Thought I'd put up a post today as a bit of a "comment cleaner" for ongoing discussions. A few days have passed, I'm not seeing much change here in Canada. Yeah, more testing done, more positive cases, but so far so good in terms of emergency departments not being overwhelmed. Preparations looking OK and containment systems not being breached. Strong health policy seems to be working within the hospital system that I can see.
In the title, we see a bit of one of Trump's late-night tweets yesterday evening which went like this:
"WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF. AT THE END OF THE 15 DAY PERIOD, WE WILL MAKE A DECISION AS TO WHICH WAY WE WANT TO GO!"While I'm sure this will get many Democrats upset and maybe even some Public Health officials concerned, this isn't unreasonable at all IMO. (Need I remind all reading this? I am no Republican, I live in Canada, and am open to both viewpoints so long as it makes sense.)
No doubt, the "cure" can be worse than the disease at times. In the history of medicine, we can point to examples both of diagnostic procedures as well as treatments. Thankfully we are way past the days of animal dung treatments, inappropriate blood-letting, mercury as medicine, invasive tests with unacceptable morbidity these days (pneumoencephalogram, anyone?), frontal lobotomies, or useful treatments which needed refinement over decades (like ECT in the 1950's without anesthesia).
As I suggested when I first posted on COVID-19 about a week ago, we need to be careful about closing the economy in excess because that could end up like the "cytokine storm" of the disease itself - we, the "hosts", could be literally mounting a response out of keeping with the threat and damaging our future as a result.
The effects we're seeing of a global economy in a state of "deep freeze" in the grasp of panic as discussed last time IMO does seem excessive.
Remember that we are not seeing a disease with high mortality to all parts of the demographic. It hits the old and those with vulnerabilities. We need to make sure that in time, the Public Health response appreciates this nuance rather than maintaining our current trajectory of using a blunt public response policy of indefinite duration.
While I'm sure we have many opinions out there, let's just lay out a few ideas that could be reasonable to consider. Clear enough to follow perhaps and provide principles to base decisions from - from my context here in North America mainly:
1. The CDC's "15 Days To Slow The Spread" is something we've basically all signed up for already.
That's good. It provides a strong response and we should already see significant change to the trajectory for the weeks ahead because of this. It was published on March 15th so by March 31st, the progress will need to be evaluated. Remind people not to freak out about total numbers. Try to be consistent with stats as well - differentiate between confirmed and "probable" cases for example.
2. Now please get the provinces and states to get the job done with enforcement. Actively shut down beaches, companies not following the rules dinged with a fine/shut-down, close parks, etc... Get the cops out there under emergency provisions. Enforce the recommendation of 10 persons or less for any small group gathering.
3. Target the message to the elderly and those with underlying medical conditions at highest risk. I know, in this day and age of "correctness", nobody wants to be "discriminated" against. Some will call this "ageism". Well guess what, pathogens do discriminate, not based on race or creed but individual vulnerabilities. This has nothing to do with social justice but everything to do with science and medicine if one wants to live. No folks, 70 is not the new 50 or any silliness like that.
Of course remind the younger folks to be vigilant but no need to "rule by fear". It's more powerful to appeal to the person's humanity and build a prosocial culture because that's just "cool" and being a "jerk" by not following instructions gets a person "no respect" in times like this. Build this through social media and public messaging - maybe leverage what Facebook/Twitter/Instagram/Google can do for this. Here's an opportunity for social media to purposely do some good! Go ahead, get some pop stars to make a nice jingle. Encourage the young to show care by calling their older loved ones, communicating with Skype/Zoom/WhatsApp, bringing food safely, keeping a healthy distance if they should see an elderly person in public...
4. On March 31st, the governments must come out in news conferences with graphs and charts to show us:
- Where the "hot spots" are
- What the mortality rates look like
- Which groups are most at risk of death (we need ages and medical comorbidities)
- What is the level of need in terms of medical equipment and staffing issues in hospital
Show everyone what's going on. Don't tell me what your "gut" says Mr. President. We don't care about whether it's a "China Virus", when borders were closed to China, or who thinks you're doing a "good job"; a better man knows that success itself is the prize.
By providing the data to the public, they can then build up trust, engage people in the intellectual exercise of working together to decide public policy. People are not stupid. Give them the fact, be transparent, show us most likely projections without stoking fear. Do not make this political. This is also not about the health care system especially in the USA taking an even bigger piece of the GDP pie or enriching the pharmaceutical industry.
5. Develop 2-week plans - "For the next 14 days, we are going to do the following..."
Remember that to the best of our knowledge, 14 days is a reasonable period whereby we can see infections clear. Therefore there's no reason to make adjustments too quickly because that will just foster chaos. Let things average out over 14 days and not get sidetracked by flareups here and there or individual stories that stoke emotions - in the big picture, it's not about individual suffering but elucidating the public good - news media need to remember this as well for what they publish. Sad stories like this might be fine for tabloids, not for intelligent discussions.
Every 2 weeks, we should see a graduated plan describing the steps forward:
- For the next 2 weeks, food and beverage vendors can open up to 50% capacity across the country except for these "hot spots".
- For the next 2 weeks, only those <60 years old and do not have a chronic illness can go to the opened public places.
- For the next 2 weeks, small group gatherings can be up to 25 from 10.
- For the next 2 weeks, there is a low risk of traveling between these states / provinces / cities if you are health and <60 years old.
- For the next 2 weeks, colleges and universities will reopen.Obviously, it will have to be more detailed and formalized than this but simple enough to be clear. Some recommendations may need to be rolled back in some places; that's fine so long as there's a plan. Others can permanently remain in place. In fact, one could identify categories of guidelines for businesses, travel, educational institutions, age criteria, etc. and make them easily accessible for example on the Google homepage so anyone can click and see where it stands at any moment within whatever jurisdiction you're in. Maintain enforcement of course within reason.
