October 12th, 2020

“Dying in a Leadership Vacuum” — Defended

This past week, the Editors of the New England Journal of Medicine published a piece entitled “Dying in a Leadership Vacuum.”

It’s a scathing indictment of the United States government’s response to COVID-19, in particular our inability to have a science- and evidenced-driven approach to control a disease that has now killed more than 215,000 Americans.

One might ask what purpose such an editorial serves. After all, those who agree with the sentiment (raises hand!) already know, less than a month before election day, how we’re going to vote.

And those who disagree will dismiss its publication as politics as usual.

Never mind that our government’s first comprehensive pandemic response program was started by a Republican president, George W. Bush. The same president who launched the largest global HIV treatment program in history, the President’s Emergency Plan For AIDS Relief (PEPFAR).

There’s hardly an ID specialist out there who didn’t strongly support these important initiatives. So no, this isn’t all about politics.

Another criticism of the editorial, say some doubters, is that it could have the paradoxical effect of driving voters away — confirmation that doctors and scientists are elitist intellectuals with a liberal bias.

In short, it does little more than “making the writers feel good.”

There is perhaps some validity to this perspective — I was accused of the same when writing an imaginary “apology” issued by the president. (Somehow we never heard from him — no surprise.). But it did make me feel better, so guilty as charged on that account.

But still — are there other benefits to such an opinion piece?

I’d say yes. An important counter view is that a pointed editorial from the usually apolitical New England Journal of Medicine signals the severity of the problem we have. Saying nothing would arguably be a political stance as well.

The piece also acts as a convenient way to catalogue some painful data, and highlight our more egregious mistakes. It’s well-written, and accurate, and already has been read over 2 million times. But if you don’t have time to read the whole thing, here are some choice selections.

First, some damming mortality statistics:

The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000.

Next, our ongoing testing and PPE fiascos:

When the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing. While the absolute numbers of tests have increased substantially, the more useful metric is the number of tests performed per infected person, a rate that puts us far down the international list, below such places as Kazakhstan, Zimbabwe, and Ethiopia, countries that cannot boast the biomedical infrastructure or the manufacturing capacity that we have.

Our inability to support coherent social policies:

Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved. And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures.

How about our usually capable and non-partisan government agencies?

The Centers for Disease Control and Prevention, which was the world’s leading disease response organization, has been eviscerated and has suffered dramatic testing and policy failures. The National Institutes of Health have played a key role in vaccine development but have been excluded from much crucial government decision making. And the Food and Drug Administration has been shamefully politicized, appearing to respond to pressure from the administration rather than scientific evidence.

And now, the big finish:

But this election gives us the power to render judgment. Reasonable people will certainly disagree about the many political positions taken by candidates. But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.

So there’s hope — and it comes on November 3.

Until then, we have dogs, and The Beatles.

14 Responses to ““Dying in a Leadership Vacuum” — Defended”

  1. URamesh Srinivasan says:

    Dear Dr Sax I was happy to read your comment on the state of inertia in the US in controlling the SARS CoV 2 pandemic.Everything is dependent on the signals from the top leadership.It would be sheer madness to re elect the same people that brought on this cross

  2. Mimi Breed says:

    Perhaps among other things, NEJM has demonstrated the value of saying nothing *most* of the time.

    I wondered whether a newish Editor-in-Chief from the worlds of infectious diseases and public health has anything to do with this.

  3. Bohdan Oryshkevich MD MPH says:

    I agreed with this editorial.

    But many of our problems relate to the character of our health care system. Our system has also failed us. These problems antedatiere our current administration.

    Secondly, our public health establishment has failed to come together and speak with one self correcting voice.

    We must ALL work TOGETHER to get us out of this mess.

    Bohdan A Oryshkevich, MD, MPH

  4. Ediriweera Desapriya says:

    Scientific American has announced its endorsement of Democratic nominee Joe Biden, the first time the magazine has endorsed apresidential candidate in its history. The 175-year-old magazine’s ScientificAmerican editors wrote that they felt compelled to break with tradition in 2020because they believe President Donald Trump has mishandled the Covid 19 pandemic,taken steps against environmental protections and threatened health care forAmericans. The evidence and the science show that the current USleadership has badly damaged the U.S. and its people-by rejecting the scienceand evidence based medicine.Not only that the current leadership interfered with WHO and the CDC and tarnished their global health care leadership reputation.

  5. Isabel says:

    Bravo. Though I am not american I follow closely the campain and debates. I agree with your analysis and your opinion. Thank you for your wise and accurate words.

  6. Gerrard Phillips says:

    How does this mesh with Nancy Pelosi’s statement on UK regulatory processes:

    “We need to be very careful about what happens in the UK. We have very stringent rules in terms of the Food and Drug Administration here, about the number of clinical trials, the timing, the number of people and all the rest,” and “My concern is that the UK’s system for that kind of judgment is not on a par with ours in the United States”

    Our systems (MHRA) are aligned with the European Medicines Agency and approved under their auspices, so she’s also criticizing them

    She added: “My concern is that the UK’s system for that kind of judgment is not on a par with ours in the United States. So if [prime minister] Boris Johnson decides he is going to approve a drug and this president embraces that, that is a concern that I have.”

