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Our ridiculous health care system, part 734

I went to get a coronavirus test today. We had to get the test for work, and I had no problem with that. What I did have a problem was with that, to get this test, I needed to make an appointment, fill out three forms and take an online “course” (clicking through a set of slides), print out two receipts, show up at the specified time and go through five different people checking these forms—first the security person at the campus building, then he points me to the person who asks me the time of my appointment and checks my form, then she sends me through the gate (I need my ID for that), then I walk down the hall and someone checks my form again and points me to another person who scans my form and sends me into a large empty room where another person is there to show me a form and give me a sticker, which I then bring to yet another person who takes the sticker and gives me a swab which I move around in my nostrils and put in a test tube. Then I can go.

Here’s the point. If it takes this much paperwork just to get a goddam test, then no wonder we as a country are having problems getting people the vaccine. The paperwork is out of control.

We’ve discussed this before.

P.S. My test results arrived the next day by email. To get to the results, I needed to create an account on some hospital system, enter my name, address, sex, and birthdate, supply a password and two ID questions, then click on two more link to get the actual results.

And here’s the jargon-laden lab report that I received:

Gelman, Andrew REQUISITION #
5O7ABT4MPAB8954 SEX
M D.O.B. **
ORDERING MD
** OFFICE ID
** COLLECTED DATE
1/4/2021 RESULTED DATE
1/5/2021
Description Value
Abnormal
Range Units
Covid19_Diagnostic
SARS-CoV2 Real-time Reverse Transcriptase (RT)-PCR Diagnostic Assay NEGATIVE Negative
2019-novel Coronavirus (2019-nCoV) not detected by the qRT-PCR assay. Consider testing for other respiratory viruses or re-collecting for 2019-nCoV testing. Note: Optimum timing for peak viral levels during infections caused by 2019-nCoV have not been determined. Collection of multiple specimens from the same patient may be necessary to detect the virus. Methods and Limitations: This Laboratory Developed Test is a high-throughput version of the CDC 2019-nCoV Realtime RT-PCR test and has been validated in accordance with the guidance issued by the College of American Pathologists (Mar 19, 2020) and the FDA (Feb 29th, 2020). This test has not been FDA cleared or approved but has been authorized by FDA under an EUA for this laboratory. This test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostic tests for detection and/or diagnosis of COVID-19 under Section 564(b)(1) of the Act, 21 U.S.C. 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. This test has been authorized only for the detection of nucleic acid from SARS-CoV-2, not for any other viruses or pathogens. The test was validated for use with respiratory specimens obtained via nasopharyngeal, oropharyngeal, or nasal swabs in liquid transport media or saline. Nasal swabs may also be sent dry. The performance of this test has not been established for other specimens. Specimens collected using other FDA recommended Specimen Collection Materials listed in the FDA COVID-19 Diagnostic Technologies communication (March 26, 2020) are processed with the caveat that they were not all validated for use with this test and the result must be interpreted in this context. Method: RNA is isolated from respiratory specimens in approved media using MagMAX-96 Viral RNA Isolation Kits (Thermo Fisher Scientific, AMB18365), is reverse transcribed to cDNA, and subsequently amplified in the Applied Biosystems ViiA7 Real-Time PCR Instrument. This system provides qualitative detection of nucleic acid from SARS-CoV-2. For more detailed information on the test methods and limitations see https://covid-19-test-info.broadinstitute.org/ Positive results are indicative of active infection with SARS-CoV-2 but do not rule out bacterial infection or co-infection with other viruses. The agent detected may not be the definite cause of disease. Negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. False negative results may occur if amplification inhibitors are present in the specimen or if inadequate numbers of organisms are present in the specimen due to improper collection, transportation, or handling. If the virus mutates in the RT-PCR target region, SARS-CoV-2 may not be detected or may be detected less predictably. Inhibitors or other types of interference may produce a false negative result. An interference study evaluating the effect of common cold medications was not performed.

Bureaucracy at its finest!

77 Comments

  1. RAD says:

    The first sentence is missing the word “test”. It should read “I went to get a coronavirus *test* today.”.

    Feel free to delete this comment.

  2. jimmy says:

    It also does not help when the people checking you in are too busy texting or playing on their cell phones.

  3. mp says:

    on the other hand, I got a test in the Seattle area a couple of days ago: drive to checkpoint, use phone to go to link/QR code, fill out simple form online, go through the (hellish, for me) experience of the nasal swab, get letter with QR code to check in a couple of days for results, done. results were available the day after. no appointment needed, documents asked but not required, most of the time (15min) was actually due to the line as it was a saturday. and I’ve never even left the car.

    so it is possible to be efficient at this. the line at the testing site seemed to me like proof people like this sort of thing but of course I don’t have the numbers.

  4. Southern Flagship says:

    For months now, faculty and staff at my public university have merely had to show up during daily windows (4 hour window, students have a separate window/testing site), show their ID, sign a piece of paper, and get a test. No appointment, results same- or next-day.

    There are American cities with walk-in testing as well.

    While the general point is well-taken, this seems to be a situation where Columbia, rather than the health care system writ large, is the issue. There are plenty of points of failure, but certain cities/universities are doing a much better job than others, despite facing common regulatory environments.

    And from reports of colleagues in Canada, Ireland, and the UK on the ease (or more accurately, nigh-impossibility) of getting testing, we’ve got it pretty good.

  5. Lizzie says:

    Isn’t that fun — you got a sticker! Too bad they took it away.

    The paperwork is one thing, but that’s also an impressive number of contacts you made to get tested for a highly transmissible virus.

