1. Ventilators do not produce good outcomes. My guess is that there are some people walking around today who are happy after having been on a ventilator, but I don’t like the odds. If I were to give an advanced directive for how I want to be treated, it would be “Do not ventilate.” There are other benefits of “flattening the curve,” but I would not promote “making sure we have an adequate supply of ventilators” as a major influence on policy.
In general, treatment is proving to be very difficult. I hope that we will discover a set of protocols and pharmaceuticals that will be effective. For now, the virus seems to have effects on the body that are complex and variable. I can imagine that it will turn out that no one treatment method works for everyone. It could take a very long time to sort this out.
2. I am not counting on finding a vaccine soon. On the one hand, scientists are trying very hard and using a variety of approaches. On the other hand, the track record of not finding vaccines for some other viruses is sobering.
3. Testing does not work well. The problem is that even a low rate of false negatives and false positives can be very misleading, both for the individual and for policy makers. I won’t go through the arithmetic here (I did some in this post). Because of the way that seemingly small rates of false negatives and false positives undermine the efficacy of testing, I doubt that “test, track and trace” is the main way that Asian countries have contained the virus.
4. It is worse than the flu. I never doubted this, and very early on I attacked the point of view that this is just like an ordinary flu. But if you still want to hold onto that view, ask health care workers what they are seeing. Or wait a couple weeks until the number of deaths in the U.S. has doubled again.
5. The differences in severity by age group are staggering. It is catastrophically worse than the flu for patients in nursing homes. It may or may not be worse than the flu for people in their twenties, pending studies of long-term effects.
6. Close contact in enclosed spaces is a much more important transmission mechanism than doorknob effects. I don’t care any more that “the virus can live on surfaces for hours.” Case studies of how people got the disease point to personal contact and/or HVAC (heating and airconditioning).
7. Social distancing works less well than one would hope. That is, while it seems as though you can detect a bit of slowdown in infections in times/places where social distancing increased, the differences are not nearly as dramatic as the age differences or the Asian/Western difference. I am afraid that as a defensive system, social distancing as we practice it leaves too many gaps, especially around nursing homes and sectors that are essential, such as health care and food. People’s impulse to shelter in multi-generational families tends to undermine the benefits of social distancing–the “escape from New York” phenomenon.
To successfully drive down the infection rate close to zero, you need more drastic measures than what we have undertaken in the U.S. and Europe. You cannot let people leave home for “essential” purposes, but instead you have to deliver food rations via the army. You have to keep multi-generational families apart. If you want to quarantine infected people, you have to really do that in separate compounds, not in their homes. Maybe something like that can be enforced in Wuhan or Israel, but I would not want to even try it in this country. And even where it seems to work, the virus could come back.
8. A fresh-air lifestyle is good for you. I am struck by the low death rate among homeless people and in India. Those populations ought to be at high risk, and the only story I can come up with is that they don’t spend as much time as we do indoors with HVAC.
9. Masks are good for society. Places like Taiwan and Hong Kong, which have the sort of density conditions and indoor-living conditions that we have, nonetheless have performed much better. There are other differences in how they cope with the virus, but the contrast between East and West on mask-wearing stands out to me.
Those beliefs may or may not be correct. But I have tried to arrive at them by reading with an open mind. I do have strong political opinions, but I hope that I have not let those opinions drive what I believe about the virus.
Arnold. You have to look at NYC death stats. It’s not age. It is Co-morbities. The P of healthy person as a NYC resident is vanishingly small only 58 deaths with no underlying condition in city of 8.7 mill. I’ve been following this for weeks.
One of the problems with the “no underlying conditions” narrative is that 35-50% of the population has obesity, hypertension, diabetes, etc.
Does a person whose HT or T2DM is well-controlled with no complications have the same risk as someone who takes no care to manage their illness? There is a huge continuum here.
I’ve seen informed speculation that the 40-something with well-controlled hypertension should have lower risk than the untreated one, but until there’s more confirmation it’s cold comfort to say only half the population is at elevated risk.
Both factors are important, but age is much more important.
A study on this point came out just yesterday at JAMA, “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the NewYork City Area”.
Speaking of ventilators, mortality for those who received mechanical ventilation was 88.1%. For older than 65: 97.2%. Damn. I might take the chance at 1/9, but probably not 1/36.
Now, it is true that if you are a healthy, young person, you’re chance of dying from this is very small.
But look at the tables: age is a huge factor, median age was 63. Yes, comorbidities also a big factor, but the big ones (which all tend to go together) are hypertension (57%), obesity (42%), and diabetes (34%). You can’t explain the disparate case or death rates on the basis of those. Far too many middle-aged people have them, and actually, unfortunately, too many young people have them too.
Of the 342 cases of people hospitalized under 40, only 3.5% died. But most of those were over 30, and there is plenty of obesity in NYC from 30-40. On the other hand, 45% of the patients over 70 died.
Here’s a way to look at it: People that die in car crashes tend to be driving fast and/or not wearing their seat belts.
People who are driving fast tend to get into more crashes. If they weren’t wearing their seat belt, they almost certainly died. But many died even if they were wearing the belts.
Lots of people who drive slow don’t wear seat belts, but because they are driving slow, whether they weren’t wearing a seat belt doesn’t matter, because they don’t tend to get into crashes. On the rare occassion that they get into a crash, then not wearing the seat belt makes a big difference.
