#been trying to gaslight myself for the past few days that no actually its fine it didnt affect me all that much

[wizard-in-a-gaybar]

thinking about your no love like a parasite's for its host art again..

what loves you

[ollieofthebeholder]

leaves too high to touch (roots too strong to fall): a The Magnus Archives fanfic

Also on AO3.

Chapter 1: Martin

It’s been six weeks now that Martin’s been living in the Archives, and he’s beginning to feel like he’s going a bit mad.

In the first place, it’s really hard to separate work and personal life when they’re both conducted in the same space, and even though he tries to keep from doing work in the area he’s been sleeping in, it still creeps in. He’ll do anything for Jon, of course—not that he’ll admit that out loud—but it does get a bit wearing, being on the job, so to speak, all the time.

In the second place, there’s the paranoia. The worms are real and present. They’re outside the Institute, and apparently just about everyone has seen them by now, but they’re inside, too, or at least in the Archives. It’s been a while since Jon rolled his eyes or Sasha got that I am being tactful look on her face when Martin suspects he sees one, because they’ve all seen them and gone after them. The trouble is that knowing the worms are getting inside, that he’s not just jumping at shadows, makes his nerves worse, not better. He tries not to bring it up so much to the others unless he has proof, but he’s getting twitchier by the day and it’s getting harder and harder to sleep.

In the third place, he’s apparently getting forgetful.

 It’s something he’s really only noticed in the last week, but Tim and Sasha will bring something up, ask him about something they wanted him to look up or reference a previous conversation, and then act confused when he doesn’t know what they’re talking about. He’d think they’re gaslighting him if they were the type to do that, but as much as Tim likes to tease, he’s not malicious about it. And Sasha banters, but doesn’t tease, not like that. Which means he’s losing moments and chunks of time. He supposes he should just be thankful he hasn’t forgotten anything Jon’s asked of him yet, or at least that Jon hasn’t brought it up if he has.

It’s probably from lack of sleep, which tells Martin he should definitely be getting more of it, but it’s hard. Partly it’s the worrying about the worms and partly it’s the fact that he’s got this persistent feeling of being watched, but if he’s honest, a lot of it also has to do with the fact that he worries about Jon. The man doesn’t take care of himself, he looks positively exhausted some days, and he hasn’t snapped at Martin in almost two weeks, a new record. Martin wants to wrap Jon in a blanket and hold him until he gets some rest already, but that desire sends his mind down paths he’s trying to keep it from wandering, thank you very much. Still, Martin’s not sleeping much either and it’s probably affecting his memory. Still worrying, though.

He sighs heavily and turns over on the cot, like he’s trying to get comfortable. He already is comfortable, at least physically. It’s his mind that’s uneasy, that won’t rest.

Finally, he gives up. Maybe if he gets up and does a quick circuit of the Archives, just to assure himself there aren’t any worms, he’ll feel better. And if all else fails, he can busy himself with quietly removing staples from documents so they’ll be in better condition years down the line. He gets where Jon is coming from, wanting them all to be together, but come on, even Martin knows you’re not supposed to do that.

He climbs out of the cot, replaces his glasses, and pulls on his trousers; no one else is supposed to be there, but it’d be just his luck if Jon stayed late or passed out at his desk or something. Or worse, Tim’s still around, ready to make a cheeky comment about his choice of sleepwear. He slips the torch into one pocket and the corkscrew into the other, picks up the fire extinguisher he keeps with him at all times now, and heads out barefoot into the Archives.

It’s—there’s no other word for it—spooky at night, with no one else around. The emergency lights stay on all the time, sporadic lights that don’t so much illuminate as give texture to the darkness. You can see your way around, but if you want to do any serious work you’ll need to either turn on a regular light or use a torch. Martin’s at the point where he trusts anything about the Institute about as far as he can see it, including the electricity, hence why he always carries the torch with him. Also, he’s discovered that this emergency lighting isn’t all over the Institute, not that he plans on venturing out of the Archives tonight. This is just a quick tour to reassure himself that his sleep will be worm-free, so that maybe he can get some.

He’s a few steps away from one of the empty offices, its lights dark—no emergency lighting in there—when he hears a sound from a nearby aisle and freezes. Someone—or something—is in the Archives.

Oddly enough, the fact that it sounds too big to be a worm is not reassuring.

Martin’s not stupid, far from it. He’s read the statements, and he’s also got a secret, rarely-indulged fondness for Gothic horror that dates back to his discovery of Samuel Taylor Coleridge’s Christabel. He knows that going towards the sound and calling out a questioning hello is asking for trouble. He’ll end up with all the blood drained out of him, or fed to a giant monster, or with some creep wearing his face like a mask.

On the other hand, what can he actually do? He doesn’t have his cell phone anymore, didn’t grab his laptop before bolting out of his flat, and the only phone in the Archives is in Jon’s office. Martin doesn’t even know if it’s a real phone or if it’s just a fancy-looking intercom system. If he retreats back to the room he’s been staying in and hides under the blankets, it won’t stop whatever is in there from coming after him if it wants to, plus he’ll be trapped. At least out here he can, in theory, get away if it attacks.

Plus...he’s too damned curious, he supposes. Not knowing bothers him almost as much as the risks of finding out.

He takes a deep breath, slips his hand into his pocket to reassure himself the corkscrew is there just in case, and steps around the shelves.

“Hey!” he calls, and then yelps in surprise.

Standing a few yards away down the aisle is him.

The other person doesn’t just look a lot like him. It is him. Same height, same build, same coloring. Same messy mop of hair that needs a cut, never mind a comb. Same bags under the eyes. Hell, he’s even wearing the same damn sweater Martin is, the one he refuses to admit out loud why he likes to wear so often. And he’s looking at Martin with the same startled expression on his face that Martin must have on his own.

Then the other Martin sighs and closes his eyes, his shoulders slumping, and suddenly he looks...old. Tired for more reasons than just a simple lack of sleep. “Christ. You’re the one person I was trying to avoid. Couldn’t sleep, could you?”

“Wh-who are you? What are you?” Martin demands, aware that his voice is creeping towards a higher register. “I-I’ve got a knife!”

The other looks up again. “Really? You haven’t switched to the corkscrew yet?”

“Th—what?”

“Corkscrew,” the other repeats. “It works better on the worms than a knife would. They go straight in, more or less, and they don’t move quickly, so you can...pull them out with it easier. If you need to.”

Martin’s fingers tighten around the corkscrew’s handle, unsettled at hearing his logic spilling from another’s mouth, especially a mouth that matches his own. “How—how do you know about the corkscrew? Or the worms?”

The other’s lips twitch in a smile that doesn’t have a lot of amusement in it. “I’m you from the future.”

Martin blinks. “Shut up.”

“No, honest.”

“You expect me to believe in time travel.”

The other actually laughs. It sounds like the way Martin laughs when he’s not so much amused at what’s happening or what’s been said as at his own reaction to it. “Honestly? I didn’t completely believe in time travel until I woke up here in the Archives and heard Tim’s voice.”

There’s something a bit wistful in the other’s voice that, weirdly enough, makes Martin believe him a little bit. Not completely, but a little bit. On the other hand, the fact that the other claims to have known he was in the past because he heard Tim’s voice is...probably not good. Martin decides he’s not quite ready to know that yet. “So...you’re from the future. In the past. Why?”

“You want the short answer or the long one?”

“Short,” Martin says after a moment’s deliberation. “Until I decide if I trust you.”

The other nods, as if he expected that answer—which, well, if he really is Martin from the future, he probably did. “To stop the world from ending.”

Martin gives a short bark of incredulous laughter. “So—so are you saying you’re here to prevent nuclear warfare, o-or climate change, or are we talking biblical Armageddon with angels and demons and seven years of darkness?”

“The last one’s the closest, really,” the other says seriously. “No demons or angels, though. Not the traditional type, anyway. And I can’t really say how many years of darkness we’ve had. Time hasn’t meant all that much since it ended.”

“Wait, wait. You’re saying the world already ended. Will end. In my lifetime. And I’ll...survive it, somehow?”

The other’s gaze is...disconcerting, to say the least. It’s like he’s seeing through Martin, looking not at him but at a fixed point in his life. “Not your lifetime. That’s what we’re here to stop. Maybe it’s better to say I’m from a future, but not yours.” He smiles faintly. “I never met myself, so we’ve already changed that much, at least.”

We, Martin notes. Not I. That’s not terrifying at all. He decides that most questions can wait until he’s sure he actually believes the other, though. “What are you planning to do to stop it?”

The other hesitates. “That’s...there’s not really a short answer to that one, and it won’t make much sense without the long answer to the other.”

“F-fine. Fine. What can I do to help you prevent the world from ending?”

“Keep Jon safe.” The other speaks with an intensity and gravity that settles into Martin’s bones, pinning him to the ground with the weight of it. “Don’t let him get hurt.”

“He gets hurt?” Martin’s voice goes slightly shrill for a moment. His growing feelings for Jon are a tightly-kept secret, or at least he wants them to be—Tim’s probably figured it out, he seems to figure out everything else—but the mere idea of Jon being hurt sends him into a minor panic. A small, more rational part of him wonders if this is proof that the other isn’t him, that he isn’t panicking at the thought.

“Not if you can help it,” the other says. “I—I can’t go into too many details. Not right now. You’re—you’re probably safe, whatever you know, but I can’t be certain, and it’s a lot to risk at the moment. Just...trust me. Keep Jon safe. Don’t hover,” he adds hastily, as if he knows how likely it is that Martin’s going to do exactly that, “but just...keep a sharp eye out for worms. And spiders.”

“Spiders aren’t dangerous.” Martin narrows his eyes at the other as another tendril of doubt curls through him. “Not all of them. Not inherently.”

“No, not spiders themselves,” the other agrees. “But...well. Let’s just say Jon has his reasons for being afraid of them, and they’re...very valid. Spiders won’t hurt him, exactly, but they’re liable to be a sign that something that will hurt him very nearby.”

“The worms. Am I in danger?”

Again the other hesitates. “Not tonight. Not...Jane Prentiss knows where you live, so she toyed with you, set you off-balance as a warning to the others. It’s why you can’t go home. But she only knows because she followed you back from that basement. You’re not what she’s after. She won’t attack the Institute while you’re sleeping.”

Martin stares. “That’s...not as comforting as you might think.”

“No,” the other says, with an odd sort of smile and laugh, as if at a private joke Martin doesn’t get. “No, I guess not.”

Martin bites his lip, then asks the only question he feels like he can ask. “How can I trust you? How can I know you’re...really me from the future?”

The other tilts his head, as if considering that question from all angles. Martin knows it’s not a fair question. He can’t really expect the other to tell him something that happens in the future and then just...wait around until it happens. Especially since now it might not happen, if the other has already changed things. The thought gives him a slight headache.

Finally, the other says, “You should tell Jon the truth.”

Martin’s heart rate accelerates dramatically. Oh, no. No, no, no, no, no. “A-about what?”

“About your CV. That you lied to get the job. Tell him, first thing tomorrow.”

That’s not what Martin was afraid the other was going to suggest telling the truth about, but it doesn’t noticeably calm him, either. “He’ll kill me! Or worse, fire me!”

“He can’t.” The other speaks with the weirdest mix of authority and sadness Martin’s ever heard. “At least, he can’t fire you, any more than you can quit. And he won’t kill you. Anyway, better for it to come out now than...the way it eventually came out for me. Trust me.”

Martin swallows, hard. In the grand scheme of things, it’s not that big a deal, really. Anyway, he’s been at the Institute for eleven years now, so it’s not like he doesn’t have some qualifications by now. Isn’t university just supposed to be a shortcut to experience? “A-all right. I’ll talk to him tomorrow. And if he doesn’t completely lose his mind, I’ll...be back to talk to you tomorrow night. I’m living here right now.”

“I know. It’s been...what, a month?”

“Six weeks and a bit.”

“So it’s the end of April,” the other mumbles, more to himself than anything. “Plenty of time then. I can hold off a bit longer.”

Martin’s nerves can’t take much more of this. “I’m—I’m going to go—lie down.”

The other’s gaze flicks back to his face. “Go ahead. I promise you’ll be safe.”

It shouldn’t be comforting, to hear that from a stranger wearing his face, his skin. But to Martin’s mild surprise, when he gets into the cot and pulls the blanket up over his shoulders, he falls asleep almost right away.

[blindedbythedarkness]

A Rant into the Void

I am so fucking sick of my body right now. Actually, no, that’s not the problem at all. I am actually fucking sick of the response of medical professionals to my body. My body itself is doing its fucking best, all things considered.

Put simply, I can’t face going to the doctor anymore. I’m too afraid. Which isn’t exactly a great place to be, mentally or physically, when you have a genetic condition that can (though rarely) result in life threatening complications. 

I’ve never fucking liked it. Not one bit. It’s been built into me from a young age to suck things up and carry on. My dad used to passively scold me for ever taking a day off school by reminding me that he never did and telling me about all the days he’d gone to work with one ailment or another. He’s also the reason I’m so afraid of taking any medication now after years of me hearing how “taking paracetamol isn’t good for you. If you take it enough it stops working. It damages your liver too.” Even though painkillers do barely work, I can’t remember the last time I gave them a try. Now I’m older I know that he probably has his own deep seated issues that led to the things he said, but the things he said still stick like glue.

My mum was no better. As a nurse, she never took any shit from me and I would never have been able to skive off school. At one point I went to school for a week with an unknown broken arm, despite my protests. It’s rare that she explicitly called me a “hypochondriac”, but I could always tell that she was exasperated by my numerous visits to the GP, hospital and A&E. It’s only in the past year, now that my EDS has been confirmed for a second time (within the new guidelines) that she’s started to take me more seriously. I still don’t often feel able to tell her about my health concerns though, despite her having (a more mild version of) the same condition. I think she feels guilty for passing it onto me, but her responses usually comes across as frustration and annoyance. 

In the past year, my fear of doctors has grown even more. Firstly, now I’ve seen what a real illness faker looks like and does, I’m forever terrified that I look like I’m doing the same. I’ve almost obsessively started taking photographic evidence of my various ailments for fear of being accused of Munchhausen's by a medical professional (despite the difficulty of convincing others of a real case of fii). Given I have also spoken out about this girl, I also live in fear of seeming like a hypocrite. Those close to me say “we know you’re really ill, we’ve seen it, we know you aren’t faking it and you’re nothing like her” but still I can’t shake the fear.

Doctors have been pretty shit lately, too. I’d had bad experiences in the past: a GP that couldn’t identify a broken elbow and a gastro consultant who suggested my pain was all in my head, but for a while I’d had a good run. The past year has been fucking awful though. One particular GP at the surgery has been the cause of almost all of it, to the point where I was going to make a formal complaint before corona got in the way. For the first time ever I had gone to an outpatients appointment alone (something I’d be afraid of due to the potential for gaslighting) and for once the consultant was amazing- he gave me a reason for my pain  that had been found on an MRI and reassured me he would explain it all to my GP. However, the consultant had lied. He didn’t write in the letter anything that he said to me and GP soon decided that I was lying about my account, to the point where I questioned my own memory. Contrary to the advice of the consultant, and later my physio (who confirmed what the consultant has originally said), he advised me to walk more to solve my issue. It also took me refusing to leave his room until I got a referral to a rheumatology consultant for him to allow it. That was after him patronizing me consistently and insisting that “there’s no EDS cure you know?” and  “physio is your only option”. The arrogant cunt obviously thought his single lecture had taught him more than 10 years learning about this condition had taught me. I knew my rights and got what I wanted, but I live in fear of my record being marked with “fii” or “anxious patient” that would virtually destroy any further chances of me getting treatment.

