During a COVID-19 Surge, ‘Crisis Standards of Care’ Involve Excruciating Choices and Impossible Ethical Decisions for Hospital Staff

Yves here. IM Doc has been sending us grim accounts from his hospital. Yesterday he was the only MD in the ER, with one nurse, and a massive influx of cases. The hospital is not overloaded but the price has been the ER becoming a war zone.

By Matthew Wynia, Director of the Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus. Originally published at The Conversation

As the omicron variant brings a new wave of uncertainty and fear, I can’t help reflecting back to March 2020, when people in health care across the U.S. watched in horror as COVID-19 swamped New York City.

Hospitals were overflowing with sick and dying patients, while ventilators and personal protective equipment were in short supply. Patients sat for hours or days in ambulances and hallways, waiting for a hospital bed to open up. Some never made it to the intensive care unit bed they needed.

I’m an infectious disease specialist and bioethicist at the University of Colorado’s Anschutz Medical Campus. I worked with a team nonstop from March into June 2020, helping my hospital and state get ready for the massive influx of COVID-19 cases we expected might inundate our health care system.

When health systems are moving toward crisis conditions, the first steps we take are to do all we can to conserve and reallocate scarce resources. Hoping to keep delivering quality care – despite shortages of space, staff and stuff – we do things like canceling elective surgeries, moving surgical staff to inpatient units to provide care and holding patients in the emergency department when the hospital is full. These are called “contingency” measures. Though they can be inconvenient for patients, we hope patients won’t be harmed by them.

But when a crisis escalates to the point that we simply can’t provide necessary services to everyone who needs them, we are forced to perform crisis triage. At that point, the care provided to some patients is admittedly less than high quality – sometimes much less.

The care provided under such extreme levels of resource shortages is called “crisis standards of care.” Crisis standards can impact the use of any type of resource that is in extremely short supply, from staff (like nurses or respiratory therapists) to stuff (like ventilators or N95 masks) to space (like ICU beds).

And because the care we can provide during crisis standards is much lower than normal quality for some patients, the process is supposed to be fully transparent and formally allowed by the state.

What Triage Looks Like in Practice

In the spring of 2020, our plans assumed the worst – that we wouldn’t have enough ventilators for all the people who would surely die without one. So we focused on how to make ethical determinations about who should get the last ventilator, as though any decision like that could be ethical.

But one key fact about triage is that it’s not something you decide to do or not. If you don’t do it, then you are deciding to behave as if things are normal, and when you run out of ventilators, the next person to come along doesn’t get one. That’s still a form of triage.

Now imagine that all the ventilators are taken and the next person who needs one is a young woman with a complication delivering her baby.

That’s what we had to talk about in early 2020. My colleagues and I didn’t sleep much.

To avoid that scenario, our hospital and many others proposed using a scoring system that counts up how many of a patient’s organs are failing and how badly. That’s because people with multiple organs failing aren’t as likely to survive, which means they shouldn’t be given the last ventilator if someone with better odds also needs it.

Fortunately, before we had to use this triage system that spring, we got a reprieve. Mask-wearing, social distancing and business closures went into effect, and they worked. We bent the curve. In April 2020, Colorado had some days with almost 1,000 COVID-19 cases per day. But by early June, our daily case rates were in the low 100s. COVID-19 cases would surge back in August as those measures were relaxed, of course. And Colorado’s surge in December 2020 was especially severe, but we subdued these subsequent waves with the same basic public health measures.

Number of COVID-19 patients hospitalized from Feb. 24, 2020 to Dec. 20, 2021. Our World in Data.org, CC BY

And then what at the time felt like a miracle happened: A safe and effective vaccine became available. First it was just for people at highest risk, but then it became available for all adults by later in the spring of 2021. We were just over one year into the pandemic, and people felt like the end was in sight. So masks went by the wayside.

Too soon, it turned out.

A Haunting Reminder of 2020

Now, in December 2021 here in Colorado, hospitals are filled to the brim again. Some have even been over 100% capacity recently, and a third of the hospitals expect ICU bed shortages during the last weeks of 2021. The best estimate is that by the end of the month we’ll be overflowing and ICU beds will run out statewide.

But today, some members of the public have little patience for wearing masks or avoiding big crowds. People who’ve been vaccinated don’t think it’s fair they should be forced to cancel holiday plans, when over 80% of the people hospitalized for COVID-19 are the unvaccinated. And those who aren’t vaccinated … well, many seem to believe they just aren’t at risk, which couldn’t be further from the truth.

So, hospitals around our state are yet again facing triage-like decisions on a daily basis.

In a few important ways, the situation has changed. Today, our hospitals have plenty of ventilators, but not enough staff to run them. Stress and burnout are taking their toll.

So, those of us in the health care system are hitting our breaking point again. And when hospitals are full, we are forced into making triage decisions.

Ethical Dilemmas and Painful Conversations

Our health system in Colorado is now assuming that by the end of December, we could be 10% over capacity across all our hospitals, in both intensive care units and regular floors. In early 2020, we were looking for the patients who would die with or without a ventilator in order to preserve the ventilator; today, our planning team is looking for people who might survive outside of the ICU. And because those patients will need a bed on the main floors, we are also forced to find people on hospital floor beds who could be sent home early, even though that might not be as safe as we’d like.

For instance, take a patient who has diabetic ketoacidosis, or DKA – extremely high blood sugar with fluid and electrolyte disturbances. DKA is dangerous and typically requires admission to an ICU for a continuous infusion of insulin. But patients with DKA only rarely end up requiring mechanical ventilation. So, under crisis triage circumstances, we might move them to hospital floor beds to free up some ICU beds for very sick COVID-19 patients.

But where are we going to get regular hospital rooms for these patients with DKA, since those are full too? Here’s what we might do: People with serious infections due to IV drug use are regularly kept in the hospital while they receive long courses of IV antibiotics. This is because if they were to use an IV catheter to inject drugs at home, it could be very dangerous, even deadly. But under triage conditions, we might let them go home if they promise not to use their IV line to inject drugs.

Obviously, that’s not completely safe. It’s clearly not the usual standard of care – but it is a crisis standard of care.

Worse than all of this is anticipating the conversations with patients and their families. These are what I dread the most, and in the last few weeks of 2021, we’ve had to start practicing them again. How should we break the news to patients that the care they are getting isn’t what we’d like because we are overwhelmed? Here’s what we might have to say:

“… there are just too many sick people coming to our hospital all at once, and we don’t have enough of what is needed to take care of all the patients the way we would like to …

… at this point, it is reasonable to do a trial of treatment on the ventilator for 48 hours, to see how your dad’s lungs respond, but then we’ll need to reevaluate …

… I’m sorry, your dad is sicker than others in the hospital, and the treatments haven’t been working in the way we had hoped.”

Back when vaccines came on the horizon a year ago, we hoped we’d never need to have these conversations. It’s hard to accept that they are needed again now.

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87 comments

  1. Kevin Smith

    The unvaccinated, when they get Covid, exhale much more virus than the vaccinated, and they exhale virus for a longer period of time; so they are a particular threat to the people around them and to the people trying to take care of them.

    I wonder if special care centers could be set up for the [voluntarily] unvaccinated, where they could be taken care of by unvaccinated medical personnel?

    Reply
    1. IM Doc

      I am not sure your first sentence is even true. On multiple levels, not the least of which is that the vaccinated are making up the sick cases way higher than their proportion in cohorts. This is becoming more obvious by the day where I am, and is being increasingly reported in countries everywhere.

      And explain the cruise ships and naval ships, fully vaccinated, now with outbreaks reported daily.

      And as I have repeatedly tried to say, the unvaccinated would not be a threat to anyone, if these vaccines were actually sterilizing as you seem to believe they are. Indeed, because of the extreme bungling messaging of our officials, the vaccinated largely believe they are bullet proof. Ergo, the last three days of my life with large cohorts of patients cramming the ER who had been infected in vaccinated only parties and events.

      Had I dared say anything about “special care centers” when I was an intern in the AIDS crisis, I would have been fired instantly. Any such talk today is equally wicked.

