Ignoring the Big Impact Decisions

For the last 3 weeks the lead story across most news media has been Trump’s advocacy of the unproven drug Hydrochloroquine and his clumsy allusion to injecting “disinfectant” to fight COVID.

Let’s accept he did both without conditions or qualifications, just for argument’s sake. Will these end up mattering in the grand scheme of things? No. Doctors still have to prescribe Hydroxychloroquine. If they do it primarily because Trump said he was hopeful, well what’s the point of a medical license? And if a few dumb people inject Chlorox, it is indeed a tragedy (well, maybe not in a Darwinian sense) but the numbers will be tiny.

Why are we talking endlessly about immaterial issues? There are big decisions that need a lot more scrutiny than Trump’s false authority on scientific issues.

In almost any situation, a few big calls determine most of the outcome. Yes, 20% of the calls tend to determine 80% of the outcome. It could be years until we know the most important errors, but two are emerging as obvious candidates that seem to go barely discussed.

First, nursing homes. It’s clear nursing homes account for as many as 50% of COVID deaths in the US with similar numbers across the globe. The age, health and infection dynamics of these populations are clear ticking time bombs. Why are we not obsessed with our policies on these hot zones?

Is it that we don’t want young people to get complacent? Is it because we don’t want to appear ageist? Is it that it will undermine the strategy of widespread lockdown? Whatever it is, it’s killing a lot of people. New York has been so blind on this topic that they continue to restrict any nursing home from turning down COVID positive patients. They now have infections in as many as 80% of homes. High infection rates in homes continue across the country despite broad lockdowns. How have we not held anyone to account on this error? Swedish epidemiologists cite their slow response on nursing homes (and their 2-3x number of nursing home beds in them vs. their neighbors countries) as a primary cause of the country’s high death rate. Should we believe it, or attribute it to their loose shutdown? Time will tell, but there is no denying nursing homes,and our policies around them, as an obvious factor, mostly ignored.

Second, ventilators. Yes, Hydroxychloroquine was not fully tested and peer reviewed as a treatment for COVID-19 before its use. Well, neither has the use and protocol of ventilators. Why did they become the standard of care with little questioning or validation? The mounting evidence is they have been vastly overused. The 85-90% death rate of patients put on a ventilator should have been a clue. Yet, we redirected our top manufacturing companies to build them and shut down the economy to flatten the curve and not overwhelm their utilization. Who knows, perhaps their use is a non factor and patients put on a ventilator have little hope of survival regardless. But surely over time something that gives you a better than 1/10 shot will emerge. Tolerating that failure rate should never have been allowed to go unquestioned for so long.

Where is the media’s scrutiny on these massive drivers of the painful outcomes we face? Where is the public’s outrage and the government’s policy prescriptions? Where are the leaders examining these issues and other decisions that will really move the needle?

We have enough data now to start finding these big leverage points. But, we are losing the plot. We ignore the big decisions as conventional wisdom while obsessing on Trump’s speculations that are unlikely to impact the big outcomes. Trump should get no pass on this front—his poor leadership drives the core distraction. But, we have to get focused on the disease beyond politics. A few big calls will make all the difference. We need to start getting some of them right.