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A prelude: “Where is the humility in our public health officials to simply say we were wrong?”

On May 25th 2021, The New York Times published an article that criticized the CDC for saying that “less than 10 percent” of Covid-19 transmission occurred outdoors. It correctly said that “Saying that less than 10 percent of Covid transmission occurs outdoors is akin to saying that sharks attack fewer than 20,000 swimmers a year. (The actual worldwide number is around 150.) It’s both true and deceiving.”

This article caught the eye of Dr. Marty Makary a professor of surgery at Johns Hopkins University. Dr. Makary has been discussed on this blog before, in particular his dubious claim that medical errors were the third leading cause of death in the US. Dr. Makary reacted to The New York Times article by reasonably asking on Twitter:

 

It’s a fair question.

“Covid-19 will be mostly gone by April.”

With this is mind, it is worth revisiting another claim of Dr. Makary’s. In an article from February 18th 2021 titled “We’ll Have Herd Immunity by April,” Dr. Makary predicted that “Covid-19 will be mostly gone by April.” He felt that due to widespread immunity, from both the virus and vaccines, “there may be very little Covid-19 by April”. Many scientists found the article flawed at the time and debate ensued. Time would tell who was right and who was wrong.

Herd immunity 101

An article from Dr. Makary’s university described herd immunity thusly: “When most of a population is immune to an infectious disease, this provides indirect protection—or population immunity (also called herd immunity or herd protection)—to those who are not immune to the disease”. The article gave examples of measles, mumps, polio, and chickenpox as diseases for which herd immunity exists in the US, while noting that outbreaks can still occur in pockets of unvaccinated people, as occurred with measles during an outbreak in Disney World in 2019.

Herd immunity depends on both the virus and the population. A more contagious virus will have a higher herd immunity threshold. The chances of achieving herd immunity increases with every person who becomes immune, either through the virus or a vaccine. People’s behavior also matters. A community where choirs gather in a small, poorly ventilated rooms will have a higher herd immunity threshold than a village of isolated hermits. In the words of Dr. James Hamblin, “if we all sealed ourselves in isolation pods today,” COVID-19 could not spread and “there would be no more deaths.” Few of us are hermits though, so widespread immunity in the population, hopefully via the vaccine, is our only way out of this mess.

Importantly, herd immunity is often a highly local phenomenon. One neighborhood may have herd immunity while another may not. Outbreaks can occur in highly vaccinated populations if unvaccinated people cluster together, as they often do. There was a measles outbreak in New York in 2019 that clustered over a few neighborhoods where parents had not vaccinated their children. The rest of the city was spared.

The notion of herd immunity arriving to an entire country of 330 million people, as Dr. Makary suggested would happen in April, is largely fantastical for the foreseeable future. We’ll know the US has reached herd immunity for COVID-19 when there are sporadic, limited outbreaks here and there, but there is no sustained transmission of the disease, as is currently the case for measles and chickenpox.

“The concept of herd immunity was one that got misinterpreted as eradication”

Soon April came and went. Dear reader, I have some sad news. The US did not reach herd immunity to COVID-19 in April. On April 1st, there were over 65,000 COVID-19 cases, on April 16th, there were over 78,000 cases, and on April 30th, there were over 50,500 cases. Well over 1.5 million Americans were infected with COVID-19 in April, reflecting sustained transmission of the virus.

At this point, Dr. Makary had a choice:

 

He could admit herd immunity had not arrived to the US or he could claim it had. Dr. Makary chose to claim the US had reached herd immunity. In an article from June 8th, he wrote that “The news about the U.S. Covid pandemic is even better than you’ve heard”. He then said:

With more than 8 in 10 adults protected from either contracting or transmitting the virus, it can’t readily propagate by jumping around in the population. In public health, we call that herd immunity, defined broadly on the Johns Hopkins Covid information webpage as “when most of a population is immune.” It’s not eradication, but it’s powerful.

According to Dr. Makary, there was no problem with his prediction of herd immunity in April. Rather, everyone else failed understand the concept. As he put it in an interview, “the concept of herd immunity was one that got misinterpreted as eradication”.