Let me emphasize that ventilator mortality stat again, since the “flatten the curve” argument is about not running out of hospital resources, and in particular, the bottleneck of an inelastic supply of scarce ventilators.
Let’s say your ICU has 36 ventilators, and you’ve taken up every one for a few days to try and save people who are 65 or older. In this study, only one of those people survived, with who knows what kind of long-term damage and prognosis. I’d say there’s a strong chance that guy survived because of the intervention, but some chance he would have made it without the ventilator, and some chance one of the other 35 people died because of the trauma of invasive ventilation.
That’s not a lot of benefit for the catastrophic cost of Lockdown Socialism, for which one of the primary arguments was to ensure that there would be enough ventilators to go around for everyone that needed one.
What I hear you saying is that:
a)the purpose of lockdowns was in part to prevent hospitals from being swamped; and
b) hospitals could be swamped because they are doing too much futile care.
So, we inflicted great economic loss to enable futile care.
Here is some documentation…..
https://www.businessinsider.com/coronavirus-ventilators-some-doctors-try-reduce-use-new-york-death-rate-2020-4
“Inflicting great economic loss to enable futile medical care” . . .
Isn’t that what we do normally with our American Medical Model? “Many think the Pareto ratio applies, that 80% of US medical care is bullshit, and 20% substantive and valuable.
The average cost of the pandemic to the economy is nearly the same for states with and without lockdowns so far. In the long run it may be less in states with lockdowns, not more because fewer essential worker will die.
Are there any states without lockdowns?
One small perspective shift:
Looking at the numbers, the ventilator is a more worthwhile option if you’re under 65. The survey skewed older so if you look at the patients <65 with no outcomes you see 33 were discharged and 107 died after receiving mechanical ventilation. That's almost a 1 in 4 chance (23.5% lived, 76.5% died), which is still pretty bad, but one I'd take.
Regarding the mortality rates the JAMA paper gave, those are misleading and will likely go down substantially with longer monitoring. This is because they calculated those by comparing the intubated deaths to the total intubated patients WITH AN OUTCOME. Unfortunately the only outcomes counted are death or discharge, leaving all the existing hospitalized patients uncounted.
Those existing hospitalized patients are approximately 2-5x the number of the deaths. Since intubated covid patients take weeks to get discharged we are only just seeing discharges out of my hospital, so expect mortality rates to drop substantially into the 25-50% range once those gradually recovering patients are accounted for.
But counting everyone who is discharged from the hospital alive as a success may overstate things in the other direction.
I do not think this is the correct way to read the JAMA data on ventilators:
As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital.
So for 72%, we don’t know how ventilation will work. The mortality rate is taking a point in time estimate where the only possible outcomes are death or discharger. And…
Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1).
So it’s still very possible in this data set that ventilation is (very) helpful. We need to follow the cohort out. Anecdotally in our region (a close friend is a doc), ventilated patients are probably surviving ~50%+ of the time.
On review, what Tim S said.
Hypertension correlates with age. Saying COVID targets the hypertensive is like saying it targets grey hair.
Not sure I agree with 7. Are you just basing that on real time R estimates?
I think he’s basing it on the fact that new cases and deaths are not declining — they have only leveled off.
Re 7 & 9: I consider wearing masks a part of intelligent social distancing (is that like a true Scotsman?). Which makes social distancing considerably more effective.
(8.) In case you haven’t seen this study (open-air and Spanish flu). I suspect correlation without causality (for geeks, omitted variable bias), but it’s still interesting.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504358/
Thanks for sharing this link. An open air cure sure sounds better than putting old people in a windowless ICU room on a ventilator that may work about 3% of the time.
Very strong meat, Arnold.
While some of your beliefs are pretty good summation of some of my positions, I am very interested about your point on forced isolation and delivery by the army. Some high density places aside (NYC) that just seems disproportionate and overly-cautious as a general approach. Australia – where I leave – appears to be making great strides with a shutdown that is strong but no where as strong as that.
That aside, I endorse your view about this pandemic worse than the flu and the need for an open mind. My libertarian (really Classical Liberal) instincts mean that I applaud findings such as those coming out of the Stanford studies. But we have to remind ourselves that the fatality rates implied by those studies equate to the Flu PLUS flu vaccine and we should therefore feel less sanguine about the risks of an early move to opening up.
Thanks for the insights, and the straightforward writing style.
The enormous challenge for America and Europe is to “live with” the virus and not have an economic Depression. So far there has been too much ‘happy talk’ about testing and quarantining protocols that will not be achieved.
The service sector of bars, restaurants, hotels, conference centers, sports stadia, et al is probably doomed with or without lockdowns. Is this a large enough ‘body blow’ to the economy to bring a Depression? I wish someone would tackle this.
Given these beliefs, I’d be very interested in hearing your specific recommendations on the easing of governmental restrictions.
Upvote for this.
Excellent post. Thanks for this. In particular, I would really like to hear more about your thoughts on test and trace (and isolate and certificate) since your thoughts seem to be contrary to those of your colleagues (and elite consensus in general) who seem very strongly in favor of test, trace, etc.
6 – 8.
