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The Barry/Markel Drama - part 1. Is the CMG Hanging by a Thread?

by: SusanC

Thu Nov 29, 2007 at 02:37:13 AM EST


Someday, long after the next pandemic is over, historians may look at the process of development of the non-pharmaceutical interventions (NPI) in the Pre-pandemic guidance for community mitigation (CMG) by the CDC with interest, as a reflection of how science, public health, and perhaps politics is practiced in the early part of the 21st century.

UPDATE Part 2 of this diary is here, Little evidence for New York City quarantine in 1918 pandemic?

SusanC :: The Barry/Markel Drama - part 1. Is the CMG Hanging by a Thread?
For now, a controversy that has been bubbling over a crucial study around the subject has spilt over into the blogosphere, with the publication yesterday of this CIDRAP commentary Little evidence for New York City quarantine in 1918 pandemic by Mike Osterholm and John Barry, and today on EM with Non-pharmaceutical interventions for a pandemic: getting it right (with Addendum from John Barry).  

First of all, I want to be honest right up front, and say that I have been an ardent supporter of the CMG measures, for reasons that I have written about before in various places but summarized here and here. But of course, as revere said,

"The key point here is we shouldn't say something works just because we have nothing else to offer. If you are a public health scientist you should have a better reason for recommending something."

And if at any point, the evidence on which we base our public policy is in doubt, we must examine it with rigor, because, as Osterholm said so eloquently about his concern,
This concern does not disprove that NPIs altered the course of the pandemic. But we in public health will face overwhelming challenges with risk communication and credibility during the next pandemic. While we will surely recommend the use of NPIs at that time, we have an obligation to society to tell exactly what we know and explain the science that supports our conclusions.

Now I'm no academic/researcher, and I'm certainly not qualified to pass judgment on the works and words of people so eminent as Howard Markel, Marty Cetron, and John Barry, who all rank high on the list of people I admire.  What I'm doing here, is the same as what I've always done, which is attempt to 'translate' an issue into plain English for the general public, so that you can participate in examining the issues involved, and draw your own conclusions.  Or perhaps the nature of the problem is such that no absolute conclusions can be drawn, only relative choices.  I will leave that to the reader.

First the context:

The scientific case for the CMG measures (CMG is used here to designate the specific set of interventions recommended by the CDC, as opposed to a more general description of non-pharmaceutical interventions or NPI) is really based on 2 sets of data, one from computer models, the other from the study of NPIs used in the 1918 pandemic in US cities.  Initially, only the modeling data were available.  At the IOM meeting in October last year, and in the subsequent report, words of caution were raised that such interventions particularly school closure have serious consequences, and we mustn't base our policies on inadequate evidence.  

Subsequent to the IOM report, 3 studies were published based on examination of historical records of public health measures used in 43 US cities and their possible correlation to outcome.  I wrote a synopsis of the first two, from Hatchett, Mecher, & Lipsitch, and from Bootsma & Ferguson a little while back.  The most recent one, the JAMA paper from Markel et al, I have only made some brief comments here (due as usual to time constraints).  Suffice it to say that of the three, this is THE most authoritative study and thorough analysis of primary sources.  The bibliography is published on the CDC site with 1,144 citations, many to primary documents.  The important thing to note is that all 3 studies came to the same findings, that combinations of NPI that included school closures and banning of mass gatherings were correlated to reduction in weekly excess mortality, that timing of intervention was important for delaying the peak, reducing peak weekly excess mortality, and the total mortality, and that the effects were correlated to the duration of implementation.

Now for the controversy:

John Barry, eminent author of the book "The Great Influenza" wrote to the JAMA to say he believed that paper "has a serious problem in its data that calls its conclusions into question."  Barry said he believed there was no evidence that New York city did impose a quarantine as Markel suggested, even though the New York city health commissioner Royal Copeland was quoted in the NY Times as saying they were putting people in quarantine, and that this puts into doubt the results and conclusions drawn from the rest of the study.  He quoted 2 excerpts from the NY Medical Journal, one in which Copeland apparently argued against quarantine, and another in which his assistant cited various initiatives but these did not include imposing quarantine.

Markel et al wrote a response basically saying that Barry was wrong, that NY city started to quarantine suspected cases coming off ships even before local cases appeared, that the city made influenza a reportable and therefore actionable disease "in the same category of risk as cholera, bubonic plague, and smallpox", that the 'action' was quarantine as Copeland explained to the NY Times, and that 2 days later the NY Times reported 4 local people being quarantined.  In addition, Markel said Barry had quoted the NY Medical Journal out of context, because Copeland in that article was talking about "the futility of potential home confinement of all New Yorkers and "universal" closure of public places."  He also quoted an article from JAMA which described NY's quarantine actions.  More importantly, Markel noted that Barry in his own book had written "New York was panicking, terrified. By now Copeland was enforcing strict quarantines on all cases."

