Note: this article will be updated as more failures get highlighted by subscribers There have been 3 million deaths so far and tens of millions of people with long COVID. As I explained last week, we could have had a few thousands instead. We need to learn the lessons so that these widespread governmental failures don’t happen again. Here are the top 25 mistakes of COVID management I see so far, from least important to most.
Good analysis but I don't agree with items 24 and 23. My understanding is that past infection does not stop you from catching covid again (and passing it on to others). The idea of quarantined infection parties is highly impractical (people would have to be quarantined for the entire incubation and infectious period with leaks extremely difficult and expensive to avoid - eg via cleaners, hotel staff). My guess is that this would just lead to more infection in the broader community (as well as long covid if not death for a portion of participants - have you included lifelong medical costs and reduced earnings of long covid sufferers in your cost/benefit analysis?). Society has an obligation to help those who are too stupid to help themselves (eg mandatory seatbelts as you mention). And surely the people who are most concerned about their individual freedoms would not agree to be locked up in a hotel for 14+ days.
I think the biggest mistake was governments failing to realise that elimination of the virus was achievable, particularly with early action and strong fences, and failing to set this as the policy goal from the outset.
Thanks Jo. I appreciate your cordial and thoughtful dissent!
On the reinfection issue: I haven't seen too much data—I don't think there's too much—but it appears like one of these examples of mixing a possible event with a likely one.
It's possible to be reinfected, but it appears to be highly unlikely.
This also squares well with what we know of infectious diseases, especially respiratory ones, where immunity does build up—and remains as long as the mutations don't drift too much.
The isolations were proven in many countries. They've been pretty standard in East Asia, and even countries like NZ. Where you might be right is in the ability of the West to enforce proper quarantines. They haven't shown an ability to do that well.
I hear you on long COVID. That is a very reasonable counter-argument.
And your final take on it is also quite reasonable. Yes, they could have done it but didn't. What a shame.
There have been millions of reinfections already, quite likely tens of millions, and it would not surprise me if it has crossed the 100M mark given what's happening in India.
It's just that nobody is tracking them. The only country that is is Chile
"We assumed that reinfections induce a recrudescence (or boosting) of plasma anti-N IgG antibody levels, yielding a V-shaped time series of antibody reactivity levels. We infer that 16.9% (95% CI [9.48%, 28.5%]) of all presumed P.1 infections that were observed in 2021 were reinfections. If we also include cases of probable or possible reinfections (defined by considering the time period when the antibody levels are expected to grow after recovery and the range of half-lives for antibody waning after seroconversion), these percentages increase respectively to 25.8% (95% CI [16.7%, 37.4%]), and 31.0% (95% CI [21.4%, 42.5%])"
In South Africa during the second wave they saw ~5000 of reinfections by early January, which was only about 20-30% fewer than the number one would expect by chance if there had been absolutely no immunity given the size of the population and the number of people who had tested positive in the first and the second wave (you have to test positive twice to be observed as a probable reinfection).
Etc.
There is some protection for some time, but the working assumption should be that most people will be susceptible again even to a homologous infection within 12-24 months. But we are seeing antigenic drift doing its thing even faster than that.
It is more often asymptomatic than a first infection, but when symptomatic it is more often more severe than the previous one. However, that's within a short period and probably due to the residual protection remaining. Over longer periods it will be like a new infection altogether or worse.
This first link is not anecdotal, it collects available information from around the world. As you will notice if you look into it, that information is not available for the vast majority of the world, because countries have hard time tracking infections already, so nobody is bothering with reinfections.
For Manaus 16% is the lower bound, and yes, samples are biased, but that is what we have.
It is quite difficult to explain Manaus without a lot of reinfections -- they were at 75% seropositivity after their first wave, which has been attacked as "biased" because that study used blood donors too, but many other cities in the Amazon showed 50+ and 60+ seropositivity too, and that was with proper unbiased sampling (e.g. Iquitos) so there is nothing unlikely about the 70+ number of Manaus.
Yet the second wave was 2X worse than the first.
And yes, P.1 is a worse variant, but it is not 6X-8X worse in terms mortality if we are to explain the second wave by infection of the remaining 25-30% that did not catch it the first time (and it would have to 100% attack rate among them, which is highly unlikely on its own).
A place like Delhi is also extremely difficult to explain without mass reinfections. Yes, B.1.617 is quite a bit worse, but the Delhi serosurveys were properly done -- random sampling, covering all districts, and it showed 56% positivity back in January. Yet at not point 2020 was the city one giant funeral pyre, but right now what I hear from people there is that they cannot have their windows open because the stench of burning human flesh is too overwhelming. So it is highly doubtful we are seeing this from just the other 40%.
Finally, genetic drift in these viruses has a lot more potential that you seem to think. Keep in mind that they have been fighting bat immune systems for a very long time, and if the S protein structure had a limited potential for genetic drift, these viruses would not have survived and diversified so greatly for so long. Bats are actually fairly long lived and they live in extremely dense colonies, in which whatever such virus shows up, it sweeps through to completion almost immediately.
Thanks for your response. I am in Australia where one of our biggest issues has been the virus repeatedly escaping from hotels operating as quarantine facilities that are carefully managed by public health officials (similar leaks have occured in NZ and China too). If you are talking about having super-spreader infection party events in hotels, I would say leaks into the broader community are pretty likely. As Sweden discovered with its nursing homes - it's really hard to create barriers to the outside world when you have staff moving between the community and their workplace. Or do the poor hotel staff have to live on-site and get infected too?
I agree with what you say that reinfection is possible, not necessarily probable, but if you come from a position that every case is one too many, possible matters. I think having immunity passports before we had vaccines would have encouraged/compelled people to get infected leading to more death, disability and transmission which sounds a bit like the failed Swedish herd immunity appraoch. I'm all for immunity passports based on vaccination although it seems like we're going to need yearly boosters to cover immunity to ever-emerging new variants so these will need to be continually updated. I think you make a great point about privacy. It's crazy this issue has taken such precedence over saving lives and health in parts of the West.
I think you missed a big thing - personalizing/politicizing decisions. Statements like "Fauci lied" lead to more such statements - "a Trump failure". These diverted and continue to divert the focus from the disease to the persons/politics. Many disastrous decisions (eg. early celebration of victory in many places) arose from political needs and such statements create more political needs. Whether the statements are true or false does not matter as much as the fact that their use makes it harder to do the thing that needs to be done - focus on the disease. Anyone who mentions an individual and attaches an emotive term to them is being human in a way that is not helpful at the moment.
As a Canadian I am particularly interested in how different the Atlantic experience was. I have heard that closing the borders was easier for them, (not being on major transport routes, relatively few crossing points), that they had better test and trace, .... I do not know how significant each of those factors was.
A consequence of disease overdispersion is that some places, especially ones with low population density, can just get lucky. If we are the lucky ones, we are sure it is due to our superiority (personalizing again). Manitoba had no first wave to speak of. They lead the country now.
We need to focus. We've had 3 pandemics in 20 years. The next one may not be so mild and a vaccine may not be so quickly forthcoming. I doubt we're even half-way through this one.
This speaks to the next article I'm publishing tomorrow.
For me, it's not single people who failed. You are to expect humans to be imperfect. The problem, is not the humans. It's the system that is meant to make better decisions than any person inside of it. It's the system who failed. A big piece of the system's failure, however, is how much it relies on fallible individuals. Hence the criticism of specific individuals: it's the system of checks and balances, that ensures criticism when weighty human decisions are wrong.
The exaggerated recommendations by health care experts for more respirators leading to unnecessary and miserable deaths. The sequela of the over use of respirators has been ignored and a lesson slowly learned. Millions of dollars wasted on an unnecessary and misused technology. The early use actually caused lung damage. More needs to be acknowledged regarding this horrible error of medical judgement.
As always, a very thought provoking article, and, unless I've missed one, your first "listicle".
I wish here in France the government had followed your advice, your point about everything looking like a nail for those with a hammer applies so well. It's so frustrating the number of useless measures when the test, trace and isolate dance has barely been tried. And the vaccination ramp up has been painfully slow, but as you note, that's not only here.
So, here is my quibble: your points 24 and 10 seem to me short-sighted and not particularly well argued.
Of course, point 24 out of 25 implies that you're less invested in it, but it's linked to your point 10 "Making Privacy Sacred" so I want to make the counter argument.
This pandemic, as you know, is not the end of the world, and there will certainly be others. But which ones will need to be managed on an "Immunity Passport" ?
This isn't an easy question, and while vaccination records have long been necessary for travel (across borders), though decreasingly so, I'm much more leery about their use in "everyday life".
Again, this links back to privacy, which does not preclude paying taxes (your favorite example), since your personal information is legally protected from prying eyes. Trump's tax info was not leaked by the IRS, but by journalists who got access via a family member who had the records for other reasons.
