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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on October 14th, 2020

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COVID-19 Update 10/14: Excess Deaths, Spikes in Europe, and More

COVID-19 | Facebook Live Recap

Dr. Steven Bishop discussed several COVID-19 topics on this week's COVID-19 update, including some information related to excess deaths during 2020, his reaction to increasing cases in European countries, what the best strategy for containing the virus might be, and more. Watch the video below and read on for a transcript. 

Excess Deaths

Here is the article that we're going to talk about. The researchers at VCU have been following a lot of the death data that comes out and that's deaths of all kinds across the Commonwealth and across the country since the beginning of the pandemic in March. And so one of the major metrics that people have been following is something called excess deaths.

This is the number of deaths over and above what we would normally be seeing at a given point in the year for all the causes, the reasons people normally die, whether it's car accidents, cancer, heart disease, whatever it is, they kind of track that year-over-year.

And when things like a pandemic hit or something unusual, they're able to look at the difference between the number of deaths that have occurred in that year, so 2020 being the example, and then compare that to the number of deaths that normally would have happened.

So if normally we would see 50 deaths in a given period of time, and instead we're seeing a hundred, then the excess deaths would be 50 in that in that scenario. And then the question becomes, okay, what are the deaths from?

And we've seen obviously quite a large increase in excess deaths across the country and across the world because of the coronavirus and everything related to it. But I like to make sure we take a very balanced approach to how we think about everything related to coronavirus.

And I know we've talked about this a little bit before, but we have to remember that everything we do has both positive and negative consequences. The researchers at VCU and other places have been following this information since the beginning of the pandemic and they keep putting out reports and there was an updated report today. This one is specifically related to Virginia. But what they found was that there were 4,500 excess deaths between March and August compared to what we would expect based on the historical data.

Now, what they go on to say is that's a 16% increase in overall unexpected deaths compared to some prior data that they had looked at about unexpected deaths earlier this year. But what they actually found was that only 52% of those excess deaths in Virginia are related to the virus itself or as a direct complication of the virus or even as a contributing factor.

So that means that 48% of the excess deaths that occurred in Virginia were from other things, most likely being things that we did to try to control the pandemic. Okay. And we always knew that that this was going to be somewhat of an issue.

So why is that? Why are 45, 48% of the excess deaths due to something that we did as a society trying to control the virus?

Well, when we closed down all the hospitals for a couple of months and told people to stay in their homes, they did so. They stopped going to the emergency rooms. They stopped calling the ER, and calling 9-1-1 for their heart attacks, their strokes. They stopped getting tested and treated for cancers and other things. People became sad and despaired. And so the number of opiate-related deaths, alcohol-related deaths, skyrocketed, and this report actually shows that there was a 123% increase in non-fatal opiate hospital visits at VCU alone here in Richmond.

So, you know, I think this is what we've been saying all along. There's a very tight tension between us needing to do what we can to control the spread of the virus while also realizing that our restrictions have serious consequences for people's health that are just as real as the virus itself. And it's almost equipoised, meaning that, in this data set, about half the deaths are from COVID, half the excess deaths are from things we did to control COVID. So it is really a problem that we've got here, where we have to find the careful balance between doing what we need to do to do the social distancing and minimize the spread of the virus as much as we can... Up to the point where we start causing more harm than good.

Taking a slow and steady approach to normalizing things as much as we can over time I think remains the best way to manage these things. What we don't want to see is there to be any excess deaths at all, of course. But we specifically want to minimize excess deaths that we're actually causing in our attempts to control the virus.

We've got to be very careful about these things overall. It's a very delicate balance. There's no single right answer. The reason I bring all this up is to keep us all sort of humble and keep us all really aware that things have multiple sides to them.

I know the political atmosphere has gotten very charged and it continues to get more and more charged as we get closer to election day in terms of lockdowns, no lockdowns, this and that. There's no simple answers here. Everything we do has give and take. And I think that the more we continue to realize that and keep that in mind, I think that is healthy for everybody.

It's a healthy way to address all of these things and to realize that there are no black and white answers and people advocating for one side or the other of this issue are not evil people. They're not incompetent. They're not wrong. They're just emphasizing different aspects of these arguments. And I think that is okay. I think that's healthy and we need to continue to have that very public, very transparent debate on these things. And this research is going to go a long way to helping us have that debate. So I think that's good.