Rather than giving you more blow-by-blow accounts, I think this gives you a flavor of the kind of issues being debated.  The interesting development after that is the CIDRAP article, because it is one thing to write to the editor of JAMA, and quite another to take it to the internet.  Writing to the editor is a common practice whenever published work is being queried, because in publishing a study, the editorial board does exercise the responsibility of carefully reviewing the study, including the methodology, before approving the manuscript for publication, and in a dispute would therefore act somewhat like a referee, both to ensure the fairness of the debate and ultimately protect the standard of the publication. It is not uncommon for such debates to go back and forth for a number of rounds.  It is IMO a healthy way of getting at the truth, with the editorial board's actions or inaction passing ultimate judgment on the issue.

Be that as it may, the debate now moved to CIDRAP, which you can all read for yourself.  Barry also wrote to revere at Effect Measure here.    Barry expanded his queries about whether NYC did or did not impose quarantines, and said he himself had at first mistakenly believed that quarantine was used.  The really interesting part for me is where he raised doubts on whether the city's commissioner of health was someone whose word could be trusted, based on the fact that he was a homeopath not an MD, and that he was a crony of a corrupt political elite.  It's interesting because all of this is nothing new, it's all in Barry's own book, and yet he did initially believe in Copeland's words while writing the book, but has now apparently changed his mind.

In addition, he is also casting doubt on the findings from Chicago, saying that the overly large bibliography makes it impossible to determine where exactly the information on NPI in Chicago came from.  He cited the

"Chicago health department's 100-plus-page "Report of an Epidemic of Influenza in Chicago During the Fall of 1918, which is not in Markel's bibliography, only two actions were taken on day minus-2: The state banned public funerals and the city issued orders for teachers to inspect schoolchildren. These actions fall far short of the authors' metrics. The city's most tangible action actually did not occur until day plus-19 (21 days later)"

Now as I said, I make no claim to being able to determine which side has the 'right' answer, but I did make a little attempt in looking up some of this information.  I'm in the process of trying to get my hands on the NY Medical Journal articles that Barry says he is happy to fax to anyone (alas, my fax is not working, so I'm asking a third party to help.  I hope to get this information soon!)

Where I did have some success, is the straightforward approach of looking at the bibliography that is available for download here.    To be honest I was a little intimidated by this 76 page 1,144 item list, as Barry said, but on further reflection, I took the simple approach of searching for the word 'Chicago'.  What I was looking for was something that might look like primary data, to determine where Markel et al might have gotten their information.  Out of the 22 results returned, I found these two listed:

J. D. Robertson, Report and handbook of the department of health of the city of Chicago for the years 1911 to 1918 inclusive (Chicago, 1919).

J. D. Robertson, Report of the department of health of the city of Chicago for the years 1919, 1920, and 1921 (Chicago, 1923).

What is interesting is that at least the first of these 2 documents appear to also be the source of data for the PNAS study by Hatchett et al.  The supporting information for that paper can be found here.    If you scroll down that page, you will find that for the city of Chicago, the PNAS authors had used the same document for the dates of intervention for the following:

- reportable disease
- isolation
- quarantine
- theaters
- Dance halls
- other closures
- private funerals
- protective sequestration
- ban on public gatherings.

Now this doesn't give us the dates in and of itself, but it does suggest to me that there IS an official source of information available giving detailed accounts of the type of intervention and the date of implementation, at least for the city of Chicago.

Where does this leave us?  Frankly at this point I'm not too sure.  Because the issue under debate appears on the surface to be about whether or not NY or Chicago implemented the measures as Markel suggested, or whether these cities had milder outbreaks because they had an earlier spring wave as Barry suggested.  BTW, the CDC link does give us some really cool stuff, like this, which when you open it up is just a treasure-trove of information laid out perfectly for someone who is very visual like me.  Because it is one thing to read this in the paper

We found no statistically significant association of the EDR across the 43 cities when comparing successive waves. Specifically, the severity or occurrence of wave 1 is not associated, either positively or negatively, with the severity of wave 2; the severity of wave 2 is not associated with the severity of wave 3; and the severity of wave 3 is not associated with the severity of wave 4
and quite another to just see it on a chart, like this

In addition, if we were to go back to the big picture, and look especially at what Osterholm is saying, the issue is not just about the accuracy of the data, but also about whether we think there is enough justification for the measures recommended by the CDC.  As I said, I'm a firm supporter, so count me out for an unbiased opinion, but what I'm interested in really is where Osterholm and Barry stand with regards to school closure.  Because, the fact of the matter is, in all the debate about the CMG, none of the other measures such as voluntary home isolation and voluntary home quarantine and general social distancing ever came under dispute.  The focus was always on whether or not we should close schools early enough (before 1% AR is achieved) or wait till children start falling sick or maybe dying.  

Because, CIDRAP is one of the most credible sources for pandemic information, read by many public health officials up and down the country who will make decisions about whether and how far they want to implement the CMG recommendations, and Osterholm is a highly respected figure.  His opinion counts.  If for whatever reason he finds it hard to support early school closure, it may or may not be representative of other powerful opinions that we hear less often from, but I have a feeling that we may be in deeper water than many of us are comfortable with.  If for that reason alone, I hope this controversy is resolved sooner rather than later!

UPDATE John Barry's views on NPI, cross-posted here.  
video-link to interview
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History isn't always a good guide.
I'm a bit nervous of posting on this since I've got an engineer's viewpoint rather than a scientific one. But here goes :-)

I've never been a firm supporter of historical NPI records as a guide of how successful they may or may not be, for two reasons. 1) As these new findings suggest, they may not clearly show what happened, but more importantly IMHO 2) They didn't understand the science of NPIs or influenza itself during the 1918 pandemic.