Even after we defeat this pandemic, Facebook and other abusers of privacy will be amongst us.
I do hope that governments can be trusted to keep our important data safe, but I prefer to minimize the risk, as we have seen that governments can be more or less competent.
I hope this is cogent, despite being drafted on my phone, and I'd be interested in your reaction.
Yes, SK solved the privacy problem along the lines of what you suggest: Only some healthcare ministry employees can access the data of ppl's movement, only for the 3 weeks leading to an infection, and only during pandemic time, which is defined by their legislative branch. So these checks and balances existed and were well solved a long time before the West had to face it. We never looked at that.
My point about privacy is not to disregard the rest. Of course privacy matters. But I am yet to hear a single person who can argue to protect privacy with specifics. So let me make it clear:
I believe the West could have:
- Saved all the lives lost after June 2020
- Saved all the long COVID sicknesses
- Opened up all the countries. No lockdowns.
- Saved all the businesses and jobs that have been lost because of them
If only it had sacrificed this privacy:
- Mobile companies (who already know your position) share the data of the movements of those infected and their contacts in the 3 weeks before infection. That data is only accessible to healthcare ministry employees, it's only accessible for 2 weeks after the infection is declared, and only during a pandemic.
- Those isolated or quarantined are geotracked through their phone or another device to make sure they don't leave their homes.
I am not interested in the broad argument that privacy is important. It is.
I am interested in the hard decisions that come with the gritty details.
Hi and thanks for the response, which does make sense.
While it does seem like an obviously good deal if your hypotheticals are true (all deaths saved), I am wary of a slippery slope, and governments - as well as private companies - that can't always be trusted.
The government always promises they'll protect us against terrorism if we just give up a little privacy.
Some governments can be trusted, but then they might change.
I think we can have both safety and privacy, and I'm just leery that people will naively "trade off" privacy for safety, as we saw in the US during the Bush W administration.
Again, thanks for the reply and all of your enlightening work during the pandemic. I'll be interested in what you have to say on other subjects.
For example, I'm a big crypto-currency skeptic. Maybe you'll convince me otherwise. ;-)
My goal is not to convince you, but to find the truth. Whether it comes from your original stance, mine, or a mix, it doesn’t matter. In fact, better for me if it’s not fully mine since it means I learned!
The slippery slope is an important concept. We always need to keep it in mind, because sometimes it exists. I don’t think this is one of these situations though.
The government can already access all this info. The IRS has a huge chunk of it. A lot of it is accessible through private brokers (yes, your info is already out there!), they can already subpoena any company to get access to the data they lack.
What stops them is not their desire. It’s the law and the rule of law. They can’t access AT&T’s data without a judge’s approval because that’s what the law says.
You likely trust the rule of law, in which case this is just the same.
And if you don’t trust it, given things like what Snowden revealed, then you realize such a law doesn’t really give them any power they don’t already have.
Either way, this law doesn’t change anything fundamental—except for saving lives, the economy, and freedom.
Thanks for the exchange, I definitely have learned a lot from your writings. But like you, I try to make up my own mind and not just believe what I read / hear / see.
I do believe that the privacy question is more complex than how you portray it, but let's discuss over a drink - the terraces are open here now (is that the right timing? With TTI, they could have been long ago).
Just one last remark: the IRS has my health data? I don't believe so, just as my doctor doesn't have my tax info.
Whether to private or public interests, it's important, as GDPR stipulates (is it respected though?), that data be collected and used for clear and justified reasons, and not "just in case" it might be useful to the collector.
I should have the right to review and correct any errors, and in many (most, but not all) cases my consent is required to collect and retain it.
This is almost certainly a justified case of "legitimate interest" for health authorities to collect and manage such data to fight the pandemic.
But I'm less certain that "vaccine passports" are a good idea. But again, let's discuss over a drink. 🍷
Thanks Thomas, this is one of your more interesting articles. For me, what you did and are doing just shows us how insightful have you been and when you add the tremendous revision work you made, capturing it into your articles, we are able to read a brilliant guy. I must congrats you for your bravery, that at the end allowed people to understand better the pandemics. We know that history (and mistakes), repeat over and over again, for the good and for the bad things. We knew from the first moment, at least in January 2020, this disease was caused by a coronavirus and these viruses “traditionally” spreads by aerosols, we had two examples at the beginning of this century, so it was not very difficult to try to think about to use barriers, but you are right, we don’t listen and even we don’t want to. I am just a chilean shoulder orthop. surgeon, but from the same moment we knew with my team about the Covid-19 we started to wear masks (which by the way “clever” and young bussiness men bought earlier in January here...) and face shields, beeing immediately told not to do by our authorities, because we were scaring the rest of the health workers and patients, after 2 months, the use of them was the rule...Chile has made a terrible management of the pandemics, making a lot of the mistakes you mention, even with recent evidence before our eyes. We were said we will be the Korea of Latin America, but TTI never, ever worked, not even today. The borders never were closed really (too many international treaties to abide by...like allowed hundred of trucks and people, coming from Brasil) this was our more important mistake, we knew about what had happened in Europe, we knew about the variants and the goverment was told by many, included its scientific advisory board to close the borders or not “to open them...they suposed to be closed”, that is why we had and still have a terrible second wave. To implement this quite simple policy would save thousand of lives, but there were other more important “things” than lives that make the government to keep the borders opened. We always used just PCR tests, having even the fastest israeli ones here. Quarentines never really worked, too many works and displacement permits (and we knew they did not were the solution). The genetic survelliance we are doing is a joke and the privacy rights over the health of the people were a good excuse to keep the mess, which at the end maybe benefited some.
Chile should act like Australia, that was the advice from the start of the pandemic, beside the use of the hammer. Last year we didn’t have a first wave as a whole country because the geography of Chile, we had different peaks at different times, in our case if we would act as a kind of federal nation, perhaps we would had a different outcome. By the way, like you did, all these advices were given to the government before the chaos come. This is such a true, that right now many people want to “wash their hands”, because truth is being exposing but “they didn’t know in off about this virus”.
Concerning points 24 and 25, I thing like others who wrote here, maybe re-infection rate is understimated, I was actually twice infected, second one last 2 days and we had the Manaus recent and terrible history. I know not less people re-infected after 2 and 4 weeks from the second shot of the inert virus vaccine we are using, again, Manaus fate was before our eyes, there were some warnings about the efficacy (in vitro), of the vaccine on P.1 variant, but people was not informed at all. Amongs some other mistakes, that just showed the profound lack of solidity of our institucions, seeing the chilean whole picture of the pandemic management, one can rightly think that the government bet on immunity, without and with vaccines. They thought vaccines will save us quickly but they didn’t count on mutations and variants, because maybe and here is a point for uncertainty we never see a coronavirus pandemic before and we believed they don’t mutate that fast, now we know that.
First of all, thank you. I took what you wrote about this last year in March, shared with my students/colleagues/family, and tried to live life accordingly. My wife and I are now vaccinated. So are her grandparents, and our parents. Her grandparents were all v. high risk. I am still a little concerned about our youngest, who was hospitalized for pneumonia at both the ages of 3 and 4, but she's 6 now and hopefully could weather this storm... we remain cautious. And indeed, watching our daughters, 6 and 11, walk out of our car with masks (not asked) in places where many do/did not wear them has become a bit unnerving: we still mask up indoors so the kids do it, and if we are the only family somewhere, they have not questioned us about this since August or September... if they can adjust and just "deal with it", why couldn't others?!
We also teach at private schools, me at the college level, her at the HS level. Us and our kids have been in person all year. They don't wear masks at at my wife's school. We had ours until march or april at mine. We have not seen major spread or cases at these places because of mask mandates, and frankly, probably some luck. My University paid students to be tested once a week in the Spring still. My best student got Covid in late march, no symptoms, but did not infect anyone else that we know of either.
And therefore, what I've lived here in the U.S. and what others have lived is a completely different experience. Our youngest got sent home from school once when her class pod had to quarantine for ten days because the mom of one of the students had covid. Beyond that, I have lived life since September with few disruptions, figured out how to teach to inperson/remote students simultaneously. Sure, I grew nervous when our surrounding community numbers started growing, and remained that way well after the peak in November... but no deaths in our area under age 16 and very few since february, with much of the older part of the population no vaccinated... (that vaccination has "stalled" among those under the age of 60 is most disappointing)... will be cautious this summer still, but looking forward to next school year at this point.
So your tone when you talk about our failures doesn't fully resonate with me... it seems possible that people/communities can make their own choices and still come out of something like this ok. Maybe it's because I didn't lose much freedom/privacy and still, for the most part, our immediate communities got through this. (Our surrounding area faired better than others in this country too, probably enabling our measures to be sufficient.) And yet... we did things. We tried to teach the students to be responsible, pointing out that being in person was a privilege and such and was a privilege that could be lost again. We educated ourselves about this. I watched the infection numbers, and got upset when the numbers in our surrounding area started going up in July and they did little besides cancel large gatherings. And literally, the day the mask mandate was issued here (Midish November) is the peak of cases in our surrounding area.
