Trump: U.S. will terminate relationship with the World Health Organization in wake of Covid-19 pandemic

Trump: U.S. will terminate relationship with the World Health Organization in wake of Covid-19 pandemic

Coronavirus Fears Grind International Diplomacy to a Halt

President Trump said Friday the U.S. would halt its funding of the World Health Organization and pull out of the agency, accusing it of protecting China as the coronavirus pandemic took off. The move has alarmed health experts, who say the decision will undermine efforts to improve the health of people around the world.

In an address in the Rose Garden, Trump said the WHO had not made reforms that he said would have helped the global health agency stop the coronavirus from spreading around the world.

“We will be today terminating our relationship with the World Health Organization and redirecting those funds to other worldwide and deserving urgent global public health needs,” Trump said. “The world needs answers from China on the virus.”

It’s not immediately clear whether the president can fully withdraw U.S. funding for the WHO without an act of Congress, which typically controls all federal government spending. Democratic lawmakers have argued that doing so would be illegal, and House Speaker Nancy Pelosi threatened last month that such a move would be “swiftly challenged.”

The United States has provided roughly 15% of the WHO’s total funding over its current two-year budget period.

The WHO has repeatedly said it was committed to a review of its response, but after the pandemic had ebbed. Last month, Robert Redfield, the director of the Centers for Disease Control and Prevention, also said the “postmortem” on the pandemic should wait until the emergency was over.

As the Trump administration’s response to pandemic has come under greater scrutiny, with testing problems and a lack of coordination in deploying necessary supplies, Trump has sought to cast further blame on China and the WHO for failing to snuff out the spread when the virus was centered in China.

During his remarks, Trump alleged, without evidence, that China pressured WHO to mislead the world about the virus. Experts say that if the U.S. leaves the WHO, the influence of China will only grow.

“The world is now suffering as a result of the malfeasance of the Chinese government,” Trump said. “China’s coverup of the Wuhan virus allowed the disease to spread all over the world, instigating a global pandemic that has cost more than 100,000 American lives, and over a million lives worldwide.” (That last claim is not true; globally, there have been about 360,000 confirmed deaths from Covid-19, the disease caused by the coronavirus.)

When Trump earlier this month threatened to yank U.S. funding in a letter, Tedros Adhanom Ghebreyesus, the WHO director-general, would only say during a media briefing that the agency was reviewing it. But he and other officials stressed that the agency had a small budget — about $2.3 billion every year — relative to the impact the agency had and what it was expected to do.

Mike Ryan, head of the WHO’s emergencies program, said the U.S. funding provided the largest proportion of that program’s budget.

“So my concerns today are both for our program and … working on how we improve our funding base for WHO’s core budget,” Ryan said. “Replacing those life-saving funds for front-line health services to some of the most difficult places in the world — we’ll obviously have to work with other partners to ensure those funds can still flow. So this is going to have major implications for delivering essential health services to some of the most vulnerable people in the world and we trust that other donors will if necessary step in to fill that gap.”

 

Pandemic response complicated by public health agencies’ inability to receive data from hospitals

https://www.healthcaredive.com/news/pandemic-response-complicated-by-public-health-agencies-inability-to-recei/578663/

Dive Brief:

  • The biggest problem with electronic syndromic surveillance reporting isn’t that hospitals lack the capacity to send data — it’s that public health agencies lack the ability to receive it, according to a new report published in the Journal of the American Medical Informatics Association.
  • More than four in 10 U.S. hospitals say their local, state and federal public health agencies are unable to receive data electronically, reflecting a decade-long investment in health IT infrastructure on the private sector side without a concomitant investment from its federal partners, researchers found.
  • Hospitals in regions forecast to be some of the hardest hit from COVID-19 were more likely to say public health agencies were unable to receive health data electronically, implying areas of highest need were some of the least prepared to mount a coordinated, data-driven response going into the pandemic.

Dive Insight:

Effective pandemic response requires real-time, accurate data sharing between providers and public health agencies, allowing the government to track outbreaks and allocate resources as needed.

A lack of nationwide, interoperable reporting infrastructure has been one of the major criticisms of the Trump administration’s handling of the pandemic, which has infected almost 1.7 million and killed 99,000 people in the U.S. as of Wednesday.

