It's Not Disinformation, It's Just Complicated

The libel laws in the United States are famously protective of as much speech as possible. In the UK, in order to be protected from a libel suit, a publication must prove that the thing they said is true and that they knew it to be true when they said it. By contrast, in the US, the person suing a publication must prove not only that what was printed was false AND that the publication knew it was false AND, with “actual malice”, printed it anyway.

When it comes to disinformation in an age of COVID, I’m developing a similarly strong personal requirement for calling something “disinformation”. A lot of the information surrounding COVID requires layers of understanding. Without this layered information, it is easy to see an isolated piece of information and barrel ahead with it as if it is orphaned from any surrounding context.

With this in mind, I don’t think it helps to get snotty and sneer at people who see some piece of information and, lacking the appropriate foundational context, take it at face value and move forward with it. I’m not sure how much faith I have that I can be a convincing source when someone doesn’t want to be convinced, but I am fairly certain that calling someone an idiot is not an effective communication strategy.

To that end, I don’t want to call these things “disinformation”. I hold my ground firmly at the position that most people do not share information with the intent to mislead. I’ve been following this for months, reading studies, doing interviews, digging deep into the details. I follow dozens of healthcare professionals, virologists, and epidemiologists. And, for the second item in this newsletter, I had to have someone explain it to me like I was a child.

Understanding things is not easy. It is hard. It takes practice and patience.

I’m holding fast to the position that grace and generosity will help us through this better than sneers and condemnation.

• The 6% Solution (Are COVID deaths really only 6% of the official number?)

• Are We Overcounting COVID Infections?

• Disney Shorts: Foul Hunting

The 6% Solution

Flying around the interwebs is this concept that the CDC itself admitted that only 6% of COVID deaths are actually from COVID alone. The implication is that deaths that list and additional cause (which is known as a comorbidity) weren’t really caused by COVID but the person who died would have died of cardiac arrest or respiratory failure anyway and just happened to also have COVID.

Essentially, when we see this idea that we’re seeing a “normal” death and attributing it to COVID, this is what we are doing.

This line of reasoning comes from this CDC report that lists COVID deaths along with “Conditions Contributing to Deaths where COVID-19 was listed on the death certificate”.

The combination of COVID and other comorbidities on a death certificate has been long known. In fact, it was the study of comorbidities that first gave us the hint that COVID was a blood disease and not a respiratory one. I read about this back in March, in earliest days of the crisis when we all still thought this was primarily a respiratory disease but a study of existing conditions showed that hypertension, diabetes, and cardiovascular diseases were far more predictive of COVID complications than respiratory diseases.

What is grimly funny to me is that this is a poorly understood concept that I’ve actually written about previously. Back in May, there was this theory that Florida was having a surge in pneumonia deaths that were actually COVID deaths. It turns out this was not true, most of the COVID + pneumonia deaths were being properly captured in the medical mortality codes (which I wrote about in detail in that same issue).

The CDC report that people are talking about is a deep-dive into the topic of medical coding. When someone dies, the cause of death is complicated. It could be that someone had cancer (which has weakened their immune system) and then they caught the flu and died. If they didn’t have cancer, the flu wouldn’t have killed them. If they didn’t catch the flu, their cancer wouldn’t have killed them. The two diseases jointly contributed to the death and the death certificate is an attempt to reflect that reality.

That is what is happening here. Most of the people who die of COVID already have some health problem. Almost half of Americans have some form of heart disease. Millions more have asthma (which is considered a chronic respiratory disease). If someone with COVID died with these existing medical conditions, they would be listed as comorbidities. That does not means that COVID *didn’t* kill them, it means that COVID worked together with their other health problems to overwhelm their bodies. Insisting that COVID was merely an incidental factor… well that is like:

This comorbidity information is important to capture because it helps us learn and get better at protecting ourselves from this disease. But it’s complicated information and easily misunderstood without all that background.

Are We Overcounting COVID Infections?

The second round of misunderstanding comes from this New York Times article, which is unhelpfully titled “Your Coronavirus Test is Positive. Maybe It Shouldn’t Be”.

This was a harder one to untangle. First of all, the title sets the stage for this sense that we’re doing something wrong, that we’re over counting COVID infections. But the reality requires a little bit more nuance.

The problem we have, the problem identified in this article, is a problem that combines testing with policy proscriptions. Someone goes in for a COVID test. They test positive. Now they need to quarantine for two weeks, as does everyone they came into contact with. This is based on a binary result, positive or negative, yes or no.

But what Dr. Michael Mina (the main source of the article) was trying to get across is that there is a difference between being infected and being infectious. A person may test positive for COVID (which means they were infected) but they could have been infected weeks ago and are long past a point of being contagious. Dr Mina wants tests to start delivering more than a binary yes/no. He wants them to include the viral load.

Michael Mina @michaelmina_lab

We can use all the information obtained from the #COVID19 PCR test - including the amount of virus detected in a sample. Unfortunately, we convert a numeric value to just say positive... without distinguishing 10 viruses from 10 billion viruses! 4/17

What Dr Mina is suggesting is not that we reclassify low levels of COVID infection as “negative”, which is what it sounded like from that headline. What he is suggesting is that we find an effective way of making the distinction between someone who was infected but is not contagious and someone who is still dangerously contagious. He thinks quarantine is too severe and too blunt an instrument and that we should find a way to quarantine only those who are in the infectious stage.

Michael Mina @michaelmina_lab

Instead it turns out that most people who are found positive via asymptomatic testing are long past their infectious stage - perhaps over 70%! So perhaps 70% of asymptomatics who get quarantined don't need to be! 13/17

Michael Mina @michaelmina_lab

So much focus on sensitivity of the test. As though all tests must match up to PCR But could focusing so much on achieving the greatest molecular sensitivity for asymptomatic testing *when testing is infrequent* be doing more harm than good? I’ll explain 1/

This is a much more nuanced position than “maybe your test shouldn’t be positive”. but it is one that could have very big ramifications in how someone who has taken a COVID test should properly respond.

I feel like we’ve been at this long enough that we shouldn’t still be making these kinds of nuanced discoveries, but we are. There is still a lot to learn, a lot to process, and a lot to improve in our responses and proscriptions, from our personal responses to state or national policies.

We need to remain open and flexible to new information and new strategies. And we need to try to hold off on acting before we understand the full context of the new information we just learned.

Disney Shorts: Foul Hunting

This is a delightful Goofy short that is actually a pretty good pair for Goofy and Wilbur (which I watched about a month ago). Goofy goes duck hunting and the first half of the short holds a really funny sequence in which Goofy gets frustrated for a real duck for acting too much like his decoy duck, Clementine. As we move through the short, we get jokes about gun safety, about Goofy’s sneezes attracting ducks, mimicry and the hunter’s joy of abundant game.

This short is just non-stop high-quality physical comedy and it reminds me of why I love Goofy so much. I’ve seen this a dozen times and I still laugh out loud at several parts, especially the delightful ending.