Rising Cases in Europe

About infections: Europe seems to be undergoing a new surge of infection, with record infections in Russia, Italy, and France. Other parts of the world are spiking too, for example India. Are we experiencing a similar surge in the US? If not, can we expect it to hit us at some point? Why or why not?"

These are really interesting questions. I don't know. I hope that we don't have renewed spikes in the US. Some of this, I wonder, is it related to more testing? I'd have to look at their testing data and see if they are doing more testing and so therefore finding more cases. I haven't seen if their hospitalization rate has gone up or their death rate has gone up lately. I don't think it has, but again, I haven't looked at the data for Europe lately and things in the US are pretty stable. Stable in not a great way.

We're still sitting around in this 40 to 50,000 new cases a day. But overall, our hospitalizations and death rates in most places seem to be stable or declining along with the positivity rates for the tests, which is good, because I think what that means is we're doing more testing, which is what we should've been doing all along, so I'm hoping we're going to get there. But so the cases and the case rates as we test more and more and more people that may go up.

What I'm really worried about and have been since the beginning and will be more, much more worried about as we get into the fall and flu season really comes into swing, is what are the hospitalization rates? What are the death rates?

Because I think that tells us a lot more useful information than just the case rate. So I'm hoping that those numbers stay low. I know in Virginia, for example, our hospitalization and death rate has continued this extremely slow decline. But it's not gone to zero.

And I don't think we're anywhere close to it going to zero at this point. But definitely is going down. I think that we're probably going to reach a new, low, stable baseline for hospitalizations and deaths, assuming every, all of the things remain equal, right?

Assuming that we don't have this massive surge in transmission because of people being indoors and all these sorts of things. But I think time is just going to have to tell those things out. So I'm not sure just yet. But I think probably what will happen is we'll reach sort of this low, but stable rate of hospitalization and death, which is manageable by the health care system, but obviously is not good thing. And I think we'll stay there until we get a good vaccine or an extremely effective treatment.

Death Rates in U.S. vs. Other Developed Countries

"Have you read the article published yesterday comparing death rates in various developed countries? It was published by Zeke Emanuel in the Journal of the AMA and concludes that the US per capita death rates are higher than all other peer developed countries. If you have read the study, what do you think of its results? Could it be that Americans are older or less healthy or more obese or more risk taking than citizens of other developed countries?"

I have not actually seen that study yet. That being said it doesn't surprise me to be honest, and I've seen conflicting data. I think it all depends on which data set people are looking at, but it does not surprise me. It would not surprise me that our basically population death rate is higher than many other places for a lot of reasons.

The primary one is that our population is just very unhealthy in general, about 88 to 90% of Americans are metabolically unwell, meaning that they either have hyperinsulinemia, pre-diabetes, diabetes, or have obesity, one of those types of types of things. Again, 88 to 90%, so that's most people in the US have one of these problems. So that is sort of one factor.

The second factor really is uneven access to good primary care. There's a lot of reasons behind that. There's economic reasons behind that. There are social reasons behind that. There are racial issues embedded in there in terms of equitable access to quality medical care. And we have a lot more of a heterogeneous population in that way in terms of access to care and economics and such than many other countries do.

So between those two things alone, I'm not overly surprised that our death rates are higher than other places. I think that probably our death rates are much more variable than in other places...A because we're a big country, but B because state to state and even zip code to zip code, your access to care and all sorts of other things in your overall health can be vastly different.

And there's tons of research on this that basically your health outcomes are determined by your zip code. This isn't a new concept. It's well established in the medical literature. And so I'm not overly surprised by those findings, Andy. It's dismaying and disappointing but not not surprising.

The Great Barrington Declaration

"I missed the very beginning of your talk today so you might have already covered this but I'm curious if you've read the Great Barrington Declaration and your professional reaction."

Yeah. So I think that's a little bit of what we were addressing. I have not actually read the full declaration. I've heard about this. What she's referring to for those that may not know is this was a sort of a public, I guess petition for lack of a better word, that a lot of scientists have added their names to basically saying that we should stop aggressively locking down things to control the virus because it's probably not the best strategy.

And I think there's something to that. And I think this excess death data speaks to that. Like I said, I haven't read the full declaration, so I don't know all of what they're calling for, but I know that the World Health Organization has put out some information essentially agreeing with some of what's in that declaration saying, now that we've learned some things, maybe extremely strict lockdowns are not the best thing in terms of balancing the risks and benefits to the population.