At the briefings after every 2 weeks do as you did on item (4) above. Clear presentations. No BS. Don't get emotional. This is not a campaign rally for any political party.
6. As expected, the elderly and those with health conditions should be the last to be relieved from isolation. Long-term care facilities, assisted living buildings, hospitals will need to remain under limited access.
Again, the illness does prejudice who it's going to kill. Accept that fact and take care of oneself if one is older or has health conditions. The public policy should likewise recognize that fact and work with it.
It's time to see a concerted (seriously, what's the point of 50 state-by-state declarations of similar policies that can be broadly applied?), realistic, evidence-based, and most of all consistent leadership that recognizes the fundamental balance between public health and economic policy because nobody (including the government) can sustain a prolonged loss of productivity.
They keep calling the financial relief packages "stimulus" which is ridiculous! How can any amount of money "stimulate" when there is barely any activity present? The longer this drags on, the less there will be any kind of rapid "V-shaped" recovery to come back to if the pieces of an interconnected economy drop like dominoes.
Bottom line: Time for leadership, people. Lead from the front with plans, visions, and at least the appearance of competence. (Use deliberate speech rather than brief tweets that foster more uncertainty and chaos!)
Have some courage, seek wisdom and fortitude, get the job done. Most importantly, remember that so far it doesn't look like there's any kind of "existential crisis" for humanity whatsoever from this infection. Review the rates of death from yearly respiratory infections like flu and pneumonia for context. This is a containable health emergency as China has demonstrated already.
Hopefully the Powers That Be don't make it much more than that...
Good luck everyone. Let's hope the early easing in cases in Italy continues to improve!
Thanks for clarifying things once more in these muddled times.ReplyDelete
The example of China should give some of our policymakers something to go on as we struggle through this.
It can, and will be overcome.
IMO, no question that this will be overcome.Delete
I'm watching the silliness of Washington and the games between the Democrats and Republicans on how to hand out money and can't help but think how ridiculous this is.
Economically, they're negotiating coverage for a PAUSE in business.
Halt debt collection for a couple months.
Prevent evictions so nobody on the streets.
Provide unemployment insurance. Cover necessary wages.
No interest loans for companies to weather through the rough patch with reasonable terms for repayment to begin once the economy seems to be running again (the "UNPAUSE" moment).
No stock buy-backs - absolutely.
But what does the idea of $30,000 student debt forgiveness have to do with this?
This is not a time to get "free stuff" driven by politics. Not for Republicans and their corporation buddies. Not for Democrats and their, errr... people who want free stuff.
One more thing:
I wish they would slow down the talk about shutting down everything. Start talking about the current phase of weathering the hardships as hospitals and caregivers do what they're trained for with support.
Then in the near future, talk more about allowing a responsible "opening up" for the younger people with lower health risks as a start.
I've decided that from now on my Covid-virus information diet will consist solely of reading Arch's blog and re-reading this article every day until things get better:ReplyDelete
Didn't see that article so this is indeed good news and in many ways consistent with what I'm seeing in the data and news items overall.
Given how far we have not taken the shut-down of cities and "social distancing", no doubt this will make a very strong impact at least in the cities where the virus has not already spread far and wide (like NYC perhaps). Best outcome is that this peaks out in the next two weeks and we see cessation of numbers and "hot spots" across the continent thereafter.
I know this is the "minority report" since most epidemiologists seem to be calling for weeks and months of virus outbreak. Will see. So long as the numbers not extreme with massive numbers of high acuity cases, the medical system will hold.
A cytokine storm in the real economy is a perfect metaphor, Arch. I'm going to steal that. :)ReplyDelete
By all means Allan!Delete
The response has been so dramatic. Just look at the remarkable charts of world markets, gyrations of currencies, and collapse of commodities.
The response was so swift that it attacked the beating heart of the world economy, now floundering in a state of pulseless electrical activity from cardiomyopathy. Have to somehow restart the system in a reasonable time, get the life blood flowing again before the end organs go necrotic!
I think this is naive. Take account if the fact that the duration of the illness can be at least 14 days, and the incubation period at least the same. That's 28 days. The minimum if someone had just become infected at lock down. Also take account of the growing reports of more serious illness in younger people. This is a monster on the loose.ReplyDelete
Will see Audio,Delete
I'm looking at the data I have here in the city as well. Not seeing unexpected demographic stats. It's elderly individuals and those who have preexisting issues that need the higher levels of care in the hospital and at risk of death. Of course when we look at tens of thousands infected, there will be some younger people - an exception, not the rule - important to account for this when we look at mass public policy...
If we look at the time frame in China and Italy, a 14-day regular update on major "goal posts" I think is very reasonable. Some people will incubate longer, others take longer to recover. Of course, hold daily updates as reminders for vigilance, but show us the stats over 14 days so we can truly appreciate the most vulnerable.
Remember the data like this paper:
Median incubation is 5.1 days; and 97.5% will develop symptoms within 11.5 days. By the end of March, we will have 14+ days of social distancing, reduced work hours, curtailed travel massively. It should be a good start to let everyone know what the numbers look like, the severity, the risk factors. The anticipated curve without needing to be dramatic and fear-inducing. This was never a massive killer pandemic except to those highly vulnerable that we can identify in the community.
I'm listening to Andrew Cuomo right now and he admits that something like 95-98% will not be affected... And he acknowledges it's about those vulnerable. But I fear that he's also building IMO a straw man argument that "the train needed to stop" to the extent that it has at this point for everyone.
