Good discussion, wrong conclusion. I was a family doc in (antique) solo practice in an urban area for 35 years and I have an MPH and good knowledge of epidemiology. I always thought my random biopsy of life (smaller than an ER's) would give me good insight if I paid attention. Some years I was the first in the County to report a flu case; I reported and closed a restaurant causing an infectious diarrhea out break; I stopped using the Dalkon shield long before it was taken off the market; after a case I fought and persuaded our DPH to establish a TBC control program; I have seen tertiary syphilis, and back in the day before there were any tests I was dxing HIV.
That said, we live in a third world country: the CDC should be running population surveys of COVID incidence, so docs (and people at risk) should not be guessing or using intuition about actual risk and we would have valid information about when to maskup, etc.
Your fine essay lets responsible officials and politicians off the hook.
Thank you for posting this--and it makes me think! One thing I'll say is that not all observers are equally reliable and not all questioners are. For example, in my essay, I wrote that I always try to caveat my observations ("take this with a grain of salt") but then I'll see someone then later post about it saying things like, "My doctor friend said XYZ" and they've mischaracterized the *certainty* of my observation, if not the actual viewpoint I took.
I certainly do not mean to let anyone off the hook, nor do I think that anecdotes should not drive us to ask important questions. (Your examples are fascinating ones!) My aim is to have everyone be a little more careful with what they ask, how they answer, and what everyone does with that information.
I really appreciate your contribution here! Thank you for posting.
OMG, I would be less heated if it were not true that the USA with 4% of the world's population had 14% (I think I have the number right) of the world's known COVID deaths.
The deflection of the known epi facts early on, the lack of surge capacity, the lack of needed PPEs, the lack of effective anticipatory surveillance, the disparities in incidence and care, the lack of an effective distribution system for tests and vaccinations are all dramatic and tragic deficiencies, even if we did not have a lying idiot as President. The Profession of Medicine needs to stand up, head held high and proclaim we are used and abused, and we can and must do better.
Wow - amazing to see this comment (about the lack of surveillance by the US CDC)!
As someone not in medicine, it seems almost unbelievable an institution dedicated to public health avoids looking at one specific disease. One can find data about the prevalence of HIV, TB, and other diseases, but not the most prevalent serious infectious disease in the nation. We are reduced to looking at wastewater data which are certainly useful, but sparse and now given no case data, uncalibrated.
I hope you as a person with relevant credentials are able to continue to point out this situation.
I am glad you tuned in! Yes, you are totally right, it is unbelievable. Not only is the CDC poorly structured and dysfunctional in real time circumstances (it does well investigating and documenting after the fact), it is hugely underfunded and the Republicans want further budget cuts. We are all at risk and vulnerable. Americans should not stand for this.
As a hospitalist, I’ve always thought I might have a better chance at answering this question - at least with rates. When half of my list was COVID during 2020 and again at Delta, that was one thing. Then I didn’t see COVID for over a year- and then now I have 2-3 cases each day on my service. Suggests to me there’s either 1) more infections or 2) increased severity. I strongly suspect it’s number 1 based on how many people were sick over the past month. But anecdotally the COVID ones I’m seeing are the immune compromised and unvaccinated, and they do have severe disease. 🤷♀️
You are a major league super player in the game of medicine and making sense for us! Thank you AND how do we and by that I mean you and your superstar partner Benjy then make the “what to do” easier to discern. People are fatigued from COVID vaccines, they are miraculous and yet knock you down for a couple of days. Again better than actual disease but when you add getting a new vaccine every 6- 8 months public health must do better in developing vaccines that people can take once a year or not be so potent. Think shingles- my own Dr hasn’t had his yet as it’s not fun. Keep us informed as we love this news letter and the humans behind it.
Great essay. I'm not in medicine but am familiar with numbers. The answer is clear, no? Research. The US CDC is capable of amazing detective work when not being used for perceived political gain (and this is entirely non-partisan, or maybe "both partisan" assessment). For example, in reporting influenza numbers they make an educated guess at what the real numbers are instead of minimizing and hiding the state of the disease as they have with SARS-2.