Herd immunity has not arrived in the US

Unfortunately, the virus did not read Dr. Makary’s article, and it doesn’t know that “it can’t readily propagate by jumping around in the population”. In fact, according to The New York Times, as of July 23rd, cases have increased 173% in the past two weeks and cases are on the rise in all 50 states. There were 81,732 cases on July 23rd. Not once during the summer of 2020 did this many people contract COVID-19. According to one report, “91 million people, live in a county considered to have ‘high’ Covid-19 transmission, according to data from the CDC”. Florida is leading the way with an average of 10,000 cases per day. Los Angeles, which Dr. Makary singled out as a success story to demonstrate herd immunity had arrived, had 10,000 new cases last week. According to one news report, “The county reported a 20-fold increase in new cases over the previous month, according to the public health department.”

I never thought herd immunity was around the corner, but we seem to be in much worse shape than I thought we’d be just six weeks ago.  At that time I wrote, “Barring a nasty variant, the worst is over for America and its children.”  Sadly, a nasty variant arrived, and I now fear the worst may be yet to come for children in America.

Perhaps Dr. Makary is right, and I am confusing the concept of herd immunity with eradication. But cases rising 173% over the past two weeks does not seem consistent with a country that has enough immunity that the non-immune are protected. If there was enough immunity for that kind of protection, how could cases have risen by 173%? Tens of thousands of people are still getting COVID-19 every day. This number doesn’t disturb us as much as it should because we compare it to the hundreds of thousands of Americans who contacted the virus daily this winter.

“We need to move on at some point”

We will likely never completely eradicate COVID-19, but we are getting a bit closer every day as hundreds of thousands of Americans gain immunity. Happily, many more people are gaining immunity via the vaccine than via the virus. Just because I acknowledge the obvious fact that herd immunity has not arrived for the US, I am not obligated to take a pessimistic view of America’s future. Dr. Makary is right that most adults in America are immune to COVID-19. We will almost certainly never have months in a row where over 1,000 Americans die daily. Again with the caveat that a nasty variant could change everything, I am confident the worst is over for the US as a whole, at least for vaccinated people.

But it’s not entirely over, and the trends are not encouraging. Currently, decreasing numbers of people are gaining immunity via the vaccine and increasing numbers of people are gaining immunity via the virus. Many parts of the country are having worse outbreaks than they did in 2020. The stories coming out from places such as Arkansas and Missouri are heartbreaking, especially since many children and young adults are getting really sick, an avoidable fate for those 12 years and older.

As with cases, hospitalization and deaths are also increasing. Hospitalizations have increased 57% and deaths have increased 20% over the past two weeks. 271 Americans are dying every day of COVID-19. Again, I think this number seems small only because we compare it to the horror of this winter. There’s no expectation that this will change for the better in the immediate future. Some disease models are forecasting it will get much worse in a few months, actually. Hopefully this is wrong.

However, tens of millions of Americans remain vulnerable, and though the reasons are varied, many of them won’t be vaccinated it seems. Eventually, I believe almost every American will gain some form of immunity to COVID-19. This is probably true for most people in the world, actually. Hopefully most people will get immunity via the vaccine. Unfortunately, vaccinations rates remain very low in large swaths of the country, and this is unlikely to change.

In 2019, measles outbreaks impacting just over 1,000 people none of whom died were rightly considered unacceptable. I remember in 2015 when the death of one woman from measles was a big deal. Now, 270 people are dying an easily-preventable death every day. Many thousands more are hospitalized. COVID-19 has drastically changed our perception of how much death and suffering we find acceptable. This is especially the case considering that almost none of this would be happening now if every eligible American had been vaccinated. Indeed, the news is full of people regretting their decision not to get vaccinated.

I realize that some people still have significant barriers to getting vaccinated, but I don’t think we’ve really appreciated the stunning body count that is the direct responsibility of the anti-vaccine movement today. Anti-vaxxers recently harassed a cancer patient for wearing a mask. There is something deeply broken in our country. Dr. Makary did acknowledge that people “need to be careful if they’re unvaccinated and not had the infection” but he followed this by saying “we need to move on at some point”.

