Category: covid-19

One thing that has become predicable throughout the SARS-CoV-2 pandemic is that any story, any recommendation, any development, or any piece of data that can be interpreted as meaning that the danger of COVID-19 has been inflated, misrepresented, or exaggerated by medical experts will be interpreted that way by a large percentage of our population. This is no longer surprising, but honestly it’s also completely understandable. We all hate this pandemic. Whether you are working on the front lines in clinic or in the trenches at the hospital treating COVID-19 every day, whether the virus has harmed or killed a friend or family member, whether your job or business has been affected, or even if you just really miss people, we are all ready for this to be over. The hard path forward involves biomedical research, redoubling mitigation efforts that we are all exhausted of, and at this point, modifying holiday plans and preparing to deal with the quagmire of cascading clinical probabilities that are required to fight the virus in the midst of cold and flu season. But the quicker and easier path to getting rid of this hated virus is undoubtedly to just choose not to believe in it at all. And while this “just don’t believe in it” approach is likely to be about as effective as it has been for any of the other problems I’ve tried it for (taxes, bills, excess carbs), I am sympathetic to the appeal of it. If the pandemic has not affected you directly- or maybe even if it has- it may be very tempting indeed to buy into a video like Plandemic, which tells you that the whole thing is just a government conspiracy, or into the America’s Frontline Doctors‘ video which tells you that there is already an easy and inexpensive cure if you just drive to the see the right doctor. Life can be normal again right now, these sources say; all of your hopes are true and all of your caution and privations can finally come to an end. I’m not saying it’s right, I’m just saying I get it.

But what has been surprising- and consistently surprising, to me at least- is which wild facts people will latch onto to create these false narratives. Before today, I would never have expected this paragraph from the CDC’s weekly updates by select demographic and geographic characteristics to be the next cause of viral misinformation:

What is the claim being made?

If I chose to end this blog after today, I would feel I had really come full circle; my very first blog post was about the myth, popular late in March (and persistent even today), that doctors were lying on death certificates to make the virus seem more dangerous than it really was. Today’s myth is that analyzing the diagnostic codes on death certificates –those incorruptible sources of reliable data- reveals that the virus isn’t actually very dangerous at all, and the CDC has just admitted to it. Bypassing the irony that this later misinformation is being circulated by exactly the same people who have been sharing the first for months, we can spend today’s blog post (48 hours late as usual, this time because our internet was out all day yesterday!) analyzing these claims. They seem to have taken two forms.

The first, and more moderate, is to claim (or at least strongly imply) that because 94% of deaths from COVID-19 also had other diagnostic codes listed on the death certificate, it means that people without ‘underlying medical conditions’ are not actually at a very high risk of dying from the virus. And in one sense this is true, even if this new data from the CDC doesn’t actually really have anything to do with that. Your Local Epidemiologist says this better and more succinctly than I can:

And she’s absolutely right; we have been saying this from early in the pandemic. But not just saying it; thinking it and believing it, too. Every decision I make as a physician, from admitting someone for COVID-19 to starting or stopping a medication, referring them to a specialist, or even recommending exercise or lifestyle changes has to take into account their medical history (and a host of other factors). While there are some symptoms we can warn everyone about, the counseling and support we provide for patients seeking evaluation and treatment of COVID-19 has a lot to do with their individual risks from the virus and how it might manifest in their lives based on their age and other medical conditions. This 6% misinformation became viral just yesterday, yet if you asked any doctor last week they would have already told you that the younger and healthier you are the less likely you are to end up in the hospital or die from COVID-19, and the more medical complications you have the more concerned they are about you having the virus. I know because this is exactly what I was saying to people in clinic last week, and the week before that, and the week before that. Yes, many young and otherwise healthy people have died tragically and shockingly from complications of the virus; but this is still a rare occurrence on the whole compared to the number of young, healthy people who have had the virus. When I counsel people at low risk of complications from COVID-19, we of course talk about the signs and symptoms they should watch for that would trigger a trip to the ER, like chest pain and shortness of breath; but I also want to make sure they aren’t sitting at home, anxiously wondering when the virus is ‘going to get them’. I want them self-isolating; I don’t want them to be afraid. But this relative reassurance towards the young and healthy is actually undercut ever so slightly when you combine headlines like these with the actual data being reported from the CDC, which I’ve included below.

When you look at the other diagnostic codes listed in the table above, you will notice that codes like E78.2 and I10 are listed; high cholesterol and high blood pressure, respectively, both conditions I’ve been diagnosed with in the past (and probably still have, if I would ever go get a check-up. Doctors really do make the worst patients). At 35 and having never spent a night in the hospital as a patient in my life, nobody would call me high risk for complications of COVID-19. In fact, if I contracted COVID-19 and died of it this week, two things would happen. First, my blog would probably get a lot more hits for a couple of days (and this paragraph in particular would seem very bitterly ironic). But second, I would be held up as an example of how being young and in relatively good health is not a perfect guarantee of safety from the virus. Yet I would be a part of the 94%, not the 6%.

The reality is that in saying “94% of COVID-19 deaths had underlying conditions,” these stories are adding nothing to and are in fact dumbing down the more sophisticated knowledge we already have, and share with our patients daily, of the most important risk factors and conditions that predispose someone to COVID-19 being a likely threat to them. They are meant to lure you into a false sense of security, because it’s so easy to think they mean somebody else besides you (even if you do in fact have some of those diagnoses, like I do) and a relatively small group of people. But when I look at the chart, I realize that even I fall into that group with “2 or 3 underlying medical conditions” that they are saying 94% of the COVID-19 deaths occurred in; in fact, most Americans do. And when a statistic includes me, privileged to be in pretty good health as I am, but also my patient battling metastatic kidney cancer and my patient suffering from both CHF and COPD, maybe it just isn’t a very useful statistic in the first place.

But the more dishonest and blatantly ridiculous claim, which has absolutely no justification, is to say that only the 6% of deaths with just COVID-19 listed on the death certificate actually count as COVID-19 deaths. Take this one Facebook poster who has been widely shared, who had the gall to take this to the next step and “calculate” that only 9,210 people had “actually died from Covid.” Probably because she was willing to put a number on the deaths, this post has been shared 21,000 times on Facebook; but it’s hard to believe that someone with a doctorate degree, any doctorate degree, could have such little grasp on basic statistics.

This post entirely misrepresents everything within our complex understanding of medicine regarding the impact of medical comorbidities, the myriad causes and steps leading to death in COVID-19 or any other illness, and even the very process of completing a death certificate. In her estimation, Dr. Hesse is saying that a diagnostic code on the death certificate other than COVID-19, literally any other code, is sufficient evidence that the patient did not die from COVID-19. This is not only preposterous and dishonest but also just plain silly. We are going to explore these issues more thoroughly in the next section, but briefly, just look at the chart above and begin googling ICD-10 diagnostic codes for yourself to test the logic of her interpretation. Yes, I can absolutely believe that some of the patients whose death certificates reflect both COVID-19 and also diagnosis code C71, Malignant neoplasm of brain, may actually have died from the brain cancer and were only found to have the virus incidentally. We can’t tell from the data if that did in fact happen, or how many patients might have such a presentation. But with COVID-19 being an acute illness and brain cancer being a chronic illness, the disease and treatment of which also predisposes you to infectious illnesses, it is at least as reasonable to assume that the majority of patients who died from “COVID-19 and brain cancer” actually died from COVID-19, which they were more vulnerable to because of their pre-existing brain cancer.

But Dr. Hesse’s assertion that only the 9,210 “COVID-19 only” deaths should count also has to stand up to scenarios like, say, any hypothetical patient who was certified as dying with COVID-19 and R09.3, Abnormal sputum, or COVID-19 and N20.0, Kidney stones. Again, we can’t tell from this data whether any such patients with only those codes exists; but neither can Dr. Hesse, and for her argument to be valid, each and every possible diagnostic code included in the chart above would, if added to a COVID-19 death certificate, nullify COVID-19 as a primary or contributing cause of death. That is what she is saying, and it is obviously ridiculous. What this error betrays is a complete misunderstanding, whether intentional or accidental I know not, of how death certificates are completed and the information they are meant to capture. Even though it means a longer essay, I do think it’s worth taking the time to revisit this again.