      Indeed, I am now surrounded at work by recently ill and positive workers, vaccinated and boostered, coming into work sick, sneezing, and coughing, because the incompetence of our system has put the health care system in this position.

      With all respect, I believe your above comment and the brainwashing it represents, is an example of why we are in the dire straits we are in today. I am imploring the vaccinated and boostered reading this not to assume you are bulletproof.

      Reply
      1. The Historian

        Thank you, thank you, thank you for this! Whenever there is a crisis, people immediately jump to scapegoating somebody. It isn’t the unvaccinated that is the problem, it is the way this pandemic was handled from the very beginning that’s the problem.

        Reply
      2. Pate

        This linked in the article:
        “Across Colorado, about 80% of adults are now vaccinated against COVID-19. Inside our hospitals, we’re seeing that the other 20% who are unvaccinated are making up the vast majority of our patients with COVID-19. As the charts below show, about 85% of our patients hospitalized with COVID-19 are unvaccinated, and nearly 93% of our COVID-19 patients ventilated in ICUs are unvaccinated. Of our hospitalized patients who were vaccinated at the time of admission, many are immunocompromised.”

        You say “The vaccinated are making up the sick cases way higher than their proportion in cohorts“.

        Never good at math and especially statistics, I’m having a hard time making sense of this.

        I understand that the vaccines are not sterilizing and think that generally speaking they likely prevent serious illness. Have I paddled up the wrong creek?

        Reply
        1. Yves Smith Post author

          Sick does not = hospitalized. If you are being treated with monoclonal antibodies (an expensive intervention that an MD has to do in office), the point is to keep you out of the hospital but you have to be plenty sick to get that. IM Doc is seeing many Covid cases that are sick, some very sick. You are incorrectly acting as if everyone he sees is admitted.

          Reply
      3. Kevin Smith

        Thanks IM. To be clear, I don’t think the vaccinated have sterilizing immunity.

        My comment was an attempt at sarcasm, and should have been labelled as such.

        Reply
        1. T_Reg

          It certainly doesn’t read like sarcasm. It reads more like a typical comment from the new Jab Crow era, where the unvaccinated are the new “colored”.

          Reply
      4. Russ

        IM Doc I always appreciate your insights to the science and what is really happening in your world and I certainly appreciate and follow your admonition to “not assume I am bulletproof” because I am triple vaccinated. But at this point I am curious to know what you think should have been done different? Are you suggesting that vaccination is not effective and has not been the proper strategy? Given how contentious even simple steps like masking has become I have lost hope that any strategy would be successful. But would love to read your thoughts.

        Reply
        1. Arizona Slim

          How about early treatment, which can be done at home on an outpatient basis?

          Oh, wait. Early treatment might just involve the use of a certain drug that must not ever be mentioned.

          Reply
          1. Samuel Conner

            One wonders if at some point the possibility of CV prophylaxis for medical staff, via off-label use of cheap, safe, off-patent medications with demonstrated antiviral properties, will enter the minds of the people in control of our health-care industry.

            Given that profit-through-provision-of-services requires “provision of services” and functional human “service providers”, it’s hard to understand why “the Market” has not thoroughly explored this already.

            I have to admit, however, in retrospective contemplation of 2020-21, that the old Reaganite line, “government is the problem”, does appear to have some mileage left in it.

            Reply
            1. flora

              Some of the important people in control of our health care industry are Pharma execs. / ;)

              No profits in otc and off-patent meds, no profits in vit D or zinc, etc.

              Reply
                1. Yves Smith Post author

                  False.

                  It took me 20 seconds on Google to find 2 peer-reviewed articles on the National Institutes of Health that disprove your assertion:

                  Vitamin D deficiency is associated with COVID-19 positivity and severity of the disease

                  Vitamin D Deficiency Is Associated With Higher Hospitalization Risk From COVID-19: A Retrospective Case-control Study

                  Zinc is more speculative but the only studies done were on already hospitalized patients. Other recognized treatments, like monoclonal antibodies, are also ineffective when administered that late in the disease process.

                  But peer reviewed articles that the NIH had posted on its site point out that there are multiple pathways by which zinc could operate as a prophylactic:

                  Potential role of zinc supplementation in prophylaxis and treatment of COVID-19

                  This one written by European scientists and was published in peer-reviewed journal Frontiers in Immunology:

                  The Potential Impact of Zinc Supplementation on COVID-19 Pathogenesis

                  And one study, again peer reviewed and on the NIH site, found strongly positive outcomes from an OTC regime that included zinc and Vitamin D:

                  20-Week Study of Clinical Outcomes of Over-the-Counter COVID-19 Prophylaxis and Treatment

                  Making Shit Up is a violation of our written site Policies. I trust you will find your happiness elsewhere on the Internet.

                  Reply
                  1. PlutoniumKun

                    Even Taleb has been on twitter mocking people who take Vitamin D on the basis of one study that indicates it has no impact on outcomes. Of all people he should know that the original design of a study should be assessed with the same critical eye as the final result.
                    So many of the Vitamin D studies in particular seem to be particularly bad faith – assessing its use as a treatment for critical patients instead of its more probable benefit as a prophylactic.

                    Reply
        2. Lee

          We could take some lessons from some other countries that have done better. Given our relative performance, outside of Peru and a few others, just about any other country would do.

          I’d suggest looking at measures taken in countries that have done significantly better than us in keeping their cases and deaths low. In some instances critics would attribute such differences to the authoritarian nature of some of those countries. Others might attribute it to citizens trusting their government when it comes to ensuring their physical wellbeing. A combination of both is not inconceivable.

          By contrast, here in the U.S. there is the high level of distrust in government and that that I would argue that this distrust is warranted. I would also posit that we too are a type of authoritarian state governed by the interests of finance capital. A difference lies in that our authoritarians do not rank the general physical wellbeing of the citizenry as a high priority compared to financial profit.

          Given those circumstances, you are correct: we are inherently incapable of having taken other paths.

          Reply
        3. BeliTsari

          Masking, “contentious” to vaccinated churls; told continuously they were now immune & everything, “back to NORMAL!” So, we’d yet AGAIN have stereo speciously brainwashed loutish imbeciles from “both” halves of US’ petit bourgeoisie gleefully spewing virons @ club, church, work, restaurants, transit or Fight Club (each, blaming their “opposite,” by spitting viral vituperation, to spread the joy. Kind of Hochul-ing us all into a Polio Party?

          https://www.postalley.org/2021/08/30/long-covid-slow-disaster-in-the-making/

          Reply
        4. GM

          There was only ever one option and it is to do exactly what the Chinese did in Wuhan and have been doing ever since.

          If your country is not doing that, then we enter the socioeconomic and political sphere, in which there are two possibilities:

          1. Your country is incapable of doing what has to be done. In which case it is a failed state, by definition — it is failing at its most basic duty of protecting the life and wellbeing of its citizens.

          2. The ruling class of your country does not want to do what has to be done. In which case that ruling class is guilty of premeditated mass murder on a scale never seen since WWII.

          Those two possibilities are not mutually exclusive — it is clear that quite a few countries are both incapable of doing actual public health the way it’s supposed to be done and have leadership that does not want it anyway.

          But there are clear examples where the virus was contained and then it was deliberately let loose.

          Australia right now is the most striking such case since the beginning of the pandemic, but the same was done previously in quite a few other countries.

          Anyway, because we have a socioeconomic and political problem that makes it impossible to apply the already worked out purely technological solution to the medical crisis, we have to first solve the socioeconomic/political problem.

          But that takes us back to our current overlords carrying out a deliberate program of physical extermination against their own population;

          I don’t see how that gets resolved without the population understanding that and launching a counterprogram of physical extermination of the ruling class 1917-style. The population has the advantage of raw numbers, but it is hopelessly misinformed and divided.

          Where the vaccine features in this story is that it allowed the ruling class to pull the wool over the eyes of society and first, make it seem that it is doing something to solve the problem, and second, that its “solution” is sufficient.

