Reckoning with White identity to get to a durable E Pluribus Unum

Note: I submitted this to Reason for publication but they were not interested, so I decided to post it.

Mike Gonzalez raises an important question in The Federalist about the future of the United States: is demography or culture the key to the future?

Of course they are related, but his premise is that “the left” is undermining the concept of E Pluribus Unum, (the motto of the United States, “from many, one”) by focusing on divisive identity politics. He says:

“Yes, after creating a caste order dividing society into identity silos based on race, ethnicity, sex—anything that conveys feelings of victimhood—the left is now shocked that some whites could, too, fall prey to identity politics. Nothing could better illustrate the left’s gaping blind spot about human nature.”

I agree with Gonzalez that determining what E Pluribus Unum means practically today is crucial to the thriving of the United States. However, I think he misses the mark on several key points about Race and identity politics that stand in the way of his stated goal of finding a 21st Century version of E Pluribus Unum.

First, all politics are identity politics, though I shared Mr. Gonzalez’s understanding and use of the term as applying only to Black or Latina/o or LGBTQ politicians or movements until the last few years, because I did not think of myself as a White man as having an identity. I just was. This is how White identity politics has been able to operate in the United States—as the quiet, assumed default and shaper of everything it wanted to shape since the American Revolution, because it was the unquestioned source of power, and all else was other. Gonzalez is correct about self-preservation being a key attribute of human nature, and White as the default ideal is being openly challenged, which portends a loss of power, and it is uncommon to cede power without a fight.

Second, Mr. Gonzalez identifies the rise of “affirmative action” with the Presidency of Lyndon Johnson as the beginning of “the left” dividing our country into the oppressed and the oppressors, setting the United States melting pot on a stove that is ready to boil over after 50 or 60 years of such left-driven Racial division. Let’s just say that Mr. Gonzalez and I read U.S. history a bit differently. In fact, “a Racial caste system” as he terms it is plainly evident in Article 1, section 2, clause 3 of the original U. S. Constitution, ratified in 1788.

“Representatives and direct Taxes shall be apportioned among the several States which may be included within this Union, according to their respective Numbers, which shall be determined by adding to the whole Number of free Persons, including those bound to Service for a Term of Years, and excluding Indians not taxed, three fifths of all other Persons. The actual Enumeration shall be made within three Years after the first Meeting of the Congress of the United States, and within every subsequent Term of ten Years, in such Manner as they shall by Law direct.”

The refinement of the Racial caste system has been an ongoing project of the United States government since the 1790 Census and the work of figuring out where each person fits into a hierarchy of human value most commonly marked by Race is among the oldest of American ideas, long co-existing in compartmentalized fashion with equal justice under the law, freedom and equality. Mr. Gonzalez notes a paradox in his mind, that “the left” went off course with identity politics just as our nation was addressing the long standing mistreatment of Black’s throughout U.S. history. However, it was precisely the Century of White identity politics from the end of the Civil War to the Civil Rights Act of 1964 that rendered the 13th, 14th and 15th Amendments to the Constitution and the Civil Rights Act of 1866 little more than words on paper for freed Slaves, Blacks and those who could not pass as White that necessitated the new federal actions of the 1960s. These steps are viewed as revolutionary today, but they are best understood also the lurching forward in making good on a Century-long deferred promise the United States made to freed Slaves and their descendants after the Civil War. White identity politics allowed the power structure of the United States, to un-ironically fight World War II to protect freedom as we systematically denied freedom to many of our own citizens.

Third, Mr. Gonzalez invokes the period of great European migration to the United States as being the hey-day of E Pluribus Unum personified, with a slowly simmering melting pot instead of the boiling cauldron of grievance that “the left” brought about beginning in the 1960s, and stokes still today. His remembrance of the good ole days are as follows:

“The country’s leaders could have decided long ago — for instance, during the 1893-1925 Ellis Island period — to herd the teeming masses of Armenians, Greeks, Hungarians, Jews, Lebanese, Sicilians, Slavs, and Syrians under artificial identity categories. They could have labeled them “minorities” in need of compensatory justice, and constantly inculcated grievances in them.”

He goes onto describe an assimilation process that has built the fabric of improvement through immigration into our nation, which I agree is something to be celebrated, but in doing so he shows a tremendous blind spot about our shared history and how it affects us today.

“As changing demographics are challenging enough, however, America’s earlier leaders sensed that (my insert in parens: using identity politics as he says ’the left’ has done since the 1960s) would be a grave mistake. So they did the opposite, extending the enjoyment of equal treatment under the law along with the possibility of becoming American to all newcomers to the nation.”

