When Doctors Are Wrong

Well, the windsurfing and foiling has been good - we've been on the water 5 of the last 7 days, with three sessions that I'd label as "excellent". But we stayed home today, and I discovered a few things that called for another COVID-19 related blog post. Here we go:

Medical doctors are regular people - they make mistakes, and they do not know everything. That's fine ... unless they forget it, and insist that they are right, which happens all too often. For me and my lovely wife, the "hit rate" from MDs is somewhere around 50%, at best. But I won't bore you with gastritis being diagnosed as "kidney stones or maybe appendicitis - go to the emergency room for a CT scan!", or carpal tunnel syndrome mistaken as vitamin B12 deficiency, or plenty of other such stories.

Instead, I want to look at an example about how medical "experts" just "know" that COVID-19 is transmitted "almost exclusively" or "always" through "large droplets", even when there is plenty of evidence staring right at them that this is NOT the whole explanations.

The issue started when I followed up on a couple of links in a study titled "Avoiding COVID-19: Aerosol Guidelines". References 65 to 68 in this article link to three different events where a large number of choir members got infected during choir practice or performances. I had written about the choir in Washington State already, but the others were new to me. They describe two choirs in the Netherlands, in Amsterdam and the town of Heerde, where 40% respectively 75% of the choir members contracted COVID-19. I then did a quick search for similar incidents in Germany, and found three similar choir events: in Berlin, Hohenberg, and Stade.

What really got to me was the statements by a German professor, Christian Kähler of the Military University, Munich, as reported by The Guardian. He did some experiments to see how far he could see air movements from the mouths when singing; found that the air moves less than 2 feet; and concluded:

"However, we also found out that singing is quite safe. It was not the cause of the outbreaks of Covid-19 at these concerts."

 That statement goes against a lot of evidence, but it is easy to understand where he is coming from when we look at another statement he made:

"I have been studying how droplets and aerosols behave for decades and I was very doubtful that musicians and singers were spreading the virus."

So, he was very skeptical, and set out to prove his point. Never mind that you actually cannot prove a negative - his study was deeply flawed because he only looked at air movement - he did not even look at aerosols! In fact, his own institute's web page that reports the experiment results explicitly states that not only that good ventilation is essential to avoid infections, but that the air should be flowing vertically, from inlets on the floor to outlets in the ceiling.

So Kähler concludes that all the infections that happened during choir practice must have happened when people where in close proximity - less than a meter, according to his own data. But the very short forward air movement that he takes as evidence that "singing is safe" would not even reach the person in front of a singer! So practically all transmissions would have to happen during breaks, when participants get coffee and mingle. The one or perhaps two initially infected people would then have to sneeze or cough at dozens of others in very close proximity. The "direct droplet" infection route even requires that some of the sneeze droplets hit the other persons mouth, nose, or eyes directly .. dozens of times here. Never mind that sneezing is quite rare with COVID-19, and not even listed as an official symptom!

Old "expert" guys like Kähler who simple refuse to consider new evidence, and rather direct their research efforts only to prove that what they always have said must be right, are very dangerous. They remind me very much at the doctor who treated my father when his dementia got bad. The doctor was the top expert for Alzheimer's in Germany, so he diagnosed my father with Alzheimer. He gave him psychotropic drugs, which perhaps would have been ok if the diagnosis had been correct - but they put my father into a catatonic state. Weeks later, other doctors correctly diagnosed my father with the second-most common dementia, Lewy body dementia (LBD); one characteristic is that LBD patients react very badly to psychotropic drugs.

Medical doctors who re-iterate the "common knowledge" that COVID-19 is transmitted by "large droplets" are at least as dangerous as my father's doctor. My father eventually recovered from most of the side effects, but in several of the choirs listed above, one or more members or their spouses died from COVID-19. It is very likely that the primary mode of transmission was long-distance transmission through aerosolized virus particles. There is plenty of science that supports this - studies that have shown that patients emit virus when talking; studies that show the particles can remain airborne for extended times, and that the virus remains infections in airborne particles for hours; studies that show that loud speaking and singing can release thousands to tens of thousands virus-containing droplets; and studies that show that direct inhalation is actually the most effective way of getting infected (check the summaries and links in this article for details, or various posts on my COVID-19 blog).

The science is clear: there is overwhelming evidence that aerosol transmissions can cause COVID-19 infections. Even with aerosol transmissions, staying 6 feet away from others dramatically reduces the chance of infection - but if you are indoors with many others for a longer period of time, and there's a lot of talking or singing going on, that's not enough, and a substantial chance of infection remains.

Some of the basic underlying science has been known for years. Some of the COVID-19 specific information has only become available in recent weeks. Unfortunately, a lot of the information at the "official" sites like the CDC, WHO, and Germany's RKI still focus mostly on "droplets made when an infected person coughs, sneezes or talks", and elaborate that "these droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs."