  6. Adede says:

    I guess some of the paperwork is to prevent people “cheating” on the test (saying they are negative when they tested positive or just skipped the test). But I feel like the test is also kind of meaningless for the stated purpose (for work). Right after being tested, you could still end up getting infected and becoming a risk to others. So I don’t know what kind of decision they could reasonably make based on the results of the test.

    • As you may or may not know there are two primary types of tests. The PCR and the Antigen. If you have symptoms, it is recommended that you seek a PCR test. If asymptomatic, but want reassurance that you are not contagious, then consider the antigen test b/c that is a better indicator of whether you are contagious. PCR can register a positive result for several months, even after your ability to transmit the virus has passed.

      The key is frequent Antigen testing in order to prevent or reduce contagion.

      • Adede says:

        I can imagine frequent testing would help reduce contagion, but god have mercy on those forced to go through all that stuff on a frequent basis.

        • I sympathize. I am in the process of lobbying for FREE at home rapid antigen tests, which can be self administered in privacy. At this time, you can get the test in VA more easily than in DC. In DC my doctor is probably one of five or so that offers them. In VA, medicare recipients can get them at some clinics without cost I gather. Might be a co-pay.

          All of us have different assessments of contracting COVID19. I know of a case of a 73 year old person who had the mildest of symptoms. What good luck.

          We must encourage people to improve their immune functions. That may require some consequential changes to diet and exercise.

          In any case, I have spent about 6 months following the antigen test experts. I am quite sure that antigen testing can reduce transmission.

          • Adede says:

            Yes, regular testing is an important tool for reducing transmission, especially for essential workers. But for those who can do their job at home (e.g. statistics professors), I think a better use of resources (and more effective preventative measure) is to tell them to stay at home and not bother testing (unless they elect to because of some other unavoidable exposure).

            • Andrew says:

              Adede:

              To be fair, they’re only requiring this one test, and we do live in a university building. So that seems ok to me. I just wasn’t happy with the mountain of overhead. It didn’t personally inconvenience me, but it suggests a larger problem with timely and efficient health care delivery.

              • Adede says:

                Yeah, I can understand why it’s a small inconvenience for you, but if it’s just a one-off, then what’s the point? Multiply it by all the other people in the building (university?) and it’s a big waste.

          • rm bloom says:

            What are the basic dietary and exercise recommendations you make?

            • Chris Wilson says:

              Whatever is enough to wipe out mitochondrial dysfunction and restore metabolic health ;) But always allow enough rest and recovery- it is well known from athletes that sudden periods of notably higher training load temporarily suppress immunity.

              • To RM Bloom

                I have been researching diet and exercise regimes for at least 20 years. More recently, I became a vegan mostly. I have included canned salmon and mussels [once a week] which contain negligible saturated fat, a key factor in increasing risks of heart disease and stroke. I also exercise 5 or 6 times a week-an hour or so. I also take Vitamin D3, K2, C, and B vitamins. That’s about it.

                I did lose about 7 lbs within 3 months b/c much of my food intake is plant based [green vegetables and beans].

                Having unblocked arteries is crucial I would think. I follow Dean Ornish MD, Caldwell Esselstyn MD, and Mic the Vegan on Youtube. They have been able to improve the health of their patients remarkably.

                It is a lot of work to prepare vegan dishes. But you can make enough for several days.

  7. Anoneuoid says:

    Do they tell you the details of the test? Eg your ct value and the threshold used for a positive.

    • The physicians/patients do not have access to CT values nor the threshold used for a positive. There does seem to be some debate over the threshold used for a positive. Michael Mina an expert, who has commented on this blog, recommends a confirmatory antigen test manufactured by another company. Quidel and Abbott for example. What is of interest is whether you are contagious.

      There is immense controversy over the mass screening utility of PCR tests b/c you can test positive way after the transmissable period. Such debate is robust in England and among some European circles.

      I wasn’t aware of these antigen tests when I testified before the DC Council where I urged at school testing capacity. Testing is now feasible with these tests and even better if these antigen tests can be administered at home.

      Nor did I anticipate taking so much interest in COVID19 testing. I thank Michael Mina for that.

      I am focusing now on the strategy for testing here in DC. That is going to be a challenge.

  8. MJM-WA says:

    In addition to the Ct count, you should ask also how many of the (what I have read is typically) 3 gene sequences that the PCR test looks for your test identified? High Ct and/or low gene sequence count translates into false positive if positive.

    • I’m not the expert on COVID19. But I’m quite sure that at home Antigen test capacity will reduce/prevent transmission substantially. I would follow Michael Mina in particular who has a very astute Twitter following.

      https://twitter.com/michaelmina_lab

    • Joshua says:

      MJM –

      >…translates into false positive if positive…

      Could you explain what you mean by “false positive?”

      • Anoneuoid says:

        It can be observed that at Ct = 25, up to 70% of patients remain positive in culture and that at Ct = 30 this value drops to 20%. At Ct = 35, the value we used to report a positive result for PCR, <3% of cultures are positive.

        https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1491/5912603

        So cutoff of 25 yields ~30% false positives, 30 yields 80% false positives, and 35 yields 97%+ false positives.

        • Joshua says:

          Anoneuoid –

          So by your estimation, how any of the hospitalizatons, ICU admissions, and deaths thst were seeing are among people that would be testing as false positives in your estimation?

          Anyway, I don’t necessarily trust the source, but FWIW:

          https://gidmk.medium.com/most-positive-coronavirus-tests-are-true-positives-60c95fe54fec

          There are also other sources that I don’t necessarily trust.