It's almost impossible to judge the value of something when you know it was poorly adhered to. You also undermine the value of any modern NPIs by doubting they will work.

Take masks as an example, people of 1918 will have worn them intermittently. They may have worn them part of the time (eg travelling to work) but then dispensed with them when they were equally vulnerable (in a crowded office) They wouldn't have known when to replace the mask or that they needed to wash their hands after handling it. Some would have not worn them at all, even when tending a sick relative. Some would have seen friends get sick, even while wearing a mask so decided to discard thei own as pointless. Families and friends would have mingled without masks because within the home they felt 'safe' So any real benefit of the mask is buried under countless unwitting mistakes. If you can see any reduction in cases at all, there must be a significant benefit IF YOU USE THEM PROPERLY.

Right from the start, TPTB have undermined the value of mask wearing. They indicate they won't work, so there's no point buying or wearing them. They damage the chances of them being worn properly and in sufficient numbers to do any good, even before a pandemic has started.

The same will apply to quarantine, isolation or school closures.

The two outbreaks of Foot and Mouth in the UK in recent years, show how the same actions carried out with speed and conviction made a huge difference to the outcome of disease spread.

If TPTB are beginning to doubt the value of NPIs, they need to re-evaluate at what level they can't afford NOT to introduce them and how long they can wait before they act without screwing up any chances of them working.  


these are not new findings
As these new findings suggest, they may not clearly show what happened

but differences in opinion as to how to interpret the information available.

It's almost impossible to judge the value of something when you know it was poorly adhered to.

If we think through this carefully, the conclusion at least to me is the opposite.  That if NPI's were poorly adhered to, but still have such powerful effects (remember the effects are VERY powerful, in the order of 50% reduction in overall mortality), then it tells me that proper and longer implementation is likely to make them even MORE effective not less.

As for masks, there isn't any evidence as far as I know that they made a substantial difference to overall outcome to communities.  Whether that was due to improper use is beside the point, because right now the focus is on finding what evidence there IS, to discover the efficacy of the various measures.  If we do not have much idea of efficacy of masks, it doesn't negate the evidence that IS readily available now, on the efficacy of early implementation of combinations of policies that include closure of schools and mass gatherings.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Doesn't the best compliance
come from people who understand fully what is at stake for them if they do not comply?

If I draw from my experience, I do not need a physician to tell me to comply. I know to and I never forget to do what I need to do.

Give people choices. Give them tools and let them pick them up the best way that they can.

Inform their discretion!!!!

It will also be easier down the road to implement some controls if we can say "hey this is working over there, let's try this".

Don't be afraid of informed citizens.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
It takes a lot of force to push a rope
Much less to pull it.  

standingfirm, you are right on target.

Individual actions of the public that are often described as "panic" are more often uninformed and therefore misguided, but totally rational attempts to find ways to assess the level of threat and find ways to reduce or avoid it.  The "worried well" can also be described as the "under-educated but terribly concerned well".  The "panic buyer" can also be described as the "under-informed, under-prepared, and therefore last-minute-buyer".

Instead of just worrying about the public's potential non-compliance (and in darker moments considering whether and how that might be pushed into involuntary compliance), wouldn't it make more sense to spend the precious time we have in efforts, like yours standingfirm, to lead the public to a greater understanding of the threat and how to prepare for it?

I seriously doubt that anyone with whom you spoke about the pandemic turned from their shopping trip, ran home and cashed in their retirement investments.  For most, it was probably a relief to find there was finally something tangible, something well within their reach, that they could do to address any one of the big fears that constantly assail them from their televisions.  

And, as you say, when the inevitable moment arives when controls and rationing must rule the day, would it be better or worse if the public understood the necessity of and accepted the values being implemented in those decisions?

Would it be better or worse if the public was more accustomed to the fact that our knowledge, our intelligence as it were, on this enemy will be imperfect till well into and probably well after the event?

We cannot wait for certainty. We need not fear how the people will respond to a frank description of potential peril, if we also provide them the tools with which they can at least begin to build their own defense.

If we fear the uninformed among us, there is a simple path away from that fear. That path is not away from those people, it is towards them.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
I love the idea of resolving issues
by studying the data, reviewing primary sources and letting the peer review process function as it was meant to. One doesn't have to take sides between two eminent historians to appreciate that. The data will take us where the data takes us.

Whether it is handwashing or this (and I don't agree with the idea they are 'different'): explore primary sources and get comfortable understanding what's fact, what's hard fact, what's expert opinion, what's precautionary principle, what's 'best practice' and what's not.

Nor do I fear the "political consequences" of open debate. My perspective is more like Oscar Wilde's: the only thing worse than getting talked about is not getting talked about.


oh, and since I think the CDC CMG is a superb
and well-crafted document, I don't think this debate undermines it. So, my answer to the title is : no.

[ Parent ]
thanks, my answer is no too
to the CMG as a policy at the national level.  But I'm wary of the effect on the will to implement it at the state and local level, and that some will use this as the excuse for inaction.  THAT is my concern, apart from the straightforward issue of intellectual differences and honesty in debate.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
you think local folks are aware of the debate?
I wish they were!

