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Sunday, April 12, 2020

Experts and Me

This is much too self indulgent for www.angrybearblog.com. I am trying to understand what I think of the recent discussion of leaving things up to the experts. Donald Trump is making a very convincing case for leaving things up to experts by pretending to be able to outguess them using his gut. I remain not totally convinced.

I am definitely not willing to leave health care decisions to doctors. I am not talking about my own as I am generally healthy enough. I do insist on giving advice when is often to challenge doctors and argue with them about therapy. I am going to consider a typically good column by Michael Gerson here

The dangerous conservative case against expertise. He has a point. In particular, conservatives are often wrong when they disagree with experts (also when they are experts). Gerson happens to be my favorite conservative. I don't know how long he will remain a self identified conservative. I think he will follow his fellow Washington Post conservative quota hires Jennifer Rubin and Max Boot to neoliberalism.

He writes well enough that it is hard to quote.

I note here that he doesn't have an argument against medicare for all *or* for the claim that Covid 19 shows why it would be good

a human tendency to interpret disasters as confirmation of our existing beliefs. So the coronavirus outbreak proves the need for a border wall. [skip]”

Not every argument is strained or spurious. The pandemic has given our health-care system an X-ray, revealing disturbing racial inequities that need to be understood and addressed. But on the whole, we are right to be wary of people who claim great tragedies as the confirmation of pet theories and previous prophesies.

He just moves on, because his job is to be a conservative critiquing conservatives. I think there is also the point that it won't be enacted and so it isn't on the agenda. In particular he critiques

conservatives who look at the coronavirus outbreak and see, of all things, the discrediting of experts and expertise. In this view, the failures of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have brought the whole profession into disrepute. The judgments of health professionals have often been no better than the folk wisdom of the Internet. The pandemic is not only further proof of the fallibility of insiders; it has revealed the inherent inaccessibility of medical truth. All of us, scientists and nonscientists, are walking blindly on the same misty moor and may stumble on medical insights.

I think he is describing a real phenomenon and he is right to denounce it. But I have some criticisms.

First, and importantly, the internet is a medium. One can't discuss the effect of relying on the internet any more than of relying on the spoken word or books. He has something in mind, but he doesn't quite define it. I think he is thinking of social media of FacebookandTwitter. I get my opinions about Covid 19 and treatments from the internet, and, in particular from

https://www.worldometers.info/coronavirus/

https://www.ncbi.nlm.nih.gov/pubmed/

and

https://clinicaltrials.gov/

Also I have read a lot about how the Wikipedia is unreliable, but know of only one gross error (the article on Ricardian equivalence).

I don't think it is possible to understand the problem without addresses the particular problem of the conservabubble. Think of edited media (the MSM). The reliability of edited news media sources varies widely. Don't trust Fox News. Don't trust the National Enquirer. Don't trust The Wall Street Journal opinion pages. Don't pretend that this is a general or symmetric problem.

My other thought is: What about the FDA ? It is, like WHO and the CDC a center of recognized expertise. It is also (unlike WHO) a center of power -- the FDA has legal authority. It has made terrible mistakes so far, and they have killed people.

In particular it is essentially 100% responsible for the delay of testing for Covid 19 in the USA. The CDC sent out test kits which had a (still not understood) problem. This would have caused at most a week of delay without the help of the FDA.

The problem appears to be with one reagent which should consist of a pair of oligonucleotides and which sometimes seems to be contaminated. I don't claim to understand what is wrong with it, but do note that it can be just left out, that the CDC test kits work fine if it is not used, and that this is one of the main ways tests are now conducted in the USA. Also all this was discovered about 1 week after the kits were mailed which was roughly 3 weeks after the Sars Cov2 sequence was published.

The further delay (roughly 2 weeks) occurred because the FDA did not authorize the use of the modified toss out the problem causing reagent test. It also placed a heavy burden for approval of tests by private agents -- hospitals, universities, and commercial testing firms.

That was the (more) fatal problem (in thousands of deaths caused).