          • Anoneuoid says:

            Id guess bad swabs and sample handling procedure are missing ~70% of samples with the rna in it and high ct threshold, contamination, etc means ~70% of the positive tests dont correspond to presence of infectious virus.

            Ie, these tests were never validated in any way under real life conditions and are a huge waste of time and resources.

            • Joshua says:

              And yet, everywhere that positive tests go up, so do hospitalizatons and deaths. When they go down, so does morbidity and mortality.

              I think repeats antigen tests are prolly a better surveillance methodology (but you pooh-poohed them as well IIRC), and obviously there’s a problem with people quarantining when they aren’t infectious, but none of that is mutually exclusive with them having some value.

              • Anoneuoid says:

                And yet, everywhere that positive tests go up, so do hospitalizatons and deaths. When they go down, so does morbidity and mortality.

                Yes, of course.

                1) The number of tests correlates well with the number of deaths. See page 4 here: https://www.docdroid.net/feKR1mg/covidstates-pdf

                R2 = 0.734 for total tests vs deaths by state and 0.774 for cases vs deaths. So there is some additional information from positive tests but not much.

                2) To get a false positive to begin with you need three things:

                i) Exposure to circulating virus sometime before the test, more recent the better
                ii) To run the test
                iii) To choose a low enough threshold

                As explained by the WHO the cycle thresholds are supposed to be manually adjusted based on how much virus is believed to be circulating;

                As with any diagnostic procedure, the positive and negative predictive values for the product in a given testing population are important to note. As the positivity rate for SARS-CoV-2 decreases, the positive predictive value also decreases. This means that the probability that a person who has a positive result (SARS-CoV-2 detected) is truly infected with SARS-CoV-2 decreases as positivity rate decreases, irrespective of the assay specificity.

                […]

                Users of RT-PCR reagents should read the IFU carefully to determine if manual adjustment of the PCR positivity threshold is necessary to account for any background noise which may lead to a specimen with a high cycle threshold (Ct) value result being interpreted as a positive result… In some cases, the IFU will state that the cut-off should be manually adjusted to ensure that specimens with high Ct values are not incorrectly assigned SARS-CoV-2 detected due to background noise.

                https://www.who.int/news/item/14-12-2020-who-information-notice-for-ivd-users

                So when it is believed there is little virus circulating, they are supposed to lower the threshold (make it less sensitive). When there are many, they are supposed to raise it (make it more sensitive). How much this actually happens is apparently protected by licensing agreements though so we have no idea.

                Anyway, if virus is circulating the chance of a positive test goes up for those reasons. That doesn’t tell us about an individual test result though.

                Then there is also the problem with how they have been treating people that test positive.

                1) “Early intubation” as was originally recommended by the WHO was responsible for the huge number of deaths in March-May focused in NYC. You can see this on page 2 of that pdf. Nothing like that has been repeated anywhere. It seems to have been responsible for 5x higher mortality than necessary early on, but we have no idea if it is still being done in some hospitals. I’d guess at least 50k and maybe up to 150k extra deaths due to this.

                2) Giving very high doses of HCQ to ~70% of the hospitalized patients that test positive. By the time they are in the hospital most have already cleared the virus so it has no expected benefit. However, it is expected to act as a pro-oxidant that causes methemoglinemia, and moreso if the patient is already experiencing elevated oxidative stress. This is commonly seen in covid patients… when they actually checked for it.

                Coronavirus disease 2019 (COVID‐19) has been associated with a range of hematologic findings and complications [1]. We have encountered three cases of significant methemoglobinemia, and five cases of relatively mild methemoglobinemia, among patients being treated for COVID‐19 in our health system during a 4 week period in April 2020. For comparison, there was only one case of mild acquired methemoglobinemia of any cause documented in our health system during the preceding year. Below we describe the three cases of significant methemoglobinemia, including their presentations, treatments, and outcomes

                […]

                The diagnosis of methemoglobinemia is seldom thought of given its rarity, and thus may remain underdiagnosed during the COVID‐19 pandemic. The typical presentation consists of abrupt symptoms of tissue hypoxia following exposure to an oxidizing substance. Notably, as this is a condition of increased heme‐oxygen avidity rather than hypoxemia, dissolved oxygen levels on blood gas may be normal in spite of clinical evidence of hypoxia and decreased readings on pulse oximetry. A high index of suspicion is thus required and diagnosis is most often made on co‐oximetry or specific blood Met‐Hb assay.

                https://onlinelibrary.wiley.com/doi/full/10.1002/ajh.25868

                A probable reason for hypoxia in COVID-19 patients is methemoglobinemia which results from oxidation of the iron contained in hemoglobin from the ferrous to the ferric form. The oxidation is associated with a decrement in the capacity of hemoglobin to carry oxygen (Hamidi Alamdari et al., 2020).