What information do we include in a death certificate?

Once you have been trained to complete death certificates (and have actually done it), this “6%” argument is not even momentarily tempting or convincing. I know what you are thinking; “but TJ, we haven’t been trained to complete death certificates, so you are asking us to trust you with this area of specialized knowledge we don’t have access to.” Well good news reader, the Texas Department of Health and Human Services, DSHS, has got you covered. If you want to understand this 6% statistic from the CDC, I highly recommend that you watch from 1:44 to 3:08 of this video.

Obviously each state will have its own version of this software, but they are all intended to convey the same information; the death certificate is not a high-stakes multiple choice interrogation asking the doctor, “What disease caused the patient’s death? Was it COVID-19 or heart failure? ANSWER THE QUESTION!” Rather it is an opportunity to distill the sequence of events leading to the patient’s death, recorded in greater detail in the medical record, into a structured narrative that explains how they died. When a doctor includes coronary artery disease on the death certificate, they are not making a political statement or a value judgement, but rather an honest reflection of the part this disease played in the patient’s death based on their medical knowledge and their intimate understanding of the progression of illness as the patient’s treating physician. And it is exactly the same with COVID-19. Moreover, this is not something that the physician derives a financial benefit from or an opportunity to defend the medical care the patient received (in fact, I have listed iatrogenic injury on the death certificate when I felt that my own mistake or that of another medical professional contributed in some way to the death of the patient), but rather something that is important for public health information and, in various ways, important to the family of the deceased.

Briefly, I’d like us to complete a medical certification for a death certificate together, again using my hypothetical death from COVID-19 as an example. In this scenario, let’s say that I get sick with cough and loss of taste and smell this week and am diagnosed with COVID-19. Around day 10 of my symptoms I begin to experience chest pain and shortness of breath, and I go to the ER. There I am found to be hypoxic and my chest x-ray shows bilateral peripheral consolidation consistent with ARDS. they begin to treat me with dexamethasone, remdesivir, and oxygen. Over the next few days my respiratory distress increases and, even allowing some permissive hypoxia in order to avoid intubation, the doctors simply cannot keep my oxygen level within safe parameters; they make the difficult decision to intubate me and put me on a ventilator. I am ventilated in prone positioning using the latest and best evidence-based ARDS/COVID-19 ventilation strategies from the genius doctors over at EmCrit and PulmCrit. Unfortunately, I continue to become progressively, severely hypoxic, and eventually suffer cardiopulmonary arrest. Resuscitation is attempted but ultimately efforts to revive me prove futile; the lungs are not compliant, effective ventilation still cannot be achieved, and return of spontaneous circulation is impossible. I’d make a joke about making the life insurance check out to my wife, etc. at this point, but honestly when I reflect on how many people have died from this sequence of events over the past six months, it’s pretty sobering. I’ve made myself sad just now thinking about all of the families that have lost a mother, father, sibling or grandparent in exactly this way.

Once I’ve died, the doctor treating me will have to record it in a death certificate; we can use the Texas system, since it’s what I’m familiar with.

Here in Part I we list the immediate cause of death. In my case, it’s going to be cardiac arrest. Because this is technically the immediate cause of death in every death except those caused by brain death, some doctors would leave this out. Since resuscitation efforts were made and the arrest was a distinct medical event, I would probably include it, but an argument could be made either way. Next we need to describe the events that led to this. I’m not going to include respiratory arrest because I would feel it was a bit redundant, and besides, I was already not breathing on my own when the cardiac arrest happened since I was on a ventilator. Instead, I would say the arrest was due to respiratory failure. The respiratory failure was due to ARDS, Adult Respiratory Distress Syndrome, and you could make a case here for including viral pneumonia as well. Finally, the ultimate cause of this cascade of complications is my infection with COVID-19.

Next I would need to list any other contributing factors in Part II, and here is where the quandary usually comes in, because now I have to decide whether my high blood pressure and high cholesterol belongs in Part II, “other significant conditions contributing to death but not resulting in the underlying cause,” or in Part I further down in the chain of events. In this case it’s easy; my high blood pressure is a significant medical issue and made me at higher risk from the virus, so it belongs in Part II; but it didn’t cause me to get COVID-19, so it doesn’t belong in Part I. My chronic right shoulder pain didn’t contribute at all and gets left off the death certificate. These decisions aren’t always easy; sometimes a condition did lead directly to death in chain of events that are causative narratively even if not pathophysiologically; for instance a patient who is hospitalized for a hip fracture and then develops sepsis from a central line. The hip fracture didn’t cause the infection that kill them, but it was a direct part of chain of events. But what about the vertigo that caused the fall that caused the hip fracture; does that belong in Part I or Part II? I have a physician friend who works in hospice care who completes death certificates almost every day (I have completed maybe a dozen); he says this is typically the hardest decision point when it comes to completing a death certificate, deciding what was really a cause and what was ‘only’ a contributing factor. Still, it’s straight forward enough in my hypothetical case, and we can finalize my death certificate as follows:

Cause of Death – Part I:
IMMEDIATE CAUSE
a. Cardiac Arrest.
DUE TO
b. Respiratory Failure.
DUE TO
c. Adult Respiratory Distress Syndrome.
DUE TO
d. COVID-19.

Cause of Death – Part II
-Hypertension, Hyperlipidemia

So, for young, relatively healthy me who died from the most stereotyped and straightforward case of severe COVID-19 I can conceive of, we have 5 other diagnostic codes listed on the death certificate between direct cause conditions and contributing conditions. Contrast that to what a Texas death certification with only the diagnostic code for COVID-19 -the only types of death certificates Dr. Hesse believes count as COVID-19 deaths- would have to look like:

Cause of Death – Part I:
IMMEDIATE CAUSE
a. COVID-19
DUE TO
b. ________________________
DUE TO
c. ________________________
DUE TO
d. ________________________

Cause of Death – Part II
________________________

My friend, the hospice doctor, has completed over 500 death certificates (a conservative estimate) since finishing residency a few years ago. He says he has included just one diagnostic code alone maybe twice. What Dr. Hesse sees as the ‘real’ COVID-19 deaths, these 9,210 death certificates without any other documented diagnoses, I see as an anomaly; I am forced to ask myself how that many death certificates were complete in what I consider to be such an incomplete and insufficient manner. I have two theories, aside from some doctors simply not giving the proper attention to the task that they should have or not understanding the importance of completing the death certificate thoroughly. One is that some of the doctors who have been taking care of patients in this pandemic simply might not be familiar with how to complete a death certificate. This pandemic has brought doctors out of retirement and graduated 4th year medical students months early to shore up the frontlines; surely some just haven’t had even the 5 minutes of training from the video above and don’t know how to complete the forms properly; frankly it’s a low priority in their training right now. But second, some of the death certificates for COVID-19 patients have been completed by doctors who were incredibly overwhelmed. When we consider places like New York City, where doctors and nurses were dropping from exhaustion during shifts and barely had time to document at all, and were seeing multiple deaths per shift, each and every shift for weeks, it is reasonable to expect that some of those doctors no longer felt that taking the extra time to document a complete death certificate series of events was a priority. I can’t argue with them; it wouldn’t be. As important as the death certificate is to the patient’s family and for public health purposes, it is a low priority in a crisis when your time would otherwise be spent taking care of living patients or trying to shore up your own physical and mental reserves. If this is the case, the doctors who typed “COVID-19” and submitted the death certificates probably had no idea that such an action would contribute to even more dangerous medical misinformation threatening to extend the pandemic a few months later; a lesson in unintended consequences.

So what do all of these other codes mean?

There are many ways to interpret the diagnostic codes listed in the comorbidities table from the CDC’s latest update. We could spend hours in speculation, wild surmises, or careful parsing and analysis (if you’re a nerd) to try to recreate the narratives of the deaths represented by this data. The amount of analyzing, explaining, and even guesswork we could devote to this is endless. But briefly, I’d like to explain how to understand the majority of these diagnostic codes and the diseases, conditions, or symptoms they represent by considering them in three large categories.