This becomes a problem, of course, when I seem to acquire a new co-morbidity or complication every month at the minute. A few weeks ago I had it confirmed that I have a bladder (and potentially pelvic) prolapse. The doctor I had spoken to before the examination though was Dr. Self Important Prick, and he had seemed doubtful of the whole thing. So even though it was proven, I’m still too afraid to call again. This week I have had a bingo card full of the symptoms of a cerebrospinal fluid leak (and not for the first time). I don’t know what to do though. Given the susceptibility of EDS patients to them, I’m fairly certain that’s what it is. Given it’s recurring, I’m also pretty sure I need to see someone. But it’s unstoppable force meets immovable object: if I go in there having done my research I seem like a hypochondriac, yet one study showed that 0% of csf leaks are diagnosed correctly the first time. These are the complications of living with a rare condition. It’s impossible to walk the fine line between advocating for yourself and seeming like a fake because you weren’t a whole chapter in the doctor’s textbook. 

So here I am. Fed up. Angry at myself for not having the balls to get myself the help I need and angry at the medical profession for scarring me so badly. And with a lovely clear, metallic, currently unidentified liquid dripping down the back of my throat.

Since it seems these rants may get more regular, I’ve made a dedicated page to fill with my void rants @thatangryedsbitch

[tragedybunny]

The Blade’s Edge - A League of Legends Fanfiction - Chapter 9

It’s not much of a chapter, but it is a chapter. 

They had a simple arrangement. She was the weapon to be used on his enemies. Things get more complicated when emotions bleed into what should simple. Now the two of them find themselves on the precipice of something that was entirely unexpected.

I hold up the chain of black diamonds to examine it and watch them shimmer in the gaslight. The largest sits at the front, receding to smaller ones to the back. I’ve always found the cost of shiny rocks to be quite vulgar, but for once it felt worth it.

I’d offended Kat a few days ago and she’d been cold with me since. She wasn’t outright hostile, but it was clear what I’d said stuck with her, even after my apology. I hadn’t even mentioned her little art expenditure, thinking that would appease her. 

Hopefully, this little peace offering would finally put it to rest. It’d been something I had planned before all this anyway after her comments about wearing jewels that didn’t belong to her. Gwen had been an excellent source of intel for her preferences, and of course, her preferences were painfully expensive. 

I finally hear her stirring about in her room, the hour long past morning. While I’m not sure where she was all night, I suspect she was out drinking, given that she came in the front door and not a window. I tuck the necklace in a pocket and approach her door, knocking softly. I know she hates it when I don’t. I find myself spending an inordinate amount of time either avoiding offending her or figuring out how I’ve offended her. Ironic since this situation was arranged to further my influence over her. I suppose I’m only really delaying the inevitable. One day she’ll figure out that she doesn’t need me to survive, especially once she controls the Guild.

“Are you actually knocking?” She sounds half asleep still. 

I take her words as permission and enter, finding her seated at her dressing table, fighting to get a brush through the tangled waves of her hair. “You’ve requested it in the past.” 

“Since when do you ever listen to anything I say?” Of course, we have a very public event tonight and she’s trying to start a fight, definitely still indignant at me. 

“Good morning to you too Kitten.” I lean down and kiss her on the cheek, I’m not taking the bait. Her expression softens and for the moment there’s peace between us. “I have something for you, for tonight. Close your eyes.” 

She mocks annoyance but does as I ask. I withdraw the chain and clasp it around her neck. “Take a look.” I whisper in her ear and then nip it lightly. 

Her eyes get wide as soon as she opens them and her hand reaches up to lightly caress the stones settled around her neck. “It’s incredible. You can’t be serious.” There’s almost a reverence to her voice. 

“Of course I am.” I reach out and let my hand travel through her silken tresses. “You should have something of your own.”

She leans back against me, finally, I believe she is no longer cross with me. I wrap my arms around her, her head resting in the crook of my left elbow, my arm casting its glow against her pale skin. I wonder how she’s never been unnerved by it, treating it as normal. “You spoil me.” 

“Perhaps I should try it more often.” The familiar urges of having her so close start stirring. I contemplate throwing her on the bed and stripping her down to nothing but that necklace. But no, I have some last minute matters to attend to before tonight. I kiss the top of her head. “Until later, Kitten.” 

She makes a small noise of protest as I pull away, making me aware her thoughts had traveled the same path as mine. “Stay.” She purrs at me, taking my hand. 

“Busy.” I squeeze her hand and let go. 

“Fine.” She rolls her eyes but blows me a kiss on my way out.

Several hours and one clandestine meeting later I find myself waiting for her appearance so we can begin this absurdly long evening. I’ve only told her half the truth about why she’s coming with tonight. Having her company is, of course, a welcome addition to the tedium of official functions but there’s something I wish to accomplish tonight. I’m not ignorant to what’s said about her. I know the little nickname that’s trotted out behind my back, Grand Whore of Noxus. Tonight I want them to see her with me, to bow and scrape a little bit when she’s around. They can’t disrespect her in my presence without disrespecting me. Which is really the point, if they do it at all, even behind my back, it reflects on me. 

At the moment though, I’m reconsidering the whole plan since she’s taking an eternity to be ready. I pace the floor of the Hall, listening to my steps echoing off the walls, patience wearing thin. I finally hear her descending the stairs, Gwen trailing close behind her. I snap my head in her direction. “Fin..” The word dies in my throat. 

The scarlet lace clings to every one of her flawless curves, the small crystals sewn into it create a soft glow around her. The necklace is settled around a dramatic high collar, matching perfectly with the tiara set on her pinned-up hair. I involuntarily suck in a breath, the wait was admittedly worth it. 

She reaches the bottom of the stairs and stops before me. “Well, what do you think?” She turns around, letting me appreciate every angle. 

“You look like you’re somehow wearing half my fortune.” Her expressions falls, I didn’t think she’d take the comment seriously. I hurry to smooth it over before she responds. “I’m only teasing. You look lovely Kat.” She always did though, I wonder if she ever truly realized it. “But tell me how many knives have you managed to hide in there?”

Now she smiles so genuinely. When was the last time she smiled at me like that? ‘Wouldn’t you like to know.” 

Gwen wraps her cloak around her shoulders carefully avoiding her hair. I offer her my arm. “Let’s enjoy making everyone talk tonight.” 

Throngs of people from every station and background fill the Temple of the Sun. It feels as though every one of them is staring at us as we make our way toward the balcony that overlooks the temple proper. Every few feet we’re stopped to engage in meaningless pleasantries, whispering consuming the crowd in our wake. We’re successfully causing a scandal, the Grand General and his House pariah mistress. “You’ll crack a molar if you keep your jaw clenched like that all night.” 

“I’m trying to keep smiling. This is the best I can do at being congenial.” She hisses.

I pull her close, give her one quick kiss. “Just relax.” I forgot how much she dislikes crowds. 

Argos parts through the mass to stand by my side. “Greetings, Grand General, Sir.” 

The new rank insignia on display seems to have added a bit of pride to his bearing. “Argos”, I nod. I do owe Kat for that, her words pushed Darius into his part of that promotion, whether either of them knows that or not. Head of Strategic Defense would sound boring to those more interested in the outright “glory” of conquest, but Argos is smart enough to realize it puts him in a position over a rather significant force. And with his established loyalty, I tighten my grasp over the most central parts of the Empire. Too bad for his extremely incompetent predecessor, I heard they had their throat slit in their own home. 

“Will you be joining the festivities later?” He fumbles around for small talk, a true military man adrift in the sea of ceremony and formality.

“For as long as I can tolerate it. It is unfortunately expected of me.” Lady Montrose, a relic of another era, is hosting and nearly the whole of Noxian society will attend. I’ve got plans to be laid, so at least it will serve some purpose. I can’t stomach these vainglorious, ostentatious displays. “I’ll look for you there.” He starts to speak, but another voice draws my attention away. 

“Do you enjoy spreading your legs every night for your father’s murderer?” Of course, she’s here. I whirl around, leaving Argos mid-word, and storm through those pressed in around me to stand behind Kat, putting my hands on her shoulders.

“Soreana, it’s been a while.” Her eyes get even more narrow, leaving her whole pinched expression. I let my hands travel to Kat’s waist and pull her a step closer to me. 

“Good evening, Grand General.” Pure hatred flows through her words. Kat is pointedly looking staring at the ground, her mood from earlier completely evaporated. 

“You know I don’t think I’ve ever properly thanked you for that night at your home. It was good of you to reintroduce Katarina and I, much has come from it.” 

Kat laughs quietly, and finally looks up. “You make an excellent point.” She leans up and kisses my cheek. “We are grateful.” 

Soreana looks like a fish out of water, gasping for air. “We should head inside.” I slide my hand to the small of Kat’s back and guide her forward, lobbing one last parting shot behind me. “Perhaps this new year will see your husband returned to you.” She sounds like she’s choking as we walk away. Good, I always hated Soreana.

“Bit much, don’t you think?” She lets me lead her toward the pew at the front of the balcony. From here those of rank look down on the teeming masses below. 

“No, I heard what she said and I put her in her place.” I put my hand over hers and feel her run her nails along my palm. 

“It had truth to it.” She’s starting to dwell on it. 

I lean over and whisper in her ear. “Nonsense, every night would be a lot to ask of a man with my responsibilities.” I kiss her temple softly. 

“Honestly.” She slaps playfully at my shoulder and I believe she is sufficiently distracted. I hear enough murmuring to know we’re being talked about again, I find that deeply satisfying. 

“They let anyone sit up here these days.” Darius lowers his considerable form into the seat next to Kat. 

“Well, they did let you in.” She’s all smiles for him I note. 

“I kinda wish they hadn’t. The burdens of leadership I suppose.” 

“Poor DarDar, he might get bored.” It’s always like this between them, astoundingly easy. I’ve never seen them fail to get along, even when Kat is in one of her moods. Tonight it grates on me as he leans in and whispers something that has her choking back a laugh. 

Thankfully their banter is interrupted as the ceremony begins and the Priest steps forward. I note the seat next to me where the third of the Trifarix should sit is empty. Just as well, it keeps me from having to deal with LeBlanc in addition to everything else. 

It’s as though she’s summoned by that thought, her veiled figure practically floating as she approaches. She settles in, too close for comfort. “Well, someone brought their little pet with.” Her voice is so low only I can hear it. I shoot her a look and turn back to the ceremony, a sacrificial killing of the old year to bring forth the new. A deserter stands in for the old year, looking to atone for his cowardice by giving his life to satisfy the gods. It’d be meaningful if I believed in gods. 

Kat has turned her attention back to Darius, gesturing and whispering furiously. “What? I admire you, keeping up with that young little thing.” 

I wonder if the demon could strangle the immortal life out of her. “Are you jealous?”

“And if I was?” Now there’s almost a playfulness to her tone. 

Before I can answer I feel Kat’s arm hook through my mine. She carefully lays her head on my shoulder, not disturbing her pinned-up hair. I catch her hand and squeeze it a bit. She smiles up at me before exaggeratedly yawning.”Behave.” I scold and she pouts, her nails again running along my palm. Perhaps the crowd is getting to her, I should have considered that possibility. 

The ceremony is brief enough at least, Noxians don’t tend to prattle on to the gods, even when they do believe in them. Off to the self-indulgence of the nobility and, if fortune smiles, home before long. As we stand Kat turns again to Darius, and like a coiled predator waiting to strike, LeBlanc leans in to whisper to me. “You’ve been so...occupied recently, we haven’t truly spoken in ages. We should remedy that.” And with that she vanishes into the crowd, her invitation lingering behind her as we begin to leave. 

It is tempting. Leblanc can be charming when she wants something. And she most definitely wants something. Though what it is this time, I’m not sure. Perhaps she just needs to reassure herself my attention is hers when she wants it. Still, it’s always been a benefit when she gets what a little of what she wants. It keeps her docile to think she’s winning. 

“Jericho.” There’s a sharp edge of irritation to Kat’s voice.

“Yes?” She turns back to glare at me, halting the crowd a bit around her. 

“Nevermind.” She turns and starts walking away. I try to hurry after her without appearing to and catching up, I take her hand. 

There’s a moment where I feel her almost pull away. “Apologies, I was distracted.” She doesn’t say anything, but she leaves her hand in mine. It seems everything tonight must be difficult.

The crowd parts, some still daring to stare and take in the spectacle or try to whisper covertly to their companions. I stop suddenly and lean down to kiss her deeply, hands around her hips, fueling the fire. 

I’d almost say she was blushing slightly as we pulled apart. “You’re making quite a scene.” 

“That was entirely my intention, my dear.” I take her hand and continue our way out, leaving the masses gawking behind us. 

[splendi-city]

of hospitals

i am not the healthiest person. i guess on first glance i seem physically, completely capable. i have all my limbs, no obvious disabilities, and i am able to portray living a full life. however, behind the scenes, i go through problem after problem. now i say problem as an umbrella term because fuck knows my body is broken in a million more ways than i will ever be aware of. different vague health issues every damn time. but whatever, this is not meant to be a self-pity post. point is i’m sick a lot. consequentially, i spend a decent amount of time in hospitals. 

a little bit of self-pity is to be warranted in this paragraph. having to go to the hospital so much, it doesn’t seem like its a big deal anymore. those around me simply let out a sigh, “again?.” and i guess its fair. after a certain point there is no longer a sense of urgency? so u don’t rly care as much knowing at the end of it, no matter how sick i am in the moment, i am really just fine lol. regardless, it doesn’t feel great. no matter how many times it happens, my pain is still my pain. i would like to be taken care of, treated, manja-ed. but no one really does that for me. i am expected to be able to handle it with grace, simply because i have done it before. and i wish that were the case but truth be told, i am weak every time i have to go through this. and having to go through this more often than most just means that i am drained more and more every time. at this point, i am a shell of myself just dreaming of a day where i don’t feel some sort of random excruciating pain at any part of my body.

then came him.

i would like to believe i made my peace with the fact that i am responsible of taking care of myself, in general but also more specifically in the context of hospital and emergency room runs. but somehow this boy waltzes into my life, actually takes charge of making sure i am okay and physically comfortable at all times. he makes an active effort to be there for me, to care for me, to make me feel better. i was going through a whirlwind of pain today, one of the most excruciating ones i have ever felt in my life. all i had to do was tell him. without skipping a beat he was working out the logistics of how he could be the one to bring me to the hospital. how he wanted to be the one there to hold my hand through the entire process. the past few times where he actually had to bring me to the hospital, he was the most attentive person i have ever gotten the privilege to witness. from driving me (when he doesnt even drive), to pushing me on the wheelchair around the whole hospital, to letting me sleep on his lap in the waiting room, to just making sure i’m well-fed and comfortable. i’ve never been pushed on a wheelchair unless i was unconscious. he keeps saying “smol ting ony.” when it means the absolute world to me that i have one person that actually takes my pain seriously. who would actually go out of their way for my comfort. who would reassure me my pain is valid, no matter how much i try to gaslight myself that it isn’t. 

i’ve never had this from people who weren’t family. and even so, my family is truly over it and too tired to put in the effort anymore lol. i have never felt safe in hospitals. i’ve always felt like i had to fight and fend for myself. but now i have him. he makes me feel so loved and cared for. he makes me feel like i’m not alone. he is already an amazing boyfriend, through a million other facets of his presence. but seeing how he treats me when i’m sick, is a really good bonus. i would have never expected this treatment from anyone, and i am so so grateful that he came into my life to show me that it is possible to have someone with you going through tough times. this is the kind of love i believed i didn’t deserve. one i didn’t think i would ever get the privilege of experiencing. and for that i thank him. thank you sayang, for all that you do for me. for making hospitals bearable, nay, fun. if i had to go through this lifetime of pain and sickness, i’m eternally grateful to have you by my side. (preferably i would just like to stop getting sick, but ykno). i am forever indebted to your kindness, tolerance, and patience. you are truly my light at the end of this tunnel, and i love you endlessly for it.

thank you for your gentle hands, and for pushing me on wheelchairs. 