                […]
                [Table 1 and 2 show very high levels of methemoglobin in covid patients]

                Preliminary results of this clinical trial showed the treatment of severe COVID-19 with a mixture of MB, vitamin C, and N-acetyl Cysteine is safe and feasible. The reduced MB has rapid and delayed effects. The rapid effect increases the SPO2% (All patients have been received 100% oxygen) by reducing met-Hb. Delayed effects are through the acceleration of normally slow NADPH–methemoglobin reductase, the improvement of inflammatory markers such as CRP level and LDH, decreasing severity of disease that may be also due to antimicrobial effect. We suggest the optimal time of reduced methylene blue (LMB) administration should be before entering the patient to a very severe stage of the disease and multi-organ involvement and failure. It is the opinion of the authors that the observed results if verified in more patients and a randomized multicenter clinical trial could significantly reduce the mortality of COVID-19 infection and ICU stay average length.

                https://linkinghub.elsevier.com/retrieve/pii/S0014299920305860

                Treatment for methemoglobinemia with intravenous methylene blue is recommended if the blood methemoglobin level is >20%–30%. However, in G6DP deficiency, treatment with methylene blue is contraindicated because the reduction of methemoglobin is NADPH dependent. This finding might precipitate intravascular hemolysis and therapy with ascorbic acid or supportive treatment with oxygen as indicated instead.

                https://wwwnc.cdc.gov/eid/article/26/9/20-2353_article

                Treatment with chloroquine was started consisting of a first dose of 600 mg, followed by 300 mg twice a day (for 5 days).1 Initial ICU laboratory results demonstrated a hemoglobin level of 11.4 g/dL (reference 13.7‐17.7 g/dL), 12 hours later his hemoglobin level dropped to 8.9 g/dL and additional laboratory investigations demonstrated signs of severe hemolysis. A peripheral blood smear revealed findings consistent with hemolysis (Figure 1). Arterial blood gas results demonstrated increased levels of methemoglobin (9.1%; reference <1.5%). Given his ethnic background (African‐Caribbean), glucose‐6‐phospate dehydrogenase (G6PD) deficiency was suspected and chloroquine was stopped.3 He received 3 units of packed red blood cells in the following 48 hours. Although his methemoglobin level was relatively low, 1000 mg ascorbic acid (vitamin C) was administered intravenously four times a day for 2 days, to help optimize his oxygenation. His methemoglobin normalized within 6 days and laboratory testing for G6PD deficiency confirmed very low G6PD activity in the patientʼs red blood cells (Figure 1A,B). Genetic analysis demonstrated variant G6PD A‐ (the African variant).

                https://onlinelibrary.wiley.com/doi/full/10.1002/ajh.25862

                Misuse of excessive and late HCQ has probably resulted in ~10% additional mortality (~30k deaths):

                No association was apparent when only pooling the 4 RCTs (13.8% of the overall weight; pooled risk ratio: 1.11, 95%CI: 0.99 to 1.24).

                https://www.medrxiv.org/content/10.1101/2020.11.01.20223958v1.full

                3) Increased stress due to the media hysteria, lockdowns, loss of job, change in exercise/diet, etc. Watching the world cup has been estimated to increase heart attack rates by 2-3x: https://www.nejm.org/doi/full/10.1056/NEJMoa0707427

                About 800k heart attacks in the US yearly and about 15% of heart attacks result in death. Thus we could plausibly expect up to 100k additional cardiac related deaths due to increased stress.

                https://www.cdc.gov/heartdisease/facts.htm

                We see about 11% of covid deaths involved cardiac arrest, 7% arrhythmia, and 7% heart failure. The data does not tell us about the overlap so somewhere between 11 and 25% of the deaths were cardiac related, or 35-80k deaths.
                https://data.cdc.gov/NCHS/Conditions-contributing-to-deaths-involving-corona/hk9y-quqm

                4) Another thing mentioned early on that has never been dealt with is that these patients show up at the hospital after being oxygen deficient for days then they suddenly blast them with oxygen. This would be expected to lead to a kind of reperfusion injury, but I have never seen it discussed since this:

                Pulmonary oxygen toxicity: It appears that some COVID-19 patients’ symptoms worsened after being given pure oxygen. Although little is known about an increased pulmonary sensitivity to oxygen, the report suggests it would be ‘prudent’ to avoid technical diving involving the prolonged breathing of hyperoxic gas with a pO2 of 1.3 ATA or higher. Simple nitrox diving (maximum pO2 of 1.4 ATA) should not present any problem.

                http://divemagazine.co.uk/skills/8907-serious-problems-diving-after-covid19

                I have no idea how many patients that tested positive have been harmed due to that standard of care. But anyway I would guess around half the covid deaths were due to actively harmful interventions that would have been different if not for the positive test.

              • Joshua says:

                Your logic is fundamentally flawed. You argue as if people are hospitized simply because they are tested, or test positive.

                Your logic fits in with the Trump logic that we have more cases in this country because we’re testing so much.

                A similarly flawed logic as there’s a basic disconnect because our relative standing in cases per capita doesn’t match our relative standing in testing per capita.

                There are many other countries which are similar in that regard. It doesn’t necessarily follow that only where positive tests are high, are infections, hoapitizarions, and deaths high.

                And it certainly doesn’t follow that where testing is high, positive tests are high, or that where testing is high, deaths are high.

                But where positive tests are high, morbidity and mortality are high.

                Have you ever looked at Hill’s criteria for causation?

              • Joshua says:

                > But anyway I would guess around half the covid deaths were due to actively harmful interventions that would have been different if not for the positive test.

                Chances are (imo) you have the direction of cauality backwards.

              • Joshua says:

                > 3) Increased stress due to the media hysteria, lockdowns, loss of job, change in exercise/diet, etc.

                I’d say you likely have the direction of cauality backwards there as well. Although, maybe it’s just that you’re assuming too much cauality in one direction only. Life is messy. Cauality is hard.

              • Joshua says:

                For example, Iceland = 12th in tests per capita, 80th in cases per capita, and 107th in deaths per capita. There are plenty of similar examples.

              • Anoneuoid says:

                Your logic is fundamentally flawed. You argue as if people are hospitized simply because they are tested, or test positive.