We probably need to find something a little bit more balanced in terms of how to manage that. I don't know that I would go so far as to say that we we should abandon all attempts at social distancing and restricting sizes of crowds, and those sorts of things. I don't go that far. I don't think that that's the right answer to go to that extreme either.

I think there's probably some reasonable space in the middle that we can find. I think what we have going on actually in Virginia is pretty reasonable in terms of restrictions on crowd sizes and social distancing and things like that. It keeps us from having these massive super spreader events, but is allowing most of the economy to function pretty well.

So I think if we can find something balanced like that or similar for the next 12 to 18 months while we continue to vet a vaccine and things like that, I think that that's going to hopefully help us find the balance between limiting the effect of the virus as much as we can while also letting us have an economy, right, because the economy and people's health are completely intertwined. You cannot have one without the other.

Tweaking Our Pandemic Response

"To your mind, what are the best ways to tweak our response to the pandemic that address both direct pandemic deaths as well as excess deaths caused by the other factors you have discussed. There seem to be so many moving pieces, including mental health consequences of our attempts to reduce infection. Is there a pathway for addressing all the various harms in a reasonable way? Would love to hear you flesh out your vision of a reasonable middle way.”

Yeah, you know one day hopefully all the governor's offices, they're just going to give me a call and I'll be able to just tell them what to do. I think that would be great. Maybe, you know, all of our PartnerMD patients, call your governor and tell them, hey, you know, PartnerMD, they they've got the plan just give give them a ring and they'll sort it all out for you. So that would be fun.

But you know, I think there is a middle way. I think that finding that balance is going to be challenging and there's some structural things we can do as a society to try to find the middle way. I think that ultimately there are certain things that really are going to come down to people's personal risk tolerance, and I think there's no — you can't middle way that — people have to weigh what makes sense for them. In many situations based on their personal health, their risk levels, and how worried they are about getting the infection.

There's kind of two buckets to that. I think we obviously should be advocating for the certain things that we know with very little doubt that are going to be helpful, right? We should not be allowing yet there to be concerts with thousands of people you know, monster truck rallies and you know, things of all kinds of stuff like that. We shouldn't be letting thousands of people get together in very massive groups, indiscriminately. I think that's very unwise. So I think that we should continue to restrict those things to a large degree.

I think a lot of the social distancing that has been put in place, standing in queues at the grocery store, keeping some separation at tables when you're out at restaurants, a heightened awareness of hand hygiene, personal hygiene in terms of coughing, sneezing into the mask or the arm, I think all of that is good. And I don't think there's any reason to go back in terms of those things to kind of the before times as one of my patients says it. There's no reason to go back to the before times of just sort of having a willy nilly free for all, because that was always bad in terms of influencer risk and other things. So I think that's all fine.

I think that most places probably need to keep those restrictions in place, at least for now, until we really do get a really good handle on this. I think that, in the middle ground again, the slow and steady approach to reintroducing some things, like what is happening with schooling in my county where we're bringing back small groups of students at a time. We're watching. We're vetting. We're seeing how things go. I think that's wise. I think that's a good way to move forward.

And let's, for lack of a better word, have small experiments. Do one thing and see how it goes, rather than just letting everything be a free for all. Open all the stuff up, and do all the things and to heck with the consequences, I think is extremely unwise.

So I think keeping those highest risk things off the table, the things that are in the middle, move them forward slowly, and then for everything that doesn't really fall into those categories, let people decide for themselves what makes the most sense to them.

Church being one of those areas. My church and lots of other churches... They are still doing virtual church. And I think that makes sense for a lot of people, if they're higher risk, I think that's fine, and they should continue to do that.

And we should continue to serve those people the best we can. Same thing for other things. If you could do virtual work or remote work, you should especially if you're high risk, I think that's fine. And I think our governments or corporations, all of those things, you continue to make those things as easy as possible for people. 

So that's sort of where I'm at right now on all those things is trying to find this balance because everyone does need to know what their risk tolerance is. People that have mental health issues, they know what they need in terms of being out in contact with the world, with the outdoor environment, with other people. And they really are the best ones to make those judgments about the risk of infection versus the risk of having a bad outcome from their mental health or something else.

Of course, there's always boundaries around that, right? If someone does get sick and they do have symptoms and they are a risk to other people or threat to other people, then yeah, they need to be isolated. And they need to be quarantined and that's what's best for others. So again, everything has two sides to it.

National Mask Mandate?

"Would a national mask mandate be part of a reasonable middle pathway if political issues weren't part of the equation? I know this is politically controversial, but isn't masking a low-risk way to reduce infection. Freedom not to wear a mask seems problematic because that potentially hurts others. And so isn't only an individual matter. What is your sense of this?"

