The value of masks vs mask mandates? In the case of New York State the first mask mandate was April 15 at which point mask use was already very high. And obviously mandating something that people are already dry doing is going to have a minimal effect. Some folks latched onto this to say A. This proves masks don’t work. B. This proves mask mandates don’t work.
Well, another issue with Covid is that involves exponential growth. For two people in a room, masks probably do nothing. But, if everyone is interacting with hundreds or thousands of other people, even a slight reduction in the spread rate can mean a tiny fraction of people get Covid. See 1.5^10 versus 2^10. Granted, I need looked into the effect of masks on the exponential growth rate, but it was another point where there was some basic math that many didn't understand.
As for your example, yeah, I don't think comparing states is a good metric. I had a grad degree in econ, and I know they look for quasi-random experiments. When they study minimum wage laws, for instance, they'll look at two places (city, state, country, etc.) voting on an increase, one where it narrowly passes and another where it narrowly. That way, the increase is plausibly "random." Whereas if we look a liberal states that increased and it and conservative states that didn't, we'll end up comparing cultural and political differences, not just the impact of the legislation
I did an unscientific study on my facbook page. I asked my friends to rate Masks, Vaccines and Ventilation in order of preference. Aside from a few blank slate friends who said "they're equally important!", most went 1. Vaxx, 2. Mask. 3. Ventilation.
Personally I go 1. Ventilation, 2. Vaxx and 3. Mask. With masks being WAAAY down the list.
Now I agree with Bronx Zoo that maybe we thought masks had NO effect do to selective data and I guess this paradox that Freddie is talking about. But I think there's a bigger issue with how the general public views any of these issues. Basically they focus on whatever the news focus's on. I have relatives in England where there's a huge ventilation campaign. "Wisk Covid away!" or some such slogan.
Here, in the US, it's so partisan. Masks and Vaccines can be easily put into camps. Ventilation? Would that really become a left / right issue? "The libtards are cramming fresh air down our throats!" "The MAGA maniacs want us to suffocate!"
It just doesn't wash in our 'Merican Coke vs Pepsi binary.
I was really disappointed with the lack of ventilation compared to surface cleaning. I still see so many places obsessively cleaning surfaces, but I have never seen a place leave it's doors/windows open for ventilation.
My guess is that this stuff is security theater. Ventilation doesn't look like doing anything, whereas cleaning a surface does
Yup. I was in a restaurant here in NY the other day. The waiters had masks but they didn't ask for Vax cards and they cleaned surfaces like crazy. Then a woman by the front door started coughing. I don't know if she was vaxxed. I was like "if you're not gonna' open the door I'll eat outside."
I have to say, I don't share your optimism on ventilation not being a partisan issue. There was a fad a few years back where lib-owning conservatives where rigging their cars/trucks to pollute this brutal black smoke. I will never underestimate what might be done to "own the libs"
I think part of the issue is staff preferences. As a dinner you may be fine with the AC off and the windows open. But that means the cooks are roasting back in the kitchen.
A few words with reference to your comments to ventilation here in the UK.
Firstly, I genuinely adore the phrase 'Wisk Covid away!'. It's such a perfect idea of what public health campaigns used to sound like here. Hovever, among the innumerable things lost over the last thirty years or so has been the capacity for whimsy - the phase is the bluntly prosaic 'Let Fresh Air In or Meet Outside'.
Secondly, it has been a (literally) enlightening experience seeing the long-painted-over windows being opened for the first time in probably half a decade in the bougy coffee shops.
It turns out they were not just a bizarre stylistic choice coincidentally shared by all buildings built between 1700 and 1970. The huge windows are for light, and the top ones are for air! Infectious diseases fester in crowded areas. We knew this, and forgot.
Yeah. Us Yanks can't live a week without our AC. But question. Can good central AC address the Ventilation issue? I haven't read much about this. Important if Covid becomes endemic, right?
A slower exponential growth rate just means that it takes longer for everyone to get infected. It doesn't imply a lower cap on the total number of people who will eventually become infected.
That assumes that the immunity from a vaccine doesn't wane over time. And if you want to include the possibility of infection from new, vaccine escaping variants in your model (and in terms of public policy you probably do) the situation is even more complicated.
My point is that decreasing the rate at which you pour water into a glass just means that it takes longer to fill up the glass, not that the glass magically stops filling at the half way point. This point should be uncontroversial so I'm not sure what all the deflection is about.
I think it's perfectly plausible that masks are effective in the lab and useless in the real world. Given the complexity of the issue it's not surprising people can look at it and come away with two different conclusions.
I trust myself to maintain protocol for about 10-15 minutes. Eight hours in the real world? Then you have to consider the odds of touching your mask, rubbing your eyes, removing it in the presence of co-workers to eat lunch, etc.
Most people aren't as opposed to masks as you are. And even if people take them off to eat - transmission would be reduced the other seven and half hours. And touching the mask isn't an issue as fomites aren't a vehicle for transmission.
I'm not opposed to masks, I just think there is just about zero evidence that they actually have a statistically significant effect in the real world. Certainly the evidence from the RCT's is a mixed bag, at best. I would actually say that the evidence from the RCT's is that masks are almost completely useless.
I listed out a number of actions that I think would undeniably dilute the effectiveness of masking in a real world setting. Do you really think most people aren't going to fall victim to inadvertently rubbing their eyes at some point during the day? And notice that your point is "transmission would be reduced", not "transmission would be eliminated". The problem with the first scenario is that if you are completely dead set against contracting the virus then short, occasional bouts of outside contact are all that you can afford. Repeated daily interactions that are many hours long over a period of multiple months? Even with a mask my guess is that contracting the virus becomes almost a certainty.
Your evincing so much motivated reasoning I'm worried you aren't open to masks being effective. What sort of burden of proof would you require to admit you've been wrong?
I sucked at math too. But your basketball example made sense. Interestingly there's lots of videos about Simpson's paradox (which actually feels more complicated to me) than Berkson's.
I don't know how this effects Covid data specifically, (although like you I'd bet it does), but I'd also bet that our collective failure to grasp many of these large data math issues (paradox's, exponential growth, cost benefit analysis etc) contributes not only to misunderstandings about Covid and SAT scores but many other issues being argued by millions of pigeon chess champions on Twitter daily.
Sports, school, race bias, disease. "Do your own research!" No. Because I at least know that I'm not informed enough about how statistics work to do my own research. Most people don't.
(See how I centered myself at the end there like a good narcissist. Ha!)
I recently took a stats class for nursing and I think the most lasting lesson I learned was "holy crap I don't know much about data analysis." It's one of those things that you can't know till you know.
I have a PhD in physics and took 3 grad level stats courses (mostly because I wanted to; it wasn't required) and what I learned was mainly "holy shit I know nothing and there is a reason people are doing PhDs in stats". (there is a long history of physicists needing to get humble and I'm glad it came early for me)
I never understood randomness until a student, who happened to be a physics major, taking my intro stats class, explained to me what really happens at the far ends of a normal curve. Something about infinite space and time I still can’t get my mind around but made me realize the folly of trying to predict everything with stats
Not quite a paradox, but something everyone falls for:
A has a positive correlation with B.
B has a positive correlation with C.
"Statement about A being positively correlated with C."
But correlations are not transitive. It is possible for A and C to have no correlation, or even a negative correlation. The above claim can only be made with correlations very close to 1. Which pretty much never happens.
I'd like more citizen distrust, or at least hesitancy in this area. The default response to any random statistic should be "that's probably wrong". There are so many easy ways to make mistakes. We know that most Doctors don't understand sensitivity vs specificity. We are living through the replication crisis.
So yes, please more citizen thinking in this area. But it should mainly be critical thinking for the purpose of falsification.
The same problem causes us to underestimate the strength of correlations, and I believe that is happening with data on vaccine effectiveness. Just yesterday, there was a big CDC press release that “unvaccinated people are 11 times more likely to die” from covid-19. But they’re using surveillance data.
Vaccinated people with asymptomatic infections won’t show up in surveillance data because (for the most part) those people won’t know to get tested. So we aren’t counting a bunch of cases where vaccinated people had no symptoms. If we had data on those infections, the correlation between vaccination status and death would be stronger.
Specific studies where everyone gets tested will pick up asymptomatic infections, but we can’t necessarily generalize because conditions vary across time and place (new variants emerge, etc).
I'd like clearer statistics for children as well, I have a 5 and 7 year old. But there is no way children are 11x more likely to die. this chart is goofy to read but children's are < 1X likely to die than 18-29 year olds, that have a 4th of a chance that 30-39 year olds have, which nave 1/10 the odds of 40 - 49 years olds. I belive this is before vaccination.
I have been ranting about this on the Slow Boring Substack for months now. As a PCP I think it's super important to be as objective and unemotional about Covid risks as possible. I can't tell you how frustrating it is to have a lack of clear, firm data and statistics. Numbers are freakin' all over the place depending on which study you read. We just don't have a firm handle on numbers vaccinated and numbers of breakthrough infections. The data on hospitalizations, ICU admissions and deaths are a little clearer. It makes it very difficult to know how to advise individual patients about their individual risks, especially for my vaccinated seniors. For them, there is a risk to both underestimating the risk, which could lead to a breakthrough infection (even w/o hospitalization, that could take quite a toll on a senior), and to overestimating risk, leading to repeat isolation and depression. How great is their risk if they are >6 months out from their second shot? How effective are boosters going to be? Don't know. Difficult to advise.
The federal government (CDC etc) has really failed us all here rather dramatically in not coordinating this sort of data, with clear universal standards for what gets counted as what.
Ok here we go. I'm gonna rant. LOL. It's not so much that I blame CDC or public health for not having accurate data. This has been an extremely difficult 18 months with a sudden unexpected pandemic and I really try to be unjudgmental about the lack of clear data. What frustrates me is when I see data that is clearly there but not being reported. (For example it was clear that vaccines were not as effective for the delta variant, but it took AT LEAST a month for CDC, public health and MSM to report that.)
And I am really angry and resentful when CDC/public health tie my hands from making my best recommendations based on what data I do have. For example: the J&J shots and booster shots. It was always clear that the J&J shots weren't as effective as the mRNA ones, but initially, we needed everyone vaccinated as soon as possible. I reasoned that I was not going to lie to my patients. My advice to patients who asked me about this was get the J&J now. Nothing would prevent someone from getting one of the mRNA ones in the future when supply was plentiful. I didn't realize this was going to be strictly forbidden. Or that my immunocompromised patient who got J&J would now be barred from getting a booster despite the mRNA vaccinated people being qualified. How does this make sense?