This raises an interesting question. As Dr. Makary thinks the US has reached herd immunity and we need to “move on,” why is he still talking about COVID-19? This question also applies to other doctors who have begged others to stop talking about the pandemic and said it was “essentially done“. Some doctors have an unfortunate habit of declaring herd immunity was at hand in places (India, California, India again) that had large surges (India, California) shortly thereafter. Every editorial they write, every interview they give, and every tweet they send on COVID-19 is a tacit admission they were wrong, and the pandemic is not over. If doctors feel the pandemic is largely over for COVID-19 and that we need to “move on” and stop talking about it, shouldn’t they lead by example?

“I am not aware of a single healthy child in the US who has died of COVID-19 to date.”

It’s a tragedy how much vaccine is sitting unused in American refrigerators, but it’s understandable to a degree. Many young, unvaccinated Americans and their parents likely believe herd immunity has already arrived in the US. They too believe it’s time to “move on.” Many young people also likely believe the disease holds “almost no risk” for someone like them. I know where they got these ideas. Smart doctors with stellar academic credentials told it to them.

For example, in an article written June 10th 2021 titled “Think Twice Before Giving the COVID Vax to Healthy Kids”, Dr. Makary wrote:

In reviewing the medical literature and news reports, and in talking to pediatricians across the country, I am not aware of a single healthy child in the U.S. who has died of COVID-19 to date.

As evidence for his extraordinary claim that no healthy children died of COVID-19 in the US, he referenced his own paper and claimed it was a study of “pediatric COVID-19 deaths”.

He said this paper found that “100% of pediatric COVID-19 deaths were in children with a pre-existing condition”. In another editorial titled “The Flimsy Evidence Behind the CDC’s Push to Vaccinate Children”, he suggested that pediatric death tallies may be inflated. He again touted his paper, saying it examined “approximately 48,000 children under 18 diagnosed with Covid” and that “Our report found a mortality rate of zero among children without a pre-existing medical condition such as leukemia.” “If that trend holds, it has significant implications for healthy kids and whether they need two vaccine doses,” he continued.

Dr. Makary’s report, was titled “Risk Factors for COVID-19 Mortality among Privately Insured Patients: A Claims Data Analysis”. It was published as a “white paper,” not in a medical journal. Though he claimed it was a study of “pediatric COVID-19 deaths”, the words “child,” “children,” and “pediatrics” do not appear in the paper, though there is a discussion of Alzheimer’s disease in relation to COVID-19.

The paper reported on 2,753 people who died of COVID-19 from April 1, 2020, through August 31, 2020. Of these, 0.11% deaths occurred in children under 18-years. This means his supposed study of “pediatric COVID-19 deaths” reported on just three deceased children.   He has mentioned this paper in at least three editorials thus far, which equals the number of deceased children it contained.

Dr. Makary’s claim that every American child who died of COVID-19 had a pre-existing condition was based on a paper that ended in August 2020 where just three children died and his own inability to find examples of healthy children who died. The “trend” he says has “significant implications” for vaccine policy was based on less than 1% of the total pediatric deaths and cases as of today. Though Dr. Makary castigated the CDC by writing, “I can think of no journal editor who would accept the claim that 335 deaths resulted from a virus without data to indicate if the virus was incidental or causal, and without an analysis of relevant risk factors such as obesity,” his paper doesn’t meet this standard. It presented no data about the three deceased children beyond noting they were under age 18 years and had some underlying condition.

It’s great that no healthy children died of COVID-19 in his paper.  But it does not follow that all the children who died of COVID-19 therefore had underlying disabilities. The only conclusion one can possibly draw from this paper is that children are much less likely to die if they contract COVID-19 than adults, but we knew that by November 2020 when it was published. The paper says nothing about the characteristics of children who died from COVID-19. To learn about this population, we would need to study the 99.4% of deceased children that were not covered in his paper. Dr. Makary does not mention in his editorials that his paper included just three deceased children. I wonder why this is.