Yeah, I think in the US it's really complicated both politically and legally, and I think it is complicated from a medical perspective as well.

So I don't think that data is really there to support a national mask mandate if we're going to use cloth masks. Okay. I think I would actually feel more strongly and be more onboard with that if we were going to all wear surgical masks all the time. There's more data on that in terms of it reducing the spread of infection, but there really is just not sufficient data to mandate that everybody in the country wear masks, because I don't think that that the science just isn't there yet.

So that's where again, I think that it's really something that should be, I know it's not a collectivist approach to say that and say, hey, I think we need to have a little bit more leeway with that. I think that it's better to approach this as a public health issue rather than a legal issue.

Scaring people, brow beating them into things tends not to work in general. That's always true for any public health campaign. I think that if the public health authorities had addressed this, like they have addressed lots of other things in the past, I think we would have done better.

I know there's now signs up in Virginia everywhere. I've seen them on the highways....wear your mask to show you love people and things like that. That's the way the show you care. And I think if we had really gone that route primarily, rather than sort of you are going to wear this, it's illegal to not wear it, I think we would actually have higher mass compliance. A that's just human nature and B that's just the way Americans are. You know, Americans are happy to do stuff until the government tells them to do it and then suddenly no one wants to do anymore.

So I think there's something to that too. I don't think there's enough scientific data to mandate it. I think it's better treated as a public health campaign rather than as a legal campaign. And again, I'm not a legal scholar, I'm not a constitutional scholar, but my understanding of the way that the constitution is laid out in terms of our overall US government and our state governments is that public health is the responsibility of state level government, not of national government. So I personally would not agree that the national government has any authority to institute a national mask mandate, let alone whether they can actually implement it or not. So I think this is really is up to the States. It kind of gets back to this concept of the 10th amendment, right?

The state level governments are the ones that are empowered and charged with the responsibility of maintaining the health of their citizens. And so I think state or lower level government is probably the best place to make these choices.

Masks are going to make more sense in different places than others, right? If you have a highly populated state, say California, Florida, New York, somewhere like that, masks may make more sense compared to say North Dakota or Minnesota, which are much more sparsely populated much more rural. So the masks are not going to have nearly as much of an impact. So I truly do think that the state level is the best place for these decisions to be made for a whole lot of reasons. Not the least of which is legal, so that's my take on it. I know that's an area of political controversy, but I think the states treating it as a public health issue rather than as a legal issue is probably best. So, all right.

Holiday Risks

"Did you talk about the risks about holidays and gathering with family that was just mentioned yesterday?"

I think we talked about this a couple of weeks ago, but we could reiterate it again. I'm here today. So I think this really is going to fall under that gray zone, right.

There are certain things that we aren't going to do for the holidays, Halloween being the one that's coming up most, most urgently. Our neighborhood is discouraging people from coming up to the doors and things like that for trick or treating. So what we're going to do instead is we're going to have a neighborhood wide trunk retreat. So people are going to hand out candy from their trunks and we're going to try to maintain as much social distance as we can. We're asking people to wear the gloves and the masks and all that sort of thing and minimize the risk.

So I think that the kids really are looking forward to it. And for the most part, these are all the kids they're around every day anyway, because of our learning pod, because they've been playing with these same kids since May, June. So we're not mixing with new people too much. We're trying to still do some distancing and practice some precautions.

And we're obviously encouraging anyone who's not well or sick to not participate either in the giving or getting of candy for Halloween. And so I think finding some middle ground there for those things is healthy. Let the kids experience something that is going to bring them some fun and excitement while also trying to mitigate as many of the most extreme risks that we can sort of, you know, what we call tail risk management, right? It is a way to think about this.

I would practice the same approach for Thanksgiving and Christmas. Let everybody make their choices based on their own autonomous thoughts about their risk factors.

And that's each family, either going to have to make those decisions about what they do and don't want to do.

We will probably not get together with our entire extended family for all the normal things that we normally do because different people in our family have different risk levels and that's okay. We can try and connect with them other ways and that's perfectly fine. Nothing wrong with that.

So don't make people feel like they have to join in something. Try to connect with them where they're at in terms of their risk level. But for those who feel like their risk level is reasonable, I say try to maintain those connections, have the small gatherings, but be cautious and reasonable about it. Don't do anything outlandish. Cut your tail risk