One often-heard argument against updating these guidelines is that "there is no proof of aerosol transmission". That is mostly true (although there is plenty of circumstantial evidence) - but there is also no firm evidence of droplet transmission. If anything, the available evidence indicates that indirect droplet transmission ("fomite" transmission) only plays a minor role. But besides a few experts like Kähler who are unable to change their minds "just because" of new evidence, there's another factor that makes this unlikely: concerns about aerosol transmissions may keep people out of restaurants and other indoor spaces, and thus work against "restarting the economy". But so will increasing case numbers that are partly due to misinformation!

Nice Distraction

A lovely little distraction today:

First time windsurfing in almost 2 months! Flat water, averages in the low 30s, sun, and warm enough - finally, everything came together. After a couple of hesitant turns, I even remembered how to jibe again. I took the "cheater" gear (Skate 110, Idol 5.0), since I'll need a few more sessions to be fit enough for a speed session. But 29 knots on freestyle gear feels plenty fast.

When Looks Matter More Than Lives

He never understood why testing is important. However, he is very concerned that it will "make ourselves look bad". He has access to all the scientists at the CDC, NIH, FEMA, and whatever government agency he wants, but the only thing he can think of is this:

"But they think they're doing it because it'll hurt me, the longer it takes to — hurt me in the election, the longer it takes to open up"

Have a quick look at the countries that lead the "COVID-19 death chart" - the countries with the most COVID-19 death per million inhabitants:

 All the countries at the top did not understand the importance of testing until it was too late. Several of them (the UK, the Netherlands, and Sweden) tried to mostly ignore COVID-19, and only keep "old and sick" people inside. It failed miserably every single time. Most of the countries in the list had to issue "stay-at-home" orders that were much more severe than those in the US - Spain, for example, had 30,000 road blocks to keep people from driving, and kids were not allowed to leave home at all for many weeks. Here is a graph that shows how COVID-19 "surprised" Spain:

The death curve follows the cases curve with just 2 days delay. In well-managed countries, the time between first symptoms and deaths is about 19 days. Even with allowing a few days for testing, the delay should be at least 2 weeks. Spain got blindsided, and paid a very high price for it. By the time they knew that they had a problem, millions were already infected.

In countries that had testing ready, the death toll was a lot lower. Examples include Germany, Austria, Australia, New Zealand, and Taiwan. In many of these countries, the epidemic started to slow down even before the first government measures were taken: when people heard that others were dying, and saw how quickly case numbers rose, they started to be careful, going out less and keeping their distance. When someone had symptoms, they knew that they should stay home so they would not infect others.

No ramping up testing quickly enough is much worse than just covering your eyes and hoping that "it will just disappear". It has cost many lives, and continues to cost many lives. The deaths are noticed whether there are tests or not; without tests, they instill even more fear. Fear keep people at home, away from flights, restaurants, and stores; it kills the economy, even without stay-at-home orders.

The only way out for the US without many hundreds of thousands of deaths, and many months of misery, is a massive ramp up in testing. "Test and track" is important, but tracking COVID-19 infections is extremely challenging because many infections happen before symptoms, or are transmitted by people who never get symptoms. In view of the realities in the US, test and track alone will not allow a "return to normal" - not even together with "6 ft social distancing". But repeated testing on a very large scale would be one thing that might actually work in the US.

It's not about looking good. It's about containment without sacrificing hundreds of thousands of lives.

Pants on Fire

"We’re going to lose anywhere from 75-, 80- to 100,000 people," Trump said. 

A day or two later, when the New York Times presented evidence that the White house had been warned about a much higher death toll, the White House immediately rejected the report. According to an NPR article, White House spokesman Judd Deere said:

 "The president's phased guidelines to open up America again are a scientific driven approach that the top health and infectious disease experts in the federal government agreed with. The health of the American people remains President Trump's top priority"

 Let us do a quick reality check. The "top health and infectious disease experts in the federal government" are working for or with the CDC. The CDC maintains a web page that lists a number of different computer models, and explains clearly why forecasting COVID-19 deaths is critical.

The web page also includes a link to a downloadable spreadsheet file that contains the numbers for all the models listed. I looked at some of the models (which now do not include the terrible IHME model anymore), and then downloaded the data file to have a closer look. Some models only predict one week into the future, but most models predict between 4 and 7 weeks ahead. Here are the total numbers of COVID-19 deaths that the models predict:

Model	Projected COVID-19 Deaths
CU-80 contact	336,930
LANL-GrowthRate	242,352
CU-70 contact	242,043
CU-60 contact	219,258
YYG-ParamSearch	218,893
COVIDhub-ensemble	189,105
UT-Mobility	160,977
MOBS_NEU-GLEAM_COVID	143,314
UMass-MechBayes	135,688
MIT_CovidAnalytics-DELPHI	119,337

There is quite a variation in the predictions, which range from 119,337 deaths to 336,930 deaths over the next 4-7 weeks. 

