Dr. Andrew Foy stands out as the only cardiologist/boxing promoter in America, and because his specialty is research — “critical appraisal,” meaning he does meta research, or research on research — he seemed as appropriate a guest as one could want on a boxing podcast, because fight fans want to know when the fight game can return from the pandemic.
“I am part of the public school public health at Penn State,” Foy told me during a hit on the Everlast “Talkbox” podcast. “So I do have a significant interest in this. I don’t consider myself an expert necessarily because I don’t really think there are any true experts yet when it comes to coronavirus; there are people that have expertise in certain areas that are applicable to to pathogens spread within a population, but there’s nobody that is truly at this point an expert yet on coronavirus, despite the confidence that some people may have when they’re on television. I’ve seen this sort of false confidence from people on all sides of the spectrum, to be quite honest with you, so I don’t want to give the impression that I think I’m an expert on COVID.”
The virus leapt onto Foy’s radar when he and Kings Promotions partner Marshall Kauffman had their March 14 event in Bethlehem, Penn., shut down the day before, though the weigh-ins had already occurred.
“It was kind of an acutely painful process for me, and that even increased my interest in it,” Foy said. “Since then I’ve been pretty heavily invested in understanding it from multiple standpoints. I still do patient care, not as much as many physicians because I do a lot of research and teaching, as well. I want to have some sort of anticipation on when things might be able to to re-open, and I’ve said from the get-go, I think that sporting events are going to be the last thing just because it tends to be the perfect environment for the spreading of an infection. If this virus is turns out to be as dangerous as people think and potentially as overwhelming to healthcare systems as people think, then sporting events will certainly be the last thing to reopen.”
Now, here’s the thing. How you view coronavirus probably has a good deal to do with where you live. I’m in Brooklyn — nowhere have more people died from COVID than in that borough. New York, New Jersey, Connecticut, Massachusetts, Louisiana and Michigan, among others, have been walloped hard. Parts of Pennsylvania have, but in clustered zones, like in Philadelphia, rather than where Foy lives. It almost goes without saying, but shouldn’t, that sometimes all of us tend to forget that everyone is looking through a different lens. A person in New York probably tends to look at coronavirus as a ruthless assassin more so than someone in Wyoming, where about 12 people have died, per one million residents. I asked Foy to give me his take on how nasty he thinks coronavirus is.
“The initial reports on what is the fatality rate of the infection were strikingly high,” he said. “So they were in the range of three to 10 percent, depending on the reports and even in a column that I wrote for NYFights fairly early on, I was willing to at least put my nickel down and say those numbers were going to be (overblown), the question was going to be by how many orders of magnitude high, and we’re coming to find that that it’s about 10, 50, to 100 orders of magnitude too high.
“So with the studies that have been ongoing in different areas of the country where they test people for antibodies, which tell us if people have been in been infected at some point and started to develop immunity, we’re finding prevalence rates that drops the number on the infection fatality rate somewhere in the ballpark of 0.12%. And for some reference range, seasonal influenza is 0.10%. So this could still be, relatively speaking, much more deadly than something like the seasonal flu, but not to the degree that many ‘experts’ are asserting.”
We’ve seen the guesstimate that COVID is maybe 10 times as deadly as typical influenza. “That’s too high,” Foy said. “I think at most it’s going to be three to five (times as deadly as flu), and I still think there’s a chance it ends up being the same.”
A Live Science story from April 30th touched on the fatality rate.
“Among reported COVID-19 cases in the U.S., nearly 6% have died. This is what’s known as the case fatality rate, which is determined by dividing the number of deaths by the total number of confirmed cases. But the case fatality rate is limited for a few reasons. First, not everyone with COVID-19 is being diagnosed with the disease — this is in part due to testing limitations in the U.S. and the fact that people who experience mild or moderate symptoms may not be eligible for or seek out testing. As the number of confirmed cases goes up, the fatality rate may decrease. Researchers from Columbia University recently estimated that only 1 in 12 cases of COVID-19 in the U.S. are documented, which they said would translate to an infection fatality rate of about 0.6%, according to The Washington Post. But even this lower estimate is still at least six times higher than that of the flu. The case fatality rate in people who become sick with flu may be 0.1%, but when you account for people who become infected with flu but never show symptoms, the death rate will be half or even a quarter of that, the Post reported.”
