Friday 20 March 2020

MUSINGS: COVID-19 - "Abundance of Caution" | "Abundance of Fear"

As discussed a few days ago, there is remarkable fear out there with COVID-19. Last night, as I was checking out the news, I clicked on Drudge Report to see what's going on in this world and got that screen above.

Wow. What a time we live in. I suspect if we checked Drudge on September 11, 2001, the top part of the screen with numerous headlines would have all been about the same topic as well!

Unfortunately, parts of Europe are not faring as well as others. Italy and Spain particularly. As of this afternoon, the death toll in Spain sits at 1,093 vs. Italy at an unfortunate 4,032. As per previous discussions, age is an important variable; the population in Spain of 65+ sits as 17.1% vs. Italy at at >20%; I suspect this alone will make a huge difference in terms of mortality in a population where there is broad spread and especially strained medical care. France with about 12,500 cases and 450 deaths seems to have an intermediate death toll so far compared to the other nations in Europe.

Notice the variation among the countries. Germany's numbers are impressive with 68 deaths and about 20,000 total known cases. As I discussed last time, I don't think the total number of known infected is that important at this point given that pandemic spread and community transmissions are widespread; given enough time, vast percentages of the population will be infected. Note that Germany has quite an older population as well with >20% 65+ like Italy. Clearly they're doing something right when it comes to limiting spread and improving care for those infected. When the crisis is over, I'm sure there will be thousands of articles published on public health policy in "shutting down" the virus at an early stage and health care system advantages/disadvantages. Also, I'm sure we'll be seeing all kinds of interesting comparisons in the academic literature comparing how well the Asian countries have fared (esp. Japan, S. Korea) thus far compared to Europe and N. America.

Let's talk about the fear out there...

First, let me say that I am in no way trying to downplay the seriousness of what is happening. Obviously the effects of this virus needs to be mitigated. Follow the recommendations of the Public Health officials locally.

Having said this, I wonder whether news site headlines and images like the one above with people in biohazard suits pulling a guy on a stretcher also in a biohazard suit is clearly too dramatic and potentially doing harm to the cause... What's the point? Is it to impress upon people the seriousness of the situation? If it is, what's the message exactly? That even if you're protected, still be careful because COVID-19 "spreads in shadows" like the news item at the bottom? Let's stay calm folks, YOU'RE NOT (in all likelihood) GOING TO DIE from this!!!

Remember, just like everything else we consume in the media, make sure to read the news with some emotional detachment while maintaining perspective so as not to be overwhelmed by fearful headlines clearly designed to stoke anxiety (and website "hits"). Remember that on many news sites like this one, they're collecting items from numerous sources which may or may not reflect the situation locally for you; a good example is the "testing chaos" article where the Wall Street Journal reporter jumps between states and gives examples of inconsistencies but we're not given a clear perspective by the end of the article. What's the point of an article like this except to instill fear and doubt? Unless you live in those states, towns or cities, in those particular areas, this is not useful is it? Remember that the purpose of testing will change over time.

In the early phases of an outbreak, it's good to have testing available to catch as many cases as possible to start containment and halt spread. This early model of "massive free testing and treatment" was what worked in South Korea along with rigorous contact tracing to limit spread. Alas, here in North America, we are beyond that point now as we are already in a sustained community transmission phase where it's fair to say that tens of thousands plus people are now walking around already having been infected but unaware (remember that for many, the disease is mild or asymptomatic - around 20% for these studies had no symptoms).

With a disease that has no specific treatment (ie. unlike say HIV or Hepatitis C), nor immunization (like the seasonal flu), nor prophylactic drug available (eg. valacyclovir to prevent recurrence of herpes), testing availability at this point is not limitless and should be reasonably rationed to those who might spread the disease to the vulnerable (ie. health care staff), for confirmation of symptoms especially if needing hospitalization, special situations like investigation of an outbreak or within nursing care facilities where residents cannot self-quarantine. This is why Canada's prime minister Justin Trudeau has not been tested (last I heard) because his wife is known positive. So long as he is asymptomatic, self isolation is the treatment already regardless whether a test comes back positive or not.

