Unfortunate COVID Follies

08 Wednesday Jul 2020

Posted by pnoetx in Government Failure, Pandemic

Tags

Arsenic and Old Lace, BAME, Black Asian and Minority Ethnics, BLM, CDC, Coronavirus, Covid-19, Dr. Einstein, Flattening the Curve, Hydroxychloraquine, Jonathan Brewster, Lockdowns, Masks, Operation Warp Speed, Vitamin D Deficiency, World Health Organization

This post is devoted to a few coronavirus policies and positions that trouble me.

Counting Deaths: People have the general impression that counting COVID-19 cases and deaths is straightforward. The facts are more reminiscent of the following exchange in the film Arsenic and Old Lace, when Jonathan Brewster angrily insists he has offed more souls than his sweet little aunties have poisoned with elderberry wine:

Dr. Einstein: You cannot count the one in South Bend. He died of pneumonia!
Jonathan Brewster: He wouldn’t have died of pneumonia if I hadn’t shot him!

Here, Dr. Einstein wears the shoes of public health authorities who claim that C19 deaths are undercounted. But lives counted as lost from C19, in many cases, are individuals who also had the flu, pneumonia, stroke, kidney failure, and a variety of other co-morbidities. Yes, other causes of death might be induced by the coronavirus, but like Johnny’s victim in South Bend, many would not have died from C19 if they hadn’t had a prior health event. In addition, otherwise unexplained deaths are often attributed to C19 with little justification.

In fact, the C19 death toll has been distorted by a perverse federal hospital reimbursement policy that rewards hospitals for COVID patients. Death certificates seem to list C19 as the cause for almost anyone who dies in or out of a hospital during the pandemic, whether they’ve been tested or not. In fact, deaths have been attributed to C19 despite negative test results when officials decided, for one reason or another, that the test must have been unreliable!

Lockdowns: almost all of the “curve flattening” in late March and April was accomplished by voluntary action, which I’ve covered before here. The lockdowns imposed by state and local governments were highly arbitrary and tragic for many workers and business owners who could have continued to operate as safely as many so-called “essential” businesses. Lockdowns in certain areas were also blatant violations of religious rights. There is little to no evidence that lockdowns themselves led to any actual abatement of the virus. And of course, people are fed up!

The Beach: Right now I’m at a wonderful beach condo in Florida for a week. There are other people on the beach, mostly families and a few groups of friends, but there is plenty of open space. You will not catch the coronavirus on a beach like this. And there is almost zero chance you’ll catch it on any beach. In fact, the chance you’ll catch it anywhere outside is minuscule unless you’re jammed so tightly among hundreds of protesters that you can’t even turn around. Yet government officials have closed beaches in many parts of the country while allowing the protests to go on. Oh sure, they think people will CROWD onto beaches as if they’re at a BLM protest… except they’re not. Ah, then it must be banned! That takes a special kind of dumbass.

Waiting for Results: How could we have spent trillions of dollars as a nation on economic stimulus, much of it skimmed off by grifters, but we can’t seem to get sufficient resources to make calls to those awaiting test results? This is a case of misplaced priorities. Even now, people are waiting more than a week for their results, and many are wandering around in the community without knowing their status. Wouldn’t you think we’d get that done? We can conduct well over a half million tests a day, but can’t we find a few bucks to deliver results via phone, email, or text within 24 hours of processing results. This is truly absurd.

Vaccine Candidates: A similar point can be made about vaccine development: We are spending $5 billion on Operation Warp Speed to build capacity in advance for five promising vaccine candidates. These will be identified over the next few months, and it looks as if all five will come from established pharmaceutical majors. There are many more vaccine candidates, however, some being developed by smaller players using inventive new techniques. The OWS expenditure looks pretty meager when you compare it to the trillions in funds the federal government is spending on economic stimulus, especially when finding an effective vaccine would obviate much of the stimulus.

Treatment: Hydroxycloroquine has been found to lower the death rate from COVID-19 in a large controlled trial. Congratulations, morons, for trashing HCQ as a potential treatment, solely because Trump mentioned it. Way to go, dumbasses, for banning the use of a potential treatment that could have saved many thousands of lives.

Air Conditioning: I’m shocked that public health experts haven’t been more vocal about the potentially dangerous effects of running air conditioners at high levels in public buildings. The virus is known to thrive in cool, dry environments, which is exactly what AC creates, yet this seems to have been almost completely ignored.

Vitamin D: Likewise, I think public health experts have been far too reticent about the connection between Vitamin D deficiencies and the severity of C19 (also see here and here). The accumulating evidence about this association offers an explanation for the disturbingly high severity of cases among Black, Asian and Minority Ethnics (BAME), not to mention a possible role in C19 deaths among the generally D-deficient nursing home population. For the love of God, get the word out to the community that Vitamin D supplements might help, and they won’t hurt, and otherwise, tell people to get some sun!