          But it is not, and that was known to everyone who understood the situation already in 2020. This is not measles, smallpox or polio, it’s a respiratory coronavirus, and we knew immunity against those is fleeting and unreliable.

          At best we had a window of a few months in early 2021 when the short-lived protection from infection could have been used to help with an elimination program before major vaccine escape had evolved.

          But that would have required the kind of NPIs that the vaccines were used as an excuse not to implement…

          To help illustrate the problem better, what happened before vaccines?

          The following countries completely eliminated the virus, many of them multiple times:

          China, Taiwan, Australia, NZ, Vietnam, Laos, Singapore, Thailand, Cambodia, Laos, Hong Kong, Montenegro, and several others in Eastern Europe got it down to 5-6 cases a day.

          Again, that was before vaccines.

          In 2021 we had vaccines, and what happened?

          All of those countries except for China and Taiwan abandoned containment, which has resulted in a lot of deaths in many of them, and they are just getting started. NZ has not yet experienced it, but will inevitably have the opportunity to enjoy the experience unless it reverts back to elimination.

          We don’t know how exactly the decision making went in most of those cases, except for NZ and a little bit in AU — in NZ the scientists all of a sudden were left out of the loop and the government announced it is abandoning elimination. Clearly against their advice.

          And you see what is happening now with Omicron — absolute records of infections all around the world.

          So what has the net effect of vaccines been?

          Kind of negative in terms of public health outcomes.

          For which the vaccines themselves are not to blame, but again, they were used in order to provide and excuse for the policies that brought us to where we are.

          Reply
          1. Objective Ace

            Thanks GM–I’ve found all of your insights most valuable. On the Chinese isolation move, I’m curious–how far out have you “gamed” the outcome. Its obviously beneficial now, I’m not so sure 5, 10, 20+ years out. Two examples that make me question it, China’s Isolationism in the 15th Century, and the plagues inflicted upon Native Americans when Europeans came into contact.

            Isolationism may not be as much of a problem as every other country else gets weaker relative to China. But still, every other weakened country may still have more technological and economic breakthroughs and then a healthy China simply based on size. Admittedly, technology makes Isolationism this round less actually isolated for all of us.

            Virology wise, maybe it is better to let us slowly adapt with it–from a society wide perspective at least. This sounds terrible on the surface, but it was undoubtable true for Native Americans who never had to bare the pain of measles, smallox, etc… until they suddenly did. Obviously I stress the “maybe” here, and the long covid harm after catching covid again and again will be devastating for many individuals. But there appears to be to be evidence that Omicron may be more mild — not because it actually is — but because so many people have prior immunity from other variants.

            I’m, in particular, considering the youngest people in our society. Will they similarly face as dramatic longterm consequences when they’re immunological system has been exposed to a myriad of variants since birth or early childhood? How would such a person compare to a Chinese 20 year old who has never fought off any Covid infection if Covid ever did get out of hand there?

            Covid 19 could wind up being the largest “prisoners dilemma” game the world ever faces. Its a shame we couldnt convince all the actors to work together for the best outcome for everyone

            Reply
            1. Objective Ace

              Upon thinking about this further, China–with its current knowledge, technological, and infrastructure base–would likely have been able to contain and snuff out any measles, pox, etc. outbreak before it became a pandemic. Similarly, they will be able to contain further Covid outbreaks

              That leaves me coming to the same conclusion as you have ;)

              Reply
            2. GM

              But still, every other weakened country may still have more technological and economic breakthroughs and then a healthy China simply based on size.

              What breakthroughs exactly?

              The brightest minds of the West are being paid to design algorithms to game the stock market and to present people with the ads they are most likely to be influenced by.

              In other words on parasitic dissipative activities.

              Investment in real productive science and R&D is going down and down in relative terms.

              Even universities have been hollowed out because every professor is now under major pressure to launch start ups and produce patents, which has had very negative effects on actual research.

              China has a big problem with the hierarchical structure of their system that does stifle creativity.

              But when other places are so busy committing collective suicide they look poised to come out on top by default.

              And I am really not so sure that is not just a stereotype anymore.

              I have been watching carefully what they do with their response to COVID. It has been nothing short of amazing — what they do has been entirely driven by scientific considerations, even if the mandate on top has a very heavy political element to it, and has been meticulously executed at every step. Every outbreak has been both contained and studied in depth that the CDC can only dream of, and then policy has been adjusted accordingly.

              Some examples — quarantine used to be 2 weeks, now it is 3+1 (hotel + home). Because they found out 2 weeks is not enough. Other countries just abandoned it altogether if they ever had it.

              They are building special quarantine centers because they understood from bitter experience that hotels are inadequate as you get airborne spread between the rooms. A lesson that Australia and NZ also learned but refused to act on.

              When Delta appeared and it became clear people are highly contagious very quickly, they adapted their PCR testing policies for arrivals. So now you have to test within 24 hours of getting on a flight, and for some especially high-risk areas like South Africa you have to get multiple tests from multiple approved by the Chinese embassy labs (probably because there was an issue with fake tests), do quarantine for several days at a hotel at the airport, then test again, etc.

              Meanwhile the CDC spit in the face of the very concept of public health with its 5-day isolation decision the other day.

              So the bet has to be on the society that respects “science” sufficiently to base decision making on it, as inconvenient as that might be for other reasons. Not on the one where what “the science says” is determined by the short-term profit maximization objectives of corporate CEOs

              Reply
              1. PlutoniumKun

                Thank you for the excellent BTL replies, you’ve answered quite a few questions I’ve had at the back of my mind in your responses here. In particular, I’ve been wondering what would happen if covid got loose in China (they seem to be really struggling in Xi’an right now).

                The Chinese response has been outstanding, and quite ironic given how utterly terrible the Chinese healthcare system is – if there is one health system in the world that can be pointed to as being worse than the US, its China. I’ve heard endless stories from Chinese friends about family hospital experiences that would chill you to the bone. But for fairly obvious reasons the one thing they do put resources into is suppressing infectious diseases.

                The one key advantage the Chinese have is an outstanding ground game at local level – not necessarily in public health, just in getting things done. Local governments work on the basis of following vague orders from Beijing, but they have enormous discretion to do what is deemed necessary, and as failure can mean personal ruin or even a firing squad for the leaders, then things generally do get done. They have an army of people – including many retired old folks, who can be relied upon to do what is needed at a moments notice. In short, they are advanced in both digital and analogue responses. Its an interesting contrast with South Korea, which is in many ways more advanced, but also far more centralised in its responses.

                I think another key advantage China has is that its leadership is dominated by trained technocrats. They tend to see things in a very linear fashion. If a problem arises, they ask what the solution is. If its practical, they do it. If its not practical, they pretend the problem doesn’t exist (‘what flood? I didn’t see a flood? Its just water, anything else is just western propaganda‘). They don’t try to play the multidimensional chess mind games that seems to be second nature to our political and technical leaderships. This has both advantages and disadvantages – but in the face of something like the ‘rona, its clearly an advantage.

                Reply
          2. flora

            Again, that was before vaccines.

            In 2021 we had vaccines, and what happened?

            My specialty is computer science, not bio or chem science. That said, I’m starting to wonder if there’s an indication of original antigenic sin or ADE starting to signal here. Maybe not. I hope not. I can’t entirely dismiss the question as one of many reasonable questions, though.

            Reply
          3. Paleobotanist

            Dear GM

            If possible, can you explain in layperson’s terms why immunity to respiratory coronaviruses is so short and unreliable?

            Thank you,
            Paleo

            Reply
            1. GM

              Reason 1:

              Immunity against infection for all respiratory viruses is short lived because it is mucosal, not systemic.

              And mucosal immunity is not long lasting in general.

              So you lose protection from infection very quickly.

              Reason 2:

              These viruses have various mechanisms for silencing the immune system and for replicating hidden away from it, and then explode in huge numbers.

              So you need high levels of circulating antibodies to stop them before they establish a productive infection. Memory cells are often too slow to react.