                Nope, I argue that positive tests are correlated with circulating virus but a positive test does not indicate any given individual is likely to currently have infectious virus. Your logic is fundamentally flawed. Specifically, it is a form of this fallacy: https://en.wikipedia.org/wiki/Ecological_fallacy

                The second argument was that patients have been treated differently if they are said to have covid (early intubation, high dose HCQ, etc), which is obviously true.

                The third argument is that many factors long known to increase stress and mortality rates have been introduced, but are now ignored when looking at covid mortality.

                Perhaps a more careful analysis would show these other factors in mortality are not as large as I guess. But so far I have seen zero publications on the topic. Basically, all those factors are assumed zero.

              • Joshua says:

                > Nope, I argue that positive tests are correlated with circulating virus but a positive test does not indicate any given individual is likely to currently have infectious virus.

                There are clearly problems w/ using the PCR tests as public surveillance for infectiousness. It’s the wrong test for ghat. Mina has discussed that extensively.

                But you go way beyond that, for example her

                > But anyway I would guess around half the covid deaths were due to actively harmful interventions that would have been different if not for the positive test.

                Where you draw a direct line to 50% of deaths from PCR testing. There are MANY examples to falsify that thinking, and numerous flaws in the logic

              • Anoneuoid says:

                Where you draw a direct line to 50% of deaths from PCR testing. There are MANY examples to falsify that thinking, and numerous flaws in the logic

                Please explain why nothing like what happened in NYC has been seen anywhere else in the US once widespread early intubation was stopped. A practice that is now widely accepted to be a bad idea due to the very high mortality rates:

                Patients were admitted to any of 12 Northwell Health acute care hospitals between March 1, 2020, and April 4, 2020, inclusive of those dates. Clinical outcomes were monitored until April 4, 2020, the final date of follow-up.

                […]

                Mortality rates for those who received mechanical ventilation in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%, respectively. Mortality rates for those in the 18-to-65 and older-than-65 age groups who did not receive mechanical ventilation were 1.98% and 26.6%, respectively.

                https://jamanetwork.com/journals/jama/fullarticle/2765184

                Please explain how giving very high doses of a pro-oxidant like HCQ that causes methemoglobinemia to patients with elevated oxidative stress (then not monitoring methemoglibin levels) will *not* harm patients.

                Please explain why stress is no longer a risk factor for early mortality.

                Because you assume all those factors are zero. I say they could account for up to 50% of the excess mortality.

              • Anoneuoid says:

                Discussion of early intubation from December 19:
                https://rebelem.com/rebel-cast-ep93-covid-19-a-follow-up-on-not-intubating-early-and-ardsnet/

                They mention in April 50% of covid patients were intubated early, in July it had dropped to 16%.

              • Joshua says:

                Anoneuoid –

                > Please explain why nothing like what happened in NYC has been seen anywhere else in the US once widespread early intubation was stopped. A practice that is now widely accepted to be a bad idea due to the very high mortality rates:

                >> Because you assume all those factors are zero.

                No, I don’t “assume all those factors are zero.”

                I don’t doubt that intubation procedures or other treatments in NYC early on may have caused some mortality in people who wouldn’t have died otherwise. But how many deaths that may be true of, is obviously a very tough thing to figure out. Not something that should, IMO, be the subject of reverse engineering over the Interwebs.

                But the notion that people would have survived if they hadn’t been tested and found to falsely be positive?

                > I say they could account for up to 50% of the excess mortality.

                Which, of course, is a different argument than saying that people died because of false positives. Which was my point.

              • Anoneuoid says:

                A positive test meant you get early intubation and high dose HCQ. Also probably treated different in other ways too, but those are two big ones we know.

                Without the positive test, the patients would not have undergone these dangerous interventions.

                That is how you get increased mortality in patients with false positive tests. It, of course, also increased the mortality in people with true positive tests.

              • Joshua says:

                > A positive test meant you get early intubation and high dose HCQ.

                ??

                So you’re saying that they intubated and loaded up the HCQ with everyone with a positive test, irrespective of how they presented? You’re saying that they didn’t decide to intubate or load up with HCQ only those patients we presented as severely ill, and quite likely to die regardless?

                You’re assigning causality to “false” positive tests?

              • Anoneuoid says:

                So you’re saying that they intubated and loaded up the HCQ with everyone with a positive test, irrespective of how they presented?

                Obviously not, that is a strawman you made up in your own head. Anyway, I took the effort to present the data and reasoning. The info is there for people who are actually interested to investigate for themselves.

              • Joshua says:

                You said this:

                > > A positive test meant you get early intubation and high dose HCQ.

                So I asked you whether you’re saying that they intubated and loaded up the HCQ with everyone with a positive test, irrespective of how they presented?

                And you responded:

                >> Obviously not, that is a strawman you made up in your own head.

                I don’t know how to interpret “A positive test meant you get early intubation and high dose HCQ,” other than saying that they intubated and loaded you up with HCQ everyone because of getting positive test (some % of which might have been false positives).

                I mean perhaps you’re saying that if you were gasping terribly for air and displaying other obvious signs of COVID, and you tested negative, they didn’t intubate and/or give you HCQ, but my guess that in such a case they’d assume a false negative and treat you pretty much the same anyway.

                What you’re saying is only that much more confusing because early on, IIRC, even in hospital settings, it took a while to get test results back. My sense is that many people were treated under the heading of “presumed positive” (or something like that).

                Now I honestly can’t tell what your argument is if it isn’t attributing deaths to (false) positive tests.

                I don’t doubt that mistakes were made and I (think I) get that you’re talking about how patients were treated early on in NYC presumably because you thought you knew better than doctors on the ground treating people.

