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Overview: A lot has happened since I mailed the second COVID-19 newsletter three weeks ago.  At that point in time, the worst had not hit New York City.  New York survived.  However, as of this date, NYC has had over 10,000 deaths. 

COVID-19 is a paradoxical disease.  It is at the same time benign for the majority of people, and deadly for a few.  It attacks the obese and the chronically ill.  It largely spares children.  No other virus we have seen behaves this way. 

Though many have died in NYC, and though it has nearly crippled their healthcare system, national projections of the number of hospitalizations and deaths was vastly overestimated by the disease models from the University of Washington.  Initial projections were that we might experience 2.5-million deaths from COVID-19 in the United States.  That number has been revised downward to 60,000, which is just 2.4% of the original projected death toll.  How could the models be off by so much?  The answer is simple:  Bad data.  Put unreliable data into a model that makes lots of assumptions and you will get bad projections out of that model. 

This error in estimation of the severity of the disease has resulted in skepticism about expert opinion.  The sentiment of many of my patients is that we appear to be sailing on a ship without a rudder.  They are concerned that “the cure may be worse than the disease.” Dr. Fauci and Dr. Birx seem like honest, dedicated professionals. But their catastrophic projections have not even come close to occurring.  And the relatively low number of deaths is not due to mitigation and social distancing, because these things were built into the models.  The truth is that all of these experts were flying by the seat of their pants from the beginning.  The data they were using from China, Italy and other places was flawed. 

The Economic Fallout:  The epidemiologists and public health experts that we have seen on TV are sincere, good people.  Their initial recommendation for a limited period of social distancing to flatten the curve was reasonable.  The goal was to prevent our hospital systems from being overwhelmed.  But these experts have a unidimensional view of this problem and some are now hinting at longer periods of economic shutdown.  They appear to be focusing solely on the number of deaths attributable to COVID-19, to the exclusion of deaths due to other diseases and cost of life associated with unemployment or even a major depression.    

The economy is tanking.  As of the writing of this 3rd newsletter, 22-million people have filed for unemployment in just four weeks.  Fifty percent of restaurants in California have closed permanently and will not reopen.  We are entering depression level territory for unemployment. Retirement income is being wiped out.  These are catastrophic events that will have far-reaching effects on the mental and physical health of our people.     

The Medical Fallout:  The economy has not been the only casualty of “mitigation” and “social distancing.”  Patients with other medical problems have suffered.  Surgeries have been postponed.  Chronically ill people have been afraid or unable to see their doctor.  All “elective procedures” have been cancelled.  And the word “elective” is in the eye of the beholder.  Women with breast cancer in some cities are awaiting surgical dates for treatment.  Hip and knee replacements are on hold.  During the peak of the epidemic in NYC, EMTs and paramedics were told not to bring cardiac arrest victims to the ER if patients could not be resuscitated in the field, because there were no available ER doctors to run a cardiac arrest.  How many people have postponed medical visits to their doctor, either missing or delaying diagnoses that might have serious consequences?  We will never know for sure.  We have never shut down our medical system like this to singularly deal with one medical problem. 

So, do the experts know what they are talking about?  Every day, during the daily COVID-19 briefings, we are presented with graphs, charts and numbers.  These props have the patina of science.  Most people glaze over when this information is presented, but it gives the “experts” a sense of legitimacy.  However, most of the numbers behind these graphs and charts are flawed, due to problems in testing accuracy to date and the complete lack of “denominator data,” the number of people infected with mild or asymptomatic disease.  This is why the models have been so inaccurate. 

It is important to understand that even on a good day, most medical models are only rough projections of what might happen.  According to an article in the WSJ on April 19, 2020, medical modelers are concerned that there will be a backlash against them when this is over.  In that article, Keith Neal, a professor in the epidemiology of infectious diseases at the University of Nottingham said, “Any model that gets within 50% of the actual result has done well.” He said, “It is not an exact science.” I would argue that medical modeling is not science at all.  It is an educated-guess; speculation, based upon available data.

The data coming from China has been manipulated by the Communist party and it is completely unreliable.  China just magically increased the death toll from Wuhan last week by 50%.  How does that happen?  Not only did the Communist Chinese lie about the number of deaths in Wuhan, their testing was completely unreliable.  The Chinese recently sold millions of COVID-19 tests to several European countries.  These tests were evaluated by scientists at Oxford and they were deemed useless.  The Europeans are demanding their money back from China for these tests.  So, if you start with bad data, you cannot possibly predict the future, no matter how good the model might be in theory. 

The testing debacle in the United States:  Originally, the CDC decided to develop their own tests for the virus, as opposed to partnering with the private industry.  This turned out to be a huge mistake.  The story is not pretty.  We lost precious weeks during this initial period of the COVID-19 outbreak in this country, when we could have been collecting reliable data of our own.  The project of testing is no longer in the hands of the government. 

Is there any reason for optimism?  Yes!  I’m glad you asked.  As Kim Strassel has reported in the Wall Street Journal, one thing that was done right after the CDC botched the testing was for the Task Force to get private industry involved to partner with government on testing, building ventilators, and making PPE.  And just last week, two private companies, Abbott Laboratories and Roche released excellent tests for COVID-19.  These tests are extremely accurate, which is what we have needed from the beginning. 