I wonder if HVAC accounts for some of the Texas prison outbreaks. It would be good if someone were investigating it the way they did the restaurant case study. Maybe an opportunity to control spread by retrofitting HVAC systems with better filtration and possibly the far-UVC light treatment discussed here: https://www.crr.columbia.edu/research/using-power-light-preventing-airborne-spread-coronavirus-and-influenza-virus. If progress in developing practical applications is capital starved, maybe funding for such applications should be higher than bailouts.
Letting people out and allowing them to walk in parks and the beach would probably be a huge net improvement as there is minimal evidence of greater open air transmission relative to individuals stuck in the same building, breathing the same air, with a growing viral air load. Letting people go to parks would quite likely reduce both infections and case severity.
Related. Instead of returning infected nursing home residents back to their facilities, a better idea may be to convert sports arenas to treatment facilities: https://time.com/5813442/coronavirus-stadiums-hospitals/
More on 8. Somebody else seeking to prioritize improved indoor air quality, increased outdoor air exposure: https://www.nationalreview.com/corner/coronavirus-transmission-chinese-study-shows-covid-more-likely-spread-indoors/
During a previous plague that also didn’t have a cure at the time–Tuberculosis–the palliative care of choice was also to put the patients outside in “sanitariums.” My grandfather died in one in 1935. My father said they would push his bed out on a big veranda, and it was actually quite pleasant.
Mostly I agree with you. But I think social distancing does help. The new daily deaths in the NY area are dropping overall, and new infections (based on deaths with a 3 week lag) hit their peak right around the March 20th lockdown. Exactly what you would hope. And everywhere else they went from 30% per day to basically flat: figure.
About the mortality, the U.K. revealed some data on total deaths by age cohort that is staggering. For people under 45 there’s no noticeable increase in total deaths since C19 hit. For people over 45, total deaths increased around 50% in each age group. That’s a shocking increase in deaths from all causes. This is clearly worse than the flu for people over 45, at least in aggregate (though it can be hard to tell how much is the higher infection rate and how much is the higher death rate per case).
It’s interesting that over 45 death rates are all up around 50%. After all, normal death rates are vastly different at 47 and 77: about 0.3% vs 3.6% in America. The increase from Covid knocks those up to 0.45% and 5.4%.
“That’s a shocking increase in deaths from all causes.” That largely depends on how long this level of mortality lasts. If it runs for 2 months, then it increases the affected groups’ mortality about 8% on the year. If it runs the full year, it’s a 50% increase in mortality. That’s the difference between 250,000 excess deaths and 1.5 million. A bad flu year might cost 80,000.
Nice post Arnold. Your best yet on the virus in my opinion.
agree
And nice comments. Great thread!
Tyler Cowen may be your favorite blogger, but you are mine. You are a rare sane and clear thinker in a mad world.
1) I don’t disagree on policy of ventilators on policy but it does seem like the manufacturing of them can’t hurt matters here.
2) What do you mean by soon? 6 months? Not happening here 18 months? A good shot of happening. Probably the main reason why past viruses did not get a vaccination, such as H1N1, was it past in 2010, there was no money in it or interest in it. Coronavirus is getting all kinds of money shoveled at and most the population does fear it.
3) Yes, testing in the US is relatively terrible and I submit having 50 Governors do something separate was not optimal here. And even when testing is reasonable effective, then data laboratory collection is all over the place. (ie California)
5) The age impact is not surprising as the average flu for a senior citizens is close to 10x more deadlier than them than a 20 year old. And on the other end of the specturm is Measles is exceptionally deadly to all people but I have to imagine was 30 – 50% for senior citizens 100 years ago. (The reality is so many kids got Measles that the survival rate appears lower here.)
8) The reality of opening up is it appears outside transmission is significantly less than inside so open activities such as the beach will have little transmission versus say the movie theaters.
9) The whole key to mask is it only effective when everybody wears one. So it lowers the transmission for a person 10 – 20% that has enormous impact on exponential functions.
My completely wacky theory on this:
In 3 – 5 years when all the medical studies are done and the experience is 90% behind us, I do believe we are going to find out Asian nations and US West Coast had some kind of higher levels of immunity of Coronavirus than the rest of the world.
If we are going that route, I would bet on a different mix of virus strains, with Europe and the US East Coast getting a more deadly mix.
This seems plausible to me, too. I mean, Northern Italy, Iran, and NYC melted down in ways that California and Washington and Taiwan and Hong Kong and Singapore didn’t. Different strains are a plausible explanation.
Ah #2 the answer is viruses are hard even if we have related vaccines. I.e. we have Hep A/B/E, no C/D. A couple variants of HPV but not most. Most other cancer causing viruses equally no vaccine. Herpes? Annual flu vaccine itself low efficacy. How much money been spent on HIV yet it looks like we will find a cure before we find a vaccine. How’s the common cold vaccine coming?
Vaccines are hard, especially effective ones.
2) There are major biological and chemical reasons why getting a vaccine in less than a year is very unlikely. Planning on “we’ll reopen when we have a vaccine” almost certainly means not opening for at least a year.
The link is to Derek Lowe, a reasonable, informed, and non-partisan guy.
And if you want more pessimism.