The extension of equal treatment of the law to immigrants was and is the correct choice, however, the period 1893-1925 also saw active blocking of this same extension to freed Slaves and Blacks in spite of a bloody Civil War and an amended Constitution. Further, to the extent you cast “Black identity politics” as grievance based, in fairness there are at least a few grievances of note to be pressed by descendants of freed Slaves, for events taking place solely after the ratification of the 13th Amendment that used the word Slavery for the first time in the U.S. Constitution, when it was banned, namely the systematic project of seeing that the 14th and 15th Amendments were little more than words on a page in a practical sense for Blacks. The 1960s, whatever else they were, saw a Century-delayed concerted federal efforts to see that the descendants of freed Slaves would receive equal justice under the law that some European immigrants received while Blacks were being systematically oppressed and denied the rights that we said they had because they were citizens a Century before. White identity politics saw to this.

Finally, Mr. Gonzalez sees “the left” as fomenting disunion using Racial appeals in the election, and I see President Trump doing so with other Republicans participating or looking the other way to differing degrees. President Trump did not invent the appeal to Whites for their vote on the basis of fear of Blacks, and Racial equality generally. Such appeals to Whites have been a bi-partisan effort when viewed across the past 150 years, and were first systematized by the Democratic Party during Reconstruction, while the Republican Party then generally pushed for making freed slaves full citizens. The most important point is that since the Civil War, conservatism, whether practiced by the Democratic Party in 1890, or the Republican Party in 1990 or today, had as a cornerstone of its appeals, sometimes whispered at other times shouted, the danger of Whites losing power to Blacks and others. White as the quiet, unassailed default source of power was and is a lot of what was trying to be conserved.

What next? The original sin of the United States is not Slavery per se, but our inability to plainly name the paradox of the founding of the nation on two pillars: rousing language of equality against tyrannical European Kings and religious-based hegemony, and the forced Enslavement of Black Africans. We had a chance to name, own and collectively repent of this following the Civil War, in the sense of the Greek word for repentance used in the New Testament—metanoia—“to go the other way” if we had simply worked to live into what we said we were going to do in the 13th, 14th and 15th Amendments to the U.S. Constitution and the Civil Rights Act of 1866. However, we made a choice and went still another way, that saw to the systemic denial of equal justice under the law to freed Slaves and their descendants after we gave our word, as enshrined in the Constitution.

Human beings have a remarkable ability to compartmentalize divergent ideas, which enables self-deception. I agree with Mr. Gonzalez that there are many White folks who are scared and angry for a variety of reasons, but at least some of this is a sense that they can no longer view their identity as White as the default, or ultimate holder of power of a variety of types. Indeed, E Pluribus Unum would seem to assume that no Racial identity has the upper hand, instead giving way to a generative process of refreshing norms and traditions, without White serving as the quiet default to be aspired to.

The way forward into a durable E Pluribus Unum will require us to commit to a future that is based on honesty about our past and future with respect to Race. We do not need another creed, but simply need to struggle to live into the aspiration stated as fact by Thomas Jefferson in the Declaration of Independence, that all men are created equal. This has always been anything but self-evident, but it is an aspiration worth pursuing, and in doing so we can tell the truth about ourselves, and walk away from our original sin of not talking plainly about the role of Race in our shared lives together. The primary benefit to many Whites may simply be our nation telling the truth, and no longer engaging in corporate self-deception. I think that is not only enough, but a lot. It is not too late to live into the audacious idea of the United States of America.

Mike Gonzalez. After Decades of Dividing America on Race, Left Insists the Right is Really to Blame. Reason, August 29, 2020. Census Measurement of Race throughout history

Obamacare in peril–would you be affected?

In a word, yes, if you have health insurance.

Do you have an adult child who is age 26 or less on your health insurance? Do you get comfort from knowing that your employer sponsored health insurance does not have a lifetime maximum limit? Have you purchased subsidized coverage in a State exchange and took solace that when comparing premiums you knew there were not tricky “gotcha” limitations in coverage that made lower premiums fools gold? Do you have a family member covered by the Medicaid expansion undertaken in 38 of 50 states?

The ACA aka as Obamacare brought about all of these changes that many now take for granted. However, on November 10, 2020–the week after the election–the Trump Administration is going to argue that the entire ACA should be thrown out as outlined in their brief. You could be forgiven for thinking, “haven’t they been talking about that for a decade?” Yes they have, but the dog could actually catch the car now that Ruth Bader Ginsburg has passed, even if she is not replaced prior to the election because a 4-4 tie would revert to the lower court that said “throw it all out.”

If President Trump is re-elected, then these provisions I noted and more are likely to be gone. If Joe Biden is elected, I suspect they will not and a compromise will be worked out.

