COVID and the Contagion of Caricature

David L. Katz, MD, MPH, FACPM, FACP, FACLM
LinkedIn
The media, including even those elements that care about legitimate journalism, have always had some predilection for drama. As my media friend John Tesh quipped to me early in the pandemic, “if it bleeds, it leads.” There is the famously telling song by Don Henley, Dirty Laundry. There is the mantra that adorns the wall of many a news room: “comfort the afflicted, afflict the comfortable.”
Two mud wrestlers wrestling and soaked in mud.

This was all something of a liability to science, public health, and understanding before. But the stalwarts of journalism were generally a sufficient counterforce to give truth a fighting chance.

But now we are not limited to media; we have social media, too. My impression is that the Internet and Social Media have systematically replaced reflection, with refraction. Where once prevailed a pause of deliberate consideration, there is now the immediate polarization of any perspective into disfigurement and caricature- before ever it is faithfully weighed, or sensibly measured. Such blighted light is not conducive to the diffusion of insight.

And, of course, we are making our way through this bizarre interregnum of governance by tweet, of disdain for expertise, of intolerance for all nuance. We are actively encouraged from on high to pick our tribe, defend our pole, and disparage all others. This is a place where rivals cannot be teams, where hybrid means vitriol rather than vigor, where “us” and “them” exchange insults and injuries, not ideas. This is a place where the gauntlet of disagreement that should be the proving ground of good ideas, whatever the source, is on lock down. This is where good ideas and bad, alike, come to die.

And so, too, do far too many of our loved ones, because during a pandemic, all of this is, literally, lethal.

Lethal to those who got an infection they did not need to get, and died of that. Lethal to those for whom haphazard interdictions were indeed worse than the disease, activating the “social determinants of death” via the agency of desperation, destitution, and depression; hunger, addiction, violence, abuse, and suicide.

Management of COVID19 has been a global failure, but nowhere more flagrantly than in the United States. We are the on-going master class in how not to manage a pandemic and even now, every news update is refracted to suit the two polarized narratives that conspire to obscure the more temperate realities between them: to the left, the sky is falling, there is only doom and gloom, and we should remain in our cellars in Hazmat suits until further notice; and to the right, this is a hoax and a conspiracy involving Bill Gates, foreign powers, and malevolent extraterrestrials, and of course it’s perfectly fine for nursing home residents to attend area bars and night clubs, and participate in mud wrestling tournaments.

Accordingly, let us look at what we have done and said about the pandemic in this country, and what we might have done, and should have said- if we respected science, gave a damn about sense, and were actually willing to listen to an opinion we don’t already happen to own. Perhaps we might evince a bit of hope in the reality check of such juxtaposition.

What we did: We locked down.

What we might have done: Lock down far sooner, more robustly, and more selectively. The hospital overload and high death rate in New York City and the Northeast occurred because the first phase of the federal response to the pandemic was…dithering. While the federal authorities dithered, and states awaited action that did not come, the window of opportunity to lock down before the virus was widespread came and went. So, the virus rode the New York City subway for some span of days or weeks, and the rest is the history we know. For a lock down to be effective, it must occur before what you are locking out is in, and what you are locking in is out.

There was never a need to lock down everyone and everything, at least not beyond an initial phase of adjustment. There are massive risk differentials associated with COVID, and we needed far better protections for some- notably nursing home residents– and less or no protections for many at very low risk. We might have opted for risk-stratified interdiction of viral spread. We might have attempted to minimize total harm. But of course, we did not.

What we did: We started to wear masks.

What we should have done: worn them sooner, more consistently, and in combination with other careful practices to reduce exposure dose among the robust, and prevent exposure among the frail. Masks and distancing serve two purposes: the outright prevention of viral spread, and the attenuation of dose. For those likely to get safely through a bout of COVID19, dose still matters, and both masks and distancing can cut it down. Careful attention to both is crucial to curtail transmission from lower risk groups where the virus may circulate widely doing nearly no harm, to high-risk groups.

What we did: we tested very few, and mostly those with severe symptoms.

What we should have done: representative random sampling of the national population, with systematic construction of a data pyramid. We might have informed our policy from the start with knowledge of: who is infected; who has been infected; who is immune; of these, how many have had symptoms? Of these, how many were hospitalized? Of these, how many died? That we might have done this is clear, given that South Korea managed well over 200,000 tests in mere days. Absent such data, all media reports about case counts, and in particular all reported “rates” – hospitalization rates, fatality rate- are, in a word, rubbish. You cannot know case counts if you only count the cases sick enough to seek medical attention, and you cannot report rates if you do not know the denominators. Everyone reporting otherwise would have failed Epidemiology 101, which, by the way, I taught to Yale medical students for over a decade.

What we did: We opened the country back up.

What we should have done: Learned the lessons of the Northeast, and open in a sequence of risk-stratified waves. By opening up haphazardly, much of the U.S. invited the delayed first wave of contagion that was perfectly predicted by Professors Maria Chikina and Wes Pegden. When all you do is “flatten the curve” with no detailed plans for a pivot to a risk-stratified phase 2, you do not prevent hospital overload or deaths; you simply change the dates. This is especially true if a haphazard reopening is compounded by prevailing denial, so that individuals abandon caution- and interact across risk tiers, blithely passing the virus on to their vulnerable grandparents.

What we said: Case counts are likely at least ten times higher in the U.S. than documented.

What we should have said: this means the disease is mild in the vast majority, that fatality and hospitalization rates are ten times lower than they appear; and that we are ten times closer to herd immunity than we were before discerning this. Instead, even the news that ten times as many of us have made it through this contagion safely than we knew yesterday was disfigured to serve an “only bad news, here, please” agenda: many more are out there spreading this asymptomatically, and we are a long way from herd immunity. Actually, people with antibodies are NOT spreading the virus, and we are ten times closer to herd immunity than we were before we got this news.

Let’s do just a bit of math. We have had nearly 148,000 COVID deaths in the United States, and we are reporting 4.2 million cases thus far. That is a case fatality rate of 3.5%. But the global fatality rate is just a fraction of a percent- so this would seem to imply that this virus kills Americans preferentially! That, of course, is nonsense.

Rather, we have indeed had ten times more cases in the U.S. than we’ve identified- or perhaps more than that. Out of 42 million cases, the 148,000 deaths is 0.35%, meaning that other things being equal, if you get this infection, the likelihood of getting over it rather than dying from it is not 96.5%, but 99.65%. If you are anxiously waiting to see if you are going to be among those who succumb, how can this be anything other than good news?

What we are saying: many Americans are at elevated risk of bad COVID outcomes.

What we should be saying: there has never been a better time to get healthy together! We can’t change our age, but we can change our “COVID Age,” meaning our risk of bad outcomes if infected. Overwhelmingly, the risk factors for bad COVID outcomes are responsive to lifestyle- diet, physical activity, etc.- and modifiable all but immediately, with greater impacts over time.

***

Perhaps it is not too late to save lives by looking for science and sense between the polar extremes of prevailing narrative. COVID19 is not a hoax, and the sky is not falling- can we manage to hold both of those ideas in our minds at the same time? Or, are we so distracted by a parade of competing caricatures and excoriating tweets, that consideration of such nuance is out of the question?

I am not sure of the answer. I am quite sure that lives depend on it.

-fin

This article was first published on LinkedIn.

Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health

Visit his YouTube channel for a new library of COVID “reality check” videos on various aspects of the pandemic.

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