              But circulating systemic antibodies go down with quickly too. We don’t know why, for other viruses they go down too, but not to the same extent as with CoVs

              Reason 3:

              Antigenic drift

              These viruses have a very high capacity to evolve endlessly into new antigenic configurations. Same thing with flu, even worse in fact.

              And then the antibodies you have do not work very well anymore.

              Omicron is just the start.

              For reasons 2 & 3, over time protection against severe disease evaporates too, not just against infection.

              Reply
              1. Basil Pesto

                So say Pi comes along – whether it’s less or more virulent, what will it take for it to become a problem in terms of prevalence? Does it have to be transmissible to the extent that it displaces Omicron? Or could theoretical future variants co-exist with Omicron without one displacing the other (understanding that viral evolution is not linear)?

                Reply
                1. GM

                  It’s not about inherent transmissibility (R_0), it’s about the current effective transmission (R_e), which is dependent on existing immunity.

                  So Pi does not have to be more inherently transmissible if it is sufficiently distinct antigenically.

                  Same thing happened with Omicron — it does seem that after all it is more contagious in absolute terms than Delta, but it’s a small advantage. The main gain is in immune escape.

                  And it would have swept in a very similar way even if it was slightly less contagious than Delta.

                  Because the main drivers of the spread right now are the fact that existing immunity doesn’t do anything to stop it, and that NPIs have been dropped.

                  Long term there is nothing that stops multiple new serotypes and strain to evolve against which there is little to no cross immunity.

                  This is in fact exactly the situation that is observed in other coronaviruses, such as IBV in chickens.

                  And it is where we are headed.

                  In terms of severity, so far the trend has been towards worse with every variant.

                  Omicron is the first exception — it is probably slightly milder than what it evolved from.

                  Of course the propaganda has seized on this and is blasting at full volume how this is the end of the pandemic and it is a common cold from now on.

                  But Pi is under no obligation to derive from Omicron and to go in the same direction.

                  In fact based on what we know, it is obvious that multiple distinct viruses can exist that are as lethal as, or even more lethal than SARS-1, as contagious as Delta, and completely resistant to current vaccines to an extent that even Omicron is not, and against which no conceivable future vaccine will work as well as what we enjoyed in early 2021.

                  And it is very hard to see how something like that will not be highly successful in the wild.

                  But nobody will tell you that this possibility exists, except for lone voices like William Haseltine.

                  Will it get there? There is no way to know, chance plays a huge role in evolution, and it may just never travel along that path. But again, it is entirely possible.

                  The wise thing to do is to make it impossible by stopping transmission.

                  P.S. The other problem is that as I said, we know what such a virus looks like, which means we also know how to make it directly. It is also not hard technically. And a side effect of the pandemic is that a lot of people learned a lot of about coronaviruses…

                  Reply
                  1. The Rev Kev

                    Between you, me and the internet, I have found a useful metric for judging the truth of a comment is by the amount of exasperation that I am feeling when reading it such as yours. Hard truths which contrast with “the narrative” tend to set off this exasperation because you know what you are reading rings true, even if you cannot pick up on the finer technical points. Thanks.

                    Reply
          4. mistah charley, ph.d.

            My view is different with respect to “premeditated mass murder” by the ruling class during the pandemic. Did they know what would have produced the best outcome, did they have the capacity to do what would be necessary, and did they intentionally not do it? All would be necessary for a guilty verdict if there were a trial. I’m skeptical on all three counts.

            Reply
            1. GM

              Yes, they did know, and in fact it was looking a lot bleaker early on than it turned out to be in practice.

              This is the second SARS virus, not the first. We knew a lot about this one from the SARS-CoV-1 experience.

              The leaked Fauci e-mails showed very clearly that this knowledge had not been forgotten.

              And yes, this was deliberate.

              Go back to March/April 2020 and look at the discussion that was happening back then.

              It was very explicitly formulated — it will cost us too much to prevent the deaths, so we will let people die. That was said in exactly those terms, on multiple occasions. Including by politicians.

              That this will help with things like entitlement reform was not explicitly said in the beginning, but was celebrated on multiple occasions later.

              That the occasion was to be used for another massive upwards wealth transfer in a time of crisis was never openly acknowledged, but nobody has slipped on that ever in previous crises either.

              That it has also been used to destroy things like public health institutions and OSHA was a second order effect that I don’t think was deliberately sought, that just unfolded over the course of the crisis.

              Reply
            2. Noone from Nowheresville

              @mistah charley: If you ask the same questions about the Sackler family and the opioid crisis, what do or did you see?

              Reply
        5. IM Doc

          I think on this first day of the New Year, time for contemplation over the past 2 years is in order. I am currently in the hospital on duty dictating this into a computer. So sorry if there are typos and mistakes. Something could happen at any moment. Our hospital is as stressed right now as I have ever seen a hospital in my life. All kinds of staff and providers are now out on quarantine. We are inundated with patients who cannot get into their regular docs – who are COVID positive, vaccinated and pissed. We are having to man the ER with employees who are not really trained in those positions. This on top of all the other things happening in the ER. I have been running a DKA in the waiting room in front of dozens of people all night because there is simply nowhere else safe to put the patient. Many of the patients clogging the ER are scared to death from the fact that they have become positive, but in reality are having very mild symptoms. Turning the entire wing of the hospital into a superspreader event. I would ask everyone – if you are just having mild symptoms – please stay home right now. Monitor carefully your vulnerable family members and friends. If you are positive – monitor yourself carefully and your exposed family and friends with frequent pulse ox measurements. And we all need to keep our wits. Screaming and yelling like a fool in a crisis like this is not helping. Fortunately, it continues to hold that very few of these COVID patients are requiring hospitalization. I am absolutely convinced we are seeing a mix of delta and omicron.

          I could go on and on with the disaster my professional life has been this week – but I think you get the point. Contemplate that is likely going on all over America right now – and then think about these numbers. On Dec 31 2020 231K COVID cases were logged in USA – on DEC 31 2021 – that number is 443K. Deaths on DEC 31 2020 were 3,400 and on DEC 31 2021 – were 1,181. Please remember in 2020 – we were much further into the hospitalization curve so that death number may very well increase. I certainly pray every day that is the case.

          But the difference between 2021 (approximately 65% of USA fully vaccinated) and 2020 (0% vaccinated) could not be more stark and concerning. As I have repeatedly taught medical students over decades – we must look at the final common outcomes to really gauge the success of an intervention. Given these numbers, and the status of the ERs all over America, I would give the vaccines a solid F as a public health measure. That said, it is clear for INDIVIDUAL risk mitigation, there is currently an advantage – and even that is not really seeming to hold up much longer. Add to that, the numbers coming from everywhere that the vaccinated seem to be more at risk of infection with the latest variant – and I cannot see how anyone can call this a success.

          And my colleagues are finally starting to notice. This is just clearly not working and may very well be worse than if we had no intervention at all. And I had the same question asked of me in the doctor’s lounge that you asked in your comment – “We had to do SOMETHING – how can we say this was a mistake?” That is an important advance – just VERBALIZING that a few weeks ago would have gotten someone the side eye.

          It is critical for all to know that there is a decades/centuries long science in Western Medicine for public health ideals. There are standards and rules discussing how to do things in normal times – and how to do things in crises like this. It is as if that entire framework has been thrown out the window in favor of doing all we can to maximize the use of pharmaceuticals that will make Pharma lots of money – not just the vaccines but also things like Remdesevir. And they have played the game masterfully. All the psy-op tricks of the trade from Pharma that I have witnessed being done over my life have come out in spades the past 2 years. And they have now been allowed to buy out the media – so censoring and heckling anyone in their way is happening with abandon.

          My elderly Infectious Disease doctor faculty warned me decades ago that this day was coming and would likely be a coronavirus. He lamented the fact that would be the worst possible organism. Kills enough people to scare everyone to death – but makes the vast majority have very minimal symptoms. A true nightmare in every way.