It's becoming time to assume that SARS-CoV-2 is widespread and eventually is going to affect most of us before the availability of a vaccine. This is in essence the point in the article about how in California "56% will be infected". What the headline here missed is that they're talking about "over 8-week period" which is the scary part if true. It suggests that the California governor believes the current health policy of "shelter-in-place" started in San Francisco would fail and potentially overload the health care system with cases over the next 8 weeks! Hopefully this is not the scenario that plays out...

What would be "good" is to achieve that "flattening of the curve" where instead of 8 weeks, the infection rate is slowed and even if 50% of the population is to be affected, this is over something like 3+ months so the health care system does not become overwhelmed. Ideally, long enough until an efficacious vaccine is available to prevent further mortality and morbidity. Remember, as more people are affected, "herd immunity" builds up and viral transmissions slow. The initial "hit" is the most painful since the population is naive to the illness. With subsequent waves, hopefully the illness transmission drops and severity will ebb.

If we look at those article headlines, we see the other major anxiety of the day - the economy. Jobs. Financial stress.

I suspect it's going to be VERY important in a couple of weeks once the initial "tsunami" hits North America that we start focusing attention on the wisest way to re-open up. Remember, without at least some semblance of a functioning economy for extended periods of time (say >1 month), we're looking at huge pain ahead. Central governments backstopping bankruptcies, financial injections to stabilize currencies and debt obligations, subsidizing salaries, delaying tax collection, etc... will come with consequences down the road as all this needs to be unwound eventually. Nothing is truly free even if it comes from the government. The US has a GDP of almost $20T/year, and Canada $1.7T; with these kinds of numbers, even if we're asking central governments to backstop 50% for a month, that's $0.83T in the US and $71B in Canada worth of aid. This money is not "stimulus" proper, just temporary funding to keep the lights on and a roof over the business or the individual... And if businesses cannot restart at a reasonable pace, there will be permanent losses beyond the situation now.

In a world where savings are tight, the younger folks have less secure jobs, many working in "gig" arrangements, and good jobs with good benefits and pensions have been dwindling, this economic shutdown with be painful. No decent amount of government "relief" will be able to repay the productivity lost if this is prolonged for "months" as some have even suggested.

That ultimately appears to be the terrible dilemma governments will need to face... At what point after the initial COVID-19 wave would it be good to open up economic activity in a paced fashion that allows the young and healthy to resume economic productivity?

The earlier this is done, the more it will benefit the young and healthy. They will likely pick up more shifts if needed, take on more responsibilities, perhaps advance up the corporate ladder to take over positions once held by older folks nearing retirement, or those with chronic health conditions who need to remain in longer isolation until herd immunity is built. I suppose this can be seen as a form of enforced "succession" in some companies, or early retirement for those nearing the time. Let's not forget that something like 80% of seniors have their savings locked up in illiquid assets like their homes and RRSP/401Ks in stocks which IMO will never recover to the peaks of late February at this point - remarkable how things change! As such, many who were expecting to retire comfortably will need to reevaluate their expectations if we end up trapped in a perpetual deflationary spiral. Regardless of what risks might need to be taken to open up, the key here is that the health care system must be able to handle a steady stream of sick, but hopefully younger and more resilient individuals while those at high risk of death remains in self-isolation longer.

To take a safer trajectory and open up the economy later will benefit the older and those with chronic medical conditions. Obviously, if one keeps everyone in isolation until a highly efficacious drug is found or if new cases dwindle near zero, this will be best for those most at risk with hopefully minimum mortality. The cost of course will be to the otherwise young and healthy, as well as massive costs to the public purse if this freezing of activity persists for months. This is why on a grand scale, we must get a handle on mortality and morbidity risks and rates (basically the main point of my previous post). Absolute risk reduction is likely impossible if it means prolonged closures like this and I suspect that a prolonged shutdown will result in countless unexpected harms down the road for those who are not going to die from COVID-19 (already warnings about mental health impacts). Lives lived in perpetual fear rarely brings with it satisfaction, much less rewards.

