[This article deals with a rapidly developing situation. It was written by Norbert Gleicher, MD, on April 24, 2020 and published on April 27, 2020. For a list of all COVID-19 Bulletins, scroll to the bottom.]
In an article on April 23 the Daily Beast expanded on the information we provide in CHR’s Bulletin of April 22, in which we reported that autopsies in the state of Washington revaled two cases of CORONA-death already in January of this year, almost a full month earlier than, up to this point, the alleged first infection in the U.S. had been timed at. The Daily Beast (and other media outposts) now reported that during this earlier month, hidden community outbreaks had already started spreading undetected in New York City, Boston, San Francisco, Chicago, the Seattle area and, likely, elsewhere.
California Governor Gavin Newson apparently believes that the first COVID-19 cases may have hit his state already in December of last year, even before China publicly announced the new virus and let the world know how highly contagious it was. To confirm the suspicion, he has ordered autopsies performed on bodies that could have been earlier victims of the virus.
These findings also would explain preliminary findings for antibody testing in general populations, which uniformly have demonstrated a much higher rate of immunity than the number of known infections would have suggested. Preliminary studies in the U.S. and in Germany resulted in very similar findings: Immunity exceeded known infections by a factor of anywhere between 30- to 100-fold (for more on this subject, see below).
These findings have, of course, major relevance for our understanding of the COVID-19 virus: They, for example, further demonstrate how highly contagious between humans the virus is and how stealthy at the same time in what appears to be a large majority of infected individuals who demonstrate no or only minor symptoms. This, of course, makes it a significan public health risk. At the same time, these numbers very clearly demonstrate that the mortality of the virus has been highly exaggerated. These data, indeed, suggest an average mortality significantly below 1% and, therefore, in a bad year in quite a similar range to the annual flu.
In our April 13 Bulletin we already pointed out our then much more preliminary impression that widely cited mortality risk data by government experts, press, and even the U.S. President appeared highly exaggerated. It now has become rather obvious that a more conservative interpretation of risk data must be applied and this conclusion raises serious questions about what has been presented by all of above named sources to the public as established scientific facts. It now is established that prior projections were not only rather poor but, at times, almost comically incorrect (one, indeed, would not be incorrect in calling them “wild guesses”). Unfortunately, however, they ended up serving as the foundation for some of the most consequential decisions governments all around the world had to make in decades. The world finds itself, therefore, in the midst of what very well may turn out to be the most severe economic recession in modern history based on, now proven, substantially incorrect underlying assumptions.
All of this, of course, does not mean that COVID-19 can or should have been ignored. This is an unusually contagious virus which in a very small minority of individuals, for still mostly unknown reasons, can cause devastating damages (the lung damage, initially believed to be the principal cause of death, may be only a secondary phenomenon). A just published paper in JAMA by researchers from the _Northwell _hospital system, now considered the largest hospital network in the New York Tristate area, reported a devastating 88% mortality in COVID-19 patients who required intubation and mechanical respiratory ventilation support. That is even in intensive care units a horrible, almost unprecedented mortality rate for any medical condition, and, therefore, evey possible effort must, indeed, be undertaken to reduce or, hopefully, completely eliminate these deaths via prevention and improved treatments.
But at what cost?
As President Trump in almost all of his dailty briefings for the public notes, “every life counts!” But this does not mean that this country, and this world, can afford to put _everybody _at risk for every life that is threatened. If that were to be the case, car-use must be prohibited instantly because thousands of citizens die every year in car accidents, and almost every medication must be removed immediately from the market because many, if not most, list in their package inserts significant risks, including the possibility of death as a potential side effect/complication.
All medical practice is based on the so-called risk/benefit considerations. What this means is that in every medical intervention benefits must morally and ethically outweigh its downsides. The world’s reaction to the COVID-19 endemic can be viewed as the, likely, largest single medical interevention in world history. Like all other medical interventions, It, therefore, should prior to implementations of unprecedented interventions have followed a careful risk/benefit evaluation.