And where does the declaration of "8 months" booster come from? Why 8 months? Where is the data on that? I've seen data on 6 months, not 8. LA county public health just sent a vaguely threatening email to providers on Saturday that current boosters WERE ONLY APPROVED for the immunocompromised (a very narrow definition). So, for example, I had a 75 yr old insulin-diabetic, morbidly obese patient with heart problems see me last week. Her second Pfizer shot was early Feb. She is now >7 months out from that. I wrote a note for her to take to the pharmacy to get a booster. But, strictly speaking, she doesn't qualify for one and now that public health sent that email, I have to think twice about doing that. Yet, my 35-yr old patient on immunosuppressive medication for psoriasis does qualify. Is his risk of breakthrough/severe infection really greater than hers? I mean, maybe. Hard to say, right? I don't think we have enough data on that. But I'm doing the best I can with the data I do have and it makes me mad when all of these political (?) considerations are blocking me from doing what I think is best for my patients. This is not like in the beginning when we had a supply problem and people were jumping the line. Supply is not the issue. And, in fact, I'm worried supply WILL become an issue again when they open up the booster floodgates and everyone is trying to get their boosters.
It's horrifically complicated. I presume that the reason that the WHO strongly disagrees with the idea of booster shots for developed nations is partly due to the belief that low vaccination rates in the third world are driving the development of vaccine resistant strains. Is the world better off vaccinating the third world quickly if it means delaying boosters? What a mess.
Even the number of Americans who have COVID will always be suspect, when the CARES Act dramatically incentivized healthcare providers, with a 20% bonus for Medicare patients, to inflate the figure.
Wouldn't a covid diagnosis require a positive covid test on the medical record? Are you claiming these are being faked at a large scale? That would seem to be something that could be investigated.
I'm really not sure what you're talking about here. This sounds like a conspiracy theory. Maybe this was true in the hospital but I don't think hospitals were incentivized to diagnosis Covid as you are claiming. Personally, I saw MC Covid patients, mostly via telehealth. Our reimbursement wasn't higher for that diagnosis. Actually (and I think I'd have to ask my office mgr/biller about this bc I really don't know much about billing), I vaguely remember that we weren't allowed to charge a copay if the diagnosis was Covid since this was covered by the CARES act and there was a guarantee that there would be no out-of-pocket cost for the patient. So I think for some insurances, we actually got less money. If you really want to know this stuff for sure, I can ask my office mgr and get back to you.
Note it's a bonus on all medical claims if the patient has COVID, not just on COVID-related procedures.
It beggars belief this is having no effect on the reporting of cases by the for-profit healthcare industry. This isn't conspiracy theory, this is simply expected behavior from an industry long known (according to 30 years of media reporting) for dubious practices in the pursuit of profits.
Given the existence of actual cash incentives for the over-reporting of cases, I would expect scrupulous researchers and journalists to couch their reporting in warnings and caveats, but I never, ever see them. So who knows what the real numbers are?
And I don't know what incentives there might be in place for COVID-related death certificates, but bizarre things have been happening there as well:
PCR Covid tests are generally processed by a third party lab that would have no incentive to fake a huge number of covid diagnoses. There is point of care testing now, but it is done by the clinical team seeing the patient in real time. Physicians are truly not putting their licenses on the line to fake test results.
But who is reporting to . . . whomever compiles the gross numbers (Johns Hopkins University)? Surely not the labs themselves. Or are they?
The fact is, COVID over-reporting is certainly incentivized by the CARES Act. This is a fact you can't get away from, and one that has always bothered me.
How much over-reporting is occurring, which agencies are receiving the inflated numbers, if any, and where these numbers are used, would certainly be worthy of further investigation. Certainly any published numbers should be accompanied by warnings of some kind.
Instead, the response seems to be, "The numbers are accurate because, well, we really don't like the sort of people who would question the numbers in the first place; you know who we are talking about."
I don’t have any issue with questioning the data or motives of healthcare corporations but unless it’s based on something besides a gut feeling that they are probably doing something shady because there’s a monetary incentive then I don’t take it very seriously because I know a bit about how healthcare works.
First of all, the government absolutely does not want to pay hospitals and healthcare systems more than have too. They will audit and sue and are doing so on an ongoing basis. There is almost no chance that there is a nationwide effort by healthcare organization to commit Medicare fraud by making up covid diagnoses out of thin air without it having been caught. Particularly under presidential administrations that have a vested interest in making covid numbers look better rather than worse.
Second, I am not sure where John’s Hopkins gets it’s data but usually that kind of reporting comes from public health agencies from the county upward. Yes, the healthcare orgs are reporting their numbers to them but Medicare reimbursements are based on public health reporting of data. They are based on diagnosis coding which can be audited. It is not uncommon for healthcare orgs to have to pay back money if they use inappropriate coding that can’t be backed up in the chart or if they simply make mistakes.
Furthermore, healthcare orgs are subject to regular visits from accreditation bodies like the Joint Commission. TJC is not responsible for auditing coding and billing to my knowledge, but they are responsible for ensuring certain quality and safety metrics and are able to look into the patient records and it seems like a fraud at the level you are envisioning would be pretty evident in the record.
It’s not that I have faith in the goodwill of for profit healthcare organizations. It’s just that I don’t see how a fraud big enough to skew nationwide covid numbers could fly completely under the radar.
I appreciate you have confidence in institutions like the for-profit healthcare industry, government auditors and the US media (who report on all this stuff). Personally, I have no reason, based on past behavior, to harbor such confidence. Your skepticism may vary.
As I said, we know one fact: the CARES Act incentivizes over-reporting of COVID. From that unassailable fact I draw the conclusion: reported COVID rates are probably inflated. Maybe a negligible amount, maybe a lot. I have no idea. But I am almost certain they are. The credulous stenographers of the US media will never say. Again, your skepticism may vary.
That Medicare claimants are audited by bureaucrats does nothing to increase my confidence in the numbers (I say this as a guy who has received letters this year from the unemployment departments of both Nevada and California informing me that, sadly, they will have to stop sending me checks since they can't verify my identity. Though I am self-employed and never made a claim in either state, and certainly never received a check. And after Nevada helpfully reminded me they already paid me (or, rather, someone) almost $3,000. California hasn't revealed how much I (or someone) got them for). Back when I paid cash for all my medical needs (including a Mohs surgery), it was pretty obvious to me that insurance fraud, at any rate, was widespread among healthcare providers. This is simply my experience. Again, your skepticism may vary.
I'm trying to imagine how one of these Medicare audits might go:
Auditor: You say here that you had 15,540 COVID cases in February of 2021. Can I see the proof for that?
Hospital: Yes, it's right there in the files. See how every COVID case is accompanied by a test affidavit?
Auditor: Ah, so it is. Very good. And let's see, according to official records, your claims seem to jibe with the numbers for your county that month.* Everything looks ship-shape. Good-day!
It takes about 30 seconds of googling to find a case within the last several months where a large healthcare org in CA had to pay $30 million dollars to settle a justice department lawsuit that claimed they submitted inaccurate Medicare information.
Do I have faith that every instance of fraud or incompetency is immediately rooted out and healthcare is nothing but rainbows and butterflies with impeccable integrity? No. But I am saying with a fair amount of confidence that at least one healthcare org would by now have been caught if they were literally putting fake covid test results in the record to get fraudulently reimbursed. You still have not given a shred of evidence or even a theory of how this is happening.
In general I suggest we all NOT think about basal rates, cutpoints, and excluded portions of sampled populations as we continue to stumble our way through this pandemic, because almost none of us are capable of thinking about such things usefully.
If you want "to cultivate a respect for the work we all need to do in order to better understand where we are with this disease", the key point is that this work is not possible for the vast majority of us.
As in almost all areas of life, the best strategy is to identify a set of trustworthy experts, and follow their advice. That trust is earned through previous accomplishments.
"Previous accomplishments" for the public health community includes saying it was selfish and harmful to wear a mask and insisting the Covid was not airborne. The trouble is that we've been living through decades of collapsing trust in elites and institutions, which has been driven by the repeated failures of elites and institutions. (See: 9/11 and everything that came of it )
Early on, it WAS selfish and harmful to wear a mask because the totally inadequate supply was needed by front-line workers, and the disease had not yet widely spread. And early on, the airborne nature of covid was not established. Science is provisional: whether or not covid could travel and remain infectious in aerosols was not clear. I do fault the public health community for not making the first argument clearly, for not being prepared (stockpiled PPE), and for not being willing to say "we don't know yet, this is our best guess at the moment" more forthrightly.
All that said, who ya' gonna trust? If public health depended on results in my own field of expertise (which, very thankfully, is not the case), I can tell you that I absolutely would not turn to the general public for advice. I am 100% sure that debates among the general public would be utterly useless for reaching the best possible result, or even a decent result. Which we are seeing right now.
The Dunning-Kruger effect is real, and far more important to the current crisis than Berkson's bias, which I expect to be well understood by the experts.
> Early on, it WAS selfish and harmful to wear a mask because the totally inadequate supply was needed by front-line workers
This is true only if you understand mask to mean "surgical mask" and isn't true once you allow for improvised cloth masks that also provide (some) protection.
> And early on, the airborne nature of covid was not established.
This seems circular - excusing the (western - IIUC various Asian public health systems did not make these mistakes) public health community for its mistake by appealing to its beliefs. What else would "established" mean in that sentence?
> All that said, who ya' gonna trust?
Zeynep Tufekci. AFAICT every time she's deviated from the CDC recommendations she's been right and they've been wrong. She has the substantial advantage of getting to read the CDC reports, so it's not like we could replace the CDC with just Dr Tufekci and get the same result.
It isn't about "turning to the public for advice", it's about understanding that truth does not actually flow from authority and that the general public should, in principle, be able to verify what is being said.
So you've picked an expert to trust, based on evidence of their competence. Please note: that's exactly what I recommended.
But in order to pick your expert to follow, you had to do enough due diligence to make that decision. For people who are not able to do that (for whatever reason: constraints of time, personal expertise, etc), following the guidance of the public health authorities (which as you've correctly noted is not always right) remains the best strategy.
That's a fraught (but maybe unavoidable) position for modern society in general. It's an exceptionally problematic standard for Covid given the number of dramatic and humiliating reversals that the public has been witness to.
The problem is two fold: are those public pronouncements presented as "best guesses" with the expected and attendant uncertainty and potential for reversal? And are there perhaps special interest groups who have a vested interest in projecting certainty where it isn't warranted?
Are you reading their actual recommendations or are you relying on media reports? The vast majority of the actual recommendations did contain a great deal of uncertainty. But the condensed media reports didn't deal with all the nuance.
