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This is going to be a very painful two weeks.
Our strength will be tested and our endurance will be tried, but America will answer with love, and courage, and iron-clad resolve.
I’m a cheerleader for America.
These were the key quotes for me from the Tuesday presidential press briefing. President Trump is determined that Americans will win, whatever the circumstances. He had his two senior medical experts, who once again showed both the depth and narrowness of their expertise, and so of their advice, give the nation both a giant bucket of cold water in the face and then reason for hope, both grounded in the renewed advice for all Americans to sustain physical distances of at least six feet in all public spaces, really anywhere outside their immediate family. The 15 day guidance was renewed as “The President’s Coronavirus Guidelines for America,” with the theme “30 days to slow the spread.” The clear, simple two slides are now in both English and Español.
President Trump took the worst-case numbers and ran with them, pointing to between 100,000 and 200,000 Americans dying of COVID-19 by June, with the daily death tolls peaking in the next two to four weeks. He and his team repeated again and again what had been done to “flatten the curve,” both on cases and on deaths. The president even noted that he saw shock on the faces of at least two reporters as the projected death toll was revealed.
The basis for hope starts in the wild divergence between New York and New Jersey compared to Washington and California. Dr. Birx relentlessly hammered, in her steady voice, on the importance of getting on top of physical distancing and keeping on top. No one was pointing fingers of blame actively at New York and New Jersey leaders, but they were surely praising better choices.
That said, a reporter asked the right question: what about the homeless on the streets of California’s major coastal cities? President Trump acknowledged this was a real problem, a real potential tinderbox for the virus, and said people in California were working on this, without more detail. Governor Newsom certainly understands the risk, but I am not sure what he can do at this point.
The logistics expert, the Navy admiral called in to straighten out the mess created by decades of poor bioterrorism and pandemic response planning, is apparently moving rapidly to give every state and county an accurate picture of their own actual resources on hand, in addition to reserves at each level above. This came up in the Tuesday briefing in terms of multiple deployed testing platforms being invisible to the hospitals that need them, a problem being addressed by the other uniformed service, our two-century-old biodefense force, the U.S. Public Health Service.
I noticed that Dr. Birx used the University of Washington Institute for Health Metrics and Evaluation (IHME) model introduced to Ricochet readers by @rodin last week. She explained that this model is constantly updated based on the actual data in the United States. I also noticed that she had stripped out the most informative data, both the projected cases needing ventilators and the cases needing hospitalization. Those projections would have painted a more complicated picture, making harder the sale of the bitter treatment of over four more weeks of no employment, no income, and worry about loss of savings and livelihood, to say nothing of suicides, addiction relapse, and substance abuse deaths over the next few months.
Here are some of the relevant facts. In 2018, the Johns Hopkins Center for Health Security prepared a factsheet on ventilator capacity in the United States for the Clade X tabletop exercise. Yes, just two years ago our government ran a pandemic readiness exercise, which included getting the basic data any competent staff would gather. [my comments in brackets]
The US Department of Health and Human Services (HHS) estimates that 865,000 US residents would be hospitalized during a moderate pandemic (as in 1957 and 1968) and 9.9 million during a severe pandemic (as in 1918).
• Moderate (1958/68-like) = 64,875 would need mechanical ventilation
• Severe (1918-like) = 742,500 would need mechanical ventilation
One study estimated that US acute care hospitals own approximately 62,000 full-feature mechanical ventilators. Calculations suggest that around 28,883 of these ventilators (46.4%) can be used to ventilate pediatric and neonatal patients. The study also reported an additional 98,000 ventilators that are not full featured but can still provide basic function.
• Based on these numbers, the maximum number that can be potentially ventilated is around 160,000.
• US: 20.5 ICU beds with mechanical ventilation capability per 100,000 population [by far highest proportion in the world]
These numbers did not include the National Strategic Stockpile (now over 10,000 ventilators) plus extra capability from the Department of Defense war stocks (2,000 already released). Nor did they include DoD all services capacity to surge both medical facilities and personnel, both of which we now see already moving to the sound of the sirens. The fact that the exercise was run and that it made brief but sensational headlines may have informed the move to restock the National Strategic Stockpile, as President Trump commented repeatedly in response to reporters’ questions. He compared this to the military munitions shortage at the beginning of his administration.
The model on which Dr. Birx and Dr. Fauci now rely points to an expected daily peak demand, nationally, for:
- 27,000 ventilators
- 33,000 ICU beds
- 221,000 hospital beds
All of these have very large confidence intervals, fudge factors, around them. The worst cases are:
- 41,000 ventilators (out of 62,000 plus 12,000 = 74,000 in hospitals or stockpile today)
- 54,000 ICU beds (this looks to be the point on which everyone should really be focused)
- 356,000 hospital beds
A 2020 American Hospital Association report points to:
- Staffed Beds in Community Hospitals: 792,417
- Intensive Care Beds in Community Hospitals
- Medical-Surgical Intensive Care Beds in Community Hospitals: 55,663
- Cardiac Intensive Care Beds in Community Hospitals: 15,160
- Other Intensive Care Beds in Community Hospitals: 7,419
I left out pediatric, neonatal, and burn wards from the ICU report. You can see that the worst-case scenario, based on how the disease has actually progressed in America, could strain or overwhelm bed capacity, including the needed medical staff, but almost certainly not the one thing that reporters have been banging on about for weeks. Also notice that the claims by Dr. Fauci about no one expecting such a thing are clearly mistaken. He got a far worse estimate two years ago, as you can see with the Clade X numbers.
You will also notice that the projected COVID-19 deaths in the UW model, on which our two national experts now rely, total up to 84,000 by August 2020, not 200,000. However, the fudge factor is between 37,000 and 153,000 deaths. This seems to me to be about dealing with the politics of the disease, managing expectations and trying to get the best results by another very hard 30 days for Americans. Anything below 100,000 becomes a big win.
With the tough news, President Trump and his team stood, spoke, and answered questions for two hours and 13 minutes. He praised some reporters for good questions and kept taking more.
Transcript of “Remarks by President Trump, Vice President Pence, and Members of the Coronavirus Task Force in Press Briefing” posted April 1, 2020. This 2+ hour briefing could not possibly be transcribed and checked Tuesday evening. Continued commendable work by unrecognized White House staffers keeps us equipped with original news.