Also, do not underestimate the impact of election 2020! Our governor 'could not' issue a mask mandate until he won reelection because his opponent was advocating for one in October.
So I think what I'm trying to say is, as my libertarian instincts wrestle with my practical ones, choices made by governments do not fully guarantee/prevent success. There is something deeper here about cultural cohesion that I think is relevant: the people of taiwan/s.Korea/Japan succeeded, not just their governments.
Contact tracing takes cooperation. I'm not convinced we can do something like that right now in the U.S. because we seem incapable of depoliticizing any significant issue. Some areas tried to contact trace, but it doesn't work well, as you've said so many times, without getting everyone involved. How do you do that here? ... If Covid was truly the reason Trump lost re-election, millions of people in this country would say that covid worth the cost, might even go so far to say intentional mismanagement to lower his chances of reelection, all worth it. ... So maybe if you had three differently named contact tracing apps? ... But mandates have to be listened to, enforced, etc. Our national/state government are losing that level of authority/respect, or better, do have strong enough institutions to effectively implement such laws: places in the U.S. tried, after all.
At the end of the day, this has proven that knowledge WITH wisdom is power. Now trust has been broken because the people empowered to share/act on the knowledge failed: they lacked the wisdom to make the right choices and recommendations. This isn't just about voting people out of office (so many are unelected positions), or moving (which not only solves nothing in the big picture, it isn't realistic for many [teaching a private schools is even less "lucrative" than public, for example], nor tolerable for those who don't want to leave family). This is about the "greater good" actually being, you know, a concept that people can agree exists. And that our officials and people in general actually strive for. I'm worried for the future of the world when even a pandemic is not a serious enough crisis for the U.S. and many other democracies to lessen political tension.
I hear you. Luckily, we'll have time to cover these decisions more. Many more themes are going to make us face big communal decisions in the coming decades...
Agree with some/most points, however as some other commenters already pointed out privacy and individual freedom are subjects people get very worried about if the infringement comes from governments. Rightly so in my opinion.
Furthermore, it is true a lot of people died of Covid/Corona but every year around 9 million die from starvation among which there are 3 million children (according to the worldscounts.com), although there is even in practical terms enough food for everyone. Why does it still happen? Because a lot of people do not care about other people enough. The same happens with Covid/Corona. So I think you overestimate point 22.
Another example in relation to the amount of deaths is more polemic (I obviously do not agree that that course of action below should have been taken, but it illustrates that individual freedom, privacy etc have always been important). Covid will probably turn out to be less serious and deadly than HIV against which less action was taken than against Covid. Why for example were condoms not made obligatory (condoms probably work better against HIV than masks against Covid in preventing getting infected), why were non-monogamous relationships not forbidden, why were HIV positive people not quarantined (remember a few suffer so that the rest can go on with their lives)? Testing, tracing and isolation never happened in the case of HIV in the same way it happens against Covid.
Until now around 30 million people have died from HIV/Aids, my polemic point is that if people would just have given up on their privacy and individual freedoms those deaths could have been prevented as well. (I obviously do not agree that that course of action should have been taken, but it illustrates that individual freedom, privacy etc have always been important). I did read that the US border was closed for HIV positive people for a long time. However, I do not think testing before entering was obligatory (https://pubmed.ncbi.nlm.nih.gov/12286989/), although at the moment there are still countries that require a test if you stay for an extended period apparently (https://www.aidsmap.com/about-hiv/travel-restrictions-people-hiv). This is generally considered a wrong and stigmatizing course of action.
My opinion is that constitutional rights are important in particular during emergencies.
I never said individual freedom and privacy are not important. They are extremely important.
What I say is other goals are also very important, sometimes much more, and that these goals of individual freedom and privacy can't be sacrosanct. They must be judged in context with and compared to other goals.
I'm sure some of the HIV measures should have been taken.
HIV does have a couple of key differences: There was much more time to make decisions and, more importantly, every opportunity for infection required of a voluntary risk from an event that was out of the ordinary. That means individual freedom there is much more important than in situations where you can catch a virus without doing anything special.
My thoughts are that learning from mistakes and successes are imperative. This is where we start to share. Unfortunately the Federal Government will look for scapegoats. Oh yes, there are many that played a role in how the US response was negligent!! There will be those that want to take credit for "how well we are doing" and those that will go on defense to save their credibility.
I found this source the best source for laying it all out on the table. Please continue!!
I would add Politicians' relentless focus on the short term - specifically the next day's headlines or, best case, the next election. Something like Covid required long-term visionary decision making, together with the humility for politicians to listen to experts. Few national leaders have a background in science, medicine, maths or another technical discipline. And few of them have much humility!
Thank you Tomás. Great food for thought as always.
Items 16 and 4, 3 and 2 are SO IMPORTANT STILL TODAY, I think they deserve to appear somewhere in the non subscription environment...
Regarding low income areas, I think (did not try to access the data but interpreted the accounts from health personnel and some of the press) that this might be one of the few areas where efficient measures were taken in Argentina (Buenos Aires) amongst a generally disastrous pandemics management... Essentially, the DetectAR program. Teaching and isolation with heavy social support.
AFAIK DetectAR worked, but was too little too late. By the time Quilmes or 31 had stopped it, La Matanza for example was out of control and would eventually spread everywhere.
Cordoba and Medellin, CO are likely better examples, no?
Great article as usual and great insights. Your analysis is always very clear and straight to the point. Wise. It is very important what you say about freedom and the respect for the others. Thanks for sharing your thoughts!
I agree with the opening points regarding infection parties and this is perhaps the #1 missed opportunity: Why was the same fervor to track the vaccinated not applied to those who have recovered from viral infection? If that were in place your list could likely collapse down to perhaps 6-10 points as the others becomes somewhat meaningless. One (not so small) quibble: I'd be a bit circumspect about the "you can do what you want so long as it does not negatively affect anyone else..." First order logic on that is fairly easy, but what about the 2nd order logic of obesity and a host of metabolically driven co-morbidities? Either put the same level of scrutiny to those topics or perhaps finger wag a bit less about our relative "moral responsibility" to our fellow citizens. That last bit may sound nuts, but takes on a whole other layer of significance when we we consider the hypothesis Dr. Gert Vanden Bossche has put forward: that mass vaccination AMIDST a pandemic may create a remarkable evolutionary selection pressure for the virus, initiating an arms race we cannot win. It is unclear if his hypothesis will stand the test of time, but its mere existence should temper the more virtue signally elements that seem to find fertile ground in the age of Covid.
Obesity has consequences on others—externalities—because it costs everybody else in medical care. That should be incorporated in a sugar tax and equivalents.
It also has been shown to spread, but this is where I put the limit on individual vs. social freedom, personally.
The selective pressure of vaccinations doesn't make sense. It's much better to do it quickly than slowly. Did smallpox stop when it infected hundreds of millions of ppl over millenia?
One thing missing: the ridiculous time, effort and money spent on "hygiene theater" even though fomites aren't the issue. It's taken a looooong time for revision in the surface cleaning recommendations that have cost businesses and, especially, schools, a lot of money for very scant benefit.
Agreed! Good one. Although I'm wondering how much impact it has had. The direct cost is probably quite low. But maybe the negative impact came from distracting attention and a false sense of security? I'm not sure they would have paid more attention to aerosols if they hadn't focused on fomites.
I am a doctor in the UK. I have been wondering for over 12 months whether it was SAGE or the government of the UK who made those incredibly bad decisions last year. Looks like the rumour that it was Dominic Cummings who pushed for the lockdown may well be correct! I couldn't watch more than 5 minutes of the debate, it was too upsetting.
Thank you for keeping me sane over the last year and restoring my faith in the intellectual capability of humanity Tomas. I had no idea whatsoever of your background until I subscribed to your new project, because I never felt any need to check whether you were an "expert". Your clear-headed thinking and rational arguments spoke for themselves.
You forgot one mistake: allowing high levels of transmission without considering the increased risk of dangerous mutations. I recall someone raising that as another good reason to suppress Covid-19 over 12 months ago.
One further Covid mistake: underestimating the importance of seasonality in the higher latitudes. The UK government in particular were lulled into a false sense of security in the Summer of 2020 and so were tragically unprepared for the Winter to follow.
Directamente me preocupa España, pero indirectamente creo puede ser global.
Desde que fui conocedora de que se podría haber gestionado de otro modo, evitando los elevados costes que hemos y estamos pagando, he dedicado mucho tiempo informándome apoyando movimientos que promueven esa iniciativa. Pero actualmente veo demasiado conformismo y relajación y termino por pensar que cualquier movimiento en ese sentido es pérdida de tiempo. Muchas gracias!