          Look at public health interventions in a crisis as four legs on a stool – from most important to least important :

          1) Identify the organism and who is at most risk. Begin to do everything possible to isolate them and protect them. In our situation – that would have been doing all we could to isolate and protect the elderly and infirm – and once apparent that obesity and decreased activity were risk factors – to get everyone to work on losing weight, eating well, exercising, etc. THIS HAS BEEN A COMPLETE FAIL IN THE USA – Not so much in other parts of the world.

          2) Immediately begin to work on mitigation to stop the spread. In our case with COVID, ban travel from affected areas, work on masking, social distancing, grocery and drug deliveries in affected areas, immediately ascertain transmission spread (fomite, blood, aerosol or droplet) and immediately take appropriate measures and encourage all to do so. In doing so, you must treat the populace with respect. No lying or hedging. Out with it – good and bad – and talk to people as they are adults. From one of my public health texts – “THE WORST THING POSSIBLE IS TO ALLOW EFFORTS TO BE POLITICIZED……AVOID THIS AT ALL COSTS.” As we all know, this aspect has been a total fail.

          3) Find any and all drugs and other interventions that are anti-pathogen and begin their immediate use as either prophylaxis or as therapy. In the early stages, this may require the use of repurposed agents, and safety profiles over the time they have been approved are critical. Waiting for new agents or approaches is completely impractical in the first seasons of a pandemic. Again – this has been a total fail in our society. There were efforts to do this, but they have been met with derision and censoring from the very beginning. And they too were politicized.

          4) Last and of least importance, is the use of vaccines. Vaccines are almost never successful in an acute pandemic – and particulary rushed and untested vaccines have made things worse at times in both man and animal. Vaccines are among the most amazing inventions of modern medicine – right up there with antibiotics. But they are really not too effective acutely but are extremely effective as mop-up operations. One thing is for sure, putting all your eggs in the vaccine basket as we have done – and ignoring and politicizing the first three is a fool’s errand. At the same time we have engendered nothing but skepticism with the vaccines in our population. Bad studies, coercion, indemnification of the pharma companies, hiding side effects, lying about efficacy, premature end-zone dancing – have destroyed any and all credibility in a significant amount of the population.

          It must be noted that Dr. Fauci and Dr. Birx have ZERO background in public health. If they had it – it is now gone. Lots of background in politics and back room dealing, however. There were public health experts in the room ( Dr. Scott Atlas) in the beginning who are now coming out with accounts of how dreadfully prepared they were at meetings and how medical evidence and public health measures meant absolutely nothing to them. I am beginning to believe that Dr. Fauci, a brilliant politician and excellent scientist, has probably been one of the most incompetent public health figures in the entire history of medicine.

          Unfortunately – you are correct. I am not sure anything can work now. Too much has happened to the credibility of our health agencies and medicine in general. I do not blame people at all for the disgust that a good chunk of Americans have for them and us right now. My profession – out of sheer and willful ignorance and blind acquiescence to authority – has thrown its credibility to the wind. It will likely take a generation to recover if ever. Our media has been absolutely deplorable through this whole thing – they are indebted to Big Pharma – and have basically become their stenographers in a propaganda campaign.

          I am hoping that with Omicron this thing will burn out. Maybe – maybe not. There is historical precedent either way. There are some concerning little factoids coming to the fore that seem to throw cold water on the OMICRON END OF PANDEMIC IDEA. Everyone talks about cases and deaths – no one talks about other effects the virus may be plaguing folks with.

          And I am hoping we weather this current crisis – and this will just blow over quickly like an F5 tornado.

          That is where I am on this first day of the New Year.
          God Bless Us All.

          Reply
          1. Mtnwoman

            Thank you IM Doc.
            Excellent summation.
            I am going to share your summary when brainwashed friends ask me why I have even less trust now in all our institutions — public health, medicine, CDC, FDA, NIH, Media, Pharma, politicians.
            I’m not that suprised, but the past couple years have shown how easily cowed a population can be made.
            My leftie pals totally abandoned their mistrust of Pharma and Big Media, buying into The Narrative feet first.

            Reply
          2. Russ

            IM Doc: I was with you until the Dr Scott Atlas comment–I thought he was an interventional radiologist not a trained public health expert?

            Reply
        6. Mikel

          I’m looking at this senctence by the Doc:
          “I am now surrounded at work by recently ill and positive workers, vaccinated and boostered, coming into work sick, sneezing, and coughing, because the incompetence of our system has put the health care system in this position.”

          The system. Not you or I can individually prevent this. It also has implications beyond Covid.
          Too many health care systems that can NOT deal with a sustained, widespread health emergency.

          Reply
        7. Steve B

          “Are you suggesting that vaccination is not effective and has not been the proper strategy?” The vaccinated are getting sick, but *are* well protected against severe outcomes. They’re not bulletproof by any stretch, and the downside risks of COVID are such that it’s best to avoid COVID altogether, especially with hospitals in crisis mode. However, in highly vaccinated areas, the majority of cases could be vaccinated, just because there are more of them. I’m highly skeptical of reports that vaxxed are in hospital more often per capita than unvaxxed. All of the data I’ve seen to date clearly supports the opposite.

          Reply
          1. Yves Smith Post author

            You are straw manning what IM Doc said. He talked about the rate of sickness, as in symptomatic cases, not hospitalization.

            You’ve engaged in multiple site Policy violations on this threadt. It seems your eagerness to defend the vaccines, which we have pointed out have been oversold (they are not sterilizing yet have been almost pervasively presented by the officialdom and the press as such) has led you to misread at best or at worst knowingly misrepresent comments that dare to offer valid criticisms.

            Reply
          2. IM Doc

            Unfortunately, unlike what the media is pumping to the public, I have had vaccinated and boosted patients with very severe outcomes in the past month. Indeed, I have lost a fully vaccinated extended family member in my own personal life the day after Thanksgiving.

            Please do not confuse the total cases with those being admitted or in the ICU. There are multiple places all over the world reporting the total vaccinated cases are at par or exceeding the ratio of vaxx/unvaxxed in the population. No one has an adequate explanation yet, but it is clearly happening. The vaccines continue to minimize hospital admissions but not prevent them. That too has slowly become less advantageous as we go on. There is no doubt and no change in the critical ICU cases – that is absolutely still mainly an unvaccinated issue. Although even I have had vaccinated and boostered patients become critically ill. It remains true in almost all hospital patients that they have multiple comorbid conditions. Baseline healthy patients almost universally do not require admission vaxxed or not.

            These are the reasons I have been doing all I can to get high risk patients vaccinated. The failure in preventing transmission is however why I am adamantly opposed to coercion and mandates. The complete lack of effecting transmission should be obvious to all by now, thus negating mandates. The individual calculus is different for every person and this should be an individual choice.

            If we ever have a vaccine that prevents transmission, that is a whole new ball game. We certainly are not there yet. And unfortunately as a primary care provider, the silver bullet mentality engendered by our media on the vaccinated mindset has let the vaccinated continue to this day to engage in extremely risky behavior. This is widespread and likely contributing to the ongoing pandemic far more than the unvaccinated ever could. That is the Achilles heel of knowingly releasing a non-sterilizing vaccine into an acute respiratory pandemic.

            Reply
      5. Tony C

        Not sure I am reading this correctly – are you suggesting that vaccinated individuals are more likely to be seriously ill than unvaccinated individuals ( given equivalent risk profiles associated with age, comorbidities etc ) ?

        Reply
        1. marku52

          No. As I read IM Doc (not to put words in his mouth, but) it appears that the vaxxed are showing up in the ER in greater percentages than the unvaxxed.

          This may just mean the the vaxxed are engaging in more risky behavior. At any rate, it is very clear that vaxx + booster will not prevent Omicron infection.

          Reply
        2. Yves Smith Post author

          Hopefully he will clarify, but from what I have inferred from his close to daily updates, he is seeing comparable levels of sickness in the vaxxed v. unvaxxed, and if anything, the vaxxed are showing up in higher proportions than in his population (and he is in a very high vax area) EXCEPT for the very severely ill, as in ICU level sick. The vaccines are working for that but it seems not much else. He is seeing plenty of vaxxed and boosted who are also plenty sick.

