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Day 84: COVID-19 Re-Open America; Safely but Soon
Those of you who have been following this series of posts (Day X: COVID-19….) know that I have been following this story since before the virus escaped the confines of China. The “Day X” reference is back to when the first reported case occurred somewhere other than China — signaling the potential for a pandemic. In the series of posts to date, I have marked the progression of the disease and underscored the fundamental lack of information to guide policy makers even as the demands on the health care system and the sudden deaths made some action imperative. The response of politicians was understandable and predictable –indirectly controlling the disease by directly controlling people. That is an evergreen solution for government regardless of the harm they are seeking to avoid.
The US has fallen prey to this same inclination. But at least our President finds people control abhorrent and seeks solutions to problems that reside within people, not that control them. He needs to be encouraged to continue to do so even as he is getting back-pressure from progressive politicians and their allies and other politicians fearful that people-based solutions will not work.
Tomorrow the President names and officially kicks off a task force to re-open America. That group will be considering a lot of different strategies for doing so. The one I hope they will give support to is the one that Steve Hilton, host of Fox News’ The Next Revolution is promoting. His nine-minute monologue describing it can be found here. But the plan is neatly summarized in three screen grabs from the program:
In Hilton’s monologue, he contrasts this approach with other competing ideas based on more virus testing, virus surveillance and contact tracing, and controlling people with active virus. This virus centric program involves massive population control with periodic (if targeted) lockdowns to suppress contagion. It is complicated, it is expensive, and it will continue adverse economic effects. That is why it is a progressive’s dream come true.
In contrast, the plan that Hilton is promoting focuses on prevalence testing — how many people get infected — and what specific conditions lead to serious illness and deaths. I have addressed the lack of information regarding both of these in prior posts: Day 82: COVID-19 The Missing Chart and Day 68: COVID-19 Comorbidity. No appropriate public policy can be formed without this information — how bad is the disease and who suffers the most? And yet 84 days into the pandemic these are unsettled questions.
But help is on the way if we will accept it. Hilton’s program Sunday night featured the work of academics from Stanford as well as private sector entrepreneurs who have been working on antibody tests and testing to determine the prevalence of infections in the population. If, as is beginning to be suggested by the few places that have attempted antibody testing of populations without regard to them being symptomatic or not, infection is wide-spread, then the risk of serious illness is low, maybe extremely low to a given population. If true, suppression is impossible and wrong-headed. Instead, as Hilton recommends, focus needs to be placed on identifying and protecting the truly vulnerable.
Who are they? We’ve been told without precision that they are the immuno-suppressed and the old with comorbidities. But when those comorbidities are described we don’t know whether they are talking about 100,000 or 100,000,000. @theleft coast referenced in a comment the start of a more precise description:
Ontheleftcoast (View Comment):
Study of over 400o patients looking for criteria linked with bad outcomes from COVID-19:
In the decision tree for admission, the most important features were age >65 and obesity; for critical illness, the most important was SpO2<88, followed by procalcitonin >0.5, troponin <0.1 (protective), age >64 and CRP>200. Conclusions: Age and comorbidities are powerful predictors of hospitalization; however, admission oxygen impairment and markers of inflammation are most strongly associated with critical illness.
“The chronic condition with the strongest association with critical illness was obesity, with a substantially higher odds ratio than any cardiovascular or pulmonary disease,” write lead author Christopher M. Petrilli of the NYU Grossman School and colleagues in a paper, “Factors associated with hospitalization and critical illness among 4,103 patients with Covid-19 disease in New York City,” which was posted April 11th on the medRxiv pre-print server. The paper has not been peer-reviewed, which should be kept in mind in considering its conclusions.
This is a start, but much more work needs to be done. For one, the analysis reported above needs to be converted to laymen’s language. Is “obesity” simply a BMI calculation that any of us can make? Or is it some set of conditions that overweight hints at and is confirmed by other testing? After all, according to Wikipedia —
The obesity rate has steadily increased since the initial 1962 recording of 23%. By 2019, figures from the CDC found that more than one-third (36.5%) of U.S. adults[5] and 17% of children were obese.[6] A second study from the National Center for Health Statistics at the CDC showed that 39.6% of U.S. adults were obese as of 2015-2016 (37.9% for men and 41.1% for women).
