The command cultures of the U.S. Armed Forces are among the world’s best.  Any doubter should read Tom Clancy’s nonfiction biographies, Studies in Command. Another point of reference is the NOVA series, Carrier, filmed aboard the U.S.S. Nimitz, lead ship of the class of which the Theodore Roosevelt is a member.

Each of the services share the challenge of human resource management, but with differences in detail. The Army and the Marines share a problem unique to land warfare, the strain of combat where the soldier is directly and often personally responsible for killing the adversary and bearing witness to the death of one’s buddies. The challenge is to enable this frame of mind, with the soldier remaining psychologically whole in the non-combat world.

Sometimes the hardest task is the most perfectly done. Because land warfare is so upfront personal, the Army and the Marines had no choice but to excel in human resource management.  The last steps of perfection have come only in the past few years. The Navy is a little behind.  While PBS Carrier displays the best of Navy of human resources, there have been serious lapses, concentrated in the commissioned ranks.

Within the past 20 years, four lapses have involved smaller ships. Two separate problems are demonstrated:

• Conflict resolution that over prioritizes command authority.
• Excessive “can-do” attitude, where the tempo of operations exceeds watchful human endurance.

USS Shiloh (CG-67) under the command of Captain Adam M. Aycock, when it was also known as the  (Navy Times) “U.S.S. Bread and Water.” Quoting Wikipedia (boldface mine):

…reported extensive morale problems universally blamed on the CO, Captain Adam M. Aycock. Among the complaints were widespread depression and suicidal tendencies, a dysfunctional ship that sailors felt was ill-prepared for combat, an overworked and deeply stressed crew, and a constant worry of extreme punishment for minor infractions. Sailors were dismayed that despite a significant number of the ship’s crew filing severely critical complaints of Aycock’s leadership in the command climate surveys, the only action taken by the Navy was to counsel him…

USS Cowpens (CG-63), under the command of Holly Graf. Between 2002 and 2010, Graf held positions with command authority. It took 8 years for the Navy to recognize Graf was not fit for command:

…Subsequent reports by Time revealed that Graf had a history of abusive treatment of subordinates as far back as her tenure on the Curtis Wilbur. Previous complaints had not been acted upon by Navy leaders. Many who served with her thought she was the closest thing they’d seen to an actual Captain Bligh.[8] For instance, while she was commander of the Churchill, a propeller snapped just as it was leaving port, leaving it dead in the water. Graf grabbed the navigator and dragged him to the outdoor bridge wing while cursing at him.…many Churchill sailors, knowing that Graf’s career would have ended if the Churchill had run aground, started jumping for joy and singing Ding-Dong! The Witch Is Dead on the fantail. Kaprow later said that the crew’s morale was the lowest he’d ever seen in his 20-year naval career.[5] … said that Graf frequently spat at other officers and threw things at them--including ceramic coffee cups and binders…

The resolutions of these situations over weighted the importance of command authority, motivated by  fear that the final authority of the captain would be undermined by removal for maltreatment of the crew.

In 2017, two Arleigh Burke class destroyers collided with commercial vessels, killing 17 sailors. Quoting from Wikipedia,

• USS Fitzgerald and MV ACX Crystal collision

On 17 August 2017, the two senior officers and the senior enlisted sailor in charge of the naval vessel were relieved of their duties.[24] The Navy planned to discipline up to a dozen sailors, including the commanding officer, for watchstanding failures that allowed the fatal collision.[25]

• USS John S. McCain and Alnic MC collision

On June 19, 2019 the National Transportation Safety Board (NTSB) released their report on the accident.[32] Their finding that the probable cause of the incident was a “lack of effective operational oversight of the destroyer by the US Navy, which resulted in insufficient training and inadequate bridge operating procedures.” Along with their complete report they provided a series of recommendations including changes to Navy bridge equipment and training procedures. This is the first independent investigation document released on any of the recent US Navy navigation incidents.

These factors have been cited, to combine and potentiate:

• Excessive tempo of operations.
• Lack of time for training.
• Lack of training.

