Stanford professor challenges SJ Merc’s “Coronavirus Lessons Learned” assertions

Now that the coronavirus pandemic has eased, the effectiveness of local public health officials’ response to the crisis is coming under increasing scrutiny. In an exclusive interview with Opportunity Now, Dr. Jay Bhattacharya, Professor of Medicine at Stanford University, walks us through the Merc’s recent article about “lessons learned” from the outbreak, and contends that local health officials implemented a lockdown strategy that was overbroad and needlessly destructive.

SJ Merc Lesson: Timely response is of the essence

Dr. Jay Bhattacharya: Suppose public health officials knew in December or January that there were very few cases in the population, rapidly identified and isolated those infected, and locked down for a short period to confirm no further spread. In that case, a lockdown might have been effective.

But this “successful” scenario would have required exceptional circumstances, such as what occurred in New Zealand and Australia. For instance, these countries had the good fortune that the outbreak hit during their summer, or low COVID season, when the disease spreads less efficiently, while the disease struck the U.S. in the winter, during the high COVID season. Those countries are also island nations, where it is actually possible to shut out the rest of the world. There is no way the Bay Area could institute travel restrictions preventing visitors from LA or from people outside California that last 15 months, the way Australia and New Zealand have. Both countries have reinstituted draconian lockdowns several times this past year, despite their purported success in COVID control. A timely response (i.e., a quick lockdown) did not ultimately solve the epidemic for them.

By the time public health officials imposed the first lockdowns in the Bay Area, it was already too late for them to have any material effect whatsoever on the long-run spread of the virus.There were simply too many cases for a lockdown to work.  In April of last year, my colleagues and I conducted two seroprevalence studies, one in Santa Clara County and one in LA County. The goal of the studies was to measure the prevalence of people with specific antibodies to the virus – a sure indicator of someone who had been infected and (likely) recovered from infection. 

In both counties, we found between forty and fifty times more infections than cases identified by public health officials--or anyone else--knew about. It’s not their or anyone else’s fault. It is not conceivable we could have the PCR testing resources in March or April 2020 that would have helped us identify those cases. But local public health officials should’ve known they didn’t know and acted accordingly by not pushing useless, harmful lockdowns, school closures, and shelter in place orders in the hope of stopping the virus. Shockingly, there were virtually no conversations around the fact that there were vastly more cases than testing indicated by public health officials. That fact should have changed the mind of public health authorities. But it didn’t, and that mistake led them down the wrong path.

Even by mid-March 2020, it was clear that a better strategy was available to public health officials. First, the mortality data from around the world showed that older people were at a much higher risk from infection than younger people – the oldest are 1000x more likely to die if infected than the youngest.  The World Health Organization has published estimates saying that the infection survival rate worldwide for people under 70 is 99.95%, while it is 95% for people 70 and over. 

The right strategy in the face of these numbers is focused protection of the elderly and other vulnerable people. This policy should have included better protection of nursing home residents, sabbatical leave for older, vulnerable workers forced to choose between feeding their families and getting exposed to the virus at work, and provisions for temporary housing for older people living in multi-generational homes if someone in the house became sick. When the vaccines became available, older vulnerable people should have received first priority, with the only exception for health care workers caring for the elderly. Florida, which followed this policy, provided vaccines to every nursing home resident by the end of January, while the same took more than a month longer in California. Places that followed a focused protection strategy have had less public health harm from COVID and lockdowns.

Once you have a clearly and easily identifiable risk factor like age—where you can identify precisely who is at greatest risk—you should pinpoint your efforts to protect those folks. You don’t disrupt the whole society to protect the vulnerable group. The philosophy of lockdown is that by disrupting all of normal functional society, we would protect the at-risk. That turned out to be false – devastatingly false.

SJ Merc Lesson: More federal direction needed

JB: This “lesson” is in part true and in part false. Federal leadership is and was necessary to coordinate things that can be done only by the federal government. For instance, it is the correct role of the federal government to support vaccine development efforts. Coordinating monies to get those resources in the hands of scientists to conduct those investigations as quickly as possible is also a federal responsibility. So is moving resources and people across states to deal with surges.

But I don’t think a unified lockdown approach was warranted in the early days of the epidemic because there were very different levels of disease prevalence in different parts of the country: New York was hit hard in March 2020; California less so. Most hospital systems across the country were not stressed early on by COVID patients. Disease prevalence was nowhere near New York levels then. 

