Answering “Plandemic”

An Interview with Frontline New York City Healthcare Physician and Field Epidemiologist, Dr. Rupa Narra

Written by:
Toba Singer
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The “Plandemic Movie” was uploaded to YouTube on May 4, 2020. By May 9, it had been viewed eight million times. On May 12, those who had yet to see it, were surprised to find that YouTube had acted abruptly to take it down. Why? YouTube spokespeople cited its specious conspiracy claims which many online were willing to take if not seriously, at least curiously. One needs little convincing that what Plandemic’s Judy Mikovits seeks to tag as conspiracy is little more than business-as-usual medicine amidst a capitalist crisis fronting as a medical one. Still, questions Mikovits alludes to persist unanswered. Nightly TV news conferences trade barbs while pundits favor turning the pandemic into yet another Trump-bashing spectacle. Meanwhile, people continue to die in the millions. Key questions linger long after  morgue “overflow” consigns fresh corpses to refrigerated semi- trailers.

Those working in medical centers, plants, and big box stores where PPE is inadequate, and testing, hit and miss, deserve to hear from a boots on the ground epidemiologist who can breathe life into a discussion that has flatlined into a blame game, replayed day and night and tell what epidemiologists are learning from this and previous epidemics to improve managing the next one and answer such questions as: Why are individuals, symptomatic or not, bearing more responsibility for this contagion than official health care agencies take on? With a 17-year lead in predicting a SARS-family virus, why is there not yet a vaccine? What accounts for the scarcity of facilities and supplies? What does “herd immunity,” actually promise? Isn’t blanket social distancing little more than a default plan in the absence of strategic testing, a reliable vaccine,  and effective contact tracing? What can other nations’ successes teach us? I had the opportunity to interview Dr. Rupa Narra, Assistant Professor in the Department of Emergency Medicine and Pediatrics at NYU-Langone. Dr. Narra has previously worked as a medical epidemiologist for the Center for Disease Control, and was a pediatrician with Doctors Without Borders in Sub-Saharan Africa for five years.

What admitting information is collected to build both individual and community immunity profiles regarding the SARS family of viruses?

After asking age, address, and sex, the admitting nurse gathers the following medical information: History of present illness–presenting symptoms and their duration in days; 

known sick contacts; known COVID exposures, including others in the household or close contacts with COVID-like symptoms; medical history: previous conditions (hypertension, asthma, diabetes, etc.); hospitalizations and surgeries; current medications and allergies to medications; immunizations for basic vaccines, such as flu, MMR, DTaP, Prevnar, etc.; sexual history; and drug, nicotine, alcohol use history.

Most important for SARS is whether there has been close contact with the disease.  Contact Tracing is useful when conducted in a timely way and in the right location. Trained volunteers collect specific data from COVID-19 patients or contacts, gleaned from retracing their steps for prior two days, asking for all contacts who came within six feet of them, those living in their household, sharing meals; and then they contact them.  In African countries with Ebola outbreaks (Guinea, Liberia, Sierra Leone), contact tracers conducted interviews at the hospitals. Here in the US, those not infected are not permitted in hospitals, the difference being droplet transmission with Covid-19. Also, because of pre-existing structures and design, patient flow is not easily rerouted. In New York, hospitals are at maximum capacity, without unidirectional flow where HEPA filters and negative pressure are located. In Africa, with Ebola, we did create separate entrances for contact tracing and families (non-symptomatic).

Another option would be to telephone non-ventilator patients. Contact tracing is a real skill that can be adapted for tablet communication. The greatest obstacle to truthful patient reportage is stigma: shame or guilt for having violated precautions. At this stage, too much time has passed to make it useful, say, in the middle of Manhattan, where exponential contact has breached possible controls. Optimum implementation would be in new “hot spots” that are more controllable, where the number of cases is starting to rise or fall. We are trained in strategy of this kind, but health agencies aren’t making optimum use of that training.

We don’t assume that someone has immunity to coronaviruses unless they have previously had a positive SARS-COV2 RT-PCR test or reliable serology testing. (Many available test kits have poor validity and all are not FDA-approved.) People exposed to other viruses (i.e. the common cold) do not have any sort of immunity against COVID-19.