H1N1 did indeed get a vaccine–they put it into flu vaccines as soon as they could, and I remember they were hard to get for quite awhile. This was the best possible case for getting a new vaccine out into the world, since they could reuse existing formulas for flu vaccines and just put the new antigens in.
“Treatment is proving to be very difficult” … for patients already “compromised” enough to seek hospitalization !
We have lots of “studies” re HCQ, with/without antibiotic/zinc/”X”. Which are then immediately hailed/trashed, depending on the priors of those responding. My unchecked impression is that:
– the studies showing non-efficacy and/or negative effects, are ones where the patient is already “near death”, while
– the studies showing efficacy, “miracles” are ones where the patient is given medication at first onset of symptoms.
Which implies a silly question:
Since we know the number of persons taking HCQ for RA or lupus (very likely several million), and we can obtain (rapidly, at low-cost, and with relatively low error rate) the number of persons both: a) hospitalized for Covid-19 “symptoms”, AND b) died “due to Covid-19”, can we not determine whether those ALREADY taking HCQ are admitted/dying at a statistically-significant different rate than expected ??
I’ve been wondering whether the successful/unsuccessful HCQ tests are different in the way you say. Does anyone here actually know?
Doctors are conservative by nature- they don’t want to kill their patients, or probably more accurate, they don’t want to make a concrete decision for which they might get blamed in the event of a death. This is not me slamming doctors- this will apply to everyone that have life and death in their hands in a litigious society.
So, my assumption is that a lot of the HCQ/etal. treatments are prescribed when all the other standard methods of treatment are failing and the doctor becomes convinced that prescribing it is no longer a decision that might increase the likelihood of death.
Thanks, Arnold.
Some argue that the medical evaluations, with both pro- and anti- results are equally bad: https://pjmedia.com/trending/five-problems-with-the-study-that-claims-more-deaths-from-treating-coronavirus-with-hydroxychloroquine/
Exactly … The author effectively says “This study is garbage for these reasons …”. And others have criticized studies I’d be glad to tell you about because they “demonstrate” what I want to believe for these same reasons; e.g. small sample size, not representative, etc., etc.
But, what am I missing here ?? How many of the 48,000 US deaths were persons who were taking HCQ on March 1 ?? Or,if that’s “too difficult” to obtain, how many of those persons were diagnosed with RA or lupus ??
US pop. = 240 million; 1 million = 1/240 = 200 deaths.
So, even with wide error ranges, if only 45 deaths, does anyone think that might be worth trying to understand/explain ??
HCQ has been widely used for what — 25 years ?? We have , I believe, extremely good data on contraindications, safe dosage range, etc.
And, Yes, I understand that if “everyone not contraindicated” starts taking it, there will likely be shortage and RA/lupus patients will be negatively impacted.
That is a good question and I don’t know the answer, but here is one source claiming that people with lupus and taking the medications do get lupus: https://creakyjoints.org/symptoms/lupus-patients-do-get-coronavirus/
But I have heard contradictory reports from other sources. A definitive answer would be helpful.
Thanks for pointer !
Unfortunately, the data here is:
1) extremely difficult to reliably correlate,
2) primarily patient “self-reported”; less than 4% was reported by “providers”,
3) NOT addressed to question of death rate or severity index — it reports “10 of 234 (4%) patients have died”, but doesn’t attempt to correlate that to “29% on HCQ prior to Covid-19 diagnosis”
So, while it may prove prove persons on HCQ are becoming infected with Covid-19 [ you meant “do get Covid-19”, not “do get lupus” 🙂 ], it fails to address my question.
It helps to stop you from getting into an auto immune death spiral, but it can’t stop one that is going.
3. Japan tested less than that U.S. in February and March and did almost no tracking, yet it has 300 deaths after 10 weeks of dealing with coronavirus.
4. “Or wait a couple weeks until the number of deaths in the U.S. has doubled again.”
Coronavirus now looks to be somewhere as deadly as influenza, twice as deadly or possibly three times as deadly. It looks impossible for the number of U.S. deaths to double from 42,000 today to 84,000 by May 7th as deaths are now increasing at only a 5-day average of 5% a day, whereas the previous 5-day average increase was around 8% and the previous 5-day average increase before that was 13%. We can expect 50,000 to 60,000 deaths by June.
Could you check your math? By my calculations, a daily increase of 5% corresponds to a doubling time of 14.2 days, so Dr. Kling’s “couple weeks” would be correct:
ln(2)/ln(1.05)=14.2
The trend seems to be downward in the rate- in other words, it likely won’t 5% after this weekend- it will be under that. If the trend downward continues.
Right.
On March 24th, I thought there would be between 35,000 and 50,000 U.S. deaths by April 23rd – right around Earth Day – based on both how large European countries cases increases were falling and then in the U.S. I multiplied by a 1.2% to 1.6% morality rate, which was what I was seeing then, not close to the under 1% I thought we’d eventually see. I knew 50,000 could be too low so doubled the top end to 100,000. I thought closer to 50,000.
On April 7th, I could see the general pattern for the decrease in increase of deaths in Western Europe and again starting to see in the U.S., so I extrapolated a 1% increase a day, which turns out to be 1% increase on Apr 23rd with 400 deaths a day. That gave me 41,000 deaths today, which is close to the 42,000 the CDC has but at a 5% rate, not a 1% rate.