Other ways of describing COVID-19.
The first category that these “other diagnostic codes” fit into is simply other ways of describing the symptoms and complications of COVID-19 itself. If I treated you in the hospital for a CVA (cerebrovascular accident; a stroke), but I also added on diagnosis codes for right arm paralysis and slurred speech, you wouldn’t review the medical record and say, “see, I wasn’t treated for stroke after all! They were treating me for right arm paralysis and slurred speech and just added that ‘stroke’ code on because Dr. Webb probably gets some sort of kickback for it.” The paralysis and the slurred speech delineate more specifically which stroke symptoms you experienced; their inclusion creates a more complete record of your presentation and treatment. In fact, it isn’t at all uncommon to have multiple diagnostic codes that actually say the same thing, due to different doctors and different departments interacting with your medical chart and, again, for the sake of completeness. If I have already added “slurred speech” to your chart, the neurologist later adding ‘expressive aphasia’ doesn’t actually add anything to your medical record (except a little reminder that she’s smarter than me); but it might be more appropriate to document it this way for the referral to speech therapy she is ordering for after your discharge, or to have this diagnostic code associated with the MRI. The synonymous diagnostic codes are repetitive, but it doesn’t necessarily follow that they are redundant. 

Now apply this logic to death certificates and COVID-19. We’ve already discussed that most doctors would like to be as complete and thorough as possible with death certificates and that it is somewhat odd to list only one diagnostic code without providing a fuller narrative. When we see diagnostic codes like J96 (respiratory failure; 54,803 cases), R09.2 and I46 (respiratory and cardiac arrest, 3,282 and 20,210 cases respectively), and J12.9 (viral pneumonia, unknown number of cases, but contained within the “Influenza and Pneumonia” group), all the doctor is doing is using additional diagnostic codes to clarify the events affecting the patient’s lungs that led to death. In fact, it would not be inappropriate to include all four of these codes for many COVID-19 deaths, because the natural history of viral pneumonia due to COVID-19 leading to respiratory failure and eventual arrest is unfortunately far too common. The same applies to codes like A40 and A41, Sepsis (14,053), which is not even a diagnosis in itself but a syndrome describing the body’s systemic reaction to infection, and many of the “all other conditions” codes like R09.1, pleuritic chest pain and R09.0, hypoxemia.

But the most obvious example is J80, Adult Respiratory Distress Syndrome (21,899 cases). This is literally the severe respiratory syndrome caused by COVID-19, yet people like Dr. Hesse who claim to have evaluated this data carefully did not include these deaths in their “real” COVID-19 death count. To be clear, if a patient’s death certificate listed only COVID-19 and ARDS, these medical misinformation hucksters wouldn’t count them; that patient died of ARDS, they would say, not COVID-19. It’s like saying someone didn’t die from falling off a plane without a parachute, they died from the landing. It’s the bad dad joke of medical misinformation and the clearest piece of evidence we have that those originating this narrative are either extremely unqualified to interpret this information… Or else are not in earnest with their conclusions, but instead are pushing misinformation intentionally from what motivations and purposes I cannot say. 

Conditions that really do make COVID-19 more dangerous.
Much of the work I have seen refuting the “6%” misinformation so far has focused on the concept of comorbid conditions or medical comorbidities. Simply stated, these are diseases or conditions that make us more susceptible to other disease processes or more likely to have complications from them. Some of these diseases are also extremely dangerous in themselves, and others are primarily dangerous because of their role in predisposing to other conditions. A good example of the former is Congestive Heart Failure (I50, 10,562 cases). This is an extremely dangerous, chronic disease that has a fairly low 5 year survivability from the date of diagnosis (average of 62%, but as low as 48%, in African American men because of healthcare disparities). You can absolutely die of complications from heart failure, but it also increases your risk for many other diseases and infections. It is both a primary cause of death and a comorbidity, and without a more detailed dataset or an intimate understanding of each case, we cannot possibly say how many of the 10,562 people who died with both COVID-19 and heart failure died from heart failure complicated by COVID-19, from COVID-19 which they were more vulnerable to because of heart failure, or from a more complex clinical picture that involved heart failure, COVID-19, and other contributing factors. But is this information going to change anything for us? The medical misinformation spreaders want you to believe that all 10,562 of the people who died with both heart failure and COVID-19 died at the time they would have from their heart failure with or without a viral pandemic. They want you to believe this based on nothing other than the fact that it fits a more comfortable narrative; but it flies in the face of what we are hearing from doctors, nurses, family members, and patients of those with heart failure about the way that COVID-19 affects those who are already suffering from these types of chronic illnesses.

Other examples in this category include renal failure (N17-N19, 13,693 cases), COPD and other chronic respiratory disease (J40-J47, 13,780 cases), and quite a few of the “other conditions and causes” listed, such as N04 (Nephrotic Syndrome), L93 (Systemic Lupus), and of course B20 (HIV), just to name a few. The people spreading this misinformation are putting the people with these illnesses at greater risk, specifically, by either pretending that COVID-19 is not a threat to them (the “only 6% count” crowd) or by seeming to claim, callously, that caution as a society isn’t warranted on their behalf (the “94% had comorbidities” crowd).

But within this category we also include diseases that are not likely to kill you on their own, and which would have almost certainly been included on the death certificate due to the physician’s conviction that they made the patient more susceptible and less able to resist the complications of their COVID-19 infection. These include Obesity (E65-E68, 5,614 cases), Alzheimer’s disease (5,608 cases), and of course other types of dementia (F01 and F03, 18,497 cases). Do we really believe that a patient with COVID-19 and obesity listed as their causes of death have died from obesity, and that their having COVID-19 was a coincidence? That is not something that happens. Dementia in particular is an interesting conundrum, because with COVID-19 harming so many people in nursing homes it is potentially not only a physical risk factor, which it most certainly is, but also an epidemiological risk factor; many doctors might include a patient’s reason for living in an assisted living facility, such as dementia or disability, within the death certificate as part of the narrative of how the patient came to be exposed to COVID-19, the same way we might list arthritis on the death certificate for a patient who suffered a heart attack during physical therapy. Again, these are not competing diagnoses that draw responsibility for the death away from COVID-19, but rather a fuller picture (that is, as full as can be told with diagnostic codes alone outside of the full medical record) of the patient’s story leading up to their death.

Finally, a few categories of disease deserve some extra discussion, and those are diseases that could cause death all on their own but almost certainly didn’t for the patients reflected in these death certificates. Hypertension (I10-I15, 35,272 cases) is incredibly common and usually leads to longterm organ damage rather than acute crises, but can present with severely elevated pressures that lead to stroke or another vascular event. However, this would typically be indicated with the diagnosis code I16, hypertensive crisis or I16.1, hypertensive emergency, which are specifically not included in the diagnostic codes for the hypertension group in this table. It is possible that this is just a common coding error on death certificates, but I doubt it; if the physician believed that the severity of the patient’s hypertensive crisis led directly to their death, they would likely take pains to emphasize this on the death certificate; applying a code for essential or secondary hypertension instead suggests that they regarded it as a comorbidity or at most a contributing factor. Diabetes (E10-E14, 25,936 case) is another example. Diabetic Ketoacidosis (DKA) is a severe metabolic disorder that often requires ICU level care; but this is primarily due to how labor intensive it is to treat, and the mortality rate remains low. These 25,936 people who had both COVID-19 and diabetes did not die from DKA, which accounts for less than 2,500 deaths annually. Instead, both diabetes and hypertension, just like dementia and obesity, are comorbid conditions that make the patient more susceptible to and likely to experience worse outcomes from other diseases, and as such their role in this list of additional diagnostic codes on COVID-19 death certificates is the same as their role in death certificates for patients who die from stroke, heart disease, and influenza; yet no-one is claiming that because a patient had high blood pressure and diabetes, their death from the flu didn’t count.

