When You Love Your Country...You Cannot Remain Silent: An American Hero

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IN UNION THERE IS STRENGTH

General James Mattis

 

I have watched this week’s unfolding events, angry and appalled. The words “Equal Justice Under Law” are carved in the pediment of the United States Supreme Court. This is precisely what protesters are rightly demanding. It is a wholesome and unifying demand—one that all of us should be able to get behind. We must not be distracted by a small number of lawbreakers. The protests are defined by tens of thousands of people of conscience who are insisting that we live up to our values—our values as people and our values as a nation.

When I joined the military, some 50 years ago, I swore an oath to support and defend the Constitution. Never did I dream that troops taking that same oath would be ordered under any circumstance to violate the Constitutional rights of their fellow citizens—much less to provide a bizarre photo op for the elected commander-in-chief, with military leadership standing alongside.

We must reject any thinking of our cities as a “battlespace” that our uniformed military is called upon to “dominate.” At home, we should use our military only when requested to do so, on very rare occasions, by state governors. Militarizing our response, as we witnessed in Washington, D.C., sets up a conflict—a false conflict—between the military and civilian society. It erodes the moral ground that ensures a trusted bond between men and women in uniform and the society they are sworn to protect, and of which they themselves are a part. Keeping public order rests with civilian state and local leaders who best understand their communities and are answerable to them.

James Madison wrote in Federalist 14 that “America united with a handful of troops, or without a single soldier, exhibits a more forbidding posture to foreign ambition than America disunited, with a hundred thousand veterans ready for combat.” We do not need to militarize our response to protests. We need to unite around a common purpose. And it starts by guaranteeing that all of us are equal before the law.

Instructions given by the military departments to our troops before the Normandy invasion reminded soldiers that “The Nazi slogan for destroying us…was ‘Divide and Conquer.’ Our American answer is ‘In Union there is Strength.’” We must summon that unity to surmount this crisis—confident that we are better than our politics.

Donald Trump is the first president in my lifetime who does not try to unite the American people—does not even pretend to try. Instead he tries to divide us. We are witnessing the consequences of three years of this deliberate effort. We are witnessing the consequences of three years without mature leadership. We can unite without him, drawing on the strengths inherent in our civil society. This will not be easy, as the past few days have shown, but we owe it to our fellow citizens; to past generations that bled to defend our promise; and to our children.

We can come through this trying time stronger, and with a renewed sense of purpose and respect for one another. The pandemic has shown us that it is not only our troops who are willing to offer the ultimate sacrifice for the safety of the community. Americans in hospitals, grocery stores, post offices, and elsewhere have put their lives on the line in order to serve their fellow citizens and their country. We know that we are better than the abuse of executive authority that we witnessed in Lafayette Square. We must reject and hold accountable those in office who would make a mockery of our Constitution. At the same time, we must remember Lincoln’s “better angels,” and listen to them, as we work to unite.

Only by adopting a new path—which means, in truth, returning to the original path of our founding ideals—will we again be a country admired and respected at home and abroad.

SOLVING CORONA: Basic concepts

SOLVING the Problem through Knowledge

SOLVING the Problem through Knowledge

In the current coronavirus environment much public health and epidemiology discussion has occurred. One of the basic principles of determining how infectious a virus is or any pathogen is called the basic reproduction number. This is also referred to as R0 pronounced “R” “naught” or “R” zero. The number is a objective value of infectivity and used to determine how infectious any given agent is.

Some viruses are highly infectious like measles having a basic reproductive number of over 12. Other viruses are less infectious like rubella around five. Coronavirus is of unclear R0 value somewhere between 2 to 3. As we social distance and have less contact this value decreases since the virus does not have the opportunity to spread effectively

R0 scale.jpg

Understanding herd humanity is also important in public health and frequently discussed by experts. The concept of herd immunity is that if enough people have immunity to any given disease it can no longer be spread because there are not enough people available to develop the infection. An example makes the concept easy to understand. No matter how infectious a disease, in a room of 100 people , if 98 have natural immunity or immunity from a vaccine and one person has active disease, then the one uninfected person is highly unlikely to contract it. For diseases with high basic reproductive numbers like measles over 90% of the population needs immunity to protect the remaining 10%. For a disease that is much less transmissible like coronavirus if the R0 value is 2.4 then if 60% of the population has immunity, herd immunity is created and spread is highly unlikely That’s why understanding the underlying basic reproductive number is crucial to determine good public health policy. Getting the information about coronavirus will be critical moving forward. The mechanism of spread whether it be airborne, very small particles or by droplet, larger particles or body fluids (ebola) which are much more difficult to spread is critical to determine R0.