This, in our opinion, has not happened. Instead, as we will attempt to demonstrate, decision were made one-sided, only considering potential benefits from proposed interventions and, even those, were highly exaggerated. Risks from proposed interventions, both medical as well as economical (and we will demonstrate that economic risks feed back upon medical risks), were mostly ignored.
There is a second very important moral, ethical and legal principle that must be carefully considered when addressing the worldwide responses of goevrnments to the COVID-19 crisis: It is not only the right but the absolute obligation of governments to defend their countries’ best interests, - even if it, for example, means sending troops into combat and, thereby, causing fatalities. Governments make these difficult decisions all the time and, taking military actions once more as an example, do so after very careful risk/benefit evaluations that, of course, include as one of the most important consideration the number of potential fatalities. And, yes, every life counts; but accepting the responsibility of defending a nation’s best interests, sooner or later, for almost every leader, whether in military of civilian matters, will include the often excruciating but inevitable decision-making process of how many lives must be sacrificed for the better good of the nation.
There is good reason why being Commander-in-Chief is the U.S. president’s most important responsibility and title. Every president who ever sent soldiers into combat and stood at the tarmac when bodies were returned for burial, considered those among the most difficult moments of the presidency. The decision how to combat the COVID-19 endemic involves, however, very similar decision-making processes. What President Trump considers to be the “war” against COVID-19, inevitably must lead to loss of life. The government’s first responsibility then is to win the war and, to do so, with the smallest possible loss of life. But lives are always lost, and the overwhelming question always must be how can the war be won the quickest with the least possible loss of life?
Except for Sweden, practically all other countries followed what within the COVID-19 pandemic has been called the “Chinese model,” so called because first implemented in rather draconian ways during the current virus outbreak in China. Because of the country’s apparent success in suppressing the epidemic in their country, it has been copied (in less draconian ways) practically all over the world, resulting in temporary closure of all considered non-essential activities in major cities from New York to London and Tokyo. The considerations in support of this almost complete unanimity of response is, however, anything but obvious. At the beginning the rationale given was to prevent hospitals from running out of capacity (as they had done in Italy and Spain). The slogan describing this effort was “flattening the curve.” But it quickly became apparent that, while in NYC hospitals , indeed, became very busy, added bed and intensive-care capacity at Javits Center, for example, was never really needed. In other words, even in NYC, where around 30% of all the nation’s cases were located, hospitals managed quite well. In other parts of the country, where diagnosed cases were only small fractions of NYC’s experience, hospital beds, indeed, remained often empty because elective surgeries had been stopped nationwide.
But once it became clear that the feared assault on hospital capacity would not happen, the rationale for keeping the country “closed-down,” suddenly changed: Now the new purpose was to prevent a second “rebound” of COVID-19 cases, while at the same time telling us that COVID-19, very likely was here to stay with us for some time. In other words, mild fluctuations in COVID-19 cases were to be expected likely for years to come. Not only had “experts” been almost comically wrong in predicting the breakdown of the country’s hospital capacityies and about how many people COVID-19 might kill (President Trump was apparently told that the number would have exceeded over 2 million), but we are permitting those same “experts” to continue to make decisions about national strategy. How biased their opinions have been, and that their policy advice represented just opinion and was not, as so widely claimed, based on science, has now become obvious. As already previously noted in our April 13 Bulletin, the behavioral science literature warns about expert opinions for exactly these reasons.
Risk benefits assessments must be equally unbiased for and aginst both considerations. Yet, while we have seen innumerable curves about the expected beneficial effects of “flattening the curve,” it is noteworthy that we have seen exactly zero curves for similar modelling of potential adverse medical (and economic) consequences of proposed strategies by experts. For example, have we in any of the daily press briefings of the president’s COVID-19 Task Force seen figures for expected medical mortality of high-risk cardiac patients not getting proper cardiac care in current hospital settings, cancer patients not getting their cancer treatments or other patients not getting their surgeries in timely fasion? Of course not! Have we seen models for increases in suicides when, suddenly, 25 million people lose their jobs? Or how about models for increases in drug abuse, battery of women and children when families are not allowed to leave their appartments for weeks? Of course, nobody has shown these models because these issues have never even been considered! And, ultimately, has anybody given some thought to predictive models regarding what sudden poverty would do to human health if the U.S. economy falls off the cliff for millions of unemployed people? Of course not!
