Annie Duke ROCKS!

One mitigative personal upside of our continuing "all-covid19-all-the-time" period for this Parkinson's-addled non-essential non-worker and life-long unlearner has been the recent volume of compelling books I've consumed while getting "three weeks to the gallon of gas" (and Netflix binge-watching) here in the Homeland "shire."    

No read more fun and illuminating than Annie Duke's delightful "Thinking in Bets."

I'd gotten one of my routine Amazon email book pitches. Intrigued, I clicked on the book cover link. It was offered up as a Kindle edition special, which, with my always-accruing credits (I continue to buy a ton of books), would only set me back 59 cents.

"What have you got to lose?" Nonetheless, after reading the Amazon blurb, I went, as is my custom, to first reading the negative one-star reviews, which can often be show-stoppers (afterward, I would muse "did we read the same book?").

Never before having heard of Annie Duke, I recall also having had the fleeting, snarky thought: "Oh, will the yummie Jessica Chastain play her too in The Movie" (successor to Molly's Game).

LOL.

ANNIE IN THE NEW YORKER

Annie Duke Will Beat You at Your Own Game
    
Late last year, I wrote to Annie Duke, a former professional poker player, about the possibility of profiling her. Duke, who for years was the leading female money winner in the World Series of Poker, retired from the game six years ago and has since refashioned herself as a corporate speaker and strategic consultant. She struck me as someone with a potentially unique and strange set of perspectives on gender, celebrity, and money. We spent the next few weeks engaged in a polite game of psychological warfare. I became attuned, moment by moment, to infinitesimal shifts in power and grew obsessed with the notion that she might be playing our negotiations like a card game. I’m still not sure how much of it was in my head.

At first, Duke enthusiastically agreed to be profiled, and often responded to my e-mails with smiley faces and exclamation points. She invited me to accompany her to a charity event and suggested that I come along to her brother-in-law’s birthday party. When I asked her to recommend friends and colleagues who might have insight into her career, she responded eighteen minutes later with an annotated list of twenty-seven names. It included all living members of her immediate family, her ex-husband, various professional poker players, and celebrities she has taught to play the game. Duke seemed to understand instinctively that affording a journalist access can actually be a form of self-protection: her avid participation would decrease my need to ferret out potentially unflattering material elsewhere.

Since retiring, Duke, who has four children and lives near Philadelphia, has travelled across the country delivering keynote speeches to conferences held by the likes of Citibank, Pandora, and Marriott. She has co-authored multiple gaming guides, and her first general-interest book, “Thinking in Bets: Making Smarter Decisions When You Don’t Have All the Facts,” came out in February. The book’s premise is that poker players live in a world in which “risk is made explicit” and are therefore trained to assess incoming information logically and judiciously in a way that other people are not. “A hand of poker takes about two minutes,” she writes. “Over the course of that hand, I could be involved in up to twenty decisions. And each hand ends with a concrete result: I win money or I lose money. The result of each hand provides immediate feedback on how your decisions are faring.”

Duke argues that we bet all the time: on parenting, home buying, restaurant orders. Betting is merely “a decision about an uncertain future,” and our opponents are not other people but, rather, hypothetical versions of ourselves who have chosen differently than we have. Her most urgent message is that we should all be more comfortable living with self-doubt—not for ethical reasons but for intellectual ones. Embracing uncertainty, she argues, makes you a better thinker. “Real life consists of bluffing, of little tactics of deception, of asking yourself what is the other man going to think I mean to do,” she writes, quoting John von Neumann, the father of game theory…

Read all of it.

Also buy and carefully study all of "Thinking in Bets." Not kidding.

INTRODUCTION:  Why This Isn’t a Poker Book

CHAPTER 1:  Life Is Poker, Not Chess
Pete Carroll and the Monday Morning Quarterbacks
The hazards of resulting
Quick or dead: our brains weren’t built for rationality
Two-minute warning
Dr. Strangelove
Poker vs. chess
A lethal battle of wits
“I’m not sure”: using uncertainty to our advantage
Redefining wrong

CHAPTER 2:  Wanna Bet?
Thirty days in Des Moines
We’ve all been to Des Moines
All decisions are bets
Most bets are bets against ourselves
Our bets are only as good as our beliefs
Hearing is believing
“They saw a game”
The stubbornness of beliefs
Being smart makes it worse
Wanna bet?
Redefining confidence

CHAPTER 3:  Bet to Learn: Fielding the Unfolding Future
Nick the Greek, and other lessons from the Crystal Lounge
Outcomes are feedback
Luck vs. skill: fielding outcomes
Working backward is hard: the SnackWell’s Phenomenon
“If it weren’t for luck, I’d win every one”
All-or-nothing thinking rears its head again
People watching
Other people’s outcomes reflect on us
Reshaping habit
“Wanna bet?” redux
The hard way

CHAPTER 4:  The Buddy System
“Maybe you’re the problem, do you think?”
The red pill or the blue pill?
Not all groups are created equal
The group rewards focus on accuracy
“One Hundred White Castles…and a large chocolate shake”: how accountability improves decision-making
The group ideally exposes us to a diversity of viewpoints
Federal judges: drift happens
Social psychologists: confirmatory drift and Heterodox Academy
Wanna bet (on science)?