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We need much more research and testing to understand all these various factors with regard to coronavirus. Every model that is described by public health experts, governors and the president are based on these underlying principles which as we all know appear to be changing on a regular basis. In addition if a virus mutates its basic reproductive number can change upward or downward. Understanding the nature and extent of asymptomatic spread of coronavirus is also very important to plan public health policy.

Our greatest tools still remain

  1. social distancing

  2. remaining at home in, a shelter in place mode

  3. washing hands

  4. Wearing face protection covering the mouth and nose and not touching the face

To date no true effective treatment has been established in spite of many statements by politicians to the contrary. The likelihood of the vaccine being available widely within a two-year framework is virtually nil.

Continue to follow basic public health principles described above. Help those less fortunate in need. Together we will overcome this challenge

Reference

https://jamanetwork.com/journals/jama/fullarticle/2765665

Please email nargy@nicolasargy.com with questions or for speaking appearances

copyright Nicolas Argy 2020

copyright Nicolas Argy 2020

Sanitizing Triage: The UGLY Truth

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Massachusetts recently published, “Crisis Standards of Care and Planning Guidance” (1) giving guidance for institutions and providers for allocation of scarce resources, ventilators, if demand exceeds supply during the coronavirus epidemic. Much of the work was based on a Journal of the American Medical Association viewpoint(2) on a framework for rationing ventilators and critical beds during the crisis. The document states



“it should be made explicit that ventilators will not be allocated on the basis of morally irrelevant consideration such as sex, race, religion, intellectual disability, insurance status, wealth, citizenship, social status or social connections”

The claim is that the triage process is ethical and consistent with the values and practices of the medical profession and our society. There is a tragic underlying consequence which is obfuscated by the authors repeatedly.
I am writing this blog to explicitly call out the discriminatory and embedded racist as well as economically disparate outcome of these policies


Tragically as has already been reported, there is enormously disparate involvement of coronavirus infections and deaths in our minorities and in our poor populations. Health disparities have manifested in coronavirus no differently than in many healthcare areas. Predicting healthcare outcomes, mortality and morbidity based on ZIP Code is far more relevant than healthcare services. Social determinants of health account for 85% of health and wellness.

The Massachusetts committee report and the JAMA opinion suggest the use of objective, Sequential Organ Failure Assessment (SOFA) scores to make these difficult decisions. The use of the score is to create an objective measure on which to base medical decisions rather than race religion, wealth, social status.   SOFA scores are a mortality prediction score that is based on the degree of dysfunction of six organ systems. This score in combination with age criteria and pregnancy are used to decide who lives and who dies. Below are the scoring medical criteria:



SOFA-scoring-system.png


We have known for decades that the poor and minorities have a higher burden of disease and chronic conditions which will automatically generate worse SOFA scores. What the medicalization of triage has done hides the underlying huge discrimination against the poor and minorities that these scores will ultimately reflect. So the internal statements that there will be no consideration of race, insurance status, wealth, citizenship or social status are blatantly false. The social determinants of health are strong predictors of chronic health conditions as well as prognosis with those infected by coronavirus. Therefore the most vulnerable will be disproportionately removed from ventilators or not offered ventilators because of exactly those reasons , wealth, race, socioeconomic status, etc.which are claimed to be not relevant.


There is an obfuscation of the inherent bias by creating the illusion of objective medical data

This is the exact same argument we have heard from years ago when talking about admissions to higher education institutions as well as discriminatory hiring in the workforce.
How often have we heard that the poor, the disadvantaged, minorities do not have the test scores or grades to be accepted to certain educational institutions or jobs. The outcomes were justified by the claim that objective data were used for hiring and acceptance but completely ignored the implicit bias and inherent inability of the most vulnerable to achieve those alleged objective criteria.

It’s time to call out the sophistry.

