Remember the failures for when it's time for fixes: COVID-19 | A Pragmatist's Take | Douglas Moran | Palo Alto Online |


https://paloaltoonline.com/blogs/p/print/2020/03/27/remember-the-failures-for-when-its-time-for-fixes-covid-19


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By Douglas Moran

Remember the failures for when it's time for fixes: COVID-19

Uploaded: Mar 27, 2020

I likely have COVID-19, but mine is so mild that I wouldn't have noticed if I were keeping a normal sleep schedule. But like so, so many others, I will never show up in the statistics. This experience along with my earlier experiences with disaster preparedness shaped my observations here about the response to the pandemic.

My experience: After several weeks of social distancing and minimizing shopping and other public exposure, I put myself in isolation on Friday March 13, three days before the Bay Area counties declared shelter-in-place. The next day I started having some symptoms suggestive of COVID-19. Four days later, a fever appeared. My temperature started rising in the evening, entering the 100.3 to 100.9 degree range after midnight. That persisted for a few hours, returning to near-normal by the time I awoke. My only daytime symptom was a (welcome) suppression of appetite. Only for a couple of hours on a couple of nights have I felt even slightly "under the weather". After 8 days of this, I have had two days with a temperature that is pretty much (my) normal.
Please: The comments are for discussion -- please don't clutter them with well-wishes, or the opposite.

Spreading the disease: Recognize that I am asymptomatic for most of the day. In various places in the US and around the world, people seeking to enter a building must pass a temperature scan. This test wouldn't have been identified me, illustrating the limitations of such testing. At the beginning of the outbreak in the US, the CDC downplayed, even rejected, that asymptomatic people could spread the disease.(foot#1)(foot#2) Only recently has it been acknowledged that asymptomatics have likely played a large role in the spread.

When am I no longer infectious? In the anecdotal reporting of cases, I found a few mentions of my circumstances, for example, "^'A slow burn': Coronavirus symptoms often linger before worsening: Some patients may feel better before winding up in the hospital^", NBC News, 2020-03-21. "Patients tend to have symptoms for about a week before either getting better or getting really sick". Others include that the transition to "really sick" is "rapid".
A possible analogy is that the body's defenses start out strong enough to keep the disease from growing. In one case, the virus slowly wears down the body's defense until they start collapsing and the disease takes off. In the other case, the body's defenses achieve a slight advantage and slowly suppress the disease to the point that the symptoms disappear. Notice that the person is now asymptomatic, but may well still be infectious.

So, when should such an asymptomatic person be reasonably confident that he could take a quick trip to the grocery store instead of relying on friends for fresh fruit and vegetables? The answers I got were few: from 3-5 days to 14 days, including from my doctor. I had expected it to be more than 14 days. Why? Because if you have tested positive for CORVID-19 and later test negative after being asymptomatic, you are encouraged, if not required, to self-quarantine for 14 days.(foot#3) So why should someone without the confirmation of a negative test have shorter self-isolation? Recognize that becoming asymptomatic only means that your viral load has been decreased below that threshold, not that your body has pushed your viral load down enough for there to be an acceptable risk of you infecting someone else.

It's easy for me to err on the side of caution: I am decently prepared and an introvert with lots that needs doing at home. However, I am worried that bad estimates will put still-infectious people back in public: shopping, ...

We're being asked to ^Triage^ ourselves, but we aren't being given adequate information to do so properly (foreshadowing). I had to do a lot of web searching because information about my symptoms was so thinly represented. I expected that there would be relatively consistent terminology since it would parallel that of other viral diseases. Wrong. Since any discussion with your doctor would likely occur over the phone and would be short, having a consistent terminology between you and her would help her organize your symptoms. For example, the symptom would be listed as a "dry cough" in one place and "dry coughing" elsewhere. A "dry cough" means that any cough you have is simply air and moist materials from your lungs. It says nothing about the quantity or frequency -- it could be a cough every now and then. On the other hand, "dry coughing" implies that you are doing a lot of it. Using the wrong terminology could cause your doctor to think your symptoms were worse or milder than they were. Think that this isn't a real distinction in normal life? Consider the case where you are dating someone but you describe it as having gone on some dates with that person, or vice versa. Would there be any future dates?

Similarly, "a fever" was indicative of COVIS-19, or it might need to be "a fever over 103 degrees". My guess is that the former was written by someone whose use of the term "fever" implied it was over 103. A potential example of "The Curse of Knowledge" in an earlier blog(foot#4)

Having several layers of seriousness of the symptoms would seem very useful for you in communicating with your doctor and for you to do narrower web searches. By now, you should not be surprised that this is not the case. Symptoms requiring hospitalization usually corresponds to "severe", or sometimes "serious". In some places, everything else is "mild", including cases where the patient describe the experience as worse than any flu they had ever had, one that largely confined them to their bed, and left them "wrung out" for days afterward. In places that have a "mild" classification, this non-mild week of misery is classified as a "moderate" illness. My very mild illness comes close to qualifying as a "moderate" based on the number of symptoms checked off. Reason: There was no ranking of the importance of the symptoms.(foot#5)
Aside: In bird identification books, a common practice is to have pointers to the most distinguishing features.