CHAPTER 5:  Dissent to Win
CUDOS to a magician
Mertonian communism: more is more
Universalism: don’t shoot the message
Disinterestedness: we all have a conflict of interest, and it’s contagious
Organized skepticism: real skeptics make arguments and friends
Communicating with the world beyond our group

CHAPTER 6:  Adventures in Mental Time Travel
Let Marty McFly run into Marty McFly
Night Jerry
Moving regret in front of our decisions
A flat tire, the ticker, and a zoom lens
“Yeah, but what have you done for me lately?”
Tilt Ulysses contracts: time traveling to precommit
Decision swear jar
Reconnaissance: mapping the future
Scenario planning in practice
Backcasting: working backward from a positive future
Premortems: working backward from a negative future
Dendrology and hindsight bias (or, Give the chainsaw a rest)

ACKNOWLEDGMENTS
NOTES
SELECTED BIBLIOGRAPHY AND RECOMMENDATIONS FOR FURTHER READING

I was gratified to see that a lot of the books she cites are ones I own and have read. Were I still teaching "Critical Thinking" her book would be a required text.

Once something occurs, we no longer think of it as probabilistic—or as ever having been probabilistic. This is how we get into the frame of mind where we say, “I should have known” or “I told you so.” This is where unproductive regret comes from.

By keeping an accurate representation of what could have happened (and not a version edited by hindsight), memorializing the scenario plans and decision trees we create through good planning process, we can be better calibrators going forward. We can also be happier by recognizing and getting comfortable with the uncertainty of the world. Instead of living at extremes, we can find contentment with doing our best under uncertain circumstances, and being committed to improving from our experience…

One of the things poker teaches is that we have to take satisfaction in assessing the probabilities of different outcomes given the decisions under consideration and in executing the bet we think is best. With the constant stream of decisions and outcomes under uncertain conditions, you get used to losing a lot. To some degree, we’re all outcome junkies, but the more we wean ourselves from that addiction, the happier we’ll be. None of us is guaranteed a favorable outcome, and we’re all going to experience plenty of unfavorable ones. We can always, however, make a good bet. And even when we make a bad bet, we usually get a second chance because we can learn from the experience and make a better bet the next time.

Life, like poker, is one long game, and there are going to be a lot of losses, even after making the best possible bets. We are going to do better, and be happier, if we start by recognizing that we’ll never be sure of the future. That changes our task from trying to be right every time, an impossible job, to navigating our way through the uncertainty by calibrating our beliefs to move toward, little by little, a more accurate and objective representation of the world. With strategic foresight and perspective, that’s manageable work. If we keep learning and calibrating, we might even get good at it.

Duke, Annie. Thinking in Bets (pp. 230-232). Penguin Publishing Group. Kindle Edition.

Very smart woman. Lots to ponder. You will do well to watch all of it.

THE CRUX

"Once something occurs, we no longer think of it as probabilistic—or as ever having been probabilistic. This is how we get into the frame of mind where we say, “I should have known” or “I told you so.”

Annie says poker players call this "resulting." An interesting chronic problem in this time of being fashionably "data driven," and the tendency to spuriously correlate the quality of individual decisions with their singular outcomes. "Hindsight bias," in brief.

So, how does this stuff cohere with the so-called "Science of Deliberation," scientific thinking directed at accurate decisionmaking?

UPDATE: ANNIE DUKE BOOK RECOMMENDATION

She touted this one on Twitter.

I'm a couple of chapters in thus far. Very good. I can see why she recommended it.

MORE ANNIE ON YOUTUBE

Really liked this one.

Additional thoughts shortly. Stay tuned.

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More to come...

"A malevolent holiday"

From Harper's Magazine, Easy Chair column (paywalled):

“Everybody knows that pestilences have a way of recurring in the world, yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky,” writes Camus in his 1947 novel The Plague, as translated by Stuart Gilbert. He continues: “There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise.” A masterpiece of European postwar fiction, The Plague offers a uniquely clear, forceful, and meticulous account of the states and stages of inertia, ignorance, denial, learned helplessness, and—when we’re at our best—resistance that we pass through as we’re confronted with an evil as efficient as it is incomprehensible…

…For Camus, the question of sickness, of life’s two irreducible teams—pestilences and victims—and of the Sisyphean struggle for meaning in a godless, absurdly indifferent universe, was always quite literal. He worked on the book for six eventful years: first in Oran, then in the French Alpine village of Le Chambon-sur-Lignon, where he went to treat his tuberculosis, and afterward in Paris, during the Resistance, distilling into fiction his painstaking research on the history of plagues in Europe and Asia. Taken at face value as a work of extraordinary and exhaustive insight into the fundamental conditions of living under biological pestilence—and in this way contrary to Judt—The Plague does in fact offer a considerable number of lessons.

A pandemic, if you are fortunate enough not to be hospitalized or killed by it, wears you down by other, more subtle measures. It administers, by a thousand cuts, a kind of spiritual and psychological incapacitation. It sends you away on a malevolent holiday, open-ended, enough to make you crave the rhythms and ardors of labor. By stripping you of the most basic knowledge that the world will remain predictable, stable in the morning, it makes you all too aware of just how good you once had it—and that no such assurance was ever promised to you in the first place. Indeed, one of the key insights of The Plague is its emphasis on the fundamental fragility of all human arrangements, and the concomitant inability of most people to acknowledge this tenuousness until it is far too late for meaningful collective action. (Beyond the particular menace of the coronavirus, this is ultimately what is so terrifying about the climate crisis.) It is our great strength as well as our terrible weakness to live most fully in the past and in the future. But pestilences rob us of the sanctuary of both of these states, forcing us into the totalizing uncertainty and silence of the present. A pandemic, then, is an opportunity, at last, to see ourselves and our condition more clearly. If there is one, this is the virus’s silver lining…

'eh?