It’s time to recognize that the criteria being generated discriminate against the most vulnerable in our society

Let the medical profession and decision makers rethink their “objective” criteria and stop hiding behind objective medical numbers which are not objective at all.

Time to scream out the emperor has no clothes

References

  1. https://d279m997dpfwgl.cloudfront.net/wp/2020/04/CSC_April-7_2020.pdf

  2. https://jamanetwork.com/journals/jama/fullarticle/2763953

Please direct all questions to nargy@nicolasargy.com

copyright nicolasArgy 2020

copyright nicolasArgy 2020

Flawed Logic

When academics get stuck in the Ivory tower

When academics get stuck in the Ivory tower

Highly respected physician scientist John Iaonnidis falls victim to his own admonitions, coming to conclusions without data. In his keynote speech entitled “Evidence Based Medicine has been Hijacked”, Iaonnidis states that one of the downfalls of evidence based medicine is “ex cathedra pronouncements by prestigious opinion leaders”. Read below his article which is just that, an ex cathedra pronouncement of a prestigious opinion leader.

Here is the entire article with select statements Bolded by me in the article and the link to the entire piece

The current coronavirus disease, Covid-19, has been called a once-in-a-century pandemic. But it may also be a once-in-a-century evidence fiasco.

At a time when everyone needs better information, from disease modelers and governments to people quarantined or just social distancing, we lack reliable evidence on how many people have been infected with SARS-CoV-2 or who continue to become infected. Better information is needed to guide decisions and actions of monumental significance and to monitor their impact.

Draconian countermeasures have been adopted in many countries. If the pandemic dissipates — either on its own or because of these measures — short-term extreme social distancing and lockdowns may be bearable. How long, though, should measures like these be continued if the pandemic churns across the globe unabated? How can policymakers tell if they are doing more good than harm?

Vaccines or affordable treatments take many months (or even years) to develop and test properly. Given such timelines, the consequences of long-term lockdowns are entirely unknown. The data collected so far on how many people are infected and how the epidemic is evolving are utterly unreliable. Given the limited testing to date, some deaths and probably the vast majority of infections due to SARS-CoV-2 are being missed. We don’t know if we are failing to capture infections by a factor of three or 300. Three months after the outbreak emerged, most countries, including the U.S., lack the ability to test a large number of people and no countries have reliable data on the prevalence of the virus in a representative random sample of the general population.


This evidence fiasco creates tremendous uncertainty about the risk of dying from Covid-19. Reported case fatality rates, like the official 3.4% rate from the World Health Organization, cause horror — and are meaningless. Patients who have been tested for SARS-CoV-2 are disproportionately those with severe symptoms and bad outcomes. As most health systems have limited testing capacity, selection bias may even worsen in the near future.

The one situation where an entire, closed population was tested was the Diamond Princess cruise ship and its quarantine passengers. The case fatality rate there was 1.0%, but this was a largely elderly population, in which the death rate from Covid-19 is much higher.

Projecting the Diamond Princess mortality rate onto the age structure of the U.S. population, the death rate among people infected with Covid-19 would be 0.125%. But since this estimate is based on extremely thin data — there were just seven deaths among the 700 infected passengers and crew — the real death rate could stretch from five times lower (0.025%) to five times higher (0.625%). It is also possible that some of the passengers who were infected might die later, and that tourists may have different frequencies of chronic diseases — a risk factor for worse outcomes with SARS-CoV-2 infection — than the general population. Adding these extra sources of uncertainty, reasonable estimates for the case fatality ratio in the general U.S. population vary from 0.05% to 1%.

That huge range markedly affects how severe the pandemic is and what should be done. A population-wide case fatality rate of 0.05% is lower than seasonal influenza. If that is the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.

Could the Covid-19 case fatality rate be that low? No, some say, pointing to the high rate in elderly people. However, even some so-called mild or common-cold-type coronaviruses that have been known for decades can have case fatality rates as high as 8% when they infect elderly people in nursing homes. In fact, such “mild” coronaviruses infect tens of millions of people every year, and account for 3% to 11% of those hospitalized in the U.S. with lower respiratory infections each winter.

These “mild” coronaviruses may be implicated in several thousands of deaths every year worldwide, though the vast majority of them are not documented with precise testing. Instead, they are lost as noise among 60 million deaths from various causes every year.

