Dedicated to the exhausted army of doctors, nurses, and ancillary workers who have woken up in many countries to another endless day of struggle against a faceless epidemic. And particularly to those who relax reading Anglo-Saxon poetry.
From The Battle of Maldon, ca. 1000 CE. The Saxon war-leader Byrhtnoth has been killed and his band is losing the battle to the Viking invaders; some Saxons have run away. His old retainer Byrhtwold speaks to the remnant standing fast. Try reading it aloud to catch the alliteration. The letter þ is a voiced “th”. [Update: sound file on YouTube.]
In his day, there were few hospitals. Most people were born, went to their beds when they fell sick, recovered a few times, and finally died, all in their own homes. It wasn’t much different in 50,000 BC. Hospitals were for the few mobile categories: soldiers, seamen, merchants, pilgrims. Paré would have done most of his surgery in tents in the rear of the battlefield.
The hospital, as a temple of scientific medicine, is a 19th-century invention. The Dr. House TV series offers an exaggerated but basically fair image of its ethos. The model is badly adapted to a massive epidemic of nearly identical cases. In parts of Lombardy, hospitals have been overwhelmed, and resorted to triage. The older arrivals with preexisting conditions have reportedly sometimes been left in corridors to die with minimal palliative care. Ethically, this is not really problematic; in human terms, it is horrific. The same is very likely to happen in many other countries, including the UK and the USA (here, report 9).
I am 73 with asthma. I therefore have a personal stake in this problem, which has started to arise in Madrid. The army are setting up large improvised field hospitals. This fixes the bed shortage, and I trust that crash programmes are under way to make respirators and masks, but you can’t create qualified nurses in a few weeks.
So you enlist unqualified ones. Go back to the 18th century, and ask family members to care for the sick at home. Patients who fail the hospital triage would be sent home with a Happy Care package, including an army or airline-issue respirator, a bottle of oxygen, a box of antibiotics and opioids, a bedpan, a one-page guide, and a Skype helpline.
Every medical professional from Florence Nightingale to Geoffrey House will be shocked by this unprofessional atavism. But the objections are readily answered.
1. Half or more will die! Sure. The basis of comparison is not best or even average hospital practice, but the horrid reality of the triage corridor. At the very least, the sick will die with more dignity and human warmth.
2. The potential carers have to go out to work. Not just now they don’t.
3. The patients will infect the carers. They are already infected.
4. Not every patient has potential home carers physically and mentally fit enough to do the job. Absolutely. Home nursing is only part of the solution. That’s why we also need the army field hospitals. I can’t guess the relative numbers here.
An additional twist to this plan is that there is a rapidly expanding cohort of asymptomatic or recovered people with immunity, who are potentially available to support others, though home nursing assistance among other ways. In Veneto province in Italy, which has tested heavily, about 8% of the population tests positive, two-thirds without symptoms or nearly so.
If it comes to such a choice for me, I would take the home solution over the corridor. I don’t know what Lu thinks.
I really would like to know what the heirs of Florence and Ambroise make of this. If anything on these lines is the way forward, or even a last-ditch fallback, it has to be planned for.
It’s not often one gets the chance and obligation to say this. Brad DeLong :
Note to Self: Is there anything wrong with this analysis? With 14 deaths in the U.S., a 1% death rate, and 4 weeks between infection and death, that means that as of Feb 8 there were 1400 coronavirus cases in the United States. If it is doubling every seven days, then now about 22,000 people have and in the next week about 44,000 people in the U.S. will catch coronavirus. These numbers could be five times too big. These numbers could be five times too small. But with only 1 in 10,000 currently affected, it seems 4 or 5 weeks early to start imposing serious geographical quarantines …
No, no, no. R is not a function of the number of cases. It is only a function of herd immunity and the individual chance of transmission.
The condition for the decline and fall of the epidemic is lowering R below 1. There are two paths to this. Call them the Trump policy and the Xi policy.
Under the Trump policy of malign neglect, the virus spreads until most of the potential transmittees of the virus have recovered from it and are immune. Meanwhile, the cemeteries have filled up with those who didn’t recover. 200,000? 480,000? 1.7 million, if the hospitals collapse and the treatment is back to Black Death standards? The epidemic expires from satiety.