Specific measures have been taken to remediate. This does not address culture, the ingrained habits of thought that linger even as the forms are changed. A super-carrier operates at high tempo with the discipline of doing things right, which is maintained only if you keep doing them.

To bring all of this to a halt, to have 10% of U.S. surface warfare capability stand down, is an extremely difficult decision, in denial of “can-do.” It requires a comprehension of COVID-19 dangers that has been slow coming to everybody.  Captain Crozier may have been more viscerally aware than most flag rank officers of a particular danger.

The virulence of a virus can change. For each general type, there probably is an upper limit, but this is not known. In the 1918-1919 flu pandemic, virulence increased rapidly in military encampments.

This is discussed in COVID-19: A Warning. From The U.S. Military and the Influenza Pandemic of 1918–1919,

…during Chesney’s third phase, August 23 to November 8, more than one-third of the 6th Artillery Brigade, 1,636 soldiers, contracted influenza and 151 died. Chesney concluded that “…these successive outbreaks tended to be progressively more severe both in character and extent, which would speak for an increasing virulence of the causative agent.”¹³

The commanding officer of Camp Grant couldn’t take it:

…fellow officers later told reporters that Hagadorn had been showing the strain of the epidemic.^26,27 Troubled as more than 500 soldiers died of pneumonia under his command, on October 7, he committed suicide with a pistol shot to his head.

Hypothetically, in the high density living quarters of the Theodore Roosevelt, COVID-19 could mutate to greater virulence. History is full of apocryphal stories. The modern record is held by a  Hantavirus strain in the Four Corners region. In 1993,  an apparently healthy person  died in 3 hours.  (CDC) Tracking a Mystery Disease: The Detailed Story of Hantavirus Pulmonary Syndrome (HPS)

(NY Times) Navy Captain Removed From Carrier Tests Positive for Covid-19. This could be his get-out-of-jail card. It might also deprive the Navy  of a learning experience.

Captain Crozier identified and responded to a novel hazard that, without action, in all probability would have substantially disabled his ship and cost lives in the process. His response was unorthodox because the novelty might have concealed a time bomb with a short fuse.

 

 

 

 

 

 

 

 

(CNN) Commander of aircraft carrier hit by coronavirus removed for ‘poor judgment’ after sounding alarm.

Kudos, Captain Crozier.  You sacrificed your career to put pressure on the Navy brass. You saved lives.

History will judge you kindly.

***Run for office.***

 

P.S. (CNN) Sailors cheer for aircraft carrier commander who was removed after issuing coronavirus warning.

(CNN) Asia may have been right about coronavirus and face masks, and the rest of the world is coming around.

Up until this point, the media has repeated, without question, a “fact” that does not exist: “Surgical masks don’t work to protect the wearer from inoculation with airborne viruses.”  There never has been such a fact. Two studies, one lab, one clinical, contradict each other. The clinical study provides evidence that they offer some protection.

On February 29, in Can Surgical Masks Protect Against COVID-19 ? Wear a Scarf!, I wrote,

Follow the logic: If N95 masks protect, and surgical masks work about as well in clinical settings, then surgical masks protect. Remember the caveat. Now translate that into unmanaged news-speak:

Surgical masks might offer some level of protection, but nobody knows for sure.

I’m feeling righteously indignant, which is a rare and uncherished feeling. It’s not because:

• The world response has been a bungle from the start.
• The experts have been mostly wrong.
• Epidemiology failed to impact public policy in a timely manner.

No, that isn’t it. It’s this:

The healthcare establishment invented a “fact”, that surgical masks don’t work. The media swallowed it hook, line, and sinker, with these possible motivations:

• Health care professionals have good reason for priority supply of masks.
• Media may themselves have believed the “fact”, or, with overweening respect for medical authority, neglected to read readily available studies.
• It was easier to go with the flow than dig for the truth.
• A sense of paternal responsibility supervenes the above.
• It’s a white lie for a good purpose, akin to political spin.