Conditions that might have nothing to do with COVID-19 and might have actually caused the patient’s death (maybe)
Finally, we have conditions that, based on the diagnosis code alone, we know to be incredibly dangerous and also to be common causes of death. Some of these, like certain cancers (C00-C97, 7,415 cases plus some of the ‘all other conditions’ group) we can treat similarly to heart failure or COPD; they may predispose you to COVID-19 or raise the risk that your COVID-19 course of illness will be severe, or they may be immediately dangerous in and of themselves and be worsened by COVID-19 or not. If someone wants to ask how many of the thousands of deaths that included a cancer diagnosis were actually caused or hastened by COVID-19, and how many just happened have the virus during the days leading up to to death from a terminal malignancy, I think it’s a fair enough question; though from what I’ve heard from friends who provide hospital and hospice care, the former does seem to be very common. In the latter cases, if such cases are at all common, the additional suffering from COVID-19 must be felt in other ways; in the barriers it places to those individuals being surrounded by family and friends as much as possible during their final days. 

We could legitimately ask the same question for some other diagnoses on the list; heart attacks and cardiac arrhythmias (18,103 and 9,812 cases respectively), pulmonary embolism (I26, contained in the 8,743 “other disease of the circulatory system”), and strokes (I60-I69, 7,653 cases) are all very deadly on their own. However, unlike with cancer, which has no known or proposed causal relationship with COVID-19 aside from immunocompromise, the virus is known to cause a hypercoagulable state that has caused all of the above pathologies. How many of the deaths that involved these diagnostic codes were due to these conditions and how many were in turn due to COVID-19 is known only to the doctors, nurses, and family members that were involved in their care. Attempts to make absolute statements that these deaths simply were not caused by COVID-19 (despite the doctor writing the death certificate feeling they the virus did in fact contribute to the death) because another dangerous disease was also involved are based entirely on a desire to minimize the danger of the virus, and not on any interpretation or analysis that can be legitimately conducted from this set of data.

The final set of diagnostic codes we need to look at are the 5,133 included in COVID-19 death certificates under the category “Intentional and unintentional injury, poisoning and other events.” We don’t know which codes specifically show up in these death certificates, but much like the other ‘other’ catch-all categories it contains diagnoses ranging from S00.37XA, Other superficial bite of nose (a diagnosed I received today courtesy of my 16 month old), to X95.9, Assault by firearm. What is going on here? Much like the “other” diagnostic codes we talked about above, there may be any number of reasons that some of these codes might be on a COVID-19 death certificate. Some may be complications that arose in the hospital, such as SO6.9, Intracranial injury, when a COVID-19 patient experienced a syncopal episode and hit their head. Some may be part of a historical narrative, for instance a patient who experienced a prolonged hospitalization following a V03.10XA, Motor vehicle collision injuring a pedestrian, which ultimately ended when they died from respiratory failure due to COVID-19 contracted in the hospital. Again, without access to the actual death certificates, medical records, and medical staff who treated these patients we simply do not know what circumstances or patient history necessitated the physician to include both COVID-19 specific diagnostic codes and codes for accidents or intentional and accidental injuries in the same death certificate; but it absolutely does not stretch the bounds of credulity to believe that such circumstances do indeed occur.

Nevertheless, I want to cede this point to the conspiracy theorists, if only for just a moment. What if we do “admit” (as ridiculous as it is, and with apologies to the families of the individual people whom these death certificates represent) that each and every death certificate listing one or more of these accidental and non-accidental injuries represents a patient who died from some horrible accident, with COVID-19 just tacked on but clinically silent? You see, since the beginning of the pandemic the conspiracy theorists have been telling us, with no evidence, that “if somebody gets hit by a car they are calling it a COVID-19 death” and “if someone gets shot, they call it COVID-19 to inflate the numbers.” This data, from actual death certificates, now shows that the maximum possible number of such falsified death certificates tacking on COVID-19 to an accidental death is 5,133; compared to 183,000 deaths from COVID-19 and an estimated 80,000 total deaths from accidents in that same time frame. And again, that’s assuming that no other possible explanation exists for those “other accidental and non-accidental injuries” contributing to a person’s death from COVID-19.

Conclusion

Many of the diagnostic codes listed don’t fit easily into just one of the above categories, because we just don’t know enough about the history of the people whose battles with and deaths from COVID-19 are represented here. We don’t know, from this data set, whether the physician completing the death certificate was indicating a new stroke as a primary cause of death, or an stroke that lead to a rehab stay where the patient contracted COVID-19. We don’t know whether diabetes was listed because it was poorly controlled and played a major role in the hospitalization, or whether it was well controlled and was only included because that physician knew that diabetes is a risk factor for the patient’s unfortunate bad outcome from COVID-19 infection. We also have no idea what to do with codes that are so benign in themselves that they don’t really seem to have a place on a death certificate at all, yet the physician clearly regarded as an important part of the patient’s history leading up to their death.

But what we do know, with certainty, is that this new data released from the CDC does not mean. If you’ll spend just a few minutes really looking at the data, at the ages and the conditions mentioned, you will realized that it cannot mean that 94% of the people who have died from COVID-19 were incredibly sick, incredibly frail, and incredibly old people with many other diseases who would have died soon anyway; that argument is as bankrupt in its analysis of this data set as it is ugly in its callousness. That is not what the CDC means when they tell us that 94% of death certificates listed ‘more than one diagnostic code’ or contributing factor, as we’ve clearly demonstrated above. And even if it were (and it’s not), it would not somehow mean that the lives lost to COVID-19 were less valuable; those who see this false idea that 172,000 of the 183,000 people who have died from COVID-19 were sick already as a compelling reason to stop mitigation efforts need to carefully consider whether their only motivation for taking caution has been their own personal health and safety this entire time… And then try to understand why that has not been the sole or primary motive for the rest of us; that the safety of those around us, including the medically vulnerable, is actually sufficient reason for some inconvenience and even sacrifice on my part.

And we also know with certainty that no real scientist, statistician, epidemiologist, or physician, and certainly no one who actually treats patients on their death beds and then completes death certificates to capture the complex and detailed medical events of their final days would ever believe the idea that the 6% of death certificates with only COVID-19 listed as a cause of death represents the “real” death told of this horrible virus; at least not without some herculean effort of intellectual dishonesty and self-deception.

Update 11/30/2020: For some reason this particular post got picked up by Google’s algorithms and ended up on the first page of results for a few search terms like “COVID vs. Car Crashes,” and so continues to get visits frequently almost 4 months later. Which is pretty cool I guess. But the big take away here is this; just like the graphs showing COVID-19 death data from March were already inaccurate and undersold the severity of the pandemic compared to car crashes by August when I wrote this post, so the graphs and data from this post are now out of date. We were at 165,000 deaths then; it’s 267,000 now. I’ll post some updated graphs below to illustrate this, but when I said in August “there is reason to believe that COVID-19 will settle in as the 3rd leading cause of death in 2020” it just so happens I was exactly correct. It wasn’t a hard guess; the gap between Heart Disease and Cancer and the 3rd and 4th leading causes of death is so great that it was a no brainer, as anyone who plays the board game Wits and Wagers will tell you. The real question is whether or not COVID-19 will overtake even Cancer and Heart Disease in 2021. I highly doubt it, especially with effective vaccines available soon and constantly improving treatment techniques and medication regimens… But it largely depends on how overwhelmed the medical infrastructure becomes over the next few months following Thanksgiving and Christmas.

Updated graphs from November 30th, 2020:

I first saw this graph on Facebook last month; at the time I was writing extensively about asymptomatic cases, death statistics, herd immunity, and other topics and didn’t have much margin to spare for it. Besides, multiple people have written extensively and well about this topic over the last several months as these silly comparisons between COVID-19 deaths and car accidents, heart disease, cancer, and any number of other causes of human death and suffering have been rampant.

But yesterday evening, when falling asleep at 7 PM exhausted and slightly delirious from what I thought might be COVID-19 but turned out to be from not drinking enough water while working at our outside COVID-19 clinic in 95 degree heat, which is not technically a COVID-19 related illness (and would not be recorded as one regardless of what the conspiracy theorists tell you), I came across a meme along the same lines and felt it was time to say something about these fallacious comparisons. I’m going to start with traffic accidents and heart disease today, for the sake of thoroughness, but tomorrow I’ll try to address the memes that really got my blood boiling; the ones comparing COVID-19 to human trafficking and modern day slavery.