The issue is the general reaction of the lay public. You know what scientists really, really like to do? Argue with one another. Way back when in the early 1900's college counselors were telling their brightest students to skip fields like physics. The assumption was that almost everything was figured out and with no questions left to answer all that would remain would be the domain of engineers.
The only reason that anybody gets a degree in the sciences is because of all the unanswered questions still out there. Arguing about the possible answers to those questions just naturally comes with the territory. All of the "Believe in science" or "I trust scientists" nonsense? Not reflective of a reality where the important questions are still unanswered and being debated. And that of course means that the modern formulation of scientists as all knowing techno priests is so much bunk.
Agree with both you and Slaw here. I think public health and CDC knew that masks had some benefits but there was a shortage of supply. So they elected to go with the "masks don't help" line b/c the hospitals and clinics were in such short supply. I think it would have been better to have been up front about it: "masks may be beneficial, but we have a short supply and need them for hospital workers." In the end, their white lie didn't really increase supply; it just caused mistrust. And people aren't stupid: if it's beneficial to protect hospital workers, it must be beneficial for the public in general.
When it was clear to me in early July that the vaccine was not "90-95%" effective against delta, I kept wondering why they weren't reporting on that. My assumption was that it was a political calculation: that CDC was afraid if they said people were getting significant breakthrough infections, people would say "why should I get vaccinated? Vaccinated people are still getting Covid." So, instead of warning vaccinated individuals that they may not be as protected as they originally thought, they hid or shaded the truth for a while for other political reasons. When I said this to my husband at the time, he accused me of conspiracy thinking. Ok, fair enough. But sometimes it really does seem like they are not always being forthright with their "best guesses."
Question - how are breakthrough cases validated? For example if I come to you as a patient and you diagnose me with Covid presumably you'd ask - have you been vaccinated? Not wanting to sound like an idiot I say yes - is that as far as it goes?
They admit in their discussion that they may actually be missing vaccinated status if someone was vaccinated outside California. My husband works for Kaiser, which, in general, has great data. I remember you were part of the discussion on Slow Boring when I was talking about the hospital data for Southern California Kaiser back in July, which was reporting about 10-13% vaccinated, hospitalized patients. You were pretty scornful of the data bc you thought people would lie about their vaccination status. TBH I'm not 100% sure how they gathered that data. My guess is that it was a mix of having records on vaccination from Kaiser itself and self-reporting.
When someone comes to me and says they were vaccinated and now have Covid, it's also a mix of data. We're trying to keep track of pt's Covid vaccination records when they come for appts. So often we already have their vaccination status (unless they have a forged vaccine record). But often they just tell me. I guess if they're lying, I wouldn't know for sure.
Are you asking patients to bring their vaccine records? I've been to a few doctors appointments and didn't bring my records and no one asked to see them. They just asked me if I've been vaccinated.
An extended family member who works in healthcare has Covid symptoms and knows that she no longer has antibodies (she was early in the vaccination line). So at what point does the question have you been vaccinated become less meaningful than do you have antibodies?
If you want a dataset that is presumably more reliable about whether someone has actually been vaccinated, you could look to Ontario, where everyone's vaccination records are connected to their provincial health card (which covers 97% of the population; the confounder there is that the 3% who don't have provincial health insurance are largely immigrants, who do have higher COVID risks).
You know, I read all the news reports about Manaus and wondered "Why isn't anybody talking about this?" Then I read the news stories coming out of India and I wondered "Why isn't anybody screaming their head off about this?" Do you really have to be that paranoid to wonder if maybe there are vested interests that are eager to downplay bad news associated with the pandemic? Like maybe there's a good possibility that there's going to be an outbreak this winter (to go along with the rather large outbreak we are experiencing right now) and an attendant economic impact?
FWIW right now I'm looking at the efficacy of the flu shot over the years. On average 40-60% effective in any given year with a low point of around 10%. I don't mean to suggest that it is completely predictive of what happens with Covid but it is an interesting data point.
Yes changing your mind when new information becomes available is dramatic and humiliating. Tells us everything we need to know about your thought process.
Let me put it this way: based on the state of the science vis a vis masks I would say good public policy is something like "Go ahead and wear them. Can't hurt, might help." On the other hand "You are the antichrist if you refuse to wear them" is probably not consistent with our level of certainty.
I assumed “we all” meant “people who made it to the end of this post” rather than literally everyone. The people I know who think they’re “doing their own research” believe every conspiracy theory they see on Facebook.
I’d advise the average stats-illiterate person to listen to the CDC just for lack of an alternative. What else can you really tell someone who can’t make sense of conflicting arguments? I’m not going to say “read the studies and think about selection.”
Of course, those of us who dig into the research can advise our friends and family. I started wearing masks in March 2020 (already had a box) and told my parents to do the same.
Emily Oster does a good job of giving parents the latest evidence, and explaining it in an accessible way. But I only listen to her because I read her book and trust her to make sense of the studies.
Well, obviously we depend on trust in others. Nobody is doing their own studies, and we mostly aren't in a position to talk to experts ourselves.
I don't think it follows that knowing statistics isn't useful, if you can manage it. It would seem similar to how knowing something about cars helps you pick a good mechanic? You want to understand the terminology well enough to tell when people are blowing smoke.
Ideally, mechanics would give equally good service to people who know nothing about cars, doctors would give equally good care to people who know nothing about medicine, and financial advisors would give equally good service to people who don't know about money, but this isn't always the case.
And to the extent that the experts do give equally good service to anyone, in part it's because some customers are savvy enough to check.
I suspect that the narrative on mask wearing is much more complex than the popular narrative.
Consider: in 2017 about 60,000-80,000 US'ians died from the flu. It was a particularly bad season. But even over "normal" years tens of thousands of people in this country can be expected to perish. Add that up over the course of decades and it's in the range of hundreds of thousands of fatalities.
Mask wearing has been common in places like Japan and S. Korea for decades. as a countermeasure not for Covid but for the flu. And yet US health authorities never seriously considered issuing guidance on mask wearing, even during the flu scare during Obama's administration. And global authorities, such as at the WHO, have been even more reluctant to endorse mask wearing, even in the face of Covid. Why?
My guess is that it's simply because all of the trials and observational studies that examined mask wearing in Asia versus the rest of the world was never able to produce a statistically significant effect. And, most critically, initial mask guidance on Covid was 100% consistent with mask guidance on the flu: namely, that they weren't needed.
I honestly think that the mask discourse in the US is nuts. Disclaimer - I am 100% fine with wearing a mask in indoor settings. I don’t believe there is any downside and there appears to be at least some upside with properly worn surgical or higher grade masks. But the way the discourse in the United States goes, it honestly seems like liberals have become magical thinkers about masking because it is a visible marker that makes people FEEL safe. I think that’s why more than anything else some people will never be okay with giving up the mask.
I have not personally seen any convincing data that cloth masks do very much of anything (although again they don’t bother me and I’ve worn them). A recent study from India that had a way of looking at a control group did show protective benefits from surgical masks though not as high as you’d think from the discourse. I only have my kids wear surgical masks at school now even though I hate the waste. If they are going to wear one, might as well make sure it’s somewhat effective.
But I think the mask is too strong a symbol of covid seriousness/covid denialism for most people to be objective about the data.
Yeah it got slotted into the culture war really fast. I wore a mask early on since it seemed like it had a chance of a large upside with basically no downsize. Soon it become liberals screaming that masks will single handedly defeat COVID and conservatives screaming that they'll suffocate and die if they wear a mask for five consecutive seconds.
Agree about that study out of Bangladesh. It’s being touted as proof that “The Masks Were Working All Along,” as the headline of a recent article in the Atlantic by Derek Thompson has it. But if you read the fine print, you discover that the study actually showed that the villages in which adults wore surgical masks (note: not the cotton masks most of us wear) had 10 percent fewer infections than the villages that were less diligent about mask-wearing. In other words, a measurable but underwhelming effect.
At least the study isolated mask-wearing from all other factors; most of the “evidence” for the effectiveness of masks in the US is observational rather than a random controlled study that isolated mask-wearing from all other factors, as the Bangladesh study did. The US “evidence” for mask-wearing comes from comparing paired towns or states, in which multiple interventions are happening simultaneously (not just mask-wearing but also more social distancing, business closures, etc), and whose populations have markedly different attitudes to Covid (blue towns with highly scrupulous and worried people tend to follow all restrictions, including mask-wearing, while red towns with lots of Covid deniers tend to have more unmasked people crowding into indoor spaces, for example).
For me the takeaway is that mask-wearing is probably a bit helpful in certain situations (for example, I just flew from DC to Switzerland, and I was glad everyone was wearing masks in the airports and the plane). But the Bangladesh study shows that masks are not a panacea, and in many circumstances their minimal effectiveness may not outweigh how unpleasant they are to wear.
With the Bangladesh study, they didn't enforce a mask mandate on the treatment group, just did "encouragement." The control group was at 13% masking vs 42% for the treatment. I would imagine the 11% reduction would be greater with higher adherence rates.
"Every person who makes it to the league is an insanely skilled genetic marvel that’s been through a decades-long process of evaluation by coaches and scouts."
Apparently a significant proportion of 7ft plus people in the US are in the NBA. Some of them must be pretty mediocre at everything other than being tall - genetic marvel height wise, but that's it.
Also, like the phrase "Genetic marvel", so much nicer than genetic freak.
It's far from a controlled experiment. Being tall is very visible to others and that will result in environmental effects like other people encouraging you, better access to resources, more self-confidence, and so on. It seems like having that support would tend to make mediocrity less likely than average in this group.
The obvious underlying variable is "general immune system effectiveness". Presumably an actual immunologist would be able to describe this better, but people vary in the strength of their immune response and the vaccine works by priming immune response. If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine. So the hospitalized, vaccinated patients probably have worse functioning immune systems than the hospitalized, non-vaccinated patients.
I expect the immunocompromised are still benefited by getting the vaccine. I wouldn't be surprised if this is another effective selection bias, where people with certain health conditions are much more likely to be vaccinated and so make it appear the non-vaccinated are relatively safer than they really are (because those pre-existing conditions are disproportionately in the vaccinated population).
Yeah, but the IFR is between 0.2% and 0.6%. The portion of the population that is at risk is the elderly, the infirm, etc. If the vaccine can't protect the most vulnerable then, since the general population is generally not at risk, then what good is it?
Yeah, I definitely agree. I was responding to "If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine." from Matt's post.
If people who are more at-risk are more likely to be vaccinated, then even if the vaccine reduces the IFR by a factor of 100, that could still be overwhelmed by the population differences.