The logic of the President’s case is as follows. In December, 2017, the Republican controlled House and Senate passed, and President Trump signed, a law that made the penalty for not purchasing health insurance under Obamacare equal to zero. If you choose not to buy health insurance since then, there is no penalty. That’s it. A lawsuit was brought saying that since the original ACA had a penalty for not purchasing insurance, now the entire law should be thrown out because the penalty has been set by the Republicans to equal zero. The folks who made the change to the law are now making the case to throw it all out because of that change. Yes, it is that dumb and ironic.

If you hear a Republican politician saying they support pre-existing condition limitation restrictions, keeping your adult children on your health insurance, no lifetime benefit maximums, health insurance coverage increases that are now taken for granted, ask them to write the bill they say would achieve those things while they are back in Washington confirming a Supreme Court Justice.

If you would like to do some research on your own, the Kaiser Family Foundation is the best source of non partisan, factual health policy information around.

The case against President Trump’s re-election

Several of my friends and family are lifelong Republicans who voted for President Trump in 2016 and are uneasy about doing so again. A few have asked “give me the case for a Conservative not voting for President Trump again” and then further, “the case for voting for Joe Biden instead of sitting out the election or voting for a third party candidate.”

A reasonable request. My quick summary. First, I think of the job of any President as having three parts: (1) picking people to serve in the Executive branch; (2) policy preferences; and (3) ceremonial duties, particularly in times of crisis.

My policy preferences are different from folks who voted for President Trump in 2016, though I have noticed some who share my key policy goal of developing basic health care coverage for everyone, and they express support for key elements of Obamacare. President Trump is arguing before the U.S. Supreme Court on November 10, 2020 for the entirety of Obamacare to be thrown out—pre-existing coverage protections, keeping your adult child on your health insurance until they are 26 and no lifetime coverage maximums—all of it. Here is the brief that President Trump’s Solicitor General will argue from the week after the election. I agree that Obamacare needs revision, but the best first step is not starting over, and Republicans have had a decade to come up with an alternative they could support, and they failed to do so even when they had complete power in Washington; 2016-2018, for example.  

The President has trouble putting the interests of the country and defending the Constitution of the United States (the oath he took) because he always puts his personal self-interest first. Everyone is self-interested, but the President seems to think the national interest is the same as whatever is in his best self-interest. The use of the White House for a Convention speech. Calling the Press, protected by the 1st Amendment the enemy of the State. Saying anything that is not helpful to him politically is fake news. Sending persons with no experience to run communications at Health and Human Services during a pandemic. Getting involved in scientific matters at the FDA like no other President has, reducing trust in public health and institutions like the CDC. I agree that candor is winsome in politicians, but much of what the President is open about is putting himself above the national interest and that is not what we need in a leader.

The President has trouble showing empathy, and this keeps him from doing the ceremonial part of his job well. Even if you like the President’s policies, he does not do a good job of carrying out the ceremonial aspects of his job, again because I think he has trouble seeing any difference between what is in his best interest and the best interest of the country. We only have one President at a time, and they must serve all Americans, not just those who voted for them. A great example of this was President George W. Bush meeting with the family members of soldiers killed in Iraq individually, and allowing those who needed or wanted to vent and blame the President personally to do so—including yelling and screaming to his face. This would be very hard to do, but he did it because it was best for these families and the country, even if it was bad or hard for him. President Bush understood that as America buried our War dead, defending his policies and seeing to his popularity for his re-election bid was not always the most important thing. Families that grieved needed to be allowed to do so in their own way, and so he took the direct criticism. The President is supposed to show up when terrible things happen and calm and soothe both individuals who have been affected as well as the entire nation. I don’t think President Trump is capable of being a selfless leader and this has hampered his COVID19 response efforts because all he could think about was how it affected his re-election chances.

The President commonly undermines key norms of law and order and democracy. If the President said one time “maybe I will have a third term” it might be a joke. However, he has consistently said this type of thing. During this election season, he has often said the only way he could lose would be in the Democrats cheated, and he hurls charges of massive voter fraud that have been debunked. The President seems most interested in keeping power, as he showed when he filed for re-election the day he was inaugurated on January 20, 2017—most Presidents wait to start the next campaign for at least a couple of years. The American transition of power in a peaceful manner is unique for its 25 decades of existence, but it depends upon people following of norms that put the good of the nation above the good of any one person. I worry that President Trump in incapable of making this distinction and his rhetoric sounds more like a dictator of a small nation rather than the most powerful person in the World.