[urfavmurtad]

(1) Hey, I’m a 19 year old Muslim girl living in Canada. I’ve lived my entire life raised around Western culture so I guess I’m what you would call a Moderate Muslim. Until about a year ago, I believed that Islam could be accepting of values such as feminism, lgbtq+ acceptance etc. But then I realized the noticeable lack of these values in our community and realized I was kidding myself if I believed that anyone in my family would accept someone coming out as gay...

(2) So I started to preach moderate values. I told everyone I knew that some great changes had to be made in our community. That was until recently. Now, I realize I can’t really preach these changes in our community if they contradict a fundamental scripture. I came to the horrible realization that I actually disagree with the Quran. In fact, it goes beyond that: I have a problem with the whole concept of organized religion and the many basic philosophies that accompany all religions…   

(3) I’m still double-minded though. I do hijab, and was previously extremely religious (prayed extra, learned the Quran by heart) and I find it so difficult to just leave the entire religion. I feel like I need to talk to someone, because the very idea is so daunting that I can’t even think it out loud, much less mention it to anyone. And that’s a personal struggle; I haven’t even started to think about the cultural and familial backlash. What is your advice for anyone in this kind of situation?          

Anon I’m so sorry it took me forever to answer this, I’ve been in everyone’s favorite desert kingdom for exciting family bonding adventures as of late. Lemme just say before I start what is sure to be another long post that I completely understand where you’re coming from. A lot of people who leave Islam, myself included, go through a sort of bargaining phase where you really want to make it work, because so much of your life is tied to it in one way or another, and it just… doesn’t. And you realize that most Muslims aren’t really into making it work, either, and you’re just supposed to accept that. We’re also basically in the same spot with still outwardly “performing Muslim-ness” despite our thoughts on the religion itself, both for family reasons and because it’s extremely difficult to go from being outwardly pious/devout to… less devout, without people judging you and asking questions. Like you, I have never told anyone in my family that I’m even sort of non-religious. That’s gonna be a hell of a bridge to cross and I’m not even thinking about it until I finish college. Financial independence has to come first.

So I can’t pretend that I have all the answers for you here. All I can do is share some advice that has been helpful to me. First of all: never, ever feel guilty for not being fully open with your thoughts on this subject or “hiding” until you feel ready to share them. I don’t need to tell you that things like this often cause lost friendships, family drama, and cruel gossip. You don’t need that in your life right now, and given your age, there’s not much to be gained from having your lack of faith be public knowledge. The way you feel is your business and no one else’s. If you don’t feel like you’re in a good place to publicly leave the religion, there’s nothing wrong with, to put it bluntly, faking it for a while.

Someone on here asked me once if I feel guilty for “cheating” my parents (in terms of them paying for school and such), knowing that they’d disapprove of certain life choices of mine if they knew about them. And the answer to that is no. The fact that I don’t believe in Islam is none of my parents’ business and won’t be their business until I choose to inform them of it. I live a perfectly fine Muslimah life and do not cause them embarrassment or Great Family Shame. Sure, I’m just going through the motions at this point and don’t believe in any of it, from praying to “modesty”, but that is none of their concern. There is nothing wrong with keeping it personal until you feel completely comfortable being open about it irl. I do plan on getting there one day, both in terms of my (lack of) religion and my sexuality, but I am fully prepared for the possibility of my family basically refusing to interact with me afterwards. That’s a lot to deal with, and I don’t feel bad about waiting for the right time to unload all of that baggage. You shouldn’t feel bad about it, either.

That brings me to the second order of business. I already wrote about this in this post here but imo it’s so important to find a community, or multiple communities, to fill whatever void might be created in your social net if you ever do end up totally leaving. A huge part of what draws people to religion is the sense of belonging and a sense of having people who will always be there for you in your time of need. If you pull that rug out from under yourself without anything there to catch your fall, it can make you feel really lonely. Make sure you have an irl support network of some kind. Whether that takes the form of an actual group (like I said in the other post, I’m part of a charity group that is rly awesome and full of great people) or club or just a few non-religious friends, it doesn’t matter–as long as you know that you have supportive and loving people around you, no matter what. And it’s just as important to have some hobby in your life that has some sort of communal aspect to it (I do community gardening and cooking in school!). It’s so crucial, especially if you’re like me and hate socializing, because it creates a safe community for you that’s totally separate from your religion and your family/religious friends.

Another to keep in mind is that leaving Islam and recognizing its shittier aspects doesn’t mean you have to, like, abandon your ethnicity and entire sense of self. Culture and religion go hand-in-hand in most Muslim countries, but they don’t have to be totally inseparable. If there is something you like about your culture, or some practice you enjoy that is “supposed to be” for faithful Muslims only, or something that’s “supposed” to be done only in a certain religious way, you can go ahead keep doing that thing without any issue. You can still enjoy the history and past and traditions of your native country, though you are also more than allowed to look at some religious traditions you grew up with through a critical lens. You don’t have to throw away your entire identity just because you leave a religion, and you most definitely don’t have to shut up and never talk about it ever again. Keep the things you love about your culture and your upbringing and feel free to throw the bad things into the trash where they belong, now that you feel no spiritual drive to defend them. Don’t let anyone guilt you into either staying silent about the bad parts or never participating in the good parts. If I ever have kids, they’re getting so much eidi it’ll be ridiculous. And they’ll get a Christmas tree because I like the way they look. We’ll throw a Black Santa in there too, because fuck it, why not.

So that’s the summary. Keep the good, get rid of the bad. Don’t feel any guilt for either part of that. And if someone tells you “noo you can’t do X if you’re not Muslim” or “nooo you can’t do Y without doing Z”, you can feel free to tell them

On a semi-related note, I think that you’ve already started a process that I found really helpful, which is to think about exactly what you find both wrong and absurd about Islam–as in the codified faith itself, not just “cultural” matters. Whenever someone leaves a religion, you’ll always have people saying “oh, they just don’t understand the real religion”. That goes 500x for Islam; virtually all people who leave Islam are told that they just don’t get it. It can feel like gaslighting sometimes. So it’s extremely useful to be able to point to specific parts of the Quran that I find objectively wrong, to say nothing of the ahadith. I have very solid reasons for no longer believing in the faith. I no longer question them, and I don’t let people tell me that I just don’t understand.

And that leads into another hugely important process, which is finding your own system of morality outside the realm of religion. I’ve heard so many shaikhs and dawah bros say “if you’re not religious, how can you have any morals?”, often taking that to absurd conclusions, like saying you have to be fine with murder or whatever. That is, obviously, insane. I don’t need a warlord and slave owner (PBUH) to explain to me why XYZ Is Bad. I can figure it out on my own and find a personal morality that doesn’t depend on any institution and is suited for the world that I live in. It sounds like you’re pretty much already there, and that’s a big deal. Having some moral structure in your life means that you won’t feel totally lost without Islam. You’re gonna be okay, sis.

So… like I said, hell if I have all the answers to these questions anon, I’m trying to figure all of it out myself. But that’s the best advice I can give you, and I hope it was at least semi-helpful? You can always feel free to message me or send me another ask if you ever just feel like ranting or screaming into the void, trust me, I get the feeling!! 💕

[this-brownie]

04.03.20

not feeling super inspired right now to talk about anything so ill talk about my past birthdays. when I was younger, the apartment I used to live in was filled with not only Bengalis but children that were mine and my brothers’ age. we always had people to play with whether that was going to the park, going to each others houses, or simply playing on our block or backyard. we also always celebrated our birthdays together— I remember the first time I had my very first Big Mac was during my 9th birthday. in middle school, the birthdays got a little more sophisticated because we would go out to Thai restaurants instead of mcdonalds. in 8th grade, my family moved to a new house, a block away from the old apartment. the next year we all started attending different high schools and I don't rmmbr much, my feelings from the day at all except that we called it early that night and my mom and I slept on the living room sofa, lights off and everything. two of my neighbors came over to my house expecting that we were gonna go out to eat— i opened the door to see them dressed up and all they saw were me in my pjs, house dark and their faces fell. one of them said ‘we always do something for your birthday, we thought we were going to do something this year’ and I said no..not this year and kind of awkwardly sent them on their way. side note, I didnt really have social skills because I was extremely shy and super uncomfortable about being confrontational. 

the next few years in highschool my birthdays were okay—I had more School friends to celebrate with and we always went out to eat. but I never had the money or enough friends to have a huge bash like the way I always fantasized. I rmmbr in 10th grade, a few of my friends pitched in to buy me balloons and delivered them to me before first period— I had to carry them around all day and I felt embarrassed but also incredibly special and happy. I eventually became close with Fariha and we spent the next two birthdays together, always Thai food--Jen joined me for one of those outings— Fariha always took care of my bill but I realized I never extended the same courtesy to her. 

a certain pattern started developing over the years— my mom started picking fights with me and would always have me feelings miserable on the day of or very near my birthday. In 12th grade, we had a massive fight that I wasn't expecting her to remember it was my birthday or do anything about it. but near the end of the night she designed the living room with tea lights and bought me cake and dressed me up in a beautiful sari. looking back, its fucking manipulative to put me in a bad mood on a special day, and then expect those feelings to be wiped just because im presented with gifts. yes I was *eventually* showered with love but at the cost of feeling gaslighted and having to hide my negative emotions because they were considered disrespectful. my next birthday, I turned 18 but I can't rmmbr it at all. for my 19th, I was living in Toronto but I had visited Levi in Boston and for the first time ever I spent an entire week with him. I had recently gotten a credit card so I decided to buy myself expensive lingerie. that was a lot of fun.

my 20th birthday was one of the worst because I remember it had been a few months since I moved back from Toronto and my mom was especially untrusting. she completely disregarded that it was my birthday so that was a very lovely day. I remember I was working at magnolia that day but I can't rmmbr why I didnt go out with my friends…I don't rmmbr but it was a shitty day.

for my 21st, I had already been living in Boston for a little less than a year and Levi insisted I go out with my friends since I always stay in with him, I went out with two girls from the restaurant I used to work at, and another girl who I used t work at bebe with. regina (bebe) and I arrived earl/on time and decided to grab something to eat while we waited for the other two girls. we went to a Chinese hotpot place and it was a lot of fun trying something new to eat. the other two girls came and we went to a hookah place which was kind of ratchet but I remember my mindset at the time was to not plan everything out so meticulously because nothing goes to plan. however, I was TOO flowy because I was underdressed (it was fucking freezing that day) and the wait line for the hookah place without a reservation was ridiculous. I also didnt like the fact that the girls didnt dress up to the 9s like the way I did. they also didnt drink the vodka I snuck in so that was another bummer. the last annoying thing was that regina had to leave early because she used to Dorm, and the campus closed at a certain hour. even though I had more fun than usual, it wasn't the huge birthday bash one expects for their 21st.

the next year, 2015 at this point, I had moved back to New York but I can't rmmbr what I did that year. the next birthday was one of my favorites. I had finally planned out and executed an amazing girls night out. the day started off with me picking up a delicious tiramisu cake from a local bakery and heading over to nadiyas house in Astoria where Jenifer and Syndee also joined. we pregamed while getting ready. the dress code was black only— I had gotten an amazing sheer black maxi dress imprinted with gold stars from urban outfitters. all my girls looked amazing that night. we did our makeup and curled hair and even just getting ready was such fun. nadiya also put out snacks for us which was super cute. our first stop of the night was dinner at “beauty and Essex” where we had tapas like: tomato soup with a block of fried cheese in it; bone marrow with grilled bread, mini tuna tartare tacos, and shots of soup. the place was fucking fancy— they served us champagne in the ladies room, so extra haha. I knew the bill would be expensive so I covered a good portion of it which I didnt mind because I wanted to have FUN without being hindered at all. it was also a good amount of food where we were satisfied, but not too full that we felt bloated or couldn't continue drinking. we took an uber to the next stop to a placed called “beauty bar” which was a nail salon mixed with a club, that also served drinks. we each got ourselves a manicure and a drink. we danced for a little bit but didnt love the music so headed over to our last stop of the night, a nightclub called Cielo. this is where I made a mistake — I got us there a little after 11 and had to pay a $30 fee. if we had gotten there before 11pm, it would have been half the price. I remember sneaking a bottle of wine in, by squeezing it between my thighs, but it ended up being such a waste because we didnt have a bottle opener to even open it with. I ended up leaving it in the bathroom.  second thing wasn't really a mistake but it took points off from the overall day— the thing about nyc clubs is that there is SO many that they have to be different to stand out, meaning they don't play popular music or top 40. they will play what they think is cool. when you're drunk its fine, but if you're sober (like jen was), its less enjoyable. however because I was super drunk, I did enjoy dancing even tho I didnt act totally ratchet. maybe it worked out haha. I also met a very charming and handsome man that night. apparently he checked me out the minute he looked at me (according to Jen) and came up to me and…I can't rmmbr now what he asked but he offered to buy me a drink and I jokingly said back “haha I think my friends are going to be jealous if I drink without them” and then he actually bought me nadiya and Syndee drinks. I didnt expect that— afterwards we all split up and the girls danced with other people. I danced with this guy, whose name I don't even remember, but he was tall, genuine, and very charming. I met his friends and we went out for a smoke and I remember enjoying his company. I remember telling him I had a boyfriend and he will still ver pleasant and sweet, which I appreciated. afterwards us 4 girls and he, his friend and girlfriend all squished into this tiny car to grab pizza. it started raining heavy at that point and I was super drunk - on our way back to nadiyas place, we ended up having a sleepover that night, I dropped my phone into the water and it went blank. I felt horrible after because I never got the chance to thank him for the night— in his mind, I just became another girl that used him for drinks and then took flight. theres no way to change that unfortunately.

the issue with me is that I really want to execute the way I envision things, and when they don't turn out like that I become very unhappy. I started fantasizing, and still do sometimes, about having a perfect girls group thats made up of pretty girls of different ethnicities. for my next birthday I invited Syndee (Thai but can pass for Latina), Lilian (chinese), and a coworker of mine who I had never hung out with before (Mexican, but extremely pale- looks exotic white) to have a birthday brunch. this was the first time hanging out with Lilian after maybe 7-8 years so it was a bit of a reunion. we went out for drinks to a speakeasy after which was really cool too. even though the group of us looked beautiful in photos, the aesthetics of the restaurant was lovely, the food itself was amazing, and the drinks were strong-- the dynamic between all of us wasn't flowing 100%. I wanted so badly for things to look good that I didnt realize the coworker would feel out of place amongst the rest of us who had known each other for a while. so, while the day was nice and nothing bad had happened, it still didnt feel extremely memorable. thats the last time I hung out with that coworker, and the last time I tried to force things together to make them fit.