The IHME model is currently predicting that with aggressive control over the population only 61,545 people will die of COVID-19. Even if you assume that without controlling the population 100x as many would die, this would be a fraction of the US population that is obese. When you factor in the probability that the IHME prediction is high, this probability disconnect between obesity in the population and COVID-19 death becomes more pronounced. We need a more precise understanding of the comorbidities that when coupled with COVID-19 result in serious illness or death.
When we know that, it will be a much smaller group in need of protection through extreme means. And that is Hilton’s point. Rather than surveil 300 million Americans (the Gottlieb-Apple-Google approach) through their smartphones, focus on what are likely to be under 3,000,000 persons truly at risk and implement voluntary controls to protect them. The nursing home population is about 1.3 million. They reside in controlled locations and protocols can be implemented to minimize the risk to this population. The remainder are persons who can be identified and counseled regarding their risk and decisions can be made with respect to how they will live their lives.
This is a sensible, and American approach. Controlling the lives of all Americans is not.
[Note: Links to all my COVID-19 posts can be found here.]
Published in General
#31 Jack Shepherd (and Misthiocracy)
With respect, that’s asinine.
Property/Casualty insurance companies make underwriting decisions on homeowners’ policies and business real property insurance policies in part by taking into account proximity to fire stations.
Politicians may include “Don’t appear anti-firefighter” in their playbooks (so to speak), but realistically what registers higher on the Do’s-and-Don’ts List is “Don’t stupidly cause your constituents’ insurance rates to jump by closing Fire Station X.”
It sounds like you’re defending politicians who hire unnecessary fireman on the grounds that more tax money should be spent to help keep certain homeowner’s insurance costs down. No?
Maybe. The cell structure the virus invades through is found in lung, heart, kidney, and intestinal cells. And nerves; the finding of loss of taste and smell in over 60% of people testing positive worries me. I haven’t been able to find out whether those sense return to normal on recovery, though temporary loss of these senses is common in other coronavirus infections.
The cells that the virus takes over are destroyed; they may or may not be replaced by new, healthy ones; the process can also set off (or add another for those already so disposed) an autoimmune disease. A former neighbor of mine, in her 40 at the time, became a type I diabetic within weeks of recovering from the flu.
One of the lesser risk factors is elevated troponin; this is a protein found in skeletal and heart muscle. Unfortunately the paper didn’t specify whether they were testing for the heart version. If that’s what they looked at, its presence would probably be an indication of damaged heart muscle, perhaps from the virus.
I hope this helps:
The language is obtuse: being “exposed” to obesity in this context means being fat, not being in the same room with someone who is fat.
#10 Rodin
Just saying “hypertension” is too broad-brush.
As I expatiated in the Day 79 discussion thread (comments #37, #41, and #45), my mom, for example, has pulmonary hypertension (concomitant with non-smoking-attributable COPD). Her hypertension medication is a “standard” one, more or less; however, it’s one element of a small cocktail of medications — one of which is reasonably priced in this current first year but then is expected to rocket up in cost starting in Year 2.
It wasn’t a straightforward process for the pulmonologist, cardiologist, and to a lesser extent PCP to ultimately concoct this cocktail, and the anticipated Year 2 price jump in one of the medications reflects both the difficulties this physician team had with determining what diagnostic procedures would be meaningful, and with then actually deriving the needed meaning itself from the array of procedures they ultimately selected. My mom’s case has been that unusual and challenging.
At the end of the day, and as I indicated in my Day 79 remarks, this above-described elaborate road to grasping and grappling with my mom’s condition(s) has delivered on my mom’s fervent wish to sustain as normal a life as possible (albeit air travel — particularly long-haul flights to my recent Tokyo abode — has basically been off the table).
Excuse me, small but important correction to the above sentence: Not “*has* delivered” but rather “*had* delivered” — until the Wuhan Virus came along.