Even the most optimistic model predicts close to 120,000 COVID-19 deaths. On average, the models predict about 200,000 deaths; half of the models predict more than 200,000 deaths. There is not a single model that supports the numbers Trump gave; all numbers are substantially higher. A "scientific driven approach" would list the range that the models indicate, perhaps leaving out the highest and lowest predictions: 135,000 to 242,000 deaths.

Note at all of the model predictions cover a period shorter than the next 2 months, and that all models still predict a substantial daily death rate at the end of the prediction period. In my model runs, the total deaths toll at the end of 2020 was about 50% higher than for the next 6 weeks. Clearly, the overall expected death toll in 2020 is even higher than the numbers in the table, quite possibly twice as high.

Furthermore, most of the models assume that social distancing measures remain in place. There is absolutely no doubt that COVID-19 transmissions and therefore deaths will increase when states "re-open", as many states have started to do. Nobody knows exactly by how much, but even a modest increase of transmissions by about 20% would result in more than 400,000 additional deaths.  A more dramatic increase could lead to more than a million additional deaths in 2020. The only thing that will hopefully prevent such an enormous increase in deaths will be state governors who "lock down" states again when they see case numbers increasing. But it looks like they will have to do so against the resistance of the White House.

Pictures Tell The Story

On the bright side, I have finally been back on the water. It was a short foil session where the wind dropped, and my finger tips hurt the entire time because it was a bit cold, but it was sunny, and I got flying a few times. It was pretty much exactly one year after last year's disaster session,  so we'll count it as a big success.

On the not-so-bright side, it seems the US is largely ready to give up the fight against COVID-19. The federal guidelines on social distancing, meager as they were, have expired, and 30 states have announced "re-opening" plans. The likely result is at least 700,000 deaths from COVID-19 in the US, and possibly more than a million. Time to switch to picture mode.

The model that the White House loves predicts zero daily COVID-19 death by the end of June. "It will just disappear".

Well, it did disappear in China. The curve above is for the Hubei province where Wuhan, the original epicenter of the epidemic, is in. The super-smart scientists at the IHME figures that it must just happen the same way in the US.

That's an overlay of the two graphs. Quite a clear picture, right?

Let's have a quick look at the streets in Wuhan during the lockdown:

They were completely empty. Private traffic was verboten. Nobody was allowed to leave the city.

How about the US? Here's an image from Atlanta, a city that has a lot of COVID-19 cases and death:

Not empty. On Cape Cod, the rentals for summer guests are full, and the streets are as busy as in any other year. Beaches are crowded, but not yet as crowded as in California:

Surveys show that many people in the US don't bother with masks. Pictures show the same:

About a month after "social distancing" was recommended in the US, it is ignored by many.

Most flight have been canceled, but some flights still operate, and leisure travel is allowed:

For comparison, China increased the strictness of measures against the spread of COVID-19 several times in Wuhan. About a months after the first measures, teams were going door-to-door to check Wuhan citizens for COVID-19 symptoms like fever:

Anyone with symptoms was put in quarantine camps, and released only after two successive PCR tests came back negative after at least 2 weeks.

I am not advocating the same measures in the US. But it is important to understand that they were much more drastic, and therefore much more effective. Some measures remained in effect after the eventual "re-opening":

Meanwhile, the governor of Massachusetts has deemed landscaping an "essential business" that is allowed to ignore the stay-at-home order. God beware the horror of overgrown lawns! Priorities are priorities.

The result is quite predictable:

About 6 weeks after the federal guidelines were announced, and more than a months after most states have issued "stay-at-home" guidelines, the number of cases per day is almost unchanged for the peak.  Compare this to the very rapid decay for China in the second model - there really is no comparison. The IHME model is 100% based on the assumption that the "Wuhan curve" applies to the US. That's a 100% wrong assumption. The model is braindead. Worse, it appears to be intentionally misleading by predicting a completely unrealistic low number of death.

Wuhan and New York City both have about 10 to 11 million inhabitants. New York City ended up with a much higher number of COVID-19 deaths, and a higher infection rate. China prohibited all travel out of Wuhan until the number of cases was near zero; NYC residents are, and always have been, free to travel wherever they want to. But the so-called president calls armed and masked protesters like these "good people":

He encouraged protests against his own guidelines while they were still in effect:

The US had at least one month more warning about COVID-19 than China had. Now, the US has 14 times more COVID-19 deaths than China, and is on track to have 50, 100, or even 250 times more. No attack on China will fool anyone with half a brain about who is responsible for this.