Masks: I’m not in favor of strict mask mandates, but I have trouble understanding the aversion to masks among certain friends. Of course, there’s been way too much mixed messaging on the benefits of masks, and it didn’t all come from politicians! Scientists, the CDC, and the World Health Organization seemingly did everything possible to squander their credibility on this and other issues. However, a consensus now seems to have developed that masks protect others from the wearer and seem to protect the wearer from others as well. It should be obvious that masks offer a middle ground on which the economy can be restarted while mitigating the risks of further contagion. But even if you don’t believe masks protect the wearer, but only protect others from an infected wearer, donning a mask inside buildings, and when social distancing is impossible, still qualifies as a mannerly thing to do.

Cases Climb, Most Patients Faring Better

30 Tuesday Jun 2020

Posted by pnoetx in Pandemic, Public Health

≈ Leave a comment

Tags

Air Conditioning, Bloomberg, Cases vs. Deaths, Confirmed Cases, COVID Time Series, Covid-19, George Floyd, Immunity, Increased Testing, Nate Silver, Pandemic, Protest Effect, Social Distancing, Viral Transmission, Vitamin D Deficiency

There’s been much speculation about whether recent increases in confirmed cases of COVID-19 (first chart above) will lead to a dramatic increase in fatalities (second chart). More generally, there is curiosity or perhaps hope as to whether the virus is not as dangerous to these new patients as it was early in the pandemic. I have discussed this point in several posts, most recently here. Based on the national data (above), we’re at the point at which an upturn in deaths might be expected. Based on the experience of many individual states, however, deaths should have trended upward by now, but they haven’t done so. Cases are generally less severe and are resolving more quickly.

Of course, more testing produces more cases (though there has been a mild uptick in test positivity over the past two weeks), but that doesn’t really explain the entire increase in cases over the past few weeks. In particular, why are so many new cases in the south? After all, there is evidence that the virus doesn’t survive well in warm, humid climates with more direct sunlight.

As I have mentioned several times, heavy use of air-conditioning in the south may have contributed to the increase. Nate Silver speculates that this is the case. The weather warmed up in late May and especially June, and many southerners retreated indoors where the air is cool, dry, and the virus thrives. Managers of public buildings should avoid blasting the AC, and you might do well to heed the same advice if you live with others in a busy household. In fact, nearly all transmission is likely occurring indoors, as has been the case throughout the pandemic. At the same time, however, with the early reopening of many southern states, younger people flocked to gyms, bars and other venues, largely abandoning any pretense of social distancing. So it’s possible that these effects have combined to produce the spike in new cases.

Some contend that the protests following George Floyd’s murder precipitated the jump in confirmed cases. Perhaps they played a role, but I’m somewhat skeptical. Yes, these could have become so-called super-spreader events; there are certain cities in which the jump in cases lagged the protests by a few weeks, such as Austin, Houston, and Miami, and where some cases were confirmed to be among those who protested. But if the protests contributed much to the jump, why hasn’t New York City seen a corresponding increase? Not only that, but the protests were outside, and the protests dissuaded many others from going out at all!

The trend in coronavirus fatalities remains more favorable, despite the increase in daily confirmed cases. One exception is New Jersey, which decided to reclassify 1,800 deaths as “probable” COVID deaths about six days ago. You can see the spike caused by that decision in the second chart above. Reclassifications like that arouse my suspicion, especially when federal hospital reimbursements are tied to COVID cases, and in view of this description from Bloomberg (my emphasis):

“… those whose negative test results were considered unreliable; who were linked to known outbreaks and showed symptoms; or whose death certificates strongly suggested a coronavirus link.”

Deaths necessarily lag new cases by anywhere from a few days to several weeks, depending on the stage at the time of diagnosis and delays in test results. The lag between diagnosis and death seems to center on about 12 – 14 days. Thus far, there doesn’t appear to be an upward shift in the trend of fatal cases, but the big updraft in cases nationally only started about two weeks ago. More on that below.

Importantly, a larger share of new cases is now among a younger age cohort, for whom the virus is much less threatening. The most vulnerable people are probably taking more precautions than early in the pandemic, and shocking as might seem, there is probably some buildup in immunity in the surviving nursing home population at this point. We are also better at treatment, and there is generally plenty of hospital capacity. And to the extent that the surge in new cases is concentrated in the south, fewer patients are likely to have Vitamin D deficiencies, which is increasingly mentioned as a contributor to the severity of coronavirus infections.