          Reply
        3. IM Doc

          No, the vaxxed are not sicker than the unvaxxed. It seems to be largely the same. The time to recovery for those not admitted is almost exactly the same. There seems to be no advantage to being vaxxed to shorten the acute outpatient illness despite all the testimonials all over social media thanking the vaccine for shortening the illness. That is obviously misplaced gratitude to those of us hip deep in patients of all stripes.

          What has changed is the absolute number of outpatient vaccinated. The numbers have just gone absolutely vertical. The absolute ratio of vaccinated positives to unvaccinated positives in my area is higher than the ratio of vaxx/unvaxxed in the general population. By a startling amount. The illness itself seems to be identical. Boosters do not seem to be doing much either to decrease the illness level as outpatients. Fortunately so far everyone appears to be milder compared to earlier waves.

          I have no observation that the vaccinated are sicker now than the unvaccinated. They are just sicker than what was promised that is for sure. And lots of very very angry patients.

          Reply
      6. fajensen

        Had I dared say anything about “special care centers” when I was an intern in the AIDS crisis, I would have been fired instantly. Any such talk today is equally wicked.

        Sweden did that. They build ABC-tents outside hospitals and filled them with vintage 1980’s equipment that came with the ABC-stuff. This immediately killed a bunch of people due to inadequate care and in some cases faulty equipment.

        Thankfully, the medical professionals pulled the plug on that experiment quite rapidly. Now it is not talked about much, especially not by people who hails “The Swedish Approach”.

        Reply
      7. Van Isle

        Clearly, both the vaccinated and the unvaccinated have unrealistic expectations of being able to safely live a “normal” life. You say that “the vaccinated are making up the sick cases way higher than their proportion in cohorts.” This was a new idea to me, since the statistics I have seen do not seem to me to say this.

        Here in British Columbia, I follow the stats from our BC CDC. The most recent “data summary” is for the month ending December 7. For that month, age-standardized case rate per 100,000 is 7x greater for unvaccinated than for 2-dose vaccinated individuals; hospitalization rate is 32x greater; ICU rate is 56x greater; and death rate is 20x greater.

        Have the vaccinated/unvaccinated case rates changed that much in a month? Or is there something I’m missing in the statistics? Can anyone provide a link to similar statistics covering a more recent period for some jurisdiction?

        From the start, I have favored a Chinese-style thorough test/trace/treat/isolate model, but it seemed that early lack of supplies and political resistance made that impossible. Is it too late to take proper measures now?

        China has been living and working more or less normally since summer 2020, and has been able to deal with the small outbreaks that have turned up from time to time. The presence of a few Omicron cases in one big city and a nearby province may be worrisome, however. One hopes the methods that have worked so far will continue to work

        If I were Chinese, I would be resentful that the fecklessness of Western countries seems to have allowed the disease to spread and mutate. Perhaps if we had all applied classical public health measures from the start, we might actually have been able to get to something approaching zero world-wide.

        Reply
    2. The Rev Kev

      It does not matter this line of thought because Omicron spreads so rapidly. I suspect that a lot of vaccinated people are in shock because they were assured by people from Joe Biden down to Rachel Maddow that the vaccines would protect you and would stop this virus from being passed on. Well that is patently false on two counts and I bet a lot of people are now beginning to wonder how ‘mild’ this variant will turn out to be. We are way, way beyond the point where we have the luxury of dividing patients into categories. Our hospitals are going to resemble Korean War-era M.A.S.H. units.

      And a news update. Remember how nurses were being stood down because they refused to get themselves vaccinated and were replaced with National Guardsmen? A lot of them weren’t vaccinated either so regular care centers were being taken care of by unvaccinated medical personnel but at least those nurses were experienced. But understand this. So many doctors, nurses, etc. have been taken down by Omicron that any warm body familiar with medicine will be pressed into service soon because there will be no other choice.

      Reply
      1. ambrit

        “…because there will be no other choice.”
        That is not strictly speaking true. There is another choice; let the patients die. This “choice” looks to have already been made, in the favour of ‘Neoliberal Rule 32,’ (Go Die,) in the policy decisions now in effect here in the West.
        I cannot believe that all of the “responsible” decision makers are too stupid to have figured out the importance of aerosol transmission of the virus, or the abject failure of the “vaxvaxvax” policy, or the life saving possibilities of various therapies and therapeutics freely available, if allowed, etc.
        There is often a lively debate in the comments section over whether certain ‘boneheaded’ decisions and policies are the result of “Stupidity” or “Evil.” Concerning the Dreaded Pathogen, I’m now firmly in the camp of “Both of the Above.”
        Hang on for your lives. It is literally that serious of a problem now.

        Reply
        1. ChiGal

          The latest TWIV podcast, which dropped yesterday, interpreted the new guidance about isolating and quarantining as an implicit sea change in policy in that people carrying infection who are not themselves very sick are no longer being encouraged to eschew work/school/play on account of those who are at the greatest risk of hospital admission due to severe disease and death—the unvaccinated.

          They interpret the use of language stating that the “majority” of the asymptomatic do not shed significant virus after 5 days (with Omicron) but they should still continue to mask for another 5 days as a near-explicit statement that since the unvaccinated have chosen not to avail themselves of protection against the worst outcomes, the gen pop is no longer encouraged to be as rigorous about attempting not to infect them. They predict things will loosen even more when young children are able to be vaccinated.

          Too bad for the immunocompromised and obese I guess, they just slow down the herd anyway. Social Darwinism at its best!

          Reply
        2. fajensen

          I cannot believe that all of the “responsible” decision makers are too stupid to have figured out the importance of aerosol transmission of the virus, or the abject failure of the “vaxvaxvax” policy,

          I have believed for a long time that the thing about loosing “face” that the asians supposedly have, is a projection: Because, it clearly seems to be the case in our culture, that once some “expert” has opinionated on something in public, they can never go back or change or learn from new data, because then they are not the kind of infallible oracle-type of expert they imagine they are!

          So, “here in the west” it can well be “bis zum Endsieg” with whatever bollocks became the dominant state religion first.

          or the life saving possibilities of various therapies and therapeutics freely available, if allowed, etc.

          If there was an effective treatment, available to “Them”, would “Just Let it Rip” not make sense?

          We see the pattern with all other “reforms”, where everyone are hammered, except those people making them “hard decisions”, who all got theirs with a dollop of extra on top, for their hardship!

          I agree with “Stupid and Evil”!

          Reply
      2. BeliTsari

        It’s difficult NOT to attribute Biden & Hochul’s blatant infection of school children, teachers, caregivers, HCW & 1099 “essential workers” to anything but Catastrophe Capitalism’s prior COVID feeding frenzies being SO remunerative with their 0.01% funders, but also 9.9% PMC constituents all looking forward to flipping yet more serendipitously vacant rent-stabilized apartments, as we chronic PASC survivors are reinfected at work and have to return after five days, untested (or simply continue working, ill?) FIRE & PhARMA cashing-in on kids’ Mis-C, chronic PASC & life-long debilitating circulatory, brain, coronary, lung, kidney damage. Jeepers, how voters will react to being forced to work with a disease that’s killed far more Muriknz than the US Civil War, infect loved-ones; while our betters are enriched by essential workers’ demise, debilitation, debt, job displacement & despair?

        https://www.thecity.nyc/2020/4/14/21247112/memo-ordering-nyc-schools-to-keep-virus-cases-quiet-probed

        https://mobile.twitter.com/hashtag/MassDisablingEvent

        https://scheerpost.com/2022/01/01/best-of-chris-hedges-2021-columns/?utm_source=rss&utm_medium=rss&utm_campaign=best-of-chris-hedges-2021-columns

        Reply
      3. GM

        Omicron spreads so rapidly

        Note that it appears that this is because it has a very short serial interval, not because of a much higher intrinsic R_0.

        Which is actually a blessing — if that kind of rapid spread is due to a superhigh R_0, then NPIs will have to be absolutely extreme to stop it.

        But a short serial interval means that just as it doubles every two days, if you push the R_t down below 1, it will be halving very quickly too.