Well folks... I think the next 2 weeks will be very telling here in North America. With all these precautions in place, hopefully the mortality rates do not turn out to be beyond expectations (low, and primarily confined to older and very old segments of the population). Furthermore, with the amount of time and foresight looking at the Asian response, let's see if central and regional governments can get their act together in a "good enough" fashion - I actually remain quite optimistic despite all the fear in the media as collected above.

Time to "hunker down" for the next 2-3 weeks - this will suck - but I think answers to the dilemma of balancing heath care and economic activity will become top-of-mind in the next month. I suspect the decisions made then will potentially having even more impact than COVID-19 itself for years to come.

Alas, my Spring Break "staycation" has been cut short to get back to the hospital in preparation for the "tsunami"/"hurricane" ahead. Today (Friday March 20, 2020), here in Vancouver it's actually eerily quiet as acute care is discharging all those that do not need to be in hospital. All elective surgeries cancelled. Our largest emergency department in the province this morning unusually almost empty. "Calm before the storm"? We'll see soon enough... And with any luck, it won't look as bad as what's happening in Italy, Spain, or France.

Stay safe. Stay cautious, but don't let caution's psychological "shadow" take over and be attacked by an abundance of fear and panic.


Addendum - March 22, 2020

I got this message from a friend in Germany yesterday. Some interesting observations about the German coronavirus data (today, almost 25k cases positive, 93 deaths):

Hey Arch,

Been pleasantly surprised by your Corona-blogging. Very informative & well written!

With regards to the German numbers - apparently Italy does post-mortem testing while Germany does not. So some case might evade the statistics.

Secondly apparently there is widespread testing in German on the scale of about ≥1000 per day allowing for early detection and isolation. There is some confusion about the validity of this number so take it with a grain of salt.

Thirdly southern Europe has much more intergenerational living and hence more transmission pathways from young to old and vice versa. Such living arrangements are uncommon in Germany (see below though).

Lastly parts of the German population live in relatively low population density areas.

Part of the reason for this is the so called "Pendlerpauschale” or commuter tax relief of €0.30 per km. Lamented by the Greens for years this subsidy of the German automotive sector makes it more attractive to live on the countryside.

The Greens call it “Zersiedlungspauschale” - one of those intranslatable German composita - basically “Siedlung” is settlement, the prefix “Zer” is to spread out and pauschale is an allowance. Paying people to settle far apart is closest to the gist of it.

The situation is quite surreal really. My partner and I early on started to prep and are well stocked. Since last Saturday we are staying in and only go outside for some gymnastics in the park. As academics with no kids we are privileged to be able to work from home. Many colleagues have more challenging situations, espc. with younger children. So far we haven’t had any Covid-19 cases in our social contexts or at the universities but I don’t trust these numbers.

Berlin not yet has a lockdown but I am certain it will come soon. As I can observe and also hear from friends many people roaming outside and espec. I am seeing some of the Arab and Turkish migrant milieus not having visibly changed their behaviour - i.e. don’t adhere to the social distancing recommendations.

Since they often live in comparably small and intergenerationaly shared apartments we might see some espc. problematic dynamics here. I am not aware of any stats differentiating between “ethnicity” for Germany so we might not get any numbers validating or invalidating this hypothesis.

Politically Merkel so far has benefited, she is relatively weak on policy in normal times but an excellent crisis manager. Glad the far right which had a considerable surge the past month appears totally lost on this and I hope it stays this way. Economically the repercussions will be severe and I fear the worst for the European Union. It might not survive this storm.

Thanks for the note!