[ Parent ]
local PH read CIDRAP
many of the attendees of conferences that I've been to are officials who as we speak are making decisions on what to do and how much to implement.  They are the ones who read CIDRAP, which is where I see the issue of imbalance of opinion as being important.  Maybe Osterholm intends to invite Markel to give his rebuttal, but until that happens this is a one-sided portrayal of the issues.  That just doesn't quite sit right with me, both in principle and in terms of the effect on the readership.

In addition, CIDRAP is read by many in the business community, maybe even more so than PH officials.  This type of ideas will give them ammunition to oppose CMG at the local level.  Already I'm hearing in senate testimony PH officials talking about how their businesses can't cope with school closures.  It is a legitimate concern that needs addressing, the issue of how businesses can cope.  But I for one think even businessmen need to be given both sides of the debate.  FWIW.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
closures
If there is a need to close schools it is just common sense to think, but fear, that businesses will close as well. The reason that schools will be closed is 1) because we close them and 2) because people will be AFRAID to send their kids to school. The urge to protect our young is very strong.

Either way schools and businesses will close. Wouldn't it be better to do so in the best way possible?

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
well, yes, you are right
Either way schools and businesses will close. Wouldn't it be better to do so in the best way possible?

As I wrote in my comments to the Guardian in the UK, which also applies in principle to any other country,

A pandemic will start, the government will embark on a campaign of reassurance as the critical window for action slips by.....Then the first child and adolescent deaths will start. Hospitals will get overwhelmed in no time, parents will panic, schools will close, people will take extreme avoidance measures out of ignorance and mistrust of government, the economy will collapse, while no lives will be saved for all that we have to pay!

The following table illustrates the effect of pandemics of varying severity on child and adolescent deaths, when compared to baseline death rates.  This is again from UK figures, but again the issues are the same.

The question therefore is not just how much evidence we have to justify early school closure, cos there will never be absolute definitive proof until after the next pandemic, or maybe not even then.  The additional and more important question is as societies how much risks are we willing to tolerate when it comes to the safety of our children.

I speak not just as a mother, but also keeping in mind the societal consequences of not addressing such genuine natural concerns, and the instinct of parents to protect their young.  We are at least 2 generations removed from when losing a child was a common occurrence, and the risk tolerance of parents is extremely low.

For example, the death rate in 1911-15 for children in the UK aged 5-9 was 3/1000. The excess death rate due to the 1918 pandemic was 1.6/1000, which would have caused just over 50% more deaths that year than would have happened without the pandemic. Tragic as that was, it would have been close enough to normal death rates for this to be a sad but accepted fact of life. But now, however, the death rate for 5-9 years old had fallen to a very low 0.1/1000. The same death rate of 1.6/1000, applied to today, (ie if a pandemic happens today with exactly the same characteristics as the 1918 virus) would cause the same proportion of deaths as in 1918, but it would be experienced as 16 times the normal death rate! Put in another way, parents and communities will be experiencing 16 years' worth of child deaths for that age group in one season.

No society can stand that.  Parents will take extreme avoidance measures, while confidence in government will collapse and all who are perceived as having known the risks but stood in silent complicity of keeping people in the dark will be the targets of mistrust and wrath.  Such social disharmony is preventable to some degree, and it will be irresponsible of us not to speak up now while there is still time to put things right.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Did Barry abandon the Journal debate?
I am wondering why Barry decided to take this debate to the net.  Osterholm says Barry was not satisfied with the responses to Barry's challenges.  But isn't there a way for him to continue that process.  Maybe not.  

Just as showing unquestioning repect for formal boundaries is not high on my list of things to do, so Barry is certainly entitled to go elsewhere if the discussion is being shut down at JAMA, but I did not get the sense that was the case.

It is also rare (often even prohibited) for members of academia or government employees to go 'slumming' down here in the blogosphere in identifiable/official form.  (Hi folks - if you're here incognito!)  So if a two sided discussion between the principles - with a goal of ferreting out what survives of the truth - is what is being sought, CIDRAP and Effect Measure both seem like slightly odd venues for Barry to take in this instance.    

I was also a bit surprised at Barry's tone and approach, which as I indicated over at EM tasted a bit more like a political broadside than scientific inquiry.  Hope they can all get back to the substance and leave the rest at the doorstep.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
good question
Did Barry abandon the Journal debate?  I am wondering why Barry decided to take this debate to the net

As I said, it is quite common for such debates to go through several rounds in the prestigious journals.  There is no reason why Barry could not have written to JAMA about the additional points, eg on Chicago.  Or at least in principle.

However, we need also to bear in mind that journals like JAMA scrutinize the letters to editors by the same standards as they judge submitted manuscripts.  It's not like anybody can write any objection and expect to be published; these letters also have to follow the same standard as the original study.

It is also rare (often even prohibited) for members of academia or government employees to go 'slumming' down here in the blogosphere in identifiable/official form.

That would be my general understanding, although I don't know whether it applies to all institutions.