----A failure preordained by multi-administration failures----

The primary failures of the US response occurred among the professional staffs of various US agencies, most notably those of the ^Public Health Service^ division of the Cabinet-level ^Department of Health and Human Services^ (HHS), including CDC (^Centers for Disease Control and Prevention^), FDA (^Food and Drug Administration^), and ^National Institute of Allergy and Infectious Disease^ (NIAID) of the ^National Institutes of Health^ (NIH). Aside: Dr. Anthony Fauci, a fixture at Presidential briefings, is the head of NIAID.

You might expect that having these key agencies grouped together in the Organization Chart would facilitate coordination and cooperation. Apparently not. A national series of exercises -- code-named Crimson Contagion -- was held from January to August 2019 to assess the readiness of the US for a major flu outbreak. 12 states participated, California was not among them. Predictably, the exercise was an absolute failure -- over a decade of similar exercises(foot#6) had similarly failed to be followed up by little or no effort to fix the identified problems.

Way back when Federal emergency response was reorganized in the aftermath of ^Hurricane Katrina^ (2005), legislation designed HSS to be the lead agency for illness-related emergencies, but failed to give HHS the legal authority to function in that role. For most emergencies -- hurricane, earthquake, wildfire -- FEMA (^Federal Emergency Management Agency^) was given legal authority to be the lead agency.

An antidote to optimism: The unrestricted publication of the "Key Findings" of the Crimson Contagion exercise has not appeared, but an October draft was made available by the New York Times.(foot#7) The PDF of this document is 63 pages, but some are boilerplate wrappers. The body is essentially a topic list that I found easy to browse -- there aren't the details that would motivate a close reading.
A very few examples:
- Cooperation between agencies was impeded by the absence of common terminology.
- To facilitate inter-operation with the Feds, one state wanted to "mirror" the organization that the Feds would use. Problem: The Feds couldn't tell that state what it would be.
- They had problems organizing teleconferences. They had significant failings in determining who should be invited and in providing descriptions that would allow people to determine whether they should attend.

----Inexplicable errors----

At the federal level, inexplicable errors continue to pile up and are more than enough to convey the urgency of fixes before the next epidemic. Additional recountings serve only to provide daily doses of outrage. OK, just one: Despite having active COVID-19 cases onboard, a cruise ship disembarked its passengers in Miami without them having to go through any medical screening before going home. Initial reporting is that although the CDC knew of the problem, they failed to alert port officials.(foot#8)

At the county level, I was shocked by the March 24th news that the Santa Clara County (and others) was beginning to require reporting of not just positive tests for COVID-19, but also negative and inconclusive tests. (foot#9) Managing this outbreak depends upon statistics, but they hadn't been bothering to collect data that was easily available?

----The Failures of the National Media----

Polling data collected from 10 countries March 6-10 found journalists to be the least "trusted information source to tell the truth about the virus".(foot#10) A CBS/YouGov poll found that the national media was the second least trusted source of such information, ranking ahead of only Social Media.(foot#11)

A discussion of the causes of this situation would be pointless here: Speculation at best, but would more likely be dominated by ad hominem attacks. Instead, ask yourself how well have you been served by the national media.
- Did you get a good-enough presentation of what "exponential growth" meant in terms of how fast medical facilities could be overwhelmed?
- Did you get a good-enough explanation, or even any, of why "flattening the curve" was necessary to keep that from happening?
- Or that it also applied to not overtaxing stores with over-buying?
- Was the presentation good-enough to strongly persuade others to do what was needed?

Or did partisan sniping dominate the coverage, followed by statistics about the current situation that did little to help you respond to the epidemic?

----Alternate Media----

I have long given up on national media as a worthwhile source of information. Its focus is on corporate objectives: its economic interests and its political agendas. However, I do scan it to see what others are seeing.

I have been depending heavily on alternative media, but many of these sites are small operations -- many only 2-3 people -- with a focus in a single area and weekly or semi-weekly postings. The weakness of this was reinforced by the coronavirus outbreak. Many of the sources I look to on this topic are on YouTube, but YouTube decided to suppress videos mentioning any of the virus' names. This included recognized journalists with many years on YouTube. While the videos were not being deleted, they were classified as ineligible for ads -- and the associated revenue -- and they would not be recommended to users and would not appear in search results. The YouTube channels that continued to post stories about coronavirus were ones supported by subscriptions and donations from viewers. Most of the best information I got on the virus came from these channels, especially how severe the situation was in China in January.

