COVID-19 in BC:
From Eric Sigmund: To what extent are we utilizing evidence on COVID-19 testing sensitivity/specificity to approximate post-test probability values? This is obviously critical in guiding public health protocols to mitigate viral transmission, yet it really doesn't seem to get enough attention; this is especially concerning considering the studies (such as the one linked below) showing significant false-negative rates. For example, in this particular study, the false negative rate was at least 20%.
My COVID-19 rants:
March 12th, 2020
Summary of some of my humble opinions:
1) Close schools and universities proactively rather than reactively, using technology to continue classes/learning remotely where possible.
Stanford University has set a good example of this. The closures would have the additional benefit of increasing the pressure on employers to accommodate telecommuting so that parents can be at home with their children. Although the studies relevant to COVID-19 are limited, there is still significant evidence to support immediate school/university closures. An example of such evidence is provided below.
Markel H, Lipman HB, Navarro JA, et al. Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic. JAMA. 2007;298(6):644–654. doi:10.1001/jama.298.6.644
2) Support employees in exercising their right to work from home as much as possible.
To give a sense of how much progress is required in this domain, in the past week I have had several patients come to the medical clinic for sick notes (requested by their employers) after they correctly heeded advice by not attending work with significant cold-like symptoms.
3) Increase telehealth services offered to patients so that they can avoid attending a medical clinic as much as possible.
Most visits to a family doctor do not require a physical exam, so we could immediately reduce the number of in-person visits by more than half. This is especially important when considering that the cohort of patients attending a clinic on any given day is disproportionately older or otherwise vulnerable due to various chronic medical conditions. With this in mind, it is difficult to justify unnecessarily exposing such a patient who only needs a simple medication refill that could have been provided via telehealth. For any physicians reading this who are unsure where to start in initiating telehealth services, please feel free to message me for assistance.
4) Improve and expand coronavirus testing protocols to increase accessibility and decrease risk to patients and health care providers (e.g., establish drive-through testing stations).
South Korea has demonstrated many examples of such protocols. These protocols should reduce iatrogenic transmissions while helping to close the gap between the number of known cases and the number of actual cases of COVID-19. Otherwise, the gap will remain large and thereby limit the effectiveness of our responses (especially around quarantining and contact tracing).
Last, but certainly not least, …
5) Stop the ongoing dissemination of dangerous misinformation from politicians and other public figures.
With COVID-19, there is a massive disconnect between the administrative discourse and the scientific community. The former is clearly echoing dangerous false reassurances, while the latter has largely been silenced at the podiums.
Obviously, there is no place for unfounded opinions or simple intuitions when planning responses to COVID-19, yet political leaders and even physicians are regularly showing complete disregard for the stark limitations of their subjective and qualitative presumptions packaged and presented as logical inferences. These limitations are potentiated by many factors, such as the frank inability to have any kind of reliable intuitions involving exponential growth curves that model pandemics like COVID-19. This limitation is inherent to all of us, and awareness of this well-known psychological hurdle is long-standing in the scientific community as it even cultivated the invention of mathematical structures such as logarithms (which convert an exponential function into a linear one that a human is naturally wired to grasp and extrapolate).
Unfortunately, this awareness does not seem to permeate the administrative and political spheres as they interface with the general public. Moreover, this represents only one of many examples of their apparent inability to know what they don’t know.
I may be a physician with a math degree, but I am nevertheless grossly incapable in predicting the future dynamics of COVID-19 without rigorously referring to and relying on the mathematical models being created through the collaboration of thousands of experts around the world. These models are clearly critical to our COVID-19 response, yet they seem to be less of a basis in government planning as compared to the unreliable heuristics undermining so many of the discussions and presentations. For example, New York City Mayor Bill de Blasio recently communicated (to millions) the dangerously false fact that the coronavirus only survives on surfaces for “literally a matter of minutes,” when we know from the WHO that it can last on certain surfaces for days.
We don’t speculate on something like the diameter of a fuel injection nozzle to be used in an engine of an aircraft being constructed. Why don’t we expect the same standard of rigor in the construction of a plan in response to a pandemic? The uncertainty around the details of the coronavirus is no excuse for such a standard to be dangerously low. To the contrary, the uncertainty should mandate an even higher standard of rigor as we must further abandon our intuitions in favor of robust mathematical structures developed precisely to manage the counterintuitive features and probabilistic parameters in projecting a pandemic. Indeed, the overall expected specific outcome generated by such an approach is no more important than the systematic calculation of the range of possible outcomes and the corresponding probability values. This data is essential in optimizing a dynamic response that provides for a range of possible contingencies and their corresponding real-time probabilities that change in response to emerging trends.
In short, the uncertainty around coronavirus clearly heightens the stakes, and this should be reflected via higher standards for rigor and reasoning when communicating to the public about COVID-19. Instead, we continue to witness this uncertainty make more room for further false “facts” and dangerously imprecise discourse punctuated by pseudo-pleasantries.
That said, this is not meant to detract from the tireless and fruitful efforts of so many individuals (including regional leadership) working in our health authorities and elsewhere. Rather, this long rant is intended (in part) to express my view that these leaders and team members, along with the rest of the broader collective, should be empowered with better information and direction via the evidence-based tools discussed above.
March 22nd, 2020
Shut it all down before it shuts us down. Be proactive rather than reactive.
This requires aggressive interventions that are initiated early enough such that they seem excessive and overly alarmist at the time. In fact, these concerns around the potential prematurity of dramatic actions, along with the corresponding feelings of uncertainty and insecurity, should actually reassure us that the interventions may be early enough to be effective. As Sam Harris explains, this is precisely when we need to act.
Otherwise, if we continue this step-wise approach of waiting until the local COVID-19 numbers seem to warrant the next tier of action intensity, then our collective behavior will remain a function of the exponential trajectory rather than the converse. In other words, this continued reliance on a reactive response ultimately hinders proactive preventative action that is more effective in flattening the curve.
Let's aggressively shape this curve instead of continuing to wait for it to shape us.