the next year I was pretty down about and around my birthday— this was the first birthday after being married. I remember Levi asking me what I wanted to do and what gift I wanted. im not super materialistic anymore so I don't like receiving gifts. we did go out to Indochine for dinner which was nice but not as great as it was the previous time we had gone. instead, we went out to see Jim Jeffereys in Madison sq garden. it was okay— he made a joke about taking a shit which lasted 15 minutes. it was annoying. also Levi got mad at me because I went out to get a drink and missed an entire segment. wooh. I am weird because I want people to show me a lot of love— it doesn't have to constant, or grand gestures but I like when its thoughtful. I hate having to ask for attention or affection, it makes it less special if I receive it after that. even though Jen is my best friend, I have celebrated most of my birthdays without her. she's usually unable to come see me during the school term. this year she was at med school and wasn't able to make it because she was busy studying. she's missed out on a lot of them and it hurts because not only is she my best friend and should do things to make me special, but that I always go out of my way for her to make her feel amazing on her day (I will make a separate post for HER  birthdays). I am relatively low key about my birthday too, ever since 10th grade it hasn't been on facebook profile. I don't tell people about it, if they ask for the date I try to evade their questions. I know its strange, but its because I don't like revealing personal info, or things that are meaningful to me, and have others disregard or forget them. most of my friends didnt remember to wish me but I don't hold it against them because I don't make their birthdays special. I only do that with Jen, so I only expect it from her. however, fimo did make me feel special. we went out to eat at a Sri Lankan restaurant and then got ice cream after from a different place. she printed me a cute celebratory card with a picture of me on it and got a beautiful vase (I told her not to get me anything tho!). she gave me black and white triangular shaped earrings and said, I noticed you like geometrical shapes so I thought you would like these (I did like them a lot). she also did something very sweet and unique- she cut out scraps of paper and wrote little compliments and inside jokes we shared on the. that was my favorite because it showed that there are little moments of me that she remembers, and that she has taken time to think of me and what would make me happy. 

out of all my birthdays, the last one where I turned 26 has been my favorite. im not always moody and a downer! this was one of the first birthdays that I actually DID get to spend with Jen. I become very moody around my birthday- in the past because my mom would pick fights with me..these days because I prefer to isolate myself rather than be happy, or optimistic, and then be disappointed. I would want someone to do for me what I do for them. is that selfish of me? maybe. which is why I like to keep my expectations extremely low. Jen had recently broken up with her boyfriend of a long time and she was actually available to come see me, without being hindered or guilted into spending a part of the weekend with him. she asked what I wanted to do and if I wanted anything for my birthday. I feel embarrassed and shy about being given gifts so I always say no to that— I like to have special experiences instead. I gave her an ambivalent answer, showing my hesitation and hinting that ill be working and ill be pretty busy that weekend. the reason I do this is because 1. im manipulative and 2. I'm an asshole. id rather exaggerate to her and make it seem like *IM* the one whose busy and can't make time for her, rather than have her say yes and hope that she's coming and be let down if she can't make it (which has happened in the past before). I also am…apparently unsatisfied by how people show me love. im a scorpio… meaning I am excessive, intense, and “relentless” (according to levi). when I do something, I do it big and I try my best to make it perfect. when people are very lax, like the way Jen is, about certain things it conveys to me that they are not as serious about me. its not necessarily true but thats how I feel. so I tell her im busy, to test her and see whether she will still come to see me for my birthday even tho it may be inconvenient for her. I was wishy washy, but I wasn't completely adamant about her not coming so she decided to ignore my hesitance and come anyway. good decision.

several days before my mom hinted that she would throw a surprise party for me— she tried to be clever about it, in her defense, but when she asked me for fimos number I knew something was up. I played along— I found it very endearing that my mom would do something like this for me. this was part of the reason I decided Jen should come anyway, it would be more fun with her there after all. she came Friday night and we had dinner and talked for a little bit before heading to bed. I had work the next morning; after I came come we both got ready to go to my moms place. she made it seem like we were going to a wedding so I had to get there, get dressed and then we would all head out together. I knew it was gonna be a party so I tried to get Levi to come but he didn't think it was appropriate. once we got there and opened the curtains, I was greeted loudly with “HAPPY BIRTHDAYYYY!!!” it was my two brothers, a couple of my little brothers friends, fimo and her bf, my aunt, and my cousin and his parents. it was very sweet, I was honestly touched to see a room of happy faces all leathered around because of me. my mom was elated, it was so fucking cute. she spent all day cooking a ton of food— making all my favorites ofc— and got this delicious cake adorned with a picture of me. the room was designed with HBD banners and streamers, confetti balloons, and pretty fairy lights. my brothers even got a disco light that displayed different colored lights all over the walls, and champagne candles (the ones that shoot out that pretend fire until they die out). I felt so fucking loved— I feel happy right now thinking back to that night. 

the next morning I had planned to go to the spa with just Levi but Jenifer wanted to join us. I didnt want to at first because I wanted to spend some alone time, but thankfully it ended up being a great time. Levi rented a car and we drove to this luxe spa in New Jersey. it was three floors filled with different temperature jacuzzis, pools, saunas, and steam rooms. the pool on the rooftop was an infinity pool, filled with a ton of instagrammers, but the view was stunning and we caught a delightful sunset. Jenifer being there added a lot to my pleasure and peace— I got to take as many photos as I wanted without being judged and I had fun running around to all the different areas instead of being told to sit quiet. I really do love that girl, but any actions of me being distant or cold are a result of being let down so many times, intentional or not, that I always expect only the worst now. however, her being there that weekend solidified our bond greatly and I appreciated that. we got pizza afterwards which was tasty but not so great. we drove back home and Levi let us off at st marks so that Jen and I could spend the last hour before she had to leave back to Philly. she spontaneously told me she wanted to get a belly piercing, and if I was down. we had gotten one together a long time ago but it fell out and we didnt have it re pierced. I didnt care either way so I went for it. now we have matching bffl belly rings all over again. nice end to a great weekend.

a few days later I met fimo for brunch at an Italian place in Brooklyn, that happened to be near the movie theaters where we planned on going after. brunch was whatever but she got me a fucking $100 Chanel perfume even though I demanded that she not get me anything. the perfume smells heavenly, and I only wear it on special occasions now. but it was too expensive, and I really didnt want that from her. later, we watched ‘Parasite’ at this theatre called Nitehawk Cinema which allows you to eat and drink right while you're watching the movie. we munched on popcorn and drank wine and felt like badasses. Parasite was absolutely amazing and thrilling- a Korean horror/thriller about a family that trick, and uses, a richer family into employing them. the name of the movie makes it seem like THEY are the parasites, but the crazy plot twist is that the rich family’s former employees were doing the same thing. but worse. they were secretly living/hiding out in the rich family basement/bunker. shit gets crazy when current employees find the ex employees. we both really enjoyed the movie, and didnt expect to like it as much as we did. it got nominated for several awards, so we were not the only ones who thought so.

the last person I saw for my birthday was Syndee but it wasn't really a bday hangout. I recently had a falling out with Ivan (more on that on a different post), and had reached out to all my closest friends. Sydnee and I see each other once every couple months so it was time. we got Detroit style pizza at this famous place near my work/home. the food was pretty good and it was nice to catch up with her. I let her know that I would be less busy in the future and that maybe we should start calling each other so that the stretches in person wouldn't feel as long. she agreed, and it was interesting as were catching up that for the first time I had only good news to share and she had not so good news. I told her that I had gotten a new job where I was planning to get promoted, had very recently gotten my green card, and that my mom was finally coming to terms with my marriage. I talked about my birthday, and she casually got the date for my birthday wrong (she was off by two days)— so I guess it really has been a while since we've been thorough with each other. she lamented about having to move out soon from her apt because she and her bf (who pays most of the rent) might be splitting up. she also said she wasn't doing as well at her new job as she had hoped. It was unfortunate that she was going through a tough time but I told her that she wasn't completely helpless, and that she still had options. its difficult for me to hear about people going through a tough time because I want to be able to change that, even if im not always in the position to do so. we did end on a good note and she seemed happy about seeing me which was nice. I am happy and grateful for the friends and the freedom I have. they don't always show me affection in the way I want but they do show it how they can, which I acknowledge and cherish.

[kristinsimmons]

A Conversation with John Ioannidis

By SAURABH JHA, MD

The COVID-19 pandemic has been a testing time for the already testy academic discourse. Decisions have had to be made with partial information. Information has come in drizzles, showers and downpours. The velocity with which new information has arrived has outstripped our ability to make sense of it. On top of that, the science has been politicized in a polarized country with a polarizing president at its helm.

As the country awoke to an unprecedented economic lockdown in the middle of March, John Ioannidis, professor of epidemiology at Stanford University and one of the most cited physician scientists who practically invented “metaresearch”, questioned the lockdown and wondered if we might cause more harm than good in trying to control coronavirus. What would normally pass for skepticism in the midst of uncertainty of a novel virus became tinder in the social media outrage fire.

Ioannidis was likened to the discredited anti-vax doctor, Andrew Wakefield. His colleagues in epidemiology could barely contain their disgust, which ranged from visceral disappointment – the sort one feels when their gifted child has lost their way in college, to deep anger. He was accused of misunderstanding risk, misunderstanding statistics, and cherry picking data to prove his point.

The pushback was partly a testament to the stature of Ioannidis, whose skepticism could have weakened the resoluteness with which people complied with the lockdown. Some academics defended him, or rather defended the need for a contrarian voice like his. The conservative media lauded him.

In this pandemic, where we have learnt as much about ourselves as we have about the virus, understanding the pushback to Ioannidis is critical to understanding how academic discourse shapes public’s perception of public policy.

Saurabh Jha (SJ): On March 17th, at the start of the lockdown, you wrote in STAT News cautioning us against overreacting to COVID-19. You likened our response to an elephant accidentally jumping off a cliff because it was attacked by a house cat. The lockdown had just begun. What motivated you to write that editorial?

John P.A. Ioannidis (JPA): March seems a long time ago. I should explain my thinking in the early days of the COVID-19 pandemic. Like many, I saw a train approaching. Like many, I couldn’t sense the train’s precise size and speed. Many said we should be bracing for a calamity and in many ways I agreed. But I was concerned that we might inflict undue damage, what I’d call “iatrogenic harm”, controlling the pandemic.

To answer your question specifically, I wrote the piece because I felt that the touted fatality rate of COVID-19 of 3.4 % was inflated, but we had so limited data and so much uncertainty that infection fatality rate values as different as 0.05% and 1% were clearly still possible. I was pleading for better data on COVID-19 to make our response more precise and proportionate.

SJ: We now know that the infection fatality rate (IFR) is much lower than 3.4 %.  I’m curious – why did you doubt this figure? At the time, the virus created havoc in Iran and Italy. Hospitals in the richest areas in Italy rationed ventilators. Was a fatality rate of 3.4 % so implausible?

JPA: Small changes in the fatality rate make a dramatic difference in the number of deaths. 3.4 % is an entirely different universe from 0.5 %. Imperial College epidemiologists, using an overall IFR of 0.9 %, assumed that if 60-80 % of the population were infected, as would happen without precaution or immunity, 2.2 million Americans would die.

I’m a physician and epidemiologist with a fellowship training in infectious diseases. Though I felt that COVID-19 was a serious threat, I didn’t think it was Spanish Flu redux. COVID-19 wasn’t behaving like a “3.4 % fatality rate” pandemic. I doubted that widely quoted fatality rate, which is what the Chinese public health authorities told the WHO, because by March it was apparent that COVID-19 infection comprised a clinical spectrum, ranging from mild symptoms which could be managed at home, to severe lung disease which needed ventilatory support. The crucial piece of the epidemiological puzzle was the number of people who were infected but didn’t know they were infected because they had no, or very minimal, symptoms.

The presence of asymptomatic and mildly symptomatic people who are not detected changes the shape of the pandemic and should change our response to it, too. For starters, it means that the infection fatality rate – the fatality rate amongst the infected – will, by definition, be lower than the case fatality rate (CFR) – the fatality rate amongst known symptomatic people who get tested.

The second implication is that the infection is more contagious and has spread further than what we believe, which makes testing, tracking, and isolating infected people more challenging. Testing remains important but each day we delay rolling out mass testing, testing becomes less efficacious, and even less so when there are so many asymptomatics or people with mild symptoms who won’t seek testing.

Figuring the true IFR of a virus isn’t some petty academic musing. To be clear, distinguishing between IFR and CFR for a virus like Ebola is silly because its CFR is about 50 %. But when the CFR of a virus is less than 5 %, we must ask– what’s the true IFR? Does the CFR diverge much from the IFR? How many asymptomatic carriers of the virus are there?

SJ: Few would argue against better data. But decisions must be made with the data we have rather than the data we wish we had. The consequences of a delay in acting because we wait for better data can only be guessed, rather than proven, at the time. Nevertheless, inaction has consequences. Some felt that you were advocating that we do nothing in the pandemic until we obtained data robust enough to design policy.

JPA: That wasn’t my position, though I can see why people thought I was advocating inaction when I was actually asking, begging actually, for better data to inform our actions. The two – decisions and knowledge – aren’t mutually exclusive. We can design policy on imperfect information yet keep gathering evidence so that our approach is fine tuned. A decision such as an economic lockdown should be assumed provisional, awaiting more research and better information. Of course, we can’t know everything there is to know about a novel virus in the beginning. Inaction is a false choice. What we’re choosing between is an immutable decision and a decision updated by emerging evidence, rather than between inaction and gathering evidence.

SJ: Let me ask you, frankly. Did you support the lockdown?

JPA: Let me answer, frankly. Yes. But only as a temporary measure.

SJ: So, you’re not against locking down the economy?

JPA: By February, we missed the window for nipping the novel coronavirus in the bud. Had we acted earlier, with aggressive testing, tracing, and isolating, like the South Koreans, the Taiwanese and the Singaporeans did, the virus wouldn’t have spread as wildly as it did. The biggest lesson from this pandemic is that the costs of delaying controlling the infection can be substantial. Act decisively in haste or repent at leisure.

Once we missed the boat, the lockdown was inevitable. I say “inevitable” grudgingly because I don’t think it should have reached that eventuality.

SJ: The situation would certainly have been different had the extent of the spread been identified in January, and the infection was controlled. If I understand you correctly, given our situation in March, as avoidable as it could have been, and our state of knowledge at that time, you supported the lockdown.

JPA: That’s correct.

Once the country was locked down, I felt we should be focusing in minimizing its duration. I view “lockdown” as a drug with dangerous side effects when its use is prolonged. It’s an extreme measure – a last resort, the nuclear option.

A country should be locked down not a minute longer than absolutely necessary. We have to keep assessing its risk-benefit calculus, by collecting and analyzing data, making sure we’re measuring the denominator accurately, and finding vulnerable and not vulnerable sub-groups.

SJ: I don’t mean to play “gotcha.” But isn’t what you’re saying contradictory? You didn’t believe that COVID-19 was a “3.4 % fatality rate” pandemic but you also supported the lockdown, which you, rightly, call an “extreme” measure.

JPA: If the fatality rate were truly 3.4 %, I’d have myself tied like Ulysses did, perhaps to my refrigerator to avoid ever getting out of my house. I’d want an even stricter lockdown.  One of the challenges in science communication is downgrading the threat of an infection, which you believe is inflated, without making it sound harmless. That I didn’t think that COVID-19 was that dangerous didn’t mean that I thought it was harmless.