Not voting or voting for a third party candidate is better than voting for President Trump, but there are only two people who could be President on January 20, 2021, and if you do not think President Trump should be, the clearest way to show that is voting for Joe Biden. This election is not about policy, but about restoring the idea that the President serves us, and not that the nation serves the President.

Respectfully submitted,


More on Duke’s testing program

Update: I confess to being shocked at how well Duke’s COVID19 mitigation strategy is going as evidenced by the very small number of positive tests. We had and have a robust testing program, but so do other Universities that have still had outbreaks, and that still could happen at Duke. Here are the latest results for the period September 5-11, 2020–1 contact-traced case among 87 faculty or staff who were potentially exposed, and 7 in precautionary quarantine; 0 of 416 faculty and staff positive in surveillance tested (surveyed below). For students, 3 cases identified from 100 with symptoms or possibly exposed, and all of them in precautionary quarantine, and 2 of 6,969.

Duke needs to lay out in detail exactly what we are doing to get such good results so that others can learn from our experience. Duke also needs to release information on how many people were asked to undergo survey testing, and how many had the test.

Duke has what seems to be among the most successful COVID19 testing programs, based on the small number of positive tests as shown on Duke’s testing dashboard (cases updated each Monday). As I noted last week, it is difficult to know what the surveillance or survey testing means, since students have reported to me being selected for such testing and not getting the test done. At a minimum, Duke should make clear how many persons were selected for surveillance testing and how many actually received a test.

Below is an email that a colleague received today (name redacted by me).

From: <>
Sent: Sunday, September 13, 2020 10:33 AM
To:  [Redacted by me]

Subject: Message from Duke United Testing

As part of helping to ensure your safety and the safety of our community, Duke is expanding its COVID-19 testing to include asymptomatic faculty and staff working on campus and off-campus students taking classes remotely.

You have been recommended for a surveillance test this week. While this test is not required, we encourage you get tested to help us identify and respond to the asymptomatic spread of the virus and limit the potential for local outbreaks.

Please visit any of the many locations on East or West campus to complete this test, which should take no more than 5 minutes. Testing will be conducted from 9 a.m. to 4 p.m. Monday through Friday.

You will only be contacted afterward if you test positive, at which point you will receive further medical guidance and support.

You can find more information about the process, testing locations and answers to frequently asked questions on the Duke United website.

At a minimum, Duke needs to provide information regarding how many persons have been “recommended” for testing, and how many actually receive the test. The rate of compliance with such a clearly voluntary testing program would be of interest, and any selection bias that may be present is important.

All my questions about what the data provided in the dashboard mean remain, and the continued lack of transparency by Universities not having an agreed upon set of data to track cases harms our ability to produce evidence that is useful and very much needed.

Muzzling the MMWR–When Incompetence and Malevolence Join Forces

Dan Diamond has an explosive scoop that makes my blood boil–the Trump Administration is directing political operatives to influence and control messages put out by the CDC’s Morbidity and Mortality Weekly Report (MMWR), the usually obscure source of breaking health information for many decades. Instead of leaving public health discovery and communication to civil servant professionals, political operatives who are loyalists of the President and who have no health or public health expertise like Michael Caputo have been seeking since April, 2020 to turn the CDC into just another tool for the stoking of the President’s ego and his re-election bid.

Both my undergraduate and Ph.D. degrees are from the UNC School of Public Health, and we learned about MMWR as being the “just the facts” first report source for outbreaks and widespread health risks. To provide context, the Obama Administration sought a synopsis of what MMWR reports would be the day before they were released, and that was initially denied! What the Trump Administration has been doing is beyond the pale. This is “Dear Leader” level co-opting of every tool of government for the personal aggrandizement of the President, and people have and will die because of it.

An important note about MMWR and public health surveillance during a novel disease outbreak–things are always clearer in retrospect, and there will be errors, mistakes and rabbit trails that turn out to be unproductive. Being able to trust MMWR to play it straight with what is known each week is of vital importance to the health of the American people. It is unclear if anything that emanates from the Trump Administration can be trusted to do anything other than advance the interests of the President as he understands them.

A quick historical example. Here is the MMWR on June 5, 1981, that concluded this way (emphasis mine):

All the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis and candidiasis. Although the role of CMV infection in the pathogenesis of pneumocystosis remains unknown, the possibility of P. carinii infection must be carefully considered in a differential diagnosis for previously healthy homosexual males with dyspnea and pneumonia.

This June 5, 1981 piece is remarkably prescient–it is the first note of what would become known as HIV/AIDS, which is a virus that makes people susceptible to opportunistic infections of all types because they become immuno-compromised.