If we pretend that meaningful information about pediatric mortality could be gleaned from a paper with just three deceased children, we’d realize it found a relatively high mortality rate. It examined 467,773 patients diagnosed with COVID-19 and 6.61%, (31,000 patients) were under age 18 years. (I do not know why Dr. Makary claimed in an editorial that it studied “approximately 48,000 children.”) As three children died, this means about 1 in 10,000 children died, a much higher rate than reported elsewhere. As there are 73 million children in the US, this death rate would mean that over 7,000 children would die if the virus were allowed to spread unchecked throughout the pediatric population. This would easily make COVID-19 one of the leading causes of death for American children. As they say, “big, if true.” Yet, to my knowledge, Dr. Makary has not commented on this particular “trend” his paper uncovered. I wonder why this is.

I am aware of healthy children in the US who have died of COVID-19

Like Dr. Makary, I too reviewed the medical literature and news reports. I found different results. According to the CDC’s COVID Data Tracker, 498 children 17 years or younger years have died of COVID-19 in the US. This number was derived from an analysis of 83% of the total number of COVID-19 deaths, so the actual number of pediatric deaths is certainly a bit higher than this.

Moreover, a simple Google search returned an article titled “Parents Say 5-Year-Old Daughter Who Died From COVID-19 was ‘Perfectly Healthy'” and another titled “4-Year-Old CNY Boy Who Died of Covid Complications Had Been Healthy: ‘I Lost My Miracle Baby.'” I read about a child from Minnesota in an article titled “Child Under 10 With No Underlying Conditions Dies From COVID.” A 9-month-old who “did not have an underlying health condition” also died in Minnesota. I read about a child “with no underlying conditions” who died in Tennessee and a 7-year-old from Georgia who “had no underlying health conditions.” Kimora Lynum, a 9-year-old with “no underlying conditions” died in my hometown, Gainesville, Florida. Skylar Herbert, a 5 year-old from Detroit also had “no underlying health conditions” when she died of COVID-19. I read about Dykota Morgan, a 15-year-old girl from Illinois, “whose parents said she had no underlying medical conditions.” She was a basketball player who died just two days after contracting the virus.

Even though my quick Google search yielded triple the number of data points as Dr. Makary’s paper, I am well aware that the only conclusion that can be drawn from such a small sample size is that Dr. Makary is wrong – some healthy children have died of COVID-19. Dr. Makary’s supposed “trend” of no healthy children dying of COVID-19 didn’t hold up, sadly.  Each of these deaths is a tragedy, and I encourage you to read about a few of these children. Even though healthy children rarely die of COVID-19, it’s important to remember there are real lives behind the numbers. As CDC Director Dr. Rochelle Walensky said, “Children are not supposed to die”.

More formal evidence exists that healthy children can die of COVID-19 is readily available. In September 2020 the CDC reported on 121 deaths of people younger than 21 years, half of whom were younger than 18 years. It found that “Among the 121 decedents, 30 (25%) were previously healthy (no reported underlying medical condition).” Presumably at least one of these 30 deaths was in someone younger than 18 years. Although I would like to see updated numbers, there’s no reason to think that they would be substantially different than these 121 cases. Dr. Makary is either unaware of this study or inexplicably chose to omit it from his editorials. In fact, he wrote a whole editorial in a major American newspaper largely predicated on his belief that this CDC analysis did not exist.

To be clear, I fully agree that healthy children dying of COVID-19 is an exceptionally rare occurrence. It is so rare that these tragedies often make the news. The overwhelming majority of children who contract COVID-19 will be just fine, thankfully. About 500 children have died of COVID-19 and over 26 million have been infected, according to CDC estimates. This means that only about 1 child in 50,000 who contracts COVID-19 will die, and the risk for healthy children is lower than this.

But there is some risk of a devastating outcome, for even healthy children, and these low-risk events multiplied many millions of times add up to non-trivial numbers. At least I feel that way. As around 25% of deaths are in healthy children, this means COVID-19 has killed about 125 healthy children so far. Tens of millions of children remain vulnerable, and more healthy children will certainly die moving forward, including some who are currently eligible for the vaccine.