I think there are two lessons. First there is a bias towards small c conservatism. A delay in adopting something new is always considered acceptable. This makes no sense. Another is that the expertise can be familiarity with the way things have been done (combined with the conservativism). Experts on Covid 19 testing include experts on RT-PCR and experts on obscure FDA regulations which implied that the declaration of an emergency slowed the response to the virus. The second group of experts (call them lawyers) know about current laws, rules and regulations. They don't know if they are optimal.

Notice that I haven't gotten close to saying that "medical truth" is inaccessible. One doesn't get there from questioning experts and especially not from questioning experts when they disagree.

OK I quote "And the CDC did badly mishandle the early stage of diagnostic testing." But what about the FDA ? Yes they made some mistake at the CDC, but it caused only a third of the total delay. Such problems are inevitable -- human perfection is impossible. But refusing to allow the correct solution to be used is not inevitable. By "solution" I mean solution with a solvent and solutes not including the powder which was supposed to be a pair of oligonucleotides (and may have been -- we don't know if it was contaminated).

another quote

Judgments based on that information are not infallible. But they are always preferable to the aggregate opinion of the Internet.

I am quite sure there is no such thing as the aggregate opinion on the internet. Again, he is thinking of something other than the medium. Again he ignores the fact that the peer reviewed literature is available on the internet (at least abstracts). I think he is on to somethng but the entity he has in mind is not "the internet". I'd call it "the conservabubble".

Gerson also leaves out experts. He notes the experts who warned of the pandemic and who advocated social distancing. He is right. He is also right that conservatives mostly dismissed them and that Trump is a disaster. In fact, I guess I agree with him about almost everything except his definition of "experts" and "the internet".

One aspect of the scientific literature is that extreme caution is favored. Guesses are not published (unless the person guessing is really famous). Claims to have found the answer are deliberately understated (which doesn't mean they aren't often wrong -- there is a constant struggle between the professional norms and the inclinations of enthusiasts).

But this is not appropriate as a guide for action in a crisis. The default response that we don't know and we have to do more research does not suggest what to do during that research.

The actual practice is to stick to business as usual. In medicine it is to stick to standard of care until and new therapy is proven to be superior (and the standard of proof is much stricter than the supposed proof beyond reasonable doubt which gets people locked up in prison). This makes no sense in the treatment of a disease first described 4 months ago. But it absolutely does describe actual choices made by actual doctors here "She listened patiently to Hall and expressed her concern that his suggestions did not conform to standard medical procedure or C.D.C. guidelines." The patient had Covid 19. How could there be standard medical procedure already ?

It is definitely a fact that doctors are very determined to define a standard of care (which is described in a document which in cases with which I am familiar is written by a private voluntary association of physicians). The reason for this is, I think, perfectly clear. If a patient is given care according to the standard, then bad outcomes do not imply malpractice liability. This means that sticking to the standard is sensible for the cautious physician who cares a lot about not being sued for malpractice and considers that more important than ding what, according to a posterior probability distribution updated with the available data, maximizes expected patient welfare.

This is the way it is done. The key experts include lawyers who explain malpractice liability (correctly).Then there are the standards of care, the official guidelines, whose key roles include defence in malpractice suits.

I assert that there is a problem here -- a moral problem and a policy problem.

I have been asserting this for years. As Gerson might predict, I now assert that the Covid 19 epidemic proves I was right.

31 comments:

Dan Crawford said...

Well Robert,

I disagree with your disclamer so am lifting this post to Angry Bear as an op-ed.

juwan james said...

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JimV said...

Re: Wikipedia reliability.

1) I read somewhere that Wikipedia and Britannica were tested by having outside experts review a large number of articles and that Wikipedia scored higher in accuracy.

2) But it is not a reliable source for citations because it can change rapidly, so a quote one cites from it may not be there a year from now. One wants something fixed in stone as a source ideally.

You probably knew all of this, but if I can expound on something on the Internet in the afternoon I sleep good at night. (Channeling Mel Brooks in The Muppet Movie.)

GC said...

Re (2).