                But at any rate, irrespective how they treated patients early on in NYC, that would only apply to a relatively small % of cases overall. And further, you aren’t responding to this:

                >> > And we can see this incredible accuracy happening in real life. In Australia, despite hundreds of thousands of tests conducted every week, there are vanishingly few positive results. In New South Wales, the state that I live in, we conduct more than 115,000 tests every week with <40 positive results. Even if every one of those were a false positive, the false positive rate would still be less than a fraction of 0.1%.

              • Joshua says:

                Anoneuoid –

                Once again, I think that you and I probably agree that the PCR test is ill-suited as a public health surveillance tool in the context of the active COVID pandemic. No doubt, as Mina has talked about consistently, repeated antigen tests would be a better tool for assessing infectiousness on a population-wide basis.

                That said, you still seem to be (from what I can tell) pushing an illogical argument – that many people died because of poor standards of care, that were administered only based on an inclusion criterion of a (in most cases falsely) positive PCR test.

                You have provided zero evidence to support that claim. You have provided indirect evidence that some of the standards of care, early in, may have done more harm than good. But you haven’t shown that those procedures differentially caused deaths in people who wouldn’t have died regardless. I don’t doubt that for some percentage of those who were ill early on, the care administered might havs done more harm than good, but trying to infer what % that is, should only be done, imo, with comprehensive and high quality evidence of a sort we don’t have. Reverse engineering to estimate %’s over the Interwebs seems to me like an open invitation for confirmation bias. Further, you have provided zero evidence that people were administered ill-advised treatments solely or even presomnarky because of (in most cases falsely) positive PCR tests, as opposed to how they presented based on myriad metrics and symptoms.

            • Joshua says:

              > And we can see this incredible accuracy happening in real life. In Australia, despite hundreds of thousands of tests conducted every week, there are vanishingly few positive results. In New South Wales, the state that I live in, we conduct more than 115,000 tests every week with <40 positive results. Even if every one of those were a false positive, the false positive rate would still be less than a fraction of 0.1%.

              • Anonymous says:

                You’re missing the gist of his argument, which is that the excessive deaths (and the rest of the troubles too) are entirely a consequence of his advisement being scandalously ignored.

              • Anoneuoid says:

                You’re missing the gist of his argument, which is that the excessive deaths (and the rest of the troubles too) are entirely a consequence of his advisement being scandalously ignored.

                I don’t expect anyone to listen to me. But just take a look around you… Look how great things are going listening to the same people who keep figuring out obvious stuff months later than necessary.

                You will just keep listening to the same wrong people.

              • Anonymous says:

                Anon: “I don’t expect anyone to listen to me. But just take a look around you… Look how great things are going listening to the same people who keep figuring out obvious stuff months later than necessary.”

                Things are not going “great” at all. But that is not a proof that someone else knows a better way. The muddling of many is not a proof of the omniscience of a few.

                “You will just keep listening to the same wrong people.”

                Ditto

              • Anoneuoid says:

                But that is not a proof that someone else knows a better way.

                Correct, the proof someone knows a better way is correct predictions. Historically these are best arrived at by using science, ie generalizing using reason and evidence. It has a long history of success applied to many diverse endeavors.

                That is what I use.

              • Anonymous says:

                Anon: “Correct, the proof someone knows a better way is correct predictions. Historically these are best arrived at by using science, ie generalizing using reason and evidence. It has a long history of success applied to many diverse endeavors.

                That is what I use.”

                And it goes without saying that *you* have found the better way, doesn’t it?

              • Anoneuoid says:

                Yes, science is better than brute force trial and error (EBM). I didn’t find it though, it has been known for a long time.

                How about this? When someone has a vitamin deficiency, give them enough vitamins to stop the deficiency. To me this is as obvious as solving a puzzle by putting a square plug in a square hole and a round plug in round hole, whether the square/circle is blue or red makes no difference.

                The people making decisions this entire pandemic with EBM can’t seem to figure that one out though.

              • Joshua says:

                Anoneuoid –

                > the proof someone knows a better way is correct predictions

                >> That is what I use.

                How any false positives will there be in 115,000 tests a week? Can you give us a prediction?

                Don’t forget, you’re on record.

              • Anoneuoid says:

                By asking that question, it is obvious you haven’t managed to assimilate anything I took the time to explain.

                Anyway, too many low effort posts in response to my high effort one here. Moving on.

              • Joshua says:

                Anoneuid –

                > By asking that question, it is obvious you haven’t managed to assimilate anything I took the time to explain.

                Indeed. A teacher can often see a student’s misunderstanding based on the questions the student asks.

                I’m sorry I’m not smarter and can’t “assimilate” your wisdom more easily.

                It looked to me like you were arguing that it is inevitable that with a high number of tests there will necessarily be a high number of false positives.

                I know that its a strain for you to explain your high-level reasoning to someone with such limited ability as mine to “assimilate,” but I’d appreciate it if you could try once more to explain why my understanding is wrong – rather than just embarrassing me by pointing out how truly limited I am.

                Why isn’t the high number of tests in Austria with so few positives (let alone false positives) problematic to your argument? Are you agreeing that there is no reason to think that the PCR tests necessarily produce a high % of false positives?

                Are you saying that if a lot of tests are given then won’t necessarily produce a lot of false positives, but if there are a lot of positive results a high % of them will necessarily be false positives?

                I’ve asked you to address the question regarding the outcomes in Australia a testing a number of times and I can’t help but notice you provided no direct answer.

                Think of me as a student asking a mentor for guidance.