Though Dr. Makary has not minimized the dangers to children with underlying medical conditions, many others ignore these children too. I’ve read multiple essays on COVID-19 and children that don’t even mention that children can die of COVID-19. Instead, they only describe severe harms to children as “very rare”. Often on social media it seems as if children with medical co-morbidities don’t really matter.  But as obesity and asthma are the most common underlying condition in children who die of COVID-19, most deceased children were robbed of many decades of life.  Even the vast majority children with leukemia, which Dr. Makary gave as an example of an underlying condition, are expected to be alive five years from now.

Of course, the death of a vulnerable child is just as tragic as the death of a healthy child. This is too often forgotten, as is the fact that these vulnerable children can be further protected when their healthy classmates are vaccinated.  Again, children are not supposed to die,

Death is not the only bad outcome from COVID-19

In one of his editorials on the vaccine, Dr. Makary said “A tremendous number of government and private policies affecting kids are based on one number”, the number of children who have died of COVID-19. While death is clearly the worst outcome of COVID-19, it is not the only bad outcome, and Dr. Makary is wrong that policies are based solely on the number of deceased children.

The CDC was quite explicit that preventing hospitalizations was a driving force behind vaccinating adolescents. As they put it, “The benefits (prevention of COVID-19 disease and associated hospitalizations, ICU admissions, and deaths) outweighed the risks (expected myocarditis cases after vaccination) in all populations for which vaccination has been recommended”. They even calculated exactly how many cases and hospital/ICU admissions they expected the vaccine would prevent and put this on widely-viewed slides.

 

 

Readers of Dr. Makary’s editorial won’t know any of this, of course.  Dr. Makary’s incorrect claim that vaccine policies are based on just one number opens his editorial, and the rest proceeds in a similar fashion.

Many children have been hospitalized with COVID-19. Even accounting for over-counting due to incidental COVID-19 cases, tens of thousands of children have been hospitalized. A non-trivial number of these children are very sick, intubated in the ICU.  A very small number of children have been devastated by the virus.  One 17-year-old needed a double lung transplant, while a 10-year-old had his hands and feet amputatedStrokes have also been reported in children due to COVID-19.  These children survived, thankfully, but they suffered tremendously, and their lives have been permanently altered.  Those of us who favor vaccination in adolescents expect the vaccine will prevent these tragedies as well as save lives.

There are warnings the next few months could be very difficult for the vast majority of children who are unvaccinated.  According to one doctor in Arkansas, half of the children currently hospitalized with COVID-19 are “old enough to be vaccinated but have not received the vaccine yet”.  He said these adolescents are “the ones that are in the ICU that have COVID-pneumonia and are requiring significant support”. He also said that hospitalization rates are increasing, and incidental COVID-19 diagnoses are now uncommon.  Additionally, there may be long-term consequences we cannot currently appreciate. Articles that suggest healthy children should not be vaccinated against COVID-19 rarely mention any of this, even as they invariably mention the shorter, less frequent hospitalizations caused by vaccine-induced myocarditis.

To his credit, in one of his editorials, Dr. Makary did acknowledge multisystem inflammatory syndrome (MIS-C) and its complications, including death in some children. Surprisingly, many articles on children and COVID-19 omit this devastating entity. Dr. Makary noted that no cases of MIS-C were reported to the CDC the week he wrote his editorial. At that time, he reported 4,018 children had the disease. Eighteen days later the CDC reported 4,196 MIS-C cases, though this may be a substantial undercount of the total cases. So, 178 cases of MIS-C were added to the tally less than three weeks after Dr. Makary wrote his article. Most children with MIS-C go to the ICU and many need to be intubated. These children are very sick, and MIS-C can affect children without underlying conditions.

People who declare some bad aspect of the pandemic over because metrics are good at that moment remind me of Senator Jim Inhofe, who famously brought a snowball to Congress to refute climate change. Because it was cold that day, he reasoned, climate change must be a hoax. COVID-19 will ebb and flow as viruses always do, but it won’t vanish, and we must not be too careful to predict its future by looking at a small snapshot of time. If unvaccinated people wish to avoid the virus, they will not just have to do so not just this week or this fall, but for the rest of their lives. I think the Delta variant will make that very difficult to do for all but the most isolated people. As recently as May, UK health ministers were predicting COVID-19 would be gone there by August. I thought it was possible too. Now cases are surging there even before they fully opened up. This is all due to the Delta variant, which accounts for 83% of new cases in the US.