There are a lot of lessons to be learned from the pandemic, and there is value to rear-view assessments of actions taken or not taken. But it is easier to comment on actions in hindsight than it often was to make those decisions in the early stages of the pandemic, when we had less information. I think it's too harsh to say that Fauci "lied" about mask use. The understanding about virus transmission by aerosol was still evolving. Faced with the criminal national PPE shortage, a Trump failure, Fauci was in the difficult position of deciding whether to recommend mask use by the public knowing that this would lead to stockpiling and clearing of the shelves, or preserve mask use for health care workers. I am a university biomedical researcher with several family members who are doctors who worked with covid patients. Even with Fauci's advice, they were placed in the terrible position of having to reuse and sterilize masks as the numbers of covid patients was increasing exponentially. I assisted with covid testing at my university and we had to reuse masks and gloves. Had Fauci recommended public mask use before the aerosal picture became clear, the mask supply for health workers would have been much worse. Each doctor and nurse working on covid wards helps many patients; one mask used by one of them has a greater mask:user benefit than one mask used by the public. Of course the real lesson to be learned was that we should never have had to make these decisions due to an inadequate PPE supply. That is directly the fault of Trump's administration ignoring the warnings they received about pandemic preparedness.
I also wish to comment on "Be Unable to Make Decisions Under Uncertainty." This is really a Monday morning post-game comment. I was in contact with epidemiologists at my university and public health personnel in King county, WA, where the first cases in the US occurred. These people were trying to make informed decisions with inadequate information and in the face of a crisis that exploded with little warning and worsened every day. There wasn't the luxury of time to collect and analyze data before acting. But contrary to Tomas' assertion, these people acted quickly, using whatever information they had available. I agree that the federal public health establishment failed to act quickly enough, but this I largely attribute to Trump placing unqualified political hacks in charge of FDA and CDC, and then imposing obstacles to the efforts of permanent staff to act.
My last point is about not knowing who to trust. I think that one of the negative side effects of the pandemic has been the proliferation of experts without expertise, all of them shouting with certainty about things for which they often had little knowledge. Scott Atlas and Zeynap Tufecki lie on a continuum of experts without expertise, with Atlas at the malevolent end and Tufecki at the well-intentioned end. Combine the proliferation of experts without expertise with the explosion of "pre-reviewed" articles on MedRxiv. I think that this clamor of voices created more confusion than useful knowledge, with a frightened public not knowing who to trust.
Tomas, I say all this as a long time admirer of your amazing ability to bring together disparate data sets and integrate them visually in a clear and compelling way. I have followed all your postings since the start and regard you as someone who has contributed in positive ways.
Your point about not knowing who to trust is obviously a key one with respect to the pandemic, but also one of the central issues of life in the 2020s. There is a such a huge amount of information and opinion available now in this technological world. What is true, what is not? What is a good opinion and what is not? The fact remains, however, that to a large extent the people and institutions set up to deal with a potential pandemic or who were in leadership positions at the time failed miserably (certainly in the UK where I am based). That said, no one is perfect and there were many people who did incredibly well in difficult circumstances as you have detailed above.
I agree. One lesson, which we already knew, is that information and advice should be disseminated by one trusted person or office. During the ebola pandemic, the CDC in the US took the lead and its effective director, Tom Friedan, was the person who held press briefings. This focus was completely lacking during the Trump year of the pandemic, with him, Pence, Atlas, and various voices from CDC, FDA, and NIH all talking at once and often giving contradictory messages. Confusion was inevitable and this undermined public trust. CDC should have taken the lead as with ebola, but its director Redfield was in far over his head, as was FDA director Hahn. Fauci is the director of NIAID at NIH, a research institue, and should not have had to be the voice of public health. But I suspect that he and his boss, Francis Collins director on NIH, saw the train wreck of the Trump administration's handling of the pandemic and decided that Fauci had to step forward. I don't envy him having to deal with this gang that couldn't shoot straight.
Don't need to caveat it at the end, respectful and thoughtful dissent is the key to improvement. Thanks!
On "Be Unable to Make Decisions Under Uncertainty", I don't mean anybody was able to. I mean it was a common failure. The US government was one, but definitely not the only one.
On the expertise, here's a more detailed perspective on this. You'll see the definition of "experts" is not as clear cut.
Thanks Tomas. Not a caveat, I meant the positive comments about your contributions. We agree that it is difficult to know who to trust when there are so many voices clamoring. I confer trust on those with experience in relevant fields, solid records of training and accomplishment in those fields, and most importantly communicate clearly that their knowledge and recommendations are provisional, based on the best current information but subject to revision as new information is obtained. I avoid anyone who speaks with certainty in loud authoritative voices. Nationally I trust sources such as Medscape and Brief 19, and individuals like Rasmussen, Offit, Osterholm, Marr, and Fauci.
I read your twitter thread! As a PhD who has trained PhDs, I have to respectfully disagree with your statement that one earns a PhD by taking a test made up by other PhDs. At least at my institution, the University of Washington, a graduate student in biomedical sciences must produce a substantial body of original research that is deemed to be rigorous by a committee of four or more PhDs and that passes peer review. If only it were as easy as taking a test!
Thanks again for your contributions and for starting this interesting discussion.
Just to clarify your last point: the claim that your body of research was deemed rigorous was made by a committee of four more PhDs. So it's only as good as those 4 PhDs, is that right? And that is recursively true. Those PhDs are such because other PhDs thought so.
I don't want to take away from the hard work of a PhD, and I'm definitely not saying a PhD should be disregarded. Far from that. I am just saying that a PhD is no a universal title that vouches for any holder. A PhD is only as good as the PhDs who vouch for him/her.
And thank you. Seems like this discussion is drifting away from the original issue of who to trust on covid information. I suppose you could say that awarding the PhD only has as much credibility as the individual examiners. Seems like any professional accreditation is subject to the same critique. But earning the PhD degree is really just the ticket that gets you in the door, and the credibility/trust invested in a newly minted PhD over time is only as good as a much larger community of fellow PhDs deems it to be, based on the body of scholarship produced through peer review of publications and a tough process of review of federal grant proposals in the sciences. You could say that a PhD's reputation is crowd sourced. In the biomedical sciences reputation is continually updated by the crowd's assessment of one's most recent research, and can rise or fall quickly. In my 30 years as a professor I never felt that earning the piece of paper that bestowed the PhD was something I could coast on for the rest of my career. There is nothing like a harsh review of a paper to deflate one's ego.
Having said this, I don't think that trust should be conferred (or denied) on anyone just because they have letters after their name. As I said earlier in this conversation, I confer trust based on training, a record of accomplishment, and an honest acknowledgement that their knowledge is provisional and subject to revision. For an excellent example of this latter point, I recommend listening to a conversation between Drs. Michael Osterholm, a widely recognized authority on infectious disease, and Eric Topol, an expert in cardiology and editor in chief of Medscape (https://www.medscape.com/viewarticle/951101?src=mkm_covid_update_210517_MSCPEDIT&uac=369548FV&impID=3380802&faf=1#vp_1). Osterholm shows admirable frankness in acknowledging that there are many aspects of SARS-CoV2 that he still doesn't understand. It's this type of honesty about what he doesn't know that makes Osterholm someone whose information and recommendations on covid-19 I trust.
Tying it back to the original dissent, I reacted specifically to the comment of "experts without expertise", naming Atlas and Tufekci.
I would argue that Tufekci is an expert with plenty of expertise. She might not have the paper with the letters for epidemiology, but she's better than many. That aligns with what you say: Sure, the PhD is one signal, only as strong as the PhDs who vouched for the new one, but what matters most is the track record overall. And Tufekci has a pretty good one I'd reckon. Hence I wouldn't call her an expert without expertise.
Yes, we're close enough to agreement to call it good. Tufecki has done good work, as have you. CDC isn't looking as good, the more we learn about what went on there last year. It used to be the model for the rest of the world's public health agencies. Sad to see its decline when we most needed it to lead the way.
Good analysis but I don't agree with items 24 and 23. My understanding is that past infection does not stop you from catching covid again (and passing it on to others). The idea of quarantined infection parties is highly impractical (people would have to be quarantined for the entire incubation and infectious period with leaks extremely difficult and expensive to avoid - eg via cleaners, hotel staff). My guess is that this would just lead to more infection in the broader community (as well as long covid if not death for a portion of participants - have you included lifelong medical costs and reduced earnings of long covid sufferers in your cost/benefit analysis?). Society has an obligation to help those who are too stupid to help themselves (eg mandatory seatbelts as you mention). And surely the people who are most concerned about their individual freedoms would not agree to be locked up in a hotel for 14+ days.
I think the biggest mistake was governments failing to realise that elimination of the virus was achievable, particularly with early action and strong fences, and failing to set this as the policy goal from the outset.
Thanks Jo. I appreciate your cordial and thoughtful dissent!
On the reinfection issue: I haven't seen too much data—I don't think there's too much—but it appears like one of these examples of mixing a possible event with a likely one.