Define “herd immunity”

In simple terms, herd immunity is resistance to the spread of an infectious disease because a large proportion of the population is immune to it. Depending on the infectivity of the disease, the proportion of the population needed to be immune varies. Immunity is attained via natural immunity from contracting the disease (even if asymptomatic or with mild symptoms) or vaccination. It only works for diseases spread directly from person-to-person. “Herd immunity” is an umbrella term comprising a group having immunity via vaccine or natural immunity by having contracted and survived the disease. The greater number of such individuals in a given area, the better; meaning that the  susceptible are more protected. Different viruses have different infectivity potential. Measles has a high infectivity, requiring 90-95% herd immunity to create a safe environment.  Haemophilus Influenza Type B is not as infective, Scientists are still trying to determine the level required for COVID-19 and so a 70% herd immunity is sufficient protection. For more on how to calculate Herd Immunity, see: https://thoughtscapism.com/2015/04/20/the-simple-math-of-herd-immunity/

Governor Andrew Cuomo recently revealed that 66% of COVID-19 cases occur among those who are sheltering in place and only 2% from “congregates.” His statistics seem to countermand precautions from health agency experts. How do you interpret his statistics, and their implications?
I don’t know how this information was gathered. If they used contact tracers, it may have been gathered and synthesized, but I would be surprised if we had that degree of information for the vast number of cases we have had in New York.

What happens to immunity when we isolate indefinitely? Do we “lose” defenses by not coming into contact with others over a prolonged period?
We normally would not lose immunity against infectious pathogens during a short period of time, such as a few months, but it depends on the age group.  Most adults in the US (that have been vaccinated against pathogens with routine vaccines) have already attained immunity against many diseases, except those that are seasonal, such as influenza varieties. 

Comment on the relationship between two seemingly opposing concepts, “social distancing,” and “social solidarity,” in an epidemic situation.

To my knowledge, social solidarity is a concept developed by sociologists whereas social distancing is a term utilized by public health officials. Both concepts and practices are extremely important, but require a delicate balance and expertise from a variety of disciplines, asking whether they are guided by fact or supposition.  In epidemics where we achieved successful control and prevention measures, we utilized a multisectoral approach.  For example, for both cholera and Ebola, we had pillars comprising experts from all fields: Epidemiology (public health experts and epidemiologists); Clinical management (medical providers such as nurses and doctors and hospital administrators); Logistics and supply; Social mobilization/communication for development (sociologists, anthropologists, community leaders, communication experts, translators); Water, sanitation and hygiene (WaSH) engineers, city planners, water scientists; Laboratory testing of  both clinical and environmental samples, with oversight by microbiologists and environmental lab experts; Vaccine implementation and delivery (epidemiologists to sort delivery strategy, such as ring vaccination; vaccine experts; pharmaceutical company reps; and institutions (Gates, National Institutes of Health, Federal Drug Administration) which could mass produce vaccines safely and fund projects.

Are WaSH bodies set up and operative in major cities?

Having worked for the CDC, I know that we are limited because the CDC is a government organization. There are gags on what we may say. There are entire areas, such injury and deaths that resulted from gun violence, that we have been forbidden to research or publish information about. We’re now face to face with the biggest pandemic in a century, and find that health institutions have been relegated to the sidelines, or are outright gagged. Since The World Health Organization is limited in the information it receives, it is limited in what it is able to report.

In Africa, we met at the local level. That may also be the case with the Navajo Nation, dependent on the corresponding state health departments. The New York City Department of Health is in charge of running their response. In some countries, a strong response can be mandated by law: coordination of water levels, testing for x, y, or z presence, all in accordance with the law. The CDC offers guidance,  but does not make policy: “We’re experts and  we’d highly recommend. . . .” They have done this with outbreaks such as measles, meningitis, and Legionella. When I was in Africa during Ebola, we would meet around a table. The Epidemiologist would report the case count/24hours/map/death rate/ age, sex. Clinical would give a facilities and equipment report, and what moves could be made to adjust for demand. Logistics and supply organized distribution. Water supply and hygiene coordinated water, Infection Prevention and Control measures, opening of a new Incident Command Center, determined the logical place, and staff consist. Within half an hour you would have a ton of information. It is hard to confirm whether this is being done in various major cities in the U.S.