I put 40,000 at the low end and thought there could still be in the low hundreds of deaths after April 23rd so put 60,000 at the high end. I realized an hour after I extrapolated 1% decline that based on Western Europe it should have been maybe a 0.7% increase a day but the point was to get a general range. I thought 50,000 deaths by June, then over for Round 1.
I’d question the use of the 5-day average, as I question Dr. Kling’s 3DDRR: the latter shows a pronounced dependence on the day of the week, and, while I haven’t tried to plot the former, I suspect that it would as well. I use a 7-day average, so that I’m comparing, say, this Tuesday to last Tuesday, and the plot seems to be free of those weekly peaks and dips.
As of April 22, the daily increase, calculated as r_7=(7DDRR)^(1/7), was 5.9%. As of April 15, it was 9.9%. If we extrapolate linearly from that, we should reach 0%, or a constant death rate, in just over 10 days.
But that seems to rely on some highly dubious assumptions. We can expect a given set of practices, when combined with the intrinsic properties of virus-human interaction, to yield a certain value of the daily death-rate increase r. We can expect that a change in practices won’t instantly alter r, but that there’ll be a gradual move toward the new value. But we can’t say that the rate of change in r will remain constant; it’s more likely that the curve will flatten out at some value that might be above or below 1.
Looking at my plot of r_7 versus time, the graph shows some signs of being concave-upward since about April 9.
Using CDC data for known deaths on Wiki, here is the 7 day average of increases in deaths over the past 28 days:
Mar 19 to 25…32%
Mar 26 to 1…..26%
Apr 2 to 8…… 17%
Apr 9 to 15…..10%
Apr 16 to 22…..6%
That looks like a clear downward trend to me, although I’d ignore the first Mar 19 to 25 week since fewer deaths than. I’m not sure how long the increase in deaths will stay at 2% or 1% from later next week or so but deaths each day will be significantly lower than the past five days at 1,700 deaths per day. I don’t see how there can be over 60,000 by June.
Re: 8, I agree that the outdoors is probably safer than indoors. But since so many homeless appear to be infected, this would have to be an argument about viral load. Also, what is the obesity rate among the homeless and in India?
I just looked up India: 3.7% (compared with nearly 40% of adults in the US). And while the US poor have high obesity rates, I don’t think that’s true of the homeless. That may help explain why they have high infection rates without so many deaths. Also, not so many elderly homeless, I imagine.
Re: Taiwan, they shut down travel from Wuhan on Dec 31, banned Wuhan residents on Jan 23, banned all Chinese visitors on Feb 6th. They also only have 4 international airports, so a bit easier to manage. I’m sure masks help too. Acting early and having a smaller “attack surface” for incoming visitors probably also helped them a lot.
Re: 7, I think social distancing has almost certainly lowered the infection rate compared to some strange counterfactual where people ignored the news from Italy, China, Iran, Spain, etc, and carried on as usual.
The way I see it, there are some people with jobs that cannot be done from home who continued to work, and people in situations like nursing homes who were dependent on others and could not isolate. The initial wave of infections mostly affected these people. As restrictions lighten up, many will continue to choose to isolate, especially those who can work from home, but I would think that subsequent waves may be less strong because those who are in the jobs that cannot be done from home were the ones most exposed to it already. So there might be something approaching herd immunity within some economic network hubs (think cashiers, for instance). This isn’t a strong view I hold though.
One grim but possible explanation is that most of the homeless people who weren’t robust enough to survive COVID-19 didn’t survive the rigors of living on the streets for the last several years.
3. “I doubt that “test, track and trace” is the main way that Asian countries have contained the virus.”
A CDC article suggests that a Singapore approach might work early in the beginning of an outbreak, but says nothing about whether it is either practical or effective once the horse is out of the barn:
“Singapore implemented strong surveillance and containment measures, which appear to have slowed the growth of the outbreak. These measures might be useful for detection and containment of COVID-19 in other countries that are experiencing the start of local COVID-19 outbreaks.”
The South Korean track and trace program appears effective but that may be because the initial outbreak was a superspreader at a church event, a relatively simple track and trace situation. Given the relatively large portion of USA cases already tracked and traced in nursing homes and prisons, and the reality that many cases are transmitted between family members already sheltering in place, one wonders how much marginal improvement additional tracking and tracing would actually provide. Seems like a waste of resources. Making sure each household in the USA has a no-touch thermometer and an oximeter would offer much greater return on investment especially long term.
And a good City Journal article buttresses your points in 3: Political Leaders and Citizens Need Better Understanding of How Covid-19 Testing Works
https://www.city-journal.org/understanding-covid-19-testing
Here is what Hong Kong did:
https://medium.com/@samgellman/what-hong-kong-has-done-right-2563004e7871
FYI, here’s an analysis of super-spreaders. The major mode of transmission (in such events, YMMV) seems to be ballistic projection of dropules while coughing, singing, or speaking loudly. Masks are recommended. Religious activities, parties, and funerals were particularly risky. Superspreading events were often upper-class, but IMHO this is probably associated with the demographics of travel.
This doesn’t make sense. If no one is going out, then there’s no harm in having multi-generational families together. There shouldn’t even be much harm with a reasonable level of going out with proper social distancing.