I decided to make some casual comparisons of new cases versus COVID deaths on a state-by-state basis, but I got a little carried away. Using the COVID Time Series web site, I started by checking some of the southern states with recent large increases in case counts. I ended up looking at 15 states in the south and west, and I added Missouri and Minnesota as well. I passed over a few others because their trends were basically flat. The 17 states all had upward trends in new cases over the past one to two months, or they had an increase in new cases more recently. However, only four of those states experienced any discernible increase in daily deaths over the corresponding time frames. These are Arizona, Arkansas, Tennessee, and Texas, and their increases are so modest they might be statistical noise.

Again, deaths tend to lag new cases by a couple of weeks, so the timing of the increase in case counts matters. Five of the states were trending upward beginning in May or even earlier, and 13 of the states saw an acceleration or a shift to an upward trend in new cases after Memorial Day, in late May or June. Of those 13, the changes in trend occurred between one and five weeks ago. Six states, including Texas, had a shift within the past two weeks. It’s probably too early to draw conclusions for those six states, but in general there is little to suggest that fatal cases will soar like they did early in the pandemic. Case fatality rates are likely to remain at much lower levels.

We’ll know much more within a week or two. It’s very encouraging that the upward trend in new cases hasn’t resulted in more deaths thus far, especially at the state level, as many states have had case counts drift upward for over a month. If it’s going to occur, it should be well underway within a week or so. Much also depends on whether new cases continue to climb in July, in which case we’ll be waiting in trepidation for whether more deaths transpire.

Coronavirus Framing #7: Second Wave Uncertainty

19 Friday Jun 2020

Posted by pnoetx in Pandemic

≈ 1 Comment

Tags

Air Conditioning, Asian Flu, Case Fatality Rate, CDC, Coronavirus, COVID Time Series, Covid Tracking Project, Effective Herd Immunity, George Floyd, HHS, High Cholesterol, Hong Kong Flu, Johns Hopkins, Operation Warp Speed, Pooled Testing, Reverse Seasonal Effect, Rich Lowry, Social Distancing, Testing, Vitamin D Deficiency

We’re now said to be on the cusp of a “second wave” of coronavirus infections. It’s become a new focus of media attention in the past week or so. Increased infections have been reported across a number of states, especially in the south, but I’m not especially alarmed at this point for reasons explained below. Either way, the public policy response will certainly be different this time, at least in most areas. We’ve learned that a more targeted approach to managing coronavirus risk is far less costly, which means eschewing general lockdowns in favor of focusing resources on protecting the most vulnerable. That approach is supported by research weighing the costs and benefits of the alternatives (also see here and here).

The targeted approach I’ve advocated does not call for any less caution on the part of individuals. That means avoiding prolonged, close contact with others, especially indoors. I don’t mind wearing a mask when inside stores or public buildings, but I believe it should be voluntary. I do my best to stay out of close proximity to most others in public places anyway, masked or otherwise. This is voluntary social distancing. I also believe public health authorities should be more active in disseminating information on known correlates of coronavirus severity, such as Vitamin D deficiency, high LDL cholesterol, and the “reverse seasonal effect” caused by low humidity in air-conditioned spaces. I would also strongly agree that the effort to identify and mass produce vaccine candidates, known as Operation Warp Speed, should be ramped up considerably, with heavier funding and more than five vaccine candidates.

We’ve seen a continuing increase in coronavirus testing since my last “framing” post about a month ago. Testing has increased to a daily average of almost 500,000 over the past two weeks. At present we appear to have an excess supply of testing capacity in many areas, as Rich Lowry notes:

“The problem with testing nationally is becoming less a shortfall of availability of the tests and more a shortfall of people showing up to get tested. An insider in the diagnostics industry says that laboratories are reporting that they are ‘sample starved’ — i.e., they aren’t getting enough specimens. He notes, ‘We have all seen stories about sample-collection sites in some regions not seeing that many patients.’

An HHS official says that in May there was the capacity to do twice as many tests as were actually performed, calling it a function of ‘allocation and efficiency, but more just demand.’ Says Giroir, ‘We really see areas in the country now that there’s more tests available than people who want to get tested or the need for testing.'”

Before turning to some charts, a word about the data in the charts I’ve been using throughout the pandemic. Some of the nationwide information was directly from the CDC or the Johns Hopkins dashboard. In other cases, I’ve reported state level data and some nationwide data published by The COVID Tracking Project (CTP) and the COVID Time Series (CTS) dashboard, which uses state data from CTP. I first noticed a few discrepancies in the national totals in April, which have become larger with growth in the counts of cases and deaths. Here is a key part of CTP’s explanation:

“For many states, the CDC publishes higher testing numbers than the states themselves report, which raises questions about the structure and integrity of both state and federal data reporting. … Another point of contrast between the CDC’s new reporting and the official state data compiled by The COVID Tracking Project is that the CDC has not released historical, state-level testing data for the first three months of the outbreak.”

