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Chicken, Egg: Heart disease, COVID-19
This Wednesday, Dr. Fauci gave one of his occasional snippy, generally poor answers when indirectly challenged. The set up was a leftist White House press reporter (but I repeat myself) putting the “conspiracy” label on anyone pointing out that loose counting in COVID-19 fatalities helps juice the badly sagging projected numbers. Vice President Pence failed to reject the premise and show respect to Americans daring to challenge “experts.” Dr. Fauci signaled his first instinct to avoid honest discourse by appealing back to AIDS conspiracy theories. Dr. Birx, on the other hand, added a bit of context.* Let me explain.
The most appropriate models for the question of a population’s risk of dying from a disease are competing risk models. Such models do what they sound like. Consider an example:
- The chance of developing severe adult onset mental illness, usually between 18 and your early 20s, and committing suicide, is affected by
- The chance of you and your friends, as high school students, getting into a fatal car accident, which is affected by
- The chance of dying from a childhood cancer, which is affected by
- The chance of dying from infant and early childhood diseases, now mostly controlled by immunization, which is affected by
- The chance of dying from a birth defect, which is affected by
- The chance of dying in the womb as your mother is killed or severely injured by some cause or another.
You can, of course, run the analysis forward as well, right to the point of actuarial life span for the demographic. For now, let us come back to the completely legitimate question that Dr. Fauci wrongly dismissed, and that Dr. Birx obliquely acknowledged.
If you have a serious respiratory disease, or poorly managed diabetes, or serious heart disease, and likely more than one of these, combined with extreme obesity, you have multiple risks all vying to get credit for doing you in. Now we get to add COVID-19. So, how should we count the causes of death?
If you had none of these, perhaps you would still die of a COVID-19 infection. You might also die of a heart attack before COVID-19 gets a chance to even infect you. You might die of lung and organ failure, starved of oxygen, after COVID-19 gets into your body but before it gets a chance to multiply enough and actively manifest. You might start showing all the symptoms of COVID-19 infection and suffer heart failure, dying.
So, we have multiple possible causes of death. And. We all already understand “comorbidity,” the idea that lung and heart disease and diabetes and obesity have a tendency to feed off each other and reinforce each other in various ways. Now, we have a virus that gets to play with these other killers. Dismissing the virus, when we acknowledge all the other interactions, would not be consistent.
Consider the example of someone with undiagnosed heart disease. Today, he is exposed to the Chinese coronavirus. Tonight he has his first massive heart attack. If he dies before he can get heart surgery, it is clear he died of heart disease, period. However, if our amazing medical system saves him, now COVID-19 gets a chance to manifest while this person is recovering from heart surgery. If this goes poorly, and the poor fellow has another cardiac event from which the medical team cannot rescue him, what is the proper cause of death? Best answer: we do not know.
So, we need to look at competing risks and at the interaction between these risks. Crudely we can express this as: HEART DISEASE + (HEART AND COVID-19) + COVID-19. Since there is a good chance of a lung condition or diabetes as well, the equation, the expression of a model, gets rather more complicated.** To connect equations and models to reality takes quite a bit of close study, and that study that takes years. Dr. Birx acknowledged this complex research project briefly. I believe she will give a fuller explanation in the days ahead.
The term Dr. Birx used was “pathophysiology.” A quick search revealed this definition:
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease or resulting from an abnormal syndrome.
Right now, public health officials are trying to tag all deaths where COVID-19 is detected as “COVID-19 death.” Yet, Dr. Birx acknowledges that no one has a scientific understanding of the way this virus, in itself or in combination with other diseases or abnormal syndromes, changes normal mechanical, physical, and biochemical functions in human bodies. We should be getting multiple meta-tags on each death, I believe we are, and should be seeing graphics that clearly display the instances where there may be interaction and instances where there are known competing risks.
The patient dies of heart failure, with a history of serious heart disease and also an active case of COVID-19. Today, we cannot answer how causality should be precisely modeled and expressed. We can expect that all of our public servants would show us the basic respect of acknowledging they are in the earliest stages of finding their way towards understanding this virus and are really working off their best guesses based on past experience, revised as rapidly as possible with new observations.