Much more important IMO is to be smart and identify the vulnerable with a good margin of safety - for example, all those >60 years old with medical conditions (plus those with organ transplants, cancer, autoimmune disease, Type I diabetes...) immediately off the job, on income replacement, halt bill/debt collection, food and groceries safely delivered, etc. Self isolate, stay calm, society will have you covered with whatever medical needs you may have. For Canada and USA, we're looking at about 20% of the population conservatively - especially in countries where intergenerational living is low. Everyone else, observe some prudent distancing, wash hands regularly, stay home if feeling sick, reduce major gathering places like restaurants, pubs, and concerts to 50% capacity to slow down the spread within the younger folks. The roles that grandparents played like family meals can be supported with incentive to restaurants to provide and deliver. Support a parent who needs to stay home with young children or sick kids at home.
Wouldn't that still be reasonably safe? Of course, persist with getting PPE, ventilators, stock up hospitals. But it would not have meant a wholesale "rescue" of literally everything. Almost everyone in the country!
Yes, you'd still need to help out companies like cruise lines, airlines, hotels, entertainment industry can go to government for interest-free loans, etc... But many small companies and individuals would get by with tax credits to keep more $$$ in their pocket and would get through this even if income is a bit leaner for a season or a quarter. Direct funding to restaurants to provide for the elderly and vulnerable would also have been money well spent to maintain the strength of this sector in hard times when asked to reduce on-site capacity by 50%.
IMO, we knew these demographic risk factors already weeks before the start of the N. American phase of the crisis. While that paper above came out March 10th, epidemiologists would have known well before then. Interesting that the solutions from the governments were emergency declarations and travel shutdowns rather than talking to people earlier and showing people the stats.Delete
I suspect these ideas will be the type of debates we'll be seeing in the news cycle ahead as numbers hit their peaks and subside likely in April, and everyone's looking around and starting to recognize that "We've beat the pandemic (for now)!". But wondering if the trillions of dollars were money well spent and especially when governments need to look at clawing back tax $$$ in the years ahead.
Enjoy the party coming up. This will not be pretty in the longterm.
I'm not getting it.Delete
Overall, the experience from other countries is that about 20% of cases require hospitalization. That's heavily weighted to the over-60. For the under-50 population, the hospitalization rate is much lower. 5%? Let's be really optimistic and say 1%.
Conservatively, that's 3 million people in the US. (We'll just assume the over-60 set just stay home, regardless of their infection status.)
We need to spread out those 3 million cases over as many months as possible, to avoid overloading the healthcare system.
Without severe social-distancing measures, the doubling rate for new infections is 3-4 days. With the half-hearted measures you are advocating, maybe that slows the doubling rate by a factor of two. Clearly, that's not enough to avoid running out of hospital beds a month or two from now.
Exponentials are devilishly hard.
We need to have a better idea of what "20% of cases require hospitalization" means. I believe it's more like "20% reached out for medical care". In the early days of Wuhan when nobody knew what we were dealing with, they admitted to hospital everybody because for all we knew, this could be a 10% killer and you definitely needed to quarantine in a massive way!
Not only was this prudent in November/December/January, remember that in general, the threshold of hospitalizations is lower in China for the most part. They overall have a poorer system of community medical care than in the West.
I've been there and have seen how the hospitals operate - it's a massive bureaucracy run by Party Officials, with directors of hospitals often not even specialized in the areas they control but politically appointed. There is also general acceptance for perceived more aggressive health care. This is why in Asia you see all kinds of silly "full body exams" being marketed by private hospitals and I'm sure doing great business. In Asia they give antibiotics to people with colds and start IVs and "hospitalized" for mild cases that would be unnecessary (in fact unacceptable) here in North America.
Months later, we're in late March now, we are looking at the European and North American context and how we handle these things. Knowing now also that the pathogen is not as terrifying as the early scenarios feared or the "worst case scenario" of the headline grabbing Imperial College 2.2M death report, it's reasonable to take a deep breath and evaluate.
It's not like we're "doing nothing" here. It's not like anyone is saying to reopen for business tomorrow or next week! Let's wait until March 30-31st anyways. If the numbers look OK, the idea of a wise, graduated reopening as we get closer to Easter which is being spoken of by the government might not be unreasonable.
I have not seen prevalence data which is what the Oxford study article below hinted at. For all we know, if we walked around and tested everybody downtown Seattle or Vancouver or NYC or LA with no symptoms, we could already be seeing 5% or 10% antibody positivity... That "denominator" number is another piece in the puzzle we're missing; and it could already be much larger than the media is currently talking about. If so, this is a "game changer" on how we view the projections.
Senator Ted Cruz put it all out there on what congress is doing to a much needed bill that has become more about other things than helping those hurt by COVID-19. He has called out everyone to stop putting in things that don't belong. If there was ever a time for term limits this truly proves that point. 1 term, 4 years in the house; and 1 term 8 years in the senate and you are done. No retirement will save millions. You don't have to worry about your vote(s) as you are not coming back and no constituents to please for their money for your next election. Character and class have died with this partisanship.ReplyDelete
I agree Jim,Delete
The political structure needs a major overhaul which includes here in Canada talking about "senate reform" for generations and remains an appointed senate.
Doubt this will ever change since they'll never vote themselves out. When was the last time they voted for a pay reduction even in the midst of recessions for example or consideration for reduction in pension? Unless I'm mistaken, probably back in 1933 back in the Depression (and that's years later after the crash of 1929).
Last I heard, bills like these die:
Will likely literally need a revolution of sorts before this ever happens!