So if a two sided discussion between the principles - with a goal of ferreting out what survives of the truth - is what is being sought, CIDRAP and Effect Measure both seem like slightly odd venues for Barry to take in this instance.    

Yep, I have a great sense of disquiet on this issue.  Barry of course has the freedom to write wherever he wants, and rightly so.  Where I have some reservations is with CIDRAP.  I wonder if they ever invited Markel and/or his colleagues to write their POV?  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
right
we cannot wait until we can judge the severity of the disease...then the bell has rung.

We fear for credibility, this is again where I wrestle but on a different plane. This is one of those instances where we have to go forward blindly. We do not have the answer for this pandemic only trust in moving forward. In that we will find some answers for the next time.

The only way we can fail is by throwing up our hands in defeat because the foe is so great. Sometimes ya just have to go with your gut.

History is a guide but spotty at best because they lacked the information that we now have.

----------------
Common sense is not all that common.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
Forward blindly - as in the dark, but with eyes front and wide open
And while we are learning more about past pandemics every day, even if we had perfect knowledge of the past (1918), all that would mean is that we could prepare for 1918, which will not come again.  While many apsects may remain the same, many more will change (a JIT global economy comes to mind).

I don't remember who said it, but it applies in some ways to NPI as it does to PI:  If you've seen one pandemic, you've seen one pandemic. That's why historical studies are instructive, but should not lead us into only preparing to fight the last war.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
JK Taubenberger
that's who said it.

;-)



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
it seems to me
that compliance IS the issue. No NPI will work without thorough education as to why steps are necessary. Not every NPI will work in every area. Take New England for example, staunch yankees may resist efforts that seem as controlling while somewhere else, a different population say in hurricane alley, will be more willing to follow some NPIs due to their other experiences.

two quotes said about government but also applies to safeguarding public health, at least to my mind. I am sorry if this is seen as political speech....it is not intended as such. I am sure that we could point to other statements elsewhere in successful government.

"Whenever the people are well-informed, they can be trusted with their own government;... whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights." --Thomas Jefferson to Richard Price, 1789

"And say, finally, whether peace is best preserved by giving energy to the government or information to the people. This last is the most certain and the most legitimate engine of government. Educate and inform the whole mass of the people. Enable them to see that it is their interest to preserve peace and order, and they will preserve them. And it requires no very high degree of education to convince them of this. They are the only sure reliance for the preservation of our liberty." --Thomas Jefferson to James Madison, 1787.  

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


can't go wrong with jefferson
but this has international implications, of course.

[ Parent ]
i try
to draw from many sources ;) including my own informed discretion.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
Jefferson was an internationalist. n/t


"I am opposed to any form of tyranny over the mind of man."  Thomas Jefferson

[ Parent ]
Compliance need not be perfect to be effective
It's important to remember, but I think the modeling that has been done indicates that even at compliance rates of 30%, significant positive impact is predicted (SusanC or Dem can correct me if my memory fails on the exact number).

Each community must approach its efforts in the way that works best for them, but we can think about it like a batting average.  If you are batting in the 300s you're doing fine.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
30% compliance is correct
there is not a lot of gain to force higher compliance on any measure, but much more if you apply multiple measures, ie a layered approach with multiple imperfect measures with imperfect compliance gets the best results.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Severity
The severity of the disease will drive action.  Put simply, this debate is relevant only if the disease is mild to moderate in its effects.  If it is as bad or worse than the 1918 virus then the motivation will be there for local governments to implement some pretty stringent NPI.  Maybe not  in the first cities affected (in the U.S.), but most definitely in the rest of the country as they see the body counts rise.  Yes, ideally this would be implemented in the first cities early on, but this will only happen (no matter what the CDC or DHS or anyone else dictates) if there is already a high and rapidly growing body count in other countries.  

Regardless what comes out of this debate between historians I do not see it having very much effect upon what CMG is developed.  Historical information such as what we have from 1918 is only a guide in a general sense, not in specifics.  It tells us timing is important.  The specifics concerning actions to prevent spread of disease is pretty much common knowledge within the health/epidemiology community.  What is up for questioning is the politics and economics.  Again, the severity of the disease will resolve this question.


yes and no
What is up for questioning is the politics and economics.  Again, the severity of the disease will resolve this question.

YOu are absolutely right that this is about the politics and economics.  But the problem is more immediate than waiting for the next pandemic to unfold so we can discover about the severity, because planning needs to happen NOW.  Any undermining of the will to implement this undermines immediately the will to make the right choices and the right preparations.  THAT is where I see where the CMG can be undermined.  Not in the theoretical nor in the policy at the federal level, but in the will at the state and local level.

Which btw (and I'm not just talking to you here) means it will affect every one of you.
 



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
the CMG anticipated some of this
which is why cat 1 does not have school dismissal on the menu.

[ Parent ]
anticipated but
the anticipation may be there on the part of tptb but the citizens need that information. That spigot has not started flowing.  

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
I'm with SF on this
State and local PH as well as citizens and businesses need to plan for more than Cat 1.  The issue as I said lies in the planning stage, which is right now, not in the unfolding of the next pandemic.

If we leave the issues to then, it will mean the same as not preparing at all!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
tptb
I would have to ask tptb this question.