And remember, by shutting down hospital systems for COVID, a lot of negative results accrued. What purpose was served by telling cancer and heart disease patients to avoid hospitals, other than to harm them?  And in places where there was little to no risk of hospitals being overrun by COVID? Even in New York, where there were federal resources brought to bear (medical equipment, field hospitals, the Mercy ship), many of those resources went unused. 

Putting localities’ needs first is a better approach than top-down direction from the federal government.

SJ Merc Lesson: Accelerated research needed

JB: Agreed. As I said earlier, coordinating federal resources to enable scientists to conduct research rapidly is a great need. For instance, the investments and decisions made by the federal government last year in Operation Warp Speed paid considerable dividends in delivering several effective vaccines in record time.

At the same time, the federal government – and the National Institutes of Health, in particular – failed spectacularly to make the necessary investments needed to develop and assess effective treatments for COVID. It was and is an absolute scandal we didn’t have large clinical trials for the early treatment of the disease. 

So there was a mixed bag with regard to how well the government did in accelerating research. 

SJ Merc Lesson: An early warning system needed.

JB: Agreed. A more robust population-level disease surveillance tracking system in place for COVID would have been of enormous value. Instead, we have relied on testing data that are not from randomly drawn, population-representative samples. In the early days of the epidemic tests tended to be reserved for people who were seriously ill. The disease has a wide range of clinical presentations, with severe illness representing only a small fraction of all infections. Since our tests focused on the most severely ill part of the population in the early days, we greatly overestimated how deadly the disease was for much of the population.

These considerations point to one crucial caveat about early warning systems and data trackers. We need to educate both scientists and the public about how not to panic in the face of various signals, which are inevitably noisy and have significant limitations. 

One ongoing example of this concerns the emergence of viral variants.  Many places have good early warning systems on variants. The key facts to know about the variants are whether they are more deadly than the wild-type virus (they are not!) and if they evade natural or vaccine-mediate protection against severe disease outcomes (they do not!).  Despite these reassuring findings in the scientific literature, the press (and some scientists) have picked up on the emergence of variants to panic the public.

SJ Merc Lesson: Better and more standardized data collection needed

JB: As I mentioned earlier, I worked on the Santa Clara and LA County seroprevalence studies to measure the prevalence of COVID infections early in the epidemic. This kind of work should have been the responsibility of the CDC and the State of California. The fact that it fell to academics like me to conduct these studies (the CDC did not have a nationwide seroprevalence study done until the summer of 2020, and even that study had very few regions represented) was not good. For our studies, we followed a template issued by the World Health Organization for such studies, which was helpful.  

A standardized approach to data collection for studies like this helps with comparisons across regions. But what’s important is that these types of studies get conducted at all—you can work on interpretation after the fact. These are studies that require some amount of creativity, so the cycles needed for standardization that slow down the implementation of the study would represent a needless delay. 

The Mercury News and other media outlets have obsessively reported COVID cases over the past year and a half, yet they have done nothing to inform their readers and viewers about the limitations of the polymerase chain reaction test that forms the basis for those case numbers. For instance, many positive PCR tests are functional false positives, representing people who are not infectious and pose no risk of spreading the infection to others.  Also, PCR testing is not randomly conducted in the population and hence does not necessarily represent community disease spread. By reporting these numbers without this context, the Merc and other outlets misled the public.

There were virtually no conversations around the fact that there were vastly more cases than testing indicated. That fact should have changed the mind of public health authorities.  But it didn’t, and that mistake led them down the wrong path.

Summary:

JB: Very early in the epidemic, public health officials implemented lockdowns and shelter in place orders based on the incorrect assumption that their actions controlled the disease. They assumed that by modulating levels of lockdown, we would control the disease. Whenever disease levels rose, public health officials from Dr. Fauci on down blamed the public for no complying hard enough with their orders and causing the epidemic to spread,  

In fact, the public has made tremendous sacrifices to comply with lockdowns: We denied our children a normal education, keeping them out of school, and even preventing them from playing with their friends for more than a year. Many people have lost their jobs, businesses, and livelihoods. Others have avoided hospital trips because public health and the media made them more afraid of COVID than cancer, heart disease, and other severe diseases.  We sacrificed enormously to comply with the lockdowns, which failed to ultimately protect the vulnerable elderly, and yet the public health officials and some media have blamed the public. It’s not right, and we need to learn from these mistakes, so we do not make them in future epidemics.

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