Now, rigorous social distancing — by *other* people, and including in *other* venues where my mom isn’t necessarily present — is totally essential to ensuring my mom survives at all, as opposed to merely sustaining as normal a life as possible — at least until we get an efficacious vaccine.
(Which, considering all the funds she and my dad have shoveled at the medical and pharmaceutical establishments to date, makes $500 a jab to Bill Gates seem like an outstanding bargain.)
Let’s encapsulate this another way: Pace Steve Hilton (who?), CarolJoy, Skyler, and Al Whosis, my mom will be in zero need of anyone’s “counseling” as to what her so-called options and responsibilities for herself can be expected to be as a vulnerable person with non-obesity comorbidities, in the event that economic re-opening gets underway without a vaccine to hand; nah, no problem at all, as all she’ll have to do is just kiss her real estate agent career goodbye, and literally never set foot beyond the boundaries of her yard again — and with social distancing strictures gone at the supermarket, I’ll simply switch from food shopping once every 2 to 3 weeks to something more reasonable like maybe once a quarter, and in a hazmat suit instead of my regular clothes.
Because we already know just *soooo* much for certain about the virology, epidemiology, and other fundamental aspects of this coronavirus, right? Heck, our confidence levels are off the charts that half the West Coast must already have herd immunity!
What’s going to happen to your mother’s real estate career under the current regimen?
Stephen S” “Don’t put too much stock in the count from Easter Sunday.”
The count for new cases in LA County on Easter Sunday was 323.
The count for new cases today is 239. That is one third of the new cases from 9 days ago when it was 711. Cases started to level off on the 31st and there have only two days where the number of new cases was 600 or higher, with a consistent drop beginning 5 days ago. That is a huge drop in cases – 711 to 239. Remember there is something like 15 million people in LA County – there is no accurate count because of the millions of illegals – so that is one new case for roughly every 62, 000 people . Total number of cases: 9420 as of today. One case for roughly every 1592 people with probably a bunch of people cured and not reported. One local doctor at Mend Urgent Care had cured over a 100 patients as of many days ago. Now he alone has probably cured hundreds with the HCQ cocktail and there undoubtedly many, many other doctors like him here curing lots of other patients that are not reported.
The weather has also been unseasonably cold – 10 to 20 degrees below normal. The temp on Easter was 13 degrees below normal and was the coldest Easter I can remember. Starting tomorrow it is going to get warmer so that is another factor that will help the number of cases decline.
#35 The Reticulator
You should witness the frantic Monday/Wednesday/Friday internal Zoom meetings her brokerage’s boss conducts: For everyone in that office, not just my mom, many formerly in-person and (mandated by law) paper-based processes are all having to go virtual/all-electronic, all at once.
My mom can drive over to listings and open them up to prospective buyers, but has to maintain *well* over 6 feet of distance when rendezvousing and cannot actually accompany the prospects inside (she tours listings on her own separately/prior). Mask and gloves go without saying. Still can be nerve-wracking nevertheless, given the nationality of some prospects and the destinations of some of their business trips.
What’s going to happen to your mother’s real estate career under the current regimen?
Real Estate values are greatly affected by employment. If many people are permanently laid off from this quarantine real estate values will crash and there will be a raft of foreclosures which will make 2008/9 look like child’s play. That is why for anyone owning real estate, particularly those with a hefty mortgage, it is important that the quarantine end soon and that as many people as possible go back to work soon or otherwise real estate values could seriously crash.
Showing houses now makes no sense. The market is in complete turmoil with real estate values in total flux. Now is definitely not the time to buy and selling now will be very difficult particularly since mortgages are very hard to come by .
Even if someone made an offer and had it accepted the buyers would likely come to their senses during escrow and pull out of the deal.
I was wondering more whether the economy will support a real estate career going forward under the current regime, but this is informative, too. Thx.
#39 The Reticulator
Asking prices will probably get pushed down somewhat, but not by eye-popping amounts — not where my mom is an agent anyway. Continual torrent of all-cash/no-contingency offers from buyers of a certain nationality, for one thing. Lots of buyers working in the life sciences industry, for another — *that* is a sector where demand is surely likely to remain robust.