CMS requires hospitals be able to electronically send and receive health information, including lab results and syndromic surveillance data, to and from public health agencies like their state’s department of health. For more than a decade, providers have funneled significant resources into their IT infrastructure due to a slurry of federal incentive programs, though EHR implementation remains piecemeal across the U.S. due to cost and other barriers.

The JAMIA study, one of the first looking at the state of health data reporting, analyzed 2018 American Hospital Association data to identify hospital-reported barriers to surveillance data reporting, and Harvard Global Health Institute data on the coronavirus pandemic’s projected impact on hospital capacity at the hospital referral region (HRR) level. Researchers assumed a 40% population infection rate over 12 months.

The group found 31 high-need HRRs, those in the top quartile of projected beds needed for COVID-19 patients, with more than half of the hospitals in the region saying the relevant public health agency couldn’t electronically receive data.

That suggests areas more likely to be overwhelmed by the pandemic had some of the least interoperable data-sharing capabilities going into it, hamstringing outbreak response.

Researchers found the most common barrier to data-sharing nationwide, reported by 41% of hospitals, was that public health agencies didn’t have the capacity to receive data electronically.

The next most common, reported by 32% of hospitals, was interface-related issues, such as costs or implementation complexity; followed by difficulty extracting data from the EHR (14% of hospitals reporting), different data standards (also 14%), hospitals lacking the capacity to send data (8%) and hospitals being unsure what public health agencies to send the data to (3%).

Researchers also found significant state variance in hospitals saying public health agencies couldn’t receive needed data electronically, running the gamut from 83% of hospitals saying so in Hawaii and Rhode Island to 40% in New Jersey and Virginia to none in Delaware.

Geographic variation is likely due to different funding priorities in different places, as some agencies may only be able to receive specific data elements or interface with a select number of EHRs. This spotty IT implementation results in a patchwork picture of disease progression across the U.S., though the Centers for Disease Control and Prevention is working to automate the COVID-19 reporting process.

The study does have some significant limitations. It’s a relatively one-sided portrayal of the issue, as researchers did not have access to data or survey results from public health agencies. And, since AHA survey results were from two years ago, the EHR landscape could have shifted since 2018.

However, researchers called upon policymakers to build up public health agencies’ IT capabilities, especially as states begin to reopen despite an increasingly likely resurgence of the virus in the fall.

“Policymakers should prioritize investment in public health IT infrastructure along with broader health system information technology for both long-term COVID-19 monitoring as well as future pandemic preparedness,” authors A Jay Holmgren, a doctoral candidate at Harvard Business School; Nate Apathy, a doctoral candidate at Indiana University’s Richard M. Fairbanks School of Public Health; and Julia Adler-Milstein, a professor at University of San Francisco Department of Medicine, wrote.

 

 

 

Vaccine experts say Moderna didn’t produce data critical to assessing Covid-19 vaccine

Vaccine experts say Moderna didn’t produce data critical to assessing Covid-19 vaccine

Moderna taps $1.34B stock offering to bankroll its promising COVID ...

Heavy hearts soared Monday with news that Moderna’s Covid-19 vaccine candidate — the frontrunner in the American market — seemed to be generating an immune response in Phase 1 trial subjects. The company’s stock valuation also surged, hitting $29 billion, an astonishing feat for a company that currently sells zero products.

But was there good reason for so much enthusiasm? Several vaccine experts asked by STAT concluded that, based on the information made available by the Cambridge, Mass.-based company, there’s really no way to know how impressive — or not — the vaccine may be.

While Moderna blitzed the media, it revealed very little information — and most of what it did disclose were words, not data. That’s important: If you ask scientists to read a journal article, they will scour data tables, not corporate statements. With science, numbers speak much louder than words.

Even the figures the company did release don’t mean much on their own, because critical information — effectively the key to interpreting them — was withheld.

Experts suggest we ought to take the early readout with a big grain of salt. Here are a few reasons why.

The silence of the NIAID

The National Institute for Allergy and Infectious Diseases has partnered with Moderna on this vaccine. Scientists at NIAID made the vaccine’s construct, or prototype, and the agency is running the Phase 1 trial. This week’s Moderna readout came from the earliest of data from the NIAID-led Phase 1.