All in all, Foy has been monitoring the messaging and reporting, and no, he’s not overly impressed with the quality of info being dispensed by some people presented on TV or print as “experts.”
“The messaging in regard to this has been really botched,” Foy said. “And so when it comes to the purpose of the self-isolation in the first place and the shutting down of the economy, whatever people want to call it, the lockdown — the theoretical purpose of that is to flatten the curve. I think people have heard that term while maybe not understanding what it actually means.
“It does not mean eradicate the virus from the population. What it means is reducing the peak of infections, so you do not overwhelm healthcare systems, and end up with an excess of potentially preventable deaths. There’s going to be an unavoidable death toll from coronavirus because the infection fatality rate is the infection fatality rate. And even though we haven’t zeroed in on what that is yet, let’s just agree, it’s 0.10% to 1%. So somewhere between one and 10, to one in 1,000 people that get it will pass away from it.
“But here’s the other reality: even if we flatten the curve, we don’t eradicate it, because we don’t have herd immunity yet within the population, we don’t have a vaccine; we’re not going to get one for 12 to 18 months. So when you flatten the curve, still at some point you have to return to life and unless you have a vaccine or cure, the number of people that were going to get the infection are still going to get the infection, and it actually is going to be a little more than it would be if you just did it all at once and got the herd immunity that people talk about, which I don’t think they truly understand when they talk about it.”
Foy isn’t giving the US response to the virus a high mark.
“By doing this we’ve actually extended the amount of time where people are going to continue to get infected and we’ve not actually reduced the area under the curve. We just change the dimension of the curve. So I think yeah, we should anticipate that in places that open up there will be continuing cases of coronavirus infection,” said Foy.
“There will be continued hospitalizations, and there will be continuing deaths at whatever the rate of the infection fatality rate is now.”
Every place isn’t New Yoek, of course, so it makes sense that all regions will be smart to evaluate their handling of the response to the presence of the virus.
“There’s very special things about New York City that made it the hub that it’s become for coronavirus. It’s one of the top traveled cities in the world, and public transit is used (so heavily),” Foy said. “There’s things about the population density, the crowding in New York City, the public transit, the makeup of the population relative to the hospitals that are caring for those people, and it’s very predictable that New York City would be hit hard and probably harder than anywhere else in the country.”
So, who dropped the ball? President Trump? Governor Cuomo?
“I don’t think that there’s really any country around the world that can really truly be accused of dropping the ball on this, because we didn’t know and we didn’t know early, and when people talk about how about we could have done testing and contact tracing,” Foy said, his voice trailing off, as he indicated that, basically, many people are Rhodes Scholars with the benefit of hindsight.
So what if testing ramps up and we get humming, so that everyone who wants a test can be tested?
“The specifics of COVID are really not going to lend itself very well to the mass testing and contact tracing. We know that the majority of people that get this don’t have severe symptoms,” Foy told me. “We know that they’re spreading the virus, as are people who are asymptomatic, at least we think we know that, and so what you have to do is you have to carry out mass surveillance testing of just normal people all the time.
“There’s some infections that lend themselves to testing and contact tracing because people get really sick really fast and there’s no mistaking it, and it also doesn’t necessarily have some of these characteristics of asymptomatic spreading. There’s a whole lot of things about this virus that make it the perfect storm in some ways. The fact that the severity was not tremendous in the majority of people that get it make it quite difficult to detect as a result of that. I don’t think there’s been any countries that have really avoided it.”