Among my decades-long hardcopy periodicals subscriptions are The Atlantic, The New Yorker, and Harper's. The latter remains primus inter pares.

COVID19 FREEDUMB UPDATE

"Let's say you woke up with a terrible cough, a fever, and severe body aches. Immediately, you rush to the doctor and unfortunately, you’re diagnosed with COVID-19. For the last two weeks, you’ve been unaware that you were infected and you’ve ignored "the rules." You've gotten together with some close friends for pizza, had a few people over, even visited a park and a beach. You figured, 'I don’t feel sick. I have the right to keep living my normal life. No one can tell me what to do.'

With your diagnosis, you spend the next few days at home on the couch, feeling pretty crappy; but then you’re well again because you’re young, healthy and strong. Lucky you.

But your best friend caught it from you during a visit to your house, and because she didn't know she was contagious, she visited her 82-year-old grandfather, who uses oxygen tanks daily to help him breathe because he has COPD and heart failure. Now, he’s dead.

Your co-worker, who has asthma, caught it too, during your little pizza get-together. Now, he’s in the ICU, and he's spread it to a few others in his family, too--but they won't know that for another couple of weeks yet.

The cashier at the restaurant where you picked up the pizza carried the infection home to his wife, who has MS, which makes her immunosuppressed. She’s not as lucky as you, so she’s admitted to the hospital because she’s having trouble breathing. She may need to be placed in a medically-induced coma and intubated; she may not get to say goodbye to her loved ones. She may die surrounded by machines, with no family at her bedside.

All because you couldn't stand the inconvenience of a mask; of staying home; of changing your familiar routines for just a little while. Because you have the right, above all others’ rights, to continue living your normal life and no one, I mean no one, has the right to tell you what to do.”

     — Anonymous

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More to come...

ASQ webinar on Covid19 assay QA

Better late than never. These new coronavirus tests have been rife with error.

PROGRAM OVERVIEW

Testing is dominating our conversation during the current Covid-19 crisis as we think about reopening our economy. FDA has rapidly authorized nearly 100 different tests for emergency use to help detect, diagnose, and treat the infection caused by the novel coronavirus. There is widespread concern about the quality and reliability of these tests because of the perception that the FDA has relaxed the normally stringent requirements for performance validation.

In this webinar, the focus will be on recently authorized serology tests for the detection of antibodies and review their reported performance. The presenter will discuss how we can assess the level of uncertainty and risk when these tests are used for population serological surveys. Finally, the presenter will share thoughts on current misconceptions about testing and how Quality professionals can help facilitate a more informed public conversation and awareness.

Free, but name and email address registration required. I signed up to attend. From the email notice, it's obviously available to all ASQ members, but whether registration extends to the public at large is not clear.

I've been harping on the testing validation issues for more than two months. See here as well. My ASQ (in particular the BioMed Division) has been MIA up to now.

UPDATE FROM SCIENCE-BASED MEDICINE

COVID-19 Testing
Currently available tests for COVID-19 are imperfect but useful if used properly, with rapidly evolving research on new tests underway.

As states are beginning to phase out total lockdown in the US, there is much discussion about how best to do it, minimizing the chance of causing a resurgence in COVID-19 cases. Just about every expert questioned about this topic focuses on testing – we have to do lots of testing in order to track people who have the disease, trace their contacts, and isolate them. At its core the idea is simple – instead of isolated everyone, we isolate those who have the virus, but in order to do that we have to know who has it and who doesn’t. Symptoms are one guide, but you can have the virus and pass it on without displaying symptoms. Therefore testing is critical. Some experts estimate we will need to do millions of tests per day to safely open up.

What is the state of our testing technology, and how reliable is it? There is a lot of work in this area, so this is a rapidly moving target, but some recent reviews help put things into perspective…

BTW, the Wiki has a nice, detailed entry on Covid-19 assay technologies, methodologies, and issues.

POST-WEBINAR UPDATE

It was good, notwithanding the CusterFluck Webex interface login and recurrent bandwidth issues.

Niec presentation deck.

I would say, in deference to his Copyright, contact the author for the slide deck. He has lots of good stuff on his site. Attendees all got pdf access to it, but I don't want to usurp his show.

All good information, but nothing much I'd not already addressed in detail. I was looking for useful particulars on assay tech/methodology R&D QA and SARS-CoV-2 screening deployment workflow QA. They remain substantive concerns.

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More to come...

95 days of tracking #COVID19

I first mounted a screen shot of the Johns Hopkins Covid-19 tracking site on February 11th.

This morning:

Yeah, "we're all (however begrudgingly) in this together." Widespread continuing willful denial in the U.S. notwithstanding.

Screening assay availability at scale and accuracy remain glaringly unresolved concerns.

But...

Is it too early to start drinking?

91 DAYS SINCE CALVIN WAS BORN

Four days after my first Covid19 post, our new grandson Calvin arrived.

Frustrating to not be with him more. Going on months old now. Fabulous.

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More to come...

"During these challenging times,

we're all in this together."

Right.

Don't know about you, but I'm getting sick of that banal ad copywriter blather. "Let them eat clichés."

And, yeah, I know it's lexically true.

ERRATUM

The Day in Stupid.