Taking into account viral load, its dispersal and spread, mechanisms built into our indoor environments, such as forced air systems, flush toilets et al., what must be completely changed, re-engineered, overhauled, and restructured about our government, economy, culture, way of life, medical education, and practice, to create viable infrastructure and superstructures to take on the SARS family of viruses? 

Coronaviruses spread predominantly through droplet exposure (direct exposure by an infected person actively coughing, sneezing or speaking in close contact), but can also spread via other bodily fluids, such as vomit or diarrhea.  We are studying bodily fluids such as breast milk, semen, tears, etc., but focus on what we currently know about droplet spread. For a disease such as cholera, which mainly spreads from drinking contaminated water or fecal-oral routes, WaSH interventions are essential.  Trying to attain negative pressure or HEPA filters in public places would be very difficult even if we could assume they would contain the spread of the disease. This is why social distancing measures were implemented.

Given your experience, if you “ran the zoo,” how would you design community medicine in a country the size of the United States, taking into account differing needs of urban centers, and less densely populated prairie, port, and mountain regions?
We need a multisectoral response.  Each city and state needs committees of experts from various backgrounds, meeting or teleconferencing daily to discuss new case counts, needs, challenges, and innovative response tactics. This is basic to approaching any epidemic. The problem in the US is that city and state health departments govern idiosyncratically, and there is no means to enforce a uniform and comprehensive protocol without a willing and responsive leadership. 

What about public education, including biochemistry, biostatistical probability for laypeople?

A simple thing to institute would be an instant command center, where a team, expert in several disciplines, presents a map of the US showing number of cases, hospital capacity by state, and relevant links to more information. Two hundred cases in South Dakota might be hospital maximum capacity there. In New York, capacity might max out at 10,000 cases. Using data to inform the public is far superior to scientists getting into arguments with random antagonists just because the media provides an arena for them to go at it. 

According to the Encyclopedia Britannica, Case Fatality Rate, also called Case Fatality Risk or Case Fatality Ratio (CFR), is the proportion of people who die from a specified disease among all individuals diagnosed over a certain period of time. What impact does Case Fatality Rate have in the current discussion?
Case Fatality Rate is a measure of disease severity and often used for prognosis, where comparatively high rates would suggest relatively poor outcomes. It can also be used to evaluate the effect of new treatments, with measures decreasing as treatments improve. Case fatality rates are not constant; they can vary between populations and over time, depending on the interplay between the causative agent of disease, the host, and the environment, as well as available treatments and quality of patient care.

CFR is calculated by dividing the number of deaths from a specified disease over a defined period of time by the number of individuals diagnosed with it during that time; the resulting ratio is then multiplied by 100 to yield a percentage. This calculation differs from that used for mortality rate, another measure of death for a given population. Although number of deaths serves as the numerator for both measures, mortality rate is calculated by dividing the number of deaths by the population at risk during a certain time frame. As a true rate, it estimates the risk of dying of a certain disease. Hence, the two measures provide different information.

Consider two populations. One consists of 1,000 people; 300 of them have the specified disease, 100 of whom die from it. The mortality rate for the disease is 100 ÷ 1,000 = 0.1, or 10 percent. The case fatality rate is 100 ÷ 300 = 0.33, or 33 percent. The second population also has 1,000 people; 50 have the disease and 40 die from it. Here the mortality rate is 40 ÷ 1,000 = 0.04, or 4 percent; the case fatality rate, however, is 40 ÷ 50 = 0.8, or 80 percent. Death incidence from the disease is higher in the first population, but the severity of disease is greater in the second.

A major difficulty in estimating CFR is ensuring accuracy of the numerator and the denominator, and as duration of the disease of lengthens, a person becomes increasingly likely to die of causes not associated with the specified disease. If death from another cause is inadvertently counted in the numerator, the case fatality rate will be overestimated. If the death was caused by the disease in question but was not included in the numerator, the case fatality rate will be underestimated. 

Would you care to comment on how the math ratios are presented to the public by the media in the instance of this COVID-19 pandemic?
In media reports, it seems that they put the total death numerator over the total population instead of total number of confirmed cases! Using inaccurate calculations results in incorrect metrics substituting for educating and supporting people in their effort to remain healthy. 