As somebody who lives in Hawaii where, unlike the rest of America, multigenerational housing is truly the norm as in “four bedroom 1500 sqft house with four generations living in it complete with adult bunk beds” I think he is saying is chances are at least one of those fifteen people are an “essential” work or regularly comes into contact with one and will spread it to the other fourteen.
He’s not talking mainland single family McMansion with grandma to as a free babysitter.
Has anyone seen any studies of reasonable social distancing outcomes? IOW, is there any evidence that people who go out of the house twice a week with masks and sanitizer and practice good social distancing are catching the virus?
My guess is their risk is negligible. I wouldn’t be surprised if they were more likely to die while driving to Walmart than by getting sick from Walmart.
It seems those getting sick now are nurses, people still going into crowds, those in crowded nursing homes, idiots still riding public transportation, and those lined up shoulder to shoulder plucking chickens.
But I could very well be wrong.
My husband works in a care home for the elderly in central London. He doesn’t drive. To get there he has to use public transport. He is not an idiot.
Sounds unsafe for the elderly he works with. He sounds like a virus vector to me.
[On this blog, comments are phrased politely–ed.]
If you’re correct, then the only practical alternative is to come up with ways to live with coronavirus long term, including:
– Wearing masks
– Upgrading A/C systems to include anti-viral (UV?) equipment
– Flooding workplaces, restaurants, arenas, airports, etc. with far-UV radiation
– Increasing janitorial staffs to more frequently and more thoroughly disinfect bathrooms, kitchen areas, banisters, etc.
Right, but which measures we need to take depends on which modes of transmission are most important, which isn’t so clear. If the main issue is spread by big respiratory droplets at close range, usually indoors, then that gives us some ideas (masks, physical separation, all doors closed unless otherwise required, etc). If very small airborne droplet nuclei floating through the HVAC system are a major mode of transmission, we need to do different things–probably things that will be expensive and hard to do quickly. (How hard is it to upgrade normal office HVAC systems to use hospital-grade filtration to stop airborne transmission?).
I caution against using HVAC as the catch-all. I see some have already misunderstood that reference. The “HVAC” vector was not the actual system but rather individuals were infected by being downwind of an infected person in an airstream created by an HVAC vent. It is telling that no one else in the restaurant was infected which reveals that the virus is not surviving to be propagated by the HVAC system. This could be either poor stability in real world conditions compared to lab tests or more likely dilution. In the Chinese study, only those downwind at adjacent tables were infected. This pushes against the large droplet transmission, but only that smaller nuclei can travel further in an airstream.
This low speed air transmission was shown for influenza was demonstrate in original experiments in 1941.
I project several mods may be implemented in the conditioned air. One, diffusers that do not create airstreams across patrons. And perhaps increased use of ERV/HRVs (energy recovery ventilation/heat recovery ventilation) to bring in more fresh air. And possibly creating a slight negative air pressure in public venues to whisk away exhalations.
These will not be cheap for restaurants already on the ropes and possibly not possible in restaurants in multi-story buildings in urban areas.
I do not see HVAC filtration or UV-C lights being much use as the virus likely is deactivated/diluted by the trip through the ducts. It would likely be caught in the condensate draining during cooling and the hot elements during heating (as has less stability at higher temps and none at 104 F)
I should have noted that a simple fan is as likely to create the attack vector found in the restaurant as a HVAC system.
Thank you. I am glad that you are thinking about the issue and that better alternatives can be found.
1. Early treatment with oxygen probably is better than later. Using a pulse oximeter daily to detect lung impairment early, before other symptoms appear, might increase your chances. Steve Sailer has a couple of posts: https://www.unz.com/isteve/buy-a-pulse-oximeter
Am I less concerned with the shortage of ventilators than the shortage of the likes of you, Arnold Kling. To the extent that such a personal decision (to continue treatment during desperate illness) weighs the value of “society”, please know how important your work is and will continue to be.
Take the ventilator.
My wife was on a ventilator, then off. Then, back on, and, finally, *successfully* taken off the ventilator. She was nutty as a fruitcake for a couple months, and it definitely did not look like fun while she was doing it, but she made it. I know that is an N of 1.
We get a tremendous positive externality from your existence, for whatever that’s worth.
I was in the ICU for 7 days, and a regular room for 6 days. On the 3rd day in ICU, the doctor told me if I did not improve in 24 hours he would recommend the ventilator. I told him I did not want to be intubated under any circumstances. I think the ventilator is a death sentence. I improved on oxygen therapy and drugs. I am now home, with perhaps 40% reduction in lung capacity. Nobody can tell me if the reduced lung function is temporary or permanent.
Thank you Chuck, and sounds like that was a wise decision. If you don’t mind, could you tell us more about your story? If you have a suspicion of how you caught it, where you live, how your symptoms progressed, what you were told, when you were tested and got results, and so forth. I know everyone here would greatly appreciate it.
The ventilator is almost certainly not the reason for the poor outcomes- it is simply a marker for more serious illness. It is like blaming chemotherapy for cancer deaths. In almost all cases it is foolish to refuse it because you think it will worsen your disease. There is such a thing as ventilator induced lung injury but it occurs in people we already existing serious lung problems ( that is why they get a ventilator in the 1st place) and can be mitigated by careful titration of respiratory support. It is certainly true that for many of the elderly and sick COVID patients the ventilator is close to futile therapy-but that is because there outlook is so grim-not because the ventilator causes their demise.