Contagious vs. Non-Contagious Illnesses

You have no doubt seen some version of this argument before now. It usually has a very simple formula, which we will try to tackle one by one:

1. Compare COVID-19 deaths to another leading cause of death.
2. Ask why the other cause of death isn’t being talked about/doesn’t shutdown the economy/isn’t a national issue.
3. Imply or outright state it’s because the media/doctors/the powers that be want you to be afraid for some nefarious purpose.

(In all fairness, the authors of the article above seemed to be writing it just to raise awareness about programs to help teens drive safer; the headline comparing it to COVID-19, while typical of the format this argument has taken across the internet, is seemingly just to garner clicks in this case)

We’ve seen charts like the one above, showing the “incredibly small number of deaths” from COVID-19 compared to real killers like heart disease and stroke. “See, it isn’t even as bad as the flu!” We’ve seen statistics that are next to meaningless, like “COVID-19 will only make up 5% of deaths in the US this year,” which is supposed to sound to laypeople like COVID-19 isn’t that big of a deal, but is actually a terrifying thing to hear as a physician. We’ve been asked, knowingly, why we didn’t “shut-down the economy” for H1N1 in 2009… Maybe because nobody was trying to undermine the president’s chances of re-election? We’ve been asked why we don’t social distance because of car accidents, and then been told the answer; because COVID-19 is all about creating fear.

During the SARS-CoV-2 pandemic we’ve seen physicians, epidemiologists, laypeople, politicians, and misinformation hucksters compare COVID-19 to the common cold, influenza, measles, ebola, HIV, SARS and MERS, and the Spanish Flu pandemic of 1918. While these comparisons have often been made with false statistics or poor understanding of epidemiology and thus led to incorrect, often diametrically misleading conclusions, the comparisons themselves are indeed apt. SARS-CoV-2 is a contagious, viral illness, just like those other diseases, and the danger it poses depends on how contagious it is, how deadly each individual case is, and the long-lasting sequelae it causes, just like those other illnesses.

But the comparisons in the chart above are not all apt, because most are not contagious diseases, and fighting them requires entirely different monitoring, treatment, and prevention principles compared to viruses like measles, ebola, or COVID-19. Yes, preventing diabetes would be easier if we, as a society, decided to rearrange our lives and our community norms to focus on physical activity and healthy eating, eliminate food desserts (or is it deserts? both contribute to diabetes so I’m going to leave it as-is), provide nutrition education as core curriculum in our high schools, and take any number of other steps to become a healthier nation with better and more equitable access to healthy choices overall. But those changes take a lot of time to implement. While there are plenty of ways to help in such efforts, such as shopping at grocery stores intentionally built in food deserts, places like Waco’s Jubilee Food Market, there’s very little that you can do, right here in the middle of your afternoon, to prevent someone you are coming into casual contact with from developing diabetes or heart disease today. As passionate as you are about fighting heart disease and diabetes, you can’t go to a coffee shop and start yelling about metabolic syndrome to try to raise awareness; they kick you out for stuff like that. But you can do things today to prevent the spread of COVID-19, like wearing a mask and social distancing, and a big societal push in that direction makes sense for COVID-19, where for chronic illnesses with modifiable risk factors it makes more sense to focus on sustained, long-term efforts over generations than urgent, short-term pushes.

Me at Pinewood Roasters, trying to warn people about chronic illnesses.

Moreover, diseases like diabetes and coronary artery disease don’t typically kill you all at one time. As we’ve discussed multiple times before, these chronic diseases increase your risk of multiple other ailments, including your risk of a severe case of COVID-19. Saying we shouldn’t worry about COVID-19 because ‘look how bad heart disease is’ is a bit like saying the people on the Titanic shouldn’t worry about the iceberg, because it’s really the water that ultimately killed most of them. There’s a synergy between COVID-19 and heart disease, lung disease, diabetes, and other chronic health conditions, and you aren’t doing congestive heart failure patients any favors by trying to shift the focus off of COVID-19 transmission and slowing the spread of the pandemic; that kind of approach is only going to increase the number of deaths from both conditions.

“Why don’t we shut down the economy for ________?”

But the other reason these comparisons fail is because, to the degree that the approach to treating and preventing them is similar, the responses of the media and doctors to these causes of death has been similar to that of COVID-19. Various people who share these statistics say things like, “we don’t shut down the economy over diabetes,” “we don’t close schools because of car accidents,” and “we don’t social distance and stop going to bars because of liver disease” (I made that last one up because it was the most ironic possible instance of that line of argument). Dr. Phil made this exact same argument on Fox News back in April.

But none of this is actually true, is it? One of the reasons that school gets cancelled on days with severe snow storms (or in Texas, days where someone might have seen some white stuff falling from the sky when it was the wrong season for Crepe Myrtles) is because severe ice on the roads would increase the risks inherent in traveling back and forth to schools; we cancel school precisely because there is an increased risk, above that at normal times, of people dying in car accidents. We also have tons of laws related to traffic safety, including speed limits and traffic signals, without which we could no doubt get to work quicker and be more productive, and laws about texting while driving without which doctors, at the very least, could be much more productive during our commutes. We have all of these rules and regulations in place because the danger has been recognized.

We also have laws about cigarette advertising and smoking inside restaurants and places of business, laws regarding industrial and toxic exposures, laws about medical leave for chronic, progressive illnesses like cancer, and laws about sick leave and not being fired because of medical issues. It’s true that these laws often provide depressingly little protection for employees, but they are in place and it’s erroneous to say that we don’t “allow” these medical issues to affect ‘the economy’ or ‘our freedoms’. The one key difference is that none of these approaches are proactive the way that masking, social distancing, and strategic closings are in a viral pandemic. Things like scheduled exercise breaks and company-sponsored healthy meals are proactive ways to fight heart disease and diabetes and would definitely boost the economy if adopted widely, but they are difficult to implement and need a high degree of buy-in from both businesses and employees; they are going to require cultural changes that take time, something we don’t have a lot of in the midst of a viral pandemic. Yet the economic costs of these diseases is so great that if we could somehow drastically reduce deaths and hospitalizations from them by strategically shutting down non-essential businesses and engaging in social distancing and mask wearing for a discrete period of time, it would be an obvious win for the economy, even aside from the question of the inestimable value of those human lives. But while heart disease doesn’t work that way, contagious illnesses like COVID-19 do, and the idea that any of the measures we have adopted have been ‘overreactions’ that we ‘wouldn’t do for any other disease’ belies the fact that we definitely would if we had similar options to fight those diseases (or I hope we would; I’m probably letting my naive optimism show a little too much here).

But even apart from questions of economics, diseases like cancer, diabetes, and coronary artery disease are important topics that are talked about constantly in the news, and that millions of people like me devote literally every day of their full time jobs to fighting, preventing, diagnosing, treating, and counseling people about. COVID-19 is causing a pandemic, and it’s understandable to feel some frustration that it has sometimes seemed like the only thing the news has been reporting on; but we shouldn’t pretend that sensationalization of medical topics is new or that the media has never spent significant energy and focus on these other diseases. When something negatively effects peoples’ lives to an extreme degree, like COVID-19 and these other diseases do, people are going to read and write about it; but unlike COVID-19, the interest is more or less sustained over the years. This isn’t just true for the news; it’s true for us, too; just look at this graph of searches from Google Trends. We are always thinking about these issues, as a society, at a pretty steady rate; COVID-19 is new and very dangerous, and so we are thinking about it now all at the same time.

COVID-19 is just as incredibly dangerous as the leading causes of death.

But the final and most important issue here, and maybe the one I should have started with, is that these statistics are lies, at least when you are seeing them shared on social media now. That graph above showing COVID-19 deaths compared to cancer and heart disease is from March, when ‘only’ a few thousand people had died from COVID-19 and the US had yet to hit any regional surges. It compares cases at the beginning of the pandemic to deaths from other causes for the entire year. But by the second week in April COVID-19 had become the leading cause of death, in deaths per day, and stayed there throughout all of April and half of May. Since then it has continued to jockey for position with cancer and heart disease (while disproportionately affecting people already battling these diseases), and is now on the rise again.