FROM THE NEW YORKER:

"Zoonotic, Vector-borne Diseases"

In 2006, the idea that an unknown virus might spill out of some wild animal into humans, achieving person-to-person transmission and causing a global pandemic, seemed a distant prospect to most people. As an engaging science-fiction scare, it ranked somewhere beneath “Alien: Resurrection.” But Ali S. Khan, of the National Center for Zoonotic, Vector-Borne, and Enteric Diseases, was tasked with dreaming that nightmare by daylight.

NCVED (pronounced “N. C. Zved,” according to Khan), part of the Centers for Disease Control and Prevention, resided in an unobtrusive gray brick building, behind locked gates and locked doors in the C.D.C.’s compound on Clifton Road, six miles northeast of downtown Atlanta. During a two-day visit that year, I worked my way along the NCVED corridors, interviewing scientists who knew all about Ebola viruses (yes, there are more than one) and their lethal cousin Marburg; about West Nile virus in the Bronx and Sin Nombre virus in Arizona; about simian foamy virus in Bali, which is carried by temple monkeys that crawl over tourists, and monkeypox, which reached Illinois in giant Gambian rats sold as pets; about Junin virus in Argentina and Machupo virus in Bolivia; about Lassa virus in West Africa, Nipah virus in Malaysia, Hendra virus in Australia, and rabies everywhere. All these viruses are zoonotic, meaning that they can pass from animals to people. Most of them, once in a human body, cause mayhem. Some of them also transmit well among people, bursting into local outbreaks that may kill hundreds. They are new to science and to human immune systems; they emerge unpredictably and are difficult to treat; and they can be especially dangerous, as reflected in the name of the branch within NCVED that studied them—Special Pathogens. For these reasons, some scientists and public-health experts, including Ali Khan, find the viruses an irresistible challenge. “It’s because they keep you on your toes,” he told me…

About a 40 minute read (has audio embed also). Excellent.

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More to come...

#SocialDistancing: alone together

Just saw this reviewed in my current hardcopy Science Magazine (paywalled).

The other public health crisis

As a fledgling physician, Vivek Murthy considered social issues such as loneliness to be outside the domain of doctoring. That all changed when he met a patient named James, whose health concerns appeared to stem from social isolation that started after winning the lottery. In restructuring his life to his new economic standing, James had inadvertently cut himself off from his existing support network, sending his health into a downward spiral. In his book Together, Murthy—who served as the 19th surgeon general of the United States—draws from decades of scientific research and his own experiences with patients like James to show just how damaging loneliness can be.

The timing of the book's release coincides with a global public health crisis, as people around the world adapt to the ongoing COVID-19 pandemic. Murthy's account of the factors driving loneliness and his suggestions to combat isolation are particularly poignant now, as many abide by recommendations to stay home and avoid social contact with others…

Had to buy the Kindle edition. Glad to have done so.

Author’s Note
This is a book about the importance of human connection, the hidden impact of loneliness on our health, and the social power of community. As a physician, I felt compelled to address these issues because of the rising physical and emotional toll of social disconnection that I’ve watched throughout society over the past few decades. What I could not anticipate, however, was the unprecedented test that our global community would face just as this book was going to press.

In the first weeks of 2020, the COVID-19 pandemic turned physical human contact into a potentially mortal threat. The novel coronavirus was on the loose, like an invisible stalker, and any of our fellow human beings could have been its carrier. Almost overnight, it seemed, getting close enough to breathe on another person became synonymous with danger. The public health imperative was clear: to save lives, we’d need to radically increase the space between us.

As I write these words, we are still in the middle of this pandemic. With health workers at risk, hospital equipment in short supply, and death rates from the coronavirus spiking by the day, governments the world over have mandated “social distancing,” closed schools and most businesses, and ordered everyone but essential service workers to stay home. Those first responders, health-care and food-supply workers, and others who must stay on the job to protect us are now putting their lives on the line. They remind us just how much we depend on each other…

This pandemic isn’t the first and won’t be the last time our social connections are tested, but it is rare for the whole world to face such a grave challenge simultaneously. For all our differences, our shared experience is itself a bond. We will have this memory in common for the rest of our lives. And if we learn from this moment to be better together, we won’t just endure this crisis. We will thrive.

March 2020

AMONG THE NUMEROUS ACCOLADES

“This powerful and important book looks at loneliness as a public health issue. Vivek Murthy shows why loneliness evolved in our species, how it can be harmful, why it’s on the rise today, and what we can do about it. By creating better connections with our friends and our communities, we can lead healthier lives and help our friends be healthier.” 

   —Walter Isaacson, New York Times bestselling author 

“Murthy’s book makes a powerful case for the role of community and human connection in medicine. He provides cogent and compassionate insights about how to heal the art of healing.”

   —Siddhartha Mukherjee, the Pulitzer Prize–winning, New York Times bestselling author of The Emperor of All Maladies

We shall see. Amazon reviews were all lauditory. A timely read. Just getting started, stay tuned. I am reminded of another fine book I cited on this blog some time back.

6: SOCIAL FACTORS
Life with people

Philosopher Jean-Paul Sartre famously wrote, “L’enfer, c’est les autres”—hell is other people. No. Not if you want to live long. One of the keys to a long health span and a long life is social connectedness.

Loneliness is associated with early mortality. It has been implicated in just about every medical problem you can think of, including cardiovascular incidents, personality disorders, psychoses, and cognitive decline. Loneliness can double the likelihood of developing Alzheimer’s disease. It increases the production of stress hormones, which in turn lead to arthritis and diabetes, dementia, and increased suicide attempts. It leads to inflammation, increasing proinflammatory cytokines such as interleukin-6 (IL-6), and it negates the beneficial effects of exercise on neurogenesis, the growth of new neurons. Loneliness is worse for your health than smoking fifteen cigarettes a day. If you are chronically lonely, the risk that you will die in the next seven years goes up by 30 percent.