        So a proper lockdown is a more powerful tool than before.

        But is anyone explaining that? Of course not, let it rip, baby…

        Reply
      4. Malo

        Even Fauci was assuring people that if they were vaxxed and boosted they could gather with vaxxed/boosted friends and family. Everyone doing rapid tests just prior would be another layer of protection.

        And now, some of these folks are getting sick. They feel misled, probably angry, and a bit scared. How sick will they get? What long lasting effects might they suffer?

        The US response to the pandemic has been a hot mess from the git go, and I don’t expect improvement. It really feels like we are all on our own, to figure out what actions we should take to protect ourselves.

        Reply
    3. Lee

      Between the jab and those who have been previously infected, there is a dwindling number of us who are Covid naïve, (https://covid.cdc.gov/covid-data-tracker/#national-lab). One or another of the various epidemiologists now regularly appearing in the news provided an estimate that there are only 10 to 15 percent of us who are are neither vaccinated nor previously infected.

      It seems unlikely that this group alone is accounting for the current spike in total cases, although it is not implausible to assume that they are accounting for a disproportionate number of more serious ones. When patients are streaming through the doors, just how would the parsing you suggest be accomplished, and how would forceful popular resistance to such parsing be dealt with? Be careful what you wish for.

      Reply
  2. Northeaster

    Imagine if The U.S. actually had a “health policy” that focused on Americans being healthy? Instead, we have a nation of unhealthy, obese diabetics that has led to the world worst COVID outcomes in response. Of course the money that flows to keep Americans fat & happy (and dead), will continue.

    Reply
  3. Larry

    The messaging has surely been muddled, but for elites, the confusion sowed by political divisions and pandemic policies has been fantastic. Large firms are reaping windfall profits, the media sphere gets attention, and the proles are fighting each other of masks and public health measures.

    Reply
  4. Tom Stone

    I’m,old.vaxxed and have several comorbidities.
    I expect to be subject to triage when, not if, I catch Covid.
    That is appropriate.
    I take the precautions I can and avoid the risks I can, but it is a matter of time and luck.

    It’s very hard on those that have to make the choice of who shall live and who will die, especially in a case like this where many of these deaths could have been avoided by a functional society.
    For many it’s a choice between faith and the bottle as coping strategies.

    Reply
  5. S Runnels MD

    It is as predicted. It will continue to progress as predicted. The path is set and one can choose not to look down the path, but it leads to where it leads regardless.
    Providers are the medical systems. Deep structural damage to providers is happening now. This has obvious, but largely ignored consequences now and in the future. The shortage in providers is only beginning. No one in medicine signed up to be cannon fodder for politicians, corporations, and politicians.
    Society, heal thyself.

    Reply
  6. SouthSideGT

    Happy New Year, everybody and welcome to 2022. Scary stuff for sure. Sounds like we as a nation and not just in Colorado are looking at a winter of severe illness and death because hospitals everywhere and not just in Colorado may soon be overwhelmed. True to form like the Biden Admin and the CDC the governor of Colorado is blaming the unvaccinated while admitting Colorado hospitals are overrun. Like everything I read during the pandemic this link contains a curious mix of solid information of ways to stay safe and misinformation that may be wrong. Buyer beware I suppose.

    https://www.cpr.org/2021/12/10/interview-gov-jared-polis-mask-mandates-covid/

    But for myself, this is not a moment to panic because I have gotten both Pfizer shots this past spring and the Pfizer booster this past early fall.

    Going forward I will be using my industrial N95 mask, which I purchased in February 2020, for the duration of the surge when I am out and about and exposed to crowds. And this way I can protect myself, my children and grandchildren, and my community.

    Reply
    1. Joe Well

      >>not a moment to panic because I have gotten both Pfizer shots this past spring and the Pfizer booster this past early fall.

      But we’re in uncharted territory here. Who knows how strong your immunity is three months after the third shot? We know it’s not great three months after the second.

      Reply
      1. SouthSideGT

        “we’re in uncharted territory here” I agree. So many known unknowns. But I like my knowns. I am a 67 year old in good health. My wife is also in good health. Neither of us have comorbidities. Except for one son who is a health care professional my immediate family is able to stay home. I like my odds of survival during this surge more than I like the odds of these unfortunates and others like them who for whatever reason did not get vaccinated……

        https://www.sorryantivaxxer.com

        And I don’t have to fully trust my vax/booster efficacy I guess because I am putting my faith in my N95 mask and being as conscientious about anti-virus hygiene as I was in March 2020 before the vax/boosters came along.

        Reply
        1. ChiGal

          Wow, that is one ugly website. Is it even legal for them to be posting other people’s pics and words snagged off of social media to make object lessons out of their deaths?

          Despicable.

          Makes me think the TWIV take I commented on above is right—we’re just done with minimizing harm to those we feel have not done their part to protect themselves.

          The exact opposite of harm reduction (referring to the excellent Maia Szalavitz post earlier this week): it’s the judgement that kills, the policy, not the disease.

          Reply
          1. SouthSideGT

            I agree. I have been visiting the website since IIRC Halloween or so and I believe that the owner of the website has been in contact with an attorney and so far the owner has not been public about any legal difficulty s/he may be in.

            I noticed that the NYT noticed the site but did not mention the name of the site in the body of a story that highlighted some of the social media abuse directed of those stricken dead by COVID who were also virulently antivax and posting antivax memes and propaganda. Perhaps not surprisingly they were also pro Trump.

            https://www.nytimes.com/2021/11/27/style/anti-vaccine-deaths-social-media.html

            Reply
          2. Arakawa

            Unfortunately, although this kind of thing would be taboo in a healthy society (aside from legal repercussions), both sides in the vaccine ‘cold civil war’ have long since escalated past such taboos. You can find plenty of sites (eg thecovidblog) doing that in the anti-vac direction too, digging up people who gloated at anti-vaxxers on social media and then died suddenly after getting their shot.

            Essentially, you have to start looking at this as a guerilla war type conflict between an occupying power and a distributed resistance. “Who started it?” is historically interesting but rarely a useful question for figuring out how to de-escalate.

            Reply
    2. Pat

      From everything I am reading now, currently that mask is far more important in your protection and in the protection of others than those shots.

      I await the day that masking and ventilation along with prophylactic use of vitamins are taken as far more important than vaccine status with our current vaccines, as they should have been all along. When that happens I will know that finally facts and not rose colored market loving glasses are running policy.

      Reply
      1. SouthSideGT

        I agree. I should add that in addition to my precautions in my reply to Joe Well above, I have been for years perhaps 15 or so every morning taking a supplement of 1000mg of Vitamin C, and 25mg of zinc as well as a normal multi-vitamin. And green tea every night before bed time.

        Reply
  7. Joe Well

    If you do get symptomatic COVID in the US, what are you even supposed to do?

    It sounds like our healthcare system has no options for us now except to keep us breathing after the disease has ravaged our lungs and probably other organs, too.

    Reply
  8. LAS

    A lot of public health people do NOT communicate well. Their language that vaccines and boosters are “protective” is taken from epidemiology literature, and all that means is that the result is associated with lower risk than the comparison group, not that it confers risklessness. So while the comparison group might test 60% positive, the vaccinated group testing 30% positive will be referred to as protected. I’ve never seen anyone explain this to the public, how in fact vaccination is not shield-like protection. There’s a probabilistic reduction in likelihood of an undesirable outcome between vaccinated and unvaccinated people, and that’s all.

    I think there’s another looming mis-communication about the home test kits now being distributed to the public; these tests are biased toward a negative finding. People would be wise to not assume they are covid-19 free just b/c the result is negative; in fact, there is a material probability that some part of the home test was not strictly within protocol and the timing window (which are rather important requirements). So, if your test result is positive, you almost certainly do have covid-19, but if your test result is negative, you might have and simply not successfully detected it. Be cautious when using these tests.

    Reply
    1. Jason Boxman

      The CDC was even more explicit: It was said that you cannot cary the virus if you’re vaccinated, full stop.

      Bad communication, or outright falsehood? A noble lie in support of capitalism?