NIAID doesn’t hide its light under a bushel. The institute generally trumpets its findings, often offering director Anthony Fauci — who, fair enough, is pretty busy these days — or other senior personnel for interviews.

But NIAID did not put out a press release Monday and declined to provide comment on Moderna’s announcement.

The n = 8 thing

The company’s statement led with the fact that all 45 subjects (in this analysis) who received doses of 25 micrograms (two doses each), 100 micrograms (two doses each), or a 250 micrograms (one dose) developed binding antibodies.

Later, the statement indicated that eight volunteers — four each from the 25-microgram and 100-microgram arms — developed neutralizing antibodies. Of the two types, these are the ones you’d really want to see.

We don’t know results from the other 37 trial participants. This doesn’t mean that they didn’t develop neutralizing antibodies. Testing for neutralizing antibodies is more time-consuming than other antibody tests and must be done in a biosecurity level 3 laboratory. Moderna disclosed the findings from eight subjects because that’s all it had at that point. Still, it’s a reason for caution.

Separately, while the Phase 1 trial included healthy volunteers ages 18 to 55 years, the exact ages of these eight people are unknown. If, by chance, they mostly clustered around the younger end of the age spectrum, you might expect a better response to the vaccine than if they were mostly from the senior end of it. And given who is at highest risk from the SARS-CoV-2 coronavirus, protecting older adults is what Covid-19 vaccines need to do.

There’s no way to know how durable the response will be

The report of neutralizing antibodies in subjects who were vaccinated comes from blood drawn two weeks after they received their second dose of vaccine.

Two weeks.

“That’s very early. We don’t know if those antibodies are durable,” said Anna Durbin, a vaccine researcher at Johns Hopkins University.

There’s no real way to contextualize the findings

Moderna stated that the antibody levels seen were on a par with — or greater than, in the case of the 100-microgram dose — those seen in people who have recovered from Covid-19 infection.

But studies have shown antibody levels among people who have recovered from the illness vary enormously; the range that may be influenced by the severity of a person’s disease. John “Jack” Rose, a vaccine researcher from Yale University, pointed STAT to a study from China that showed that, among 175 recovered Covid-19 patients studied, 10 had no detectable neutralizing antibodies. Recovered patients at the other end of the spectrum had really high antibody levels.

So though the company said the antibody levels induced by vaccine were as good as those generated by infection, there’s no real way to know what that comparison means.

STAT asked Moderna for information on the antibody levels it used as a comparator. The response: That will be disclosed in an eventual journal article from NIAID, which is part of the National Institutes of Health.

“The convalescent sera levels are not being detailed in our data readout, but would be expected in a downstream full data exposition with NIH and its academic collaborators,” Colleen Hussey, the company’s senior manager for corporate communications, said in an email.

Durbin was struck by the wording of the company’s statement, pointing to this sentence: “The levels of neutralizing antibodies at day 43 were at or above levels generally seen in convalescent sera.”

“I thought: Generally? What does that mean?” Durbin said. Her question, for the time being, can’t be answered.

Rose said the company should disclose the information. “When a company like Moderna with such incredibly vast resources says they have generated SARS-2 neutralizing antibodies in a human trial, I would really like to see numbers from whatever assay they are using,” he said.

Moderna’s approach to disclosure

The company has not yet brought a vaccine to market, but it has a variety of vaccines for infectious diseases in its pipeline. It doesn’t publish on its work in scientific journals. What is known has been disclosed through press releases. That’s not enough to generate confidence within the scientific community.

“My guess is that their numbers are marginal or they would say more,” Rose said about the company’s SARS-2 vaccine, echoing a suspicion that others have about some of the company’s other work.

“I do think it’s a bit of a concern that they haven’t published the results of any of their ongoing trials that they mention in their press release. They have not published any of that,” Durbin noted.

Still, she characterized herself as “cautiously optimistic” based on what the company has said so far.

“I would like to see the data to make my own interpretation of the data. But I think it is at least encouraging that we’ve seen immune responses with this RNA vaccine that we haven’t seen with previous RNA vaccines for other pathogens. Whether it’s going to be enough, we don’t know,” Durbin said.