It's possible to be reinfected, but it appears to be highly unlikely.
This also squares well with what we know of infectious diseases, especially respiratory ones, where immunity does build up—and remains as long as the mutations don't drift too much.
The isolations were proven in many countries. They've been pretty standard in East Asia, and even countries like NZ. Where you might be right is in the ability of the West to enforce proper quarantines. They haven't shown an ability to do that well.
I hear you on long COVID. That is a very reasonable counter-argument.
And your final take on it is also quite reasonable. Yes, they could have done it but didn't. What a shame.
There have been millions of reinfections already, quite likely tens of millions, and it would not surprise me if it has crossed the 100M mark given what's happening in India.
It's just that nobody is tracking them. The only country that is is Chile
https://bnonews.com/index.php/reinfection-tracker-suspected-cases/
This came out about Manaus yesterday:
https://www.medrxiv.org/content/10.1101/2021.05.10.21256644v1
Quote:
"We assumed that reinfections induce a recrudescence (or boosting) of plasma anti-N IgG antibody levels, yielding a V-shaped time series of antibody reactivity levels. We infer that 16.9% (95% CI [9.48%, 28.5%]) of all presumed P.1 infections that were observed in 2021 were reinfections. If we also include cases of probable or possible reinfections (defined by considering the time period when the antibody levels are expected to grow after recovery and the range of half-lives for antibody waning after seroconversion), these percentages increase respectively to 25.8% (95% CI [16.7%, 37.4%]), and 31.0% (95% CI [21.4%, 42.5%])"
In South Africa during the second wave they saw ~5000 of reinfections by early January, which was only about 20-30% fewer than the number one would expect by chance if there had been absolutely no immunity given the size of the population and the number of people who had tested positive in the first and the second wave (you have to test positive twice to be observed as a probable reinfection).
Etc.
There is some protection for some time, but the working assumption should be that most people will be susceptible again even to a homologous infection within 12-24 months. But we are seeing antigenic drift doing its thing even faster than that.
It is more often asymptomatic than a first infection, but when symptomatic it is more often more severe than the previous one. However, that's within a short period and probably due to the residual protection remaining. Over longer periods it will be like a new infection altogether or worse.
Hi, thanks for the links! I didn't know.
The first one is anecdotal.
The 1nd one is interesting though
16% is an interesting number.
Caveats:
- Serology of blood banks is biased by nature
- 16% is not that high. At that level, with everybody infected, R would have fallen below 1
- This is in the context of P1, which is vastly more contagious. It is likely that genetic drift has diminishing returns.
This first link is not anecdotal, it collects available information from around the world. As you will notice if you look into it, that information is not available for the vast majority of the world, because countries have hard time tracking infections already, so nobody is bothering with reinfections.
For Manaus 16% is the lower bound, and yes, samples are biased, but that is what we have.
It is quite difficult to explain Manaus without a lot of reinfections -- they were at 75% seropositivity after their first wave, which has been attacked as "biased" because that study used blood donors too, but many other cities in the Amazon showed 50+ and 60+ seropositivity too, and that was with proper unbiased sampling (e.g. Iquitos) so there is nothing unlikely about the 70+ number of Manaus.
Yet the second wave was 2X worse than the first.
And yes, P.1 is a worse variant, but it is not 6X-8X worse in terms mortality if we are to explain the second wave by infection of the remaining 25-30% that did not catch it the first time (and it would have to 100% attack rate among them, which is highly unlikely on its own).
A place like Delhi is also extremely difficult to explain without mass reinfections. Yes, B.1.617 is quite a bit worse, but the Delhi serosurveys were properly done -- random sampling, covering all districts, and it showed 56% positivity back in January. Yet at not point 2020 was the city one giant funeral pyre, but right now what I hear from people there is that they cannot have their windows open because the stench of burning human flesh is too overwhelming. So it is highly doubtful we are seeing this from just the other 40%.
Finally, genetic drift in these viruses has a lot more potential that you seem to think. Keep in mind that they have been fighting bat immune systems for a very long time, and if the S protein structure had a limited potential for genetic drift, these viruses would not have survived and diversified so greatly for so long. Bats are actually fairly long lived and they live in extremely dense colonies, in which whatever such virus shows up, it sweeps through to completion almost immediately.
Oh interesting. Can you share with me the seropositivity studies of Iquitos and Delhi? Thx!
Iquitos:
https://www.medrxiv.org/content/10.1101/2021.01.17.21249913v1
Delhi:
https://www.hindustantimes.com/cities/delhi-news
Thanks for your response. I am in Australia where one of our biggest issues has been the virus repeatedly escaping from hotels operating as quarantine facilities that are carefully managed by public health officials (similar leaks have occured in NZ and China too). If you are talking about having super-spreader infection party events in hotels, I would say leaks into the broader community are pretty likely. As Sweden discovered with its nursing homes - it's really hard to create barriers to the outside world when you have staff moving between the community and their workplace. Or do the poor hotel staff have to live on-site and get infected too?
I agree with what you say that reinfection is possible, not necessarily probable, but if you come from a position that every case is one too many, possible matters. I think having immunity passports before we had vaccines would have encouraged/compelled people to get infected leading to more death, disability and transmission which sounds a bit like the failed Swedish herd immunity appraoch. I'm all for immunity passports based on vaccination although it seems like we're going to need yearly boosters to cover immunity to ever-emerging new variants so these will need to be continually updated. I think you make a great point about privacy. It's crazy this issue has taken such precedence over saving lives and health in parts of the West.
I am currently in hotel quarantine in Melbourne. Very interesting to see it from the inside.
Do tell! What's it like?
Surprisingly ok. Not very evidence based though.
I think you missed a big thing - personalizing/politicizing decisions. Statements like "Fauci lied" lead to more such statements - "a Trump failure". These diverted and continue to divert the focus from the disease to the persons/politics. Many disastrous decisions (eg. early celebration of victory in many places) arose from political needs and such statements create more political needs. Whether the statements are true or false does not matter as much as the fact that their use makes it harder to do the thing that needs to be done - focus on the disease. Anyone who mentions an individual and attaches an emotive term to them is being human in a way that is not helpful at the moment.
As a Canadian I am particularly interested in how different the Atlantic experience was. I have heard that closing the borders was easier for them, (not being on major transport routes, relatively few crossing points), that they had better test and trace, .... I do not know how significant each of those factors was.
A consequence of disease overdispersion is that some places, especially ones with low population density, can just get lucky. If we are the lucky ones, we are sure it is due to our superiority (personalizing again). Manitoba had no first wave to speak of. They lead the country now.
We need to focus. We've had 3 pandemics in 20 years. The next one may not be so mild and a vaccine may not be so quickly forthcoming. I doubt we're even half-way through this one.
If only everybody was like you!
This speaks to the next article I'm publishing tomorrow.
For me, it's not single people who failed. You are to expect humans to be imperfect. The problem, is not the humans. It's the system that is meant to make better decisions than any person inside of it. It's the system who failed. A big piece of the system's failure, however, is how much it relies on fallible individuals. Hence the criticism of specific individuals: it's the system of checks and balances, that ensures criticism when weighty human decisions are wrong.
The exaggerated recommendations by health care experts for more respirators leading to unnecessary and miserable deaths. The sequela of the over use of respirators has been ignored and a lesson slowly learned. Millions of dollars wasted on an unnecessary and misused technology. The early use actually caused lung damage. More needs to be acknowledged regarding this horrible error of medical judgement.
As always, a very thought provoking article, and, unless I've missed one, your first "listicle".
I wish here in France the government had followed your advice, your point about everything looking like a nail for those with a hammer applies so well. It's so frustrating the number of useless measures when the test, trace and isolate dance has barely been tried. And the vaccination ramp up has been painfully slow, but as you note, that's not only here.
So, here is my quibble: your points 24 and 10 seem to me short-sighted and not particularly well argued.
Of course, point 24 out of 25 implies that you're less invested in it, but it's linked to your point 10 "Making Privacy Sacred" so I want to make the counter argument.
This pandemic, as you know, is not the end of the world, and there will certainly be others. But which ones will need to be managed on an "Immunity Passport" ?
This isn't an easy question, and while vaccination records have long been necessary for travel (across borders), though decreasingly so, I'm much more leery about their use in "everyday life".
Again, this links back to privacy, which does not preclude paying taxes (your favorite example), since your personal information is legally protected from prying eyes. Trump's tax info was not leaked by the IRS, but by journalists who got access via a family member who had the records for other reasons.
Even after we defeat this pandemic, Facebook and other abusers of privacy will be amongst us.
I do hope that governments can be trusted to keep our important data safe, but I prefer to minimize the risk, as we have seen that governments can be more or less competent.
I hope this is cogent, despite being drafted on my phone, and I'd be interested in your reaction.
Thanks Jim.