Foy is not as inclined to shout about mismanagement of the virus, especially as it was in the “impending” category. Me? Too many stories about docs and nurses having to re-use masks and gowns piss me off. We really can’t be boasting about being an exceptional nation when, as the wealthiest nation in the world, two months after it is clear the virus is coming, there aren’t enough masks for people battling the respiratory virus. Supplies and PPEs weren’t ordered by the federal government until mid-March? That is a bad ball drop, to me.
Foy isn’t of the same mind.
“I guess I’m not fully on board with that and I can only speak for myself and say that,” he told me. “At the beginning of this crisis a lot of people may recall there was actually tremendous debate about the merits of PPE or wearing a mask and who should wear a mask and when they should wear a mask and, you know, our current rules now that everybody needs to wear a mask when they go out in public. I mean it might surprise you to hear these were pulled out of our ass. I can tell you before this crisis most healthcare workers didn’t personally take PPEs very seriously.
“I’m trying to say this in a way that I don’t want to offend anybody. But if you were to ask the average healthcare worker before COVID-19, ‘Do we have enough PPE in hospitals and do we have enough guidelines about it?’ And I predict that nine out of 10 would say we have too much of that shit, and I’m so annoyed at all the guidelines about how often I have to wear it, and for what purpose?”
Of course, he’s heard plenty of anecdotes about shortages, but demands rigorous standards in data collection — he wants dug down research before he can really confidently weigh in.
Foy works in Dauphin County, Penn., where they’ve been OK with PPEs, and so he gets nervous, he says, about making too much out of anecdotal reports.
“And as a lesson, I think anecdotal reports on the fatality of this have been one of the biggest areas that have misled when it comes to this whole thing. So I just don’t want to speak too much on that because I haven’t seen much systematic reporting on it. I worry that these type of stories (touch) people’s heart strings and then can become very easily politicized, and I’m not saying it’s wrong, I’m just saying I don’t have enough information to (make an informed call.)”
Foy isn’t inclined to second guess Trump and company, even though I threw him softballs that he could have hit out of all the parks. Full disclosure: I get irked, hard, that there was ample information made available to the President in January, and US intelligence got wind of the virus in China in November, and this administration hasn’t shown us all that they took it seriously until much later than “better safe than sorry types” would have.
From an NBC report April 9:
“Even after public health authorities began sounding the alarm in January, the U.S. took few steps to ready itself for a pandemic. There was no effort to boost national stockpiles of medical equipment or encourage social distancing, for example. While Trump touts his decision to stop flights from China coming to the U.S. on Jan. 31, about 381,000 people had flown from China to the U.S. in January, according to an analysis by The New York Times.”
Trump’s repeated references to the defense stockpile against such a virus being almost non-existent defy published accounts on the contrary, and, to me, constitute a strong case that his behavior left this nation’s citizens at a deficit.
My friend Dr. Foy and I aren’t on the same page across the board, it’s clear. To me, this info screams malfeasance, while Foy is looking to give the virus credit for being a more than solid adversary.
“It’s going to make its way through (much of the nation, especially dense zones) unless you isolate indefinitely,” he said. ”So the thought experiment is, absent isolating earlier, and maintaining it until we have a vaccine or cure, what would the approach actually have been? And so what people will tell you is we needed more testing and contact tracing, but I also told you earlier that the testing and contact tracing is a bit of magical thinking at this point, because this virus is well-suited to evade the testing and contact tracing approach.
“We also have to acknowledge, we live in a really large country and carrying out asymptomatic surveillance testing on 100 percent of the population is not feasible. And then how often are you going to do it? You do it every day and do it every week, every month and have people pricking themselves like diabetics do for blood sugar, I tell you right now, a lot of people aren’t going to do that if they feel fine and aren’t sick.”
He repeats, to cement the point, that some of the critiquing and such is basically a “thought experiment.”
“I don’t think you can blame policy leaders, in my opinion, really across the world for that,” he continued. “I don’t even know that you can blame people in China for that. I mean, it’s a new infection. So what what could their response have been, and is it reality to think that absent a vaccine, absent a cure we can do anything to alter what’s going to be the natural history of this virus? Which is that the virus will spread and it’s going to have the infection fatality rate that it has.”