I do not think that too much to ask. I also do not think it too much to ask of our news media and commentariat that they should express a bit of nuance, a bit more that tried and tested bits designed to draw familiar reactions. We are seeing some good reporting and we are seeing some good questions, even in the daily White House briefing. We need more.
* Here is the relevant passage, from the coronavirus task force briefing on April 8, for your own assessment:
Q Can I ask a question of Dr. Birx or Dr. Fauci?
THE VICE PRESIDENT: Of course.
Q As you are both probably aware, there’s a lot of misinformation and conspiracy theories out there about the coronavirus. There are some commentators who are suggesting that the number of dead are being inflated because they’re saying that people who are dying with other issues are being listed as COVID-19 deaths. Perhaps, you’ve seen some of this commentary. You may be too busy to see it, but it is out there.
What do you say to those folks who are — who are making the claim without really any evidence that these deaths are being padded, that the number of COVID-19 deaths are being padded? For example, somebody who might die from a number of factors, but had coronavirus are being listed as “coronavirus deaths.” And because of that, the number is being inflated.
THE VICE PRESIDENT: That’s a fair question. And you might also speak about the converse.
DR. BIRX: Yeah, we’ve been hearing the converse too.
DR. FAUCI: We’ve been hearing the opposite.
DR. BIRX: (Laughs.) We’ve been hearing both sides of that. I — you know, I think, we’ve made it very clear, I think, every time I’ve been up here, about the comorbidities.
And so, they — most of the people — and we’ve talked about the Italy data. The majority of the Italians who succumbed to this had three or more comorbidities. So, this has been known from the beginning. So those individuals will have an underlying condition, but that underlying condition did not cause their acute death when it’s related to a COVID infection. In fact, it’s the opposite. Having an underlying condition and getting this virus, we know is particularly damaging to those individuals.
We don’t know all the pathophysiology. I wish we did right now. We see that a lot of vasculitis — where Tony and I came from. Tony actually — Dr. Fauci started in the vasculitis in Wegener’s. So, I mean, these are things we have studied for a long time. We are trying to understand the pathophysiology.
But what we can tell you at this moment: If you have asthma, if you have renal disease, if you have diabetes, if you have hypertension — these are preexisting conditions that put you at a greater risk to having a worse outcome.
DR. FAUCI: Yeah. So, Jim, just to add a comment to that because, you know, having been through other serious issues, particularly the very painful early years of HIV-AIDS, when people talk about conspiracy theories — you will always have conspiracy theories when you have very challenging public health crises. They are nothing but distractions.
You know, I can assure you we have so much to do to protect the health and the welfare of the American people that I would just hope we just put those conspiracy stuff, and let somebody write a book about it later on, but not now.
** Just for starters, roughly, for heart, lung, and COVID-19: [HEART + LUNG + COVID-19 + HEART and LUNG + HEART and COVID-19 + LUNG and COVID-19 + HEART and LUNG and COVID-19]. The idea is to separate out how much each of these pieces affects the outcome.
Published in General
Email from Anthony Fauci to Cheryl Mills, all about how great Hillary is (he donated to her campaign):
https://wikileaks.org/clinton-emails/emailid/4755
Ugh.
He should have been booted long AGO. He is out there every day in front of cameras making everything worse on purpose. What he and others are doing to this country and its people is indefensible.
It was my impression or interpretation of Dr. Birx’ comment, that we are NOT getting (nor requesting) multiple tags on each death. They are instructing the attending doctors to list only Covid 19, when it is detected in a deceased patient. Regardless of my personal interpretation of Dr. Birx’ comment, I suspect that there is a significant variation in how individual doctors record cause of death. Some are likely quite diligent in recording multiple tags, especially if they personally know the history of the patient. Others likely only list Covid 19, even when it would appear obvious that other comorbidities exist.
If I tested positive for Covid 19 and on the way home to self-quarantine got hit by a bus she would count it as a Covid-19 death.
This is why she needs to publicly clarify her comments, and why Dr. Fauci needs to retract his, as he did once before.