SJ: But you compared COVID-19 to the flu. That comparison irked many doctors, particularly those in the frontline, who felt they were being gaslighted. Doctors from Lombardy, New York City (NYC), Seattle were seeing jam packed ICUs, high mortality rates in the ICU, multi-organ failure, and ventilator shortages. They were overwhelmed. They had never seen so much carnage caused by an infection, certainly not by the flu. Surely, we don’t need the denominator to figure out that COVID-19 isn’t just the flu. Surely, the numerator speaks for itself.

JPA: When conveying the severity of a novel virus, it’s useful anchoring to past infections for perspective. The seasonal flu is a natural choice for comparison. I agree “just the flu” sounds dismissive, even insulting to healthcare workers, because it sounds like the common cold. The seasonal flu isn’t “just the flu” either. It actually kills 350, 000 to 700, 000 people a year worldwide. In the USA it kills 30,000 to 70,000 people per year, and would kill even more if we didn’t vaccinate healthcare workers and half the population.

I don’t think comparing COVID-19 to the seasonal flu is unscientific, but that comparison must be nuanced. COVID-19 is a strange beast. It’s way more dangerous than the flu in the elderly and in those with comorbidities. Yet the flu is more dangerous than COVID-19 in children and young adults, even allowing for the fact that COVID-19 causes Kawasaki-disease-like syndrome in some children. Again, we face a communication challenge – how do we convey the severity of a virus which is both more dangerous and less dangerous than the flu? If I emphasize the less vulnerable group, I’ll be accused of being flippant about the virus. Yet if I focus only on its devastation in the most vulnerable group, I’m not painting the true picture.

Even though I spent lot of effort nailing the precise IFR of COVID-19, any single number IFR is misleading, because the average fatality rate hides the heterogeneity of risk. Once we figure out that the virus, on average, isn’t as bad as we thought, the next step is identifying the low-risk and the high-risk, i.e. risk stratifying.

SJ: I’m going to challenge the mortality statistics of the seasonal flu you have quoted, which are widely quoted, and was quoted by Donald Trump, too – though its source isn’t fake news but the CDC. Aren’t these figures an estimation or projection? And isn’t it true that the deaths attributable to COVID-19 is derived more from direct counting than from an estimation and, therefore, likely to be more accurate?

JPA: It’s true that mortality of seasonal flu is an estimation. But this estimation isn’t science fiction. It’s derived from sound scientific principles. The data on seasonal flu (flu-like illnesses) is robust. We know much more about the seasonal flu than COVID-19.

Now, your point that we’re literally counting, as opposed to estimating, deaths from coronavirus is correct. But I’ll push back that this may not yield mortality figures as accurately as people think. Because of the attention on coronavirus, we’re better at knowing that a deceased person had coronavirus than had the flu. This means we’re good at knowing when someone died with coronavirus – but not necessarily that they died from the infection. We assume that dying with coronavirus is dying from coronavirus.

SJ: But many have died in their homes with no documentation of being infected. We have assumed that dying without documented coronavirus is not dying from coronavirus. Surely, misattribution of deaths to coronavirus works in both directions.

JPA: I agree. Which is why we need better data to understand this virus better. One point I want to emphasize – the misattribution is paradoxically greatest in the group most vulnerable to coronavirus, i.e. those with limited life expectancy. This group is most likely to die from COVID-19. Because of their limited life expectancy, this group is also likely to die from their non-COVID morbidities.

One way to better measure the impact of COVID-19 is measuring excess deaths, which is the death rate beyond what one usually encounters annually. Excess deaths comprise several groups – e.g. people killed by COVID-19 infection and people who have died because they didn’t receive timely care because they were afraid to go to the hospital, or because healthcare resources were focused on COVID-19 patients. The magnitude of the latter group will be more evident in years to come. Another group are deaths caused by the social and economic consequences of the lockdown, such as from suicides and alcohol and drug abuse. This number, which’ll also be evident in years to come, shouldn’t be underestimated. At a global level, consequences of lockdown-induced starvation, derailment of immunizations for lethal childhood diseases, and lack of proper management of tuberculosis are tremendous threats.  

SJ: In your editorial you said that the bulk of the mortality of COVID-19 was in people with limited life expectancy, rather than young people. You said “vast majority of this hecatomb would be people with limited life expectancies. That’s in contrast to 1918, when many young people died”. Some felt you were minimizing the live of the elderly. That you didn’t think that their lives were worth the economic consequences of the lockdown was because they’d be dead soon, anyway.

JPA: That’s an unfortunate misrepresentation of my position.

There is an age gradient of fatality with COVID-19. This fact has been shown in several studies. Not only is there an age gradient but a steep inflection point with age, around 70. The hazard ratios are striking. Age predicts mortality better than even comorbidities. This scientific fact can easily be hijacked by demagogues by calling people concerned about the negative consequences of the lockdown “heartless granny killers.” That isn’t helpful.

The fact that COVID-19 disproportionately affects the elderly, i.e. older people are more vulnerable, means that they need more precise and thoughtful protection. I have been advocating for more attention to and protection for elderly people, not less. Unfortunately, that’s not what happened. For instance, Andrew Cuomo, governor of New York, told hospitals to send infected nursing home residents back to their nursing homes, which was like putting out a forest fire with kerosene.  The same happened also in other states. This act alone may have caused countless deaths amongst nursing home residents. We failed to protect our most vulnerable, in part because of our “one-size-fits-all” approach. In Lombardy, there were disproportionate deaths in nursing homes. It is estimated that 45-53% of US deaths were in nursing home residents, and similar or even higher percentages were seen in several European countries.

We needed extra precautionary effort in high-risk settings such as nursing homes, prisons, meat processing plants, and homeless shelters. The corollary of having high-risk groups is that there must be low-risk groups, and low-risk people can continue working. We can’t treat everyone as “high risk” because then the high risk won’t get the extra attention and care they deserve. In our approach to controlling coronavirus we made no distinction between teenagers partying on beaches in Florida and debilitated, frail residents living in congested nursing homes in NYC. Our uniform approach was neither scientific nor safe.

COVID-19 is a virus which unmasks our social and economic fault lines.

SJ: You’ve criticized models for using faulty data in projecting the death toll. When the lockdown started there were only 60 deaths in the US. You projected 10, 000 deaths using an IFR computed from infected passengers on Diamond princess cruise ship. Yet today there more than 132, 000 deaths – the figure would likely have been even higher were it not for the social distancing/ lockdown we employed on March 16th. Though the mortality numbers are still much lower than the doomsday predictions of Imperial college, they do make your projections overly optimistic.

JPA: I never said that I knew that the death toll was going to be “10,000 deaths in the US”. How could I, in a piece where the message was “we don’t know”! The 10,000 deaths in the US projection was meant to be in the most optimistic range of the spectrum and in the same piece I also described the most pessimistic end of the spectrum, 40 million deaths. The point I wanted to emphasize was the huge uncertainty.

Now, it’s perfectly reasonable following the precautionary principle advocated by Nassim Taleb and basing our response on the worst-case forecast. But as scientists it’s not reasonable staring such huge residual uncertainty in its face and doing nothing about it. It’s our job to reduce uncertainty by collecting more robust data.

SJ: You calculated the IFR of COVID-19 using the published fatality rates in various settings. We’ll get to the methods later. For now, I want to focus on the result. By your calculation, the IFR ranged from 0.02 to 0.86 % with a median estimate of 0.26. Let’s take just one data point: NYC. There were 18, 000 deaths. Even if we assume the entire city, population of 8.3 million, was infected – a big assumption – that yields an IFR of at least 0.21 %. The lowest bound of the fatality rate of NYC is far higher than the lowest bounds of your estimate. Does this fact not challenge your calculation and the assumptions made in the calculations?

JPA: IFR is not a fixed physical property like the Avogadro’s constant.  It’s highly variable which depends as much on the virus as it does on us. Perhaps it depends even more on us than the virus. It depends how we interact with each other, how close we are to each other, who gets infected, who gets ill. As we know the virus more, we get better at dealing with it. The IFR is a shape-shifting moving target.

Which brings me to NYC. It certainly faced the infection courageously head on. Yet neither its experience nor its IFR can be generalized. At least three factors contributed to the high death toll in NYC: the disproportionate number of deaths in nursing homes because of a catastrophic policy blunder, the very compact nature of the city, particularly where the vulnerable populations live, and nosocomial spread of infection. Also, doctors were still learning how best to manage patients in the ICU and their approach to ventilatory support was probably too aggressive, in hindsight. I’m not blaming doctors. NYC was dealt a bad hand.

SJ: If the IFR is “shape-shifting moving target” – why did you labor so hard to measure it?

JPA: It’s still important knowing the mean and range, particularly if one wants to calculate the risk-benefit of different policies in different settings. We just can’t assume that the IFR of COVID-19 in NYC in April is the same as its IFR in Houston in July or the IFR of Singapore either in April or in July. Some hotbeds in NYC must have had IFR of 1% or more. Singapore has already detected 43,000 cases and had only 26 deaths, so the upper bound of its IFR is 0.06% and may be even smaller. The IFR of Houston in July is something that we can hopefully shape and decrease with precise actions. When we learn from history, when we understand the special circumstances of the past and ensure we don’t repeat the mistakes, hopefully the IFR doesn’t repeat itself.

Also, I showed in my methods of computing the IFR the huge diversity of IFR because of wide variation in seroprevalence estimates. It’s not just the final result that’s important, it’s the individual components which make the final number which are important as well.

SJ: Could you expand more on nosocomial spread of COVID-19.

JPA: Many patients were likely infected in hospitals by infected healthcare workers. This is understandably a controversial issue which people are reluctant to broach.

We don’t know the exact scale of the nosocomial spread but in several hard-hit locations it was probably not trivial. This happened because many infected healthcare workers, particularly those < 60 had no idea they were infected. Once again, it underscores how important it was understanding the extent of the asymptomatics and people with only mild symptoms to which they naturally pay no attention. They unwittingly and unknowingly infected patients.

Like nursing homes, hospitals house the most vulnerable. Only a handful of unaware infected healthcare workers would have been sufficient to allow the virus to spread and feast on patients in hospital. This happened even more prominently early in the pandemic, when precautionary measures, such as wearing personal protection equipment, weren’t universally adopted, and we had no idea how far coronavirus had spread.

Deaths are a lagging indicator of the extent of infection. By the time the first death from COVID-19 in the US was recorded, the virus had comfortably set foot in American society. By believing the virus was deadlier than it actually was, we underestimated how far it had spread, and thus allowed the virus to be more deadly than it needed have been.

SJ: You received considerable pushback for your piece. Has it changed your opinion of academic discourse?

JPA: Appearing on Fox may have infuriated some of my colleagues – but that speaks to the polarization in the US. I’m a data-driven technocrat. It’s unlikely I would fit well with “conservative ideology” (good grief)!

I welcome academic discourse and disagreement. I have no doubt that I know very little and that I make mistakes, but I am just trying to learn a bit more and to make fewer mistakes, if possible. I consider that people who criticize me with valid scientific arguments are my greatest benefactors. But the outrage propagated by social media is a force of its own, and destroys any intelligent discourse, civil or uncivil. Once the outrage gets going, platforms for academic discourse censor and the discourse just doesn’t happen. I was unable to publish my essay about nosocomial spread of COVID-19 in nursing homes and hospitals. I submitted to many outlets. I suspect the editors feared social media backlash against my raising an uncomfortable issue. Fear isn’t healthy for science.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

A Conversation with John Ioannidis published first on https://wittooth.tumblr.com/

[lauramalchowblog]

A Conversation with John Ioannidis

By SAURABH JHA, MD

The COVID-19 pandemic has been a testing time for the already testy academic discourse. Decisions have had to be made with partial information. Information has come in drizzles, showers and downpours. The velocity with which new information has arrived has outstripped our ability to make sense of it. On top of that, the science has been politicized in a polarized country with a polarizing president at its helm.

As the country awoke to an unprecedented economic lockdown in the middle of March, John Ioannidis, professor of epidemiology at Stanford University and one of the most cited physician scientists who practically invented “metaresearch”, questioned the lockdown and wondered if we might cause more harm than good in trying to control coronavirus. What would normally pass for skepticism in the midst of uncertainty of a novel virus became tinder in the social media outrage fire.

Ioannidis was likened to the discredited anti-vax doctor, Andrew Wakefield. His colleagues in epidemiology could barely contain their disgust, which ranged from visceral disappointment – the sort one feels when their gifted child has lost their way in college, to deep anger. He was accused of misunderstanding risk, misunderstanding statistics, and cherry picking data to prove his point.

The pushback was partly a testament to the stature of Ioannidis, whose skepticism could have weakened the resoluteness with which people complied with the lockdown. Some academics defended him, or rather defended the need for a contrarian voice like his. The conservative media lauded him.

In this pandemic, where we have learnt as much about ourselves as we have about the virus, understanding the pushback to Ioannidis is critical to understanding how academic discourse shapes public’s perception of public policy.

Saurabh Jha (SJ): On March 17th, at the start of the lockdown, you wrote in STAT News cautioning us against overreacting to COVID-19. You likened our response to an elephant accidentally jumping off a cliff because it was attacked by a house cat. The lockdown had just begun. What motivated you to write that editorial?

John P.A. Ioannidis (JPA): March seems a long time ago. I should explain my thinking in the early days of the COVID-19 pandemic. Like many, I saw a train approaching. Like many, I couldn’t sense the train’s precise size and speed. Many said we should be bracing for a calamity and in many ways I agreed. But I was concerned that we might inflict undue damage, what I’d call “iatrogenic harm”, controlling the pandemic.

To answer your question specifically, I wrote the piece because I felt that the touted fatality rate of COVID-19 of 3.4 % was inflated, but we had so limited data and so much uncertainty that infection fatality rate values as different as 0.05% and 1% were clearly still possible. I was pleading for better data on COVID-19 to make our response more precise and proportionate.

SJ: We now know that the infection fatality rate (IFR) is much lower than 3.4 %.  I’m curious – why did you doubt this figure? At the time, the virus created havoc in Iran and Italy. Hospitals in the richest areas in Italy rationed ventilators. Was a fatality rate of 3.4 % so implausible?

JPA: Small changes in the fatality rate make a dramatic difference in the number of deaths. 3.4 % is an entirely different universe from 0.5 %. Imperial College epidemiologists, using an overall IFR of 0.9 %, assumed that if 60-80 % of the population were infected, as would happen without precaution or immunity, 2.2 million Americans would die.

I’m a physician and epidemiologist with a fellowship training in infectious diseases. Though I felt that COVID-19 was a serious threat, I didn’t think it was Spanish Flu redux. COVID-19 wasn’t behaving like a “3.4 % fatality rate” pandemic. I doubted that widely quoted fatality rate, which is what the Chinese public health authorities told the WHO, because by March it was apparent that COVID-19 infection comprised a clinical spectrum, ranging from mild symptoms which could be managed at home, to severe lung disease which needed ventilatory support. The crucial piece of the epidemiological puzzle was the number of people who were infected but didn’t know they were infected because they had no, or very minimal, symptoms.

The presence of asymptomatic and mildly symptomatic people who are not detected changes the shape of the pandemic and should change our response to it, too. For starters, it means that the infection fatality rate – the fatality rate amongst the infected – will, by definition, be lower than the case fatality rate (CFR) – the fatality rate amongst known symptomatic people who get tested.