              • Anoneuoid says:

                your high-level reasoning

                Even if you ignore what I said, here is a thread you posted over 20 times on explaining one reason your question makes no sense:

                https://statmodeling.stat.columbia.edu/2020/12/15/literally-a-textbook-problem-if-you-get-a-positive-covid-test-how-likely-is-it-that-its-a-false-positive/

                Anyway, I gain little from repeating myself when the responses just keep repeating well known logical fallacies. Tldr, the false positive rate depends on the level of circulating virus for multiple reasons.

              • Joshua says:

                Anoneuoid –

                > Anyway, I gain little from repeating myself when the responses just keep repeating well known logical fallacies.

                Which “fallacy” do I keep repeating? Explain it to me. The base rate fallacy? How?

                > Tldr, the false positive rate depends on the level of circulating virus for multiple reasons

                I’ve don’t dispute that. Sure, the base rate affects the probability of a positive result being a false positive result. How does anything I said “repeat” that fallacy? Explain it to me.

                You don’t explain, but even if true (I’d like an explanation for how it’s true) that doesn’t justify claims that (1 ) the PCR test is useless or harmful or effective in balance, or (2) a lot of people died because they (falsely or otherwise) tested positive.

                That’s quite a claim on your part.

                Why do you repeatedly not answer the questions that I ask you? Why don’t you address the points thet I made? I keep asking you to justify your claims that people died BECAUSE they (falsely) tested positive.

              • Joshua says:

                And keep in mind, early on in NYC the only people getting tested (and almost certainly those who were intubated) were those who were very symptomatic, presenting symptoms strongly associated with COVID. Anyone else was sent home without even getting tested. So the base rate among those who were tested early on was probably quite high. Certainly among those who were tested and then intubated.

                Do you seriously believe that people who weren’t suffering severe COVID symptoms were just intubated regardless symptoms, just because they tested positive? Is that what you’re arguing? If not, how do you determine cauality to their deaths from the fact of (falsely) testing positive? I keep asking you this but you don’t answer. Even if I repeatedly misunderstand the base rate fallacy, it’s becoming curious that you don’t address that question.

              • Anoneuoid says:

                How any false positives will there be in 115,000 tests a week? Can you give us a prediction?

                Don’t forget, you’re on record.

                Which “fallacy” do I keep repeating? Explain it to me. The base rate fallacy? How?

                > Tldr, the false positive rate depends on the level of circulating virus for multiple reasons

                I’ve don’t dispute that. Sure, the base rate affects the probability of a positive result being a false positive result. How does anything I said “repeat” that fallacy? Explain it to me.

                Yet you want someone to predict the false positive rate given only number of tests… Your posts amount to:

                4 + x = y

                If you are so smart why cant you tell us why y equals?

                The other fallacy you keep repeating is the ecological fallacy. Ok, really leaving it at that. Responding is simply not productive.

              • Anoneuoid says:

                typo: *what* y equals

              • Joshua says:

                Anoneuoid –

                > Yet you want someone to predict the false positive rate given only number of tests…

                Well, you were repeatedly also given the number of positive tests among the total number of tests, even if not when I repeated the question that time. Here, I’ll give it to you again:

                >> > And we can see this incredible accuracy happening in real life. In Australia, despite hundreds of thousands of tests conducted every week, there are vanishingly few positive results. In New South Wales, the state that I live in, we conduct more than 115,000 tests every week with <40 positive results. Even if every one of those were a false positive, the false positive rate would still be less than a fraction of 0.1%.

              • Joshua says:

                Anoneuoid –

                > The other fallacy you keep repeating is the ecological fallacy.

                Yes, that’s the second time you’ve said that. But you haven’t explained in context how what I’ve said embodies that fallacy. How am I going to learn if you don’t explain that to me.

                Also, are you ever going to explain how you justify the claim that people died merely as a result of (falsely) testing positive? You repeatedly respond on other points but never on that one (at least that I can tell in my limited capacity).

  9. Michael Nelson says:

    Everybody always complains about the weather, but nobody ever does anything about it.

  10. Not Trampis says:

    I encountered two problems down under
    first was they assumed I had a smart phone. We went straight to paper once this was settled.
    the second was it took some ten attempts until they successfully put the damn thing down my throat. It hurt my nose as well.

    It doesn’t cost us at all here

  11. Joshua says:

    Andrew –

    > Here’s the point. If it takes this much paperwork just to get a goddam test, then no wonder we as a country are having problems getting people the vaccine. The paperwork is out of control.

    Do you have any idea why you went through that seemingly redundant process? Do you know the reason for the series of form-checks?

    I’m not sure I get why you’re linking the redundancy of that process you went through to the vaccine inefficiencies. For one thing, it seems that many other countries where processes are presumably different are also having inefficienncies in rolling out vaccines. Do you have reason to think that paperwork or other procedural redundancies are the reason why arm sticks haven’t happened as quickly as promised?

    • Andrew says:

      Joshua:

      I don’t really know. It just seems that if they have this many layers of paperwork for a test, I’d expect just as much for a new vaccine. I don’t claim that U.S.-style paperwork is the source of vaccine difficulties; rather, if there are vaccine difficulties, I’d expect U.S.-styule paperwork to make everything that much worse.

    • jim says:

      “countries where processes are presumably different “

      I don’t think it’s correct to say the “processes” are different. It’s probably more accurate to say the *pathways* are different. The *processes* is everywhere the same exercise in bureaucratic stupidity and inefficiency.