This report–dispassionate and clinical in noting that the first 5 cases of of Pneumocystis Carinii pneumonia occurred among gay men–lead to the stigma that came with it being labelled as the “gay disease” when in fact we now know that body fluids of numerous types can lead to transmission and heterosexuals are also at risk. Similarly, there was a great deal of energy put into the fact that all of the first 5 cases repored “huffing” inhaled drugs, leading to investigation of drug impurities that could plausibly cause pneumonia. Eventually more data won out and we came to understand how the disease was spread and how folks were at risk and how that risk could be minimized. Now we have treatments that have rendered HIV/AIDS a chronic disease instead of a death sentence, but that outcome was built brick by brick on public health findings and reports that stuck to what facts were known at the time.

The indepedence of MMWR has been bipartisan as can be seen by looking at these 25 key MMWR reports on HIV/AIDS from 1981-2001 (Reagan x2, GHW Bush x1, Clinton x2) and here is a 30 year look back (adding W Bush x2, Obama to the span of Presidents who allowed the CDC to do its thing and report via MMWR in an unvarnished manner). Ronald Reagan is often criticized, and I think rightfully so, for not talking about AIDS while he was in office, thus missing a bully pulpit opportunity to comfort and provide leadership in the fight against the disease and reduce its stigma. However, he didn’t manipulate what MMWR put out, even if he choose not to be vocal about it.

None of this is normal. President Trump is not a normal politician, there is nothing sacred in his mind, expect for himself. All of our institutions and norms are in jeopardy so long as he remains in office. Next June will be the 40th Anniversary of HIV/AIDS. One wonders what the state of the trusted MMWR will be then if Donald Trump is still the President.

COVID and Research Universities–so much info, so little evidence

Research Universities have largely failed to amass and communicate evidence of how testing regimes can be used to re-open college campuses. The great college reopening of 2020 is a natural experiment (very different approaches on testing across many schools) on a grand scale, being conducted by institutions who are supposed to exist to do research, teaching and service to society. However, we failed to work together to develop a common protocol for counting and reporting cases, greatly truncating what could be learned from our efforts. Let me say that I share in this failure since I direct a Research Institute at Duke.

The past few months have been very difficult for us all, but we need to be able to learn from what we are doing and we are now largely failing at generating useful evidence. We have much experience studying medical conditions using cross-institutional protocols, but we the Ivy plus institutions have the most resources and are distributed in communities with divergent levels of community spread setting up a very nice natural experiment of how testing and others policies impact spread of COVID19. Why have we not been able to apply our scientific methods to ourselves, for example, by agreeing across University’s how to report cases?

Here is a link to Duke University’s covid19 tracker, and Duke is emerging in media reports as doing about as well as possible in reopening, suggesting that the huge investment in testing done means it is possible to re-open safely. As fewer and fewer schools manage to be open without large amounts of transmission, interest in how Duke has managed this will increase. Folks ask me and I say (1) lots of testing; (2) luck; and (3) I am unsure but quite (pleasantly) surprised.

I teach a graduate health policy seminar this Fall and we are spending quite a bit of time discussing COVID19 and we spent an hour discussing what we could and could not learn from Duke’s tracker during class last night (screen shot below of the cumulative report of the tracker from August 2-28, 2020; link to the notes of Duke’s tracker).

A summary of the class discussion last night.

  • There are 3 types of testing: entry (when students come back to Duke; contact traced or symptomatic; surveyed or surveillance testing). This is an expensive, robust effort.
  • This is an astonishingly low number of positive tests. 24 students had a positive test result upon returning to Duke from Aug 2-28, 2020 out of (24 out of 8,235); all 3 students tested due to symptoms or contact tracing were positive; 2 of 7,471 students who have been tested as a part of sampling or surveillance testing tested positive.
  • The rate of overall positivity (29 divided by 15,709) is astounding for a group of young people who returned to Durham from all over.
  • If there are outbreaks later, such an overall positivity rate is not particularly meaningful, however, since it blends three different rates. You would expect the contact tracing rate to be highest (3 of 3 cannot get any higher, but such a small number); the entry test rate is very low (24 of 8,235); and given that, you expect the survey or surveillance rate to be low (2 of 7,471 is super low)….but this rate is the early warning system.
  • Several of the graduate students in my class reported not being a part of entry testing, since they live off campus in Durham, and were not planning to come to campus for any reason (their Duke card won’t open buildings if they have not been entry tested and complete a daily symptom tracker). It is unclear how many students are living in Durham, but did not receive entry testing.
  • The surveillance or survey testing is a key early warning symptom that will allow the identification and contact tracing of hot spots. One student in the class reported being selected for the survey or surveillance testing but not being testing because s/he was unable to make the testing appointment provided. A key bit of info needed is how many students selected for testing survey testing are not being tested, and why?
  • Another student reported being selected for surveillance testing but feeling that going to one of the campus sites for testing would be the most risky thing s/he had done in a while (fwiw I do not think Duke’s testing locations are risky). The class suggested maybe a drive through, contact-less testing route. There are also a variety of mail testing options.
  • The dashboard should be updated to note how many were selected for surveillance testing but did not receive it. This is not a “gotcha” this is a research university being who we are and trying to build evidence of how to live in a pandemic.
  • Students had a variety of questions about student athletes. This note at the bottom of the tracker was a bit confusing for students in my class