Moderna has been more forthcoming with data on at least one of its other vaccine candidates. In a statement issued in January about a Phase 1 trial for its cytomegalovirus (CMV) vaccine, it quantified how far over baseline measures antibody levels rose in vaccines.

 

 

 

COVID-19 and the End of Individualism

https://www.project-syndicate.org/commentary/covid19-economic-interdependence-waning-individualism-by-diane-coyle-2020-05?utm_source=Project+Syndicate+Newsletter&utm_campaign=1cfd702284-covid_newsletter_07_05_2020&utm_medium=email&utm_term=0_73bad5b7d8-1cfd702284-105592221&mc_cid=1cfd702284&mc_eid=5f214075f8

Daniel Innerarity - Project Syndicate

The pandemic has shown that it is not existential dangers, but rather everyday economic activities, that reveal the collective, connected character of modern life. Just as a spider’s web crumples when a few strands are broken, so the coronavirus has highlighted the risks arising from our economic interdependence.

CAMBRIDGE – Aristotle was right. Humans have never been atomized individuals, but rather social beings whose every decision affects other people. And now the COVID-19 pandemic is driving home this fundamental point: each of us is morally responsible for the infection risks we pose to others through our own behavior.

In fact, this pandemic is just one of many collective-action problems facing humankind, including climate change, catastrophic biodiversity loss, antimicrobial resistance, nuclear tensions fueled by escalating geopolitical uncertainty, and even potential threats such as a collision with an asteroid.

As the pandemic has demonstrated, however, it is not these existential dangers, but rather everyday economic activities, that reveal the collective, connected character of modern life beneath the individualist façade of rights and contracts.

Those of us in white-collar jobs who are able to work from home and swap sourdough tips are more dependent than we perhaps realized on previously invisible essential workers, such as hospital cleaners and medics, supermarket staff, parcel couriers, and telecoms technicians who maintain our connectivity.

Similarly, manufacturers of new essentials such as face masks and chemical reagents depend on imports from the other side of the world. And many people who are ill, self-isolating, or suddenly unemployed depend on the kindness of neighbors, friends, and strangers to get by.

The sudden stop to economic activity underscores a truth about the modern, interconnected economy: what affects some parts substantially affects the whole. This web of linkages is therefore a vulnerability when disrupted. But it is also a strength, because it shows once again how the division of labor makes everyone better off, exactly as Adam Smith pointed out over two centuries ago.

Today’s transformative digital technologies are dramatically increasing such social spillovers, and not only because they underpin sophisticated logistics networks and just-in-time supply chains. The very nature of the digital economy means that each of our individual choices will affect many other people.

Consider the question of data, which has become even more salient today because of the policy debate about whether digital contact-tracing apps can help the economy to emerge from lockdown faster.

This approach will be effective only if a high enough proportion of the population uses the same app and shares the data it gathers. And, as the Ada Lovelace Institute points out in a thoughtful report, that will depend on whether people regard the app as trustworthy and are sure that using it will help them. No app will be effective if people are unwilling to provide “their” data to governments rolling out the system. If I decide to withhold information about my movements and contacts, this would adversely affect everyone.

Yet, while much information certainly should remain private, data about individuals is only rarely “personal,” in the sense that it is only about them. Indeed, very little data with useful information content concerns a single individual; it is the context – whether population data, location, or the activities of others – that gives it value.

Most commentators recognize that privacy and trust must be balanced with the need to fill the huge gaps in our knowledge about COVID-19. But the balance is tipping toward the latter. In the current circumstances, the collective goal outweighs individual preferences.

But the current emergency is only an acute symptom of increasing interdependence. Underlying it is the steady shift from an economy in which the classical assumptions of diminishing or constant returns to scale hold true to one in which there are increasing returns to scale almost everywhere.

In the conventional framework, adding a unit of input (capital and labor) produces a smaller or (at best) the same increment to output. For an economy based on agriculture and manufacturing, this was a reasonable assumption.

But much of today’s economy is characterized by increasing returns, with bigger firms doing ever better. The network effects that drive the growth of digital platforms are one example of this. And because most sectors of the economy have high upfront costs, bigger producers face lower unit costs.