Loneliness and social isolation are not the same thing. Social isolation refers to having few interactions with people and can be evaluated objectively (for example, how many people you interact with in a week and for how long). Loneliness is entirely subjective—it’s your emotional state. Social isolation can be calculated. Loneliness is felt.

People can feel lonely even when surrounded by others, such as in the middle of a party or inside a large family. Loneliness is a feeling of being detached from meaningful relationships, and that may arise from feeling unacknowledged, from feeling misunderstood, or from a lack of intimacy. Having a spouse sometimes helps, and sometimes not. There are certainly people who enjoy being alone and who do not feel lonely, just as there are people who are constantly in the presence of others, perhaps making small talk, but feeling completely alone. Being unmarried raises the risk of loneliness and a host of health-related problems, but being married doesn’t help in all cases—not all marriages are happy ones.

Social isolation can lead to loneliness, of course, and both can increase in old age owing to a variety of factors. People retire and swiftly lose the social contact they had with co-workers. Friends die. Health and mobility problems make it more difficult to leave home. Ageism, present in many modern societies, leaves older adults feeling devalued, unwanted, or invisible. Younger friends and family members become caught up in their own lives and might not take time to visit older people. Government research in the UK found that two hundred thousand older adults had not had a conversation with a friend or relative in more than a month. Clearly that kind of extreme social isolation can lead to loneliness.

Levitin, Daniel J. Successful Aging (pp. 179-180). Penguin Publishing Group. Kindle Edition.

ANTISOCIAL DISTANCING AT THE MICHIGAN STATEHOUSE

Angrily protesting the governor's emergency stay-at-home order. Just out of photo range above, the requisite "patriotic" Confederate flags, crude swastika placards, and assault weapons replete with playtriot army surplus store garb.

#COVIDIOTS
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The latest from Hopkins.

Speaking of Hopkins, and "public health" more broadly. From NPR:

Opinion: Always The Bridesmaid, Public Health Rarely Spotlighted Until It's Too Late

The U.S. is in the midst of both a public health crisis and a health care crisis. Yet most people aren't aware these are two distinct things. And the response for each is going to be crucial.

If you're not a health professional of some stripe, you might not realize that the nation's public health system operates, in large part, separately from the system that provides most people's medical care.

Dr. Joshua Sharfstein, a former deputy commissioner for the Food and Drug Administration and now vice dean at the school of public health at Johns Hopkins in Baltimore, distinguishes the health care system from the public health system as "the difference between taking care     of patients with COVID and preventing people from getting COVID in the first place."

In general, the health care system cares for patients individually, while public health is about caring for an entire population. Public health includes many things a population takes for granted, like clean air, clean water, effective sanitation, food that is safe to eat, as well as injury prevention, vaccines and other methods of ensuring the control of contagious and environmental diseases.

In fact, it is public health, not advances in medical care, that has accounted for most of the increases in life expectancy during the past two centuries. Well before the advent of antibiotics and other 20th Century medical interventions, public-health activities around clean water, food safety and safer housing led to enormous gains.

"It's pretty invisible" if the public health system is working well, said Sharfstein, who also once served as Maryland's state health secretary. "It's the dog-that-doesn't-bark agency."

But while public health isn't as flashy as a new drug or medical device or surgical procedure, it can simultaneously affect many more lives at once…

Still, because the public-health system mostly operates in the background, it rarely gets the attention — or funding — it deserves, until there's a crisis.

Public health is "a victim of its own success," said Jonathan Oberlander, a health policy researcher and professor at the University of North Carolina-Chapel Hill.

"People can enjoy clean water and clean air but don't always attribute it to public health," he said. "We pay attention to public health when things go awry. But we tend to pay not a lot of attention in the normal course of events.”

Public health as a scientific field was created largely to address the sort of problem the world is facing today. Sharfstein noted that Baltimore established the nation's first public health department in 1793 to address a yellow fever epidemic. But between emergencies, the public health domain is largely ignored.

"In the U.S., 97 cents of every health dollar goes to medical care," he said. "Three cents goes to public health.”…

Read all of it. Very good.

UPDATE

Finished Dr. Murthy's book. Very enjoyable read. The Science Magazine review sums it up nicely:

…Collectivistic communities—those that emphasize the needs of the group over the needs of individuals—can foster connectedness by providing social institutions that bind people together. But oppressive social norms inherent in many such communities can cause undue stress, and those who do not conform to these norms can be ostracized and left even more isolated than those from individualistic communities. Understanding the profound necessity of connectedness and how we can protect ourselves from isolation in modern society can help us to take deliberate action to cultivate our relationships with others.

For those who are fortunate, the practice of social distancing during the COVID-19 pandemic may provide valuable opportunities to reconnect with family and loved ones quarantined at home. For many others, the situation will be dire. Those living alone will experience increased isolation, and those most at risk, such as the elderly and ill, may be kept in isolation from their loved ones. On a societal level, the public health implications of this widespread disconnect may be severe.

By showcasing research on the impact of loneliness and its social and environmental antecedents, Murthy presents a road map of the various pathways that lead to connection or isolation. Although the path to connectedness may be long and arduous, particularly while social distancing, the direction in which we must head is clear.