Just to clarify - Senate term is 6 years. So one term, 12 years?ReplyDelete
I said 1 term in the Senate 8 years and done. You only go through 1 election for the house and the senate and you are history. Change the both longer and then, out. No retirement.ReplyDelete
Just saw this coming through:ReplyDelete
Coronavirus may have infected half of UK population — Oxford study
If true, then herd immunity coming much quicker than expected and it means re-opening of economy will come quicker than expected as well. From an economic perspective, it means we're not going to be "struck in the trenches" for months and months.
Also if true, hospitals will need to prepare for massive surge in cases over the next couple weeks.
I wouldn't take any solace from that study. If true, then this corona virus is much more infectious than we previously thought.Delete
The more infectious the pathogen, the less beneficial herd immunity is (or, more precisely, the higher the percentage of the population that needs to be immune in order to confer any protection to those who are still susceptible).
For half the UK population to be already-infected, we're talking measles-like levels of infectiousness. In which case ... we're screwed.
This should show up some pretty serious problems in how we do business. National health care is a need not a want. Even those with the best plans are now endangered by those with the worst. This cuts across all class lines. It really shouldn't be true that so many people are so far down on the socioeconomic ladder. We haven't caught up with how we distribute money so even a minor disruption is a huge problem for a massive part of the population. Fundamental change should come out of this. Our supply lines are too long. We also need to end animal trafficking now as SARS, Covid, Aids and Ebola all jumped from wild animals to people eating 'bush meat'. If this isn't big enough to make some real changes I don't know what is.ReplyDelete
As a Canadian, Adam, I can wholeheartedly agree about the importance of national health care.Delete
Yes, we all need health care, but governments do it badly. Look at what politicians have done to Medicare...robbed it to pay for other things they can't get passed. What is needed is the largest open enrollment in the U.S. where millions can buy private insurance from a national group plan at affordable rates. My wife had cancer twice (colon then liver) , 6 months of chemo at 12 X $17grand and even with good Public School teacher Blue Cross our out of pocket was tremendous. In the middle of chemo she had emergency gall bladder surgery. If one could convince the likes of the biggest insurers to offer millions of people a buy-in that was affordable I think they would. If you had 25,000,000 families paying $400 a month that would be a good way for DRs and Hospitals to get reimbursed for their costs and unfunded emergency room costs that might go unneeded if regular office visits were available. If my math is right that is $10 billion a month to cover medical costs we don't have now.(Check it) People often think that medical care is a right, but it is not, it is a paid for service like everything else. No person is going to take on the tremendous cost of medical school with no payback. Our brightest deserve to paid well, better than members of our do nothing congress with ridiculous retirement plans. There is a solution, but the government will just mess it up. Look at how mismanaged the VA hospitals are.Delete
Only Distler above makes sense to me. The way I read what Archimago is proposing, and some of the other comments here, there is a very conservative political agenda at play. The situation growing in the USA will risk mass social disorder, possible rioting, and all sorts of nasty responses if the right leadership is not in place.ReplyDelete
We shall see Audio.Delete
I think it goes both ways. Both the liberals and conservatives are playing this, as I suspect are the other power brokers and financial brokers. Yes, we could see social disorder. But it's not necessarily just because of coronavirus; it's the catalyst for a much broader societal disequilibrium already building.
Anyhow, let me stop talking about this :-| as we're getting even more into speculation. Watch the numbers, let's see where the science leads us over the next few days. As I said, I think we'll know much more in a couple of weeks where COVID-19 is heading.
Just a comment watching this Trump Task Force conference today. Kudlow saying total of $6T available for the triple-package financial stimulus.ReplyDelete
I suspect Wall Street and companies licking their lips at the prospect of this kind of "support". Paired with the prospect of COVID-19 "not as bad as we thought" in a few weeks, we could see a massive market bounce as this kind of stimulus could be providing more liquidity than necessary.
Humans being what we are, I know, everybody wants free money. Congress and the Senate will want to grab whatever their constituents and supporters want, that's got to be the only reason it's taking so long to sign off on a "final" bill. The biggest "cash grab" in on, my friends.
Hmmmm, "party like it's 1999"? Remember, the hangover could be very bad. Be prepared if this is what we see into late spring and summer...
Still, where are the tests?ReplyDelete
What tests Adam?Delete
Remember, we are now in the phase of active community spread essentially worldwide. Assume anyone you come across has the virus. Isolation, distancing, hand hygiene, cover mouth, etc...
Tests should be reserved for special groups and especially those with symptoms and risk factors. Unless the CDC wants to investigate a cluster of cases, there's no need for the most part.
In hospital/extended care at least here now, all care providers are to have protection equipment on with ALL clinical contact - minimum of surgical masks, goggles/face shield, gown, gloves. N95 for procedures with possible aerosolization.
We're in the thick of things now.
Well Arch, lots of interesting viewpoints. What do you think of Bill Gates saying the US missed its chance to avoid coronavirus shutdown and businesses should stay closed? That's in sharp contrast to Trump saying that his target date to open the nation by April 12. "I thought it was a beautiful time. A beautiful timeline." LOL!ReplyDelete
I don't know much about politics, but I do know math. Looking at the available data for the US, one could say they are in the "knee of the curve" when a trend is about to go exponential. If I were a betting man, I would not be betting against an exponential function.
Stay safe and healthy my friend!
Yeah, as usual Trump is rather silly to speak like that... Sure, it'd be "beautiful" to have businesses open "by Easter", but that's not realistic. Even though I think I'm more optimistic than much of the news out there, we'd be fortunate if the US can start relaxing precautions by mid-April.
We definitely need to see the death rate subside first and I would not be surprised if this peaks out around Easter long weekend. Agree, we're still somewhere in the "knee". This is why I think the government and public will need to take things 14 days at a time.