Although successful surveillance systems have long existed for influenza, the disease is confirmed by a laboratory in a tiny minority of cases. In the U.S., for example, so far this season 1,073,976 specimens have been tested and 222,552 (20.7%) have tested positive for influenza. In the same period, the estimated number of influenza-like illnesses is between 36,000,000 and 51,000,000, with an estimated 22,000 to 55,000 flu deaths.

Note the uncertainty about influenza-like illness deaths: a 2.5-fold range, corresponding to tens of thousands of deaths. Every year, some of these deaths are due to influenza and some to other viruses, like common-cold coronaviruses.

In an autopsy series that tested for respiratory viruses in specimens from 57 elderly persons who died during the 2016 to 2017 influenza season, influenza viruses were detected in 18% of the specimens, while any kind of respiratory virus was found in 47%. In some people who die from viral respiratory pathogens, more than one virus is found upon autopsy and bacteria are often superimposed. A positive test for coronavirus does not mean necessarily that this virus is always primarily responsible for a patient’s demise.

If we assume that case fatality rate among individuals infected by SARS-CoV-2 is 0.3% in the general population — a mid-range guess from my Diamond Princess analysis — and that 1% of the U.S. population gets infected (about 3.3 million people), this would translate to about 10,000 deaths. This sounds like a huge number, but it is buried within the noise of the estimate of deaths from “influenza-like illness.” If we had not known about a new virus out there, and had not checked individuals with PCR tests, the number of total deaths due to “influenza-like illness” would not seem unusual this year. At most, we might have casually noted that flu this season seems to be a bit worse than average. The media coverage would have been less than for an NBA game between the two most indifferent teams.

Some worry that the 68 deaths from Covid-19 in the U.S. as of March 16 will increase exponentially to 680, 6,800, 68,000, 680,000 … along with similar catastrophic patterns around the globe. Is that a realistic scenario, or bad science fiction? How can we tell at what point such a curve might stop?

The most valuable piece of information for answering those questions would be to know the current prevalence of the infection in a random sample of a population and to repeat this exercise at regular time intervals to estimate the incidence of new infections. Sadly, that’s information we don’t have.

In the absence of data, prepare-for-the-worst reasoning leads to extreme measures of social distancing and lockdowns. Unfortunately, we do not know if these measures work. School closures, for example, may reduce transmission rates. But they may also backfire if children socialize anyhow, if school closure leads children to spend more time with susceptible elderly family members, if children at home disrupt their parents ability to work, and more. School closures may also diminish the chances of developing herd immunity in an age group that is spared serious disease.

This has been the perspective behind the different stance of the United Kingdom keeping schools open, at least until as I write this. In the absence of data on the real course of the epidemic, we don’t know whether this perspective was brilliant or catastrophic.

Flattening the curve to avoid overwhelming the health system is conceptually sound — in theory. A visual that has become viral in media and social media shows how flattening the curve reduces the volume of the epidemic that is above the threshold of what the health system can handle at any moment.

Yet if the health system does become overwhelmed, the majority of the extra deaths may not be due to coronavirus but to other common diseases and conditions such as heart attacks, strokes, trauma, bleeding, and the like that are not adequately treated. If the level of the epidemic does overwhelm the health system and extreme measures have only modest effectiveness, then flattening the curve may make things worse: Instead of being overwhelmed during a short, acute phase, the health system will remain overwhelmed for a more protracted period. That’s another reason we need data about the exact level of the epidemic activity.

One of the bottom lines is that we don’t know how long social distancing measures and lockdowns can be maintained without major consequences to the economy, society, and mental health. Unpredictable evolutions may ensue, including financial crisis, unrest, civil strife, war, and a meltdown of the social fabric. At a minimum, we need unbiased prevalence and incidence data for the evolving infectious load to guide decision-making.

In the most pessimistic scenario, which I do not espouse, if the new coronavirus infects 60% of the global population and 1% of the infected people die, that will translate into more than 40 million deaths globally, matching the 1918 influenza pandemic.

The vast majority of this hecatomb would be people with limited life expectancies. That’s in contrast to 1918, when many young people died.

One can only hope that, much like in 1918, life will continue. Conversely, with lockdowns of months, if not years, life largely stops, short-term and long-term consequences are entirely unknown, and billions, not just millions, of lives may be eventually at stake.