I have to wonder what it's like internally. I like to think most of the people who work there want to make the world a healthier place and it must be painful to be prevented from doing their best work.
The book Merchants of Doubt is a great but unsettling read on how this can happen in science as it documents the details of the tobacco industries' war on the epidemiology of the smoking and cancer connection. Many prominent scientists were enlisted in the fight. Feels discouraging to see it happening again.
Dr. Faust, I complete agree with you, and the waste water monitoring should have jumped out to us a lot earlier than it did. Of course, this is assuming that the local and state officials want the information made public. We lived in FL during the beginning of the pandemic before realizing that the FL state government was at odds with public health transparency. FL survives on sales tax revenues, no personal income tax, and property taxes from real estate sales. As soon as the governor realized that keeping the state locked down was going to tank state tax revenues and tourism and real estate sales, he manipulated county reporting of hospitalizations and death certificates coming from county coroners. He made vaccinations and Covid a political issue and a lot of people died as a result of poor vaccination rates in FL and other states. We sold our house and left the state. Other red states did the same thing as FL did, so the data on a national level is a mess. It is doubtful that we'll ever know the extent of the infections and the deaths.
So, just to be clear, are we talking virulence or severity in term of impact? Nothing wrong with observational information as long as we recognize the limitations but it does inform us. I recall an study in Hong Kong that concluded the virulence has not changed since ancestral/delta dominance. I do see contagiousness and transmissibility as measures of severity. Originally, the theory that pathogens over time become less virulence but observations have cast doubts on this. I am inclined to believe that virulence has not changed just by looking at the number of deaths that is still occuring. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10066022/
So, over time, pathogens are highly favored by evolutionary principles to become more infectious (or to mutate so as to be able to break through barriers which try to prevent infection, including antibodies from prior infections and vaccines). However, there is no particular evolutionary pressure for them to become more or less severe once they infect a person *provided* that they do not incapacitate the host so greatly (or kill) so as to render spread impossible. A dead person (or a person who is literally in bed with no visitors) does not spread disease.
The “perfect” pathogen from the standpoint of *its own survival* would be: extremely contagious while causing the host zero harm.
Basic evolutionary principles, yes, but I am referring to the use of severity which I am trying to get clarity. According to the "law of declining virulence" suggested by Dr. Theobald Smith in the 1800's, we since learned that viral evolution is bit more chaotic than this. So, is severity is about virulence (lethality) or contagiousness/infectivity?
I would think the ED would be a good gauge, because you know what you’re admitting and sending home day in and day out and if you’re not admitting much COVID it should stand out.
Yes, in fact the Omicron wave discussion above is a very good example of that.
That said, these days, Covid can look like everything *but* "classic covid pneumonia" that we saw non-stop in 2020 and early 2021. So, we'll admit someone with a diabetic crisis. We'll get the covid test. The result may come back 4-12 hours later--by which time they're upstairs on the inpatient unit. So, we never know unless we follow up those cases. As a result, we sometimes have a really good view on things, and other times, not so much.
I was unfamiliar with this. But the description rings true. I'm doing an interview for some convention next month and one of the discussion points is how I think we should be reading research (and conducting our own). The needle of skepticism should err towards "hard to impress," as I know you agree! However, we also can't be too rigid.
Something my research team is very good about is doing a lot sensitivity analyses. That is, asking the same question a bunch of different ways to make sure that the answer comes out the same no matter how you slice/dice. It's not perfect, but it helps.
I think people are asking because there is an information vacuum. We are in a surge of COVID ( and flu and other respiratory illnesses), but only have waste water data and some slow and incomplete data on hospitalizations and deaths. The major hospital systems in Rhode Island and Massachusetts have quietly reintroduced masking but the source of their data is not clear. Personally I think it’s driven by staffing outages as much as illness prevalence. So we turn to clinicians and ask what you’re seeing.