  7. Libby Hohmann says:

    It is indeed telling and appropriate that the historically apolitical Science and NEJM have weighed in here! VOTE!

  8. Frank P. Castrina MD says:

    This is the first time the NEJM has advocated a political solution (voting against a presidential candidate) on the basis of his incompetent public health policies. The AID initiative referenced by Dr. Sax was a presidential action that resulted in over 80 billion dollars in aid and is purported to have saved millions of lives. If the policy of the NEJM is to advocate a political solution (voting against an administration) on the basis of bad public health policies then they should also advocate a political solution (voting for an administration) that has supported exemplary public health policies. To do otherwise is disingenuous – one man’s incompetence may have caused tens of thousands of deaths and the other man’s competence may have saved millions of lives.

  9. Jacob Wood, MD says:

    As a physician, I cannot argue with the points made, but I will say that one factor is greatly overlooked. The mindset of Americans is fiercely individual in contrast to most of the rest of the world. When our governor put in a statewide stay at home policy and a mask mandate, you would not have known it when going to Walmart or Home Depot. They were full. Neighborhood parties were happening regularly. Some will say this is a trickle down of the attitudes of our leaders. I think it is the other way around. I think our leaders have a bent in the libertarian/individualistic direction because the constituency is largely that way and votes them in. Right or left, the majority seems to agree that people should be free to do what they feel is best for themselves — whether in relation to this pandemic or other issues of public and private health. I am not pronouncing judgement on that sentiment nor am I supporting it. I am just pointing out that it is a seemingly overlooked root cause of our failure to control the virus in this country compared to other countries where fierce individualism is not part of the equation.

  10. Evan L Lipkis MD says:

    Unfortunately, the editorial simply reflects political bias and targeted America just before elections. If you are going to criticize the current administration, please look at both sides of an issue rather than having a political agenda. Try suggesting solutions rather than innuendos. Here are just a few holes in this disappointing editorial:

    1. Of course there is a higher death rate for Covid 19 in the US vs. China. They don’t report any data that criticizes their own communist regime.
    2. Certainly undeveloped nations have a lower death rate than the US because the average age is far lower. For instance, the average age in Uganda is 16 vs 38 in the USA. It’s expected that death rates here are higher due to age. Also we have the highest rate of obesity for a developed nation and obesity is a risk factor.
    3. Canada has half the death rate of of the USA because they don’t have cities that are nearly as dense as NY or LA.
    4. What about the good stuff? The travel ban to China with only 5 reported cases in the USA saved countless lives. In NY, the current administration provided a large medical ship for sick patients, set up portable hospitals and supplied all the necessary ventilators. The gov’t united private businesses with governmental agencies for the faster production of vaccines, the institution of mass testing and the development of new treatments. We have never made an RNA vaccine and one will likely be ready in November or December. Operation Warp Speed is a big deal but you’re editorial doesn’t utter a word about this positively impactful initiative.
    5. Why did you not editorialize the poor response of our gov’t to H1N1 back in 2009? Why don’t you comment about crowded marchers not wearing masks or social distancing?

    I’m really disappointed. Stick to medicine and not politics under the guise of medicine. Promulgate solutions instead of criticizing policy.

  11. STEVEN BERMAN says:

    Mandatory masking has been and continues to be the key to controlling transmission. Politicians of neither party have had the courage to force the voters to comply. The rest is malarky!

  12. CLMD says:

    I do not believe it helps a situation when a vocal group acts as if their opinion reflects the majority without discovering first what the majority opinion is. Hubris…

  13. Clancy Hughes says:

    I think the scathing editorial amounts to both an unscientific and an un-academic mis-step. Bohdan Oryshkevich MD MPH at least had the courage to point out our public health shortcomings. Public Health lacks the teeth to impose quarantine and other isolation measures and lives with the US HIV numbers, testing and confidentiality limitations. Secondly our healthcare system remains among the poorest among other developed nations including infant mortality, nutrition, and longevity. Thirdly, most of our medical supplies come from China including test kits, drugs and devices, in fact, nearly everything medical. China closed the supply chain at the same time they left open the travel from Wuhan to the rest of the World. Trump closed travel from China against the advise from the medical establishment. That’s an indisputable fact. Furthermore, Trump rallied manufacturers. He staged daily TV and online briefings that rallied the nation. You can argue with his ambivalent attitude about masks and you are right, but the POTUS sees far greater responsibility than just the pandemic. One could just as well praise his leadership in putting the pandemic back in the hands of state governors, actually a constitutional question, while securing national security, defense and the economy. US health care must stop holding its-self out as all knowing and best quality. The NEJM editorial can be read as more of an inditement on those who wrote it and on a dysfunctional US healthcare system including Public Health than on over-all elected US leadership. One must ask, how much Chinese, CCP, bias motivated the editorial.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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