Good discussions about the complexity of this pandemic and how we do need to consider all aspects of the medical system including how numbers are generated for stats and societal variables including intergenerational living arrangements, cultural differences among immigrant populations, etc... Important to know because this is where public health policy will need to target the message to these populations. Here in Vancouver for example, the homeless and "Downtown Eastside" population are highly vulnerable and will need stronger measures such as testing and ensuring health care availability.

My friend could be right, repercussions may even affect the geopolitical level with considerations like the fate of the EU held together by very disparate states; some will be much more economically distressed than others with good reasons already!


  1. "And with any luck, it won't look as bad as what's happening in Italy, Spain, or France."

    Is there a reason to expect a better outcome? More aggressive testing and contact-tracing? Sterner social isolation and quarantine measures? More abundant and better equipped hospitals and medical personnel?

    1. Hi distler,
      Yes. I think there is good reason to be optimistic.

      North America is YOUNGER.

      North America except for large cities like NYC or downtown San Fran is overall LESS DENSE so transmission will be slower.

      Despite the apparent chaos of Washington and the bumbling news conferences of Trump, the complexity of various organizations, the health care system in North America is better than something like Italy. Much more reassuring to watch Cuomo's conferences for NY.

      If you look at the most intensive treatment option which is an ICU bed with mechanical ventilation as a proxy of health care capability, countries like US, Germany, Belgium have been reported to be better than Canada. IMO as long as there is social order in the US (and not freaked out by the news), it will be fine.

      Here's an article concerned about Canada BTW:

      Despite the ICU data, remember that the "battle" is NOT in the ICU or for mechanical ventilation folks. It's on the front lines of containing the spread and reasonable medical options to maintain health until the infection passes - roof over one's head, good nutrition, plenty of fluids, clean air, nothing to harm oneself (no smoking, no alcohol of course), and some acetaminophen for fevers and pain. Don't fool around with your meds at this point (no reason to stop ACE inhibitors or ASA if you're on them).

      Remember that by the time a person needs intensive care, survival is already poor. Check out this paper in the Lancet the other day:

      Mortality once a person needs ICU with ventilator support is 81-97%. Save that for the small number of younger patients who have higher likelihood of survival.

      What matters most is the general health of the population. Even in China where there is more pollution and likely lower overall health of the population (one proxy we can use is that the overall life expectancy in China is at least 2 years younger than USA, and even 4 years lower than Canada), >80% of those infected never needed to go to a hospital. in fact, keep those people away from the hospital and let them convalesce at home in self-isolation.

      Stay calm folks. We'll get through this...

  2. After making the mistake of peeking at news from Italy before going to bed, which seems to be described by participants as an apocalyptic horror show at this point, I was not going to be able to sleep.

    Your post at least will get me to sleep tonight. Thanks Arch!

    1. Glad the post served as a hypnotic Vaal :-),
      Yeah, horror show in Italy... Hundreds dead a day like in China. Terrible strain on the health care system and front line workers. Despite this, they will get through. Watching it happen in a European/North American context brings it home to us how severe infectious diseases are for almost all of human existence save the last 100 years or so. This is the trauma of what happened in China in January-February. It's an important reminder to show the "anti-vaxxers" what life is like in a population if everybody stopped getting measles, rubella, flu, etc... vaccines. The fact that every year we're able to keep most people healthy and not have massive social upheaval of this scale for every contagion that comes through is a nice reminder of the importance of science.

      For the audiophiles, I think it's important to remember this when life gets back to normal and we start debating the petty squabbles between what is "objective" and "subjective" in audio equipment again. Seriously, I hope everybody has had enough of what Trump feels in his "gut" as a particularly sickening example of non-objective reasoning.

    2. Hold it Arch, are you saying I need to stop getting my vaccine info from the CrazyMothers facebook page??!! They've done the research on what Big Pharma and The Government and "experts" keeps hidden from us. How will I become informed? ;-)

    3. "CrazyMothers" Facebook eh? Sounds like this could be "DangerousMothers" depending on what's being trotted out.