      WRT the vax rollout, here in our state they’re now squawking that they just don’t have enough $$$ to roll out, as though they didn’t know this was coming. Fortunately for my portfolio the tech horde has already cashed in by building hundreds of stupid case count dashboard websites for states, cities, counties, ferry systems, school systems, universities, colleges, fire districts, park districts…yada yada yada

      • Joshua says:

        The point being?

        Shit’s hard. Yes bureaucracies are imperfect. Have you checked out the private sector lately? Remember when Trump was the only one who could fix it because he’s used to having “skin in the game?”

        I’d imagine that a lot of the redundancies are because it’s complicated, people make mistakes and it’s at least partially a way to ensure against catastrophic errors. Like when you’re asked ten times what your name is and why you’re in the hospital when you’re there for surgery. Mix in the problems from infectiousness.

        That’s not an excuse, but I just think there is an old man yelling at clouds element here.

        • Joshua says:

          Just saw a related clip on CNN.

          In Florida, seniors are camping out overnight to get vaccines. Governor asked why, he said because the hospitals announced first come first served distribution policy and the state government isn’t equipped to design a process for distributing vaccines.

          Yeah, unintended consequences exist. I wonder how well vaccine distribution is going in Somalia?

        • jim says:

          “Yes bureaucracies are imperfect.”

          The reason the bureaucracy needs five signatures is that the government provides a high level of safety for incompetent people. All problems are hard for people who don’t have the tools to solve them.

          • Anonymous says:

            It also provides for you your roads, your sewers, your air-traffic control; your police, your fire, your emergency services; it provides the army, air-force, the marines; in case you’ve got an earthquake, the national guard should show up and build field hospitals (why they’re not doing that right now is a question of command not of mission). The 8086 architecture on your crappy computer was paid for by the pentagon by the way. But this is all too much of a cliche isn’t it? Go live in a hole or a cave if you like. The rest of us don’t get by by bluster and bluff. Whether we get along or not — like New Yorkers we have to make the effort. A very long time ago it was discovered that trade could not occur without what they called the “King’s Peace” running through the land; and across the sea as well. There is *no* commerce that can be conducted when every local feudal potentate extracts a toll on his half-mile of dirt-track. It is so ancient a lesson perhaps it’s so taken for granted that “libertarians” like yourself, who imagine that your well-being lands in your basket merely by reflection of the force of your solitary will power and no one else’s? Nothing — not a thing — can be traded or contracted for absent the expectation that a contract is an enforceable instrument, no less powerful than the sword; whether for a basket of eggs, or a Boeing 777, is solid and who do you suppose ensures that is the case? Or should it be left to the kin, the hillbilly Hatfields, and the blood-feud to straighten out every disagreement in law, custom, egress, contract? It’s a big country and it’s still possible to go find a whole-in-the-ground and sit there, stewing over the slight of having being forced to live in consensus with others.

  12. Chebyshev says:

    Sounds like bootcamp, with a steady dose of discomfort and humiliation (presumed sick). For the greater good though – will lead to a more compliant society.

    • Anoneuoid says:

      It could be worse.

      I worked at a federal facility when they tried to switch over to new IDs. You had to go to three different buildings for various paperwork then at the end there was a nearly half mile long line to get the photo taken. The line seemed to move slowly but it turned out that was just people giving up and going back to work. I saw at the photo station the workers were just staring at their shoes not doing anything. Not chatting or reading, just literally doing nothing.

      By the time I left a few years later the process still had not completed.

  13. Andre says:

    Ha.

    My last doc outside the US, is saw a cardio in Mexico. They gave me a cardiac ultrasound, sent me the images via WhatsApp, and didn’t even charge me for the appointment. I didn’t just walk out, too. I asked to pay for the appointment.

    I asked for imaging work done at a previous hospital visit in the US and I had to sign off and go to some basement room in a hospital outside Detroit to get the image on CD, which I can’t even do anything with anymore. Just email it to me, I consent to you all looking at images of my heart. I could care less.

    I asked for an HIV test at a clinic last summer, which I do regularly as I would a physical, or any responsible sexually active person should do. The clinic said no, we don’t allow you to get an HIV test if you’re experiencing symptoms. One, that’s ridiculous. Two, it’s an immune system issue. Literally anything could be a symptom of HIV. A rash, a sinus infection that won’t go away. There’s a clinics in China and Thailand that will test you same day. Same with Mexico, no questions asked.

    US healthcare system is ridiculous.

    I don’t even have health insurance here anymore, so I can’t see a doc. Had to get meds and the NP, who’s not even in the same state as me, was sympathetic enough not to charge me for the appointment.

    I don’t know. WRT to covid, I mean, I’d quarantine if I had symptoms, and obviously get tested if I travel anywhere, but I need to see a doctor for other reasons. Can’t do that in the USA because of no insurance, and lack of money.

    I can apply for Medicaid but in guessing that’s another 8 months out just waiting on paper work for a shit doc. I’d rather just move than deal with it. It’s not even worth it.

    Why would I stay here?

  14. Shravan says:

    I had to go to emergency here in Berlin last week due to a dialysis related issue. They were pretty well organized. There are different entrances for corona-suspected and other patients. They did a fast test (15 mins) before doing anything else. I was amazed. The last time i landed in emergency in March, also unrelated to corona, they did a test, waited five days, then told me, sorry we lost the swab. It was another 5 days plus a weekend before the results ccame in.

  15. David Marcus says:

    Cambridge MA is offering testing. You don’t have to be a resident (I live in Somerville MA). You don’t need an appointment, but if you have one, you can skip the line. The line moves quickly; last time I was tested, I waited in line half an hour. I got the results within a day.

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