Re: #1 (from an anesthesiologist/intensivist)
In most acute illness, a ventilator is a bridge to recovery from the underlying disease. Mechanical ventilation can slow the progression to death, or stave it off long enough for a patient to improve. Age, comorbidities, etc. can help to stratify who, but prediction is still hard, especially with our knowledge of the disease being as limited as it is. If you “require” mechanical ventilation, you may not survive the disease even with that intervention, but you definitely won’t survive without it. Even without considering ventilators there is still a finite (if somewhat elastic) capacity to provide patients with non-invasive oxygen therapy, and in most hospitals I’ve worked at those are still therapies that “require” a spot in the ICU. We may not need to “flatten the curve” to conserve ventilators, but the new capacity limit may be critical care resources more generally.
An underappreciated driver of our seeming need for so many ventilators earlier on: PPE shortages and concerns of risk to healthcare professionals. The goal was to put COVID patients on ventilators very early in their course. Only part of this was for their benefit. The non-invasive alternatives (high-flow nasal oxygen, non-invasive ventilation) have the potential to aerosolize the virus and expose hospital workers to a much greater extent, or so it’s been thought. Many hospitals initially ruled out using those therapies on COVID patients, meaning earlier escalation to invasive ventilation. Better understanding of the dynamics of transmission, and more reliable access to PPE have started to reduce this particular drive to ventilate early.
Perhaps off-topic for an economist’s blog comments, but I’d add that the mortality among ventilated patients reported in the JAMA study referenced earlier will likely be high compared to any later studies. There’s nuance in managing mechanical ventilation, and more and more data suggests we’ve been doing it wrong in COVID patients. Our usual “lung-protective” protocols for ventilator management have probably been causing harm to a large subset. One of my colleagues still in NYC tells me that most of her COVID ICU patients have had pneumothoraces of both lungs (essentially, both lungs blown out by the ventilator… hardly “lung-protective”). Improved ventilator strategies cut mortality in certain other lung diseases by half once adopted… hopefully we’ll see something similar here.
Thank you for sharing info from the front lines. I’m reminded that hospitals are dangerous places.
When it comes to COVID-19, we can run but we cannot hide.
No vaccine on the horizon.
Lockdowns are frightfully expensive, and may not be effective in containing the virus anyway.
So what is the least bad option? Probably getting to herd immunity naturally, with very unpleasant results for the elderly with co-morbidities.
Early antibody tests are estimating infection rates as high as 20.0%+ which dramatically reduces the infection fatality rate (“IFR”) to 0.5% which is 5x higher than the seasonal flu at 0.1%. If the IFR is really 0.5% does this change your opinion on any of this?
All cause mortality is 2x reported coronavirus deaths, so at least 1%. And about 10% hospitalized. Lot more than the flu.
#8 — Is it possible that their immune systems are stronger? Perhaps, either by exposure to more stuff over time, or by survivor bias?
I can’t read all the comments, so I don’t know if this has been adequately commented on, but I have to comment on one point Arnold raised.
Social distancing as practiced in the US is hasn’t worked as well as everyone assumes because we have not been very socially distanced. Almost all of us have to get out for groceries or other necessities. I have observed for the last several weeks that the majority of people neither wear masks or gloves. In grocery stores people constantly come in close proximity to each other.
The economy is being destroyed on a daily basis, and the policy makers, press, and citizen commentators seem to think that social distancing has been correctly practiced. It hasn’t. It is time to end the charade and carefully get to work. Not everywhere, but most of us don’t, thankfully, live in New York or similar crowded big cities. The condescending blathering about listening to scientists and using data is just argument points…I’m a scientist and I see very little useful and accurate information about a host of important questions, some of which Arnold mentions.
This has been a period of people doing the best they can to govern or simply exist in this situation, but basically from top to bottom we have been stumbling in the dark. Just look at how many theories have come out about transmission – and no definitive answer. This contentiousness and acrimony and gotcha discussions hasn’t served anyone well. But from what I can tell, we probably have infected a higher fraction of the population than we imagine – too many people have not protected themselves. It is time to quit doing things that are not working very well. Curve fits to the data show that nationally we are two weeks past the peak. We have ‘flattened’ the curved for most of the country, which was the purpose of social distancing (not bringing the rate of infection down to close to zero).
Good post, as usual.
But, can we at least have full disclosure here in terms of the costs and benefits?
The virus is heavily concentrated in the 60+ cohort and/or those with pre existing health conditions. We should take reasonable efforts to protect these people.
However, on the other side of the ledger is the vast majority of the population that isn’t particularly at risk of adverse reactions, but they now find themselves unemployed.
Is there a more reasonable or cost effective approach to balancing the conflicting needs?
Tyler Cowen reprints an email suggesting that about half of the COVID-19 deaths are from nursing homes. So, pre-existing conditions, indoors, breathing the same air. Two comments from that post:
“It should be noted for scale that about 4% of the elderly in the US live in nursing homes*, so numbers like half the deaths in MA being in long-term care facilities really are staggering.”
“So, essentially we’re destroying the economy because of nursing homes.”