      Remember the old saying:
      "There are only two truly infinite things, the universe and stupidity. And I am unsure about the universe."

      Some say this is from Einstein but maybe not...

  3. Good thoughts, Arch.

  4. I agree that the media is not helping and only serving themselves for the most part. Pharm companies, I believe, are doing all they can and help may be coming with some old drugs that may, (or not), work, but if you are very sick and may die, something is better than nothing if supplies can be maintained for those already using said drugs already. I think that one thing that needs to go away are inventory taxes at all levels and this would allow pharmacies to carry what ever drugs they wanted at any level they wanted and not worry about inventory cost. We have a bad habit in this country of taxing everything to the max.

    1. hile it's bad, this is potentially a "trial run" for something even worse. Imagine an even more contagious form of MERS or God forbid a hemorrhagic fever like ebola - each with >30% case fatality rates including the young compared to COVID-19 with most likely <1% and primarily the elderly.

      This raises the question of what is a realistic scenario for a much deadlier pathogen/virus. As I understand it, the deadlier the virus (or at least, the quicker it incapacitates or kills it's host) the less it's able to easily spread. So high mortality pathogens burn out sooner, which is why this COVID virus is able to spread more easily to pandemic proportions.

      I wonder what the numbers tend to be in terms of what type of mortality rate a virus causes to it's spreadability? (It seems the Coronavirus is dialed in very well, like the Spanish Flu).

      I guess I can imagine a sort of perfect storm of characteristics for a virus with a very high mortality rate: asymptomatic people very contagious for long periods before symptoms arise and add easily aerosoled like the measles -

    2. Hey Jim,
      Yeah, after this has passed, I think the government, health care systems, pharma, hospitals, clinics, will need to use what is learned to better prepare for next time. While it's bad, this is potentially a "trial run" for something even worse. Imagine an even more contagious form of MERS or God forbid a hemorrhagic fever like ebola - each with >30% case fatality rates including the young compared to COVID-19 with most likely <1% and primarily the elderly.

      I expect there must be some complex calculations when it comes to inventory for medications since there is a shelf-life for these things.

      Take care man...

    3. Hey there Vaal,
      Good comment about the pathogenicity and we can imagine some kind of morbid "Goldilocks" combination of factors that decimate populations before it burns itself out. Highly contagious while incubating (for longer period of time), immunologically naive population, "low but significant" fatality rate. Not surprisingly, these are the results of a review on this topic from Johns Hopkins in 2018:

      1918 flu probably a good analogy to what we have here but of course back then the technology for detection, sanitation, overall medical care much poorer - especially after WWI. Furthermore they did not have the tools to develop a medical response in the form of immunizations quickly nor the various potential medications nor respiratory assistive technologies as today.

      Once we get through this first wave, that immunization piece will be essential to prevent the possibility of an even more severe "wave 2" like they saw in 1918 potentially coming our way winter 2020-2021. I'm sure we'll hear more of this in the summer! As mentioned in a response below, this is potentially even more important for Asia.

      CDC brief history on the 3 wave of the 1918 flu:

  5. Yes, very reassuring to see someone keeping a cool rational head especially now that it mattters more than ever.

    I think it's clear that we don't want to get this thing. Better to sit back and enjoy some music and conversation, and take things slow for a while.

    1. Yup. Slow this down... We'll get through this.

      Once this first wave passes not just weeks but hopefully a trickling of cases over the next 2 months, there will be rebuilding to do and the pharma companies will need to keep working on that vaccine to get it out pronto.

      Depending on how many % of the population gets this, if say 50% in the next few months in North America and we get a break during the summer, the Western nations should be able to weather "wave 2" better if it doesn't burn out like SARS-CoV-1. Remember, because China/Korea/Japan contained it so efficiently, most of that >1 billion people still have no immunity and wave 2 could be nasty for them if not vaccinated. They will need to be careful about imported outbreaks over the months ahead.