Does not include testing of student athletes who returned to campus in July 2020, before the survey testing program was launched. Duke previously reported that 26 student-athletes tested positive for COVID-19. All went through the required isolation and were cleared to return to their daily activities.

It is clear that Duke’s tracker does not include the 26 student athletes who tested positive in July, 2020, but are they included in the August 2-28, 2020 testing data? Presumably they already had a entry test, but were they a part of the sampling testing? It is unclear.

The ACC has detailed testing guidelines that mandate that athletes in high risk transmission sports, like football, be tested three times each week once competition begins (Duke has a football at Notre Dame scheduled for Saturday, September 12, 2020). Will the athletes “in competition” testing be included in that of the other students? They should not be since they will be tested more often with probability of 1.0 and are living in a “bubble” of sorts in the Washington Duke Inn (other athletes and upper class students are also living there).

I am glad that Duke has put out testing information. It remains a work in progress to be as useful as it might be. It is not too late for Research Universities to work together to try and convert some of the reams of information being collected into meaningful evidence about how testing and other policies can allow the re-opening of large organizations with mobile populations.

Across the board, our country has some much information and so little evidence. If the University cannot lead the way, then who can? It is not too late.

College and Coronavirus

UNC Chapel Hill, NCSU and the other constituent campuses of the UNC System never had a chance to reopen successfully because they did not have the required testing (re-entry and surveillance in addition to their symptomatic and contact tracing informed testing that was in place).

The UNC system Board of Governors and System President Peter Hans and outgoing interim President Bill Roper (who was the head of the CDC from 1990-93!) told the campuses they had to open and did not need a testing program. The cost of testing required for such a huge public system is certainly a barrier, but that simply reinforces the failure of the Trump Administration’s COVID-19 response–we still do not have a national testing policy that could and should have provided the needed testing necessary to open colleges and universities as we manage the pandemic.

Lurking in the background is the degradation of the CDC, until COVID19, the premier public health authority in the World. Public Health is always political in the Harold Laswell sense of “who gets what?” but the anti-science, conspiracy theory penchant of President Trump and his administration (he talks about Qanon in nice terms for heaven’s sake) has rendered everything the CDC touches with a hint of skepticism. For example, the CDC both said re-entry testing was not needed for colleges (makes no sense), and also that UNC Chapel Hill’s plans for dormitory occupancy were too dense (does make sense).

Even with a robust testing program, there are more ways for things to go wrong than right on a college campus as the Notre Dame experience shows; the tale will begin to be told for Duke over the next week. If Duke’s huge amount of testing allows for a successful reopening, then it further underlines the need for a national testing policy/infrastructure expansion. If it does not, it will show you cannot open up in a community with fairly wide spread (Durham and Orange County). Boston College has a robust testing program and Massachusetts in one of only four States in the U.S. with a “green” for re-opening. By Labor Day, we should have some sense of whether robust testing can allow colleges to reopen successfully, in low and higher spread areas.

There were huge failures at my alma mater UNC Chapel Hill–a Chancellor and Provost not sharing a request from the local health department to delay in person classes for several weeks with the faculty, staff, and students is unconscionable. The leaders of individual UNC system campuses have operated in a purely politicized context given the complete takeover by the Republican Party of the Board of Governors and their more aggressive stance at management and hostility toward UNC Chapel Hill have been clear for some time. Chancellor Guskiewicz and Provost Blouin were in a tough spot, leading an institution that has been under assault from within the system for some time, but they have likely lost their faculty’s trust through all of this.

As a nation what a mess, what a comprehensive failure, or as my granddaddy might say, “a bad plan, poorly executed.”

It’s Not Too Late (to have a National Testing Strategy)

I was fixing a fence with my granddaddy one morning when I was 12, and a guy in a loaded grain truck pulled up seeking directions to the mill. My granddaddy looked at the farm stenciled on the door and said with a quick smile “if that was where I started, I sure wouldn’t have come this way if that was where I wanted to go.”