It is reasonable to expect a doctor with a large platform to be accurate and thorough when engaging with the public about children and a deadly virus

The CDC report and the articles of healthy children dying of COVID-19 were all written before Dr. Makary’s June 10th editorial where he said he was “not aware of a single healthy child in the U.S. who has died of COVID-19 to date”. If I found these articles in 10 seconds, he could have as well. In fact, two of these articles appear just below his article if you Google “healthy child died covid” as I did. Perhaps he knows something I don’t about these cases. Perhaps the CDC and news reports are all wrong. Perhaps all of these children were found to have underlying medical problems after all. It’s possible. If so, Dr. Makary should publish his findings. If not one “single healthy child” died from the virus in the US that would be important to know.

Presently however, it seems that Dr. Makary, a professor at a top medical school who claims to have reviewed “the medical literature and news reports”, actually didn’t bother to do the most basic fact-checking when he claimed no healthy American child had died of COVID-19. He referenced his own “study”, where just three children died, to claim that no healthy child in all of American has died of COVID-19. He lambasted the CDC for not providing information on deceased children when it had done so several months prior. This is in contrast to his “study,” which gave no such information. He did this all in widely read articles meant for the general public. It may seem that I am nitpicking, but this is a big deal to me.  This includes earlier this month when Dr. Makary favorably tweeted out a study that purportedly showed that masks harm children. The study was written by literal anti-vaxxers and was laughably bad, as many people pointed out to him. It has since been retracted, but not before Dr. Makary and others helped spread it far and wide.

There are real-world consequences to spreading wrong information to the public.  With help from other doctors who also didn’t bother the fact-check the claim, the notion that healthy children don’t die of COVID-19 seems poised to become a medical myth on par with the old trope that we only use 10% of our brains. Indeed, anti-vaxx propagandist Tucker Carlson repeated Dr. Makary’s claim verbatim on his program. Misinformed politicians have also repeated this false claim as if it were established fact during congressional hearings. Unfortunately, this is not the first time I’ve written about the consequences when supposed proponents of evidence-based medicine make claims that are not just without evidence, but in direct contradiction to readily available evidence. It is reasonable to expect a doctor with a large platform to be accurate and thorough when engaging with the public about children and a deadly virus.

So, why can’t some people simply say they were wrong?

I’ve written previously of the highly credentialed academics and QAnon fanatics/right-wing politicians (there’s sometimes no difference), whose minimization of COVID-19 and fear mongering about the vaccine has led us to a point where hundreds of Americans are dying a preventable death every day. In these essays, along with Dr. Makary, I too have wondered why some people readily admit error while others tie themselves in knots to avoid doing so.

Infectious-disease expert Dr. Paul Offit, for example, predicted on March 2nd, 2020 that COVID-19 would cause less than “one-tenth of the damage that influenza causes every year in the United States”. He later acknowledged his error saying, “If you’re going to be wrong, be wrong in front of millions of people. Make a complete ass of yourself”. I trust him completely as does everyone else I know and admire. Former Surgeon General Dr. Jerome Adams recently acknowledged his early advice not to wear masks was wrong. I too have acknowledged errors. This wasn’t fun, but it wasn’t particularly hard either. I’ll do it again when I have to. I deserve no special credit for this. We all make mistakes and acknowledging them doesn’t require self flagellation.

So, why can’t some people simply say they were wrong? I have no idea. However, Dr. Makary seems to be in the perfect position to answer to his own question.

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  • Dr. Jonathan Howard is a neurologist and psychiatrist based in New York City who has been interested in vaccines since long before COVID-19.

Posted by Jonathan Howard

Dr. Jonathan Howard is a neurologist and psychiatrist based in New York City who has been interested in vaccines since long before COVID-19.