In the COVID-19 battle, commanders-in-chief in the U.S. and elsewhere (except for Sweden), thus, apparently did not receive balanced expert advice. It appears that nobody considered counter balancing opinions about what could and, likely, would go wrong with the universal strategy of closing down whole economies. This is a peculiar way of practicing medicine, considering that the first dogma of medical practice has always been, first, do no harm!
As the only renegade nation, what has been happening in Sweden is, indeed, very interesting: First, it is important to note that, in contrast to practically all of the rest of Europe and the world, Sweden has _not _shut down its economy and, indeed, has not shut down normal life. Schools and universities are open and function normally, people go to work, cafes and restaurants are open and packed as usual, serving hundreds of different hering dishes with fitting alcoholic drinks. Even some entertainment venues, like movie houses, have remained open and gatherings up to 500 people are apparently permitted.
This, of course, does not mean that Swedes were not advised to wash their hands frequently and try not to touch their faces. They were also told to stay home if they felt sick or anybody else in their family was sick; but life has been going on with at least 95% normality.
And what has happened?
Not very much. Swedish hospitals are quite full but not overloaded. Indeed, like the Javits Center in NYC, a military hospital established in Stockholm as a precaution, never saw patients. Hospitalization rates, admissions to intensive care units and mortality from COVID-19 are barely higher than in neighboring Norway (a country with very similar genetic traits and alcohol consumption) which, like the rest of the European Union, closed down its economy. In other words, without desocializing, without school and university closings and without shutting down a country’s economy, Sweden has been doing practically equally well as all the other countries, including the U.S., which have gone the opposite way. It, indeed, in many outcomes is far ahead of other European countries, like Italy and Spain.
You may ask, how is that possible? We, likely, answered this question already in our April 13 Bulletin. The answer is, likely, herd immunity. Sweden has not blocked herd immunity from developing, while we and most of the rest of the world have done our best to do exactly that. Above noted studies which detected that 30- to 100-times as many people as expected to have developed immunity to COVID-19 than have been diagnosed as infected, still, only suggest roughly 2% of the population currently being immune to the virus in the U.S. We suggested in our April 13, Bulletin that NYC may derive benefit from having peak infection rates in the country because that would mean that the city would be ahead of the rest of the nation in developing herd immunity.
And, lo and behold, first studies about immunity in New York State were just published on April 24: With ca. 20% immunity, Manhattan, indeed, demonstrates the highest recorded immunity to COVID-19 anywhere in the world so far. NYC as a whole seems to have ca. 14% immunity and New York state overall only ca. 4%. We, therefore, have still quite a way to go because herd immunity effectively shuts down new infections only at ca. 50-60% immunity levels in a population. Our Swedish colleagues in their more unbiased expert opinions understood the wisdom of nature, which limits viral outbreaks through achievement of herd immunity. All the other experts in the world very obviously became victims of their own unproven and, ultimately, incorrect hypotheses and, as a result, have made things, likely, worse by preventing the U.S. (and many other countries in the world) from developing as quickly as possible adequate herd immunity. And because, as national statistics now well demonstrate, the mortality rate of COVID-9 is extremely low, coming back to risk-benefit considerations, our experts have been obviously wrong in preventing the nation from getting herd-immunity as quickly as possible.
Yes, mortality, as in Sweden, might have been even a little bit higher than it is currently, and, yes, every life counts, but consider how much additional research the nation could have funded on improving COVID-19 treatments (and other maladies) with only a small fraction of the funds the federal government is currently forced to spend on rescuing the country’s devastated economy that was shut down for really no good scientific reasons. One really has to wonder where else in the decision-making process in government herd-thinking outweighs real science to such substantial degrees and with such devastating consequences?
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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