For the time being, I'd like to see Italy's death rate consistently drop (highest so far March 21) to be more confident that they're on the other side of that curve. If so, in a week it certainly won't look (and feel) so dire.
North America is geographically spread out with various "hot spots" distributed and this will likely make the graphs protracted and look more bumpy for the mortality curve... Longer duration but hopefully I suspect at the same time less mortality. Smart public policy will need to address regional differences.
Yup, hope the weather is beautiful for you Mitch. Take care and stay safe!
Just a quick comment before off to work:ReplyDelete
Cuomo says this AM that most of the cases likely will be people who contracted the virus but no symptoms. I agree and the data is looking this way... I wish the media would portray this almost certainty more, rather than the usual amount of fear.
He also talks about opening the the economy after testing a person to have developed immunity then he/she goes back to work... That's nonsense. That's silly to be drawing blood to check seropositivity before getting people back to work. Waste of resources.
Get people back to work when it looks like with good evidence that the maximum "hump" has passed of cases needing hospital care and it looks like the hospital critical care resources will hold. By that stage, probably the majority of hospital workers will also be exposed and recovered.
Again, the main talking points should be:
1. YOU (with all likelihood) WILL NOT DIE. Be kind. Follow recommendations. Even if one personally will not die, be mindful of the hundreds of thousands, even millions of those at risk (not necessarily of death of course!).
2. PROTECT THE OLDER AND VULNERABLE.
3. GET THRU THE "HUMP" OF CASES NEEDING URGENT CARE IN THE NEXT 2-3 WEEKS. I think this will cover most places in N. America even though "hot spots" will show up here and there. This is why the Public Health folks are being paid the big bucks :-).
4. REMAIN DATA DRIVEN. Open things up to the young and healthy first to get the engine going (I see Cuomo saying this now).
Let's see if we party like 1999 when the world eventually sighs a breath of relief.
An observation in the hospital today...ReplyDelete
Outside of the specialized respiratory testing area, the emergency departments around here are very quiet. Literally handful of patients at any one time when in normal times, we'd be looking at tens of patients at least, and commonly overcapacity.
Speaks to how quiet things have become out there (fewer car accidents, falls, work-related injuries...), plus with the pandemic people are just staying away from hospital - likely a good number of "non-urgent" cases that never needed to come to ER during normal times. ICU demand OK so far around here in Vancouver.
Another observation, a number of COVID-19 tests have come back as influenza positive. It might be interesting to not just report on COVID-19 positivity, but where the testing is also checking for influenza, also report alongside for context. Likewise, how about ICUs also report on daily rates of admitted influenza + deaths; again, this is useful information for context. Who knows, coinfection of influenza A/B + coronavirus might be relevant when it comes to mortality and morbidity.
This global challenge could eventually make us to think more about seeing us like a unique group of beings sharing time and space than individual nations or cultures. Most, always fighting to prevail over the rest trying to exploit all the natural resources available out there without control or limits. A chance to keep our focus on the true relevant things we need to take care of. Very sad, we usually learn through pain.ReplyDelete
Good luck to everyone!!
Very true Gedeon,Delete
It's times like this where we as humans must recognize that we are truly in the "same boat". I believe there will be plenty of opportunities in the days ahead to show grace, compassion, and faith to fellow citizens of the world.
As I look at the news these days, watch the politicians (especially the elderly politicians, some of whom clearly should be retired at this point), and the way the news media has portrayed coronavirus, I worry about what is ahead for us.
Yes, there will be hard times in the health care system. There will be deaths on the order of thousands, likely tens, even hundreds of thousands worldwide especially in places with poor sanitation and availability of health care. But like I said, this was never an existential event yet we're treating it like it is, and that will have consequences!
Unless the systems of government can be nimble enough to negotiate and optimize the response which I believe includes a timely resumption of economic activity which may not appear to be the "abundance of caution" some demand, we're all going to be in a world of pain worse than coronavirus.
I'll shut-up now about this and this weekend will put up a more uplifting audio-related post. Be careful out there everyone. Watch the events of this world unfold in the big picture. Life is very much about weighing risks and taking chances when we need to in order to be wise; it's not good enough to be just comfortable and "secure".
Sometimes being wise takes the form of obvious understanding about how things work and decision-making. This is why it's fun for me to write about audio stuff and it's in fact relaxing to write about all the nonsensical "snake oil" after a busy day at work dealing with the "subjectivity" of humanity. The situation is obviously orders of magnitude more complex and nuanced when we're looking at what humanity is facing now and the decisions that need to be made in the weeks ahead.
Good luck everyone. This likely will be getting very ugly and for much longer than people can anticipate; and I'm not just talking about coronavirus of course.
One of the things we want to know that AFAIK hasn't been established yet:
Once you've had the virus, what degree of immunity does that confer, and how long does it last?
I'm wondering how exactly that question will be answered. Is there some non-ethically-dubious way that this can be tested in people who previously had the virus? Or will it be some inference from population/tracing studies? Or...?
As far as I am aware, this is not known yet but presumably it should be like other infections and one develops IgG immunity which if strong enough the first time around should cover this strain for life. Of course there have been articles questioning this with anecdotes:
Just got off a telecon this evening about experience with COVID including some input from NYC. Clearly the data too early to tell...
Oh yeah, for the record, looks like the Imperial College model folks are revising their model of death from 500,000 in the UK to a much more reasonable <20,000. Well... That model was a bit "off" the first time round, eh? This is a good example of why I'm thinking the panic seemed a bit excessive!Delete
Imperial College scientist who predicted 500K coronavirus deaths in UK adjusts to 20K or fewer
Since everyone's throwing out numbers, as I said in comments back on March 19, I'm thinking <15,200 in US and <2000 in Canada total deaths by the time things settle here in North America. Based on the dynamics in China, I think death rate will flatten out by around April 25 in the US although maybe a little longer due to wider regional differences.