Maybe surgical masks protect, and maybe they don’t, but there is no “fact.” It’s the job of the press to question, and they did not question this easy to undermine pseudo-fact. A study that suggests they are effective is referenced in Can Surgical Masks Protect Against COVID-19 ? Wear a Scarf!.

The media could have presented the whole argument, and appealed to patriotism, or the common good. I wrote,

Treat people like adults, and they are more likely to act as such. Even if you’re [media] into managing, there is another reason to avoid it: If and when the shit hits the fan, they are more likely to follow your lead.

Put another way, telling the truth grows the public trust and sense of responsibility. Treat them like children, and you get children.

Consciously or no, this media error is a manipulation of truth. Whatever the purpose, it is not harmless.  As pure as  intentions may be, the nonexistent “fact” that surgical masks don’t work against COVID is the essence of a white lie. It feeds the conspiracy appetite of the unbalanced.

We’re shocked when the conspiracy nuts crawl out of the woodwork. The nuts grow on trees, which we plant.

 

 

 

 

 

(NY Times) 72 Hours Inside a Hospital Battling Coronavirus  interviews Dr. Colleen Smith at Elmhurst Hospital in Queens, NYC. The Times is providing COVID coverage free to non-subscribers; this video should be universally viewable. At 4:00 in the video, she says, “What’s getting a little scary now is that the patients we’re getting are much sicker”,… “young people without comorbidity” , that is, underlying health conditions.”

Dr. Smith’s observation is unavoidably subject to confounding factors, a.k.a. “noise.” The swell of sicker patients could be individuals who thought they could tough it out, or are not very aware of how they feel. Still, it’s appropriate to consider that COVID-19 may be gaining virulence in NYC. COVID-19: A Warning.

Plagues of the past were characterized by  virulence that increased in waves. Many mechanisms, including but not limited to, mutation-evolution, are involved. Some of these are understood. Virulence factors are identified features of a pathogen which affect the severity of a disease.

There are huge holes of understanding. Knowledge of how these factors  work at the viral level varies from complete to partial to slight. How they turn on or off is partly, or in a few cases, completely understood. There  is no quantitative understanding that connects biochemical understanding of virulence with epidemiology. Yet the macroscopic viewpoint of epidemiology, with centuries of observation,  has much to say about it.

There is no way to predict the virulence of a  novel virus from viral genes. Understanding has come from the reverse direction: the mechanism of virulence is observed, and then identified in the viral genetics. This is because, despite unraveling of the genetic code, and detailed knowledge of a minority of cellular enzyme systems, most enzyme systems remain a mystery. There are just too many of them.

If you’ve been following the news, you know there is no way to predict R_o, or lethality of COVID, at all. It’s purely observational, depending not just on the pathogen, but the behavior of people, and how they live. It may depend so much on local circumstances to be an invalid concept. Later on, we’ll understand more.

The demand to know the future fuels predictions that have no basis. (CNN) Coronavirus deaths in the US could reach peak in three weeks, epidemiologist says. Of the four authorities, three are doubtful, or subject to misinterpretation in the context of the article. Dr. Stefan Flasche is credible. Quoting,

Dr. Stefan Flasche, a disease modeler at The London School of Hygiene & Tropical Medicine, told CNN by email the peak was influenced by the efficiency of lockdown measures, and “may be anywhere between some time very soon and not for another few months.”

“One scenario is we can indeed reverse the spread as done in China and South Korea, then reach a point to lift the distancing measures,” Flasche said. “But (we may) have to repeat this cycle for a few times because of an inevitable resurgence of cases in the absence of population immunity. In that scenario, we would see multiple peaks in the upcoming 12 months.”

In this vagueness, we have found an honest man. An honest team may be found at (pdf 16 March 2020, Imperial College COVID-19 Response Team) Impact of non-pharmaceutical interventions to reduce COVID-19 mortality and healthcare demand. They are honest because they lay out all of their assumptions, which are unavoidably incorrect. They are predictably wrong, just as the CEP (circular error probable for a gravity bomb) is predictable.