One important source of increasing returns is the extensive experience-based know-how needed in high-value activities such as software design, architecture, and advanced manufacturing. Such returns not only favor incumbents, but also mean that choices by individual producers and consumers have spillover effects on others.

The pervasiveness of increasing returns to scale, and spillovers more generally, has been surprisingly slow to influence policy choices, even though economists have been focusing on the phenomenon for many years now. The COVID-19 pandemic may make it harder to ignore.

Just as a spider’s web crumples when a few strands are broken, so the pandemic has highlighted the risks arising from our economic interdependence. And now California and Georgia, Germany and Italy, and China and the United States need each other to recover and rebuild. No one should waste time yearning for an unsustainable fantasy.

 

 

 

New Studies Add to Evidence that Children May Transmit the Coronavirus

New Studies Add to Evidence that Children May Transmit the ...

Experts said the new data suggest that cases could soar in many U.S. communities if schools reopen soon.

Among the most important unanswered questions about Covid-19 is this: What role do children play in keeping the pandemic going?

Fewer children seem to get infected by the coronavirus than adults, and most of those who do have mild symptoms, if any. But do they pass the virus on to adults and continue the chain of transmission?

The answer is key to deciding whether and when to reopen schools, a step that President Trump urged states to consider before the summer.

Two new studies offer compelling evidence that children can transmit the virus. Neither proved it, but the evidence was strong enough to suggest that schools should be kept closed for now, many epidemiologists who were not involved in the research said.

Many other countries, including Israel, Finland, France, Germany, the Netherlands and the United Kingdom have all either reopened schools or are considering doing so in the next few weeks.

In some of those countries, the rate of community transmission is low enough to take the risk. But in others, including the United States, reopening schools may nudge the epidemic’s reproduction number — the number of new infections estimated to stem from a single case, commonly referred to as R0 — to dangerous levels, epidemiologists warned after reviewing the results from the new studies.

In one study, published last week in the journal Science, a team analyzed data from two cities in China — Wuhan, where the virus first emerged, and Shanghai — and found that children were about a third as susceptible to coronavirus infection as adults were. But when schools were open, they found, children had about three times as many contacts as adults, and three times as many opportunities to become infected, essentially evening out their risk.

Based on their data, the researchers estimated that closing schools is not enough on its own to stop an outbreak, but it can reduce the surge by about 40 to 60 percent and slow the epidemic’s course.

“My simulation shows that yes, if you reopen the schools, you’ll see a big increase in the reproduction number, which is exactly what you don’t want,” said Marco Ajelli, a mathematical epidemiologist who did the work while at the Bruno Kessler Foundation in Trento, Italy.

The second study, by a group of German researchers, was more straightforward. The team tested children and adults and found that children who test positive harbor just as much virus as adults do — sometimes more — and so, presumably, are just as infectious.

“Are any of these studies definitive? The answer is ‘No, of course not,’” said Jeffrey Shaman, an epidemiologist at Columbia University who was not involved in either study. But, he said, “to open schools because of some uninvestigated notion that children aren’t really involved in this, that would be a very foolish thing.”

The German study was led by Christian Drosten, a virologist who has ascended to something like celebrity status in recent months for his candid and clear commentary on the pandemic. Dr. Drosten leads a large virology lab in Berlin that has tested about 60,000 people for the coronavirus. Consistent with other studies, he and his colleagues found many more infected adults than children.

The team also analyzed a group of 47 infected children between ages 1 and 11. Fifteen of them had an underlying condition or were hospitalized, but the remaining were mostly free of symptoms. The children who were asymptomatic had viral loads that were just as high or higher than the symptomatic children or adults.

“In this cloud of children, there are these few children that have a virus concentration that is sky-high,” Dr. Drosten said.

He noted that there is a significant body of work suggesting that a person’s viral load tracks closely with their infectiousness. “So I’m a bit reluctant to happily recommend to politicians that we can now reopen day cares and schools.”

Dr. Drosten said he posted his study on his lab’s website ahead of its peer review because of the ongoing discussion about schools in Germany.

Many statisticians contacted him via Twitter suggesting one or another more sophisticated analysis. His team applied the suggestions, Dr. Drosten said, and even invited one of the statisticians to collaborate.