Indeed, first listicle for COVID!
Yes, SK solved the privacy problem along the lines of what you suggest: Only some healthcare ministry employees can access the data of ppl's movement, only for the 3 weeks leading to an infection, and only during pandemic time, which is defined by their legislative branch. So these checks and balances existed and were well solved a long time before the West had to face it. We never looked at that.
My point about privacy is not to disregard the rest. Of course privacy matters. But I am yet to hear a single person who can argue to protect privacy with specifics. So let me make it clear:
I believe the West could have:
- Saved all the lives lost after June 2020
- Saved all the long COVID sicknesses
- Opened up all the countries. No lockdowns.
- Saved all the businesses and jobs that have been lost because of them
If only it had sacrificed this privacy:
- Mobile companies (who already know your position) share the data of the movements of those infected and their contacts in the 3 weeks before infection. That data is only accessible to healthcare ministry employees, it's only accessible for 2 weeks after the infection is declared, and only during a pandemic.
- Those isolated or quarantined are geotracked through their phone or another device to make sure they don't leave their homes.
I am not interested in the broad argument that privacy is important. It is.
I am interested in the hard decisions that come with the gritty details.
Does that make sense?
Hi and thanks for the response, which does make sense.
While it does seem like an obviously good deal if your hypotheticals are true (all deaths saved), I am wary of a slippery slope, and governments - as well as private companies - that can't always be trusted.
The government always promises they'll protect us against terrorism if we just give up a little privacy.
Some governments can be trusted, but then they might change.
I think we can have both safety and privacy, and I'm just leery that people will naively "trade off" privacy for safety, as we saw in the US during the Bush W administration.
Again, thanks for the reply and all of your enlightening work during the pandemic. I'll be interested in what you have to say on other subjects.
For example, I'm a big crypto-currency skeptic. Maybe you'll convince me otherwise. ;-)
My goal is not to convince you, but to find the truth. Whether it comes from your original stance, mine, or a mix, it doesn’t matter. In fact, better for me if it’s not fully mine since it means I learned!
The slippery slope is an important concept. We always need to keep it in mind, because sometimes it exists. I don’t think this is one of these situations though.
The government can already access all this info. The IRS has a huge chunk of it. A lot of it is accessible through private brokers (yes, your info is already out there!), they can already subpoena any company to get access to the data they lack.
What stops them is not their desire. It’s the law and the rule of law. They can’t access AT&T’s data without a judge’s approval because that’s what the law says.
You likely trust the rule of law, in which case this is just the same.
And if you don’t trust it, given things like what Snowden revealed, then you realize such a law doesn’t really give them any power they don’t already have.
Either way, this law doesn’t change anything fundamental—except for saving lives, the economy, and freedom.
Thanks for the exchange, I definitely have learned a lot from your writings. But like you, I try to make up my own mind and not just believe what I read / hear / see.
I do believe that the privacy question is more complex than how you portray it, but let's discuss over a drink - the terraces are open here now (is that the right timing? With TTI, they could have been long ago).
Just one last remark: the IRS has my health data? I don't believe so, just as my doctor doesn't have my tax info.
Whether to private or public interests, it's important, as GDPR stipulates (is it respected though?), that data be collected and used for clear and justified reasons, and not "just in case" it might be useful to the collector.
I should have the right to review and correct any errors, and in many (most, but not all) cases my consent is required to collect and retain it.
This is almost certainly a justified case of "legitimate interest" for health authorities to collect and manage such data to fight the pandemic.
But I'm less certain that "vaccine passports" are a good idea. But again, let's discuss over a drink. 🍷
Thanks Thomas, this is one of your more interesting articles. For me, what you did and are doing just shows us how insightful have you been and when you add the tremendous revision work you made, capturing it into your articles, we are able to read a brilliant guy. I must congrats you for your bravery, that at the end allowed people to understand better the pandemics. We know that history (and mistakes), repeat over and over again, for the good and for the bad things. We knew from the first moment, at least in January 2020, this disease was caused by a coronavirus and these viruses “traditionally” spreads by aerosols, we had two examples at the beginning of this century, so it was not very difficult to try to think about to use barriers, but you are right, we don’t listen and even we don’t want to. I am just a chilean shoulder orthop. surgeon, but from the same moment we knew with my team about the Covid-19 we started to wear masks (which by the way “clever” and young bussiness men bought earlier in January here...) and face shields, beeing immediately told not to do by our authorities, because we were scaring the rest of the health workers and patients, after 2 months, the use of them was the rule...Chile has made a terrible management of the pandemics, making a lot of the mistakes you mention, even with recent evidence before our eyes. We were said we will be the Korea of Latin America, but TTI never, ever worked, not even today. The borders never were closed really (too many international treaties to abide by...like allowed hundred of trucks and people, coming from Brasil) this was our more important mistake, we knew about what had happened in Europe, we knew about the variants and the goverment was told by many, included its scientific advisory board to close the borders or not “to open them...they suposed to be closed”, that is why we had and still have a terrible second wave. To implement this quite simple policy would save thousand of lives, but there were other more important “things” than lives that make the government to keep the borders opened. We always used just PCR tests, having even the fastest israeli ones here. Quarentines never really worked, too many works and displacement permits (and we knew they did not were the solution). The genetic survelliance we are doing is a joke and the privacy rights over the health of the people were a good excuse to keep the mess, which at the end maybe benefited some.
Chile should act like Australia, that was the advice from the start of the pandemic, beside the use of the hammer. Last year we didn’t have a first wave as a whole country because the geography of Chile, we had different peaks at different times, in our case if we would act as a kind of federal nation, perhaps we would had a different outcome. By the way, like you did, all these advices were given to the government before the chaos come. This is such a true, that right now many people want to “wash their hands”, because truth is being exposing but “they didn’t know in off about this virus”.
Concerning points 24 and 25, I thing like others who wrote here, maybe re-infection rate is understimated, I was actually twice infected, second one last 2 days and we had the Manaus recent and terrible history. I know not less people re-infected after 2 and 4 weeks from the second shot of the inert virus vaccine we are using, again, Manaus fate was before our eyes, there were some warnings about the efficacy (in vitro), of the vaccine on P.1 variant, but people was not informed at all. Amongs some other mistakes, that just showed the profound lack of solidity of our institucions, seeing the chilean whole picture of the pandemic management, one can rightly think that the government bet on immunity, without and with vaccines. They thought vaccines will save us quickly but they didn’t count on mutations and variants, because maybe and here is a point for uncertainty we never see a coronavirus pandemic before and we believed they don’t mutate that fast, now we know that.
Thank you for your kind words!
Yes, what happened in Chile is very sad... But not unlike what happened in so may similar countries, unfortuantely.
Yes, the evidence on reinfection makes me think I need to be more cautious about it. I agree.
Thank you!
First of all, thank you. I took what you wrote about this last year in March, shared with my students/colleagues/family, and tried to live life accordingly. My wife and I are now vaccinated. So are her grandparents, and our parents. Her grandparents were all v. high risk. I am still a little concerned about our youngest, who was hospitalized for pneumonia at both the ages of 3 and 4, but she's 6 now and hopefully could weather this storm... we remain cautious. And indeed, watching our daughters, 6 and 11, walk out of our car with masks (not asked) in places where many do/did not wear them has become a bit unnerving: we still mask up indoors so the kids do it, and if we are the only family somewhere, they have not questioned us about this since August or September... if they can adjust and just "deal with it", why couldn't others?!
We also teach at private schools, me at the college level, her at the HS level. Us and our kids have been in person all year. They don't wear masks at at my wife's school. We had ours until march or april at mine. We have not seen major spread or cases at these places because of mask mandates, and frankly, probably some luck. My University paid students to be tested once a week in the Spring still. My best student got Covid in late march, no symptoms, but did not infect anyone else that we know of either.
And therefore, what I've lived here in the U.S. and what others have lived is a completely different experience. Our youngest got sent home from school once when her class pod had to quarantine for ten days because the mom of one of the students had covid. Beyond that, I have lived life since September with few disruptions, figured out how to teach to inperson/remote students simultaneously. Sure, I grew nervous when our surrounding community numbers started growing, and remained that way well after the peak in November... but no deaths in our area under age 16 and very few since february, with much of the older part of the population no vaccinated... (that vaccination has "stalled" among those under the age of 60 is most disappointing)... will be cautious this summer still, but looking forward to next school year at this point.
So your tone when you talk about our failures doesn't fully resonate with me... it seems possible that people/communities can make their own choices and still come out of something like this ok. Maybe it's because I didn't lose much freedom/privacy and still, for the most part, our immediate communities got through this. (Our surrounding area faired better than others in this country too, probably enabling our measures to be sufficient.) And yet... we did things. We tried to teach the students to be responsible, pointing out that being in person was a privilege and such and was a privilege that could be lost again. We educated ourselves about this. I watched the infection numbers, and got upset when the numbers in our surrounding area started going up in July and they did little besides cancel large gatherings. And literally, the day the mask mandate was issued here (Midish November) is the peak of cases in our surrounding area.
