editors. Washington, D.C.: Public Health Foundation; 2011. Available at:  www.cdc.gov/vaccines/pubs/pinkbook/downloads/table-of-contents.pdf. 

8. Keech M, Scott AJ, Ryan PJJ. The impact of influenza and influenza-like illness on productivity and healthcare resource utilization in a working population. Occup Med. 1998;48:85–90. 

9. Simonsen L, Clarke MJ, Schonberger LB, et al. Pandemic versus epidemic influenza mortality: A pattern of changing age distribution. J Infect Dis. 1998;178:53–60. 

10. Szucs T. The socio-economic burden of influenza. J Antimicrob Chemother. 1999;44:11–15. 

11. Kochanek KD, Xu J, Murphy SL, et al. Deaths: Preliminary data for 2009. Natl Vital Stat Rep. 2011;59:1–69. 

12. Molinari NAM, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the U.S.: Measuring disease burden and costs. Vaccine. 2007;25:5086–5096. [

13. Wang CS, Wang ST, Lai CT, et al. Impact of influenza vaccination on major cause-specific mortality. Vaccine. 2007;25:1196–1203

PHYSICIANS FIGHT AGAINST CORONAVIRUS

Physicians are a sturdy lot. They come in all shapes and sizes, yet they all have a common goal; to find means to heal and comfort the sick. Ask any doctor, in an Emergency Room filled with patients; where some are crying in agony, others are gasping for air and still, others are infirmed into total silence. These physicians never let the trauma of life and living alter their sense of being. One by one, each is given the remedy he or she seeks and while most withdraw to their homes in comfort, some remain under the vigil of others within the walls of the hospitals till recovery. It is not only the ER doctors but most, in all different specialties who carry the same burden. Ask a bleary-eyed surgeon awakened in the middle of darkness, with adrenaline coursing through his veins, while he rushes to suture a gaping wound, an aorta, or a ruptured viscus all without a peep of self-doubt or self-pity. Or ask a family physician who sees a patient in the fit of a coughing spell calmly administer relief without a pat on the back. No, physicians by their very nature are destined to quietly move through society and life, bearing the burdens without calling attention to the burden itself or to themselves. 

If further proof was needed, look at the 136 physicians who have quietly given up their lives in the wake of this Coronavirus pandemic. Called to arms, they, the physicians, have gathered up their collective selves and hurled into the maelstrom with both feet. Like wilted twigs of winter turning into the stout blossoms of spring, physicians are by their very nature blossoms of humanity for all seasons. Quick on the learning, even quicker on the healing.

Their wisdom is derived from past leaders in medicine. When their science is carefully cogitated with their experiential references, voila a bouquet of therapeutic offerings emerges! Looking back at history, several notables took their cue from the human interaction with nature itself. Look for instance at Edward Jenner, after observing the benefit of cowpox stemming the risk of smallpox, he ventured into a trial vaccination of an 8-year-old boy delivering immunity to the child in Gloucester in 1757. He might have been vilified in this day and age for not doing a randomized controlled trial, but he manifestly saved millions of lives from the disabling and deadly disease. Another stalwart who lived in the same venous tributary of a thinker and doer named Barry Marshall. After many attempts to educate his fellow experts about the cause of peptic ulcers as not emanating from too much acid in the stomach but from a bacterium named Helicobacter Pylori, he failed to gain their support. He was ignored, then laughed at and finally given the gravity of his findings he had to drink a glass full of the H Pylori and develop an ulcer to prove his findings when organized medical science was forced to take notice of the causal nature of the disease.  He did receive the Nobel Prize for his findings eventually. 

Deep in our most convincing organ called intuition, there are many valves and levers of balance. The valves open to input from nature, from observations and the levers of balance, are the risks and benefits of using those observations as therapy. Doctors have long deployed this intuitive-complex, in their armamentarium to ascertain the best possible therapy for their patients. But over time a steady stream of complexity has overshadowed this modus operandi. The complexity craves for unending and at times valueless research that does little to advance the hypothesis but only to prove at the outset what was envisioned. We have come to a time where even large meta-studies are filled with the bias of the offering author. In the field of Oncology alone, for instance, data from one meta-analytic study revealed that only 11% of the “Landmark” studies were reproducible, verifiable or could be validated. That in itself is a damnable smudge on the progress of scientific evidence. But having said that, not all scientific data is reproachable. There are valid reasons to conduct studies in an organized manner so as to prove the benefit and lack of harm to the patient. That rigor, however, takes time. 