But what is an epidemiologist to do? WHO couldn’t even predict COVID-19 would get out of China, and we now demand detail? Ignored in normal times, this honorable and troubled profession is now belabored with impossible demands. In the press, this includes a hopeful confusion of “peak deaths”, which is a rate, versus cumulative mortality, which most article writers ignore, and looms bleakly in our future.

In China, two variants of COVID-19 have already been identified, Type L and Type S. COVID-19: A Warning. This factor is absent from all the predictions. The epidemiologists have too much on their plates to deal with it.

How do you find an epidemiologist you can trust? Throw him in the snake pit:

The Fortune Cookie (Snake Pit)

My apologies to all epidemiologists. I couldn’t resist it.

To be continued shortly.

 

 

You might think that all there is to a mask are billions of very tiny holes, small enough to admit air, but block particles. This is wrong.

Before the electron microscope was invented in the 1930’s, biologists already knew of infectious agents that could pass through a block of unglazed porcelain. Hence the term, seldom heard these days, filterable virus.

So catching a virus that can pass through porcelain with something that looks like fabric is quite a trick. The secret: electrostatic charge. If on a dry day, you’ve ever had to unpack a box containing packing peanuts, and found that the peanuts tend to stick to you — that’s electrostatic charge.

It turns out that common, nonconducting materials can be so charged. Synthetic fibers can be placed between high voltage plates. When heated, the fibers become electrets, behaving  analogous to magnets, acquiring permanent electric polarization. An electret has a + side and a – side. There are excess electrons on the – side, and a shortage of electrons on the + side. (Don’t be confused by the + and -. It’s an old convention.)

Electret materials are found in most microphones, many furnace filters, and high efficiency masks. Electrets attract and grip most small particles, even if they are small enough to pass through the pores of the mask.

But electrets have a shelf life. The charge in the fibers equalizes in time, at which point the mask behaves like it is made of plain fabric.

This is also why a high efficiency mask cannot be washed. On contact with water, the electret charge leaks around and equalizes. The excess electrons on the – side fill the vacancies on the + side. After washing, the mask is about as good as your scarf.

Your scarf is not totally useless, but it’s not enough for the exposure of a clinical setting.

 

 

(CNN) Fauci says ‘there isn’t, fundamentally, a difference’ between his view and Trump’s on coronavirus. Quoting,

“I, on the other side, have said I’m not disagreeing with the fact anecdotally they might work, but my job is to prove definitively from a scientific standpoint that they do work,”

There is a disagreement. Fauci may not have ice-water in his veins, and Trump knows the meaning of “Show me the money”, but the two are close to opposite poles. Some philosopher, so obscure I can’t Google him up, said, “Truth is found at the meeting of opposites.” If we were flies on the wall, their differences might sound like that.

Medicine restricts “proof” to double blind testing, which means that neither the physician or the patient know whether the actual treatment, or a placebo, is being received. This avoids prejudice in the observations of the clinician. Even subjective observations of the clinician, like “patient seems stronger”,  have value in a double-blind study.

What of the patients who are harmed? The ethical rationale is that it saves lives in the long run.  Let’s consider a double-blind drug trial which enrolls 1000 patients. Half receive the drug-candidate. Half receive the placebo. Unknown to the experimenters, the drug has one of three actions:

• Promotes recovery.
• Has no effect.
• Harms the patient .

After some period of time, the results are “unblinded.” For the first time, it is possible to see who was getting what, and the likely effects of the drug. Results:

• If the drug is bad, no more than 500 patients will get hurt.
• If the drug has no effect, nobody gets hurt.
• If the drug is good, how many people get hurt?

A double blind trial, with patient consent, is a unique loophole in our legal system, and the exception to the Hippocratic “Do no harm.”  Suppose the drug is one which may have a very long use. For the next 50 years, the drug will be the standard of care.  The double blind method attempts to ensure the maximum benefit for all future patients. It does this by risking the lives of current patients for the benefit of the indefinite future.

Now I’m done extolling the virtues of double-blind testing. It has these disadvantages:

• It is too slow for a plague situation.
• It may be sacrificial of people’s lives.
• Alternatives exist that, sacrificing scientific purity of thought, would likely save more lives.