Or, playing off the OP, you test positive for COVID-19 and then get creamed by a teen-age driver on your way home to self-quarantine.
Outstanding. Thank you.
There is an argument (the validity of which I do not dispute) that when a condition would not have led to death at the time that it happened unless COVID-19 had initiated a series of events that led to death, that citing COVID-19 as the direct cause is appropriate. But I would also submit that if someone with a heart condition went out for a run and had a heart attack, I don’t think they would cite “running” or “exercise” as the direct cause of death.
Thank you for the post, Colonel. You are a constant source of great information.
Related to the topic, I am beginning to doubt that we will ever have any meaningful numbers on the number of death attributable to COVID-19. I think far too many people who have access to the facts may be too heavily invested in the inflated projections, and will be motivated to protect their credibility.
This is why all of the comorbidities need to be listed. With a large enough data set, you can then construct an equation that lets you separate out, in the math, the relative significance, the weight, of the pre-existing condition (in itself), COVID-19, in itself, and the interaction between COVID-19 and the pre-existing condition.
I owe it to my sociometrics professor who asked two or three times every class session: “So what? What does this (number or equation) actually mean?”
I’d be very surprised if we get that much data in this much detail.
We might have a chance this time, as the feds are effectively paying for so much of the coverage that we should get close to all reported cases. Drilling down from there will certainly not be easy, but may not be impossible. I do not know enough to say further.
If the rumors are true that the CDC only wants “COVID-19” as the singular cause of death, it’ll be hard. And I would not be surprised to see the death rate go down a lot over the next two weeks.
The presence of the virus should not be sufficient. The patient/victim needs to exhibit severe lung impairment too. That can be shown by an autopsy, chest x-ray, a record of oximeter readings, or a record of interventions used (ventilator, intubation,…). It just takes a little time and effort to get it right.
Are Days I and Bird accountable to anyone?
To whom is the CDC accountable? To any branch of government?
It’s under HHS.
In addition to the preexisting condition aspect of this question, there is also the fact that there have been several bugs making people ill during this time period. In fact, that’s what made the first batch of tests unusable. There was too much noise (too many bacteria and viruses in the samples from the patients) to detect the covid-19 signal (SARS-CoV-2) clearly.
I’m sure this is weather related. This has been the warmest winter on record for a long time. Different microorganisms are released as temperatures and humidities change. And when the change is abnormal, the microorganism kingdom responds with viruses and bacteria we haven’t seen in a while or with newly mutated strains entirely.
Recording the death as due to the flu when there were several possible boxes to be checked has always happened with the flu if the patient had the flu but died of a secondary infection. It is inaccurate to do so, and it creates misleading data.
There is a great deal of evidence, for example, that the Spanish flu was accompanied by a particularly virulent bacterial pneumonia, which was the actual cause of death.
This is why we have got to store small vials of blood (or perhaps the secretions in the lungs) from deceased people so that we can determine the exact microorganisms present at the time of death. Otherwise, we will never know exactly what happened this winter. It would help us with diagnosis going forward, and it would help us figure out some of our ongoing big problems with secondary infections, antibiotics, and superbugs.
What we are seeing is excess deaths. We normally don’t need reefers and mass graves in NY parks.
“deaths due to Covid-19 “may be misclassified as pneumonia deaths in the absence of positive test results, and pneumonia may appear on death certificates as a comorbid condition,” the CDC noted, adding that “analyses to better understand and quantify reporting delays” for Covid-19 deaths and “related causes” are underway. In March, the CDC introduced a new code to accurately capture mortality due to Covid-19 on death certificates.”
“With that code, the CDC noted that Covid-19 “should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death.”
Just like what we do with the Flu every year.
And if this occurred to a staggering large number of people (more than 17 per day) then it still wouldn’t move the number of COVID deaths by any appreciable margin.
But the deaths were attributed to Spanish flu.
Just like the “80,000 seasonal flu deaths” we see. Almost no one dies of influenza itself.
Behind all this questioning of case fatality rate estimates and comorbidities is the question: “Do we really have to be in lock-down?”