Under the Xi policy (also now the Moon, Conte, Sanchez, and Merkel policy), the state cuts the opportunities for transmission, including quarantines as well as contact tracing and mass preventive screening. The cost of this, direct and indirect, is fixed and independent of the number of cases. Imagine a perfect lockdown in which everybody stays in their house or flat, living out of tins by candlelight, for a fortnight: end of epidemic. This can’t be done perfectly of course, so real outcomes are a risk distribution, but you can get pretty close, as Singapore and Taiwan have shown. The death toll is still 1% or 1.6% or whatever of those infected.
It is lower the earlier you start the policy. Starting when the diagnosed cases are in the thousands, as seems to be the political trigger, looks as if it might limit ultimate deaths also to the thousands or tens of thousands. QED.
A more picturesque way of looking at this is from the point of view of the virus. It’s a clone army of dumb replicants with no leader and a single mission: reproduce. For the Virus Army as a whole, a pandemic is a death ride. At the end of it they will all be dead, apart from the small source population living quietly in non-fatal parasitism with its animal hosts. The fun part is how many non-standard hosts they can kill along the way.
No zoom in on the virus commando that has infiltrated a single human host, you. The commando is doomed. In 14 days, either you are dead (end of viruses) or your immune system has destroyed them all and you are recovered (end of viruses). Their only hope for reproduction is for some members of the commando to jump ship and invade another disarmed host. The jumping ship is nearly always fatal, as the viruses can only survive a few hours outside a host. They have no independent motility and are dependent on cooperation by the hosts: handshakes, kisses, cough aerosols, unwiped door handles. Reduce that cooperation, and the survival odds for SEAL Team Virus drop to almost nothing. That, in essence, is the Xi policy: and it works.
I frequently hear the claim that “doctors have just stopped prescribing opioids”. The truth is that U.S. doctors prescribe fewer opioids than they did 5 years ago, but the U.S. still dwarfs the world in its per capita prescribing even among the heaviest prescribing nations. For details, see my latest piece at The Washington Monthly.
The literature seems stronger on indoor air pollution than outdoor. Second-hand tobacco smoke is a culprit, as are wood fires and incense. I found a serious controlled Taiwanese study on indoor pollution making the link. The effect of outdoor pollution has been less studied for animals. One Mexican study creepily found similar lesions in the brains of big-city dogs to those found in humans with Alzheimer’s.
It seems safer just to rely on the parallelism in the symptoms and mechanisms of cat and human asthma, and the massive literature connecting the human form to air pollution, to conclude that all air pollution is bad for cats too. The effect is reinforced by the height difference: cats and dogs breathe in air at car exhaust level.
This hypothesis suggests a political strategy. In the USA, there are said to be 49.2 million households with a cat. There are 50.4 million with children under 18. That’s 39% each. I couldn’t find a combined breakdown, but let’s assume that the two are independent. That would give 30 million childless households with a cat. The real total will be different, but it’s still a very large number.
skews old, white and therefore Republican. It cares for its cats. It
strikes me as a good argument to make to this group in favour of the
energy transition and the GND that the policy will protect the health
of their pets.
Some will say: this
is ridiculous. Are there really a non-trivial number of voters who
will be swayed by the health of cats but not the health of children?
If there are, surely they are either “low-information voters” –
idiots – or moral imbeciles, and lost causes in either case?
My answers are (a)
quite likely and (b) no.
Let me make the case
for the defence. The questions are linked by the broader issue of
“We see a 4 percent increase in the risk of cancer even at 15 grams a day, which is a single slice of ham on a sandwich,” said Dr. Nigel Brockton, director of research for the American Institute for Cancer Research. Eating a more typical serving of 50 grams of processed meat a day would increase the risk of colorectal cancer by 18 percent, a 2011 review of studies found.
What does this really mean? Lifetime risk of colorectal cancer is about 1 in 23, or a little over 4%. Now, does that slice of ham double your risk (4% to 8%), or merely increase it from 4.3% to (1.04*.043 = .045), 4.5%? Do a full fifth (18 + 4 = 22) of the 50-gram noshers get these specific cancers? Of course not. The quote, and the story, are completely ambiguous, but if you follow the link, you find that the data are relative risk values, which is the second interpretation. 50 grams a day entails about a 1% extra risk, and that’s not even counting all the people already in the 4.3% who eat deli meat and get cancer. If you do, and you stop, your risk of these cancers goes down from about 4% to…a little more than 3%. Perhaps Zabar’s should sue the Times over this alarmism.
Eating a reasonable amount of these exceptionally yummy foods seems to me a good deal, at the price of being 1% more likely to get this type of cancer before I get one of the other kinds or a heart attack. YMMV, of course. Everyone dies of something, so a much more useful statistic would be the average number of [quality adjusted ?] life years I’m putting at risk from a ham habit, and from an occasional indulgence.