Well worth your time.

AS IS THIS

My current read, just started.

Fun stuff. Clear thinker.

apropos of last year's riff on "Deliberation Science."
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More to come...

#COVID19 May Day, lockdown protests, and Remdesivir

From the Editor of Science Magazine.

Pandemics are international. A virus doesn't respect borders between countries—or between states, as we are seeing with severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2) in the United States. Unfortunately, too many world leaders want to treat the situation as a problem for their nation alone and not the world.

Science will rise to the challenge of coronavirus disease 2019 (COVID-19) and is doing so. The structures of the most important SARS-CoV-2 proteins are now known. Although we are still in the early stages of understanding human immunity to the virus, neutralizing antibodies are being identified. Clinical trials have begun on vaccines and drugs. There's no shortcut, but there's reason to think we can conquer this if we can get enough time and collaboration. Most world leaders don't seem focused on giving the scientific and biomedical communities these two things…

Nobody wants to continue social distancing forever (or thinks they can). Even the most pessimistic modelers of COVID-19 spread agree that this degree of behavioral change can't be sustained for many months. But the tools needed to get to the next phase in the United States are still not showing up: increased testing, staffing and gear for the hospitals with the greatest needs, and masks for everyone.

Courageous and confident world leaders believe that nations work best together through international institutions; this process has benefited the world for decades. Weak leaders believe in this but only if it benefits their country alone or even themselves. The WHO is not perfect, but it has helped put out many fires around the world for a long time. - H. Holden Thorp

More editorial content from the same issue of Science Magazine:

LOST IN TRANSLATION

Coronavirus disease 2019 (COVID-19) has been the greatest disruption to the movement of people since World War II. Many who had plans—and permission—to move permanently from one country to another have seen their transition put on hold. Worldwide, the flows of tourists, business and professional travelers, and students are all affected. But those most vulnerable to the virus and virus-related policies are low-paid migrant workers who have lost their jobs, and refugees or displaced people. Their lives were precarious even before the pandemic spread.

Migrant workers suffer as they struggle to return home with little or no money, often in the face of travel restrictions and suspension of transport links. In India, after Prime Minister Modi imposed a country-wide lockdown on 24 March, hundreds of thousands of internal migrants crowded the roads on foot, creating the very conditions that the lockdown was meant to prevent. Many foreigners are being summarily expelled, such as in India and Saudi Arabia. Others are stranded in foreign countries. Losing jobs creates a cascade of other losses for migrant workers—of legal status and access to health care and other public services. Only a few places, including Portugal and New York state, have opened their health care systems to migrants regardless of legal status (as Thailand has done since 2013 in response to the AIDS epidemic and other infectious diseases brought to the country by migrant workers). These migrants' families back home will suffer too, from the loss of remittances that fund health care, housing, education, and better nutrition. The departure of temporary migrant workers also creates risks for the native population. Agricultural producers in Europe, for example, are predicting crippling labor shortages this spring and summer.
   
Refugee camps are densely packed—the largest one in the world, in the Cox's Bazar District of Bangladesh, has three times the population density of New York City, without a single high-rise building. Social distancing is impossible in such a setting. Clean water for handwashing is scarce. Medical resources are thin, although humanitarian agencies are ramping up hand-washing stations, protective gear, isolation units, and ambulance services. Conditions in European “reception centers” for refugees and asylum seekers, like that near Moria village on the Greek island of Lesvos, are worse than in many refugee camps in poor countries. Moria holds about 22,000 people in a site built for 3000. There are 1300 residents per water tap... - Kathleen Newland

Ugh.

Meanwhile in the U.S., armed Branch Covidian Playtriots are storming a number of state capitols to protest their relatively comfy stay-at-home inconveniences.

Manly stuff, 'eh?

REMDESIVIR?

Just got emergency FDA clearance. Good idea?

Early tentative efficacy findings, via WIRED.

MAY 4TH UPDATE

From Science Based Medicine.

COVID-19: Out-of-control science and bypassing science-based medicine
During the COVID-19 pandemic, there hasn’t just been a pandemic of coronavirus-caused disease. There’s also a pandemic of misinformation and bad science. It turns out that doctors today are just as prone as doctors 100 years ago during the 1918-19 influenza pandemic to bypass science-based medicine in their desperation to treat patients…

Important reading.
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More to come...

#COVID19 assay update: "Test performance evaluation of SARS-CoV-2 serological assay"

"This is a preliminary report of work that has not been certified by peer review. This should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information."

Ran across a link to this recent R&D paper (39 pg PDF) over at Naked Capitalism. Interesting, in light of my prior rants on lab QA issues.

ABSTRACT
Background
Serological tests are crucial tools for assessments of SARS-CoV-2 exposure, infection and potential immunity. Their appropriate use and interpretation require accurate assay performance data.

Method
We conducted an evaluation of 10 lateral flow assays (LFAs) and two ELISAs to detect anti SARS-CoV-2 antibodies. The specimen set comprised 130 plasma or serum samples from 80 symptomatic SARSCoV-2 RT-PCR-positive individuals; 108 pre-COVID-19 negative controls; and 52 recent samples from individuals who underwent respiratory viral testing but were not diagnosed with Coronavirus Disease 2019 (COVID-19). Samples were blinded and LFA results were interpreted by two independent readers, using a standardized intensity scoring system.