Obviously this is morbid stuff talking like this... But I think it's reasonable to throw it out there as an "optimistic" view on the illness if we're thinking about the "big picture". Months and months of "physical distancing" (the new terminology) doesn't seem realistic to me at all.
Then there are the economic ramifications. Hmmmm...
Also for the record, that 500,000 dead UK model is the same one that predicted 2.2M dead Americans. So I guess they're calling for <88,000 dead Americans now (assuming the reduction is about the same)?Delete
I'm sure people at some point will say that the big "scare number" was needed for social distancing policies. And that because we did that, hopefully the number of dead looks much better. Regardless of the big number, after what happened in China, I assume no reasonable country would have done nothing!
Anyhow, the exponential deaths are coming up soon across N. America and many other parts of the world. We're starting to see the increase in numbers.
Good luck. And wishing you good health everyone...
About the Imperial College revision, Neil Ferguson of the study clarified that although the number of predicted deaths would be down, the predicted mortality rate is not revised. He tweeted about this here:
As expected, he's basically saying that "look, social distancing worked", right?Delete
I don't know about that. As far as I can tell, the disease was never really one of high mortality. Remember, treatments are basically SUPPORTIVE in nature. Is he saying that in the UK, the social distancing measures were so good, that it prevented 25x the numbers dead!? That's a little too flattering for the work the UK did, don't you think!?
Thanks for the boots-on-the-ground update, Arch. Outside of NYC and a few suspiciously partisan reports, my (albeit very limited) checking-in with non-political hospital workers is like you state... business has an eerie down feeling to it because everything elective is cancelled and the covid tsunami everyone is expecting hasn't hit.ReplyDelete
Everyone is mentally prepped that this is the calm before the storm. No one in the hospitals is ready to think about what happens next if there's no storm?
Since you've mentioned business aspect and this is more of a US feature, but I think the average person is going to be very upset when the insurance companies come out of this smelling like a rose! Gov is picking up covid case costs and non-covid healthcare is off a huge amount... 50%? Hospitals are taking it on the chin financially in the US, ironically further underscoring the epithet that they are glorified hotels.
Finally, speaking of underscores, this thread underscores a point I made elsewhere that partisanship has driven the whole friggin' world mad. Ronald Reagan said on a couple occasions that he half wished an alien invasion would happen as that would cause the world to set aside its petty differences, see all that we shared, and work to fight the true common enemy. A novel virus is literally as close as you could get to an alien invasion and, yet, all I'm seeing is people doubling-down on their biases and partisanship. It's pretty remarkable when you think about it. Maybe this shows my own bias, but I take it to mean the virus threat is grossly overblown. If it were a true existential threat, I don't think it would need very much debating. There'd be kook's embracing the catastrophe -- there always are -- but for the most part I think the discussion would be between doing more and even more. I'm not seeing that with covid.
Almost forgot... music chaser because the world needs to chill. And since I love a good cover, Jimmy Fallon covering Neil Young every bit as good as Neil Young covering Neil Young:Delete
Thanks Allan, that's an awesome performance! Fallon did an amazing job! Hmmm, wonder if Neil was promoting Pono on that episode in 2015?Delete
Yeah, it's surreal in the hospitals. Normally the cafeteria is quite full on a weekday, easily >100 staff and students, today there were maybe 10 nurses, doctors, and allied health there; all appropriately physically distanced of course!
Most outpatients now telehealth through Zoom or Facetime... Unless one is really feeling sick, hospital is the last place one should be at this point. In fact, hospitals here essentially on lock-down. No visitors or family, every entry point with hand sanitizers and ID access only.
Remember folks, as much as people focus on masks for droplet precaution, the likelihood is that much/most of the spread happens through fomites; coming into contact with viral particles on contaminated hand rails, doors, table tops, keyboards, etc. then touching one's face.
KEEP HANDS CLEAN.
Yeah, it is interesting the lack of "coming together". I can imagine that it would take quite alot to get the world together - like that alien invasion or maybe an oncoming asteroid. But the disharmony between political parties either is as you said, this threat isn't severe enough, or maybe it really is just a reflection of the dysfunction in the world. I wonder if this were to happen not on an election year in the US, what it might look like.
Regardless. It's here... Time to deal with it.
I have a different opinion on the point of testing. I do not understand why you don't consider aggressive testing (near-blanket testing such as S.Korea), as one possible mean to replace the total lock down.ReplyDelete
In S.Korea, what they are doing is aggressive testing, and lock-down only those people and clusters infected, instead of region or country. South Korea entered community spreading phase pretty early, but already (seemingly) contained the first wave with their near-blanket testing. At this time point, South Korea provides unique example that contained community spreading phase without having a full or regional lock-down. They didn't even stopped planes coming from China. It was always open, and it is still open.
Business as-usual over there. "Social distancing" is recommended, especially for those who have prior conditions and old. They do closed large events (e.g. 100+ people), and also postponed start of the school and university. But basically that's just it. Restaurants are open, golf courses are open, human-contact required business such as hair shops and nail shops are all open as usual.
Hidden cost of S.Korean-style TTQ is the privacy, though. Each positive-tested personal are visited by Police and forced to reveal who they meet, where they visited, for last 2 weeks, also need to submit their mobile device, and its internal geo-location data. Each trace (name anonymized, but with true location & time) data are opened up on KCDC trace web pages, so people can see what behavior can make you infected: in what distance, in how long interaction, in which setting (e.g. in church, in car, from table, from cough... ). This reveals many interesting insights, such as even within same house/family, infected daughter could stop spreading her virus to the family members in the same house for two longs days, by wearing a N95 mask. Churches were the most wide-spreading hot spots, etc.