Why did YouTube choose to suppress news about coronavirus except from major corporate media sites? There is much speculation, and little more.

----Summary----

Now is the time to be noticing all the things that went wrong and things that were needed. When the situation becomes calmer, these are memories be dragged up to provide the anger and outrage to convince our political elite that things must change.

Perhaps we might start with changing the slogan of the infectious disease response from "Failure is not an option. It's a feature."

----My other blogs on coronavirus (COVID-19)----
"Is Palo Alto prepared for a Coronavirus outbreak?", 2020-01-30.
"Coronavirus (COVID-19): Underappreciated Unknowns & inexplicable failures", 2020-02-28.
"Preparing for COVID-19: An epidemic is not a hurricane. Panic buying harmful", 2020-03-03.
"COVID-19: Critiquing News Releases: What's missing + teachable opportunities", 2020-03-19.

----Footnotes----
1. CDC: who should be tested?
"^Infected people without symptoms might be driving the spread of coronavirus more than we realized^" - CNN, 2020-03-14.A related miscalculation -- that the virus was largely bypassing the young -- is now regarded as having provided a very large pool of infected asymptomatic people who interacted with many others, individually, in groups and crowds, and in crowded placed and events.

2. CDC: who shall be tested?
In section "Serious failures ..." of my earlier blog ^Coronavirus (COVID-19): Underappreciated Unknowns & inexplicable failures^, 2020-02-28, I cited a case where the CDC refused to authorize a test despite the patient having severe symptoms that strongly indicated COVID-19. In my readings since then, I have encountered many additional instances. From the Central Coast comes a report (^Women showing symptoms of coronavirus hasn’t been tested due to CDC guidelines^ - KSBW-TV) of a woman whose doctor requested she be tested was denied because she hadn't visited any hotspots, although she was reportedly in contact with many international tourists. Notice the problem, which the CDC doesn't: Being in contact with lots of potentially infected people is a substantial risk if you are a tourist and they are the locals, but not vice versa.

3. Origins of 14-day quarantine:
In January, reports from China claimed that most people became symptomatic within a few days (3-5?) of being infected, and few beyond 14 days with 24-days and more being observed. The neatness of the numbers and "few" made me curious. Although I couldn't find any citation, I did encounter a mention that said the numbers were those for another coronavirus, that 14-days was round-off for incubation in 95% of people and that 24-days was 99%. This is credible, but is it also speculation.

4. Curse of Knowledge discussed in an earlier blog:
^Preparing for COVID-19: An epidemic is not a hurricane. Panic buying harmful^, 2020-03-03.

5. Best explanation of Mild, Moderate and Severe:
^Defining Coronavirus Symptoms: From Mild To Moderate To Severe^ in Goats and Soda, NPR (2020-03-13).

6. Earlier federal exercises on epidemics:
^Biodefensive within the US Department of Health and Human Services^ (Wikipedia) provides some exercise names as a starting point.

7. Key Findings draft for Crimson Contagion: ^Crimson Contagion 2019 Functional Exercise Key Findings: Coordination Draft^ held January-August 2019.
I do not recommend the article introducing it: ^Coronavirus Outbreak: A Cascade of Warnings, Heard but Unheeded^, New York Times, 2020-03-19. Although it provides some useful historical context, the NYT is not credible on political and national news because of its well-established intense partisanship in these areas.
If you decide to read it, I recommend using an independent archive site: ^multiple revisions of this article^, but I didn't do a comparison.
Why? Because the NYT is one of many media outlets that silently makes substantial changes to the content and headlines of its articles, including fine-tuning the politics of the article.

8. Cruise ship with COVID-19 cases not checked:
^MSC passengers disembark in Miami without medical screenings^ - Miami Herald, 2020-03-16. ^Independent archive copy^.

9. Start reporting negative and inconclusive COVID-19 tests:
^Palo Alto Online's cumulative daily reporting on coronavirus with changing headline^: See the update for March 24.

10. Trust of sources of info on COVID-19:
Overview: ^Edelman Trust Barometer: Coronavirus Special Report^, 2020-03-16.
See ^page 9 of the results^ (PDF).

11. CBS-YouGov
^Most Americans don’t trust President Trump for accurate COVID-19 information says CBS/YouGov Poll^, 2020-03-24.
An alternative headline could have been "Americans trust the national media less than President Trump for accurate COVID-19 information". The difference is within the margin of error but the national media rarely bothers with such details.


----
An ^abbreviated index by topic and chronologically^ is available.


----Boilerplate on Commenting----
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