Norbert Gleicher, MD
I arrived in New York City (NYC) to start my residency at Mount Sinai Medical Center roughly 46 years ago. A highly rewarding professional career in academia, research, private medicine and business behind me, I was expecting a few more good years of the same, when 2020 came around. By March, the world, however, looked very different: COVID-19 had arrived, and a “war” had broken out.
I had faced a similar situation before: The Yom Kippur War started completely unexpectedly on October 6, 1973, just as my rotating internship had begun in Tel Aviv, Israel, after medical school. So many years later, I still vividly remember how always too many wounded soldiers were brought to the hospital all at once, most close to my own age, yet, often, even closer to death. Decisions had to be made on the spot, often intuitively because bringing soldiers quickly into the operating room was more important than knowing specifically where the bleeding was coming from. Who was taken first, often determined who lived and who died. It was good being only an intern since, initially, others made these decisions. We interns, however, very quickly were promoted since the more senior physicians were needed in the operating rooms.
I, instinctively, learned to trust my decisions, an ability that has served me well ever since; and it was an enthralling, almost addictive experience. Nothing is more reaffirming than having the opportunity to save lives on such a large scale, an experience that only can present itself in such extreme emergency situations as war in Tel-Aviv or, 47 years later, war against COVID-19 in NYC.
Writing about the 2020 COVID-19 experience in NYC, several authors have pointed out the analogies to war. With this virus, this included a significant risk to life, akin to combat. Symbolically speaking, NYC’s health care workers, during peaks of the pandemic, were in unprotected field hospitals under constant bombardments and, therefore, daily risking their lives. Moreover, 1973 and 2020 had in common a relentless flow of patients in extremis.
Too old for the frontlines, I this time was left to observe from a distance. The worse things got, the more I envied my colleagues at the front lines in emergency rooms and ICUs and the more an almost unbearable feeling of frustration took hold. Yet, all I could do was to record what I was witnessing from a distance. Relegated to the sidelines in such a historical moment, my personal impotence to affect the situation became painfully obvious, while the city’s hospitals literally descended into pandemonium. The only contribution left I could provide was to at least keep CHR functioning as a fertility center that did not succumb to the pandemic and shut down, as most other fertility centers did, a process in detail described elsewhere.1
Even leading academic hospitals were inadequately prepared. Most consequential, however, was the blatant absence of any in-advance strategic planning at all organizational levels, hospitals, city-, state- and federal.2
Though, as of this moment, it may appear humorous that I witnessed New York’s governor, seriously, demanding from the federal government not less than 40,000 respirators for New York City’s hospitals, while then not even using the 1,000 he got delivered. At that moment, the demand was, however, anything but funny and represented a good example of the above-noted pandemonium created by unpreparedness and incompetence of local as well as federal government agencies. The federal Centers for Disease Control and Prevention (CDC) was another good example: When investigators in a national influenza tracking system in Washington state, where the very first U.S. COVID-19 cases had been reported,3 correctly concluded that the virus had spread into the community,4 the CDC prohibited further use of their in-house developed diagnostic COVID test. A few days later, it became clear why: the agency announced a first (in-house-developed) commercially approved diagnostic test. That test, however, ended up having such poor reproducibility, that within days it had to be withdrawn.5 By then, on the West Coast important testing opportunities had been missed.
Observing all of this from the sidelines was difficult enough. But what made it, often, almost intolerable were a phalanx of inexplicitly selected “experts” and their, at times, ridiculous pronouncements. The SARS-CoV-2 virus was still a largely unknown phenomenon at that point and acknowledging the world’s ignorance would have been no shame; yet not even one among those supposed “experts” was ever willing to acknowledge this. I never heard, I don’t know, as an answer from any of them. Their guidance, moreover, constantly changed and their credibility very quickly tanked in parallel. None was, of course, more adept at making ever-changing pronouncements “of authority” than by America’s media anointed “leading” COVID-19 “expert,” Anthony Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases since 1984 (!) and just appointed by President-elect Biden as his “chief medical advisor.”
Only modelers were worse in their predictions than “experts” because the absurdity of their projections beat out the pronouncements of the most overconfident “experts.” The most infamous model was, of course, the British Imperial College model, predicting in excess of 2 million deaths from the pandemic in the U.S. alone. No big surprise then that the public (me included) lost all trust and respect in experts as well as modelers 6 and became desperate in the desire to receive correct, objective, and validated information.