“But the message of the paper is really unchanged by any type of more sophisticated statistical analysis,” he said. For the United States to even consider reopening schools, he said, “I think it’s way too early.”

In the China study, the researchers created a contact matrix of 636 people in Wuhan and 557 people in Shanghai. They called each of these people and asked them to recall everyone they’d had contact with the day before the call.

They defined a contact as either an in-person conversation involving three or more words or physical touch such as a handshake, and asked for the age of each contact as well as the relationship to the survey participant.

Comparing the lockdown with a baseline survey from Shanghai in 2018, they found that the number of contacts during the lockdown decreased by about a factor of seven in Wuhan and eight in Shanghai.

“There was a huge decrease in the number of contacts,” Dr. Ajelli said. “In both of those places, that explains why the epidemic came under control.”

The researchers also had access to a rich data set from Hunan province’s Center for Disease Control and Prevention. Officials in the province traced 7,000 contacts of 137 confirmed cases, observed them over 14 days and tested them for coronavirus infection. They had information not just for people who became ill, but for those who became infected and remained asymptomatic, and for anyone who remained virus-free.

Data from hospitals or from households tend to focus only on people who are symptomatic or severely ill, Dr. Ajelli noted. “This kind of data is better.”

The researchers stratified the data from these contacts by age and found that children between the ages of 0 and 14 years are about a third less susceptible to coronavirus infection than those ages 15 to 64, and adults 65 or older are more susceptible by about 50 percent.

They also estimated that closing schools can lower the reproduction number — again, the estimate of the number of infections tied to a single case — by about 0.3; an epidemic starts to grow exponentially once this metric tops 1.

In many parts of the United States, the number is already hovering around 0.8, Dr. Ajelli said. “If you’re so close to the threshold, an addition of 0.3 can be devastating.”

However, some other experts noted that keeping schools closed indefinitely is not just impractical, but may do lasting harm to children.

Jennifer Nuzzo, an epidemiologist at Johns Hopkins University’s Bloomberg School of Public Health, said the decision to reopen schools cannot be made based solely on trying to prevent transmission.

“I think we have to take a holistic view of the impact of school closures on kids and our families,” Dr. Nuzzo said. “I do worry at some point, the accumulated harms from the measures may exceed the harm to the kids from the virus.”

E-learning approaches may temporarily provide children with a routine, “but any parent will tell you it’s not really learning,” she said. Children are known to backslide during the summer months, and adding several more months to that might permanently hurt them, and particularly those who are already struggling.

Children also need the social aspects of school, and for some children, home may not even be a safe place, she said.

“I’m not saying we need to absolutely rip off the Band-aid and reopen schools tomorrow,” she said, “but we have to consider these other endpoints.”

Dr. Nuzzo also pointed to a study in the Netherlands, conducted by the Dutch government, which concluded that “patients under 20 years play a much smaller role in the spread than adults and the elderly.”

But other experts said that study was not well designed because it looked at household transmission. Unless the scientists deliberately tested everyone, they would have noticed and tested only more severe infections — which tend to be among adults, said Bill Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health.

“Assumptions that children are not involved in the epidemiology, because they do not have severe illness, are exactly the kind of assumption that you really, really need to question in the face of a pandemic,” Dr. Hanage said. “Because if it’s wrong, it has really pretty disastrous consequences.”

A new study by the National Institutes of Health may help provide more information to guide decisions in the United States. The project, called Heros, will follow 6,000 people from 2,000 families and collect information on which children get infected with the virus and whether they pass it on to other family members.

The experts all agreed on one thing: that governments should hold active discussions on what reopening schools looks like. Students could be scheduled to come to school on different days to reduce the number of people in the building at one time, for example; desks could be placed six feet apart; and schools could avoid having students gather in large groups.

Teachers with underlying health conditions or of advanced age should be allowed to opt out and given alternative jobs outside the classroom, if possible, Dr. Nuzzo said, and children with underlying conditions should continue to learn from home.

The leaders of the two new studies, Dr. Drosten and Dr. Ajelli, were both more circumspect, saying their role is merely to provide the data that governments can use to make policies.

“I’m somehow the bringer of the bad news but I can’t change the news,” Dr. Drosten said. “It’s in the data.”