      Reply
      1. ambrit

        The very concept of a ‘Noble Lie’ is propaganda that Orwell would be proud of.
        Let’s just drop the Noble part and speak truth to power. You in power are Liars and we will not support or cooperate with you any more.
        Now is the time for ‘Parrallel Institutions’ to flourish.

        Reply
  9. Pate

    The linked study states:

    “Across Colorado, about 80% of adults are now vaccinated against COVID-19. Inside our hospitals, we’re seeing that the other 20% who are unvaccinated are making up the vast majority of our patients with COVID-19. As the charts below show, about 85% of our patients hospitalized with COVID-19 are unvaccinated, and nearly 93% of our COVID-19 patients ventilated in ICUs are unvaccinated. Of our hospitalized patients who were vaccinated at the time of admission, many are immunocompromised.”

    IMDoc, responding to Kevin Smith’s first sentence (“The unvaccinated, when they get Covid, exhale much more virus than the vaccinated, and they exhale virus for a longer period of time; so they are a particular threat to the people around them and to the people trying to take care of them.”) says “I am not sure your first sentence is even true. On multiple levels, not the least of which is that the vaccinated are making up the sick cases way higher than their proportion in cohorts. This is becoming more obvious by the day where I am, and is being increasingly reported in countries everywhere.”

    I am confused. I am interpreting IMDoc to be stating as true from his experience that “the vaccinated are making up the sick cases way higher than their proportion in cohorts”?

    If this interpretation is correct, how does it square with the linked study that states “85% of our patients hospitalized with COVID-19 are unvaccinated”?

    Or is IMDoc attributing the claim “the vaccinated are making up the sick cases way higher than their proportion in cohorts” to KS (as a false notion)? (I don’t see KS making that claim in his firs sentence.)

    Reply
  10. IM Doc

    What I am seeing and what is being reported in some other countries is the number of CASES in the vaccinated is out of proportion to the total vaccinated in the area. This is total cases – not just admitted or critically ill.

    For example, a tweet yesterday from Germany which is about 70% vaccinated is showing their COVID cases are above 90% vaccinated.

    The number of vaccinated getting admitted for illness has been on a slow upward climb since the fall. Yesterday, for example, the few admissions we had in my hospital were about 50/50 unvaccinated to vaccinated.

    It is still absolutely the case that the unvaccinated are the absolute majority of those critically ill in the ICU. That does not appear to be changing at all.

    Thankfully, the number of admissions remains very low.

    There is a big difference between total cases in the community and cases in the hospital. I try my best to be very clear about that.

    https://twitter.com/Tim_Roehn/status/1476575806969335812

    Reply
    1. Pate

      Thank you. May I add my name to the long list of folks in this community who deeply appreciate you as both a dedicated clinician and a contributor to this site. Best to you.

      Reply
    2. GM

      For example, a tweet yesterday from Germany which is about 70% vaccinated is showing their COVID cases are above 90% vaccinated.

      Germany did a “lockdown for the unvaccinated” with the vaccination passports.

      So what may have happened is that the unvaccinated are not exposed as often.

      The vaccinated are not protected from infection either, but they are out there living it up as if it’s 2019 and are exposed much more often.

      So it is confounded.

      Reply
    3. Anonymous

      My brother-in-law, a pulmonologist who works in a U.S. hospital, also says that nearly everyone in the ICU is unvaccinated.

      Reply
  11. Larry Carlson

    My understanding is that the original double-blind studies for vaccine approval in the United States were unblinded fairly quickly, as it would be unethical to deny the control groups access to the vaccine. Is anyone aware of a country that has tracked long-term vaccine effectiveness using proper control groups?

    Unfortunately, even careful tracking of infections, hospitalizations, and deaths between vaccinated and unvaccinated groups doesn’t tell us much about vaccine effectiveness if the groups self select, since in this case vaccinated individuals are in general likely to be more concerned about their health and take other preventative measures. You can try to correct for demographics, wealth, various behaviors, etc. when you compare two self-selected groups, but this is very difficult to do cleanly.

    My fear is that at this point, most COVID vaccines are marginally effective, but that self-selection effects mean that the vaccinated have much lower morbidity and mortality. We’ve seen this with flu vaccines: comparisons of vaccinated and unvaccinated groups show strong differences, but aggregate population mortality wasn’t strongly affected when flu vaccines became widely used.

    Reply
  12. LawnDart

    In a civil society, in theory, citizens do not fend for themselves in a Darwinian struggle for survival, but give authority to a government to act on their behalf for the common good of every individual.

    In USA and elsewhere, many who thought that they were protected by their governments are finally, finally beginning to realize that they, too, are expendable in the eyes of the ruling state: it’s not just the minorities and the poors, not this time: this time it’s everyone, but the elite, who are screwed or who face a royal screwing.

    The elite will not face triage because they need not rely upon public services, or otherwise can afford to jump to the head of the line if no other services are available. As the elites have opportunities in life not available to you and I, they can afford protections, special treatment, not available to you and I.

    Doctors and nurses on the front lines will continue to make life-and-death decisions based upon the resources made available to them, resources determined by budgetary priorities (in a real democracy, priorities determined by you and I). My heart goes out to them: what a s#!t position to be in.

    “Welfare” isn’t just means-tested bennies sparingly sprinkled upon the poors and the unfortunates: many have seemed to have forgotten, or have never been taught, that welfare is many things, and that public health is welfare too. Back in the 80s-90s, in the 51 states of America (to include our lapdog across the pond, GB) “I got mine!” and “No such thing as society!” overcame “Ask not what your country can do for you – ask what you can do for your country.” The result of this is quite plain today for all to see: the unnecessary death that surrounds us, that may itself await us, this is what reformed welfare looks like.

    As we resort to triage, it seems best to keep in mind that sometimes losing as little as possible is winning.

    Reply
  13. kareninca

    I have a close relative in PA who is the palliative care doctor in her mid-sized hospital. Her husband told me last night that her caseload just went up forty percent, because they are mostly not bothering with ventilators now because it is their view that they don’t work so the patients are being sent straight to palliative care.

    Reply
    1. ambrit

      That’s an explicit Triage if no other therapeutic measures are being applied.
      I remember reading that the ventilators were an end stage therapy attempt and subject to pretty poor outcomes as a group. But, some people did pull through with the help of the ventilators. Hasn’t anyone done any work on how to predict which ventilated patients have the best chance of surviving? Surely there is enough data now available from which to draw a preliminary conclusion. Otherwise, is no one doing the work needed? I understand the frontline medical workers being stressed unto burnout, but how many statisticians are suffering from burnout because of the Coronavirus? The Insurance companies work on the premise that “The numbers do not lie.” We have the numbers now. Time for someone to do a proper analysis.

      Reply
    1. MonkeyBusiness

      They haven’t been following US CDC for the longest time. That’s why I said I will only take off my mask only after every single Asian has taken off his/hers.

      Reply
      1. MonkeyBusiness

        Indonesia just bumped the quarantine requirement from 10 to 14 days for countries with known community transmission of Omicron.

        Reply
  14. Ahimsa

    I am in Germany.

    Sorry, but that tweet (I follow Tim Röhn and he has been doing an excellent job of exposing the #Datastrophe of official figures) is somewhat misleading.

    Of the reported Omicron cases in Germany, the vax status is only known for ~40%.

    Of this 40%, there are certainly disproportionate incidences in the various (un)vaxxed populations/categories, eg. higher incidence among double vaxxed.

    I think GM may overstate the effect of lockdown restrictions on unvaxxed incidences. They still go to work, school, and continue to socialise in private. Though I too suspect some severe confounding in these figures.

    More complete data (~75% of Omicron cases with known vax status) from Denmark still suggests disproportionately high incidence in vaxxed with unvaxxed accounting for less than 10% of Omicron cases.

    https://twitter.com/Tim_Roehn/status/1477193093279629314?s=20

    Best case scenario, Omicron is an equal opportunity infecter, but the emerging data points to the vaxxed being more susceptible.

    Reply

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