The second implication is that the infection is more contagious and has spread further than what we believe, which makes testing, tracking, and isolating infected people more challenging. Testing remains important but each day we delay rolling out mass testing, testing becomes less efficacious, and even less so when there are so many asymptomatics or people with mild symptoms who won’t seek testing.

Figuring the true IFR of a virus isn’t some petty academic musing. To be clear, distinguishing between IFR and CFR for a virus like Ebola is silly because its CFR is about 50 %. But when the CFR of a virus is less than 5 %, we must ask– what’s the true IFR? Does the CFR diverge much from the IFR? How many asymptomatic carriers of the virus are there?

SJ: Few would argue against better data. But decisions must be made with the data we have rather than the data we wish we had. The consequences of a delay in acting because we wait for better data can only be guessed, rather than proven, at the time. Nevertheless, inaction has consequences. Some felt that you were advocating that we do nothing in the pandemic until we obtained data robust enough to design policy.

JPA: That wasn’t my position, though I can see why people thought I was advocating inaction when I was actually asking, begging actually, for better data to inform our actions. The two – decisions and knowledge – aren’t mutually exclusive. We can design policy on imperfect information yet keep gathering evidence so that our approach is fine tuned. A decision such as an economic lockdown should be assumed provisional, awaiting more research and better information. Of course, we can’t know everything there is to know about a novel virus in the beginning. Inaction is a false choice. What we’re choosing between is an immutable decision and a decision updated by emerging evidence, rather than between inaction and gathering evidence.

SJ: Let me ask you, frankly. Did you support the lockdown?

JPA: Let me answer, frankly. Yes. But only as a temporary measure.

SJ: So, you’re not against locking down the economy?

JPA: By February, we missed the window for nipping the novel coronavirus in the bud. Had we acted earlier, with aggressive testing, tracing, and isolating, like the South Koreans, the Taiwanese and the Singaporeans did, the virus wouldn’t have spread as wildly as it did. The biggest lesson from this pandemic is that the costs of delaying controlling the infection can be substantial. Act decisively in haste or repent at leisure.

Once we missed the boat, the lockdown was inevitable. I say “inevitable” grudgingly because I don’t think it should have reached that eventuality.

SJ: The situation would certainly have been different had the extent of the spread been identified in January, and the infection was controlled. If I understand you correctly, given our situation in March, as avoidable as it could have been, and our state of knowledge at that time, you supported the lockdown.

JPA: That’s correct.

Once the country was locked down, I felt we should be focusing in minimizing its duration. I view “lockdown” as a drug with dangerous side effects when its use is prolonged. It’s an extreme measure – a last resort, the nuclear option.

A country should be locked down not a minute longer than absolutely necessary. We have to keep assessing its risk-benefit calculus, by collecting and analyzing data, making sure we’re measuring the denominator accurately, and finding vulnerable and not vulnerable sub-groups.

SJ: I don’t mean to play “gotcha.” But isn’t what you’re saying contradictory? You didn’t believe that COVID-19 was a “3.4 % fatality rate” pandemic but you also supported the lockdown, which you, rightly, call an “extreme” measure.

JPA: If the fatality rate were truly 3.4 %, I’d have myself tied like Ulysses did, perhaps to my refrigerator to avoid ever getting out of my house. I’d want an even stricter lockdown.  One of the challenges in science communication is downgrading the threat of an infection, which you believe is inflated, without making it sound harmless. That I didn’t think that COVID-19 was that dangerous didn’t mean that I thought it was harmless.

SJ: But you compared COVID-19 to the flu. That comparison irked many doctors, particularly those in the frontline, who felt they were being gaslighted. Doctors from Lombardy, New York City (NYC), Seattle were seeing jam packed ICUs, high mortality rates in the ICU, multi-organ failure, and ventilator shortages. They were overwhelmed. They had never seen so much carnage caused by an infection, certainly not by the flu. Surely, we don’t need the denominator to figure out that COVID-19 isn’t just the flu. Surely, the numerator speaks for itself.

JPA: When conveying the severity of a novel virus, it’s useful anchoring to past infections for perspective. The seasonal flu is a natural choice for comparison. I agree “just the flu” sounds dismissive, even insulting to healthcare workers, because it sounds like the common cold. The seasonal flu isn’t “just the flu” either. It actually kills 350, 000 to 700, 000 people a year worldwide. In the USA it kills 30,000 to 70,000 people per year, and would kill even more if we didn’t vaccinate healthcare workers and half the population.

I don’t think comparing COVID-19 to the seasonal flu is unscientific, but that comparison must be nuanced. COVID-19 is a strange beast. It’s way more dangerous than the flu in the elderly and in those with comorbidities. Yet the flu is more dangerous than COVID-19 in children and young adults, even allowing for the fact that COVID-19 causes Kawasaki-disease-like syndrome in some children. Again, we face a communication challenge – how do we convey the severity of a virus which is both more dangerous and less dangerous than the flu? If I emphasize the less vulnerable group, I’ll be accused of being flippant about the virus. Yet if I focus only on its devastation in the most vulnerable group, I’m not painting the true picture.

Even though I spent lot of effort nailing the precise IFR of COVID-19, any single number IFR is misleading, because the average fatality rate hides the heterogeneity of risk. Once we figure out that the virus, on average, isn’t as bad as we thought, the next step is identifying the low-risk and the high-risk, i.e. risk stratifying.

SJ: I’m going to challenge the mortality statistics of the seasonal flu you have quoted, which are widely quoted, and was quoted by Donald Trump, too – though its source isn’t fake news but the CDC. Aren’t these figures an estimation or projection? And isn’t it true that the deaths attributable to COVID-19 is derived more from direct counting than from an estimation and, therefore, likely to be more accurate?

JPA: It’s true that mortality of seasonal flu is an estimation. But this estimation isn’t science fiction. It’s derived from sound scientific principles. The data on seasonal flu (flu-like illnesses) is robust. We know much more about the seasonal flu than COVID-19.

Now, your point that we’re literally counting, as opposed to estimating, deaths from coronavirus is correct. But I’ll push back that this may not yield mortality figures as accurately as people think. Because of the attention on coronavirus, we’re better at knowing that a deceased person had coronavirus than had the flu. This means we’re good at knowing when someone died with coronavirus – but not necessarily that they died from the infection. We assume that dying with coronavirus is dying from coronavirus.

SJ: But many have died in their homes with no documentation of being infected. We have assumed that dying without documented coronavirus is not dying from coronavirus. Surely, misattribution of deaths to coronavirus works in both directions.

JPA: I agree. Which is why we need better data to understand this virus better. One point I want to emphasize – the misattribution is paradoxically greatest in the group most vulnerable to coronavirus, i.e. those with limited life expectancy. This group is most likely to die from COVID-19. Because of their limited life expectancy, this group is also likely to die from their non-COVID morbidities.

One way to better measure the impact of COVID-19 is measuring excess deaths, which is the death rate beyond what one usually encounters annually. Excess deaths comprise several groups – e.g. people killed by COVID-19 infection and people who have died because they didn’t receive timely care because they were afraid to go to the hospital, or because healthcare resources were focused on COVID-19 patients. The magnitude of the latter group will be more evident in years to come. Another group are deaths caused by the social and economic consequences of the lockdown, such as from suicides and alcohol and drug abuse. This number, which’ll also be evident in years to come, shouldn’t be underestimated. At a global level, consequences of lockdown-induced starvation, derailment of immunizations for lethal childhood diseases, and lack of proper management of tuberculosis are tremendous threats.  

SJ: In your editorial you said that the bulk of the mortality of COVID-19 was in people with limited life expectancy, rather than young people. You said “vast majority of this hecatomb would be people with limited life expectancies. That’s in contrast to 1918, when many young people died”. Some felt you were minimizing the live of the elderly. That you didn’t think that their lives were worth the economic consequences of the lockdown was because they’d be dead soon, anyway.

JPA: That’s an unfortunate misrepresentation of my position.

There is an age gradient of fatality with COVID-19. This fact has been shown in several studies. Not only is there an age gradient but a steep inflection point with age, around 70. The hazard ratios are striking. Age predicts mortality better than even comorbidities. This scientific fact can easily be hijacked by demagogues by calling people concerned about the negative consequences of the lockdown “heartless granny killers.” That isn’t helpful.

The fact that COVID-19 disproportionately affects the elderly, i.e. older people are more vulnerable, means that they need more precise and thoughtful protection. I have been advocating for more attention to and protection for elderly people, not less. Unfortunately, that’s not what happened. For instance, Andrew Cuomo, governor of New York, told hospitals to send infected nursing home residents back to their nursing homes, which was like putting out a forest fire with kerosene.  The same happened also in other states. This act alone may have caused countless deaths amongst nursing home residents. We failed to protect our most vulnerable, in part because of our “one-size-fits-all” approach. In Lombardy, there were disproportionate deaths in nursing homes. It is estimated that 45-53% of US deaths were in nursing home residents, and similar or even higher percentages were seen in several European countries.

We needed extra precautionary effort in high-risk settings such as nursing homes, prisons, meat processing plants, and homeless shelters. The corollary of having high-risk groups is that there must be low-risk groups, and low-risk people can continue working. We can’t treat everyone as “high risk” because then the high risk won’t get the extra attention and care they deserve. In our approach to controlling coronavirus we made no distinction between teenagers partying on beaches in Florida and debilitated, frail residents living in congested nursing homes in NYC. Our uniform approach was neither scientific nor safe.

COVID-19 is a virus which unmasks our social and economic fault lines.

SJ: You’ve criticized models for using faulty data in projecting the death toll. When the lockdown started there were only 60 deaths in the US. You projected 10, 000 deaths using an IFR computed from infected passengers on Diamond princess cruise ship. Yet today there more than 132, 000 deaths – the figure would likely have been even higher were it not for the social distancing/ lockdown we employed on March 16th. Though the mortality numbers are still much lower than the doomsday predictions of Imperial college, they do make your projections overly optimistic.

JPA: I never said that I knew that the death toll was going to be “10,000 deaths in the US”. How could I, in a piece where the message was “we don’t know”! The 10,000 deaths in the US projection was meant to be in the most optimistic range of the spectrum and in the same piece I also described the most pessimistic end of the spectrum, 40 million deaths. The point I wanted to emphasize was the huge uncertainty.

Now, it’s perfectly reasonable following the precautionary principle advocated by Nassim Taleb and basing our response on the worst-case forecast. But as scientists it’s not reasonable staring such huge residual uncertainty in its face and doing nothing about it. It’s our job to reduce uncertainty by collecting more robust data.

SJ: You calculated the IFR of COVID-19 using the published fatality rates in various settings. We’ll get to the methods later. For now, I want to focus on the result. By your calculation, the IFR ranged from 0.02 to 0.86 % with a median estimate of 0.26. Let’s take just one data point: NYC. There were 18, 000 deaths. Even if we assume the entire city, population of 8.3 million, was infected – a big assumption – that yields an IFR of at least 0.21 %. The lowest bound of the fatality rate of NYC is far higher than the lowest bounds of your estimate. Does this fact not challenge your calculation and the assumptions made in the calculations?

JPA: IFR is not a fixed physical property like the Avogadro’s constant.  It’s highly variable which depends as much on the virus as it does on us. Perhaps it depends even more on us than the virus. It depends how we interact with each other, how close we are to each other, who gets infected, who gets ill. As we know the virus more, we get better at dealing with it. The IFR is a shape-shifting moving target.

Which brings me to NYC. It certainly faced the infection courageously head on. Yet neither its experience nor its IFR can be generalized. At least three factors contributed to the high death toll in NYC: the disproportionate number of deaths in nursing homes because of a catastrophic policy blunder, the very compact nature of the city, particularly where the vulnerable populations live, and nosocomial spread of infection. Also, doctors were still learning how best to manage patients in the ICU and their approach to ventilatory support was probably too aggressive, in hindsight. I’m not blaming doctors. NYC was dealt a bad hand.

SJ: If the IFR is “shape-shifting moving target” – why did you labor so hard to measure it?

JPA: It’s still important knowing the mean and range, particularly if one wants to calculate the risk-benefit of different policies in different settings. We just can’t assume that the IFR of COVID-19 in NYC in April is the same as its IFR in Houston in July or the IFR of Singapore either in April or in July. Some hotbeds in NYC must have had IFR of 1% or more. Singapore has already detected 43,000 cases and had only 26 deaths, so the upper bound of its IFR is 0.06% and may be even smaller. The IFR of Houston in July is something that we can hopefully shape and decrease with precise actions. When we learn from history, when we understand the special circumstances of the past and ensure we don’t repeat the mistakes, hopefully the IFR doesn’t repeat itself.

Also, I showed in my methods of computing the IFR the huge diversity of IFR because of wide variation in seroprevalence estimates. It’s not just the final result that’s important, it’s the individual components which make the final number which are important as well.

SJ: Could you expand more on nosocomial spread of COVID-19.

JPA: Many patients were likely infected in hospitals by infected healthcare workers. This is understandably a controversial issue which people are reluctant to broach.

We don’t know the exact scale of the nosocomial spread but in several hard-hit locations it was probably not trivial. This happened because many infected healthcare workers, particularly those < 60 had no idea they were infected. Once again, it underscores how important it was understanding the extent of the asymptomatics and people with only mild symptoms to which they naturally pay no attention. They unwittingly and unknowingly infected patients.

Like nursing homes, hospitals house the most vulnerable. Only a handful of unaware infected healthcare workers would have been sufficient to allow the virus to spread and feast on patients in hospital. This happened even more prominently early in the pandemic, when precautionary measures, such as wearing personal protection equipment, weren’t universally adopted, and we had no idea how far coronavirus had spread.

Deaths are a lagging indicator of the extent of infection. By the time the first death from COVID-19 in the US was recorded, the virus had comfortably set foot in American society. By believing the virus was deadlier than it actually was, we underestimated how far it had spread, and thus allowed the virus to be more deadly than it needed have been.

SJ: You received considerable pushback for your piece. Has it changed your opinion of academic discourse?

JPA: Appearing on Fox may have infuriated some of my colleagues – but that speaks to the polarization in the US. I’m a data-driven technocrat. It’s unlikely I would fit well with “conservative ideology” (good grief)!