      "Screw your courage to the sticking place" ladies and gentlemen for the next few weeks especially...

  6. Some potentially very good news. While media has fixated on vaccines and their long lead-time, they've ignored the treatment side almost completely. Small study out of France with pluses & minus discussed for folks' consideration.

    1. Hi Allan,

      Yup, the small study on hydoxychloroquine 600mg/d (200mg TID) +/- azithromycin (500mg day 1, 250mg x 4 days) for bacterial superinfections for about a week from France.

      Encouraging news for those with more severe infections. As I said in the previous blog post, I don't think we should be thinking about using this in asymptomatic or mild URTI patients due to the side effect profile plus as above >80% will not need hospital care, plus 25% completely asymptomatic even if tested positive.

      Some caveats about the study - have a look at the detailed data on Page 22:

      1. Very small study. I'm most interested in the LRTI results since this is the population that die from severe pneumonia. In total, ONLY 8 cases in this report with many younger people.

      2. LRTI + >65 year old only 2 cases treated with hydroxychloroquine! And neither of these cases received azithromycin.

      3. Remember, when it comes to mortality, we care most about those >65 years old if we are to have a big dent in death rates. This study only had a total of 3 patients >65 with LRTI whether treated or not.

      Bottom line, IMO, this is way too preliminary to say if HCQ is beneficial. Maybe it can speed up viral clearance, but even if this is significant, doesn't mean it'll have a big impact clinically especially when we consider potential risks... In any event, good to keep in mind as an option in the arsenal and continue with research.

    2. Some sketchiness around the guy and the study.

      "It looks like a sloppy study that was only published so quickly because one of the co-authors is also an editor of the journal that published it.

      Their controls were at a different facility, with no randomization or blinding. They also excluded a few cases that went to the ICU.

      . . .

      Excluding ICU patients (who follow a much more protracted course of the illness, often over one month) would have allowed them to get their results out faster and inflated their headline numbers."

      Looks like he over-stated things to be first to make a big media splash. He didn't come up with the treatment, however. Initially chloroquine was being used in China. Hopefully he overstated the effect for the fame and headlines, but is directionally correct, at least good enough for public health purposes.

      At this point, with the amount of fear and fear-mongering going on, and while not excusing the guy at all, I am glad the media has something positive to discuss and feel hopeful about. Black Death this ain't.

  7. Wow folks. Just saw a "wonderful" article sowing nonsensical seeds of fear:

    Coronavirus ‘exit strategy’ could be months — or years — away

    Yeah, it could be months before a widespread vaccine. Yeah, some form of quarantine especially for those vulnerable for months. What kind of "exit strategy" is the reporter talking about? It's not about an exit strategy... It's about staying calm, being prepared in the right ways, and getting through a storm that you know is coming. It's about bolstering COURAGE, not about finding cowardly "exits".

    The fabric of society is not breaking down over this. There is not going to be famine because of this. Show a bit of grace and faith in your fellow human and we'll all get through this.

    Terrible that a story like this doesn't even allow comments to be added!

  8. Good evening,

    This test was actually only carried out on 24 patients. I think it is important to point out that Professor Raoult is a first-rate scientist.

    Starting tomorrow, several European countries are starting a large-scale validation.
    France and Belgium first, then 5 other countries.
    3000 patients should be followed up.
    I hope that the results will confirm the initial study. And that we can quickly put an end to this health and economic nightmare.

    André, from Brussels, one of your regular readers.

    1. Greetings André,

      Thanks for the note. Will be looking forward to the results of the large scale validation! Hopefully it will demonstrate efficacy. Until then, doctors can certainly still try with the medication in potentially severe situations "off label". I'm sure they'll look at the various key questions:

      - Does HCQ significantly accelerate reduction of viral load?
      - Is the reduction and absence of virus permanent even if stopped in ~1 week (ie. hopefully doesn't come back!)?
      - Does it improve all forms of the illness especially lower respiratory tract infections (LRTI), and across all age groups?
      - Does it ultimately reduce mortality, especially in those >65?
      - Would be very interesting if there is evidence of reduced morbidity as well - especially in the <65 year old population who may have residual lung damage...