If we decide to jump off the cliff, we need some data to inform us about the rationale of such an action and the chances of landing somewhere safe.


Full citation https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/


I sent Prof Iaonnidis an email to which he never responded see below


John,

My name is Nicolas Argy I am a physician and lawyer and a strong proponent of evidence-based medicine and prudent public health measures. I have been your biggest advocate over the past decade.  Thank you for the amazing work you have done to date.

I read your recent article on "A fiasco in the making?"

I find your conclusions extremely troublesome and questionable and would deeply appreciate your explanation as to your conclusions.

Number one I completely agree that we are making decisions in the absence of reliable data

I also Agree completely that the actual fatality rate, extent of disease and impact of either allowing the virus to take it’s course versus profound social isolation and lockdown have unclear implications

Unfortunately you draw many conclusions from the diamond princess cruise ship which as you well know is neither statistically sound or a representative cross-section of the worldwide population

Further you make comments like if we react to coronavirus and focus our energies on that In your words "extra death may happen not due to coronavirus but to other common diseases and conditions such as heart attack stroke trauma and bleeding  that are not adequately treated."

That appears to be complete speculation.  Is that based on any scientific or objective data.

You seem to be strongly suggesting that allowing the coronavirus epidemic to take it’s course creating herd immunity killing the elderly is a better alternative then worldwide lockdown

And while I don’t have the answer as to whether either of these measures is likely to be more Detrimental to our society it strikes me as the fact that we can clearly mitigate a lockdown with financial measures and keeping people fed housed and getting the basic necessities of life allowing millions to die without data is both immoral unethical and equally not based on science.

I guess my only major point is that in the absence of data you make the best decision you can considering risks benefits and alternatives and it is completely unclear to me that lockdown is clearly worse than allowing the pandemic to proceed unchecked

I agree this is a no-win situation but I wish that the Conclusion of your article was not that it is better to let the epidemic kill the elderly and create herd immunity rather than lock down the entire world but rather to say we don’t have the data we don’t have the answer and we need to redouble our efforts to get that data

I would deeply appreciate a response of any type

Best 

Nick


Prof Iaonnidis has fallen victim to using bad data , speculation and conjecture to determine a course of action that advocates inaction based on ignorance. I would say being cautious and exercising a course of action based on the best information we have is the ultimate goal. Just guessing that the lockdowns and our current course of action “could” create more harm is frankly not reasonable or logical and not based on data.


Here are links to others who share my concern that the real fiasco is the publication of the article by Prof Iaonnidis which fails to follow his own advice.

https://www.statnews.com/2020/03/18/we-know-enough-now-to-act-decisively-against-covid-19/

https://www.researchers.one/article/2020-03-10

http://hildabastian.net/index.php/8-secondary/87


Copyright NicolasArgy 2020nargy@nicolasargy.com

Copyright NicolasArgy 2020

nargy@nicolasargy.com


Whistle Blowing, Medical Malpractice and the Duty to Disclose

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The Lancet(1) recently published an article referred to as the Patterson report, highlighting the problem of complicit silence in medical malpractice. The problem is one that affects all professions and pointedly in healthcare delivery from physicians, advanced clinical providers, as well as all the technicians and technologists whose duties can create dangers to patients if performed poorly. Further our entire society is faced with myriad examples of citizens engaging in dangerous behavior, from impaired driving to lack of supervision of children which we hope will be reported to avoid harm.


DOCTOR DEATH

DOCTOR DEATH



There is a long history unfortunately of coworker silence especially physicians in the face of overwhelming evidence of medical incompetence One of the more notorious cases is Dr Duntsch (2) a spine surgeon in Texas who caused multiple deaths and permanent disabilities during surgeries. Ultimately the grossly negligent physician was sentenced to life in prison .

While it seems obvious that observing a coworker and engaging in dangerous practices or obviously negligent practice would be likely to be reported regardless of whether it was in the physician nursing or advanced clinical provider, this unfortunately rarely happens. Why?

There are numerous reasons that people do not identify potentially dangerous behavior of colleagues.
As a society generally, there is typically no duty to disclose behavior which even if predictable could cause harm. There is no legal obligation if one sees erratic driving behavior on the road to call the police or intervene. Fortunately many bystanders and good Samaritan’s will identify this type of potentially lethal behavior.