Alas, you can only start from where you find yourself. We find ourselves as a nation failing miserably at addressing the COVID-19 pandemic, especially with respect to amassing evidence of how to deal with the disease. One problem is not having a national testing strategy, backed up by funding, and based in science.

The Margolis Center for Health Policy at Duke has developed a legislative and regulatory plan for such a strategy.

The plan calls for $75 billion in funding to allow rapid, accurate, less costly, and more effective testing, contact tracing, isolation, and containment enabled by the following:

  • Developing Smarter Testing: Fund an additional $300 million in research and development to accelerate and expand access to rapid, accurate point-of-care testing and easy sample collection. Provide additional review resources to the Food and Drug Administration (FDA) to speed authorization pathways for rapid turn-around screening tests for asymptomatic individuals, and to improve data and assessments on test performance in real-world conditions. Support a regulatory pathway to open up unused capacity to run laboratory “PCR”-based pooled screening tests at academic and research labs.
  • Increasing Testing Capacity: Provide $45 billion to create a robust national testing capacity, including Federal provision of screening test platforms and grants to states and local governments to secure testing access for at-risk populations, including public schools and colleges, nursing homes, essential workers, and others at elevated risk. Provide Federal guidance on effective screening protocols for high-risk and vulnerable populations and on contracting models to support effective and inexpensive screening.
  • Widening the Supply Chain: Direct the Department of Health and Human Services (HHS) to address critical testing supply chain shortages and report on progress, with $6 billion to fund advance purchase contracts or support use of the Defense Production Act (DPA) for testing equipment, infrastructure, and related supplies.
  • Tracing and Isolating: Provide $24 billion to support state and local governments to implement additional contact tracing, provide local isolation for those who cannot do so at home, and support infected workers who lose pay in isolation, similar to support for jury duty service.
  • Reporting: Standardize and publish key information on testing and community risk by state and region stratified by age, sex, race and ethnicity, so that local epidemic response decisions (e.g., testing, contact tracing closures) can respond effectively to shifts in the pandemic.
  • Communicating: Implement a cohesive public communications strategy at the Federal level to keep all Americans informed about testing opportunities, turn-around times for results, contact tracing, and support for preventing spread.

It is still not too late.

Duke releases COVID19 testing for athletes-what does it mean?

Duke released information last night that 25 student athletes have tested positive for the SARS COV 2 virus since they began a phased return to campus on July 12, 2020.

Nine student athletes are currently in quarantine, while 16 have been cleared by physicians to return to normal activity (I believe that means they tested positive at least 14 days ago, but that is an assumption that the quarantine is 14 days; the CDC is now saying 10 days). It is also possible that a student athlete tested positive and then negative and was cleared by a physician, I am unsure. Thankfully, none of the 25 student athletes had anything other than very mild symptoms and most were asymptomatic according the press release.

700 total tests have been provided to 309 “student athletes, coaches and staff” and no coaches and staff have tested positive. It is not stated how many of the 309 tested are student athletes versus coaches and staff; we know the rate of coaches and staff positives is zero, but cannot estimate a rate for student athletes with precision.

What do these data mean, and what evidence does this experience provide for the the overall campus reopening that begins on Thursday, August 6? It is difficult to say given how the data were released, but here is what I think that we can glean from this statement.

**No staff or coaches have tested positive since July 12, 2020 (unclear what the denominator of coaches and staff is). This is good news, as one fear of reopening is that there will be community to campus and campus to community transmission of SARS COV 2. I hope we can sustain that into the Fall, and this type of information needs to be clearly communicated.

**25 student athletes (unclear how many of the 309 are student athletes) have tested positive since July 12, 2020. According to the release “the majority of students testing positive” tested positive upon arrival at Duke. So, up to 12 student athletes had an initial negative test and a subsequent positive one at some point in the last 19 days. If I had to guess (which you have to do given how the data were released) I would guess 13 were positive on arrival given adjective choice “the majority of” and not an adjective like “the vast majority of.” Going with that assumption, 12 student athletes tested negative and then positive. Note that a negative test upon arrival and then a positive test later is not necessarily proof of transmission on campus given the reality of testing, but Duke’s testing is being done in-house and is of the highest possible quality. The pooled testing approach that has been pioneered by Duke is a strength we have in this situation.

**25 (total student athletes testing positive) divided by 309 is about 8 percent. 12 divided by 309 is 3.9%, which is the highest possible rate of student athletes testing negative and later positive based on the releases notation that “the majority tested positive upon arrival.” Let’s just say 4% tested positive on arrival, and 4% tested negative on arrival and later tested positive, but this rate has uncertainty in the both the numerator as well as the denominator given how the data were released.