If we want to compare apples to apples, we could wait to compare the number of deaths once COVID-19 had an appreciable impact; the 2nd graph below shows COVID-19 deaths compared to other causes of death today. If we wanted to compare same-sized apples, we could look at deaths from COVID-19 since the first death was reported in the US on February 29th; the 3rd graph below shows deaths from COVID-19 compared to an equivalent time period, 154 days (and for the 2017 flu and 2009 H1N1, the slightly shorter period encompassing their entire flu seasons).

Looking at the 2nd graph, COVID-19 has already surpassed stroke, drug overdose, and the very deadly Seasonal Flu of 2017-2018, and there is zero chance that it won’t also surpass accidents and chronic respiratory diseases soon. But unlike the flu, COVID-19 did not begin to disappear in the late Spring and early Summer, and we are once again seeing a surge in deaths from the virus as we enter August. If we look at the 3rd graph, there is reason to believe that COVID-19 will settle in as the 3rd leading cause of death in 2020; but it has already dwarfed all other causes except heart disease and cancer. Even this graph undersells the true impact of the virus, since the proportion of deaths occurring in February and March was very low. If we were to look at the number of deaths in the 120 days since COVID-19 deaths began to rise at the end of March, the picture would be even more bleak; but posting more and more alarming graphs by limiting the time frame to the most dangerous months of the pandemic so far, in order to show how dangerous COVID-19 really is, feels a little too much like manipulating the data in the virus’s favor; and COVID-19 doesn’t need or deserve any help from us.

So these comparisons are problematic because they ask us to believe that our society doesn’t already devote enormous resources to these other problems and that they don’t have incredible impacts on the economy, and because they are comparing very different causes of suffering, disease, and death that have to be combatted very differently. And they are deceptive because they are deliberately using old data from early in the pandemic (using old data when you know new data is available is also called lying) and discounting whatever time period of the pandemic doesn’t support their narrative. But I think the most frustrating thing for someone like me who spends hours every day talking about and thinking about diabetes and heart disease, has devoted extra time and effort to gaining proficiency with methods of treating drug dependence and preventing drug overdose, and has spent hundreds of hours working in emergency rooms and treating people following accidents and motor vehicle collisions, is that people often seem to be sharing these comparisons not because they actually care about these other important medical issues, but because they don’t mind using them to reinforce their COVID-19 denialism and conspiracy theories… and then dropping them again once they are no longer useful or convenient. But because I’ve lost my lisinopril bottle again and apparently want to see how high I can get my blood pressure this week, we are going to save that discussion for tomorrow when we talk about the comparisons being made between COVID-19 and Human Trafficking.

At some point in this sort of voluntary, part-time work, you have to face the fact that people can produce misinformation, honest misunderstandings, and conspiracy theories far more rapidly than you can write about them, and that it is literally, physically impossible to keep up. For me, this realization came around the first week of April. At times like that I am thankful for people like Dr. Mikhail Varshavski (“Dr. Mike”) and Dr. Zubin Damania (“ZDoggMD”) who are doing this work consistently on Youtube and their own websites, and for people like Dr. Emily Smith, Your Friendly Neighborhood Epidemiologist, and the anonymous Your Local Epidemiologist, who for all I know might also be Dr. Emily Smith (I’m just saying, have you ever seen them together in the same room at the same time? Probably not. Because quarantine). If you have a question about a piece of misinformation or something that’s unclear about COVID-19 that I haven’t addressed on this blog, or (as seems more likely) that I’ve addressed in such a wordy and convoluted way that you are actually worse off than you were before my ‘explanation’, chances are one of these folks has got your back. There must be many people out there doing this type work that I am missing; please feel free to link to their sites in the comments.

With so many pieces of misinformation floating around out there and so little time to write 3,000-5,000 word blog posts, today’s post is just an attempt to debulk the malignant tumor of COVID-19 misinformation. The rules are simple:

1. Memes only.
2. Each meme gets one paragraph only (paragraph length unspecified)(and it still counts as one paragraph if it is interrupted by pictures or videos).
3. The crazier or less sincere the meme, the snarkier the response.

COVID-19 Medical Information.

We’ll start out with a light one. I’ve seen this posted with the comment “Coronavirus is a cold.” It’s hard to derive any sort of conclusions from just that. Does the meme intend to convey that the entire worldwide pandemic is a hoax? Are they are trying to say that literally all of the deaths and suffering have somehow been fabricated? If I posted this meme with the comment “wow, look how much we’ve learned about Coronaviruses in the last 3 decades,” it would completely change the meaning; but the meme as written is clearly designed to imply that the pandemic has been faked because coronaviruses only cause colds. I think there’s at least three legitimate ways we could debunk this idea, and I can’t really decide between them, so we’ll do all three. First, we could do some basic education on medical history. ARDS, Acute Respiratory Distress Syndrome, was first described in 1967, just one year before Coronaviruses were classified; but the first Coronavirus that was known to cause ARDS was SARS in 2003. Obviously it wouldn’t have been known in 1989 that Coronaviruses would emerge that caused such severe respiratory complications, and thinking of them as a virus that typically only causes a common cold was perfectly reasonable. If you want a thorough explanation of the history of coronaviruses and ARDS, I recommend this article, which could have been written as debunking of this meme: A Brief History of Human Coronaviruses by Shawna Williams. It contains an excellent visual timeline, which I’ve included only a fragment of here.

The second approach I think is valid is to point out how silly it would be to fake a pandemic using a virus that is known to cause only a common cold. It seems like faking infections, hospitalizations, chronic complications, and deaths in every single country in the world and having doctors, nurses, respiratory therapists, researchers, and millions of non-medical people pretending to be patients, would take an awful lot of effort; maybe it would have been worth devoting some of that untold energy and seemingly infinite resources to attributing your fake pandemic to a pathogen that couldn’t be disproved by by pulling up any old text book from before 2003. This is what makes me think that the meme was knowingly deceptive on the part of the original creator, because it’s so hard to believe that somebody actually found this in a 30 year old text book and said to themselves “aha! got ’em!” The third and final point we could make is to just point back at the meme itself, just eight lines up:

This textbook page doesn’t list cervical cancer as a disease linked to the Papovaviruses family, which under the classification scheme used at that time included human papillomavirus; HPV. Maybe it’s a good thing that medical knowledge and research has continued to progress since 1989?

This is one of my favorites, and was actually shared to my Facebook wall by my mom (I should clarify; she shared it because she also thought it was ridiculous and knew I would enjoy it). Something like this almost has to be written facetiously, right? But for the sake of thoroughness, let’s clarify a few points here. First of all, the reason the collection is done in the nasopharynx really isn’t that complicated; that’s where the virus is more densely populated, compared to other locations that could be swabbed, and going deeper in increases the chances of picking up the virus on the swab. I know it’s uncomfortable; I’ve had it done three times now, and the second time was especially awful. Despite what people may think, doctors and nurses don’t like causing pain, and we wouldn’t use it if we felt like there were other reliable options. But so far studies comparing the sensitivity and specificity of Nasopharyngeal swabbing to other swab techniques and locations have been mixed in terms of how determining how necessary the Nasopharyngeal swab actually is. Some have shown that it clearly gives us the most reliable way to tell if you have the virus or not, and others have shown that other swab locations might be just as good. But until something like a definitive answer emerges, doesn’t it make sense for your doctor’s office to use the technique that everyone agrees is as accurate as possible? This is all pretty obvious, but doesn’t answer the question of ‘if the virus is so contagious, why wouldn’t a less invasive test work?’ The other part of this meme seems to call into question that the virus is contagious if we have to do such an uncomfortable test to detect it, and the answer here is simple too; when we test for the virus, unlike when you get infected with the virus, we don’t have the virus’s help. You see, your body is a good breeding ground for certain viruses, who use your own cellular machinery to reproduce and, when they reach a certain point (viral load), begin to cause disease. This takes time; the incubation period (how long it takes the virus to reproduce enough to cause illness) of COVID-19 is 2 to 14 days; the COVID-19 test we use in our clinic comes back in 15 minutes. That’s because the tests we use aren’t trying to let the virus go through multiple reproduction cycles until it has proliferated enough to be detected; this is a good way of testing for pathogens called a culture, but it takes longer. The rapid tests rely on detecting some part of the virus, such as its DNA or specific proteins, and the more of the virus that is collected for the test, the more likely it is for the test to be accurate. In other words, the test may require more of the virus to be reliably accurate than the virus requires of itself to make you sick. Finally, the part about the microchip is really, really silly, and if you believe it there probably isn’t much I could say to change your mind; but if it helps here are two videos; the first showing exactly what our swabs look like, and the second showing me getting the Nasopharyngeal swab done at one of our clinics.