I saw something I can't trace now when the post-trial vaccine data was first coming out saying that the reduction in the risk of death or serious symptoms when being vaccinated was equivalent to lowering age by between 20 and 30 years.
If you're an octogenarian then lowering your risk to that of an unvaccinated person in their fifties or sixties is good, but - if your unvaccinated population are all in their twenties, then the vaccinated are still going to be doing worse than the unvaccinated.
I strongly disagree with "the general population is generally not at risk".
There's this:
>The Delta variant surge reached critical levels in parts of the Central Valley this week, with some hospitals overwhelmed by a crush of COVID-19 patients and Fresno County officials warning they might take drastic action if conditions continue to deteriorate.
>Parts of the Central Valley as well as rural Northern California have become the hot zones for COVID-19 in the state even as hospitalizations are beginning to fall in many parts of California, most dramatically in Southern California and the Bay Area, which generally have higher vaccination rates.
>In a sign of how severe the crisis has become, Fresno County‘s health officer said Friday that hospitals may be forced to ration healthcare — choosing who receives lifesaving measures — because of dwindling resources.
>“The largest hospital systems that we have here in the county are telling us that they are over 100% of their normal capacity, and some of them are as high as 140%, which is really pushing the surge standards and really almost tipping us into what we call the ‘crisis standards of care,’” Dr. Rais Vohra, Fresno County’s interim health officer, said Friday.
And the 22-year-old subject of this story is the best friend of my cousin's son:
>He receives a steady stream of high-flow oxygen through a tube to his nose, with a monitor on his finger, six electrodes on his back and a port for an IV in his upper left arm. His arm shows deep bruises from being repeatedly stuck with needles. On standby is an oxygen mask that he has to put over the nasal tube to build up the strength he needs to move the 2 feet from the recliner to his bed.
Hospital crowding is a separate but related issue. And I am not sure what the stats are for Delta: there were apocryphal reports in the mass media that hospitals in India were seeing much younger patients than in the first wave. But at least with the original strain the profile for the seriously ill and those at risk for mortality skewed heavily towards the elderly and infirm, usually in combination.
In LA county in January, hospitalizations peaked at about 8000 Covid patients. From a primary care standpoint, I was taking care of patients that probably should have been hospitalized but we were doing everything we could to keep them at home b/c the ERs and hospitals were full. The hospitals managed to make room for more beds and stuck ICU beds in the ER or wherever they could, but the staff was stretched too thin to really care appropriately for all of these complicated patients. I'm sure people died that would've made it had they been hospitalized w/o that level of surge.
In the latest Delta surge, Covid hospitalizations peaked at about 1750 or so here in LA county and have been coming down for the last 2-3 weeks. But census at peak was very busy b/c non-Covid patients were hospitalized as well- sometimes for procedures that they put off during the pandemic. It got kind of crazy busy, but not scary busy if that makes sense. LA county was reporting much younger patients hospitalized than in the Jan surge. I can likely find those stats if you want them.
In Northern Ca/Central valley right now it's bad, though I don't closely monitor numbers. And one of my partners told me that her friend is a doc in Oregon and that they ARE already quietly rationing care to those who are more likely to survive. So there you go.
I admit that I am a little nonplussed by the relative lack of attention that is being paid to the current surge. Look at summer of last year: daily new cases never surpassed 100k a day. The US has been tallying 100k, 150k, almost 200k new cases a day for months now. And now there are media reports of overcrowded hospitals who are being forced to turn away patients, so I could certainly believe that conditions as described by your friend in Oregon are accurate.
And I haven't looked into this at all so take it with a grain of salt but I have heard it hypothesized that the summer surge of last year was primarily driven by southern states where high heat and humidity drove people into air conditioned interior spaces. Then the much larger winter surge was driven by northern states where people moved indoors due to snow and cold. And of course the winter surge dwarfed the summer season. It seems a little bit odd to me that this isn't a matter of greater media attention.
Slaw can correct me if I'm wrong but reading the full thread, I think he's saying that the vaccine is most important for the vulnerable, not that it is useless for everyone else - ie - if we can't even improve the IFR for the most vulnerable, we don't have a very good vaccine. (See the response to Erin E below). I constantly remind my younger patients who are reluctant to get the vaccine that we're not just talking mortality, but morbidity as well. Yeah, they may have very low risk of death, but they can still get super sick with Covid and no question: the benefit of the vaccine outweighs the risk, even for young adults.
Yes, indeed. I was nitpicking Matt's statement about the usefulness of the vaccine for the immunocompromised: "If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine." Given how heavily complications skew towards the elderly and infirm then a vaccine that cannot protect those specific populations is much less useful for society at large.
Part of this is the binary nature of the "immunocompromised" label when the reality of the situation is people having continuous variation along a bunch of different axes. Taking AIDS as an example, one definition is "CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3)". People with 199.9 & 200.1 probably have very similar outcome despite the binary of meeting this AIDS diagnostic criteria. I'm not sure how low CD4 counts can practically go, but the absolute lowest on that scale may get no benefit from the covid vaccines because the vaccines prime the immune response and those people don't have a substantial immune system to prime.
> Given how heavily complications skew towards the elderly and infirm then a vaccine that cannot protect those specific populations is much less useful for society at large.
This does not logically follow, even if the vaccine actually provided no protection to those most vulnerable subpopulations. The vaccine both directly and indirectly helps the vulnerable subpopulations, see my other response.
> The portion of the population that is at risk is the elderly, the infirm, etc.
We should be clearer about what "risk" means. Healthier people are at less risk of death, but the risk isn't 0, and the risks aren't restricted to death. Vaccines further decrease IFR and also lower hospitalization rates.
> If the vaccine can't protect the most vulnerable
The vaccine *does* protect the most vulnerable. It does that in two ways.
Directly, by improving their outcomes - across all data I've seen these people all have better now outcomes if they're vaccinated than not. Imagine the vaccine is a reduces IFR for a healthy person from 0.01% to 0.0001% and for an immunocompromised person from 2% to 1%. The immunocompromised person has less relative risk reduction (2x vs 100x) but a much more important absolute risk reduction (1% vs ~0.01%.
Indirectly, by reducing population spread. Even if you imagine someone for whom covid is 100% lethal that person derives a lot of benefit from everyone else being vaccinated. If you use a SIR model then the more people that get vaccinated rather than infected the lower that person's overall pandemic risk. If covid has a herd immunity threshold of 90% then the naive prediction is that that totally vulnerable person is about 90% to die without vaccines. But if 91% of the population gets vaccinated instead they're almost guaranteed to survive. This is probably the main reason people want vaccine mandates, is that while the vaccine is generally very effective there are vulnerable subpopulations that still face substantial risk.
Berkson's Paradox sounds like a particular form of survivor bias, or in some cases sampling bias? Also compare with Simpson's Paradox, which isn't about missing data points, but rather how you divided them up into different bins before taking averages.
Bravo! FdB goes out of his way not to call people dumb, just lacking information - which I do not believe for a minute. It doesn’t require complex statprob logic to understand how fear porn can be exploited on a gullible, receptive public. Per his example, Testing on the vaccine (technically a ‘shot’) excluded anyone who was likely to have complications. Including the aged, the overweight, diabetics, immune compromised , and pregnant women because, well, it would be unethical to test it on them, but were then immediately pushed to get vaccinated. Talk about subselecting!
The real question is, how are numbers being manipulated today?
The current diatribe: hospitalizations. Nevermind that hospitals aim for a standard 90% ICU occupancy rate anyway - just in time mode that doesn’t even leave room for a 10 car pileup. Now a Stanford study shows that half of all ‘COVID’ hospitalizations are not even due to COVID, but to other causes where patients tested positive but are asymptomatic.. MOOOOOO! MOOOOOO! Stampede!
Favorite line "(Distrust anyone who thinks less citizen thinking is better than more.)"
Hasn't that been the problem? We don't trust institutions that don't trust us to handle the transparent truth.
People are mad at Rogan for daring to say things that run against the mainstream because he has such a large platform and so undermining the push for universal vaccination. But he has such a large platform because he's willing to talk and think about issues giving air to various positions in an honest way. If our institutions were more honest they would retain greater influence and wouldn't need podcasters to keep in line. But they weren't...because they didn't trust their audience.
Fauci's fib about masks early on was ridiculous as it was something he was going to have to 180 on eventually. And it was pretty much right out of the gate to the most polarized audience of all time.
The value of masks vs mask mandates? In the case of New York State the first mask mandate was April 15 at which point mask use was already very high. And obviously mandating something that people are already dry doing is going to have a minimal effect. Some folks latched onto this to say A. This proves masks don’t work. B. This proves mask mandates don’t work.
Well, another issue with Covid is that involves exponential growth. For two people in a room, masks probably do nothing. But, if everyone is interacting with hundreds or thousands of other people, even a slight reduction in the spread rate can mean a tiny fraction of people get Covid. See 1.5^10 versus 2^10. Granted, I need looked into the effect of masks on the exponential growth rate, but it was another point where there was some basic math that many didn't understand.
As for your example, yeah, I don't think comparing states is a good metric. I had a grad degree in econ, and I know they look for quasi-random experiments. When they study minimum wage laws, for instance, they'll look at two places (city, state, country, etc.) voting on an increase, one where it narrowly passes and another where it narrowly. That way, the increase is plausibly "random." Whereas if we look a liberal states that increased and it and conservative states that didn't, we'll end up comparing cultural and political differences, not just the impact of the legislation
I did an unscientific study on my facbook page. I asked my friends to rate Masks, Vaccines and Ventilation in order of preference. Aside from a few blank slate friends who said "they're equally important!", most went 1. Vaxx, 2. Mask. 3. Ventilation.
Personally I go 1. Ventilation, 2. Vaxx and 3. Mask. With masks being WAAAY down the list.
Now I agree with Bronx Zoo that maybe we thought masks had NO effect do to selective data and I guess this paradox that Freddie is talking about. But I think there's a bigger issue with how the general public views any of these issues. Basically they focus on whatever the news focus's on. I have relatives in England where there's a huge ventilation campaign. "Wisk Covid away!" or some such slogan.
Here, in the US, it's so partisan. Masks and Vaccines can be easily put into camps. Ventilation? Would that really become a left / right issue? "The libtards are cramming fresh air down our throats!" "The MAGA maniacs want us to suffocate!"
It just doesn't wash in our 'Merican Coke vs Pepsi binary.
I was really disappointed with the lack of ventilation compared to surface cleaning. I still see so many places obsessively cleaning surfaces, but I have never seen a place leave it's doors/windows open for ventilation.