Foy gets heavy credit for his stance on how we all should process his takes.
“I would caution you from thinking that whatever I’m saying is the truth,” he declared. “I think that the verdict is still out on some of this stuff. What the verdict is not out on is that the infection fatality rate is much lower than initial reports, which is good news.”
And then, yes, we pivoted to fight sports, and boxing.
UFC’s belligerent bossman Dana White wants to come back and put mixed martial arts on May 9 in Jacksonville, Fla. Does Dr. Foy give a thumbs up or thumbs down on that plan?
“I could just tell you that in my opinion, I think it would be OK now,” he said.
He’s told me before, athletes being young and healthy, the danger they get infected and die is quite slim.
But, he added, “I think it’s a good idea to have people be tested prior to getting there, because you don’t want somebody going to the event, finding out they’re positive and you travel them on airplanes and stuff like that. Although the reality is that this is still occurring every day. People are traveling with the infection and whatnot because we haven’t totally stopped air travel and other things, but the optics of it could look bad. So I think you want to make sure that you have the people tested before they travel, but otherwise, I wouldn’t personally have huge reservations, to be quite honest with you.”
Would Dr. Foy run a mid-May card if the state gave the OK?
“I think so, and I think it depends where in Pennsylvania. I don’t think we’d want to do in a place like Philadelphia, which is a hot spot, but to do an event in Dauphin County, in Harrisburg, for example, I think that would be okay.”
Marshall Kauffman is Kings Promotions’ CEO; are he and Foy putting a return to live action in motion, laid any groundwork?
“Marshall is enthusiastic to get back as soon as it’s allowable,” Foy said. “I can tell you just from my standpoint as somebody in medicine, I don’t feel uncomfortable about moving forward with it. But I also have to acknowledge and this is one thing that we don’t talk about enough when it comes to how to manage COVID going forward: we have to acknowledge that there’s always going to be a level of uncertainty, and then it comes down to everyone’s risk tolerance. I’m a pretty risk-tolerant person, and this is one of the things we study when we look at the psychology of decision-making, so I don’t feel very uncomfortable with it.”
Of course, the commission will need to be comfortable that risk management is locked down.
“It doesn’t matter so much how I feel or even how Marshall feels, it has to do with what the state commissions are going to allow and what kind of testing that they’re going to mandate. And is it (economically) feasible to comply with, and do we have sufficient support to do it, is one thing I was talking about with Marshall.”
If all the fighters and people who have to be on site need to get tested, say that’s 60 tests, and a test is $50 or $100 per — whose pocket is that coming out of?
“I think only the people with the biggest pockets are going to be able to absorb it,” said Foy, acknowledging that there are still big “ifs” to get a handle on.
“I think there has to be some sort of agreement or acknowledgement on some of these financial costs, the promoters are working on very thin margins to begin with,” he said. “I mean if I told you how often we actually made money at a show last year, you’d instantly think that we were a terrible promotional company.”
OK, let’s get that crystal ball out. What do things look like in August, regarding live boxing action?
“The answer boils down still to peoples’ emotions and how they’re going to deal with those emotions and channel it into regulatory policy, to be quite honest,” Foy said. “I think that we will see rolling waves of infection after the lockdown is relaxed. I think that there’s going to be places where that leads to overreactions and then people are going to pull the trigger and do more episodes of self-isolation or lockdown, whatever you want to call it. But I do think that by August, for the most part, the economy will be back to business in a lot of ways, particularly in areas that are not hit very hard. But I still don’t think we’ll have fans yet at the events. I kind of think that fans will be allowed when football starts again, because football is just so big in this country that people are just not going to be able to tolerate it any longer, and I think the NFL has a lot of power as well.”
We’ll leave it on an up note. There’s maybe not enough of that going on in the coverage of the sneaking malevolence that is the coronavirus.
“I think that by August of this year,” Foy finished, “we’ll all feel better than we do now, about about how bad this can be.”