Two signs that your meme is bad:

1. Your main point can be summed up as, “people with certain medical conditions deserve to die.”
2. You add a picture of Morgan Freeman and I still don’t read it in his voice.

There’s not much to do with this one. Sometimes high blood pressure, diabetes, and obesity are significantly attributable to personal decisions, and sometimes not. It’s always, and I mean always, much more complicated than people know from the outside, and managing these conditions both as a doctor and as a patient is hard, frustrating, and often feels like an uphill battle. Sometimes people can exercise, and sometimes they can’t. Yes, smoking is bad for you, and I spend a lot of time trying to help people quit (by the way, one of the most effective and least utilized methods for quitting is getting a smoking cessation coach. You can get one for free at https://www.yesquit.org, and they can even help set you up with free nicotine patches or other medications), and you should quit, but we know it isn’t easy. The idea that anybody should be shamed or punished for a medical condition, let-alone medical conditions that are only partly modifiable with behavioral changes, is obscene. Shame on you to whoever made this meme and to anyone who shared it, and on Morgan Freeman for endorsing it.

Before I get angry e-mails, that last part was a joke; I realize that Morgan Freeman has no idea this meme exists. But isn’t there something disturbing about both this and the next meme exploiting the images of Black men- one for his gravitas, acting talent and air of wisdom, and the other for his strength, hard work and physical prowess- to minimize a pandemic that is disproportionately killing Black and minority men and women?

I’m going to just admit now, figuring out the origin of this picture took me longer to research than almost any medical question I’ve addressed on the blog so far. At first glance I had no idea what was going on here, but I braved the internet so that you don’t have to, and here’s what I came up with. According to my research, the image depicts champion body builder Blessing Awodibu, known both for his multiple body building titles and his various comedic Youtube videos, flexing next to “Daddy Long Neck”, a social media personality and musician who has Marfan Syndrome, a connective tissue disease. The two did a sketch together on Youtube back in December of 2018 where they arm wrestle, and this image appears to have been taken at the same time. We’ve already addressed this idea that by taking precautions to avoid COVID-19 you are somehow coddling you immune system into a state of weakness back when we compared your immune system to a Death Star, and on a few other occasions early on in the blog, so I won’t rehash it here. Suffice to say that while exercising is of course a healthy habit, none of the things listed by Awodibu are going to protect someone from COVID-19, and I’m fairly grossed out by the fact that whoever made this doesn’t wash their hands before eating.

There’s also a good bit of irony here, since in the original Youtube sketch Daddy Long Neck actually won the arm-wrestling match, prompting Blessing Awodibu to ask “which protein do you use?” This would imply that the immune system in the meme that is wearing a mask, using hand sanitizer, and doing curbside pickup for groceries is less likely to get sick from COVID-19, so I guess I do agree with this meme after all.

COVID-19 Statistics (Yay!)

I’ve included a few statistics memes that were sent to me recently, and this first one is the most straightforward of the bunch. Unlike the others, which make a few important intentional or accidental statistics errors, this one is clearly written by someone who has no grasp of statistics at all. Let’s look at the three statistics it gives:

1. 0.94% of Americans have contracted the virus.
   This is actually a really terrifying statistic, because if it were true, it would mean that the now 143,000 deaths (up over 10,000 since this meme was made last week) are just the tip of the iceberg; that we’ve had that many people die and over 99% of the population hasn’t even had the virus yet. Fortunately, this meme is only accounting for confirmed cases, and does not take into account any of the antibody testing and studies that have helped us get a better estimate of the number of asymptomatic and minimally symptomatic people who have already been infected with SARS-CoV-2 without realizing it. Even in areas that have already survived a surge of cases, these numbers have not been anywhere near high enough to confer herd immunity, and we definitely aren’t out of the woods yet; but if only 0.06% of people have even had COVID-19 at this point, we would be on track to blow even the most dire models from March or April completely out of the water.
   
2. The survival rate is 95.72%.
   We talked about this a lot back in the posts about the Dr. Erickson/Bakersfield Urgent Care Doctors video. The easiest way to make a really alarming statistic seem mild is to just present the inverse. A “95.72% survival rate” sounds like a good thing, because survival is good and 95% is a ‘high’ number; “see, the good thing has a high number! It’s not that bad!” But this is exactly the same as saying that COVID-19 has a mortality rate of 4.3%, instead of the still scary but much less catastrophic 0.5% to 1.3% most doctors I know would be willing to accept. A mortality rate of 4.3% is terrifying for a virus that is this contagious, and flipping it to “95.7 survival” makes it exactly 0% better.
   
   So the first two statistics by themselves actually constitute a form of misinformation about the virus we’ve seen only rarely, in that it makes this already terrible pandemic seem even more dangerous than it actually is. Which is what makes the final statistic so baffling.
   
3. Only 0.04% of Americans have died, so the survival rate is 99.96%.
   This is why you don’t make memes as a group project; it’s obvious that the person who wrote the last part hadn’t looked at the rest of the presentation, since the line immediately before this claimed a survival rate of 95.72%. What they’ve done here is divided the number of deaths by the entire population whether they’ve had the virus or not, very similar to what Dr. Erickson did in his video when looking at deaths early in the pandemic (“millions of cases, very little death”). But that’s not what a “survival rate” is at all, because you are basically making the claim that hundreds of millions of people have ‘survived’ something they haven’t been exposed to yet. I can think of exactly one type of scenario where it would be helpful to calculate a “survival rate” based on the entire population instead of just the people actually effected (i.e. the people who have survived), and that would be after an extreme mass casualty event. For example, in the 1997 movie The Lost World: Jurassic Park, a T-Rex makes it from Isla Sorna to San Diego to rescue his baby by… Swimming? Stowing away on a boat? That movie was so crazy I can’t remember. He weaves a path of destruction across the city until… something happens to stop him, I think. Anyway, in a situation like that, it would be reasonable to calculate a survival rate for the entire city once the dust settles; but using the current number of deaths compared to the US population to calculate what percentage of Americans have “survived” COVID-19 right now is like calculating the T-Rex survival rate for San Diego while it’s still running behind you on Harbor Drive.

I like this meme for three reasons: 1. It starts and ends reasonably, 2. It comes from my home state, and 3. It is the best statistics example I’ve seen yet of comparing apples to oranges, only in this case somebody has painted an orange red and glued a stem to the top to try to pass it off as an apple. Let’s break it down a bit:

“Here are some numbers that are confusing to me.”
This is a great start, and honestly if all misinformation could start out this way instead of “READ THIS BEFORE FACEBOOK DELETES IT” we would be a lot better off.

Covid-19: 3,399 deaths/88,691 cases = 4% of the people with cases have died.“
This is actually a great way to phrase this, because it emphasizes a few points that we can’t be too precise about. Louisiana has had 88,691 confirmed cases (now 95,002), but we can’t be sure how many people have had the virus without getting sick and getting tested, so saying that 3,399 of the people with confirmed cases have died, to get a case fatality rate of 4% is precisely correct. It also uses the present perfect tense instead of the past tense, a nod of recognition that this pandemic is not over. For people in Louisiana with confirmed cases of COVID-19, 4% have died up to this point; many are still fighting for their lives, many are recovering, and many more are being diagnosed as we speak; this number is dynamic.