It’s not just a coincidence that dead bodies are stacking up in New York City, New Orleans, etc.. Yes, this has a lot to do, entirely to do, with the virus. If not for the virus most of them would be alive. That’s all you need to know. And just because some Americans are old and have diabetes and hypertension is no reason to write them off.
Truth.
Truth may be one, but lock-down is many.
Dude, I am liking your comment – could have just said “word”.
Yes. This is the best way I have heard to make this point. Thank you.
When we ask how many people out of 1,000 die of this if they catch it, we are really asking what is the likelihood of my catching it – how worried should I be?
If 1,000 people run a marathon, and ten of them have heart attacks and die during the race, and then it’s established that all ten had serious heart problems and should never have been running, then it’s a LIE to tell the other 990 runners that running is bad for them.
This kind of hype doesn’t help your argument. As you know, New York is using its more than 150 year old public cemetery for unclaimed bodies, as it has for decades. And each body is being buried in its own coffin. But that doesn’t sound as scary, especially as military hospitals sit empty, not enough demand at the peek of the pandemi.
At least according to the book I read about it, the bacterial pneumonia sets up in lungs already stripped by the virus. In other words, absent the Influenza, even a particularly virulent bacterial pneumonia would not have been as lethal.
Isn’t it more like saying “if 1,000 gay men party-hearty in a bathhouse in 1981, and ten of them contract HIV and die…?” This was, in fact, the way too many did their cost-benefit analysis even after the virus was identified and its means of transmission known. “Life is short! Roll the dice!”
Lest the comparison seem outrageous, let me just point out that running a marathon is an inherently risky activity—broken ankles, heat stroke, inflammation in the muscles and, according to this article, likely injurious to even a healthy heart. (Training for a marathon is good for you—running the marathon, not so much.)
More and more of us run marathons, travel to exotic places and have sex with strangers because, if we take the gamble and lose, we assume modern medicine will come to our rescue. Most of the time, we’re right. In his chronicle of the early years of the AIDS epidemic, Randy Shilts wrote of endemic levels of gonorrhea and syphilis, but men were cruising each other at the STD clinic while waiting for their antibiotic prescriptions—the medical miracle among so many that promised them, along with the rest of us, a life of little risk and much reward. Same for those idiotic drunk college students on spring break in Florida; surely, should their impaired-decision-making lead to an unwanted pregnancy, they assume Planned Parenthood will be there to “provide care?” One useful lesson of this episode will, I hope, be that nature has not, in fact, been defanged; that we remain vulnerable to “natural consequences” —which, by the way, is not the same as saying any one of us deserves them.
Yes.
From my reading of Golden Age British mysteries, I know that back in the 1920s, a sixty year old could be considered “wonderfully active for his age” just by taking a walk, or continuing to interest himself in business. The accumulated wear-and-tear of six decades was understood, then, to create genuine and lethal vulnerabilities—that same sixty year old would be scolded for taking a walk in the rain: “you’ll catch your death!” his flapper daughter, spinster sister or crusty old family retainer would fuss. Because that was a thing.
It isn’t, now. Is it unreasonable to say that, circa 2020, the age of sixty ought not to be a “co-morbidity” for much of anything? Or that asthmatics—the ones my mystery-writers would perforce describe as “sickly” and “frail”—ought to be able to think of themselves as useful, viable people with much to live for and as worthy as anyone else of our protection?
Don’t get me wrong. I think the Disease vs. Cure debate is going to be an interesting one for historians (amateur and professional) to pursue and argue over long into the future. Our retroactive analysis will have the benefit of knowing how quickly (or slowly) the economy recovered, what progress toward treatment and prevention was made during the time purchased by the Great Flattening, and how much was learned that will prove useful when the next pandemic comes.
I was wondering that. Due you have a source more specifically a memo to show the guidance on filling out death certificate has not change from two year ago?
You just make a statement and there is no back-up to the point. My understand was if someone did test for the virus they could still claim it was death from COVID-19?
As long as they are not changing guidance on how COVID-19 verses all other strans of flu I don’t have any issues even if some of the guidance is is wrong. Its better to be consistently wrong than change the criteria for tracking purposes.