Have you thought about what you will have to say to people AFTER when we all emerge from this hurricane, when they ask...why didn't you tell me so that I could hear? Where were your voices? I would have used a mask, I would have bought more food, I would have stayed home, had I known how bad this was going to be?

History also tells us that people tend to rise to the occasion, especially when threatening their young. While we all intellectualize this, it comes down to heart in the end. At least for me.

Many voices---many methods too---and as many tools as we have. Learn from this so it's the last one!


Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
roar
One other think :)

I have been accused at times of sitting in judgment of people. I think that people know by now that I do not judge hearts. I do judge actions. I rely on discernment that years walking a rough wall engenders.

I am not unusual. People are tougher than we have allowed them to become. People will rise.

Question: What gives anyone the right to judge for me what is best for me and my children other than in how my actions may effect someone outside of my family group? You say that I am on my own to survive but in the same breath you have deemed that I am not responsible enough to have the information that I need to find my own survival supplies.

This why we have to allow people to have the information they need AND time to mount a defense.

To be honest, I really don't care what things you are going to advise me to do. I guess one gets to the point that we will advise each other anyway. As I said at the town level---here you can have the credit for the advice, and I will take responsibility for the words on the paper.

What I am saying is...you have no choice.

Time to inform, educate, and enable preparation. Will YOU work with ME or against ME.

There ya go...I feel better now :)

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
what a powerful question!
What gives anyone the right to judge for me what is best for me and my children other than in how my actions may effect someone outside of my family group? You say that I am on my own to survive but in the same breath you have deemed that I am not responsible enough to have the information that I need to find my own survival supplies.

I believe all those in positions of power, responsibility, and influence should take this to heart!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
...
"...when we all emerge..."  for the folks that could have been saved, and weren't..  it may well be "rest in peace".  if this is a severe event, i wouldn't look for too many folks to be angry with tptb for their getting ill...  i have doubts that those that get ill will be around to complain.

[ Parent ]
You know, this is kind of frustrating.
Rationally, I understand the problem.  If people don't work, everything comes to a grinding halt.  If children don't go to school, people don't work.  By the same token, if children go to school and more people become infected and die, people don't work.  Either way you look at it, everything comes to a grinding halt.  The difference is that if schools aren't closed, parents will be penalized for making the rational decision to not send their children to school.  You don't have to look far into the historical record to know that where people congregated in large groups infection rates in Spanish Influenza were higher.

Specifically, the residents of the Old Hickory community made up the majority of Nashville deaths due to Spanish Influenza.  Why?  Because Old Hickory was home to the E.I. Dupont Munitions Plant, which employed 7500 people working in close proximity to one another.

http://tennesseeencyclopedia.n...

Schools and class sizes in 1918 were way smaller than they are today.  Whether they closed schools back then is irrelevant.  Today we pack our children into schools and classrooms like sardines in a can.  Just ask any teacher about the domino effect a single viral illness can have on attendance in their classrooms.

I understand the economic impact that closing schools proactively can have, but come on!  If we don't give our children a fighting chance, what's the point?  Give people the information to prepare as best they can, but don't sell our children out for the sake of the economy.  The economy can and will recover.  If the public loses confidence in the government's willingness to protect their health and welfare in the face of potential economic struggles, economic recovery will become the least of our worries.

Millions for defense, but not one cent for tribute!


it's not a "fight to not close schools"
as i see it (maybe I differ with SusanC on this, as there are those who just don't believe, but national policy has been set). i see it as a legit question... does the data support the conclusion. And if not, why not?

That doesn't change what to do, but it helps to not oversell something that should not be oversold, or sold for the wrong reasons.


[ Parent ]
yep the data is a legit question
I have held back on commenting on it so far, simply because I hadn't gotten enough information to be able to determine, to my non-expert eyes, where the truth might lie.

But I'm working on it!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
national policy has been set
but only as recommendations.  Implementation is the critical issue here.  I have no illusions there will be lots of objections.  Whether the data is in doubt becomes a critical issue.  

As we know, most people's eyes glaze over on anything more complex than a 2-line statement, so whether the evidence is in doubt, coming from as authoritative a figure as Osterholm, has powerful effect on the ability to overcome objections towards school closure in particular, to successfully implement this policy that is supposedly set at the national level.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
That's exactly my issue.
Implementation is jeopardized significantly where states already can't make up their minds what they should do to prepare.  Tennessee has given itself some wiggle room by stating that it will adjust its reactions according to the severity of the epidemic.  In addition, it leaves some closure decisions up to local education agencies and individual schools whether to close ahead of the state recommendations.  This relieves the state of the responsibility to act quickly.  If there is controversy over the effectiveness of such measures, what LEA is going to want to be seen as the overzealous chicken little?  If there is a clear protocol, it relieves the political burden on local officials.  Somebody has to be willing to be responsible, to say the buck stops here.

Maybe my reaction would be different had Osterholm and Barry written a scholarly paper that countered the study point by point, or offered some new insights.  They didn't do that.  They just took a couple of potshots, and tried to undermine the credibility of someone who actually lived the Spanish Influenza tragedy.  A superficial review, in the absence of hunting down some heretofore unknown primary sources, seems rather like a cheap shot. Even "corrupt" authorities are capable of making decisions in the public interest.  Unless there is some substantial evidence that the NY public health official of the time actually did lie about quarantine, why should we accept that he did?