See (NCBI) Probability, proof, and clinical significance. We live in a world of probabilities. In a study of 1000 patients, there is a possibility that the study results, good, bad, or indifferent, are due to chance. This chance is called P.  Fauci’s acceptable P is probably the conventional choice, 0.05, a 5% chance the study is wrong.

Increasing P means the study can finish sooner, with earlier availability of a drug. This comes with a greater chance the study is wrong and the drug useless or harmful. This is hard to justify if we’re not in a plague situation. But note, compassionate availability of unapproved cancer drugs has been the standard for some years now.

Increasing P can be justified in a plague situation, because of the otherwise certain death of large numbers of patients. It means that regardless of the intent of the drug trial organizers, their choice of P directly affects the survival large numbers of non-study-participants.

This would be evident if a cost/benefit equation, for a drug trial in plague conditions, with the goal of optimizing P, were part of the canon of applied medical statistics. But it’s missing.

The technical resources available to Dr. Fauci could quickly provide the missing equation, minimizing cost by varying P in line  with the current crisis.

My guess: P= 0.25. It shortens the required length of the study, with the likelihood (chance always intrudes) of saving the lives of the large numbers of critically ill who are not study participants.

 

 

 

 

 

 

 

 

 

 

 

Even in this life-and-death situation for so many people, CDC remain staunch in defense of double-blind testing.  Now that several months have passed, politicians, commentators, scientists and doctors have all been humbled. Perhaps there is an opening for non conventional thinking.

Steven Collinson’s editorial,  (CNN) Trump peddles unsubstantiated hope in dark times, politicizes a scientific question. Mr. Collinson would have done better to focus on the medical issues. He chose instead to follow the path of Socrates, an otherwise great thinker who made a great mistake. Socrates declaimed that all he had to know he could learn from “men in the city.” He saw no need for natural science. Socrates was the first thinker to politicize science.

Double blind testing is dear to medicine, because for all but the last 150 years, medicine killed more people than it healed. Double blind testing is ritual purity, because it removes human judgement from the outcome. It would have saved humanity from these deadly treatments:

• Bloodletting.
• Purgatives.
• Roentgen therapy, X-rays as a healing source — not to be confused with legitimate radiation therapy.
• Thorotrast.
• Thalidomide in pregnant women.
• The opioid epidemic.
• In the 1918 flu epidemic, a massive dose of aspirin, as much as 30 grams in one dose, was frequently prescribed, which by itself would kill the patient.
• To the above, add the lay healers, swallowing chlorine bleach. Laetrile, and, in many cases, herbs.

Yet during World War I, military surgeons packed wounds with pure sugar, which worked to prevent gangrene. Pure sugar is toxic to bacteria.  Nobody thought of double blind testing while Doctor Sawbones waited.The history of medicine is littered with treatments that worked, yet are forgotten:

• Coley’s toxins.
• Arsenic for some neoplasms, which has recently been revived as an import from China.

The Wikipedia article on Coley’s toxins begins with the statement,

“There is no evidence that Coley’s toxins have any effectiveness in treating cancer, and use of them risks causing serious harm.^[4]“

The statement is false. It is true is that Coley’s toxins were extremely dangerous, yet acceptable as a personal choice in a time when no alternative treatment, even palliative, was available. If you ignore the opening statement, and read the article without the prejudice of the opening statement, you may conclude that there is a better than even chance that Coley’s toxins did some people some good. The rest faced inevitable death.

Today you have better alternatives, treatments that target the immune system blockade, without risking deadly bacterial infection.

Now refocus on the statement, “”There is no evidence that Coley’s toxins…”  It’s wrong! It is more correct to say, “If someone offers to treat you with Coley’s toxins, run in the other direction.” But somehow, it got dumbed down. Why?

It is an expression of two cultures:

• Medical culture, which medical practitioners subscribe to, based on science but going beyond science to include paternal responsibility towards the patient and the public.
• Consumer culture, which accepts the paternal role of professional medicine, with simplification of the truth.