This type of privacy-revealing may not be possible in N.America, I guess. Reading all 9000+ infected case tracing data written on plain web site... makes you feel surreal. Yes, even now reaching near 10k infected, they do make trace report for each and every case. Does this data transparency helped South Korea's current containment? I think so, but wide-range of testing is by far bigger part, IMO.
I think mass production of accurate test-kit is within easy reach for US and Canada. One of my friend (an MD in Seattle) told me that US is already heading this direction, at least it greatly improved test-kit production rate. Although she said blanket testing and tracing requires much bigger decision and manpower on government level.
At this moment of writing, aggressive test-trace-quarantine (TTQ) strategy is an already proven way of "opening up business as usual" in time of corona pandemic.
This is the context, why my opinion is differ to Archimago on testing. Testing is important regardless of the phase, because it is the only way for us to identify and quarantine people without symptoms. This (no / mild symptom) was > 20% in young people (S.Korea data), and that is why this Covid is working far worse than SARS or MERS. Morality rate is far lower, but we never had an epidemic that is so hard to contain.
Thanks for the great discussion Gil Noh!Delete
Appreciate you taking the time to go through the details. I think as a North American, this style of data gathering and surveillance with utilization of the authorities to enforce is not going to be acceptable to the general population. The culture does not have nearly the amount of trust in the government or authorities especially in the large cities if you demand access to cellphone data and have police knocking at the door like this!
I can imagine this style of control will be viewed by many as a massive threat to the foundation of liberty and you'll have all kinds of social unrest with panic. Here in Canada there will be outcries but I think as a "more socialist" country, we'd be more accepting. In the States, watch out for that highly weaponized populace - I'd hate to be the police officers trying to enforce this!
My sense is that here in North America, it's too late for a strong TTQ strategy. There is neither political will nor cultural acceptance. It's ultimately about "harm reduction", the same strategy as we use for treatment of drug addiction in these countries whereas in Asia, many nations still have a "zero tolerance" policy for drug dealers. We have "safe injection" sites, legalization advocates, widespread opioid replacement therapy, etc...
COVID-19 exposure is likely to be highly prevalent in the population in the months ahead for Europe and North America, and it ends with herd immunity. IMO, the question is simply how fast this happens. Hence the balance we must strike between preserving the health care system from being overrun vs. how quickly we open up for business and limit economic damage.
Sure, by all means we can do mass testing but without strong enforcement what is the benefit? But remember that even with good testing, sensitivity is not 100%. And given the nature of N. American society as expressed above, the battle for Asian-style suppression of the disease IMO is essentially lost. All we can really do to reduce death is to keep the vulnerable safe until the day that herd immunity is sufficient and hope for the quick arrival of an effective vaccine.
(Eh, deleted and writing again. :-) couldn't find a way to edit/fix broken sentences... )Delete
> it ends with herd immunity.
I totally agree. Even in S.Korea, the strategy is just delaying it with TTQ. Goal of TTQ is not the full containment. Goal is to keep it under the grip, until wide (again, wide-sampled) anti-body test shows about 50/60% of immunity among the population.
> mass testing but without strong enforcement what is the benefit?
Now I see why you don't think TTQ is a good strategy. I understand the concern, but I want to mention as two counter points.
- People generally bad at follow "stay-at-home / minimize contact" recommendation, but they follow far better on "stay at home, you are infected"
- S.Korea model can be applied without enforcing part. (namely TQ, instead of TTQ). The biggest assumption of S.Korea model is that 1) people will come to test without forcing, and 2) people tested positive will self-isolate without forcing.
People don't follow "stay-at-home" order, when given as "blanket" order. That is what I see here in Germany. (btw, I am a South Korean national, living in Germany). Regardless of German or Korean: if you are young, you know you won't die from virus. Sure, the government says "meeting of more than 3 people is prohibited", but who gives a f.? Schools/Unis closed, you go out and enjoy a nice corona party, till police comes up and disband the party. (Yeah, even the enforcement is half-hearted. "I am not infected!", "But gov says you have to stay at home." "Booh!").
This is what I see from my city here in Germany. I know from my heart that Korean students are also the same. And in S Korea, bars and clubs are still open (!), and nobody disbands anything. But Covid spread is rather checked in low numbers. Why? Cause, even reckless youngsters don't go join people, when he is notified "you are a virus carrier, if you go out, you can infect other people and even kill them."
What I am saying is this: even without any enforcement, widely available testing is a force-multiplier for social distancing. Also note that, S Korea model of TTQ can be applied to democratic society such as Germany (actually far closer to socialism than S.Korea). One main topic on the news yesterday here in Germany was that, can S.Korea model possible here or not.
The 2nd "Trace" step is problematic here in Germany, due to German/EU obsession (!) on privacy. (e.g. EU GDPR law, etc). Police officers have no right to ask last-2-week whereabouts. However, note that this was also not possible in S.Korea until recently. It changed only because of last MERS out-break. That outbreak changed people's mind and legislative body finally gave the gov. this power.
At any rate, TQ (without second T) is a valid measure for "knowing" when to open up the business. That is, if you can clearly see the true number of "active cases", and if it has been decreased to, say, constant number, we can gradually open up the lock-down. Of course, this cannot replace "number of anti-body grown population". So both tests are required.