It's customary in web citations to include an access date. In general you have good chances to use the Internet Archive and in the specific case of Wikipedia you can go to the page history directly.

And in general, the potential to improve with time should not be viewed as a flaw. But it can be unsettling.

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Unknown said...

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Unknown said...

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Mary Kent said...

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Good luck.

Matthew Scarlett said...

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Job Pedro said...

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patrick morrison said...

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Jessica Morgan said...

four (4) years, six (6) months and twelve (12) day with my calculations, befItsgood  a miracle that I am alive today. I encounter HERPES SIMPLEX VIRUS (HSV1/2) forore I meet the great Dr. Abumere. I am Tina Richard from Fresno California, united state of America and I was affected with herpes virus.Herpes is a viral infection cause by the Herpes simplex virus, marked by painful, watery blister in the skin or mucous membrane or on the genitals. This was what I suffered for good four years. I have visited CVS Pharmacy in Fresno for treatment but no improvement. I meet Dr.Abumere online while I was searching for herpes cure I read a testimony about his work. I give a try that now becomes a testimony in my life. I contacted Dr.Abumere on Email: doctorabumere6@gmail.com or WhatsApp: +2349021975055

Mr Lake said...

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patrick morrison said...

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(4).Hiv/aids
(5).Pcos
(6).Fibroid

Celina Gomez said...

I'm Celina Gomez from Canada, i have been cured from genital herpes with herbalist Sakura herbal Remedy.
i have been infected with genital herpes for 1 years now , i have done so many medical treatment from different hospital still
not cured. On a very good day , i decided to make a research on my computer on how to get rid of genital herpes,i found a post of Sarah Wilson on how she was  cured from herpes with herbalist Dr sakura  herbal remedy.
The Herbalist email/contact number  was there as well dr.sakuraspellalter@gmail.com/ +2348160802189. i contacted him because of my illness .He needed few of my information which i did, and also send me his medicine through FedEx courier service.
which i received  after 3 working  days of shipment,i drink the  herbal medicine the same way Herbalist Dr Sakura instructed me too.but now my genital herpes is gone totally without any side effect or harm, may God Almighty continuing to bless him abundantly .
you can contact him on mail/whats app dr.sakuraspellalter@gmail.com +2348110114739 or follow him on Instagram @Herbalist_sakura .you can also mail me for more information celinagomez784@gmail.com

desire said...

Never give up in life they all say no cure to HSV 2 which is a big lie I have pass through many process also i never believe there is really cure to HERPES until I meet Dr Shaibu the doctor that have been helping many people for many years, I came across this doctor online when I was searching for cure online I found out about this man, and to my greatest surprise this man have the herbal medicine which I have been looking for years I explain my problem to him through the email I found on someone who testify about him also, Dr Shaibu write me a reply and explain how the process work so after ordering for the medicine I got it within 4 days and I took it according to the way Dr Shaibu instructed, I was so happy after two week I took the medicine there was very big change in my health when I was done with the process I go for test, I found out I am negative that was the day I have the tears of joy you can also get in contact with my doctor through his email now drshaibuabacha@gmail.com or WhatsApp him +2349051727475. And He also have herbs medicine to cured the following diseases; eczema,urethra wart,chronic problems.Herpes, Cancer, Als,Hepatitis, Diabetes, HPV,Infections,ulcer  ETC

Unknown said...

Good News My People ..I Want To Appreciate Dr OYAKHIRE Herbal Medicine Is A Good Herbal Medicine For( HIV ),I Was Diagnosed With Hiv
Virus Last Month,And i Looked For Solution To
Be Cure,Luckily I Saw A Testimonies On How Dr
OYAKHIRE Cured Hiv Virus,I Decided To Contact Dr OYAKHIRE ,I Contacted Him and He Prepared A Herbal Medicine Portion And Sent It To Me,I Started The Herbal Medicine For My Health,He Gave Me Step By Step Instructions On How To Apply It, When I Applied It As Instructed, I Was Cured Of This Deadly HIV Virus Within 1week, I Am Now Hiv Negative.My Brothers And Sisters I
know That There Are So Many People That Have
this Same HIV Virus Please Dr OYAKHIRE is here To Help you too,And please Help Me To Thank Dr OYAKHIRE For Curing Me, I’m Cured By Dr.OYAKHIRE Herbal Medicine,His Contact you can whatapps him on is phone number okay
here is the number on Whatsapp,
(+2349039208180 or email droyakhire7@gmail.com
(1) HIV / AIDS
(2) CANCER
(3) HERPES
(4) DIABETES
(5) HERPERTITIS B
(6) HPV
(7)EX BACK
(8)Tinnitus
(9) stroke
(10) asthma
(11) fibroid