      Hopefully the answers to all the above are to the affirmative! Will take a number of weeks I suspect.

    2. Good evening,

      You can find more details on this test in the press release of March 22nd.

      Glad to see a plan B is being considered.

    3. The link to the publication of the initial study.

    4. Nice man,
      Looks like we have a multi-option trial ("Discovery") there with multiple medication options:
      - remdesivir IV
      - HIV drugs lopinavir + rotinavir
      - HIV drugs above + IFN-β (anyone know which one?)
      - chloroquine / hydroxychloroquine

      For completeness, there are other trials out there I've heard of:
      - losartan x 7 days, University of Minnesota
      - sarilumab single dose IV, Regeneron Pharma, New York
      - favipiravir aka Avigan, Japanese drug trialed in China, good results
      - umifenovir aka Arbidol, haven't heard much about this one

  9. Here are the latest numbers from Europe. Most of the countries show a very good survival rate:

    1. Thanks for the link Duck,
      As expected, survival rate *will* be excellent. Numbers should increase with vigilance around testing so at some point those total numbers are not useful other than a gross estimate of a combination of those symptomatic and increased prevalence.

      A tragedy for Italy which unfortunately serves as an example of what happens when the "tsunami" is not dampened down and we see an overwhelmed health care system in a aged population.

      One news item today claims that people <60 not offered ventilators in Italy:

      Not sure how reliable this is... Sure, I can imagine a specific hospital having an issue, but unless proven otherwise, I suspect this is not some kind of broad situation across the country. Sad state of affairs if not enough to at serve those previously healthy up to 65 at least! Remember again, by the time a case ends up with LRTI and severe respiratory failure, survival is poor even with ventilation (probably >90% mortality). Allowing the elderly to say goodbye in comfort instead of intensive medical care with intubation, central lines, mechanical ventilation in futility is actually IMO the right thing to do in most cases.

      I suspect most doctors and nurses can appreciate this even if sensationalism and drama might sell news stories. Especially in times of crisis, critical decisions need to be viewed through the lenses of quality of life and prognosis since resources are of course never unlimited. Families and the general public I think for the most part are reasonable and appreciate this as well...

    2. Good evening,

      a document has been sent to the Belgian and French clinics.
      It mentions the various objective criteria that should guide the choice of patients to be treated, should the conditions impose a choice.
      It seems to me positive to relieve the medical profession of this difficult decision, or at least to help it, when next week will put the clinics in many European cities in a delicate situation.

    3. Interesting André,
      That sounds fair. It's good to have this during times of crisis. Keeping criteria consistent reduces concerns of inconsistencies and grievances around fairness... So long as the criteria are reasonable and rapid adjustments are made of course.

      One piece of tentative good news tonight. The Italy number of deaths and new cases dropped. Looks like most of this is a result of better Lombardy numbers. Will obviously need to confirm over the next few days.

  10. Added Addendum with message from Berlin.

  11. Now it seems someone wishes to use the epidemic to create confusion and mischief, be publishing false news. Here is Reuters explanantion:

    1. Oh yeah... Our "friend" Russia. Those guys know to never waste a crisis.

      Of course, I think we can say the same thing when every issue becomes politicized; as per what's happening in the US today.

  12. Strange how the guidelines from European governments differ. In Denmark (my home country) no more than 10 people are allowed to gather, but in Sweden (one of our neighboring countries) the number is 500.

    1. Hey Duck,
      It certainly says something about Public Health and the various opinions out there. The fact that it's not a universal lockdown and restriction is actually telling...

  13. Yeah, lying and spreading misinformation is the common denominator.