How would a targeted approach to social distancing operate if in a best or even better case scenario? 

Social distancing in New York is revolutionary. It put a quick and immediate stop to flooding hospitals with patients. I know that there are a number of experts who have been working relentlessly. Sadly, I think they have not had the voice they deserve during this pandemic–at national press conferences and discussions, alongside Dr. Anthony Fauci, able to clearly state: “Here is what we know; here is what we don’t know. Here is what we think we should change based on our experience and current data.” 

Do you think that the limits of hospital capacity should drive a blanket precaution of social distancing for the entire country, state or region? 

While recognizing the importance of social distancing, where its efficacy has been proven in data for the City of New York, doing it in a blanketed way across the US has raised suspicion, loss of confidence in the expertise of medical advisors, resulting in an overall absence of credibility. 

Using that data in a meatpacking plant, for example, they could still implement rigorous social distancing and put into effect guidelines that the CDC has on its website, and by collecting all the data they can from friends, coworkers who are working 16-hour days, and applying  what they know about SARS. But if such data is being collected, it is not being distributed. Nobody is confidently saying what level of social distancing applies— and it is a missed window. There should be daily hot spot mapping in order to implement measures where needed instead of taking a scattershot approach based on whichever governor wants to open up what.

The lockdown was never meant to be a long-term solution. So, to alleviate the strain on high patient-load hospitals, they targeted all of New York. Our morgues and funeral homes were full, so there have been four refrigerated semis behind NYU. Should the entire US be subject to a social distancing plan based on New York data? Having a reasonable plan depends on good documentation. Take Houston, for example, where they are opening nail salons and dance clubs this week. It’s appalling that there’s not more systematic guidance based on documentation. Prioritize testing among known vulnerable populations, hot spots and their borders. We did this in the African Bush, using daily information reports with case counts, and a heat map. Cuba was exceptional and revolutionary, did an incredible job, and trained African staff, to boot!

How do the claims in “Plandemic” square with your experience with COVID-19?
There is some truth to Plandemic. The problem is that they mix truth with falsehood. I’m angry  that YouTube took it down; instead it should have been debunked. There was a visiting nurse who came to New York, and she spread the rumor that doctors were misidentifying deaths from other causes as COVID-19 deaths because insurance payout was greater for COVID-19 and doctors were receiving extra pay for those cases.

Regarding case definition, there is no “extra money” coming our way for identifying the cause of death as COVID-19. If there is suspected COVID once tested Polymerase Chain Reaction positive, no frontline health worker is getting a kickback from anyone, anywhere. Because of defects in the infrastructure of a given hospital, if I see a child with pneumonia who gets regular treatment, I may by needs say suspected COVID to insure that the staff caring for the patient has the correct  PPE, and is placed in a negative pressure ward. This is in order to protect that patient, other patients, and staff. I wouldn’t place a suspected COVID-19 patient next to a patient with an immunocompromised condition. Yes, we did stop elective surgeries and basic visits. As a Pediatrician, I normally see patients aged 18 and under. Now I’m seeing patients up to age 30 because our Emergency Department has been working short-staffed, with the large influx of patients requiring that we weigh specialties against immediacy of need.

I don’t know what happens at the administrative level, but it is just not the case that the number of COVID deaths are inflated so that kickbacks come our way. On the contrary, our teams are overworked. Valued professionals end up in despair, as with Dr. Lorna Breen’s suicide. She was an esteemed emergency medicine leader and mentor for my ER colleagues–a very personal loss.

Regarding the vaccine, I don’t agree with rushing through precautions to get a vaccine out. There has to be vaccine efficacy to approach herd immunity. In any case, it takes years to assure vaccine safety and efficacy. Even the yearly flu vaccine is a regularly mutating virus that can lead to reduced efficacy compared to a known bacterial infection, such as measles.  

If Judy Mikowits were to focus on what truly has gone missing, she could have focused on the need for community messaging or the comorbidities that make African-Americans, African-Caribbeans, and Hispanics more susceptible to COVID-19, and the need for a leadership that allows a more transparent voice and an organized multi-sectoral response to ease fears. An educated public is not only less susceptible to the disease, it is less susceptible to unprovable theories about its spread and prevention.

Toba Singer

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