Clara kat said...

I had my first outbreaks and I was tested back for both HSV-1 and 
HSV-2. Both my husband and I tested positive for HSV-1. Last year I found 
out my husband was cheating, so I decided to do a retest on all STDs 
including HSV-1 and HSV-2, only difference is that this time I went to a 
different clinic. Anyway I tested positive for HSV-1 which I knew I had but 
surprisingly HSV-2 as well, I was so upset and got divorced with my 
husband. 3 months ago a friend of mine recommended me to an African Herbal 
doctor DR.Edidia. I explained everything that I have been passing through 
all these years to him and he encouraged me that I will be cured 
completely!. I ordered for his herbal exploit/medicine and used it 
accordingly to his direction and within short period of using the herbal 
medicine I was cured completely from my HSV-1 and HSV-2. I'm so relieved to 
say that I've not had even one outbreak ever since again and I was also 
tested Negative by my doctor. I'm feeling so great! from within and I truly 
endorse this product, it really works. His herbal medicine is very active 
and effective, and other 
can of cure for HERPES, DIABETES, CANCER, HEPATITIS, HPV,HIV,COPD,KIDNEY FAILURE,PCOS and other diseases..... You can 
contact doctor edidia on email: dredidiaherbalhome@gmail.com and 
you can call/whatsapp him with +2349074505296 for your own cure too..    

visit his website https://dredidiaherbalhome.wixsite.com/dredidiaherbalhome
am clara kat here is my private email clarakat8@gmail.com

Matthew Scarlett said...

God bless Dr. USELU for his marvelous work in my life, I was diagnosed of HERPES SIMPLEX VIRUS since 2018 and I was taking my medications, I wasn't satisfied i needed to get the HERPES out of my system, I searched about some possible cure for HERPES i saw a comment about Dr. USELU , how he cured HERPES with his herbal medicine, I contacted him and he guided me. I asked for solutions, he started the remedy for my health, he sent me the medicine within 3 days. I took the medicine as prescribed by him and 2 weeks later i was cured from HERPES contact him via email (dr.uselucaregiver@gmail.com) once again thanks to you Dr. USELU cure the flowing virus, contact his email or add him on whatsapp (+2349019328641) cancer cure
diabetes cure
ringing ear
herpes cure
warts cure
HPV cure
HIV cure
get your ex back
pregnancy herbal medicine
Hepatitis  

susanwilliam said...

Herpes Virus is a terrible virus, if not for my Husband and the help of the great Dr.Alabi my life would have been a mess! I was diagnose with Herpes virus in 2012, my husband encouraged me, and told me not to lose hope, I manage to give birth to a baby Boy who was free from this virus, and my Husband was always there for me! One day he came to me and told me that he have found a man who can cure me. Base on scientist, they said there is no cure for Herpes virus; he told me that he has seen many testimonies about him on the internet. We decided to contact him, we filled his Herbal home form, and he asked us to buy some local root and herbs items which we did! and he prepared for me a herbal medicine and 14 days later he asked me to go for medical test, faithfully hopefully i went for the medical test, and Behold, I was cured, from this virus and its was not found in my Body system again... My Dear Husband and my Father Dr.Alabi, God will surely bless the both of you, till the end of time, in Jesus name.. If you have any problem kindly contact Dr Alabi via his email (Dr.Alabiherbalhome@yahoo.com) or whatsapp him on +1{810}4982897 for any kind of help......