I welcome academic discourse and disagreement. I have no doubt that I know very little and that I make mistakes, but I am just trying to learn a bit more and to make fewer mistakes, if possible. I consider that people who criticize me with valid scientific arguments are my greatest benefactors. But the outrage propagated by social media is a force of its own, and destroys any intelligent discourse, civil or uncivil. Once the outrage gets going, platforms for academic discourse censor and the discourse just doesn’t happen. I was unable to publish my essay about nosocomial spread of COVID-19 in nursing homes and hospitals. I submitted to many outlets. I suspect the editors feared social media backlash against my raising an uncomfortable issue. Fear isn’t healthy for science.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

A Conversation with John Ioannidis published first on https://venabeahan.tumblr.com

[lyrieux-blog]

Tuesday, 25th October

Time: 13:24

-╳-         I woke up feeling very very low this morning. It can’t be helped… I really struggled to get out of bed, and when I did my mother was in some kind of strange mood. She completely ignored me even though nothing of note had been done wrong… so I simply gave up and went back to bed. She came in twenty minutes later, seemingly completely fine to ask me something about our new kittens. You see, we rescued them from a shelter and while one is completely fine, the ginger boy is going to need to have one of his eyes removed at some point. This will all be done free of charge through a certain vet which is a 40 minute drive away - none of us can drive but she had a way of getting there. So this morning she decided that she didn’t want to have to go all the way to this certain vets - and wanted to know if the shelter would somehow be able to transfer their sponsorship to our local vets. This was covered during the time the adoption went through, that it would not be able to be transferred. But, really not feeling up to argue about it today I simply said that I did not know. So she mocked me. She insulted my intelligence, she said I was useless - that she asked a simple question and I was pathetic to not be able to answer. She then huffed at me and told me to grow up with regards to me feeling really rather severely down… and that I should ‘not feel that way because she gives me everything’. Yes - she gives me anxiety; she gaslights, she abuses mentally. Half the time I don’t think she actually knows she’s doing it. But can you see? How she escalated the situation over something so simple, just to make me feel like absolute shit because I couldn’t give her what she wanted? This happens every single day; every hour, every minute. I’m not allowed to show any negative emotions because only she has the rights to do that. I have to repress everything I feel just to keep the peace - and that is so hard when my moods are absolutely everywhere anyway… I can go from happy to unbelievably depressed in less than an hour for no apparent reason and that is so difficult. I can go through cycles of varying degrees of negative and positive emotions up to 8 times a day…  that alone is exhausting. I just… I gave up again this morning. I got in the bath, which is my only way of trying to force myself to relax… but instead of doing that I harmed myself. That’s something else that has reared its ugly head again in the past few months. I have a history of self harm dating back to when I was 17… and looking back, it has always been because I don’t know what to do, I need an outlet, something… anything to take my mind away from what  my mother makes me feel… She’s always been abusive… I just didn’t recognize it up until lately… I’m struggling. I’m really, really struggling.   

[yahoocansuckmyass]

**disclaimer: if you know me in real life, if you have anything to say, just message me on Facebook or whatever, I’m not in danger of myself, just venting about everything in my life at the moment**

only posting bc there’s really no where else for me to vent about anything

i feel so empty, especially the last few days everything feels so bleak and im unable to generate any emotion other than indifference and sadness. i know it will pass and im trying to take care of myself. going to yoga, eating well and shit like that but i don’t have any motivation. jus feels like im outside of my actual body, watching myself do these things without any feeling of accomplishment or enjoyment after.

and my friends feel so far away, maybe im dissociating? i don’t feel like i can open up to anyone without a shitty response from them. best friend has always come to me in times of need but when I come to them it’s like they’re not even listening or really even grasp that im hurting my boyfriend tells me “think about something else” as if i haven’t gone through years of trying that, im not able to change like that my thoughts flip on a dime and when they do I have 2+ other voices yelling at the only part of me trying to help it feels like a minefield. i try to think that im okay and that I can do this but they teller the sound of my breathing is too loud and i get so uncomfortable in my body that i can’t fucking move. it makes me want to tear out my hair and scratch my skin off. (I’ve been self harm free for almost 2 years and these episodes get really hard to handle but at least i haven’t hurt myself other than biting my lip a bit too much on occasion)

and group therapy now costs too much and I can’t even stop by for an hour.

work doesn’t seem to value me either, i have hardly any hours and in turn no money. I’ve hardly eaten anything in the past few days.

it’s so strange being stuck in this place where im taking care of myself and doing the things i need to and still being so detached and unmotivated. it hasn’t been like this in a long time. everything feels off.

not to mention my home life is just me waking up and already being yelled at for something I don’t even know about, it’s like I could open my eyes the wrong way and get scolded for it. she asks me if im okay and I try to say what’s wrong and she reverts back to “but im hurting too” why even bother asking me if you’re going to just talk about yourself

im never being taken seriously. the only time that i think even my group therapy took me seriously is when i sliced up my arm I remember they were talking about a girl and how “brave she was for being able to show her cuts in the open and talk about them to the group” meanwhile when I talked about my cuts but never showed them, I was almost brushed off. I had cuts that I could fit my fucking hand into, and they didn’t. Even. Believe me.

now I know this post is long and jumpy and inconsistent, and I don’t really care if anyone reads it, but if you do, I’m sorry for the jumping around. I haven’t been able to talk about anything to anyone in a long time. at least not really, not without the making it a competition and telling me it could be worse or saying some people have REAL problems as if my brain doesn’t tell me to drive off the road or cut a vein and bleed out or drown myself in the lake out back.

though I don’t harm myself, though I can keep it together and appear so happy and fine, I still think of suicide every day and it hurts to think about all of the people I’d destroy. and as reassurance, no i won’t kill myself. im not going to let my progress end like that, i know I have good things in my life, im just going through a hard time. high functioning mental illness is something else man.

the past few days have left me so out of it especially. they’ve been the worst. Saturday was a decent day up until my mom left to go out for the night. I was left alone with my thoughts, and then those thoughts blurred out into nothing. just alone. no energy. no motivation. no one to talk to. just emptiness. I walked from room to room without a sound, just to lay down and stare at a wall or ceiling for an hour at a time. I didn’t eat, didn’t sleep. just was there. finally i got up and just fucking bawled my eyes out, thoughts of suicide and self harm bombarded me, I felt so fucking depressed it was like a tidal wave was trying to drown any ounce of sanity i had left. some scars I had forgotten about found their way back to the surface of my neck and boy for some reason that fucked me up, i forgot I even cut my neck, it brought back that sharp hot pain and all the sensations that run through your body. it was terrible, I couldn’t stop thinking about it. and finally I reached out to my cousin, though she had plans, she offered to come get me and hang out at my place with her friend and boyfriend and thank fucking god i did, I would’ve been a mess if she hadn’t. im glad I didn’t try to cancel on her either. my boyfriend was supposed to stay over but ended up cancelling that night too. and he was supposed to come over today. slept through us hanging out. people tend to treat my schedule as if it’s something they can erase and write in a later time or date with no consequences. and gaslight me for being upset about it. All I ever ask for is communication, that’s it. Talk to me, I won’t be upset, but if you lie to me, that’s a slap in the face. I don’t understand how I can literally tell you “it’s fine if you don’t want to hang out or talk, but you need to let me know asap so I can adjust my plans” and you still lie to my face or just disregard me completely. I’ve had people tell me 10 minutes before I’m supposed to get them “nah sorry fam” and that’s it. Only to find out they made better plans and are posting about it all over the place.

it’s fucking shitty. everything has been shitty. I can’t afford food or anything for that matter, my friends aren’t really even there, my boyfriends always busy doing whatever he does, my mom doesn’t listen to a damn word I have to say, my work doesn’t feel like home anymore (I used to LOVE going to work and getting to make people feel beautiful and talk about new shit and now it feels like a chore, I’m not treated like a valued employee anymore rather than disposable).

all i can do is continue to exist in this cycle of high function dissociation.

next topic on miahs 5 years of nothing talked about post: self love vs self hatred

as i said before, im actually taking care of myself. I’ve had hip bursitis for years now that has turned me into a borderline cripple with excruciating pain at almost all times of the day, and this is another thing that people don’t take seriously. my mom calls me a hypochondriac and that it’s not that bad, everyone just…dismisses it i guess? regardless, this is a thing that’s impaired me during my daily life and it’s only added on to the various health issues that make it hard to feel healthy and love my body.

I’ve always been critical of myself, specifically my appearance. I’ve made lists of things I hate about myself. I’ve had people contribute to this, but it’s not anyone’s fault that I did the things I did to myself except my own. 3 years ago I graduated high school at my highest weight and met a person who would end up being my inspiration to losing weight the wrong ways. we were both entirely toxic to each other and I ended up using laxatives and throwing up, and not eating and working out excessively to lose 70lbs in less than 6 months. the only problem is that I didn’t see a change in my weight, i felt like I was just as fat, just as disgusting as when I started. it was obsessive for me to lose weight. and everyone congratulated me on the success I’ve had. until cosmetology school where I ended up gaining all of it back due to lack of time for exercise and heavy depression and my hip problems. (also congrats if you’re still reading this, im not entirely sure when ill stop writing) i felt like I failed myself, and every time I tried to adjust my diet I’d just end up not eating and it scared me, I didn’t want to be back to that place. I didn’t want to feel like that again. (Today, I’m actually doing well with my diet and sticking to it in baby steps so I don’t overwhelm myself) granted I still feel guilty every time a crumb of food enters my mouth, I have this weird paranoia that everyone is watching when I eat and that all they think is that I’m fat and of course I’d be eating now. and that’s why I can’t be the only one who eats when I’m with friends, everyone needs to eat so I don’t feel so disgusting I guess?

the few months after I stopped cutting and shit were hard but i was in a pretty good mind set, I think January 2016 was the best I’ve ever been, but as expected it didn’t last. and don’t get me wrong, i cherish the fuck out of the good times I have in my life, I’m not some dick that dismisses all of the good things and just says im a basket case with no hope or friends. I love the people in my life with all of my heart, and I love the good times we have and the good things that happen. but I’ve never been able to discuss and move past all of the bad things. it seems like I’m being told to just push it back farther and farther because they don’t want to have to deal with it right now. and i could be wrong, and for some of those people I am wrong. but again, their responses to whenever I do open up are disheartening, and some don’t mean to come off that way but it persists. which makes me question why do I even bother. see, this a good platform for me to vent because it’s just that, I don’t need anyone to reply and say sorry or tell me I’m wrong, it’s just here and I got it out. that’s all I’ve been trying to do.

I’ve really never wanted any advice, i know what I need to do and what’s right and what’s wrong, its an ongoing battle for me, and I just needed someone to listen. and that never happened, there was always competitive comparisons, always criticism, always gaslighting, always dismissive. And maybe it’s because when I actually try to TALK, I freeze up and can’t say what I need to in the right way. but still! More than half the time I open up, I just get more reasons to shut back down. back to self love and shit (sorry), I’m trying to love myself despite what it sounds like. just because a big part of me only holds dislike for myself, doesn’t mean there isn’t a part that just wants to love. it’s just been years of these expectations and standards forced down my throat to the point where quite honestly, I’m fucking confused I’m damned if I do and damned if I don’t

I’m not gonna get into relationships for the soul fact that I could go on for days about them and this is post is way longer than I anticipated already SO. That’ll be another day (probably tonight since I’m to the point of just not giving a fuck and dishing out every emotion I’ve felt in the last 5 years)

and again back to self love, lately, i don’t weigh myself because I know that if I do, I’ll get depressed and obsessive again and I really can’t deal with it now. I hate my stomach first and foremost. that’s literally the main thing that I just want to cut off my fucking body. i half the time can’t even look at myself because I’ll just get stuck in one of those fuck you miah states. and to address something real *quick*, I don’t need the, “well stop complaining and do something about it” BITCH I AM. I am actually doing everything for it!! but my shitty brain doesn’t let me see progress, for all i know I could have lost 30 lbs and still think I look exactly the same (and part of the reason why I chose yoga was because it all stems from your core so it’s always engaged…and it’s hot yoga so I sweat out at least a pound every time I go, and I went every day last week) i dunno why I can never see positive changes, but when I lost all that weight back in 2014, I didn’t even go down a bra size, let alone pant size and that really fucked me up. It was weird having people compliment me and say how good i looked but still felt the same size. I don’t get it, I could see the numbers go down but my eyes never saw a damn change on myself. Imagine losing 100lbs and still being the same pant size. And I did think we’ll maybe it’s because I still hated myself and was losing weight in an u healthy way but even now with me doin all these great things for my body, I see no change at all. I jus wanna be healthy now, not skinny.

^^talking about my body is my least favorite thing to do so if you have anything to say about it please just don’t, I’m jus here to get this shit off my chest.

I think im just about done, currently brainstorming to see if I missed anything or if I want to touch back on certain things. All that’s left I think is relationships?? So maybe I will write a bit about it? ….I wrote about it then deleted all of it because without going into brutal detail there’s no reason for it to be shoved into this.

I’m pretty sure I’m finished, I may or may not ever check back in here to update or whatever. I guess we’ll see.

If you made it to the end, congrats you spent 15 to 25 minutes reading an absolute mess of a post. Hopefully you could keep up with all my jumping around.

[kristinsimmons]

A Conversation with John Ioannidis

By SAURABH JHA, MD

The COVID-19 pandemic has been a testing time for the already testy academic discourse. Decisions have had to be made with partial information. Information has come in drizzles, showers and downpours. The velocity with which new information has arrived has outstripped our ability to make sense of it. On top of that, the science has been politicized in a polarized country with a polarizing president at its helm.

As the country awoke to an unprecedented economic lockdown in the middle of March, John Ioannidis, professor of epidemiology at Stanford University and one of the most cited physician scientists who practically invented “metaresearch”, questioned the lockdown and wondered if we might cause more harm than good in trying to control coronavirus. What would normally pass for skepticism in the midst of uncertainty of a novel virus became tinder in the social media outrage fire.

Ioannidis was likened to the discredited anti-vax doctor, Andrew Wakefield. His colleagues in epidemiology could barely contain their disgust, which ranged from visceral disappointment – the sort one feels when their gifted child has lost their way in college, to deep anger. He was accused of misunderstanding risk, misunderstanding statistics, and cherry picking data to prove his point.

The pushback was partly a testament to the stature of Ioannidis, whose skepticism could have weakened the resoluteness with which people complied with the lockdown. Some academics defended him, or rather defended the need for a contrarian voice like his. The conservative media lauded him.

In this pandemic, where we have learnt as much about ourselves as we have about the virus, understanding the pushback to Ioannidis is critical to understanding how academic discourse shapes public’s perception of public policy.

Saurabh Jha (SJ): On March 17th, at the start of the lockdown, you wrote in STAT News cautioning us against overreacting to COVID-19. You likened our response to an elephant accidentally jumping off a cliff because it was attacked by a house cat. The lockdown had just begun. What motivated you to write that editorial?

John P.A. Ioannidis (JPA): March seems a long time ago. I should explain my thinking in the early days of the COVID-19 pandemic. Like many, I saw a train approaching. Like many, I couldn’t sense the train’s precise size and speed. Many said we should be bracing for a calamity and in many ways I agreed. But I was concerned that we might inflict undue damage, what I’d call “iatrogenic harm”, controlling the pandemic.

To answer your question specifically, I wrote the piece because I felt that the touted fatality rate of COVID-19 of 3.4 % was inflated, but we had so limited data and so much uncertainty that infection fatality rate values as different as 0.05% and 1% were clearly still possible. I was pleading for better data on COVID-19 to make our response more precise and proportionate.

SJ: We now know that the infection fatality rate (IFR) is much lower than 3.4 %.  I’m curious – why did you doubt this figure? At the time, the virus created havoc in Iran and Italy. Hospitals in the richest areas in Italy rationed ventilators. Was a fatality rate of 3.4 % so implausible?

JPA: Small changes in the fatality rate make a dramatic difference in the number of deaths. 3.4 % is an entirely different universe from 0.5 %. Imperial College epidemiologists, using an overall IFR of 0.9 %, assumed that if 60-80 % of the population were infected, as would happen without precaution or immunity, 2.2 million Americans would die.

I’m a physician and epidemiologist with a fellowship training in infectious diseases. Though I felt that COVID-19 was a serious threat, I didn’t think it was Spanish Flu redux. COVID-19 wasn’t behaving like a “3.4 % fatality rate” pandemic. I doubted that widely quoted fatality rate, which is what the Chinese public health authorities told the WHO, because by March it was apparent that COVID-19 infection comprised a clinical spectrum, ranging from mild symptoms which could be managed at home, to severe lung disease which needed ventilatory support. The crucial piece of the epidemiological puzzle was the number of people who were infected but didn’t know they were infected because they had no, or very minimal, symptoms.