It seemed like the world approached the pandemic as a gigantic medical experiment, though without prior approval by any Institutional Review Board (IRB) and without even striving for any of the required criteria usually required for any IRB approval.7 The worldwide study had no protocol, offered no logical rationale for many of the proposed interventions, there was no materials and methods section and expected outcome goals that were supposed to be reached were never defined. And, now in early December, facing a temporary resurgence of the virus, “expert” opinions, driving another round of scientifically often irrational closures all around the nation, are still causing irreparable harm, especially to the have-nots or those that have only a-little, while those who make those decisions, of course, have secure employment and have nothing to worry about for themselves.
Guidance from “experts” constantly changed and is, still, changing: Face masks did not help, then they, indeed, were supposed to harm and increase infection risks, to be followed by advice that they may help and, finally, that they were an essential must. We also were strongly advised that surfaces had to be cleaned continuously, then that contamination from surfaces was rare and, finally, we heard nothing on the subject anymore; surfaces, suddenly, no longer seemed important. We, of course, also were mandated “to shelter at home;” but then we learned that most infections occurred in homes and that the outside was a much less contagious environment. But now, California and other regions again shut down their economies and issued a mandate to stay home. No wonder, the contradictory and ever-changing guidance distributed to the public left everybody confused but also increasingly disheartened because the public perceived itself as abandoned and constantly misled.
The principal initial goal of all interventions was, we were told, the “flattening of the curve;” but once that goal had been achieved, goal posts were moved, and moving them has not stopped to this day. As these words are written, desired endpoints for currently proceeding interventions against COVID-19 are still unclear. A good example is the recent closure and reopening of public schools in NYC: When schools were closed, it was unclear why. Now that the mayor ordered the reopening of some of those schools, the rationale was equally unclear. No wonder, public skepticism about government orders regarding COVID-19 has been exploding.
Yet, expectations are high for vaccines becoming available imminently and excitement is building around the discovery that long-term anti-viral immunity is not only antibody-dependent but can also rely on some contribution of long-term cellular immunity from the innate immune system. Many regions of the world, therefore, may be much closer to immunity than previously estimated.8 Cross-reactive immunity with other viruses from earlier common cold and influenza infections and, possibly, even other vaccinations may contribute. The need for vaccines may, therefore, be less pronounced than had been thought, and new therapeutic options may also become available more quickly in the war against COVID-19 disease.9
But good news never makes as many headlines as bad news and the public is, therefore, still mostly unaware of most of these positive developments. Such uneven reporting, however, only further enhances the public’s mistrust. How severe the distrust of the public has become, is best reflected in recent reports, suggesting that roughly half of the U.S. population, currently, would refuse an FDA-approved anti-COVID-19 vaccine, even if vaccines are made available for free, as the current administration has promised.
How long it took most “experts” to even mentions the possibility of unintended adverse consequences from interventions they were advocating was truly astonishing. The term unintended consequences did not even come up for the first two months of the pandemic. Only by mid-May was there a first mention of how the national economic lockdown could adversely affect health (not to speak of peoples’ pocketbooks). The most consequential catastrophic consequence was by then, however, already underway: Approximately 43% of total U.S. fatalities from COVID-19 between March and June occurred in nursing and rehabilitation homes.10 At least a third of those deaths occurred in New York state, and many additional ones in the adjacent states of New Jersey and Connecticut, where the initial wave of COVID-19 had been especially brutal. And all of this happened while NYC was sitting on over 3000 unused hospital beds for COVID-19 patients, provided by the federal government at the explicit request of the New York governor (yes, the same governor that had asked for 40,000 respirators) at significant expense and with remarkable speed.11
Thousands unnecessarily died, often in total isolation and without last words from a cleric or family, without a last look at a child, a sibling, a parent, or a best friend. Observing from the sidelines these unnecessary deaths in the thousands were devastating and offered the ultimate confirmation of the total incompetence of our system of medical governance. Remaining questions are now obvious: How do we best and most quickly recover? And, most importantly, what must be done, so the next pandemic will not have such devastating consequences all over again? We cannot early enough start working on the answers because the next pandemic may be just around the corner.
COVID-19 clearly demonstrated that the U.S. (and, likely, many other countries) must radically rethink how to prepare for future pandemic risks in all their potential variety. It is unacceptable that developed nations in the 21st century is unable to manage pandemics without fully shutting down economies, bankrupting businesses and reverting economic gains made by especially the poor and lower socioeconomic levels of society. Such a makeover, however, cannot be left to the “Faucis” of this world alone.