In unique circumstances especially in healthcare there are defined regulations and snitch laws which obligate caregivers especially physicians to report behavior which they view as putting the public at risk
Rarely do physicians come forward to identify these types of behaviors due to the risk of alienating colleagues or being viewed as a snitch. I am aware of several cases where active surgeons were allowed to practice in spite of long histories of disproportionate complications well beyond expected norms, without intervention. Eventually all the cases that I was personally aware of did come to light and were addressed but only after decades of substandard care and harm. When asking colleagues or OR staff if this was a known issue, there was acknowledgement that everyone was aware of the problem.

One of the most common reasons for refusing to report is that there is fear of retribution as is the case with many whistleblower situations in other venues (government). Fear that the reporting will be viewed as bad faith either anti-competitive or motivated for personal vendetta has been raised. Many fear being subject to potential litigation, or being investigated themselves. There is a pervasive…” thats not my problem, let some one else report it” attitude.


FOLLOW THE MONEY

FOLLOW THE MONEY



One of the most shocking and unpleasant aspects of this world is that surgeons generate tremendous revenue for hospitals and there is a strong disincentive from administration to identify potential problems and possibly create bad publicity for the institution or jeopardize their revenue stream. Often times bad outcomes are dismissed or rationalized and attributed to bad faith or understandable result due to the nature and complexity of the case mix.



CONVICTED SERIAL RAPIST OVER DECADES DR NASSAR

CONVICTED SERIAL RAPIST OVER DECADES DR NASSAR



Courts have used various standards to identify this type of outrageous behavior including gross negligence, willful and wanton disregard for patient safety, and the use of criminal statute such as manslaughter. The fact scenarios are very similar involving behavior which profoundly deviates from the standard of care. The horrible conspiracy of silence with the sexual abuse case of Olympic team physician, Larry Nassar (3) is another sickening example.
Because the failures to disclose by observers are almost impossible to identify and enforce, there is not much that is done to redress this issue.

Ultimately the recognition that in a bell curve distribution half the caregivers in any institution are below average for their setting in their specialty is a mere statistical fact. The public does not want to acknowledge this nor does the profession. Everyone views their own clinician as being exceptional. By definition of the nature of skills half the population in any profession is below average for that job. In every setting and profession there is the bottom 1%.

What are the solutions to maximize identifying problem area clinicians?

1 Promote anonymous reporting which details specific Instances and events which can be reviewed.

2 Aggressively screening complications and injuries to identify outliers even prior to any reporting by third parties

3 Immunizing all good faith identification of potential problems within the institution regardless of the profession in question physician, Nurses, advanced medical providers or others within the caregiving spectrum including technicians and technologists whose work can directly dramatically impact patient welfare.

4 Creating more comprehensive regulatory reform

5 Making corporate accountability for identification of these trends and remedial action more available

6 Making sure patients are aware of complication rates and experience of providers providing diagnostic and therapeutic interventions

7 Requiring extensive informed consent patient engagement and shared decision-making

8 Enhancing training from medical school through residency and out into the private practice of the need for the highest standards of professionalism and highest ethical duty to protect patients from harm

The conspiracy of silence occurring in the healthcare industry and likely in other public venues and professions must be called out and mitigated. Recognizing a duty to disclose over obvious public dangers needs to be re-emphasize not only in the medical profession but in society as a whole.


Further inquiries may be directed to nargy@nicolasargy.com




copyright nicolas argy 2020

copyright nicolas argy 2020

References

1 DOI: https://doi.org/10.1016/S0140-6736(20)30351-2






2 https://en.wikipedia.org/wiki/Christopher_Duntsch






3 https://en.wikipedia.org/wiki/Larry_Nassar

From Quarantine to Social Distancing: The When and How


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With the emergence of coronavirus there has been much discussion on the use, extent and importance of quarantine for containing infection. If done correctly disease transmission can be reduced. If done incorrectly or too aggressively the the effort may exacerbate the spread of disease. Efforts to round up large numbers of people or incarcerate them could actually encourage those who are sick to avoid getting medical care or worse flee, further worsening contagion. Depending on the facilities provided, corralling potentially infected individuals could promote spread. The strategies for decreasing transmission range from isolation, quarantine, cordon sanitaire to social isolation.