That is such a good point. For me, I always think about this: Is what I am seeing anecdotally similar or very different from what data are telling me. If they align, we are often in great shape (though still, can be wrong!). If they don't, I stop to think about why that might be. Anecdote and "big data" don't always have to agree for them both to be true. But it's certainly reassuring to the anecdote if they do.
I agree. The governments at all levels are not supporting continued Covid testing and preventative measures so people are on their own. They ask the medical community for guidance, but the business of hospitals is different than community health care. Hospitals need to keep staff coming to work, so they balance keeping staffing levels secure against community health care and presently no one is reliably collecting the data to give the public any sense of reality. The Feds gave up months ago and in an election year, Covid protections are not returning. No one wants to hear about it anymore. A surge in hospitalizations and deaths may change this, but then it’ll be just looking around at whom to blame. We are not good at preparation for disasters. And, we are getting worse at cleaning up the messes after they have occurred.
I'm of the opinion that more information is better. I think Jan's point above is well stated. The questions are asked because the answers are missing! In my view it's better to up the ante on public information, just like you're saying. It's nice to see wastewater become a thing (for Covid and other pathogens). Crazy to think we didn't have this before and underutilize it now!
Eric Tool recently was quoted in The Boston Globe in response to a message from the administration from 2020 that when they came into office "the pandemic was raging" and he replied--"it still is". The vaccine only strategy is not working well and there's a void of information and public health has been dismantled. Very discouraging. His recent sub stack has a link to his op ed for the LA Times: https://erictopol.substack.com/p/sotp-state-of-the-pandemic
I think there's always the question of scale. "Still raging" and "not nearly as bad as pre-vaccine days" are both true. When I think of how awful it was, I am glad we are not in 2020. But I also did not think we'd still have excess mortality in parts of 2023, which we did--to say nothing of the other outcomes.
Good discussion, wrong conclusion. I was a family doc in (antique) solo practice in an urban area for 35 years and I have an MPH and good knowledge of epidemiology. I always thought my random biopsy of life (smaller than an ER's) would give me good insight if I paid attention. Some years I was the first in the County to report a flu case; I reported and closed a restaurant causing an infectious diarrhea out break; I stopped using the Dalkon shield long before it was taken off the market; after a case I fought and persuaded our DPH to establish a TBC control program; I have seen tertiary syphilis, and back in the day before there were any tests I was dxing HIV.
That said, we live in a third world country: the CDC should be running population surveys of COVID incidence, so docs (and people at risk) should not be guessing or using intuition about actual risk and we would have valid information about when to maskup, etc.
Your fine essay lets responsible officials and politicians off the hook.
Thank you for posting this--and it makes me think! One thing I'll say is that not all observers are equally reliable and not all questioners are. For example, in my essay, I wrote that I always try to caveat my observations ("take this with a grain of salt") but then I'll see someone then later post about it saying things like, "My doctor friend said XYZ" and they've mischaracterized the *certainty* of my observation, if not the actual viewpoint I took.
I certainly do not mean to let anyone off the hook, nor do I think that anecdotes should not drive us to ask important questions. (Your examples are fascinating ones!) My aim is to have everyone be a little more careful with what they ask, how they answer, and what everyone does with that information.
I really appreciate your contribution here! Thank you for posting.
OMG, I would be less heated if it were not true that the USA with 4% of the world's population had 14% (I think I have the number right) of the world's known COVID deaths.
The deflection of the known epi facts early on, the lack of surge capacity, the lack of needed PPEs, the lack of effective anticipatory surveillance, the disparities in incidence and care, the lack of an effective distribution system for tests and vaccinations are all dramatic and tragic deficiencies, even if we did not have a lying idiot as President. The Profession of Medicine needs to stand up, head held high and proclaim we are used and abused, and we can and must do better.
Wow - amazing to see this comment (about the lack of surveillance by the US CDC)!