Millions for defense, but not one cent for tribute!


[ Parent ]
good questions!
Maybe my reaction would be different had Osterholm and Barry written a scholarly paper that countered the study point by point, or offered some new insights.  They didn't do that.  They just took a couple of potshots, and tried to undermine the credibility of someone who actually lived the Spanish Influenza tragedy.  A superficial review, in the absence of hunting down some heretofore unknown primary sources, seems rather like a cheap shot. Even "corrupt" authorities are capable of making decisions in the public interest.  Unless there is some substantial evidence that the NY public health official of the time actually did lie about quarantine, why should we accept that he did?

on substantial evidence.  And I'm finding some good answers as we speak!  I have a couple of other things to find, but the results are quite astonishing.

Stay tuned.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Well, at least I get Barry's criticism as it relates to Copeland now.
https://eee.uci.edu/clients/bj...

I found this link to a series of articles in which quarantine of those coming into the city from overseas was covered.  (It may be unavailable from 6:30 -7:15 a.m. Pacific.) Interesting reading.  There were a lot of contradictions in the messages Copeland delivered.  It's hard to say whether he was lying or just couldn't make up his mind what to do, though.  So, maybe New York was a bad example.  I dunno.  I just know I'm not ready to throw the baby out with the bathwater.  

Millions for defense, but not one cent for tribute!


[ Parent ]
the studies that were
performed / conducted and contributed the writing of the CDC's Mitgation stragities has data details that give a bigger picture of the thought that was put into the writing of the document.

(Maybe, I should go back and read this whole discussion, and make sure I am not out of line here, but time is limited tonight.)

Some of the studies were built using models.  To run these models.... assumptions had to be made..... and most times a "range" of possibilities were used to create a picture of what might happen and how best to deal with it.

That being said... there are studies that say (and were used) that talk about the first identified (confirmed)case.... but, by that time, anywhere from 1,000 to 10,000 people would be infected.

Therefore, early implementation of any mitigation measures would be very important to a community in order to contain or slow the spread.

Sorry, I cannot spend as much time on here as I used to..... miss you guys, though....... :)

Never believe that a few caring people can't change the world. For, indeed, that's all who ever have. ~ Margaret Mead


[ Parent ]
hey, we miss you too! n/t


[ Parent ]
Offical Closure is not the only way things close
Flubergasted:  Excellent points.  I keep thinking this same thing and it came up again in the discussion of the Markel study.  Just because the government does not close the schools doesn't mean they keep running as ususal.  There was some reference made that Chicago had over 45%+ absenteeism in the schools at one point.
http://scienceblogs.com/effect...

Some time ago SusanC reported that after hearing all kinds of various takes from conference participants on when schools should be closed, she asked the table when they, as parents would pull their kids out of school.  I don't remember the exact answer, but I know it was early - and pretty much unanimous.  Regardless of what the government does, people will vote with their feet, and when their children or family are at stake, they will be voting early.

Same thing for businesses.  The official pandemic plan assumes that nonessential businesses may be asked to close, or may close on their own accord due to lack of employees, supplies, inventory, power etc.  That's why there is a distinction made for, and special attention paid to, businesses that make up critical infrastructure. And even within that critical circle of businesses, unless effective countermeasures are implemented between now and then, survey after survey indicates that over 40% of health care workers may not show up for work.  

That's actually one of the under-considered positive aspects of NPI and PPE-use, that effective implementation (driven by an educated and prepared population) could actually reduce the number of businesses that close, reduce the disruption to the economy and reduce both the inconvienience and danger that could result from more serious business interuption. But to get that benefit and avoid or reduce some of the costs, we need to plan now, prepare now.

And there is a big difference between practicing effective NPI as called for in the CDC's recommendations and going to ground for 18 months.  Going into a pandemic period, I plan to have as adequate a stockpile of necessities as I can reasonably manage, but to the extent I can continue to do so in reasonable safety, I will continue to work, shop, and live outside the confines of my home.  Having the stock of supplies, including some level of PPE,  gives me options, preserves my ability to choose, and gives me the peace of mind from knowing that even if it gets really bad, I am still working with a safetly net beneath me.

Are there problems if schools and businesses close?  Yup.

Will such closures happen in a moderate or severe pandemic? Almost certainly, with or without official government action.

Are these problems as personally daunting as being forced from your home (along with a million or so of your family and closest Bangladeshi friends) by a severe cyclone? Probably not. http://www.cbsnews.com/stories...

Are they as complicated as splitting the atom? Most definitely not.

Will these problems take the same resources to address as putting a man on the moon?  Well, maybe a few - the most important ones.

William Bradford, speaking in 1630 of the founding of the Plymouth Bay Colony, said that all great and honorable actions are accompanied with great difficulties, and both must be enterprised and overcome with answerable courage.

JFK used that quote when he pledged to land a man on the moon before a decade passed.

He also said this:

We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.