Definitions from the CDC

Isolation and quarantine are public health practices used to stop or limit the spread of disease.

Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. For example, hospitals use isolation for patients with infectious tuberculosis.

Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms. Quarantine can also help limit the spread of communicable disease.


The term cordon sanitaire is a word used by some which means movement restrictions which apply to everybody, not just the exposed people. The distinction is somewhat semantic since everyone in Wuhan is potentially exposed and could be deemed to be quarantined

For purposes of this discussion I will use the terms quarantine and isolation interchangeably understanding the distinction is usually not critical except when medical care is being administered. Even when medical treatment is warranted it can often be provided through robotics or remote monitoring more safely than in health care facilities.

While on initial perusal the concept of isolating someone to prevent spread of disease seems straight forward, unfortunately the exact nature of the isolation, timing, placement and locale must be highly tailored. Balancing public welfare against the infringement on personal freedom can be very nuanced.

Based on the extent and risk of each individual Infectious disease including the mortality, morbidity and infectivity requires responses tailored to the specific circumstances. China has used large quarantine centers which may not provide adequate isolation. This strategy could be counterproductive leaving people who are not infected with people who are infected and furthering the spread. Also any gathering of quarantined groups puts those caring for them , medical workers, food distributors at risk.

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Making a cruise ship a quarantine vehicle while again seeming to be prudent can also actually exacerbate the problem especially while 1/3 of the ship, the crew, is forced to interact with each other and also distribute food and other necessities to the isolated passengers in their cabins

Does screening work?

Does screening work?


With coronavirus screening for fever or symptoms as a means to determine who should be quarantined seems misguided. There there seems to be a significant subset of asymptomatic or minimally symptomatic people who can spread the disease in addition there is always a group who are infected but are in the incubation period of 7 to 14 days but have yet to get ill.

Individuals who can spread the disease must be housed in a setting which limits spread but doesn’t put those tasked with over seeing them at risk. Ideally allowing people to stay in their own residence where they have access to the essentials for living seems prudent Distribution of essential medicines food or other needs to a home setting can be done with small risk if operationalized appropriately . Even within the home setting the individuals in the shared space with friends or family must be very careful to stay isolated.


With regard to the infringement on personal freedom again a balance must be created. Certainly sending someone to in incarceration setting is draconian. This technique has been used historically especially with tuberculosis but certainly does not represent the least restrictive alternative for containing disease. Courts in the US have variably invoked the legal standard of requiring the least restrictive alternative when depriving an individual of their personal freedom.

Especially for highly contagious and highly lethal infectious disease, quarantine becomes that much more important. The Ebola virus would fit the category of highly infectious and lethal viruses which would warrant more aggressive quarantine measures. Many are concerned that quarantine will be used in a racist or discriminatory fashion and this has happened historically. This can be avoided using evidence-based and objective measures for reducing spread. Quarantine efforts should not be racist, discriminatory or promote irrational fear or create panic.

Making public health decisions when limited information is known about a particular disease is always problematic. In those situations a balance of public welfare and protecting individual freedoms should be achieved with caution being needed. Different countries tolerate quarantine to a different extent based on cultural and legal historical differences. What may be deemed acceptable quarantine and governmental action in China may be deemed reprehensible in the United States.

It is likely that if the disease spread continues, public health officials may call for social distancing or isolation by limiting public gatherings, events , meetings and discouraging gatherings of large groups of people. Maintaining a discrete distance from other people has been discussed as well. To date China has started this policy and some international meetings including in Europe have been canceled.

quarantine tape.jpg



The issue of quarantine is highly complex, it must be addressed and implemented In a fair balanced fashion based on the scientific evidence. Both extremes of opinion on quarantine leave plenty of middle ground for compromise. Having ongoing reasoned debate as evidence accumulates is the most prudent means for achieving both protection of public health and minimizing infringing on personal freedom. Choosing the best setting for quarantine which limits spread and minimizes restriction of individual freedom is the proper balance.

Please contact Dr Argy at nargy@nicolasargy.com with inquiries

Copyright 2020 nicolasargy

Copyright 2020 nicolasargy