Also, do not underestimate the impact of election 2020! Our governor 'could not' issue a mask mandate until he won reelection because his opponent was advocating for one in October.
So I think what I'm trying to say is, as my libertarian instincts wrestle with my practical ones, choices made by governments do not fully guarantee/prevent success. There is something deeper here about cultural cohesion that I think is relevant: the people of taiwan/s.Korea/Japan succeeded, not just their governments.
Contact tracing takes cooperation. I'm not convinced we can do something like that right now in the U.S. because we seem incapable of depoliticizing any significant issue. Some areas tried to contact trace, but it doesn't work well, as you've said so many times, without getting everyone involved. How do you do that here? ... If Covid was truly the reason Trump lost re-election, millions of people in this country would say that covid worth the cost, might even go so far to say intentional mismanagement to lower his chances of reelection, all worth it. ... So maybe if you had three differently named contact tracing apps? ... But mandates have to be listened to, enforced, etc. Our national/state government are losing that level of authority/respect, or better, do have strong enough institutions to effectively implement such laws: places in the U.S. tried, after all.
At the end of the day, this has proven that knowledge WITH wisdom is power. Now trust has been broken because the people empowered to share/act on the knowledge failed: they lacked the wisdom to make the right choices and recommendations. This isn't just about voting people out of office (so many are unelected positions), or moving (which not only solves nothing in the big picture, it isn't realistic for many [teaching a private schools is even less "lucrative" than public, for example], nor tolerable for those who don't want to leave family). This is about the "greater good" actually being, you know, a concept that people can agree exists. And that our officials and people in general actually strive for. I'm worried for the future of the world when even a pandemic is not a serious enough crisis for the U.S. and many other democracies to lessen political tension.
I hear you. Luckily, we'll have time to cover these decisions more. Many more themes are going to make us face big communal decisions in the coming decades...
Agree with some/most points, however as some other commenters already pointed out privacy and individual freedom are subjects people get very worried about if the infringement comes from governments. Rightly so in my opinion.
Furthermore, it is true a lot of people died of Covid/Corona but every year around 9 million die from starvation among which there are 3 million children (according to the worldscounts.com), although there is even in practical terms enough food for everyone. Why does it still happen? Because a lot of people do not care about other people enough. The same happens with Covid/Corona. So I think you overestimate point 22.
Another example in relation to the amount of deaths is more polemic (I obviously do not agree that that course of action below should have been taken, but it illustrates that individual freedom, privacy etc have always been important). Covid will probably turn out to be less serious and deadly than HIV against which less action was taken than against Covid. Why for example were condoms not made obligatory (condoms probably work better against HIV than masks against Covid in preventing getting infected), why were non-monogamous relationships not forbidden, why were HIV positive people not quarantined (remember a few suffer so that the rest can go on with their lives)? Testing, tracing and isolation never happened in the case of HIV in the same way it happens against Covid.
Until now around 30 million people have died from HIV/Aids, my polemic point is that if people would just have given up on their privacy and individual freedoms those deaths could have been prevented as well. (I obviously do not agree that that course of action should have been taken, but it illustrates that individual freedom, privacy etc have always been important). I did read that the US border was closed for HIV positive people for a long time. However, I do not think testing before entering was obligatory (https://pubmed.ncbi.nlm.nih.gov/12286989/), although at the moment there are still countries that require a test if you stay for an extended period apparently (https://www.aidsmap.com/about-hiv/travel-restrictions-people-hiv). This is generally considered a wrong and stigmatizing course of action.
My opinion is that constitutional rights are important in particular during emergencies.
Thanks!
I never said individual freedom and privacy are not important. They are extremely important.
What I say is other goals are also very important, sometimes much more, and that these goals of individual freedom and privacy can't be sacrosanct. They must be judged in context with and compared to other goals.
I'm sure some of the HIV measures should have been taken.
HIV does have a couple of key differences: There was much more time to make decisions and, more importantly, every opportunity for infection required of a voluntary risk from an event that was out of the ordinary. That means individual freedom there is much more important than in situations where you can catch a virus without doing anything special.
My thoughts are that learning from mistakes and successes are imperative. This is where we start to share. Unfortunately the Federal Government will look for scapegoats. Oh yes, there are many that played a role in how the US response was negligent!! There will be those that want to take credit for "how well we are doing" and those that will go on defense to save their credibility.
I found this source the best source for laying it all out on the table. Please continue!!
I would add Politicians' relentless focus on the short term - specifically the next day's headlines or, best case, the next election. Something like Covid required long-term visionary decision making, together with the humility for politicians to listen to experts. Few national leaders have a background in science, medicine, maths or another technical discipline. And few of them have much humility!
Thank you Tomás. Great food for thought as always.
Items 16 and 4, 3 and 2 are SO IMPORTANT STILL TODAY, I think they deserve to appear somewhere in the non subscription environment...
Regarding low income areas, I think (did not try to access the data but interpreted the accounts from health personnel and some of the press) that this might be one of the few areas where efficient measures were taken in Argentina (Buenos Aires) amongst a generally disastrous pandemics management... Essentially, the DetectAR program. Teaching and isolation with heavy social support.
AFAIK DetectAR worked, but was too little too late. By the time Quilmes or 31 had stopped it, La Matanza for example was out of control and would eventually spread everywhere.
Cordoba and Medellin, CO are likely better examples, no?
Great article as usual and great insights. Your analysis is always very clear and straight to the point. Wise. It is very important what you say about freedom and the respect for the others. Thanks for sharing your thoughts!
Thanks! I hope to expand on individual freedoms in a future post...
I agree with the opening points regarding infection parties and this is perhaps the #1 missed opportunity: Why was the same fervor to track the vaccinated not applied to those who have recovered from viral infection? If that were in place your list could likely collapse down to perhaps 6-10 points as the others becomes somewhat meaningless. One (not so small) quibble: I'd be a bit circumspect about the "you can do what you want so long as it does not negatively affect anyone else..." First order logic on that is fairly easy, but what about the 2nd order logic of obesity and a host of metabolically driven co-morbidities? Either put the same level of scrutiny to those topics or perhaps finger wag a bit less about our relative "moral responsibility" to our fellow citizens. That last bit may sound nuts, but takes on a whole other layer of significance when we we consider the hypothesis Dr. Gert Vanden Bossche has put forward: that mass vaccination AMIDST a pandemic may create a remarkable evolutionary selection pressure for the virus, initiating an arms race we cannot win. It is unclear if his hypothesis will stand the test of time, but its mere existence should temper the more virtue signally elements that seem to find fertile ground in the age of Covid.
Obesity has consequences on others—externalities—because it costs everybody else in medical care. That should be incorporated in a sugar tax and equivalents.
It also has been shown to spread, but this is where I put the limit on individual vs. social freedom, personally.
The selective pressure of vaccinations doesn't make sense. It's much better to do it quickly than slowly. Did smallpox stop when it infected hundreds of millions of ppl over millenia?
One thing missing: the ridiculous time, effort and money spent on "hygiene theater" even though fomites aren't the issue. It's taken a looooong time for revision in the surface cleaning recommendations that have cost businesses and, especially, schools, a lot of money for very scant benefit.
Agreed! Good one. Although I'm wondering how much impact it has had. The direct cost is probably quite low. But maybe the negative impact came from distracting attention and a false sense of security? I'm not sure they would have paid more attention to aerosols if they hadn't focused on fomites.
I am a doctor in the UK. I have been wondering for over 12 months whether it was SAGE or the government of the UK who made those incredibly bad decisions last year. Looks like the rumour that it was Dominic Cummings who pushed for the lockdown may well be correct! I couldn't watch more than 5 minutes of the debate, it was too upsetting.
Thank you for keeping me sane over the last year and restoring my faith in the intellectual capability of humanity Tomas. I had no idea whatsoever of your background until I subscribed to your new project, because I never felt any need to check whether you were an "expert". Your clear-headed thinking and rational arguments spoke for themselves.
You forgot one mistake: allowing high levels of transmission without considering the increased risk of dangerous mutations. I recall someone raising that as another good reason to suppress Covid-19 over 12 months ago.
Thank you! I think the world is changing its perception of what signals to pay attention to for trust.
Yes, isn't it weird that these behavioral experts were never named? I didn't know about Cummings's role. That would made sense.
Ah yes, good point on the mutations! I will add it as a bonus. Thanks!
One further Covid mistake: underestimating the importance of seasonality in the higher latitudes. The UK government in particular were lulled into a false sense of security in the Summer of 2020 and so were tragically unprepared for the Winter to follow.
It does make sense that it was Cummings. Someone with fewer preconceived ideas than the scientific experts and who likes to think outside the box
Felicidades por su trabajo!! Me encantaría conocer su opinión sobre la situación actual, ¿cómo ve el fututo próximo?