Results
Among specimens from SARS-CoV-2 RT-PCR-positive individuals, the percent seropositive increased with time interval, peaking at 81.8-100.0% in samples taken >20 days after symptom onset. Test specificity ranged from 84.3-100.0% in pre-COVID-19 specimens. Specificity was higher when weak LFA bands were considered negative, but this decreased sensitivity. IgM detection was more variable than IgG, and detection was highest when IgM and IgG results were combined. Agreement between ELISAs and LFAs ranged from 75.8-94.8%. No consistent cross-reactivity was observed.

Conclusion
Our evaluation showed heterogeneous assay performance. Reader training is key to reliable LFA performance, and can be tailored for survey goals. Informed use of serology will require evaluations covering the full spectrum of SARS-CoV-2 infections, from asymptomatic and mild infection to severe disease, and later convalescence. Well-designed studies to elucidate the mechanisms and serological correlates of protective immunity will be crucial to guide rational clinical and public health policies.

"Well-designed studies to elucidate the mechanisms and serological correlates of protective immunity will be crucial to guide rational clinical and public health policies."

Important, vitally necessary work. This particular effort focuses on qualitative ("positive/negative") screens via which to detect the presence (or absence) of Novel Coronavirus antibodies--possible markers of immunity for those having been exposed to the pathogen (even if subsequently remaining asymptomatic).

Suffice it to observe again than bioassay accuracy does not come quickly or on the cheap (gotta love their poignantly euphemistic "heterogeneous assay performance" admission). Moreover, after a test method is validated and approved at the R&D level, ongoing vigilant QA remain necessary at the production bench level. Neither is that cheap. Concurrent best-practice minimization of false positives and false negatives (the "sensitivity" vs "specificity" thing) is no cakewalk.

We remain seriously behind the curve on effective screening at scale for the current pandemic crisis.

STATnews article:

Many states are far short of Covid-19 testing levels needed for safe reopening, new analysis shows

More than half of U.S. states will have to significantly step up their Covid-19 testing to even consider starting to relax stay-at-home orders after May 1, according to a new analysis by Harvard researchers and STAT.

The analysis shows that as the U.S. tries to move beyond its months-long coronavirus testing debacle — faulty tests, shortages of tests, and guidelines that excluded many people who should have been tested to mitigate the outbreak — it is at risk of fumbling the next challenge: testing enough people to determine which cities and states can safely reopen and stay open. Doing so will require the ability to catch reappearances of the coronavirus before it again spreads uncontrollably…

UPDATE FROM SCIENTIFIC AMERICAN

Scientists have long warned that the rate of emergence of new infectious diseases is accelerating—especially in developing countries where high densities of people and animals increasingly mingle and move about...

POTUS TODAY

President Trump: "The testing itself is going really well. No complaints." pic.twitter.com/dVSUWNOCiB

— The Hill (@thehill) April 27, 2020

APR 28TH UPDATE

 

YASCHA MOUNK, associate professor at Johns Hopkins University

America is still behind on testing for COVID-19. Although Trump promised almost two months ago that anyone who wanted a test could get one, the U.S. has still conducted only about 5.4 million. The country needs to increase its testing rate at least threefold to reopen safely.

America is also behind on test and trace. Some countries, such as South Korea, now have robust systems in place to inform people that they have been exposed to the coronavirus, and need to self-isolate. But implementing such a system requires two things the United States sorely lacks: widespread trust in the government and a coordinated response from the White House.

In the absence of a federal strategy, some states, such as New York and Massachusetts, are trying to develop their own test-and-trace systems. But without help from Washington, they will likely lack both the resources to build a comprehensive system and the ability to persuade a large majority of their residents to sign up for an app that tracks their movements. Even if, against the odds, they should succeed in both these tasks, they face another obvious obstacle: Viruses don’t respect state lines.

If he were truly interested in limiting the damage to America’s economy, and opening up the country, Trump would be laser-focused on remedying these problems. Instead, the president has doubled down on culture wars and quack cures.

Early last week, Trump fanned the flames of the irresponsible protests against stay-at-home orders that are now being staged in cities across the country. A few days later, he vowed to “suspend immigration” to the United States. Then he suggested that scientists look into the possibility of injecting patients with bleach.

For all his blustering demands to get the country back to normal, the president is failing to take the steps that are required to reopen the economy without a horrific death toll. And for all the ingenuity shown by individual governors, the absence of a coordinated federal strategy may prove impossible to overcome…

Yeah. Interesting Atlantic article.

A SAD DAY HERE

Two years ago today, my younger daughter Danielle succumbed to her severe pancreatic cancer, 20 years after we lost her elder sister Sissy to an unrelated cancer.

Sigh...
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More to come...

Presidential COVID19 update

UV gro-light exposure and Lysol ingestion.
Problem solved

PRESIDENT TRUMP [4-23-2020 White House COVID19 briefing]:

"So supposing we hit the body with a tremendous whether it’s ultraviolet or just very powerful light and I think you said that hasn’t been checked but you’re gonna test it.

And then I said supposing you bring the light inside the body which you can do either through the skin or ah in some other way and I think you said you’re gonna test that too.
Sounds interesting. Right?

And then I see the disinfectant where it knocks it out in a minute one minute and is there a way we can do something like that by injection inside or or almost a cleaning cause you see it gets in the lungs and it does a tremendous number on the lungs so it would be interesting to check that. So that you’re gonna have to use medical doctors with but it sounds sounds interesting to me."

Quacksalver-in-Chief

YouTube clip here.

He shortly thereafter lamely claimed he was just being "sarcastic," trolling the press. Like that's appropriate for the top national executive amid an epidemiological crisis.