 

 

 

California governor unveils roadmap for relaxing coronavirus lockdowns

https://www.axios.com/california-newsom-coronavirus-restrictions-3195f1b4-cbf8-4205-aeda-500d1e965486.html

California governor unveils roadmap for relaxing coronavirus ...

California Gov. Gavin Newsom released a roadmap on Tuesday that will guide how he will make the decision to relax the stay-at-home policies his state implemented to combat the spread of the coronavirus.

The big picture: While there is no timeline for modifying the stay-at-home order, Newsom’s office said California would use a “gradual, science-based and data-driven framework” to determine when it would be safe to do so. Newsom indicated efforts to flatten the curve in California “have yielded positive results.”

  • California had 24,421 confirmed cases of COVID-19 as of Tuesday afternoon, per the LA Times.
  • On Monday, Newsom announced California would create a task force with Oregon and Washington to coordinate the reopening of the regional economy. Northeastern states have announced a similar plan.

Details: Newsom said California would use six indicators to determine when to relax social distancing measures:

  1. “The ability to monitor and protect our communities through testing, contact tracing, isolating, and supporting those who are positive or exposed.”
  2. “The ability to prevent infection in people who are at risk for more severe COVID-19.”
  3. “The ability of the hospital and health systems to handle surges.”
  4. “The ability to develop therapeutics to meet the demand.”
  5. “The ability for businesses, schools, and child care facilities to support physical distancing.”
  6. “The ability to determine when to reinstitute certain measures, such as the stay-at-home orders, if necessary.”

Newsom’s roadmap also notes that life will be different even after stay-at-home orders are eased. For example, restaurants will likely reopen with fewer tables and face coverings will be more common in public.

What he’s saying: “While Californians have stepped up in a big way to flatten the curve and buy us time to prepare to fight the virus, at some point in the future we will need to modify our stay-at-home order,” Newsom said.

  • “As we contemplate reopening parts of our state, we must be guided by science and data, and we must understand that things will look different than before.”
  • “There is no light switch here. Think of it as a dimmer. It will toggle between less restrictive and more restrictive.”

 

 

 

 

How the psychology of a $4.99 price tag might influence who undergoes heart surgery

How the psychology of a $4.99 price tag might influence who undergoes heart surgery

Balloon heart

Health economists aren’t generally known for their humor. There’s something about Medicaid that’s just deeply unfunny. Make a joke, and the punch line may well be deadly. As one quip goes: What do affordable health care and sarcasm have in common? Most Americans just don’t get it.

So it might come as a surprise that, over the last few years, a team of economists in Boston, New York, and Porto Alegre, Brazil, began to ponder a wisecrack of a research question: How is a hospital like a used car lot?

Predictably, they weren’t kidding. They knew, from a 2012 study of 22 million transactions, that a slight shift in an old clunker’s mileage could significantly change how much a buyer is willing to pay for it. An odometer just above 10,000 miles entailed an irrational reduction in price.

“A car with 9,999 miles is basically the same as a car with 10,001 miles, but the mind may perceive that the 9,999-mile car is in the nine thousands,” explained Dr. Anupam Bapu Jena, an associate professor of health care policy and medicine at Harvard Medical School.

Now, he and his colleagues wanted to see whether that sort of thinking — a big decision based on a single piddling digit — might be taking place in the hospital, when doctors figure out whether an older heart attack patient should get bypass surgery.

The results, published Wednesday in the New England Journal of Medicine, aren’t funny. Among thousands of Medicare recipients admitted to the hospital with heart attacks, 7% of those who would turn 80 in a few weeks got the operation, while 5.3% of those who were just past that milestone birthday did, even though their conditions were similar. Meanwhile, the researchers didn’t see that sort of discrepancy between patients just shy of their 77th, 78th, 79th, 81st, 82nd, or 83rd birthdays and those just past them.

To the researchers, it’s a sign that the fallacy seen in the used car market is also at play in the clinic. In both cases, people are often right to be wary of higher numbers. More miles entail more wear and tear. The older you get, the likelier it is that an operation’s risks outweigh the benefits. Yet to arbitrarily — and perhaps, unknowingly — fixate on the threshold at which patients pass from their 70s into their 80s seems like an example of what’s called the “left-digit bias” — our tendency to pay more attention to the digit we read first, which explains why a corner store might shave a price down from $5 to $4.99.