My guess is that this stuff is security theater. Ventilation doesn't look like doing anything, whereas cleaning a surface does
Yup. I was in a restaurant here in NY the other day. The waiters had masks but they didn't ask for Vax cards and they cleaned surfaces like crazy. Then a woman by the front door started coughing. I don't know if she was vaxxed. I was like "if you're not gonna' open the door I'll eat outside."
I have to say, I don't share your optimism on ventilation not being a partisan issue. There was a fad a few years back where lib-owning conservatives where rigging their cars/trucks to pollute this brutal black smoke. I will never underestimate what might be done to "own the libs"
Yeah, it's like you have to trick THEM into starting it. But of course then the Woke will call us Nazis if we do it too.
It's a lose lose situation.
I think part of the issue is staff preferences. As a dinner you may be fine with the AC off and the windows open. But that means the cooks are roasting back in the kitchen.
Good point. As usual the working class gets the short end of the stick.
A few words with reference to your comments to ventilation here in the UK.
Firstly, I genuinely adore the phrase 'Wisk Covid away!'. It's such a perfect idea of what public health campaigns used to sound like here. Hovever, among the innumerable things lost over the last thirty years or so has been the capacity for whimsy - the phase is the bluntly prosaic 'Let Fresh Air In or Meet Outside'.
Secondly, it has been a (literally) enlightening experience seeing the long-painted-over windows being opened for the first time in probably half a decade in the bougy coffee shops.
It turns out they were not just a bizarre stylistic choice coincidentally shared by all buildings built between 1700 and 1970. The huge windows are for light, and the top ones are for air! Infectious diseases fester in crowded areas. We knew this, and forgot.
London’s average high in August is 74 and 49 in January. Ventilation is an especially good option given the climate.
Yeah. Us Yanks can't live a week without our AC. But question. Can good central AC address the Ventilation issue? I haven't read much about this. Important if Covid becomes endemic, right?
Should I call my cousins in London & try to sell "Wisk Covid Away" as a slogan? Or maybe
Keep Calm
and
Crack The Shutters
(I know. It needs work. Ha!)
Could be a nice little earner!
"Pass A Pint with a Puff at the Porthole"
(Stop me.)
So many school buildings and office buildings have windows that don't even open. It's a pretty major problem.
A slower exponential growth rate just means that it takes longer for everyone to get infected. It doesn't imply a lower cap on the total number of people who will eventually become infected.
Not if a vaccine will be ready in less than a year.
That assumes that the immunity from a vaccine doesn't wane over time. And if you want to include the possibility of infection from new, vaccine escaping variants in your model (and in terms of public policy you probably do) the situation is even more complicated.
The only way your statement makes sense is if an extra year of healthy life has no value.
My point is that decreasing the rate at which you pour water into a glass just means that it takes longer to fill up the glass, not that the glass magically stops filling at the half way point. This point should be uncontroversial so I'm not sure what all the deflection is about.
I think it's perfectly plausible that masks are effective in the lab and useless in the real world. Given the complexity of the issue it's not surprising people can look at it and come away with two different conclusions.
What's the plausible scenario?
I trust myself to maintain protocol for about 10-15 minutes. Eight hours in the real world? Then you have to consider the odds of touching your mask, rubbing your eyes, removing it in the presence of co-workers to eat lunch, etc.
Most people aren't as opposed to masks as you are. And even if people take them off to eat - transmission would be reduced the other seven and half hours. And touching the mask isn't an issue as fomites aren't a vehicle for transmission.
I'm not opposed to masks, I just think there is just about zero evidence that they actually have a statistically significant effect in the real world. Certainly the evidence from the RCT's is a mixed bag, at best. I would actually say that the evidence from the RCT's is that masks are almost completely useless.
I listed out a number of actions that I think would undeniably dilute the effectiveness of masking in a real world setting. Do you really think most people aren't going to fall victim to inadvertently rubbing their eyes at some point during the day? And notice that your point is "transmission would be reduced", not "transmission would be eliminated". The problem with the first scenario is that if you are completely dead set against contracting the virus then short, occasional bouts of outside contact are all that you can afford. Repeated daily interactions that are many hours long over a period of multiple months? Even with a mask my guess is that contracting the virus becomes almost a certainty.
Your evincing so much motivated reasoning I'm worried you aren't open to masks being effective. What sort of burden of proof would you require to admit you've been wrong?
There is a new study showing a statistically significant effect of masks in the real world: https://med.stanford.edu/news/all-news/2021/09/surgical-masks-covid-19.html
I sucked at math too. But your basketball example made sense. Interestingly there's lots of videos about Simpson's paradox (which actually feels more complicated to me) than Berkson's.
I don't know how this effects Covid data specifically, (although like you I'd bet it does), but I'd also bet that our collective failure to grasp many of these large data math issues (paradox's, exponential growth, cost benefit analysis etc) contributes not only to misunderstandings about Covid and SAT scores but many other issues being argued by millions of pigeon chess champions on Twitter daily.
Sports, school, race bias, disease. "Do your own research!" No. Because I at least know that I'm not informed enough about how statistics work to do my own research. Most people don't.
(See how I centered myself at the end there like a good narcissist. Ha!)
I recently took a stats class for nursing and I think the most lasting lesson I learned was "holy crap I don't know much about data analysis." It's one of those things that you can't know till you know.
I have a PhD in physics and took 3 grad level stats courses (mostly because I wanted to; it wasn't required) and what I learned was mainly "holy shit I know nothing and there is a reason people are doing PhDs in stats". (there is a long history of physicists needing to get humble and I'm glad it came early for me)
I never understood randomness until a student, who happened to be a physics major, taking my intro stats class, explained to me what really happens at the far ends of a normal curve. Something about infinite space and time I still can’t get my mind around but made me realize the folly of trying to predict everything with stats
Not quite a paradox, but something everyone falls for:
A has a positive correlation with B.
B has a positive correlation with C.
"Statement about A being positively correlated with C."
But correlations are not transitive. It is possible for A and C to have no correlation, or even a negative correlation. The above claim can only be made with correlations very close to 1. Which pretty much never happens.
I'd like more citizen distrust, or at least hesitancy in this area. The default response to any random statistic should be "that's probably wrong". There are so many easy ways to make mistakes. We know that most Doctors don't understand sensitivity vs specificity. We are living through the replication crisis.
So yes, please more citizen thinking in this area. But it should mainly be critical thinking for the purpose of falsification.
The same problem causes us to underestimate the strength of correlations, and I believe that is happening with data on vaccine effectiveness. Just yesterday, there was a big CDC press release that “unvaccinated people are 11 times more likely to die” from covid-19. But they’re using surveillance data.
Vaccinated people with asymptomatic infections won’t show up in surveillance data because (for the most part) those people won’t know to get tested. So we aren’t counting a bunch of cases where vaccinated people had no symptoms. If we had data on those infections, the correlation between vaccination status and death would be stronger.
Specific studies where everyone gets tested will pick up asymptomatic infections, but we can’t necessarily generalize because conditions vary across time and place (new variants emerge, etc).
I'd like clearer statistics for children as well, I have a 5 and 7 year old. But there is no way children are 11x more likely to die. this chart is goofy to read but children's are < 1X likely to die than 18-29 year olds, that have a 4th of a chance that 30-39 year olds have, which nave 1/10 the odds of 40 - 49 years olds. I belive this is before vaccination.
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html
I have been ranting about this on the Slow Boring Substack for months now. As a PCP I think it's super important to be as objective and unemotional about Covid risks as possible. I can't tell you how frustrating it is to have a lack of clear, firm data and statistics. Numbers are freakin' all over the place depending on which study you read. We just don't have a firm handle on numbers vaccinated and numbers of breakthrough infections. The data on hospitalizations, ICU admissions and deaths are a little clearer. It makes it very difficult to know how to advise individual patients about their individual risks, especially for my vaccinated seniors. For them, there is a risk to both underestimating the risk, which could lead to a breakthrough infection (even w/o hospitalization, that could take quite a toll on a senior), and to overestimating risk, leading to repeat isolation and depression. How great is their risk if they are >6 months out from their second shot? How effective are boosters going to be? Don't know. Difficult to advise.
The federal government (CDC etc) has really failed us all here rather dramatically in not coordinating this sort of data, with clear universal standards for what gets counted as what.
Ok here we go. I'm gonna rant. LOL. It's not so much that I blame CDC or public health for not having accurate data. This has been an extremely difficult 18 months with a sudden unexpected pandemic and I really try to be unjudgmental about the lack of clear data. What frustrates me is when I see data that is clearly there but not being reported. (For example it was clear that vaccines were not as effective for the delta variant, but it took AT LEAST a month for CDC, public health and MSM to report that.)
And I am really angry and resentful when CDC/public health tie my hands from making my best recommendations based on what data I do have. For example: the J&J shots and booster shots. It was always clear that the J&J shots weren't as effective as the mRNA ones, but initially, we needed everyone vaccinated as soon as possible. I reasoned that I was not going to lie to my patients. My advice to patients who asked me about this was get the J&J now. Nothing would prevent someone from getting one of the mRNA ones in the future when supply was plentiful. I didn't realize this was going to be strictly forbidden. Or that my immunocompromised patient who got J&J would now be barred from getting a booster despite the mRNA vaccinated people being qualified. How does this make sense?
And where does the declaration of "8 months" booster come from? Why 8 months? Where is the data on that? I've seen data on 6 months, not 8. LA county public health just sent a vaguely threatening email to providers on Saturday that current boosters WERE ONLY APPROVED for the immunocompromised (a very narrow definition). So, for example, I had a 75 yr old insulin-diabetic, morbidly obese patient with heart problems see me last week. Her second Pfizer shot was early Feb. She is now >7 months out from that. I wrote a note for her to take to the pharmacy to get a booster. But, strictly speaking, she doesn't qualify for one and now that public health sent that email, I have to think twice about doing that. Yet, my 35-yr old patient on immunosuppressive medication for psoriasis does qualify. Is his risk of breakthrough/severe infection really greater than hers? I mean, maybe. Hard to say, right? I don't think we have enough data on that. But I'm doing the best I can with the data I do have and it makes me mad when all of these political (?) considerations are blocking me from doing what I think is best for my patients. This is not like in the beginning when we had a supply problem and people were jumping the line. Supply is not the issue. And, in fact, I'm worried supply WILL become an issue again when they open up the booster floodgates and everyone is trying to get their boosters.
Ok. Rant over. Thank you for listening. :)
It's horrifically complicated. I presume that the reason that the WHO strongly disagrees with the idea of booster shots for developed nations is partly due to the belief that low vaccination rates in the third world are driving the development of vaccine resistant strains. Is the world better off vaccinating the third world quickly if it means delaying boosters? What a mess.