Muchas gracias!!
Hola Carmen,
Pues depende. Donde?
Buena pregunta!
Directamente me preocupa España, pero indirectamente creo puede ser global.
Desde que fui conocedora de que se podría haber gestionado de otro modo, evitando los elevados costes que hemos y estamos pagando, he dedicado mucho tiempo informándome apoyando movimientos que promueven esa iniciativa. Pero actualmente veo demasiado conformismo y relajación y termino por pensar que cualquier movimiento en ese sentido es pérdida de tiempo. Muchas gracias!
Personalmente, creo que si despues de todo este tiempo ninguna gestion ha cambiado, ninguna va a cambiar. Asi que prefiero centrarme en las vacunas!
Muchas gracias por su opinión!
There are a lot of lessons to be learned from the pandemic, and there is value to rear-view assessments of actions taken or not taken. But it is easier to comment on actions in hindsight than it often was to make those decisions in the early stages of the pandemic, when we had less information. I think it's too harsh to say that Fauci "lied" about mask use. The understanding about virus transmission by aerosol was still evolving. Faced with the criminal national PPE shortage, a Trump failure, Fauci was in the difficult position of deciding whether to recommend mask use by the public knowing that this would lead to stockpiling and clearing of the shelves, or preserve mask use for health care workers. I am a university biomedical researcher with several family members who are doctors who worked with covid patients. Even with Fauci's advice, they were placed in the terrible position of having to reuse and sterilize masks as the numbers of covid patients was increasing exponentially. I assisted with covid testing at my university and we had to reuse masks and gloves. Had Fauci recommended public mask use before the aerosal picture became clear, the mask supply for health workers would have been much worse. Each doctor and nurse working on covid wards helps many patients; one mask used by one of them has a greater mask:user benefit than one mask used by the public. Of course the real lesson to be learned was that we should never have had to make these decisions due to an inadequate PPE supply. That is directly the fault of Trump's administration ignoring the warnings they received about pandemic preparedness.
I also wish to comment on "Be Unable to Make Decisions Under Uncertainty." This is really a Monday morning post-game comment. I was in contact with epidemiologists at my university and public health personnel in King county, WA, where the first cases in the US occurred. These people were trying to make informed decisions with inadequate information and in the face of a crisis that exploded with little warning and worsened every day. There wasn't the luxury of time to collect and analyze data before acting. But contrary to Tomas' assertion, these people acted quickly, using whatever information they had available. I agree that the federal public health establishment failed to act quickly enough, but this I largely attribute to Trump placing unqualified political hacks in charge of FDA and CDC, and then imposing obstacles to the efforts of permanent staff to act.
My last point is about not knowing who to trust. I think that one of the negative side effects of the pandemic has been the proliferation of experts without expertise, all of them shouting with certainty about things for which they often had little knowledge. Scott Atlas and Zeynap Tufecki lie on a continuum of experts without expertise, with Atlas at the malevolent end and Tufecki at the well-intentioned end. Combine the proliferation of experts without expertise with the explosion of "pre-reviewed" articles on MedRxiv. I think that this clamor of voices created more confusion than useful knowledge, with a frightened public not knowing who to trust.
Tomas, I say all this as a long time admirer of your amazing ability to bring together disparate data sets and integrate them visually in a clear and compelling way. I have followed all your postings since the start and regard you as someone who has contributed in positive ways.
Your point about not knowing who to trust is obviously a key one with respect to the pandemic, but also one of the central issues of life in the 2020s. There is a such a huge amount of information and opinion available now in this technological world. What is true, what is not? What is a good opinion and what is not? The fact remains, however, that to a large extent the people and institutions set up to deal with a potential pandemic or who were in leadership positions at the time failed miserably (certainly in the UK where I am based). That said, no one is perfect and there were many people who did incredibly well in difficult circumstances as you have detailed above.
I agree. One lesson, which we already knew, is that information and advice should be disseminated by one trusted person or office. During the ebola pandemic, the CDC in the US took the lead and its effective director, Tom Friedan, was the person who held press briefings. This focus was completely lacking during the Trump year of the pandemic, with him, Pence, Atlas, and various voices from CDC, FDA, and NIH all talking at once and often giving contradictory messages. Confusion was inevitable and this undermined public trust. CDC should have taken the lead as with ebola, but its director Redfield was in far over his head, as was FDA director Hahn. Fauci is the director of NIAID at NIH, a research institue, and should not have had to be the voice of public health. But I suspect that he and his boss, Francis Collins director on NIH, saw the train wreck of the Trump administration's handling of the pandemic and decided that Fauci had to step forward. I don't envy him having to deal with this gang that couldn't shoot straight.
Don't need to caveat it at the end, respectful and thoughtful dissent is the key to improvement. Thanks!
On "Be Unable to Make Decisions Under Uncertainty", I don't mean anybody was able to. I mean it was a common failure. The US government was one, but definitely not the only one.
On the expertise, here's a more detailed perspective on this. You'll see the definition of "experts" is not as clear cut.
https://twitter.com/tomaspueyo/status/1369995433406259204
Thanks Tomas. Not a caveat, I meant the positive comments about your contributions. We agree that it is difficult to know who to trust when there are so many voices clamoring. I confer trust on those with experience in relevant fields, solid records of training and accomplishment in those fields, and most importantly communicate clearly that their knowledge and recommendations are provisional, based on the best current information but subject to revision as new information is obtained. I avoid anyone who speaks with certainty in loud authoritative voices. Nationally I trust sources such as Medscape and Brief 19, and individuals like Rasmussen, Offit, Osterholm, Marr, and Fauci.
I read your twitter thread! As a PhD who has trained PhDs, I have to respectfully disagree with your statement that one earns a PhD by taking a test made up by other PhDs. At least at my institution, the University of Washington, a graduate student in biomedical sciences must produce a substantial body of original research that is deemed to be rigorous by a committee of four or more PhDs and that passes peer review. If only it were as easy as taking a test!
Thanks again for your contributions and for starting this interesting discussion.
Thanks for your response!
Just to clarify your last point: the claim that your body of research was deemed rigorous was made by a committee of four more PhDs. So it's only as good as those 4 PhDs, is that right? And that is recursively true. Those PhDs are such because other PhDs thought so.
I don't want to take away from the hard work of a PhD, and I'm definitely not saying a PhD should be disregarded. Far from that. I am just saying that a PhD is no a universal title that vouches for any holder. A PhD is only as good as the PhDs who vouch for him/her.
And thank you. Seems like this discussion is drifting away from the original issue of who to trust on covid information. I suppose you could say that awarding the PhD only has as much credibility as the individual examiners. Seems like any professional accreditation is subject to the same critique. But earning the PhD degree is really just the ticket that gets you in the door, and the credibility/trust invested in a newly minted PhD over time is only as good as a much larger community of fellow PhDs deems it to be, based on the body of scholarship produced through peer review of publications and a tough process of review of federal grant proposals in the sciences. You could say that a PhD's reputation is crowd sourced. In the biomedical sciences reputation is continually updated by the crowd's assessment of one's most recent research, and can rise or fall quickly. In my 30 years as a professor I never felt that earning the piece of paper that bestowed the PhD was something I could coast on for the rest of my career. There is nothing like a harsh review of a paper to deflate one's ego.
Having said this, I don't think that trust should be conferred (or denied) on anyone just because they have letters after their name. As I said earlier in this conversation, I confer trust based on training, a record of accomplishment, and an honest acknowledgement that their knowledge is provisional and subject to revision. For an excellent example of this latter point, I recommend listening to a conversation between Drs. Michael Osterholm, a widely recognized authority on infectious disease, and Eric Topol, an expert in cardiology and editor in chief of Medscape (https://www.medscape.com/viewarticle/951101?src=mkm_covid_update_210517_MSCPEDIT&uac=369548FV&impID=3380802&faf=1#vp_1). Osterholm shows admirable frankness in acknowledging that there are many aspects of SARS-CoV2 that he still doesn't understand. It's this type of honesty about what he doesn't know that makes Osterholm someone whose information and recommendations on covid-19 I trust.
We're in complete agreement!
Tying it back to the original dissent, I reacted specifically to the comment of "experts without expertise", naming Atlas and Tufekci.
I would argue that Tufekci is an expert with plenty of expertise. She might not have the paper with the letters for epidemiology, but she's better than many. That aligns with what you say: Sure, the PhD is one signal, only as strong as the PhDs who vouched for the new one, but what matters most is the track record overall. And Tufekci has a pretty good one I'd reckon. Hence I wouldn't call her an expert without expertise.
Yes, we're close enough to agreement to call it good. Tufecki has done good work, as have you. CDC isn't looking as good, the more we learn about what went on there last year. It used to be the model for the rest of the world's public health agencies. Sad to see its decline when we most needed it to lead the way.