Flu: 1,400 deaths/14,000 cases = 10% of the people with cases died.
Notice the past tense? Because the 2018-2019 flu season is over now? Masterful. But unfortunately, here’s where it all goes off the rails, because Louisiana did not have 14,000 cases of flu last year; it had 14,000 hospitalizations for flu. And that completely changes the meaning of the statistic, because now you are comparing the very sickest flu patients with the most dangerous risk factors to all confirmed COVID-19 cases and getting a number on the same order of magnitude. That makes COVID-19 insanely scary. And we don’t yet know how many hospitalizations for COVID-19 this pandemic is going to have, or how many deaths, because we are still in the middle of the pandemic. We’ve talked about the problems inherent in comparing flu and COVID-19 before, and we’ll cover some of them again below; but if we want to compare something at least in the same fruit family, there are studies that have looked at the number of deaths compared to hospitalizations in Louisiana hospitals from COVID-19, just as this meme does for the flu. One study from the New England Journal of Medicine, which also looks at the increased burden of COVID-19 on African Americans due to chronic health disparities, found a hospital death rate of 24%, compared to the 10% for the flu in the meme above.

So, I don’t understand why we haven’t been wearing masks already?
This meme is so precise in every other respect, and the mistake between 2017-2018 flu cases and flu hospitalizations is so glaring, that I can’t help but believe it was intentional. I find that really disappointing, because otherwise I really like this one, and I definitely agree with the final point. Why haven’t we been wearing masks before now? 15,000 to 60,000 deaths from flu each season may not be COVID-19 pandemic levels, but it still represents a lot of human pain, suffering, and grief, and wearing masks during flu season would cut down flu transmission a lot. Here’s hoping that our experience with COVID-19 will teach us some useful transmission control skills as a society going forward, just as SARS did for Taiwan in 2003.

We can move due West to my new home state, Texas, to see another meme explaining to us, contrary to what every doctor and epidemiologist has been saying for months, why COVID-19 just isn’t very dangerous compared to the flu. In a perfect world, it would be enough to explain that this is a fake, and move on with our lives. This is not a table published or endorsed by the Texas Department of Health and Human Services. There are a few ways to tell. First, it looks fake.

And second, DSHS said it wasn’t from them.

And really, do we need to say anything else about it? If the meme is a lie in the first place, do we need to spend the energy picking through the data? I will never understand the mentality that says, “sure, it was a lie, but I still think it makes some good points!” When you have discovered that something (or someone) is not a truth telling thing, stop going to it for truth.

But let’s look at the numbers, briefly.

Texas Population
Yep.

Seasonal Flu Numbers 2017-2018, 2018-2019
These all check out too, and you can find them here (2017-2018) and here (2018-2019).

Flu Rates, 2017-2018, 2018-2019
We can ignore the negativity and positivity rates, because they really don’t matter for this discussion. The rest of these took me a minute, because I’ve never seen these numbers before, and they didn’t really make sense. You see, the commonly accepted case fatality rate of the flu is 0.1%, and I couldn’t figure out either how or why a meme trying to show that the flu was more dangerous than COVID-19 would cut the death rate of flu by more than half. It took a few minutes (honestly, as many times as I’ve seen this dumb trick played since I started this blog, I’m embarrassed it took that long), but then it hit me; they are dividing the numbers from the top the rows by the population of Texas to get the numbers in the bottom 5 rows. It’s the same nonsensical math they did in the first stats meme we look at in this blog post! Look at the “Seasonal 2018”:

• They calculate the “infection rate” by dividing the number of positive tests by the population of Texas. 35,339/29,677,668×100=0.11908%. The problem is, that isn’t the number of flu cases, it’s just the number of positive flu tests. I saw scores of flu patients in both of these years, in the state of Texas, but most of them aren’t represented by this data because most didn’t get a flu test. Why? Because it’s primarily a clinical diagnosis and the flu test has a sensitivity of 50-70%. Unless it’s a clinical scenario where having a specific test result is going to change the patient’s treatment, the flu test isn’t useful to me. I often offer it to people who ‘just want to know’, but if they have flu-like symptoms and flu exposure in the middle of flu season, I’ll explain that ‘if this flu test is negative, I’m not going to believe it because you definitely have the flu.’ So that infection rate is an extremely inaccurate, way too low estimate of how many Texas had the flu during the 2017-2018 flu season. Why does that matter? It doesn’t really, for this discussion, except as a hint at the fuzzy math strategy they are going to take with the more vital numbers.
• They calculate the “death rate” by diving the number of deaths by the population of Texas. 11,917/29,677,668×100=.04015%. Again, that’s not anything. You could compare the death impact of flu to other diseases by comparing the deaths per 100,000 people, or you could compare the case fatality rate by dividing the deaths by the total number of cases; but just diving the number of deaths by the total population conflates these two important numbers and gives us nothing useful at all. But it gets worse.
• They calculate the “recovery rate” by subtracting the number of deaths from the population and then dividing by the population. (29,677,668-11,917)/29,677,668 x100=99.95985%. So by their own math they are saying that 29,665,751 people in Texas recovered from the flu, including 29,642,329 people that never had it. This is by far the strangest use of the word “recovery” I’ve ever heard. Please, tell a friend that you’ve recovered from measles and when they ask, “when did you have measles?” tell them, “I didn’t; that’s why I said I’ve recovered from it. Duh.” See if you don’t get punched.

So what do they do with the COVID-19 data? Well, pretty much all the same nonsense; claim that tens of millions of people have ‘recovered’ from COVID-19 who haven’t even had it yet, divide the deaths by population instead of by confirmed cases to get a “death rate” of 3,112/29,677,668×100=0.01049% instead of 3,112/250,462×100=1.3%, and produce an infection rate that is utterly meaningless. But the two worse misinformation sins are these: first, they have gravely misunderstood the differences in our testing strategies for flu and COVID-19. In flu we test the sickest patients or the patients for whom a certain test results really guides our clinical judgement, which means we test a relative few of our actual flu patients. In COVID-19, we are testing many patients including people we don’t think have the virus because it is important for contact tracing and other epidemiology measures (and of course because we want to implant as many of those microchips as possible). This means that positive tests vs. deaths is not a useful statistic unless you really understand the testing strategy, because the COVID-19 strategy is going to catch a far higher percentage of the mildly symptomatic COVID-19 cases than we ever would for flu. But the point of this meme, I honestly believe, is to draw your eyes to the four cells right here, to try to trick you into thinking that COVID-19 is orders of magnitude less dangerous than the flu, which couldn’t be further from the truth.

But the second misinformation sin is also the most important, practically speaking, and it’s this; that they made this meme in the middle of the pandemic, and COVID-19 is still killing Texans. Since this meme appeared a week ago, we’ve gone from 250k cases to 332k, and from 3,112 deaths to 4,111. 1,000 lives in less than 10 days. The meme calls flu season a whole year (“10/17-10/18”) and tries to stretch the COVID-19 pandemic in Texas to as long as possible to make them seem comparable; “1/20-7/20”. But in January and February we had zero deaths. By the end of March we had 42, and by the end of April, 782. This has been a Summer pandemic for Texas, and the people who will increase that total by next week are fighting for their lives today. In real life, in a hospital; not on a spreadsheet. I don’t know if COVID-19 will cause more than 10,000 deaths in Texas. I hope it won’t, but it probably will; I can’t see a way around it. The people who are sharing this meme have apparently already determined, right now, that those deaths will not impact their beliefs about this pandemic. Those lives won’t count. Whether it’s because they are nameless and faceless to them, or because they were ‘faked’ by the doctors, or because they heard that somebody who was in a car accident ‘got counted as a COVID death’, they’ve decided that no matter how many human lives are lost in our state, country, or world, it can all be waved away as long as you can find some way to arrange the numbers that makes those lives seem insignificant. Until it affects them personally, which is the very thing the rest of us are all working so hard to keep it from doing.

Political Stuff (Boo!)

I don’t know about international politics, and it’s too late to look it up, but I’m assuming this is wrong; surely somebody somewhere is trying to unseat a president this year. So, ha, got you on a technicality. I wrote last week about the idea that COVID-19 was a big conspiracy to somehow hurt the president, and how that depended not only on not having any knowledge about the pandemic, but also on not knowing much about doctors, because of whom I’ve been subjected to more doctor’s lounge Fox News broadcasts in the last decade than I ever wanted to watch in my lifetime. That’s about as political as I get on this blog, except to say this; dispelling this meme, and the beliefs behind it, should not be my job. It’s the job of our national leaders, and especially the presidential administration, to challenge these lies that are so incredibly dangerous to Americans, instead of tacitly endorsing and even actively promoting them. Every time they refuse, people die as the result.