We are ALL GOING TO DIE!!!

A LONG RANT

I have been around Infectious Diseases, Microbiology, Eldercare, Infection Control and “pandemics” and other crises for near 50 years.  So maybe that allows me to have my own perspective.

I was not born in time for the Spanish Flu pandemic of 1918 which killed millions and millions.  My first influenza pandemic was in 1957-8 followed in 1968 with  the “Asian Flu (H2N2).  I don’t remember much about getting sick with either and obviously I didn’t die, so it is fair to say I survived my first pandemics without any problems.  

In 1976, when I first became a trainee (resident) to become an Infectious Diseases physician was a special year.  First there was the H3N2 pandemic and then suddenly there was a second outbreak in an army camp in New Jersey (Fort Dix) that spread quickly.  This second one (the Swine Flu) scared everyone because it was an (H1N1) just the Spanish Flu.    

Everyone (well almost everyone) agreed.  This is it!!  I was TOTALLY convinced.

The US President at the time (Gerald Ford) created a “gold medal advisory panel” which some real superstars, like Jonas Salk, and Albert Sabin, the creators of the  polio vaccines.  The politicians decided that the only solution was to create a new vaccine and immunize everyone immediately.  Have to be seen to be leading.  Sabin, both brilliant and bold (he tested his oral polio vaccine on himself) was never happy with the hurry up vaccine.  In a New York Times editorial, he said that while he agreed with the decision to create the vaccine and thought preparedness for an outbreak was good, he criticized the "scare tactics" used by Washington to promote mass vaccination (“scare tactics”… sounding familiar?). He suggested stockpiling and waiting to see what might happen.  

Sabin lost the battle and the mass immunization started, but he turned out to be right and the charge-aheads were wrong.  Some 450 people were paralyzed with a vaccine related syndrome called Guillain-Barré syndrome.  The government relented and stopped the ill fated hurry-up  vaccine program.   

Despite the absence of vaccination, the outbreak burned itself out, and the sun rose.  Despite the absence of vaccine, (and no “social distancing”) the world survived. 

Over the next bunch of decades leaders have repeated this same exercise.  Most times it was influenza, other times HIV or West Nile Virus, or St. Louis Encephalitis, or other coronaviruses (SARS, MERS).   Occasionally they decided to go extreme because of bacteria - C. difficile diarrhea or antibiotic resistance (MRSA).  The message was always  the same.  We are all unsafe… the world is coming to an end… we are all going to DIE!!!!!

Today is just the latest version; “experts” who know exactly what to do,  and politicians and the media all prepared to run with them.  They run their SCARE TACTICS, and spout stuff that sounds like science instead of opinion.   

This time has had its own twist: Shelter-in-place, snitch on your neighbours, hide in your basement. “socially distance”, keeping count of “cases” on an hourly basis.    If Hippocrates was around, he would remind us "First, Do NO Harm"

We will forever remember this as the great panic-demic of 2020.

This time it will be just like the Spanish Flu of 1918.   But think about it…  1918 was the last year of World War 1.  Europe was a mess.  Food was not plentiful.  Most homes did not have running water or indoor plumbing.  There was no refrigeration, no food storage.  Intravenous rehydration was in its infancy (no disposable needles).   There were no antibiotics.  Therapeutic oxygen was only being experimented with for poison gas in 1916-17  (Modern use of oxygen didn’t start until 1962).  The “modern medical and nursing care” of the time in NO way resembled the care we have available today.  There were NO laboratories to help diagnose diabetes, infection, sepsis, kidney failure, or strands of viral RNA.  

 So how exactly is this “just like 1918”? 

This panic-demic speaks more about the nature of us as a species.  We have these great brains, but we seem to prefer to use them to experience horror movies like Rosemary’s Baby and The Exorcist and The Night of the Living Dead.  We love virus movies like Andromeda Strain and Outbreak and Contagion.  We construct fear stories and convince ourselves of the dangers solar eclipse and the boogeyman under the bed, and witchcraft and devil worship and changing clocks (remember Y2K).  Each time it is the same: “… well sure before it was shameless hype and hysteria, but this time, THIS TIME, IT’S REAL!

 “Fool me once, shame on you; fool me twice, shame on me.”

CVP - The Coronavirus Vanity Project.

In his 1984 book Quality Without Tears: The Art of Hassle-free Management, Philip Crosby wrote:  “Take everything that would not have to be done if everything were done right the first time and count that as the price of non-conformance.”   He referred to that as the Measurement Absolute of Quality.   

He went on to say that all too often these non-conformance costs could add to more than 10 fold the costs of “doing it right the first time”

In our annual Certificate course in Laboratory Quality Management participants work their way through the analysis of poor quality costs for common examples of a laboratory error.  The wastes involved often range between $6,000 to $12,000 for a simple error that could have  been prevented but ultimately resulted in 50 patients receiving some incorrect results over few hour period.  In a medical laboratory that is a lot of wasted resources.

It is a useful and enlightening exercise.

But perhaps we should apply the same exercise to the disaster that we can now call covid-19.  

Stepping back, a few days before the New Years celebrations and its associated massive country-wide travel, doctors in China identified a small cluster of people with pneumonia.  They decided that if this was going to be another SARS like episode they better do something early and so they decided to curtail any and all travel in or out of Hubei province where these pneumonias were found.  (This was a definitely high risk but probably appropriate decision based on what they knew at the time in a country that has the authoritarian power to make those kinds of decisions)  Using modern technology they recovered a piece of viral nucleic acid from the secretions of one of the patients, and then passed the information to high level laboratories around the world so that other countries could use that as the basis of a diagnostic test.  