Updated 5 days ago.
What You Need to Know
COVID-19 vaccines are safe and effective.
Millions of people in the United States have received COVID-19 vaccines under the most intense safety monitoring in US history.
CDC recommends COVID-19 vaccines for everyone 6 months and older and boosters for everyone 5 years and older, if eligible.
Even the number of Americans who have COVID will always be suspect, when the CARES Act dramatically incentivized healthcare providers, with a 20% bonus for Medicare patients, to inflate the figure.
I feel for you.
Wouldn't a covid diagnosis require a positive covid test on the medical record? Are you claiming these are being faked at a large scale? That would seem to be something that could be investigated.
Who would investigate it?
The Medicare Fraud Strike Force ought to be pretty interested: https://oig.hhs.gov/fraud/strike-force/
I'm really not sure what you're talking about here. This sounds like a conspiracy theory. Maybe this was true in the hospital but I don't think hospitals were incentivized to diagnosis Covid as you are claiming. Personally, I saw MC Covid patients, mostly via telehealth. Our reimbursement wasn't higher for that diagnosis. Actually (and I think I'd have to ask my office mgr/biller about this bc I really don't know much about billing), I vaguely remember that we weren't allowed to charge a copay if the diagnosis was Covid since this was covered by the CARES act and there was a guarantee that there would be no out-of-pocket cost for the patient. So I think for some insurances, we actually got less money. If you really want to know this stuff for sure, I can ask my office mgr and get back to you.
The 20% bonus for medicare recipients (and I suppose most COVID patients requiring hospitalization are Medicare recipients) was part of the CARES Act:
https://www.denverpost.com/2020/05/20/coronavirus-covid-medicare-payments-hospitals/
Note it's a bonus on all medical claims if the patient has COVID, not just on COVID-related procedures.
It beggars belief this is having no effect on the reporting of cases by the for-profit healthcare industry. This isn't conspiracy theory, this is simply expected behavior from an industry long known (according to 30 years of media reporting) for dubious practices in the pursuit of profits.
Given the existence of actual cash incentives for the over-reporting of cases, I would expect scrupulous researchers and journalists to couch their reporting in warnings and caveats, but I never, ever see them. So who knows what the real numbers are?
And I don't know what incentives there might be in place for COVID-related death certificates, but bizarre things have been happening there as well:
https://denver.cbslocal.com/2020/12/17/grand-county-coronavirus-deaths-covid/
https://www.cebm.net/covid-19/death-certificate-data-covid-19-as-the-underlying-cause-of-death/
PCR Covid tests are generally processed by a third party lab that would have no incentive to fake a huge number of covid diagnoses. There is point of care testing now, but it is done by the clinical team seeing the patient in real time. Physicians are truly not putting their licenses on the line to fake test results.
But who is reporting to . . . whomever compiles the gross numbers (Johns Hopkins University)? Surely not the labs themselves. Or are they?
The fact is, COVID over-reporting is certainly incentivized by the CARES Act. This is a fact you can't get away from, and one that has always bothered me.
How much over-reporting is occurring, which agencies are receiving the inflated numbers, if any, and where these numbers are used, would certainly be worthy of further investigation. Certainly any published numbers should be accompanied by warnings of some kind.
Instead, the response seems to be, "The numbers are accurate because, well, we really don't like the sort of people who would question the numbers in the first place; you know who we are talking about."
I don’t have any issue with questioning the data or motives of healthcare corporations but unless it’s based on something besides a gut feeling that they are probably doing something shady because there’s a monetary incentive then I don’t take it very seriously because I know a bit about how healthcare works.
First of all, the government absolutely does not want to pay hospitals and healthcare systems more than have too. They will audit and sue and are doing so on an ongoing basis. There is almost no chance that there is a nationwide effort by healthcare organization to commit Medicare fraud by making up covid diagnoses out of thin air without it having been caught. Particularly under presidential administrations that have a vested interest in making covid numbers look better rather than worse.
Second, I am not sure where John’s Hopkins gets it’s data but usually that kind of reporting comes from public health agencies from the county upward. Yes, the healthcare orgs are reporting their numbers to them but Medicare reimbursements are based on public health reporting of data. They are based on diagnosis coding which can be audited. It is not uncommon for healthcare orgs to have to pay back money if they use inappropriate coding that can’t be backed up in the chart or if they simply make mistakes.
Furthermore, healthcare orgs are subject to regular visits from accreditation bodies like the Joint Commission. TJC is not responsible for auditing coding and billing to my knowledge, but they are responsible for ensuring certain quality and safety metrics and are able to look into the patient records and it seems like a fraud at the level you are envisioning would be pretty evident in the record.
It’s not that I have faith in the goodwill of for profit healthcare organizations. It’s just that I don’t see how a fraud big enough to skew nationwide covid numbers could fly completely under the radar.
I appreciate you have confidence in institutions like the for-profit healthcare industry, government auditors and the US media (who report on all this stuff). Personally, I have no reason, based on past behavior, to harbor such confidence. Your skepticism may vary.
As I said, we know one fact: the CARES Act incentivizes over-reporting of COVID. From that unassailable fact I draw the conclusion: reported COVID rates are probably inflated. Maybe a negligible amount, maybe a lot. I have no idea. But I am almost certain they are. The credulous stenographers of the US media will never say. Again, your skepticism may vary.
That Medicare claimants are audited by bureaucrats does nothing to increase my confidence in the numbers (I say this as a guy who has received letters this year from the unemployment departments of both Nevada and California informing me that, sadly, they will have to stop sending me checks since they can't verify my identity. Though I am self-employed and never made a claim in either state, and certainly never received a check. And after Nevada helpfully reminded me they already paid me (or, rather, someone) almost $3,000. California hasn't revealed how much I (or someone) got them for). Back when I paid cash for all my medical needs (including a Mohs surgery), it was pretty obvious to me that insurance fraud, at any rate, was widespread among healthcare providers. This is simply my experience. Again, your skepticism may vary.
I'm trying to imagine how one of these Medicare audits might go:
Auditor: You say here that you had 15,540 COVID cases in February of 2021. Can I see the proof for that?
Hospital: Yes, it's right there in the files. See how every COVID case is accompanied by a test affidavit?
Auditor: Ah, so it is. Very good. And let's see, according to official records, your claims seem to jibe with the numbers for your county that month.* Everything looks ship-shape. Good-day!
* I think we can guess why.
It takes about 30 seconds of googling to find a case within the last several months where a large healthcare org in CA had to pay $30 million dollars to settle a justice department lawsuit that claimed they submitted inaccurate Medicare information.
Do I have faith that every instance of fraud or incompetency is immediately rooted out and healthcare is nothing but rainbows and butterflies with impeccable integrity? No. But I am saying with a fair amount of confidence that at least one healthcare org would by now have been caught if they were literally putting fake covid test results in the record to get fraudulently reimbursed. You still have not given a shred of evidence or even a theory of how this is happening.
3 horror stories of deaths that were not reported - and those were related to me by nurses.
In general I suggest we all NOT think about basal rates, cutpoints, and excluded portions of sampled populations as we continue to stumble our way through this pandemic, because almost none of us are capable of thinking about such things usefully.
If you want "to cultivate a respect for the work we all need to do in order to better understand where we are with this disease", the key point is that this work is not possible for the vast majority of us.
As in almost all areas of life, the best strategy is to identify a set of trustworthy experts, and follow their advice. That trust is earned through previous accomplishments.
"Previous accomplishments" for the public health community includes saying it was selfish and harmful to wear a mask and insisting the Covid was not airborne. The trouble is that we've been living through decades of collapsing trust in elites and institutions, which has been driven by the repeated failures of elites and institutions. (See: 9/11 and everything that came of it )
Early on, it WAS selfish and harmful to wear a mask because the totally inadequate supply was needed by front-line workers, and the disease had not yet widely spread. And early on, the airborne nature of covid was not established. Science is provisional: whether or not covid could travel and remain infectious in aerosols was not clear. I do fault the public health community for not making the first argument clearly, for not being prepared (stockpiled PPE), and for not being willing to say "we don't know yet, this is our best guess at the moment" more forthrightly.
All that said, who ya' gonna trust? If public health depended on results in my own field of expertise (which, very thankfully, is not the case), I can tell you that I absolutely would not turn to the general public for advice. I am 100% sure that debates among the general public would be utterly useless for reaching the best possible result, or even a decent result. Which we are seeing right now.
The Dunning-Kruger effect is real, and far more important to the current crisis than Berkson's bias, which I expect to be well understood by the experts.
> Early on, it WAS selfish and harmful to wear a mask because the totally inadequate supply was needed by front-line workers
This is true only if you understand mask to mean "surgical mask" and isn't true once you allow for improvised cloth masks that also provide (some) protection.
> And early on, the airborne nature of covid was not established.
This seems circular - excusing the (western - IIUC various Asian public health systems did not make these mistakes) public health community for its mistake by appealing to its beliefs. What else would "established" mean in that sentence?
> All that said, who ya' gonna trust?
Zeynep Tufekci. AFAICT every time she's deviated from the CDC recommendations she's been right and they've been wrong. She has the substantial advantage of getting to read the CDC reports, so it's not like we could replace the CDC with just Dr Tufekci and get the same result.
It isn't about "turning to the public for advice", it's about understanding that truth does not actually flow from authority and that the general public should, in principle, be able to verify what is being said.
So you've picked an expert to trust, based on evidence of their competence. Please note: that's exactly what I recommended.
But in order to pick your expert to follow, you had to do enough due diligence to make that decision. For people who are not able to do that (for whatever reason: constraints of time, personal expertise, etc), following the guidance of the public health authorities (which as you've correctly noted is not always right) remains the best strategy.
Which is pretty much also what Carina said below.
That's a fraught (but maybe unavoidable) position for modern society in general. It's an exceptionally problematic standard for Covid given the number of dramatic and humiliating reversals that the public has been witness to.
What you call "dramatic and humiliating reversals" seem to me to be the unavoidable consequences of making "best guesses" with imperfect information.
The problem is two fold: are those public pronouncements presented as "best guesses" with the expected and attendant uncertainty and potential for reversal? And are there perhaps special interest groups who have a vested interest in projecting certainty where it isn't warranted?
Are you reading their actual recommendations or are you relying on media reports? The vast majority of the actual recommendations did contain a great deal of uncertainty. But the condensed media reports didn't deal with all the nuance.
The issue is the general reaction of the lay public. You know what scientists really, really like to do? Argue with one another. Way back when in the early 1900's college counselors were telling their brightest students to skip fields like physics. The assumption was that almost everything was figured out and with no questions left to answer all that would remain would be the domain of engineers.