“Studies like this are really to show physicians, ‘Here’s a common mistake or error that people make,’” said Andrew Olenski, an economics Ph.D. student at Columbia and the paper’s first author. “This is not to say, ‘You should now be giving a lot more bypass surgeries to 80-year-olds than you would have.”

Yet Dr. Ruth Benson, a vascular surgeon at the University of Birmingham, in England, who was not involved in the study, cautioned that this sort of correlational research can’t tell us what causes such disparities or what the implications are. To her, it’s “a snapshot that raises more questions than answers.”

It’s hardly surprising that doctors might make choices shaped by unconscious bias. We all do. We think memorable anecdotes are representative. We give too much credence to evidence that fits our beliefs and discount everything else. Those same fallacies, famously described by economist Daniel Kahneman and psychologist Amos Tversky, creep into the highly trained thinking of physicians, too.

As Dr. Silvia Mamede, associate professor at the Institute of Medical Education Research in Rotterdam, put it, it’s easy enough for a physician’s mind to snag on some salient feature in a patient’s case — a mother who had tuberculosis, say — and allow that to shape the ensuing thoughts and questions, or to let a supervisor’s hypothesis influence the interpretation of a suite of symptoms.

In 2017, for instance, one of the authors of the new study, Columbia University’s Stephen Coussens, had found that people arriving at the emergency room were much more likely to get certain blood tests to look for heart disease if they’d just turned 40 then if they were enjoying the last weeks of being 39.

To Mamede, that earlier study fit the general pattern of medical decision-making research. “Most studies are on bias in diagnosis,” she said. It’s an easier situation in which to understand potential fallacies because there’s often a right answer that can be confirmed in the lab. “But with treatment,” Mamede went on, “it’s difficult to say.” Even with guidelines, the variables are often so complex that the correct treatment is a matter of debate.

That makes the new study stand out — but also raises questions.

It’s unclear what the findings mean for heart attack patients who are about to turn or have just turned 80. As Dr. Donald Redelmeier, a professor of medicine at the University of Toronto, explained, “The study does not answer the question about which rate is right, i.e. whether there’s too much surgery going on beforehand or too little afterward.”

The researchers did find that 17.7% of those who were about to turn 80 died within 30 days of being hospitalized, while the rate was 19.8% for those who’d just passed their birthdays — but that difference can’t necessarily be explained by the discrepancies in the percentage of patients getting surgery. To Jena, unconscious biases are more likely to come into play not for the healthiest or the most frail — not for the 65-year-old at death’s door or for the healthy-as-an-ox 82-year-old marathon runner — but for those borderline cases in which it’s hard to make a call.

The procedure is deeply invasive. It involves putting a patient on a machine that acts as an external heart and lungs. A surgeon slits the skin of the chest and breaks through the flat of the sternum with a motorized saw, allowing the operating team to take a snip of a vessel from elsewhere in the body and sew it in as a detour around a blocked artery so that blood can keep flowing normally. For some patients, medications might be a better option; for others, it might be advisable to try threading in a little balloon to break up the blockage through a tiny keyhole incision in the arm or the groin, and then to put in a metal stent to prop open the vessel.

Even among cardiac surgeons at Jena’s own hospital, who weren’t involved in the research, the reaction to these findings changed from person to person. To Dr. George Tolis Jr., surgical director of coronary bypass surgery at Massachusetts General Hospital, the analysis didn’t seem detailed enough to say whether this was something he needed to worry about. He wondered, for example, whether those patients who didn’t get surgery had even been referred to a surgeon.

“A surgeon, in order to turn down a patient, needs to know about the patient. Did these surgeons know about these patients and either unconsciously or consciously turn them down? That’s a key missing element here,” he said, adding: “Before raising flags of concern, we have to understand what the source of the initial decision is.”

Meanwhile, Dr. Thoralf Sundt, chief of cardiac surgery at the same hospital, saw the research as a useful reminder — even if to him the findings do not show an act of age discrimination. “We need to understand ourselves better and understand these subtle biases so we can control for them,” he said. “It’s not sinister. It’s human. We’re all built this way.”