The rest of the speech is amazingly on point as well (if you like that kind of thing.)  

http://www.quotesandsayings.co...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
voting with their feet!
Some time ago SusanC reported that after hearing all kinds of various takes from conference participants on when schools should be closed, she asked the table when they, as parents would pull their kids out of school.  I don't remember the exact answer, but I know it was early - and pretty much unanimous.  Regardless of what the government does, people will vote with their feet, and when their children or family are at stake, they will be voting early.

Sorry, I missed this the first time round. No, it wasn't quite like that.  It was in the Atlanta Stakeholders' meeting on community mitigation, when all of the issues around school closure were being thrashed out.  By the afternoon of the second day, people were exhausted, but still the arguments were going round and round, about being cautious, and being responsible, and making sure there is enough evidence, and that the measures do not do more harm than the pandemic, etc etc.  In the middle of all that, Marty Cetron asked how many people had school-aged kids.  A whole bunch of people raise their hands.  I had turned around to look, cos I was sitting at the front of the room.  Then Marty asked them how many would send their kids to school in a pandemic, and NOBODY RAISED THEIR HAND!

I tell you, I was gobsmacked.  It was diabolical, because, here's this bunch of dedicated public health professionals, carrying on about prudence, evidence, and responsibility, while the whole time they already understood the risks enough to know they weren't going to send their kids to school!

Unfortunately, that's the kind of double-standard that is far more prevalent than any of us like to admit.  Someone said to me the other day, that those who have worked in government for a long time develop an entirely different and separate compartment for thinking at their job, compared to their own private lives.

The kind of question that Marty asked, helps to bring them back to reality, to be connected even just for an instant to what the REAL deal is.  Unfortunately, men of vision like Marty are rare.  Most don't see beyond their paperwork and their bureaucratic handbook, and if they do get a glimpse of the possibilities or their REAL responsibilities, most would choose comfort over ingenuity, guaranteed mediocrity over reaching for the stars.

That's what I see, it's very sad, and it's a tough job trying to shake people out of complacency.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
this is what I mean
Some speak from their intellect, some from their heart. Sometimes there is a good mix.

I think the best mitigation strategy will be a blending of both...as a heart speaker, I favor that approach...but that's just me.

When this is over though, I think that we will look back and find that the most resilient communities will be the ones who have a lot of heart sense. JMVHO

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
Which is closer to the general public
Some speak from their intellect, some from their heart. Sometimes there is a good mix.

And that's the real indicator.  Their response as parents is a much stronger indicator of the how the general public will respond, so in charting their strategies, they don't have to get all mushy about it, but they do have to acknowledge the reality that the general public will vote early with their feet - causing all or most of the "cost" of closing the schools. (Look at Barry's descriptions of towns, businesses etc during the 1918 pandemic.)

But an early, uniform and coordinated 'official' closing in a given area may purchase for us a significant benefit with that mostly invevitable cost.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
i am charting this
In my towns forum.

There have been a lot of bitter posts in the past directed at different issues and people within the town. I have stayed out of the talk. Recently I am reaching out from my heart and they are responding. The results you can view for yourselves. To me, and in my "rose colored glasses view" they are responding to my heart.

Can I go hide yet?  

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
the arithmetics, and economics, of childminding
Actually, I have come to discover, over time, that the absenteeism issue is not as bad as some would portray.

This is part of a poster that I made for ReadyMoms.org displays.  

There are many ways that families, extended families, neighbors and friends can get together and share childcare needs, and put their children as well as the college students in protective sequestration if they want to, without significant increases in general absenteeism due to childcare needs.  

Don't forget that CMG will in itself 'flatten' absenteeism due to disease and the need to care for family.

(The full poster with the rest of the 'challenges and benefits of CMG can be downloaded here)



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
A Formal Response to Barry's and Osterholm's Critique of the Markel Study
http://www.cdc.gov/ncidod/dq/1...

A Commentary on the JAMA Study's Interpretation of the Influenza Experiences in New York City and Chicago, 1918-19
...

Recently, assertions were made on the internet challenging our interpretation of the historical record of New York City and Chicago during the 1918-19 pandemic. We therefore offer the following additional evidence to support our conclusion, and invite you to review the primary source documents linked to the endnotes of this commentary.

Among the assertions made are claims that our interpretation of data in New York City and Chicago is incorrect, and that such "putative errors" are sufficient to drop the findings below statistical significance.  This assertion, however, ignores our approach in doing robust statistical analysis using a comprehensive dataset.  Our comprehensive analysis of all 43 cities across the United States is far more robust than a disputed data point for a single city.  
...

Conclusion
The historical record is, by definition, incomplete and often fragmentary.  Indeed, scholars frequently disagree about interpretations and meanings of the past and a healthy exchange of ideas makes for a better understanding of the human condition.  While we make no claims to definitive conclusions about important questions raised by our paper, as scholars committed to scientific and historical inquiry, we insist on the rigor of peer-reviewed and evidence-based research to formally support or contradict any scientific study.

We hope that the additional historical insight and facts provided in this commentary clarify some of the misinformation that has recently been directed toward the study.  We stand by the conclusions made in our JAMA paper and are confident that a careful, scholarly reading and review of our work demonstrates the rigor with which the research was performed, especially given the constraints and limitations of investigating a pandemic that occurred nearly a century ago.

The long awaited response.  It looks like it was worth the wait.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


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