Having met many epidemiologists, I don’t think that’s a fair assessment. In fact, I’ve met quite a few epidemiologists who were truly brilliant people.
I think the problem is a different one – it’s not that they aren’t smart enough, it’s the type of thinking and worldview involved. To oversimplify it, there is an underlying messiness to many biomedical phenomena that our algorithmic abilities simply aren’t yet able to grasp. Moreover, this type of messiness is also of a nature which is inherently foreign to people who immerse themselves in studying mathematics to the extent required to be a top-notch epidemiologist.
This isn’t just limited to trained epidemiologists. Google famously tried to harness their dataset to predict an upcoming flu season and ended up failing miserably.
So it’s not that epidemiologists are inherently less smart; it’s more that there are currently no humans smart enough to accurately predict many complex natural phenomena – not just viral outbreaks.
The two underlying questions were: a) what factors predict whether a given Covid-19 patient will need to be hospitalized, and b) what factors predict whether a hospitalized Covid-19 patient will turn critical.
The answer to a) was age and comorbidities (obesity, heart disease, etc.), while the answer to b) was the level of oxygen in a patient’s blood at the time of admission (plus a few other lab levels). Presumably, this means that age and comorbidities were NOT strong predictors of whether a patient would become critical.
Is your wife by any chance also a Ricochet member who also happens to have a John Singer Sargent-like painting as an avatar?
This may sound cold, but a society of 350 million cannot cripple itself for your mother’s survival. It can’t so cripple itself for even 10% of its population, except briefly. It is not society’s problem. It is your mother’s problem. Her rights cease where they smash someone else’s nose.
I’m not a libertarian, but am sympathetic to those ideals. As ideals.
I am a conservative. That behooves me to consider the value of quarantine practices in societies throughout human history. The sick and the likely infected were the ones quarantined, and the vulnerable isolated further. The likely uninfected healthy people, and the recovered immune, were expected to keep society operating. If your mother is so vulnerable, society’s answer, backed by millennia of practice, says she should isolate herself from us, not restrict the rest of us for her benefit.
As her loving son, we don’t expect you to consider this subject rationally. But we aren’t going to commit societal suicide to coddle you.
Thanks for clearing that up!
Pretty good guess! You must be psychic……………or an avid Ricochet reader.
……or someone who appreciates fine artwork when he sees it.
I am not an epidemiologist but something strikes me wrong about this “social distancing” thing.
From what I read from doctors, the most effective way to keep yourself from getting infected from this and most every other virus is to refrain from touching your eyes and the inside of your mouth and nose with unclean hands. That’s why hand washing is deemed so important. The virus cannot penetrate your skin, only mucous membranes found inside your mouth, nose, and eyes. Supposedly you cannot get infected from just breathing the air near an infected person unless he directly coughs or sneezes at you. If this were so, pretty much 80% of people would be infected by now all over the World.
This, to me, makes the “social distancing” thing kind of a lame method to stop the spread of the disease. I theorize that it is promoted so widely because it is so easy to understand and that most people will willingly adopt that behavior, rather than the more burdensome yet effective behavior of washing your hands and being careful not to scratch your face at the wrong time.
Any thoughts from infectious disease specialists?
Why do people suppose that? If I have a virus and cough, the virus particles can be aerosolized and hang in the air for a while where they can get breathed in by others. I don’t know the odds of actually getting infected that way vs touching one’s eyes or nasal membranes, nor do I know how one would conduct research to find out, but I would be very interested in the results. I would not place any large bets on the results.
With any infectious respiratory disease, there are three obvious potential routes of transmission: droplets (i.e. accelerated particles emitted from sneezing or coughing), aerosols (i.e. the air we exhale normally), and by touch. While these are all theoretical possibilities, for most actual pathogens only one or two routes predominate in real life while the other(s) aren’t anywhere near as much of a threat.
The problem is that we don’t know which of these three routes is the real driver of spreading SARS-CoV-2 and which play a more minor role. There are some clear-cut individual examples of all three, as well as laboratory demonstrations of the feasibility of all three. But all that means is that we can’t rule any of these routes out, not that all three are equally dangerous.
