New England Journal of Medicine’s “Dying in a Leadership Vacuum”

For the first time in the history of the New England Journal of Medicine they made an endorsement in a presidential race. The driving factor in the endorsement? How the COVID-19 pandemic is being mishandled.

“When you meet someone for the first time, that’s not the whole book. That’s just the first page.”

Brody Armstrong

This really stuns me and has been on my mind for the last several days. The New England Journal of Medicine is one of the most respected, if not the most respected journal in American medicine. My Dad who was a Neurosurgeon for years had deep respect for them and I heard about them from time to time. If you work in the medical community you know how prestigious the New England Journal of Medicine is in the medical profession. The other day for the first time in their history – 208 years of history they came out and called for President Trump to be removed. Why? It deals with how the COVID-19 pandemic has been severally mishandled. I never thought I would see such an editorial, so I just want to add this to the blog. Its a different post, but one that I wanted to add. For context you can read more about this in the Washington Post in, “The New England Journal of Medicine avoided politics for 208 years. Now it’s urging voters to oust Trump.” Also The New York Times wrote about this as well in, “In a First, New England Journal of Medicine Joins Never-Trumpers.” You can read the full article by the New England Journal of Medicine in, “Dying in a Leadership Vacuum.” 

Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.

The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. 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. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.

We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.

Why has the United States handled this pandemic so badly? We have failed at almost every step. We had ample warning, but 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.2 Moreover, a lack of emphasis on developing capacity has meant that U.S. test results are often long delayed, rendering the results useless for disease control.

Although we tend to focus on technology, most of the interventions that have large effects are not complicated. The United States instituted quarantine and isolation measures late and inconsistently, often without any effort to enforce them, after the disease had spread substantially in many communities. 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. The government has appropriately invested heavily in vaccine development, but its rhetoric has politicized the development process and led to growing public distrust.

The United States came into this crisis with enormous advantages. Along with tremendous manufacturing capacity, we have a biomedical research system that is the envy of the world. We have enormous expertise in public health, health policy, and basic biology and have consistently been able to turn that expertise into new therapies and preventive measures. And much of that national expertise resides in government institutions. Yet our leaders have largely chosen to ignore and even denigrate experts.

The response of our nation’s leaders has been consistently inadequate. The federal government has largely abandoned disease control to the states. Governors have varied in their responses, not so much by party as by competence. But whatever their competence, governors do not have the tools that Washington controls. Instead of using those tools, the federal government has undermined them. 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,3 appearing to respond to pressure from the administration rather than scientific evidence. Our current leaders have undercut trust in science and in government,4 causing damage that will certainly outlast them. Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

Let’s be clear about the cost of not taking even simple measures. An outbreak that has disproportionately affected communities of color has exacerbated the tensions associated with inequality. Many of our children are missing school at critical times in their social and intellectual development. The hard work of health care professionals, who have put their lives on the line, has not been used wisely. Our current leadership takes pride in the economy, but while most of the world has opened up to some extent, the United States still suffers from disease rates that have prevented many businesses from reopening, with a resultant loss of hundreds of billions of dollars and millions of jobs. And more than 200,000 Americans have died. Some deaths from Covid-19 were unavoidable. But, although it is impossible to project the precise number of additional American lives lost because of weak and inappropriate government policies, it is at least in the tens of thousands in a pandemic that has already killed more Americans than any conflict since World War II.

Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. 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.

References (4)

  1. 1.Johns Hopkins University Coronavirus Resource Center. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University ( opens in new tab).

    Google Scholar. opens in new tab

  2. 2.Total number of COVID-19 tests per confirmed case, September 14, 2020. Our World in Data ( opens in new tab).

    Google Scholar. opens in new tab

  3. 3.McGinley L, Abutaleb L, Johnson CY. Inside Trump’s pressure campaign on federal scientists over a Covid-19 treatment. Washington Post. August 302020 ( opens in new tab).

    Google Scholar. opens in new tab

  4. 4.Haberman M. Trump admits downplaying the virus knowing it was ‘deadly stuff.’ New York Times. September 92020 ( opens in new tab).

    Google Scholar

One thought on “New England Journal of Medicine’s “Dying in a Leadership Vacuum”

  1. I cannot begin to speculate on the motives resulting in the NEJM article you link to. However, it is not an explicit endorsement or repudiation of any specific politician, leader or political candidate. The words “Trump,” “Biden,” “President,” or “Vice-President” do not occur in the text. At best it is an exhortation to not allow incompetent but unnamed leaders to keep their jobs, ostensibly by voting for someone else who is also not named.

    I would be more inclined to take their position seriously if I didn’t think the editors who composed this screed weren’t so blatantly naïve or so selective in their outrage.

    Their naïveté shines brightly in their lauding the People’s Republic of China for their response to the virus. They cite China’s death rate of 3 per million. They don’t mention that China “reports” a total of less than 4,800 deaths, nor do they note that China has reported only 114 additional deaths since April 17. In fact, China hasn’t reported a single death due to Covid since September 26. The NEJM believes these reports. If you believe that the Chinese are being transparent in terms of their numbers of reported infections or deaths, then I want to sell you an orange bridge in northern California!

    The article notes that when the virus first arrived, we were incapable of effective testing and lacked adequate PPE. Well, it was a “novel” coronavirus, and so a new test had to be invented. That takes time. And as for the lack of adequate PPE, this was the result of the prior administration drawing down these supplies to deal with an earlier epidemic without then subsequently replenishing these supplies. The current administration did an unexpectedly good job of providing additional PPE and hospital beds in the hotspots, almost all of which hospital beds went unoccupied in the event. The article asserts a more useful metric for evaluating our response to the pandemic is “the number of tests performed per infected person, a rate that puts us far down [compared to] places like Kazakhstan, Zimbabwe and Ethiopia.” But note that the NEJM doesn’t explain why this is a more “useful” metric. It’s not self-evident to me why this is more “useful.” And if anyone who contracts COVID wishes to be treated in Zimbabwe or Kazakhstan, be my guest.

    As far as their complaint about people “simply not wearing masks,” the CDC initially said not to wear masks, and now says (according to at least 1 spokesman) that wearing masks is more effective than taking a vaccine. Given the CDC’s report of last week of the effectiveness of previously approved flu vaccines, some as low as 10% and the average being around 40%, that assessment may well be accurate. Still, I’m waiting for someone, anyone, to explain to me how a cloth mask porous enough to breathe through will somehow trap or block an aerosolized virus particle c. .1 microns in size. I grant that a cloth mask or bandana may trap droplets expelled in a cough or sneeze. But for someone who has contracted the virus but is asymptomatic, they will be shedding aerosolized virus particles. Given the size of the virus particle, that’s tantamount to expecting a chain link fence to stop a mosquito! If I’ve misunderstood the physics of mask effectiveness, I’m willing to be instructed. But I won’t hold my breath, mask or no mask.

    I won’t continue to drill down on the ad hominem and false assumptions on display in this editorial. The unsupported assertions are numerous. But assertions without evidence are empty at best, and divisive at worst.

    What concerns me most however is the editorial’s implicit position that because we don’t have an authoritarian federal government that can whip these recalcitrant states into line, and impose the ever-changing dictates of the medical “experts” on the citizenry, that somehow this is a failure of leadership. As if the Constitution and the Bill of Rights have a invisible clause (in the Preamble? Where?) that says, “Oh, by the way, we had our fingers crossed when we ratified this compact. If a pandemic strikes, then all of this goes in the trash can.” What the editorial board is decrying is that we don’t live in a dictatorship, whether of the medical experts, or of the political class who defer without question to the medical experts. At least now their cards are on the table!


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