Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Strategy in the Age of COVID-19: Just Assume You Are Wrong

“I” before “E” except after “C” and when sounding like “A” as in neighbor or weigh, and on weekends and holidays and throughout May, and you’ll always be wrong no matter what you say!!” –Brian Regan

Not surprisingly this came to mind as Beth and I were talking about the best, or right, or acceptable way to start to resume life outside of our houses. How to return to the office, go to the grocery store, visit a family member or a friend. Fantastically superistically smart people who spend their entire lives thinking about this kind of stuff haven’t been able to find even the tiniest kernel of agreement, and yet we poor intellectual peasants are out here picking at their intellectual crumbs as we try to do the right thing. Go out/stay in? Hug the grandchild or wave? Mask/no mask? You get the idea.

The issue of testing is a great example of the conundrum faced by both the intelligentsia and the hoi polloi. It’s not even as easy as test or don’t test. Nah, that’d be altogether too easy. You gotta decide which test. Do you have the virus now? 4, 5, maybe 6 tests to choose from, all of which are substandard when it comes to accuracy in a normal world. Which one do you choose? How many times must you be tested? How long between? Have you ever had the virus? Meh, same issues. All but the most recently pseudo-approved tests in both categories take days to return a result. Does it really matter, that result, after it’s been a couple or a few days? Is it better to choose a slightly less accurate test in order to get the result within minutes, or wait for a slightly more accurate result arriving soon come? Now decide if you should venture out based on your decision.

See? No matter what you do you’re wrong.

We have all lost sight, at least a super majority of our government officials and many of our non-governmental experts have lost sight, of what “flatten the curve” was meant to do. It all made so much more sense, and the resulting overshoot on stuff like saving PPE for the tip of the spear workers was more tolerable, when we had a clear mandate that could be graphed accurately: prevent the surge of infected individuals from flowing over the level at which our acute care facilities would run out of space and materials necessary to provide the highest levels of care. Easy. Easy to be right. There were no extrapolations necessary to see if you were succeeding; you used real data. The line below which you succeeded was a known number: ICU beds + respirators. Nowhere in the U.S. have we seen the tragedies of Lombardy where doctors had to decide who made it into the ICU and who did not. We saw the curve, we understood the curve, and we successfully flattened the curve.

So what’s been lost? It’s a little more difficult to understand the concept of the AREA under the curve. How many people either get sick with the virus or die from the virus. Very few of our experts showed the far right side of their graphs. Fewer still gave any explanation regarding the dirty little secret of “flattening the curve”: all you are doing is pushing out the infections and resultant deaths from the virus. Pushing them out further in time. Flattening the curve simply means that you are not having EXCESS deaths caused by insufficient acute care availability in an overwhelmed  system. Without either a vaccine to prevent infection or a medication that treats the virus such that people don’t die, the same absolute number of people will eventually become infected, same number of people will become sick, and the same number of people will die.

Let me say that again so that it is clear: flattening the curve saves only those excess lives lost to insufficient hospital resources during a surge. Over time it does not save lives unless a vaccine and/or treatment arises.

Once again, no matter what you do, just like “I” before “E”, if you persist in flattening the curve edicts you are wrong unless you have a hard arrival date for a vaccine or a treatment/cure. You see, lockdown policies such as those in place in much of the world now are not entirely benign when it comes to health. Or death. Lockdown policies that mandate isolation, especially those that make it difficult to take care of what would otherwise be well-controlled chronic medical problems, actually cause EXCESS deaths. How many? The cold reality is that not a single model is capable to telling us that. Or at least telling us with enough degree of certainty and accuracy that we could titrate the “flattening” policies in such a way that the EXCESS deaths caused by the lockdown are more tolerable to a society than the excess deaths caused by system overload. No flattening of the curve? Excess deaths from system overload. Extend the curve? Excess deaths caused by solitude, reduced access to typical medical care, and the well-known health effects of an economic recession or depression.

Are the experts saving lives by insisting on these draconian lockdown policies across the country? Sure. Today. They are saving the lives of those who would not survive a viral infection should they become infected today. Are these lives that will ultimately be saved from being ended by the virus entirely? As of today the answer is a resounding “No” despite the earnest pleas and declarations from the various governmental pulpits. Absent a vaccine or a treatment/cure the math is as inescapable as math can be: the area under the curve, flattened or not, remains the same if you look far enough to the right. Deaths from the virus will be equal over time.

The REAL curve, the one we’ve yet to see and the one we are unlikely to see from those same pulpits, is one that adds the deaths from the virus to the excess deaths caused by the lockdown policies. Preventable deaths from untreated or inadequately treated cardiac disease or cancer for example.  That curve will show that no matter what you do, at home or behind the desk where you sign the lockdown edict, you will be wrong. That’s what makes this all so discouraging for me. What makes it all so dark. You can’t be right. Like “I” before “, be it May or just any old today, no matter what you do you’ll be wrong. Literally the only thing that changes that is a vaccine or a cure, two highly elusive solutions, the  achievement of which historically takes years, not months. Only then does the curve flatten to zero. Only then can we say that lives in the absolute have been saved.

There is only one thing left now, and that is a vaccine or a cure. Whatever light remains in the shadow of the virus, it exists here. Will it be months as we’ve been told? Will this virus fall to a vaccine in months where prior scourges took years to defeat (HIV), while we still await victory over others (Ebola)?  We must all pray that in this one single instance the people who are leading us are not wrong. For if they are wrong, if the area under the curve is the same no matter what shape the curve takes, it will upon the souls of our Government, our elected and appointed leaders, that each excess lockdown death will weigh.

“I” before “E” as directed by “G” means that the weight of being right falls on them, not on you or me.

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