I was initially very skeptical of these tests from Abbott and Roche, because the manufacturers did not release any data regarding accuracy.  However, independent researchers from the University of Washington virology lab have been working 24/7 to determine the accuracy of these tests.  They have concluded that the Abbott test is “100% accurate,” with a sensitivity of 100% and a specificity of 99.6%.   This accomplishment is nothing short of miraculous in such a short period of time.  And it should inspire us to see some remaining sparks of American ingenuity in this time of crisis.

Regarding getting reliable to better understand this disease, this week begins the first week of reliable data collection.  For the first time, we will be collecting meaningful data so that we can get a handle on how many people in a given community have had mild or asymptomatic infections.  We will be able to get a true mortality rate for this disease.  And though we cannot know how long immunity will last, if people have antibodies, they should feel a sense of comfort that their body has already seen the virus and handled it without consequences.    

So Why Do Some People Get Deathly Ill?  We don’t really understand that mechanism of this disease yet.  When COVID-19 infects the lungs, it does not behave like other viral pneumonias.  Depending on the city where you live, once you go on a ventilator, your mortality is somewhere between 50% and 80%.  Pulmonary specialists have had to change the way that they use ventilators, because patients don’t respond the way that normal acute respiratory distress patients respond.  There is so much about this disease that we still do not understand.  Why are the obese so vulnerable to this virus?  We don’t know.  We’ve never seen this with other viral infections. 

What about drugs?  Remdesivir has shown some promise in preliminary analysis, but we still don’t know how good it is or when people should be treated in the course of their disease.  Should people be treated early or only if they are hospitalized?  Hydroxychloroquine and azithromycin?  We are still waiting on reliable data, even as many people are being treated with this drug regimen. 

What are we to do about the economic destruction?  When do we reopen the country?  One suggestion I have would be to stop treating our epidemiologists as the sole experts in this complex problem.  I believe that what Dr. Fauci and Birx are smart people.  But they are not economists.  It is not their job to think about the number of lives that will be lost by having 22-million people immediately unemployed.  This is a multidimensional problem.  But experts, by definition, operate in a limited area of expertise.  And when these experts come from big name institutions, their opinions carry a lot of weight. 

Last week, MIT released a new COVID-19 model to much fanfare, which predicted an “exponential explosion” in COVID-19 cases if the nation’s lockdown measures are lifted too early.  Okay.  Maybe this model is better than the University of Washington model, even though MIT does not have reliable data about this how this disease behaves.  But where is the computer model from MIT estimating the number of deaths that will result from cancelling all “elective medical procedures” or routine medical visits for months at a time?  Where is the MIT model on the number of deaths expected from a global recession or depression?  What about the consequences of unemployment, such as substance abuse, divorce, child abuse and suicide?  AGAIN, THIS IS NOT A UNIDIMENSIONAL PROBLEM.  You can’t focus exclusively on the number of people who will die from COVID-19 if we reopen the economy, without regard to the other consequences of this decision. 

You are going to have to chart your own course:  What all this information means to you as an individual is that you are going to have to do your own risk/benefit analysis and behave accordingly.  You can’t rely on experts alone.  If you are going to wait for a safe environment before you resume your public life, this will only happen in two situations:  If herd immunity develops through natural spread of the disease or if scientists develop a good vaccine.  These are the only ways to “return to normal.”  If you are betting on the vaccine, you will likely be waiting 18-24 months, and even then, we’ll have to see how effective that vaccine it is.  If you are elderly or chronically ill, you may want to play it on the safer side.  If you are younger, you may not want to stay locked up until it is safe to come out and play.    

What I am doing in my office:  As for my medical office, I am now opening up to anyone who wants to come in for regular visits and physicals.  And to protect my higher risk patients, I am implementing some innovative safety measures to reduce the risk of infection.  This week, Marshall Dennington of Temco Air Environmental will begin construction of a negative pressure exam room in my office.  This is the kind of room used in hospitals for COVID-19 patients and other infectious patients.  This room will continuously exhaust used air to the outside and recirculate fresh air.  Temco has already installed two ultraviolet air purifiers on our HVAC systems to kill airborne pathogens.  We will also be installing HEPA filters, defined as “high-efficiency particulate air” filters. 

I have made the professional decision, based upon current information, that I am not going to operate a unidimensional medical practice.  I do not think it is in your best interests to have you stay away from the office and ignore your chronic medical problems until there is herd immunity in Tucson or until the entire city is vaccinated in two years.  I have people with serious diseases.   I cannot pretend that the only threat they face is possibly getting COVID-19.  If people want to stay away from the office, I will respect their decision and that is fine with me.  I will be available to those folks for emergencies only.  But for those who want to come in, I am implementing these innovative measures to try to keep everyone safe as I treat your ongoing medical issues. 

Your Mental Health:  To quote Goethe, “The dangers of life are infinite, and among them is safety.”  As a culture, we have taken “safety” to a level that I believe is unhealthy.  Many people believe that the government can protect them.  We have bubble wrapped our children and, in many cases, we have protected them from failure – which means we have protected them from growing.  And this COVID-19 pandemic has been tantamount to pouring gasoline on the American obsession with safety and its phobia of germs. 

As the late George Carlin said in one of his famous comedy routines, “Americans have become so germophobic that we actually use an alcohol prep to wipe down the arm of a death row prisoner before we give him a lethal injection into his veins.”  Think about that one for a moment.  This could be a metaphor for our ongoing, national lockdown strategy to combat COVID-19.  As we make the decision to commit mass suicide by destroying our economy, we will take every measure necessary to make sure that we don’t get COVID-19 first, which probably carries a mortality of around 1 in 1,000.  Above all, we must not die of COVID-19.