As someone not in medicine, it seems almost unbelievable an institution dedicated to public health avoids looking at one specific disease. One can find data about the prevalence of HIV, TB, and other diseases, but not the most prevalent serious infectious disease in the nation. We are reduced to looking at wastewater data which are certainly useful, but sparse and now given no case data, uncalibrated.
I hope you as a person with relevant credentials are able to continue to point out this situation.
Thank you.
I am glad you tuned in! Yes, you are totally right, it is unbelievable. Not only is the CDC poorly structured and dysfunctional in real time circumstances (it does well investigating and documenting after the fact), it is hugely underfunded and the Republicans want further budget cuts. We are all at risk and vulnerable. Americans should not stand for this.
As a hospitalist, I’ve always thought I might have a better chance at answering this question - at least with rates. When half of my list was COVID during 2020 and again at Delta, that was one thing. Then I didn’t see COVID for over a year- and then now I have 2-3 cases each day on my service. Suggests to me there’s either 1) more infections or 2) increased severity. I strongly suspect it’s number 1 based on how many people were sick over the past month. But anecdotally the COVID ones I’m seeing are the immune compromised and unvaccinated, and they do have severe disease. 🤷♀️
You are a major league super player in the game of medicine and making sense for us! Thank you AND how do we and by that I mean you and your superstar partner Benjy then make the “what to do” easier to discern. People are fatigued from COVID vaccines, they are miraculous and yet knock you down for a couple of days. Again better than actual disease but when you add getting a new vaccine every 6- 8 months public health must do better in developing vaccines that people can take once a year or not be so potent. Think shingles- my own Dr hasn’t had his yet as it’s not fun. Keep us informed as we love this news letter and the humans behind it.
Great essay. I'm not in medicine but am familiar with numbers. The answer is clear, no? Research. The US CDC is capable of amazing detective work when not being used for perceived political gain (and this is entirely non-partisan, or maybe "both partisan" assessment). For example, in reporting influenza numbers they make an educated guess at what the real numbers are instead of minimizing and hiding the state of the disease as they have with SARS-2.
I have to wonder what it's like internally. I like to think most of the people who work there want to make the world a healthier place and it must be painful to be prevented from doing their best work.
The book Merchants of Doubt is a great but unsettling read on how this can happen in science as it documents the details of the tobacco industries' war on the epidemiology of the smoking and cancer connection. Many prominent scientists were enlisted in the fight. Feels discouraging to see it happening again.
Dr. Faust, I complete agree with you, and the waste water monitoring should have jumped out to us a lot earlier than it did. Of course, this is assuming that the local and state officials want the information made public. We lived in FL during the beginning of the pandemic before realizing that the FL state government was at odds with public health transparency. FL survives on sales tax revenues, no personal income tax, and property taxes from real estate sales. As soon as the governor realized that keeping the state locked down was going to tank state tax revenues and tourism and real estate sales, he manipulated county reporting of hospitalizations and death certificates coming from county coroners. He made vaccinations and Covid a political issue and a lot of people died as a result of poor vaccination rates in FL and other states. We sold our house and left the state. Other red states did the same thing as FL did, so the data on a national level is a mess. It is doubtful that we'll ever know the extent of the infections and the deaths.
So, just to be clear, are we talking virulence or severity in term of impact? Nothing wrong with observational information as long as we recognize the limitations but it does inform us. I recall an study in Hong Kong that concluded the virulence has not changed since ancestral/delta dominance. I do see contagiousness and transmissibility as measures of severity. Originally, the theory that pathogens over time become less virulence but observations have cast doubts on this. I am inclined to believe that virulence has not changed just by looking at the number of deaths that is still occuring. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10066022/
So, over time, pathogens are highly favored by evolutionary principles to become more infectious (or to mutate so as to be able to break through barriers which try to prevent infection, including antibodies from prior infections and vaccines). However, there is no particular evolutionary pressure for them to become more or less severe once they infect a person *provided* that they do not incapacitate the host so greatly (or kill) so as to render spread impossible. A dead person (or a person who is literally in bed with no visitors) does not spread disease.