With all this culture, and the very sophisticated statistical methods of research medicine, something is missing: modern decision theory. It’s missing because double-blind testing is the medical equivalent of ritual purity. We need it now.

To be continued shortly.

 

 

 

 

 

 

 

 

Inspired by the brave Italians, let’s do a little singing. In NYC, there aren’t many balconies, but there are plenty of fire escapes:

Luciano Pavarotti – Funiculì Funiculà

There is actually a joke-inside the joke. The song is not from opera. It was written as a  joke by an Italian newsman.

Now belt it out!

I wrote this so long ago, it’s fresh as a daisy. Just substitute “COVID-19” for “Ebola”:

Ebola Vaccines, Medical Ethics, and Manslaughter.

It’s about conflicting values:

• Purity of the scientific approach, which requires double-blind testing.
• Fear of legal liability.
• Saving lives now.

The system rewards adherence to norms. If, like many pandemics of the past, there is a second more deadly wave, the practically impenetrable defense is “We didn’t see it coming.” No good deed goes unpunished.

Health care is the one area of our lives where we accept a level of paternalism that is otherwise unacceptable. You don’t have to be a libertarian to see the value of a partial exception for COVID-19:

Legislation that permits a private individual, and a vaccine company of good scientific repute which has completed favorable Phase 1 trials, to make a contract that limits liability for the many vague and unsubstantiated complaints that can be wrongly blamed on a novel antigen.

If life were a gaming table, our mutual choices, of citizen and vaccine maker, would be:

• Keep playing.
• Step away from the table

But it’s not a game, and we can’t step away from this.

 

This is a short continuation of U.S. spy agencies monitor COVID-19, concerns about India, mainly for people who understand the basics. The primer will come later. We now know that there are at least two strains of COVID-19, which compete by the laws of natural selection.  (Oxford Scientific) On the origin and continuing evolution of SARS-CoV-2. Type L produces severe disease; Type S is comparatively mild.

The following was mentioned in COVID pandemic “could be over by June” Chinese adviser; Third World Reservoir.   Delving deeper,

• In China, selective pressure towards Type S may have occurred, resulting from stringent quarantine, a reduction of virulence.
• Yet Type L evolved from Type S, in the direction of greater virulence. It is logical to extend the inference: Early in the Wuhan transmission chain, before quarantines, Type L was selected, with greater virulence.
• This partly thought and partly real experiment implies that social behavior, particular to a society, strongly affects the competition of Types L and S.

Village India, like Village Pakistan, harbors the remains of tribal culture in the panchayati raj system of local government, dating to 250 AD. Villages contain strong elements of extended family, frequently acting in ways that are officially forbidden by  central governments. Items that occasionally make international news  include honor killings and femicide, with infanticide too common to report.

Now assume that in some village somewhere in the Third World,

• There are not already circulating corona viruses with enough sero-similarity to provide some immunity.
• COVID-19  arrives, quickly differentiating into something like Type L and S.
• The sanitary infrastructure is weak, so isolation is impossible.

How natural selection acts on types L and S depends upon social choices innate to the villages. Types L and S may not even be identified by a village as related diseases. Customs older than recorded history provide the framework for response. Which custom will dominate?

• The village implements a non selective quarantine, nurses the sick, and disposes of the dead with aseptic funerary rituals. No selective pressure.
• The severely ill die before expulsion. As with Ebola, preparation of the dead for burial is a major driver. Type L out-competes Type S.
• Expulsion of the severely ill. Type L-infected dies alone on the road. Possibly selective for Type S.
• Inside-out reverse quarantine. With leprosy as the precedent, the village nurses the mildly ill and expels the severely  ill. The severely ill person transits to another village, and is taken in by relatives. Type L out propagates Type S.

While the China experience suggests that quarantine allows Type S to out compete Type L, the inside-out reverse quarantine does the opposite. It promotes Type L, of greater virulence.

See COVID-19: A Warning. Other ways in which virulence can be promoted will shortly be discussed.