Because we still don’t know which of those three routes is the major threat, the blunt tool of drastic social distancing is the most effective way of stopping the spread – there is quite a bit of evidence supporting this hypothesis. There is also plenty of evidence that drastic social distancing has by far the highest cost, as well. So if we could figure out whether the majority of real-world transmission was occurring by aerosols, droplets, or fomites, we could enact much more targeted measures that would be equally as effective at much less cost.
But there’s a real Catch-22 here: in order to determine which route of transmission is the most important in the real world, we need to let people actually become infected (and then study them). But in order for people to get infected, we would need to loosen the drastic social distancing. But our leaders are obviously unwilling to loosen those measures without knowing more about the routes of transmission.
Again, I am not an expert, but supposedly the virus does not hang around in the air long enough to be a threat. It is attached to the tiny droplets of watery fluid expelled by the cougher and sneezer and falls to the ground or on surfaces. While the virus can be detected in the air of some Covid patients rooms, it might not be a large enough concentration to cause an infection in another human. You cannot be infected from one or two floating viruses. There is some sort of critical mass involved for it to be effective.
Addendum:
For what it’s worth, the World Health Organization put out a report in which they claimed”
“Airborne spread has not been reported for COVID-19 and it is not believed to be a major driver of transmission based on available evidence; however, it can be envisaged if certain aerosol-generating procedures are conducted in health care facilities.”
https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
There has been increased skepticism over the WHO’s findings and motives concerning China so I’m not sure if this is to be taken as gospel or not. They are the organization who originally said that the disease cannot be spread by human to human contact, though they definitely contradict that notion in this report.
#44 Phil Turmel
Cold is fine — irresponsibly half-cocked (with a generous side-helping of patronizing about the elements of and qualifications for rational analysis and argument), is not.
From the blog post/analysis that Ontheleftcoast has linked to further back in the thread here:
“Many people question the importance of this outbreak, and suggest that these are just people dying who would have died anyway from something else. The New York data invalidate this idea.”
Damn straight! No one is even remotely correct in simply shrugging their shoulders, after yet another over-50-year-old (or my mom, Ch”v) slips into the evil maw of the Wuhan Virus, and lamely mumbling “Well, it was probably just his/her time to go.”
I have to ask again: At this juncture, are we even *ballpark* accurate in our understanding of what the Wuhan Virus’s characteristics and likely short-to-medium-term health impacts are going to be — even on nominally *healthy* people, let alone on the vulnerable with comorbidities — in a scenario in which social-distancing strictures (only just *now* being proven efficacious) are cancelled across the board as part of a vaunted “re-opening” of the American economy?
Hardly — and thus I repeat: Absent a vaccine being readied *beforehand*, all this blithe chatter about a rollback to the status quo ante, and about somehow getting to herd immunity is worse than frivolous — it is murderously irresponsible.
The Constitution is not a suicide pact, and it for damn sure isn’t a euthanasia pact either.
My understanding (just from the medical literature) is that different scientists are still debating this topic, although it does seem like most agree that droplets play a bigger role than airborne transmission.
But there are several different degrees of airborne transmission. SARS-CoV-2 is certainly not measles or legionnaire’s disease, which can linger in the air for long periods of time and remain infectious while traveling through HVAC ducts through large buildings. However, there have been many documented cases of transmission by asymptomatic individuals, which almost by definition means it wasn’t spread by coughing or sneezing. So it does seem like “airborne” transmission in the form of a normal conversation with a healthy-looking person is a real risk, which is fairly scary if true.
Some of it might be irresponsible talk, but not murderously irresponsible in any sense that it should be a matter of interest to law enforcement. And some of the blithe chatter is entirely appropriate, for example, about incremental, staged rollbacks to the status quo ante. Our Constitution protects the right of people to petition for redress of grievances, and we have some grievances. Some of the “not a suicide pact” talk we hear might tend to undermine that right, and I would put it in the category of dangerous. I certainly had that opinion when that phrase was being bandied about after 9/11. But we live with lots of danger.