The only reason that anybody gets a degree in the sciences is because of all the unanswered questions still out there. Arguing about the possible answers to those questions just naturally comes with the territory. All of the "Believe in science" or "I trust scientists" nonsense? Not reflective of a reality where the important questions are still unanswered and being debated. And that of course means that the modern formulation of scientists as all knowing techno priests is so much bunk.
Of course - but you're blinded by your own cognitive biases and related motivated reasoning. So blind that you don't even acknowledge its existence.
Agree with both you and Slaw here. I think public health and CDC knew that masks had some benefits but there was a shortage of supply. So they elected to go with the "masks don't help" line b/c the hospitals and clinics were in such short supply. I think it would have been better to have been up front about it: "masks may be beneficial, but we have a short supply and need them for hospital workers." In the end, their white lie didn't really increase supply; it just caused mistrust. And people aren't stupid: if it's beneficial to protect hospital workers, it must be beneficial for the public in general.
When it was clear to me in early July that the vaccine was not "90-95%" effective against delta, I kept wondering why they weren't reporting on that. My assumption was that it was a political calculation: that CDC was afraid if they said people were getting significant breakthrough infections, people would say "why should I get vaccinated? Vaccinated people are still getting Covid." So, instead of warning vaccinated individuals that they may not be as protected as they originally thought, they hid or shaded the truth for a while for other political reasons. When I said this to my husband at the time, he accused me of conspiracy thinking. Ok, fair enough. But sometimes it really does seem like they are not always being forthright with their "best guesses."
Question - how are breakthrough cases validated? For example if I come to you as a patient and you diagnose me with Covid presumably you'd ask - have you been vaccinated? Not wanting to sound like an idiot I say yes - is that as far as it goes?
It depends. So here's a study from LA county where they matched positive Covid tests to vaccination data, from the California registry. https://www.cdc.gov/mmwr/volumes/70/wr/mm7034e5.htm?s_cid=mm7034e5_w
They admit in their discussion that they may actually be missing vaccinated status if someone was vaccinated outside California. My husband works for Kaiser, which, in general, has great data. I remember you were part of the discussion on Slow Boring when I was talking about the hospital data for Southern California Kaiser back in July, which was reporting about 10-13% vaccinated, hospitalized patients. You were pretty scornful of the data bc you thought people would lie about their vaccination status. TBH I'm not 100% sure how they gathered that data. My guess is that it was a mix of having records on vaccination from Kaiser itself and self-reporting.
When someone comes to me and says they were vaccinated and now have Covid, it's also a mix of data. We're trying to keep track of pt's Covid vaccination records when they come for appts. So often we already have their vaccination status (unless they have a forged vaccine record). But often they just tell me. I guess if they're lying, I wouldn't know for sure.
Are you asking patients to bring their vaccine records? I've been to a few doctors appointments and didn't bring my records and no one asked to see them. They just asked me if I've been vaccinated.
An extended family member who works in healthcare has Covid symptoms and knows that she no longer has antibodies (she was early in the vaccination line). So at what point does the question have you been vaccinated become less meaningful than do you have antibodies?
If you want a dataset that is presumably more reliable about whether someone has actually been vaccinated, you could look to Ontario, where everyone's vaccination records are connected to their provincial health card (which covers 97% of the population; the confounder there is that the 3% who don't have provincial health insurance are largely immigrants, who do have higher COVID risks).
https://covid-19.ontario.ca/data
This guy processes it into relative rates, although a big caveat is that the province does not yet release the data by age group: https://twitter.com/EdTubb/status/1437780646684995594
You know, I read all the news reports about Manaus and wondered "Why isn't anybody talking about this?" Then I read the news stories coming out of India and I wondered "Why isn't anybody screaming their head off about this?" Do you really have to be that paranoid to wonder if maybe there are vested interests that are eager to downplay bad news associated with the pandemic? Like maybe there's a good possibility that there's going to be an outbreak this winter (to go along with the rather large outbreak we are experiencing right now) and an attendant economic impact?
FWIW right now I'm looking at the efficacy of the flu shot over the years. On average 40-60% effective in any given year with a low point of around 10%. I don't mean to suggest that it is completely predictive of what happens with Covid but it is an interesting data point.
Yes changing your mind when new information becomes available is dramatic and humiliating. Tells us everything we need to know about your thought process.
Let me put it this way: based on the state of the science vis a vis masks I would say good public policy is something like "Go ahead and wear them. Can't hurt, might help." On the other hand "You are the antichrist if you refuse to wear them" is probably not consistent with our level of certainty.
I assumed “we all” meant “people who made it to the end of this post” rather than literally everyone. The people I know who think they’re “doing their own research” believe every conspiracy theory they see on Facebook.
I’d advise the average stats-illiterate person to listen to the CDC just for lack of an alternative. What else can you really tell someone who can’t make sense of conflicting arguments? I’m not going to say “read the studies and think about selection.”
Of course, those of us who dig into the research can advise our friends and family. I started wearing masks in March 2020 (already had a box) and told my parents to do the same.
Emily Oster does a good job of giving parents the latest evidence, and explaining it in an accessible way. But I only listen to her because I read her book and trust her to make sense of the studies.
Well, obviously we depend on trust in others. Nobody is doing their own studies, and we mostly aren't in a position to talk to experts ourselves.
I don't think it follows that knowing statistics isn't useful, if you can manage it. It would seem similar to how knowing something about cars helps you pick a good mechanic? You want to understand the terminology well enough to tell when people are blowing smoke.
Ideally, mechanics would give equally good service to people who know nothing about cars, doctors would give equally good care to people who know nothing about medicine, and financial advisors would give equally good service to people who don't know about money, but this isn't always the case.
And to the extent that the experts do give equally good service to anyone, in part it's because some customers are savvy enough to check.
(Or in many cases, they have friends or relatives who can advocate for them.)
I suspect that the narrative on mask wearing is much more complex than the popular narrative.
Consider: in 2017 about 60,000-80,000 US'ians died from the flu. It was a particularly bad season. But even over "normal" years tens of thousands of people in this country can be expected to perish. Add that up over the course of decades and it's in the range of hundreds of thousands of fatalities.
Mask wearing has been common in places like Japan and S. Korea for decades. as a countermeasure not for Covid but for the flu. And yet US health authorities never seriously considered issuing guidance on mask wearing, even during the flu scare during Obama's administration. And global authorities, such as at the WHO, have been even more reluctant to endorse mask wearing, even in the face of Covid. Why?
My guess is that it's simply because all of the trials and observational studies that examined mask wearing in Asia versus the rest of the world was never able to produce a statistically significant effect. And, most critically, initial mask guidance on Covid was 100% consistent with mask guidance on the flu: namely, that they weren't needed.
I honestly think that the mask discourse in the US is nuts. Disclaimer - I am 100% fine with wearing a mask in indoor settings. I don’t believe there is any downside and there appears to be at least some upside with properly worn surgical or higher grade masks. But the way the discourse in the United States goes, it honestly seems like liberals have become magical thinkers about masking because it is a visible marker that makes people FEEL safe. I think that’s why more than anything else some people will never be okay with giving up the mask.
I have not personally seen any convincing data that cloth masks do very much of anything (although again they don’t bother me and I’ve worn them). A recent study from India that had a way of looking at a control group did show protective benefits from surgical masks though not as high as you’d think from the discourse. I only have my kids wear surgical masks at school now even though I hate the waste. If they are going to wear one, might as well make sure it’s somewhat effective.
But I think the mask is too strong a symbol of covid seriousness/covid denialism for most people to be objective about the data.
Yeah it got slotted into the culture war really fast. I wore a mask early on since it seemed like it had a chance of a large upside with basically no downsize. Soon it become liberals screaming that masks will single handedly defeat COVID and conservatives screaming that they'll suffocate and die if they wear a mask for five consecutive seconds.
Our local research university did early mask testing. The volunteer group I joined to make masks during the shortage used those guidelines and high quality double layer quilters cotton. https://newsroom.wakehealth.edu/News-Releases/2020/04/Testing-Shows-Type-of-Cloth-Used-in-Homemade-Masks-Makes-a-Difference#:~:text=Testing%20was%20done%20by%20the%20Manufacturing%20Development%20Center,masks%20%2862%25%20to%2065%25%29%20and%20N95%20masks%20%2897%25%29.
Agree about that study out of Bangladesh. It’s being touted as proof that “The Masks Were Working All Along,” as the headline of a recent article in the Atlantic by Derek Thompson has it. But if you read the fine print, you discover that the study actually showed that the villages in which adults wore surgical masks (note: not the cotton masks most of us wear) had 10 percent fewer infections than the villages that were less diligent about mask-wearing. In other words, a measurable but underwhelming effect.
At least the study isolated mask-wearing from all other factors; most of the “evidence” for the effectiveness of masks in the US is observational rather than a random controlled study that isolated mask-wearing from all other factors, as the Bangladesh study did. The US “evidence” for mask-wearing comes from comparing paired towns or states, in which multiple interventions are happening simultaneously (not just mask-wearing but also more social distancing, business closures, etc), and whose populations have markedly different attitudes to Covid (blue towns with highly scrupulous and worried people tend to follow all restrictions, including mask-wearing, while red towns with lots of Covid deniers tend to have more unmasked people crowding into indoor spaces, for example).
For me the takeaway is that mask-wearing is probably a bit helpful in certain situations (for example, I just flew from DC to Switzerland, and I was glad everyone was wearing masks in the airports and the plane). But the Bangladesh study shows that masks are not a panacea, and in many circumstances their minimal effectiveness may not outweigh how unpleasant they are to wear.
With the Bangladesh study, they didn't enforce a mask mandate on the treatment group, just did "encouragement." The control group was at 13% masking vs 42% for the treatment. I would imagine the 11% reduction would be greater with higher adherence rates.
"Every person who makes it to the league is an insanely skilled genetic marvel that’s been through a decades-long process of evaluation by coaches and scouts."
Apparently a significant proportion of 7ft plus people in the US are in the NBA. Some of them must be pretty mediocre at everything other than being tall - genetic marvel height wise, but that's it.
Also, like the phrase "Genetic marvel", so much nicer than genetic freak.
It's far from a controlled experiment. Being tall is very visible to others and that will result in environmental effects like other people encouraging you, better access to resources, more self-confidence, and so on. It seems like having that support would tend to make mediocrity less likely than average in this group.
Are you saying that life isn't a controlled experiment? :)
The obvious underlying variable is "general immune system effectiveness". Presumably an actual immunologist would be able to describe this better, but people vary in the strength of their immune response and the vaccine works by priming immune response. If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine. So the hospitalized, vaccinated patients probably have worse functioning immune systems than the hospitalized, non-vaccinated patients.