The presence of asymptomatic and mildly symptomatic people who are not detected changes the shape of the pandemic and should change our response to it, too. For starters, it means that the infection fatality rate – the fatality rate amongst the infected – will, by definition, be lower than the case fatality rate (CFR) – the fatality rate amongst known symptomatic people who get tested.

The second implication is that the infection is more contagious and has spread further than what we believe, which makes testing, tracking, and isolating infected people more challenging. Testing remains important but each day we delay rolling out mass testing, testing becomes less efficacious, and even less so when there are so many asymptomatics or people with mild symptoms who won’t seek testing.

Figuring the true IFR of a virus isn’t some petty academic musing. To be clear, distinguishing between IFR and CFR for a virus like Ebola is silly because its CFR is about 50 %. But when the CFR of a virus is less than 5 %, we must ask– what’s the true IFR? Does the CFR diverge much from the IFR? How many asymptomatic carriers of the virus are there?

SJ: Few would argue against better data. But decisions must be made with the data we have rather than the data we wish we had. The consequences of a delay in acting because we wait for better data can only be guessed, rather than proven, at the time. Nevertheless, inaction has consequences. Some felt that you were advocating that we do nothing in the pandemic until we obtained data robust enough to design policy.

JPA: That wasn’t my position, though I can see why people thought I was advocating inaction when I was actually asking, begging actually, for better data to inform our actions. The two – decisions and knowledge – aren’t mutually exclusive. We can design policy on imperfect information yet keep gathering evidence so that our approach is fine tuned. A decision such as an economic lockdown should be assumed provisional, awaiting more research and better information. Of course, we can’t know everything there is to know about a novel virus in the beginning. Inaction is a false choice. What we’re choosing between is an immutable decision and a decision updated by emerging evidence, rather than between inaction and gathering evidence.

SJ: Let me ask you, frankly. Did you support the lockdown?

JPA: Let me answer, frankly. Yes. But only as a temporary measure.

SJ: So, you’re not against locking down the economy?

JPA: By February, we missed the window for nipping the novel coronavirus in the bud. Had we acted earlier, with aggressive testing, tracing, and isolating, like the South Koreans, the Taiwanese and the Singaporeans did, the virus wouldn’t have spread as wildly as it did. The biggest lesson from this pandemic is that the costs of delaying controlling the infection can be substantial. Act decisively in haste or repent at leisure.

Once we missed the boat, the lockdown was inevitable. I say “inevitable” grudgingly because I don’t think it should have reached that eventuality.

SJ: The situation would certainly have been different had the extent of the spread been identified in January, and the infection was controlled. If I understand you correctly, given our situation in March, as avoidable as it could have been, and our state of knowledge at that time, you supported the lockdown.

JPA: That’s correct.

Once the country was locked down, I felt we should be focusing in minimizing its duration. I view “lockdown” as a drug with dangerous side effects when its use is prolonged. It’s an extreme measure – a last resort, the nuclear option.

A country should be locked down not a minute longer than absolutely necessary. We have to keep assessing its risk-benefit calculus, by collecting and analyzing data, making sure we’re measuring the denominator accurately, and finding vulnerable and not vulnerable sub-groups.

SJ: I don’t mean to play “gotcha.” But isn’t what you’re saying contradictory? You didn’t believe that COVID-19 was a “3.4 % fatality rate” pandemic but you also supported the lockdown, which you, rightly, call an “extreme” measure.

JPA: If the fatality rate were truly 3.4 %, I’d have myself tied like Ulysses did, perhaps to my refrigerator to avoid ever getting out of my house. I’d want an even stricter lockdown.  One of the challenges in science communication is downgrading the threat of an infection, which you believe is inflated, without making it sound harmless. That I didn’t think that COVID-19 was that dangerous didn’t mean that I thought it was harmless.

SJ: But you compared COVID-19 to the flu. That comparison irked many doctors, particularly those in the frontline, who felt they were being gaslighted. Doctors from Lombardy, New York City (NYC), Seattle were seeing jam packed ICUs, high mortality rates in the ICU, multi-organ failure, and ventilator shortages. They were overwhelmed. They had never seen so much carnage caused by an infection, certainly not by the flu. Surely, we don’t need the denominator to figure out that COVID-19 isn’t just the flu. Surely, the numerator speaks for itself.

JPA: When conveying the severity of a novel virus, it’s useful anchoring to past infections for perspective. The seasonal flu is a natural choice for comparison. I agree “just the flu” sounds dismissive, even insulting to healthcare workers, because it sounds like the common cold. The seasonal flu isn’t “just the flu” either. It actually kills 350, 000 to 700, 000 people a year worldwide. In the USA it kills 30,000 to 70,000 people per year, and would kill even more if we didn’t vaccinate healthcare workers and half the population.

I don’t think comparing COVID-19 to the seasonal flu is unscientific, but that comparison must be nuanced. COVID-19 is a strange beast. It’s way more dangerous than the flu in the elderly and in those with comorbidities. Yet the flu is more dangerous than COVID-19 in children and young adults, even allowing for the fact that COVID-19 causes Kawasaki-disease-like syndrome in some children. Again, we face a communication challenge – how do we convey the severity of a virus which is both more dangerous and less dangerous than the flu? If I emphasize the less vulnerable group, I’ll be accused of being flippant about the virus. Yet if I focus only on its devastation in the most vulnerable group, I’m not painting the true picture.

Even though I spent lot of effort nailing the precise IFR of COVID-19, any single number IFR is misleading, because the average fatality rate hides the heterogeneity of risk. Once we figure out that the virus, on average, isn’t as bad as we thought, the next step is identifying the low-risk and the high-risk, i.e. risk stratifying.

SJ: I’m going to challenge the mortality statistics of the seasonal flu you have quoted, which are widely quoted, and was quoted by Donald Trump, too – though its source isn’t fake news but the CDC. Aren’t these figures an estimation or projection? And isn’t it true that the deaths attributable to COVID-19 is derived more from direct counting than from an estimation and, therefore, likely to be more accurate?

JPA: It’s true that mortality of seasonal flu is an estimation. But this estimation isn’t science fiction. It’s derived from sound scientific principles. The data on seasonal flu (flu-like illnesses) is robust. We know much more about the seasonal flu than COVID-19.

Now, your point that we’re literally counting, as opposed to estimating, deaths from coronavirus is correct. But I’ll push back that this may not yield mortality figures as accurately as people think. Because of the attention on coronavirus, we’re better at knowing that a deceased person had coronavirus than had the flu. This means we’re good at knowing when someone died with coronavirus – but not necessarily that they died from the infection. We assume that dying with coronavirus is dying from coronavirus.

SJ: But many have died in their homes with no documentation of being infected. We have assumed that dying without documented coronavirus is not dying from coronavirus. Surely, misattribution of deaths to coronavirus works in both directions.

JPA: I agree. Which is why we need better data to understand this virus better. One point I want to emphasize – the misattribution is paradoxically greatest in the group most vulnerable to coronavirus, i.e. those with limited life expectancy. This group is most likely to die from COVID-19. Because of their limited life expectancy, this group is also likely to die from their non-COVID morbidities.

One way to better measure the impact of COVID-19 is measuring excess deaths, which is the death rate beyond what one usually encounters annually. Excess deaths comprise several groups – e.g. people killed by COVID-19 infection and people who have died because they didn’t receive timely care because they were afraid to go to the hospital, or because healthcare resources were focused on COVID-19 patients. The magnitude of the latter group will be more evident in years to come. Another group are deaths caused by the social and economic consequences of the lockdown, such as from suicides and alcohol and drug abuse. This number, which’ll also be evident in years to come, shouldn’t be underestimated. At a global level, consequences of lockdown-induced starvation, derailment of immunizations for lethal childhood diseases, and lack of proper management of tuberculosis are tremendous threats.  

SJ: In your editorial you said that the bulk of the mortality of COVID-19 was in people with limited life expectancy, rather than young people. You said “vast majority of this hecatomb would be people with limited life expectancies. That’s in contrast to 1918, when many young people died”. Some felt you were minimizing the live of the elderly. That you didn’t think that their lives were worth the economic consequences of the lockdown was because they’d be dead soon, anyway.

JPA: That’s an unfortunate misrepresentation of my position.

There is an age gradient of fatality with COVID-19. This fact has been shown in several studies. Not only is there an age gradient but a steep inflection point with age, around 70. The hazard ratios are striking. Age predicts mortality better than even comorbidities. This scientific fact can easily be hijacked by demagogues by calling people concerned about the negative consequences of the lockdown “heartless granny killers.” That isn’t helpful.

The fact that COVID-19 disproportionately affects the elderly, i.e. older people are more vulnerable, means that they need more precise and thoughtful protection. I have been advocating for more attention to and protection for elderly people, not less. Unfortunately, that’s not what happened. For instance, Andrew Cuomo, governor of New York, told hospitals to send infected nursing home residents back to their nursing homes, which was like putting out a forest fire with kerosene.  The same happened also in other states. This act alone may have caused countless deaths amongst nursing home residents. We failed to protect our most vulnerable, in part because of our “one-size-fits-all” approach. In Lombardy, there were disproportionate deaths in nursing homes. It is estimated that 45-53% of US deaths were in nursing home residents, and similar or even higher percentages were seen in several European countries.

We needed extra precautionary effort in high-risk settings such as nursing homes, prisons, meat processing plants, and homeless shelters. The corollary of having high-risk groups is that there must be low-risk groups, and low-risk people can continue working. We can’t treat everyone as “high risk” because then the high risk won’t get the extra attention and care they deserve. In our approach to controlling coronavirus we made no distinction between teenagers partying on beaches in Florida and debilitated, frail residents living in congested nursing homes in NYC. Our uniform approach was neither scientific nor safe.

COVID-19 is a virus which unmasks our social and economic fault lines.

SJ: You’ve criticized models for using faulty data in projecting the death toll. When the lockdown started there were only 60 deaths in the US. You projected 10, 000 deaths using an IFR computed from infected passengers on Diamond princess cruise ship. Yet today there more than 132, 000 deaths – the figure would likely have been even higher were it not for the social distancing/ lockdown we employed on March 16th. Though the mortality numbers are still much lower than the doomsday predictions of Imperial college, they do make your projections overly optimistic.

JPA: I never said that I knew that the death toll was going to be “10,000 deaths in the US”. How could I, in a piece where the message was “we don’t know”! The 10,000 deaths in the US projection was meant to be in the most optimistic range of the spectrum and in the same piece I also described the most pessimistic end of the spectrum, 40 million deaths. The point I wanted to emphasize was the huge uncertainty.

Now, it’s perfectly reasonable following the precautionary principle advocated by Nassim Taleb and basing our response on the worst-case forecast. But as scientists it’s not reasonable staring such huge residual uncertainty in its face and doing nothing about it. It’s our job to reduce uncertainty by collecting more robust data.

SJ: You calculated the IFR of COVID-19 using the published fatality rates in various settings. We’ll get to the methods later. For now, I want to focus on the result. By your calculation, the IFR ranged from 0.02 to 0.86 % with a median estimate of 0.26. Let’s take just one data point: NYC. There were 18, 000 deaths. Even if we assume the entire city, population of 8.3 million, was infected – a big assumption – that yields an IFR of at least 0.21 %. The lowest bound of the fatality rate of NYC is far higher than the lowest bounds of your estimate. Does this fact not challenge your calculation and the assumptions made in the calculations?

JPA: IFR is not a fixed physical property like the Avogadro’s constant.  It’s highly variable which depends as much on the virus as it does on us. Perhaps it depends even more on us than the virus. It depends how we interact with each other, how close we are to each other, who gets infected, who gets ill. As we know the virus more, we get better at dealing with it. The IFR is a shape-shifting moving target.

Which brings me to NYC. It certainly faced the infection courageously head on. Yet neither its experience nor its IFR can be generalized. At least three factors contributed to the high death toll in NYC: the disproportionate number of deaths in nursing homes because of a catastrophic policy blunder, the very compact nature of the city, particularly where the vulnerable populations live, and nosocomial spread of infection. Also, doctors were still learning how best to manage patients in the ICU and their approach to ventilatory support was probably too aggressive, in hindsight. I’m not blaming doctors. NYC was dealt a bad hand.

SJ: If the IFR is “shape-shifting moving target” – why did you labor so hard to measure it?

JPA: It’s still important knowing the mean and range, particularly if one wants to calculate the risk-benefit of different policies in different settings. We just can’t assume that the IFR of COVID-19 in NYC in April is the same as its IFR in Houston in July or the IFR of Singapore either in April or in July. Some hotbeds in NYC must have had IFR of 1% or more. Singapore has already detected 43,000 cases and had only 26 deaths, so the upper bound of its IFR is 0.06% and may be even smaller. The IFR of Houston in July is something that we can hopefully shape and decrease with precise actions. When we learn from history, when we understand the special circumstances of the past and ensure we don’t repeat the mistakes, hopefully the IFR doesn’t repeat itself.

Also, I showed in my methods of computing the IFR the huge diversity of IFR because of wide variation in seroprevalence estimates. It’s not just the final result that’s important, it’s the individual components which make the final number which are important as well.

SJ: Could you expand more on nosocomial spread of COVID-19.

JPA: Many patients were likely infected in hospitals by infected healthcare workers. This is understandably a controversial issue which people are reluctant to broach.

We don’t know the exact scale of the nosocomial spread but in several hard-hit locations it was probably not trivial. This happened because many infected healthcare workers, particularly those < 60 had no idea they were infected. Once again, it underscores how important it was understanding the extent of the asymptomatics and people with only mild symptoms to which they naturally pay no attention. They unwittingly and unknowingly infected patients.

Like nursing homes, hospitals house the most vulnerable. Only a handful of unaware infected healthcare workers would have been sufficient to allow the virus to spread and feast on patients in hospital. This happened even more prominently early in the pandemic, when precautionary measures, such as wearing personal protection equipment, weren’t universally adopted, and we had no idea how far coronavirus had spread.

Deaths are a lagging indicator of the extent of infection. By the time the first death from COVID-19 in the US was recorded, the virus had comfortably set foot in American society. By believing the virus was deadlier than it actually was, we underestimated how far it had spread, and thus allowed the virus to be more deadly than it needed have been.

SJ: You received considerable pushback for your piece. Has it changed your opinion of academic discourse?

JPA: Appearing on Fox may have infuriated some of my colleagues – but that speaks to the polarization in the US. I’m a data-driven technocrat. It’s unlikely I would fit well with “conservative ideology” (good grief)!

I welcome academic discourse and disagreement. I have no doubt that I know very little and that I make mistakes, but I am just trying to learn a bit more and to make fewer mistakes, if possible. I consider that people who criticize me with valid scientific arguments are my greatest benefactors. But the outrage propagated by social media is a force of its own, and destroys any intelligent discourse, civil or uncivil. Once the outrage gets going, platforms for academic discourse censor and the discourse just doesn’t happen. I was unable to publish my essay about nosocomial spread of COVID-19 in nursing homes and hospitals. I submitted to many outlets. I suspect the editors feared social media backlash against my raising an uncomfortable issue. Fear isn’t healthy for science.

Saurabh Jha is an associate editor of THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner.

A Conversation with John Ioannidis published first on https://wittooth.tumblr.com/