In the time of such panic when lives are being lost as now while facing a pandemic, the automatic response of RCT (Randomized Control Trial) as the only form of control to the use of potentially life-saving medication must need to withdraw. Even Anecdotal data that may reduce illness or thwart the disease from gaining a foothold and claiming more lives should be considered as an intuitive reason to forgo the strict complexity and delay of published “evidence.” If physicians in the battlefield against the pandemic are seeing the benefit and perhaps even through the colored lenses of their viewpoint, it is imperative that hurdles not be placed in their decisions. They are the frontline soldiers, not the commanders in a tent 100 miles behind. They see the ugliness of the fight; lives won and lost daily, while the commanders plot in the distant background. The wars are never won if the soldiers and their battalion leaders are forced to take a course of action that negates their intuition of the ebb and flow of the nature of the incoming fire. 

Hydroxychloroquine is a classic example of this new(old) potential armor against the current COVID19 pandemic. Several small “anecdotal” studies seem to validate the findings of this drug in conjunction with Azithromycin and possibly Zinc as having an influence on attenuating the course of this COVID19 induced illness within a human body. The data is mostly gathered in observational form and lacks the RCT of this vs. that to fit the Kaplan Meier curves. But this limited data even when viewed through rose-colored glasses suggest a potential benefit to some. When one adds the past common literature, which is found in abundance, that these drugs by themselves have few side effects, the common-sense test would be to use it in the earlier cases where the pulmonary cytokine storm has not yet overwhelmed the patient. Using it in late stages where the body’s immune surveillance has been overwhelmed, would be counterproductive and again looking to confirm biased belief. If Hydroxychloroquine (HCQ) can thwart the entry of the virus into the cell and within the cytoplasm, reduce the pH and prevent entry into the endoplasmic reticulum to prevent the replication of the virus based on basic scientific data, then it must be given the go-ahead as a treatment choice, especially when nothing else is available. Waiting for Godot is a fool’s paradise as is waiting for the results of a placebo-controlled trial. Waiting is not a wartime battlefield strategy given the urgency of the need. That these drugs are effective against COVID-19 has been proven in laboratory experiments. And now evidence is mounting that these drugs are working to decrease viral load in patients . Decreased viral loads mean patients not only avoid the hospital but are less infectious to others. This will decrease the burden on the healthcare system and upon the doctors and nurses that bear the ultimate responsibility of the patient’s care. In fact, India is officially considering health care professionals and family members of sick patients prophylactically take HCQ. The New York Times reports of a recent study: “Cough, fever, and pneumonia went away faster, and the disease seemed less likely to turn severe in people who received hydroxychloroquine than in a comparison group not given the drug.” More recently a Randomized Trial shows similar benefits as well.

Certain State Officials in various States have been misled into thinking that using HCQ + Azithromycin is removing the HCQ from the stockpiles needed to treat Malaria, Lupus or Rheumatoid Arthritis. For one, Malaria does not exist in the US, for another, the numbers of RA and Lupus patients do not require millions of doses that are already stockpiled. Officials should understand the urgent need of the patient and not the fancy of the stockpiled biases that exist when considering policies. For instance, the New Jersey Governor has placed a restriction on the use of HCQ, which is unfortunate. It bears on the thinking that perhaps using these relatively non-toxic medications by the physicians, nurses and first responders as a precaution just might prevent the loss of these front-line soldiers also. Empty virtue signaling of “for the public good,” while placing unnecessary constraints leads to harm and loss of life for both patients, their physicians, and nurses. As mentioned above, early treatment is crucial for keeping patients out of the hospital and off ventilators. Delaying treatment results in the opposite, more sick patients ending up in overburdened facilities. Besides, other State Governors of Nevada and Michigan, who formulated similar mechanisms of restrictions to the use of Hydroxychloroquine quickly reversed course, when seeing the burgeoning loss of life. If the restriction is to prevent hoarding of the medication, then perhaps using the Texas model of limiting the drug dosing for 10 days might be more appropriate. It prevents harm to our vulnerable, sick and infirmed patients and potential loss of life. 

In keeping with the oath of Hippocrates and in keeping with the welfare of our patients foremost, we physicians must not have arbitrary and capricious hurdles placed in front of us while treating and managing the patients who are struggling to gain a foothold on their lives against the Coronavirus. It is time to unshackle the constraints and allow physicians to heal the sick as they are trained to do.