In case you’re interested, I think most of your blithe assertion is irresponsible, perhaps even murderously responsible, though not in the sense that it should be a matter of interest to law enforcement. It’s hardly unique in the chatter around here or anywhere else.
Meh. I’ve already lost family to Covid-19. You still have your mother and can act to protect her, though letting her go out in public to conduct real estate transactions seems a far cry from that.
Complete straw man. I’ve not taken those positions at all. And I would argue they aren’t implied by my comment.
You have restated the “precautionary principle”. It has been used by activists to promote favored policies to avoid predicted catastrophes for all manner of asinine ideas. You and modern medical experts have decided that society cannot survive without draconian isolation policies, particular the isolation of healthy people, that has never been used in human history. The closest analog would be the public gathering bans that were used to good effect by some jurisdictions during the Spanish Flu pandemic. I would argue that the burden of proof is on you to impose these draconian policies, not on the rest of us to prove that they can be lifted.
Do you mean that failing to go to extraordinary lengths to help your mother is equivalent to killing her? When she won’t even participate in any reasonably-expected level self-isolation to deal with her own problem? Sorry, no sale.
Folks, if you’ve got a vaccine for this virus, one you’ve quietly been keeping in your back pocket as you’ve been reading how this thread plays out, please raise your hand(s).
I mean, really, how impertinent I’ve been: The solution has been staring me in the face the whole time, evidently — just ask everyone here in plain English if we (my mom and I) can transact for somebody’s spare jab of whatever vaccine they’ve come up with.
In fact, betcha 90 percent of you don’t need either your spare jab or the main one given to you; so maybe we could transact to get that one to someone else in the (what I’m told is the) 10 percent, too — one of those oddball 10-percenters whose blood oxygenation levels drop like a rock when they catch someone else’s cold which turns into bronchitis which turns into pneumonia quicker’n you can say “logarithmic scale.”
Because we definitely know that healthy 40-year-olds don’t succumb to the Wuhan Virus, no sirree — and that’s just one tidbit from the encyclopedic knowledge base about this coronavirus that we have to hand.
Ah, but silly me — sorry I forgot!
After all, we know accordingly that herd immunity (“Monorail!…”) for sure functions reliably for *every* healthy person in the presence of this virus, as has been so authoritatively explained — and that once developed this herd immunity well-nigh instantaneously furnishes us with further unmatched visibility into the workings of the virus.
Future’s so bright my mom and I gotta wear shades…
You are avoiding discussion of the tradeoffs that need to be made. You are talking as though there is only one variable that needs to be optimized.
#56 Phil Turmel
Totally specious assertions made about what my mother does and doesn’t do, based on zero knowledge.
Today represents the first time in a month that she’s gone to meet a prospective real estate buyer at a listing; she is not physically getting within 25 feet of the prospect and will not be accompanying him into the house — and then she will drive right back home, resuming business via phone and laptop.
Aside from the occasional stroll around our block, she has gone nowhere else outside the house and yard — again, for the past month.
My dad lost a longtime friend to the virus about ten days ago — does that qualify in this pissing contest you seem interested in conducting?
#58 The Reticulator
The CCP/PLA regime possesses but is obscuring key information about the workings of this hyper-transmissible virus.
Unless and until a vaccine is made available (and assuming it’s a reliable one, I know my mom wouldn’t flinch at a high price-tag — how’s that for personal responsibility and living in a world of acceptable tradeoffs?), our variables for assessing what constitutes an economically fair, Constitutionally viable, and physically minimally-lethal approach to re-opening the economy and our national life are, sorry to say, significantly more circumscribed than we all would wish.
Not just because otherwise my mom’s probability of dying would hit Van Allen Belt levels (because I could more easily be exposed in my supermarket excursions to the virus and thus be far more likely to transport the virus by accident into our home, where she is now and would have to remain as a complete shut-in).
But also because a surprisingly high percentage of otherwise presumably healthy people would also land in the ICUs as well; I suppose their untimely deaths would have to be chalked up to involuntary sacrifices for the rest of us, in the fitful ongoing effort to expand the frontiers of our understanding of the virus in the absence of CCP candor, while we all continue to await a vaccine.