That too was a good and responsible decision, but assumed that everyone would be able to use the material to recreate the same strand that could be used for uniform responsible world wide diagnostic testing. Unfortunately that didn't happen.

Instead it created the opportunity for some really unhelpful next steps… like mass screenings on tourist ships… like quarantining totally asymptomatic people for extended periods… like allowing media analysts to go out to the public airways with beyond irresponsible panic… like politicians jumping onboard using the Churchillian axiom  "Never let a good crisis go to waste".  Ego and opportunism… the most deadly combination of the modern era. 

With hindsight (what should have been foresight) it became universally clear very early on that based on a untried untested unverified experimental diagnostic assay that the vast majority of people who were being tested and found positive were asymptomatic or at most had the signs of a mild common cold.  (What a surprise, since coronavirus has been long recognized as a common virus of the common cold for decades).   

So did we use that information for the next level of decision making?  Nooooooo!  We just kept on going.  An exercise in futility and vanity.

Forget influenza; forget common colds that kill as many elderly and infirm as influenza, Let’s all focus on our new favorite virus.

Which brings me back to Philip Crosby and the costs of nonconformance and poor quality.  In our course we look at costs in terms of TEEM (Time, Effort, Energy and Money).   

Let me argue that if we had accepted after the first two weeks that this was NOT the once-in-a century crisis that it might have been and had decided to step down, how much TEEM would we have saved: Quarantining, lost time and income for asymptomatic people… N-95 masks and hazmat suits, curtailment of travel; disruption of enterprise; reallocation of resources from serious medical and laboratory science to a glorified diversion.  

I suspect that somewhere there is a graduate student who will be asked to take on the task of working out the total costs of the last few weeks, compared to the benefits (maybe a manuscript or a book or a t-shirt).  My guess is that the total poor quality costs will be way beyond millions, and perhaps beyond billions.  

Take everything that would not have to be done if everything were done right the first time and count that as the price of bad judgement.

At least that is my personal opinion and I am sticking to it!!!

Coronavirus from a laboratory quality perspective.

Call me paranoid or jaded, but I have become increasingly uncomfortable with the news about the current coronavirus outbreak.  

Over the weeks that all this has been going on what we have been told in the public media is that this is a new virus.  This is possible, but maybe not.  What is probably closer to the truth is that this is the first time it has come to light with the availabilities of today’s science technologies.  

Coronaviruses are ubiquitous, and while hardly ever tested, they and rhinoviruses probably are responsible for the vast majority of  common cold that circulate around the world all the time.  Some are found in non-human mammals (civet cats, camels, bats, pangolins), but many reside in humans and cause what is usually thought of a benign illness.

Note: while we all understand colds are a benign nuisance  in healthy children and adults, common colds are a significant cause of death in the very elderly (Hung IFN et al, Unexpectedly Higher Morbidity and Mortality of Hospitalized Elderly Patients Associated with Rhinovirus Compared with Influenza Virus Respiratory Tract Infection.  Int J Mol Sci. 2017 Feb; 18(2): 259. ), at a rate significantly higher than influenza or covid-19.

A new nucleic acid test was developed very quickly to help identify the presence of this new virus in people’s noses and respiratory secretions.  It was based on the nucleic acids of one of the first isolates found in China.  The test used is said to be  very specific, but I suspect that it was NOT tested for reactivity with other coronaviruses normally found in humans.  (Maybe I’m wrong on this but few virus banks would have enough common cold viruses available in their freezers.

The test that was developed was created in a highly specialized laboratories under very controlled ideal conditions.  There are very specific requirements for how the sample should be collected and how the sample to be kept cold (between 2-8^oC) and be transported on ice.  If routine laboratory testing is taken as an indicator of how often that happens, we can say with almost certainty, many do not get that treatment.

Most people who are tested are either totally symptom free or have a mild cold.  That would be typical of about 80 percent of people living in the northern hemisphere in January and February.  That appears to be true for people who test positive and who test negative.  The vast majority remain that way from the beginning of their inspection to the end.  

If you go into a typical busy laboratory in North America the number of tests that get incorrectly labelled is very low, and often when incorrect labelling does occur it is usually with either infants or adults with communication problems (poor hearing or distraction or communication in a language other than what the laboratory workers communicate in).   Usually busy laboratories have a semblance of organization.  I suspect that when samples are collected by people working under stress, wearing hazmat suits and dealing with hundreds of stressed people, the rate of incorrect labelling goes up significantly. 

So just because the label says the sample came from John Smith, maybe it actually came from Joe Smith, or John Smithe, or Jane Smith, or maybe the guy who was in line but just after John Smith.

When these tests were designed it was in a controlled laboratory with research organized staff.  In the real world laboratory where there are hundreds or thousands of samples, the opportunity for error or confusion while testing mounts considerably. 

Finally, when tests are done in routine laboratories there are all sorts of Quality Control checks to make sure that the tests are working correctly.  

So in summary, this is a new test being used to test people who have no symptoms or any way to correlate with results.  The samples are being collected in chaotic situations with high stress.  And there is no other confirming test available. 

So with the highest regard for my laboratory colleagues, I suspect that the risks of errors going by undetected is considerable.  

Bottom line: 

Be VERY careful when you listen, watch or read in the media about what is going on.  The opportunity for the information to be at best misleading and at worse wrong is probably substantial.