Here in Germany, expert groups in the government seems to be discussing this: should we directly go to testing of "anti-body" to measure immunity rate?, or is there still some time for use test to limit isolation scale? At any rate, they are ordering a large number of test-kit production.
And one final point :-) Eh, not related to TTQ strategy, but just an observation / opinion.Delete
As an Asian who previously lived in US, Singapore, and now in Germany; I think people are often over-estimating the role of cultural differences. I mean, countries do have big differences (e.g. guns in US, total censorship in China), but they are not that relevant in fighting epidemic. More essential issues are emergency logistics & manpower build-up: Test kits, protective suites, ventilators, ICU beds... whatever that could be the bottle-neck in epidemic. Do the government has a working plan to react on any sudden rise of such needs? If one local region can't handle it due to lack of manpower / items, which next area should send what doctors and nurses, in which orders, on what transport methods? Do people already know their role? If there's a manual, are they expected to play it blind, or have practiced this before?
Asian countries suffered not just once, but twice in last 20 years, due to lack of "emergency logistics & manpower": namely, SARS and MERS outbreaks. Covid19 is the 3rd one. Some countries are now prepared, and has whatever working plan for their society. If you ask my opinion, this single fact (previous exposure to serious epidemic) is far more essential difference than any cultural differences combined.
Thanks again Gil Noh,Delete
Fantastic comments and observations!
Good points about the (T)TQ strategy and I can certainly appreciate the psychological force multiplier effect of testing positive and knowing that one is positive and be extra careful.
Alas, I suspect the "train has left the station" at this point when >100k are positive in the US and that's of course likely a gross underestimate to actual infected. It actually might be more useful now to start looking at those antibody results and estimate resistance within the "herd".
Nothing left to do really but to hope that mitigation measures so far doesn't overwhelm the medical system for those who actually can be helped with critical care and ventilators...
For those monitoring things in Europe, my friend in Germany sent me this link of their national update for March 26th:ReplyDelete
Germany - National COVID-19 Update - March 26, 2020
It's in German.
- 78% of deaths are 70+
- Most cases 35-59 (but obviously they live)
- Graph 5 shows that men affected generally more than women especially older age groups (boys, I guess our immune systems suck as we get older)
Not on there but he told me that the reported median age of deaths is 82 years old, and about 10% needed hospital care of some form. More information on the younger people who die and comorbidities would be very useful!
As I've said over and over again, the disease does discriminate in a big way; age and comorbities essential to understand. In the health care systems, we need to know this for wise allocation of resources such as who gets a ventilator and an ICU bed in the even of resource limitations. Public health policy likewise needs to do the same once we pass the "hump" and need to look at opening up the economy again in terms of who can work, who stays home, how to manage health care facility access policy.
Take care everyone...
Same information for BelgiumDelete
Interesting reading about aerosol transmission
And finally, after two weeks stuck at home, I'm going to take advantage of this Saturday to take some distance and relax by listening to music.Delete
Thanks André, I think many people must be getting "cabin fever" at this point especially with the allure of hopefully beautiful weather ahead!Delete
Data around the "not too badly hit" parts of the Western world I think looking similar. This AM, the Canadian data showing 9% hospitalization rates for those infected with severe symptoms. 3% ICU. About 30% younger people <65 needing hospital care but not many deaths.
Last I checked yesterday, hospital system and critical care services holding well here in Vancouver.
Still remarkable to me how little spoken of regarding ages and premorbid conditions. It's almost like they're afraid to talk about this as if the results would make younger people feel "invincible" or something. I think by not showing the data, this actually makes things worse with anxiety.
Long enough with the populace stuck in isolation and fear will foster anger in the weeks ahead if questions linger and those who communicate do a poor job of expressing the rationale for what is being recommended. This could be especially bad in the US with the bipartisanship along with the lack of trust in media and government.
Always remember the big picture. As the "15 days" are over next week, decisions made will be important. The cost is not just in "lives lost"... But also opportunities missed and ultimately the hard-to-measure quality of life if weeks leads to months. It's comparatively "easy" to post graphs, and have websites full of numbers of those infected and dead. They need to make sure to use those "objective" methods to also explain the "cost-benefit" of public measures on everything else beyond health care - otherwise there almost definitely will be anger.
So far so good... Preparations still ongoing though since we don't expect the peak until Easter or thereabouts.Delete
At least one of the medical wards in my hospital being converted to negative pressure rooms this weekend as inpatient departments targeting 50% occupancy rates. Will see how the battle goes soon enough!
BTW, when we're looking at impacts this virus has had and responses we make, don't forget that we are a highly interconnected world now.ReplyDelete
I find especially US media tends to be highly self-centered, and many have no concept of other cultures or even geography. Even the extreme "liberals" who fight for illegal immigrants, rights of the poor, right to use drugs, etc. seem to forget the magnitude of suffering we see in this world and the repercussions of the choices make.
Never forget that as a world we rise and fall together now. Yes, look at the death toll from coronavirus. Be aware of the strain on hospitals locally. Then look at the death toll from influenza every year. For hard-hit countries like Italy, look at the typical death rate per year in that country - how many % do you think COVID-19 is going to represent when we look at all of 2020? How many of the deaths will actually be children or adults in the productive years of life?
Read and watch the video in this article:
Coronavirus: India defiant as millions struggle under lockdown
Look beyond and at the toll this virus brings and likewise how the decisions we make as nations may be amplified to the masses who are in much greater need than us in the West. Let that sink in when we talk about $2.2T stimuli, discussions about life and death if there is a need to triage, and what "power" we have over such things.
Ultimately, what sacrifices are each of us willing to make? Even what sacrifices do we actually need to make to reduce the burden of suffering (the other side of the coin to the quality of life) in the world?