The “perfect” pathogen from the standpoint of *its own survival* would be: extremely contagious while causing the host zero harm.
Basic evolutionary principles, yes, but I am referring to the use of severity which I am trying to get clarity. According to the "law of declining virulence" suggested by Dr. Theobald Smith in the 1800's, we since learned that viral evolution is bit more chaotic than this. So, is severity is about virulence (lethality) or contagiousness/infectivity?
I would think the ED would be a good gauge, because you know what you’re admitting and sending home day in and day out and if you’re not admitting much COVID it should stand out.
Yes, in fact the Omicron wave discussion above is a very good example of that.
That said, these days, Covid can look like everything *but* "classic covid pneumonia" that we saw non-stop in 2020 and early 2021. So, we'll admit someone with a diabetic crisis. We'll get the covid test. The result may come back 4-12 hours later--by which time they're upstairs on the inpatient unit. So, we never know unless we follow up those cases. As a result, we sometimes have a really good view on things, and other times, not so much.
Your analysis fits with Julia Galef's approach detailed in the The Scout Mindset https://www.goodreads.com/en/book/show/42041926 which it appears you may be familiar.
I was unfamiliar with this. But the description rings true. I'm doing an interview for some convention next month and one of the discussion points is how I think we should be reading research (and conducting our own). The needle of skepticism should err towards "hard to impress," as I know you agree! However, we also can't be too rigid.
Something my research team is very good about is doing a lot sensitivity analyses. That is, asking the same question a bunch of different ways to make sure that the answer comes out the same no matter how you slice/dice. It's not perfect, but it helps.
I think people are asking because there is an information vacuum. We are in a surge of COVID ( and flu and other respiratory illnesses), but only have waste water data and some slow and incomplete data on hospitalizations and deaths. The major hospital systems in Rhode Island and Massachusetts have quietly reintroduced masking but the source of their data is not clear. Personally I think it’s driven by staffing outages as much as illness prevalence. So we turn to clinicians and ask what you’re seeing.
That is such a good point. For me, I always think about this: Is what I am seeing anecdotally similar or very different from what data are telling me. If they align, we are often in great shape (though still, can be wrong!). If they don't, I stop to think about why that might be. Anecdote and "big data" don't always have to agree for them both to be true. But it's certainly reassuring to the anecdote if they do.
I agree. The governments at all levels are not supporting continued Covid testing and preventative measures so people are on their own. They ask the medical community for guidance, but the business of hospitals is different than community health care. Hospitals need to keep staff coming to work, so they balance keeping staffing levels secure against community health care and presently no one is reliably collecting the data to give the public any sense of reality. The Feds gave up months ago and in an election year, Covid protections are not returning. No one wants to hear about it anymore. A surge in hospitalizations and deaths may change this, but then it’ll be just looking around at whom to blame. We are not good at preparation for disasters. And, we are getting worse at cleaning up the messes after they have occurred.
I'm of the opinion that more information is better. I think Jan's point above is well stated. The questions are asked because the answers are missing! In my view it's better to up the ante on public information, just like you're saying. It's nice to see wastewater become a thing (for Covid and other pathogens). Crazy to think we didn't have this before and underutilize it now!
Eric Tool recently was quoted in The Boston Globe in response to a message from the administration from 2020 that when they came into office "the pandemic was raging" and he replied--"it still is". The vaccine only strategy is not working well and there's a void of information and public health has been dismantled. Very discouraging. His recent sub stack has a link to his op ed for the LA Times: https://erictopol.substack.com/p/sotp-state-of-the-pandemic
I think there's always the question of scale. "Still raging" and "not nearly as bad as pre-vaccine days" are both true. When I think of how awful it was, I am glad we are not in 2020. But I also did not think we'd still have excess mortality in parts of 2023, which we did--to say nothing of the other outcomes.