HOPKINS DATA SITE

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More to come...

"Give Me Liberty, or Give Me #COVID19!"

OK, FreeDumb Fighters, how about we give you BOTH?

Be careful what you ask for.

How long before the Bundys' World Branch Stupidian Playtriots recall themselves to active duty?

UPDATE: SIGNS YOU MAY BE A #COVIDIOT

No caption necessary

Below, NY mass grave, COVID16 victims' bodies stacked 3 high in plain wood coffins.

No more "Freedom & Liberty" for these folks.

UPDATE

The Body Collectors of the Coronavirus Pandemic
As the death toll from COVID-19 rises, the funeral homes and hospital morgues of New York City are struggling to keep up.

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More to come...

#Covid19 Venting

APRIL 21ST UPDATE: Criminally negligent, lethal lab QA failure at the CDC.

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Many #Covid19 patients are reported to have to be on ICU ventilators for 7 to 14 days (or longer).

I can hardly imagine.

I've only been intubated and on an ICU ventilator once, for just part of a day. Don't want to ever go there again. As I recounted in a prior post:

UPDATE
SAVR the experience. 

Up at 3:45 a.m., after a difficult, anxious, short night's sleep. No foods of liquids allowed. Ugh. Off to Concord, arriving at the Cardiovascular Institute at 5:23. Preregistered, straight up to “Short Stay” on the 2nd floor to begin pre-op prep. First (after vitals and a bunch of Consent signatures), neck-to-ankles full-frontal body shave (“OMG! I’m a Foster Farms Thighs & Breasts Valu-Pack!"), then blood draws and chest x-rays. IV insertions next (both arms), and EKG telemetry hookups follow forthwith.

Quick discussions ensue informing my wife and sister as to where to go to wait and what to expect in the way of surgery progress notifications. The anesthesiologist comes by to introduce herself and chat reassuringly. My cardiac surgeon stops by to warmly greet and further encourage me. Cardiac staffers would subsequently remark, on multiple occasions, “boy, did you ever get the A-Team!”

All good to hear. My anxiety is pretty minimal, all things considered, but it would not be true to claim there wasn’t any. I guess I’ll wake up. Or not.

More prep — lost of stuff going on all around me in tandem — and then it’s off to the OR.

They sidle my gurney up aside the operating table, which has a large stainless steel hump on it. I’m instructed to slide over on to it, with my upper-mid back positioned over the hump. It’s uncomfortable…

That’s the last thing I remember until waking up several hours later in Cardiac ICU (it seemed like mere minutes). Eventually the intubation is removed, I and have episodic bouts of harsh coughing. Right away they push me to begin using the spirometer. Pre-op I’d been pinning it at 2,500, no sweat. Now I can barely get it to move.

In short order I start intractable bouts of rather harsh, persistent hiccups from my irritated windpipe, some of which last 2-3 hours at a time through Saturday. Nothing works to abate it. They finally resort to two sequential IM doses of thorazine, which knock me out.

I will never EVER do thorazine again. You can just forget it. The most vivid adverse side effect was my mouth feeling like the surface of planet Mercury. Bone dry. By Saturday evening I was totally exhausted...

I simply cannot fathom being vented for a week or two (or longer). Ugh.

Given the emerged exigent clinical picture thus far, were I to come down ill with Covid19 seriously enough to end up ICU'd and vented, I wouldn't be thrilled about my survival odds.

UPDATE

WaPo article about a doc who now does nothing but Covid19 pt intubations for vents.

One more (April 15th):

The new coronavirus kills by inflaming and clogging the tiny air sacs in the lungs, choking off the body’s oxygen supply until it shuts down the organs essential for life.

But clinicians around the world are seeing evidence that suggests the virus also may be causing heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage and liver problems. That development has complicated treatment for the most severe cases of covid-19, the illness caused by the virus, and makes the course of recovery less certain, they said…

UPDATE:

The Next Coronavirus Nightmare Is What Happens After the ICU
For many coronavirus patients lucky enough to make it off a ventilator, getting out of the ICU is only half the battle.

Decades of research shows many of the sickest ICU patients will never return to their former selves. An ailment called Post-Intensive Care Syndrome (PICS) causes cognitive, physical, and psychological problems in up to 80 percent of all critical-care survivors. About a third never return to work.

Now physicians say they are witnessing many of these effects in COVID-19 survivors, at a scale they’ve never seen before. And some are not sure we’re ready for the influx of ICU survivors this crisis will bring…

UPDATE, SCIENCE MAGAZINE

How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes

On rounds in a 20-bed intensive care unit (ICU) one recent day, physician Joshua Denson assessed two patients with seizures, many with respiratory failure and others whose kidneys were on a dangerous downhill slide. Days earlier, his rounds had been interrupted as his team tried, and failed, to resuscitate a young woman whose heart had stopped. All shared one thing, says Denson, a pulmonary and critical care physician at the Tulane University School of Medicine. “They are all COVID positive.”

As the number of confirmed cases of COVID-19 surges past 2.2 million globally and deaths surpass 150,000, clinicians and pathologists are struggling to understand the damage wrought by the coronavirus as it tears through the body. They are realizing that although the lungs are ground zero, its reach can extend to many organs including the heart and blood vessels, kidneys, gut, and brain…

Lordy Mercy. Read all of it.

ERRATUM: CUCKOO FOR COVID19

Comment in my Facebook feed.

Okeee-Dokeee, then.
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More to come...