I expect the immunocompromised are still benefited by getting the vaccine. I wouldn't be surprised if this is another effective selection bias, where people with certain health conditions are much more likely to be vaccinated and so make it appear the non-vaccinated are relatively safer than they really are (because those pre-existing conditions are disproportionately in the vaccinated population).
Yeah, but the IFR is between 0.2% and 0.6%. The portion of the population that is at risk is the elderly, the infirm, etc. If the vaccine can't protect the most vulnerable then, since the general population is generally not at risk, then what good is it?
How do you define "protect"? Reduction in seriousness of symptoms is an important metric.
Yeah, I definitely agree. I was responding to "If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine." from Matt's post.
The IFR for subsamples is much higher than that, though.
Just going by age, the IFR for people aged 90 is 5000 times that for people aged 20.
(source: https://www.nature.com/articles/s41586-020-2918-0)
If people who are more at-risk are more likely to be vaccinated, then even if the vaccine reduces the IFR by a factor of 100, that could still be overwhelmed by the population differences.
I saw something I can't trace now when the post-trial vaccine data was first coming out saying that the reduction in the risk of death or serious symptoms when being vaccinated was equivalent to lowering age by between 20 and 30 years.
If you're an octogenarian then lowering your risk to that of an unvaccinated person in their fifties or sixties is good, but - if your unvaccinated population are all in their twenties, then the vaccinated are still going to be doing worse than the unvaccinated.
I strongly disagree with "the general population is generally not at risk".
There's this:
>The Delta variant surge reached critical levels in parts of the Central Valley this week, with some hospitals overwhelmed by a crush of COVID-19 patients and Fresno County officials warning they might take drastic action if conditions continue to deteriorate.
>Parts of the Central Valley as well as rural Northern California have become the hot zones for COVID-19 in the state even as hospitalizations are beginning to fall in many parts of California, most dramatically in Southern California and the Bay Area, which generally have higher vaccination rates.
>In a sign of how severe the crisis has become, Fresno County‘s health officer said Friday that hospitals may be forced to ration healthcare — choosing who receives lifesaving measures — because of dwindling resources.
>“The largest hospital systems that we have here in the county are telling us that they are over 100% of their normal capacity, and some of them are as high as 140%, which is really pushing the surge standards and really almost tipping us into what we call the ‘crisis standards of care,’” Dr. Rais Vohra, Fresno County’s interim health officer, said Friday.
https://www.latimes.com/california/story/2021-09-10/fresno-hospitals-on-brink-of-rationing-care-amid-covid-surge
And this:
>Alabama man dies after being turned away from 43 hospitals as covid packs ICUs, family says
https://www.washingtonpost.com/health/2021/09/12/alabama-ray-demonia-hospitals-icu/
And the 22-year-old subject of this story is the best friend of my cousin's son:
>He receives a steady stream of high-flow oxygen through a tube to his nose, with a monitor on his finger, six electrodes on his back and a port for an IV in his upper left arm. His arm shows deep bruises from being repeatedly stuck with needles. On standby is an oxygen mask that he has to put over the nasal tube to build up the strength he needs to move the 2 feet from the recliner to his bed.
https://www.stltoday.com/news/local/metro/on-mend-again-from-covid-19-o-fallon-mo-man-warns-just-don-t-be/article_d6040319-de39-53c7-8164-6c9ef5a43d4b.html
Hospital crowding is a separate but related issue. And I am not sure what the stats are for Delta: there were apocryphal reports in the mass media that hospitals in India were seeing much younger patients than in the first wave. But at least with the original strain the profile for the seriously ill and those at risk for mortality skewed heavily towards the elderly and infirm, usually in combination.
In LA county in January, hospitalizations peaked at about 8000 Covid patients. From a primary care standpoint, I was taking care of patients that probably should have been hospitalized but we were doing everything we could to keep them at home b/c the ERs and hospitals were full. The hospitals managed to make room for more beds and stuck ICU beds in the ER or wherever they could, but the staff was stretched too thin to really care appropriately for all of these complicated patients. I'm sure people died that would've made it had they been hospitalized w/o that level of surge.
In the latest Delta surge, Covid hospitalizations peaked at about 1750 or so here in LA county and have been coming down for the last 2-3 weeks. But census at peak was very busy b/c non-Covid patients were hospitalized as well- sometimes for procedures that they put off during the pandemic. It got kind of crazy busy, but not scary busy if that makes sense. LA county was reporting much younger patients hospitalized than in the Jan surge. I can likely find those stats if you want them.
In Northern Ca/Central valley right now it's bad, though I don't closely monitor numbers. And one of my partners told me that her friend is a doc in Oregon and that they ARE already quietly rationing care to those who are more likely to survive. So there you go.
I admit that I am a little nonplussed by the relative lack of attention that is being paid to the current surge. Look at summer of last year: daily new cases never surpassed 100k a day. The US has been tallying 100k, 150k, almost 200k new cases a day for months now. And now there are media reports of overcrowded hospitals who are being forced to turn away patients, so I could certainly believe that conditions as described by your friend in Oregon are accurate.
And I haven't looked into this at all so take it with a grain of salt but I have heard it hypothesized that the summer surge of last year was primarily driven by southern states where high heat and humidity drove people into air conditioned interior spaces. Then the much larger winter surge was driven by northern states where people moved indoors due to snow and cold. And of course the winter surge dwarfed the summer season. It seems a little bit odd to me that this isn't a matter of greater media attention.
Slaw can correct me if I'm wrong but reading the full thread, I think he's saying that the vaccine is most important for the vulnerable, not that it is useless for everyone else - ie - if we can't even improve the IFR for the most vulnerable, we don't have a very good vaccine. (See the response to Erin E below). I constantly remind my younger patients who are reluctant to get the vaccine that we're not just talking mortality, but morbidity as well. Yeah, they may have very low risk of death, but they can still get super sick with Covid and no question: the benefit of the vaccine outweighs the risk, even for young adults.
Yes, indeed. I was nitpicking Matt's statement about the usefulness of the vaccine for the immunocompromised: "If your immune system is bad (immunocompromised) the vaccine does relatively little to help you and you're much more likely to get seriously sick from covid, with or without the vaccine." Given how heavily complications skew towards the elderly and infirm then a vaccine that cannot protect those specific populations is much less useful for society at large.
I reject your nitpicks.
Part of this is the binary nature of the "immunocompromised" label when the reality of the situation is people having continuous variation along a bunch of different axes. Taking AIDS as an example, one definition is "CD4 cells falls below 200 cells per cubic millimeter of blood (200 cells/mm3)". People with 199.9 & 200.1 probably have very similar outcome despite the binary of meeting this AIDS diagnostic criteria. I'm not sure how low CD4 counts can practically go, but the absolute lowest on that scale may get no benefit from the covid vaccines because the vaccines prime the immune response and those people don't have a substantial immune system to prime.
> Given how heavily complications skew towards the elderly and infirm then a vaccine that cannot protect those specific populations is much less useful for society at large.
This does not logically follow, even if the vaccine actually provided no protection to those most vulnerable subpopulations. The vaccine both directly and indirectly helps the vulnerable subpopulations, see my other response.
> The portion of the population that is at risk is the elderly, the infirm, etc.
We should be clearer about what "risk" means. Healthier people are at less risk of death, but the risk isn't 0, and the risks aren't restricted to death. Vaccines further decrease IFR and also lower hospitalization rates.
> If the vaccine can't protect the most vulnerable
The vaccine *does* protect the most vulnerable. It does that in two ways.
Directly, by improving their outcomes - across all data I've seen these people all have better now outcomes if they're vaccinated than not. Imagine the vaccine is a reduces IFR for a healthy person from 0.01% to 0.0001% and for an immunocompromised person from 2% to 1%. The immunocompromised person has less relative risk reduction (2x vs 100x) but a much more important absolute risk reduction (1% vs ~0.01%.
Indirectly, by reducing population spread. Even if you imagine someone for whom covid is 100% lethal that person derives a lot of benefit from everyone else being vaccinated. If you use a SIR model then the more people that get vaccinated rather than infected the lower that person's overall pandemic risk. If covid has a herd immunity threshold of 90% then the naive prediction is that that totally vulnerable person is about 90% to die without vaccines. But if 91% of the population gets vaccinated instead they're almost guaranteed to survive. This is probably the main reason people want vaccine mandates, is that while the vaccine is generally very effective there are vulnerable subpopulations that still face substantial risk.
Berkson's Paradox sounds like a particular form of survivor bias, or in some cases sampling bias? Also compare with Simpson's Paradox, which isn't about missing data points, but rather how you divided them up into different bins before taking averages.
I think some people feel that Berkson's and Simpson's are essentially the same. I'm not informed enough to proffer an opinion on that.
The explanations here seem useful: https://stats.stackexchange.com/questions/445341/simpsons-paradox-vs-berksons-paradox
Bravo! FdB goes out of his way not to call people dumb, just lacking information - which I do not believe for a minute. It doesn’t require complex statprob logic to understand how fear porn can be exploited on a gullible, receptive public. Per his example, Testing on the vaccine (technically a ‘shot’) excluded anyone who was likely to have complications. Including the aged, the overweight, diabetics, immune compromised , and pregnant women because, well, it would be unethical to test it on them, but were then immediately pushed to get vaccinated. Talk about subselecting!
The real question is, how are numbers being manipulated today?
The current diatribe: hospitalizations. Nevermind that hospitals aim for a standard 90% ICU occupancy rate anyway - just in time mode that doesn’t even leave room for a 10 car pileup. Now a Stanford study shows that half of all ‘COVID’ hospitalizations are not even due to COVID, but to other causes where patients tested positive but are asymptomatic.. MOOOOOO! MOOOOOO! Stampede!
Favorite line "(Distrust anyone who thinks less citizen thinking is better than more.)"
Hasn't that been the problem? We don't trust institutions that don't trust us to handle the transparent truth.
People are mad at Rogan for daring to say things that run against the mainstream because he has such a large platform and so undermining the push for universal vaccination. But he has such a large platform because he's willing to talk and think about issues giving air to various positions in an honest way. If our institutions were more honest they would retain greater influence and wouldn't need podcasters to keep in line. But they weren't...because they didn't trust their audience.
Fauci's fib about masks early on was ridiculous as it was something he was going to have to 180 on eventually. And it was pretty much right out of the gate to the most polarized audience of all time.
I think this line underrates how bad a lot of citizen thinking is when it comes to things that involve even moderately difficult stats.
actually, no need for the 'moderately difficult'. just stats