Expertise brought into these discussions must be much broader and include experts in all areas of medicine not only potentially affected by a virus but also affected by hospitals flooded by pandemic patients and, therefore, unable to care for the “regular” patient population presenting with cancer, heart disease or other common medical problems. Hospital administrations must be mandated to establish space, staffing and equipment redundancies, that allow quick scaling up of all necessary patient care should a pandemic occur. The process must also include economists, logistics experts and psychiatric experts, not only concerned about physical but also mental health.
Public health and infectious disease “experts” governments have relied on in this crisis may be the best in their respective small areas of expertise. To battle a worldwide pandemic requires, however, much more than those very limited levels of expertise. For good reasons, in medicine “expert” opinions are considered the lowest level of evidence.12 Well demonstrated in the literature by colleagues in the behavioral sciences, in economics and in law, there are good reasons for the low esteem for “expert” opinions,13 recently smartly presented by the philosophy professor Maria Baghramian, when rhetorically asking, ”who needs experts?” 14
Had physicians caused the thousands of potentially avoidable deaths in nursing homes, caused by governors in New York state and in other states, such physicians with absolute certainty would no longer practice medicine and, indeed, likely be in prison. Yet, the “experts” on whose advice governors by law mandated transfer of COVID-19-infected seniors back into nursing and old-age homes, are still on television, continuing their usual “expert” pronouncements, while governors who followed their advice are still comfortably situated in their mansions. Those people, alone, cannot again be entrusted to save us from another pandemic!
- Gleicher N. The COVID-19 pandemic through eyes of a NYC fertility center: a unique learning experience with often unexpected results. Reprod Biol Endocrinol 2020;18:105
- Horton R., The Covid-19 Catastrophe: What’s Gone Wrong and How To Stop It happening Again. Polity (2020)
- Aleccia JN. How intrepid lab sleuths ramped up tests as Coronavirus closed in. Kaiser Health News 2020; https://khn.org/news/how-intrepid-seattle-scientists-ramped-up-tests-as-coronavirus-closed-in/
- Boburg S, OHarrow Je. R, Satia N, Goldstein A. Inside the coronavirus testing failure” Alarm and dismay among the scientists who thought o help/ The Washington Post, April 3, 2020; https://www.washingtonpost.com/investigations/2020/04/03/coronavirus-cdc-test-kits-public-health-labs/?arc404=true
- Saltelli A, Bammer G, Bruno I, Charters E, Di Fiore M, Didier E, Nelson Espeland W, Kay J, Lo Piano S, Mayo D, Pielke Jr. R, Portaluri T, Porter TM, Puy A Rafols I, Ravetz JR, Reinert E, Sarewitz D, Stark PB, Stirling A, van der Sluijs J, Vineis P. Five ways to ensure that models serve society: a manifesto. Nature 2020;582:482-484.
- Britton T, Ball F, Trapman P. A mathematical model reveals the influence of population heterogeneity o herd immunity to SARS-CoV-2. Science 2020;369(6505):846-849
- Cohen J. Antibodies may curb pandemic before vaccines. Science 2020;369(6505):752-753
- The New York Times. 43% of U.S. Coronavirus deaths are linked to nursing homes., The New York Times, June 27, 2020; https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html
- Narishkin A, Cameron S, Brandt L. Why NYC’s largest emergency hospital is pretty much empty. Business Insider, April 20, 2020; https://www.businessinsider.com/why-nycs-largest-emergency-hospital-javits-center-pretty-much-empty-2020-4
- Ouchi F. A literature review on the use of expert opinion in probabilistic risk analysis. The New Google Books. 20120; https://books.google.com/books?id=98o4qHEEjvMC&pg=PA3&lpg=PA3&dq=Behavioral+studies+that+warn+about+expert+opinions&source=bl&ots=focGUZdhLV&sig=ACfU3U0KgWN0BxVQGeWCe8MP1Fdh7AkMIg&hl=en&sa=X&ved=2ahUKEwjj3-6wuK_qAhUthHIEHcLpC_sQ6AEwBXoECAoQAQ#v=onepage&q=Behavioral%20studies%20that%20warn%20about%20expert%20opinions&f=false
- Baghramian M. Trust in experts: Why and why not? 2020; https://jerichochambers.com/trust-in-experts-why-and-why-not/
This is part of the December 2020 VOICE!