“So, essentially we’re destroying the economy because of nursing homes.”
Yes, but you’re not supposed to say it that way.
And, definitely not to be repeated or discussed: the more elderly people that die, the better off we are from a fiscal perspective. The Medicare savings alone dwarf any whining about the stimulus.
The Medicare savings actually aren’t that big:
1) A good number of the people who died from COVID would have died within the next year anyway.
2) The number of people who have died of COVID is just not that big for a country of 350,000,000 people. They are not a very large percentage of the total number of Medicare-receiving people.
“The Medicare savings actually aren’t that big”
Please provide some evidence. An inordinate amount of Medicare spending occurs in the last year or so of life. I feel awkward saying it, but a lot of this cost is foregone with the virus.
If people are going to whine about the stimulus, then this cost savings must be accounted for as well.
Medicare spending in the last year(s) of life is off the charts, astronomical.
The bailouts pale in comparison.
According to this article, the total cost of Medicare in 2015 was about 18 billion dollars and the cost for the last year of life was about 3.8 billion (21%). That seems low to me. Does anyone have better figures? In any case, the bailouts are hundreds of billions. The paling may go in the opposite direction.
Thanks! So, what is the spending / lives saved? And, more importantly, what is the NPV in economic activity per capita vs. the cost?
I don’t have the patience to read that article, but 2019 federal spending on Medicare was $775 billion (looked up on Wikipedia, but seems in the right ballpark at least) — a bit more than $18 billion. And I suspect the end-of-life care for patients dying of COVID is plenty high, so it’s not at all obvious that it would reduce costs.
That sounds like a more realistic number. Assuming generously that a little over a quarter of that is last year of life spending gives a nice round number of $200 billion. The CARES Act is ten times that, about 2,000 billlion. I don’t know how much is loans that will actually be repaid. The new bill that was just passed adds another 484 billion dollars.
I’d second that 21% figure. This issue came up with Tyler Cowen a few years back, and it was about 30% of whole-life expenditure in last year of life. Less than most people were expecting.
USA 2017 causes of death (p. 9)(in thousands):
Total 2,814 100%
1. heart disease 647 23.0%
2. cancer 599 21.3%
3. accidents 170 6.0%
4. chronic lung 160 5.7%
5. strokes, etc. 146 5.2%
6. Alzheimer’s 121 4.3%
7. diabetes 84 3.0%
8. flu, pneumonia 56 2.0%
9. kidney 51 1.8%
10. self-harm 47 1.7%
Together, they make up 74% of total deaths (and, of course, many deaths involve more than one “co-morbidity”). If there were 100 thousand COVID deaths this year, that would be 3.6% of the 2017 total.
SPENDING not mortality.
I hope my 7:57 comment above is responsive to your concerns. What I was concerned with here is “how big a deal is COVID when it comes to deaths?”
Thank you for this, Roger!
Like you, I also am wondering just “how big a deal is COVID when it comes to deaths?”
Far be it for me to question the veracity of “data” coming from our own Federal Bureaucracy titled the Center for Disease Control, but I noted a rather glaring omission in their “causes of death” list.
And that glaring omission is not trivial, especially in this context. It is in fact the persistent 3rd largest Cause of Death in the U.S., according to researchers at Johns Hopkins, and often referenced in JAMA – as described, discussed AND referenced .
(the rest…)
… as described, discussed AND referenced HERE:
https://www.cardiovascularbusiness.com/topics/practice-management/medical-errors-lead-more-250k-deaths-year-us-are-often-unreported
Quarantining suspected cases and their contacts, separately from each other, can be effective at reducing spread at the population level even with high rates of false positives and false negatives. But you can do that without even having enough tests for all if you go ahead and quarantine contacts once there’s symptoms or a positive test for one. You’re absolutely right that they undermine policies that allow people to continue seeing their families.
I think that you are right to look at what successful countries have done. While it’s quite possible that there are uncontrollable external factors like weather (including temperature, humidity, and amount of sunlight), there’s still a difference between countries maximizing their advantages and those that are not.
I don’t think anyone questioned the fact that COVID-19 is worse than the flu. The numbers have been consistent that this is 5-10 times worse than the flu. Is it worth tanking the economy over? That is a separate question.
What is very clear is that people with no co-morbidity (obesity, CVD, diabetes, etc.) are almost immune to the harmful effects of COVID-19. This alone suggests though it was reasonable to shutdown restaurants, bars, and much of face to face retail, that it was utterly stupid to insist that the fitness gyms should close.
It is well-known that resistive weight training (e.g. “body building” workout) increases one’s production of HGH naturally. it has now been proven that increased HGH regenerates the thymus gland to give an older person the immunity comparable to a young person. Shutting the gyms is a very stupid policy.
The ventilators is an example of iatrogenic effects. It turns out that all of the lung damage that was blamed on the virus itself is due entirely to ventilation. The ventilators are run at a higher than necessary setting, which damages the avioli in the lungs. This is the “permanent” lung damage we’ve been hearing about.
Where are you getting the information about the homeless population? I know that the homeless population in San Francisco has been hit pretty hard in shelters but I haven’t seen statistics on the homeless population outside the shelters. I would think that measuring the out of doors homeless homeless might be especially hard since many of them could die undiagnosed.