I am unsure if this is a lot, a little, or as expected? It is best understood simply as a first data point of Duke’s experience in testing student athletes. I do assume that we will have more control over student athletes than we will have over all students, but of course that is nothing more than a testable hypothesis.

If 3,000 first year and second year students return to campus starting August 6 (which assumes ~500 do not show up), for the first day of class of August 17, a 4% rate of testing positive upon return would be ~ 120 first and second year students. Using the student athlete testing data as a predictor, then a similar number of ~120 first and second year students would have a negative test upon arrival on campus and positive one within 3 weeks or so. Of course, the denominator of students on campus will be more than 10x the total number of people being tested in the first 19 days of the student athlete protocol of 309 athletes, coaches and staff.

Duke should provide more data on testing, cases and transmission as we reopen the University, and we can do so in full compliance of HIPPA, even without invoking public health exceptions. Our ethos of “Knowledge in the Service of Society” and our position as a top 10 research university assumes, expects and requires more transparency in the midst of a Public Health emergency.

As I am known to say in numerous contexts, “free the data!”

Post Script–Just after I hit send, I thought of another key uncertainty with the data release. It is unclear if the 700 tests were 700 individual tests, or if they were using the pooled sampling method that will be used for surveillance this fall. Under pooled surveillance, you would test everyone on a dorm floor, for example, and if the pooled sample is positive, then you test the B sample collected at the same time for each individual on the floor. If the 700 tests means many pooled samples with follow ups, that is tons more surveillance than 700 individual tests. I am unsure of what they did based on the release.

Dear Duke: More Transparency Please

So many people at Duke University (including the Health System that the University owns) have and are continuing to work so hard to address the SARS COV 2 pandemic. The Duke University Health System (DUHS) has remade myriad care delivery processes in real time while caring for Durham and the State, and demonstrated that it can be done safely for workers.

The unprecedented shut down of the Duke University lab facilities and research buildings, and the reopening of same in rolling fashion over the last 6 weeks has been a herculean effort, and there is internal evidence that has been described to me that shows this has been managed without much, if any, transmission of SARS COV 2 in Duke research buildings (there have been cases, but they have been traced to community contacts in virtually every case, as described to me).

In less than 6 weeks, the first year students are set to return to campus, and there has been so much planning, and there are so many plans. Everyone is exhausted. When I review the plans, and since I know about the Health System and research building success in controlling the spread of SARS COV 2 I think “maybe that can work.” And then I think of my 19 year old son who will be a sophomore at another University in the Fall.

I am skeptical, but willing to listen and hear my faculty colleagues with expertise, talk.

To my many exhausted Administrator colleagues who are also my friends, I have a simple plea: broaden the discussion about what we do in the Fall by being fully transparent about the data that Duke has gleaned from our health care delivery and reopening of research lab experience about preventing the spread of SARS COV 2.

And then lets be a University and talk publicly about what the data means, thereby allowing Duke’s leaders to make a fully informed decision after hearing what the faculty and staff think about our plans. Several questions are at the top of my mind:

What type of testing program should we have for students, staff and faculty? The CDC currently says widespread testing is not required for students, faculty or staff for reopening a University, but their credibility has been greatly shaken by their performance in the pandemic (Duke has committed to testing students once, when they return to school) and the politicization of the issue. I have recently begun working with a handful of infectious disease physicians at Duke as we have written research grants to address SARS COV 2. The most surprising insight for me is the disagreement among infectious disease physicians at Duke about the efficacy of widespread testing. And most say after giving their opinion that no one really knows. I want to hear this conversation in public, and in writing from our Faculty colleagues who are the most expert in this field. Communicating uncertainty is at the heart of being a scholar, so no one expects perfect predictions. The disagreement of experts is at least part of the point.

What epidemiological model(s) of SARS COV 2 spread at Duke University and in Durham, N.C. is being used to simulate different scenarios to plan for the Fall semester? I would like to hear from my Faculty colleagues with expertise on this matter as well.

What are the behavioral assumptions/evidence that Duke is using to extrapolate the success that Duke has had in preventing transmission to and among health care and lab workers to undergraduate students? The experience of football teams nationally with SARS COV 2 transmission is troubling; I assume football teams will be more closely controlled than a general student population will be. Duke has not brought any student athletes back, so we have no direct evidence on this front.

Finally, Duke should commit to publicly dash-boarding the key items of evidence that are informing our decisions. This can easily be done in a HIPPA-compliant manner that protects individual privacy, and is the essence of knowledge in the service of society.

I do not write this with a spirit of attack, though I know from being a leader at Duke that in the midst of a crisis it can feel that way, and I am sorry if it does. What I am saying is let us reason together and then decide.