The lesson here is that any statistics involving percentages have to be stated carefully to make it clear whether an increase adds to an existing rate or multiplies it, and “X% added risk” simply doesn’t cut it. Dr. Brockton and the reporter are equally at fault here, along with the Times copy editor. Students and colleagues: don’t make this mistake, especially when you’re explaining science to the public. What Dr. Brockton meant to say is that “the 15g pigout habit raises your lifetime risk from 4 to 5%”. There’s no escaping the additional words. Or reporting base rates: something that “quadruples your risk of contracting the gleeps” is not a big deal if the incidence of gleeps is a fraction of a percent.
Lessons of the great row in the Cochrane collaboration.
Want a change from watching the turds circle the drain in the Kavanaugh confirmation circus? Let me bring you a nasty academic spat between high-minded medical researchers. This is how learned gentlemen stab each other in the back! With a couple of serious morals. Everybody named below is a highly credentialed professional; I leave the titles out to avoid repetition.
The milieu is the Cochrane collaboration. Inspired by and named after the epidemiologist Archibald Cochrane (d. 1988), the Cochrane people promote evidence-based medicine through meta-analyses of randomised clinical research trials using methods as rigorous and objective as they can make them. (Our own Keith Humphries has been a Cochrane reviewer.) [Update] The very solid proposition is that if you can analyse correctly a handful of properly conducted trials, you are in effect adding the sample sizes, so you can draw much more statistically reliable conclusions than by cherry-picking one. There is of course a lot of art here behind “correctly”, “properly”, and “in effect’. [/update] They are not the only researchers carrying out meta-analyses, but a Cochrane review is widely regarded as the gold standard. Depressingly often, the answer is “we don’t know”.
One recent Cochrane review (lead author Marc Arbyn) was on vaccines against human papilloma virus (HPV), which causes much cervical cancer among women and lesser numbers of anal and penile cancers in men. This is not a trivial health issue. Fortunately there are vaccines sold by Merck (Gardasil) and GSK (Cervarix). Do these work? Short answer: yes. Are they dangerous? Short answer: no. (Please DO NOT quote me, read and cite the report, they do provide a summary for dummies.)
So far so routine. But then an article was published in the journal BMJ – Evidence-Based Medicine by Lars Jørgensen, Peter Gøtzsche, and Tom Jefferson, alleging that the vaccine review was sloppy on several counts and hinting that it was influenced by pressures from the Big Pharma vaccine vendors. (Note that while they argue that the side-effects are greater than the review says, the critique does not recommend stopping or curtailing vaccination programmes.) This naturally provoked a rebuttal from the Cochrane management (David Tovey and Karla Soares-Weiser), saying the criticism is wrong on all counts.
It did not stop there. Gøtzsche is, or rather was, a member of the Cochrane board, indeed a founder member of the organisation. He could presumably have raised his concerns there first rather than publicly. After a presumably furious board meeting, Gøtzsche was expelled and four other board members quit. The great collaboration is now in existential danger. Will donors, including the Gates Foundation, keep the funding flowing? Will Gøtzsche set up a breakaway fitzCochrane, applying his own higher standards? Will anti-vaxxers and misogynists exploit the row to attack the vaccination campaign? Only 27 % of American men under 26 are vaccinated.
It’s important that the crisis be resolved quickly and the collaboration continue. There’s not much outsiders can do to help this in the short term, and I am quite unqualified to take sides. I have though one reflection and one suggestion for the future. Continue reading “Evidence-based catfighting”
Lenny Bernstein of Washington Post moderated this panel with Vanda Felbab-Brown, me, and Pagan Harleman. The audience and panelists had just watched the first episode of Pagan’s Showtime documentary series The Trade.
But “not taking action” now means continuing to criminalize even the possession of cannabis. If cannabis substitutes for opioids, those laws cost lives: lives that can’t be regained ten years from now, after the clinical-trial results are in.
We all learnt to walk very young, normally in the second year of life. It’s completely automatic. Severely neglected babies in orphanages ( update – assuming they are physically normal, see comments /update) get up on their feet and walk (Bowlby, 1952, page 20) just as soon as the adored princelings of modern parents, who cheer on every step with praise and console with hugs after every fall. As with any self-taught skill, our methods are approximate, and we stick with what works.
Skills acquired like this can often be improved. Here is a tip sheet from British sports scientist and walking guru, Joanna Hall.
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