Thus, the CDC currently reports almost 120,000 U.S. deaths, while CTP reports about 112,000. Nevertheless, I will continue to report numbers from both sources for the sake of continuity, and I will try to remember to note the source in each case.

The first chart below shows the number of daily tests from CTP; the second chart shows the number of daily confirmed cases (CTP). Since mid-May, daily testing has increased by more than 50%, calculated on a moving average basis, and is now approaching half a million per day or more than 3 million per week. Pooled testing is coming, which will ultimately increase testing capacity several-fold. Daily confirmed cases have been hovered just above 20,000 since around Memorial Day, with a recent turn upward to around 24,000.

Early in the pandemic, I made the mistake of focusing too heavily on case numbers. Yes, I adjusted for population size and was aware that the initial shortage of tests was restraining diagnoses. Still, I did not foresee the great expansion in testing we’ve witnessed, the great transmissibility of the virus in some regions, nor the large number of asymptomatic cases that would ultimately be diagnosed.

The daily percentage of positive tests (CTP), which is smoothed in the chart below using a seven-day moving average to eliminate within-week variability, has declined gradually since early April to about 4% before the uptick in the last few days. Still, that’s a drop of about 75% from the peak when tests were in very short supply. Those were days when even heavily symptomatic individuals were having trouble getting tested.

We’d hope to see a resumption in the decline of the positive percentage as testing continues to grow, but even with a relatively constant positivity rate, the number of daily confirmed cases must grow as testing expands. There may be several reasons the positivity rate has remained stubbornly near 5% over the past few weeks. One is the obvious reversal in social distancing as states have opened up. People became less fearful about the virus in general, and protesters jammed the streets after the George Floyd murder in Minneapolis. Another reason is that there are new areas of focus for testing that might be picking up cases. For example, hospitals in some states are now testing all admissions for COVID-19. This will tend to pick up more infections to the extent that individuals with co-morbidities are hospitalized at higher rates in general and are also more susceptible to the coronavirus. Finally, testing more broadly is likely to pick up a larger share of asymptomatic cases even as the “true rate” of infection declines.

The daily death toll (CTP) attributed to coronavirus has continued to decline. See below. It is now running at about a third of the peak level it reached in mid-April. There are several reasons for the decline. One is the lower number of active cases, changes in which lead deaths by a few weeks. Awareness and testing capacity have undoubtedly led to earlier diagnosis of the most severe cases. There is also the strong possibility that the virus, having felled some of the most susceptible individuals, is now up against more hosts with effective immune responses. An ongoing degree of social distancing, more humid weather, and more direct sunlight have probably reduced initial viral loads from those experienced early-on, when the case load was escalating. Finally, treatment has improved in multiple ways, and there are now a few medications that have shown promise in shortening the duration and severity of infection.

The course of the pandemic has varied greatly across countries and across regions of the U.S. The New York City area was especially hard hit along with several other large cities, as well as Louisiana. CTS shows that states with the highest cumulative number of coronavirus deaths (New York (blue line), New Jersey (green), Massachusetts, Illinois, and Pennsylvania in the charts below) have experienced downward trends in positive cases per day (the first chart below), leading daily deaths downward in May and early June (the second chart — NY’s downtrend began earlier). I apologize if the charts below are difficult to read, but they have resisted my efforts at resizing. Note: I’m mainly focused on trends here, and I have not shown these series on a per capita basis.

More recently, almost two dozen states have begun to see higher daily case diagnoses. Several of these had more favorable outcomes in the early months of the pandemic and were in more advanced stages of reopening. The charts below (CTS) show results for Arizona, Florida, Georgia, and Texas. The new “hot spots” in these states are mostly urban centers. It’s not clear that the reopenings are to blame, however. The protests after George Floyd’s murder may have contributed in cities like Houston, though no increase in New York is apparent as yet. The states in the chart are all in the south or southwest, so the increases have occurred despite sunny, warm conditions. It’s possible that hot weather has prompted more intensive use of air conditioning, which dries indoor environments and can promote the spread of the virus. These southern states have not yet experienced a corresponding increase in deaths, though that would occur with a lag.

Missouri has seen an slow upward trend in its daily positive test count over the past four weeks, even though the state’s positive rate has trended down slowly since early May. I show MO’s confirmed cases per day below (in green) together with Illinois’ (because my hometown is on the border and the two states are a nice contrast). IL is much larger and has had a much higher case load, but the downward trend in new cases in IL is impressive. Coronavirus deaths per day are shown in the second chart below, with seven-day averages superimposed. Deaths have also trended down in both states, though MO has experienced a few bad days very recently, and MO’s case fatality rate is slightly higher than in IL.

We’ll know fairly soon whether we’re really headed for a second major wave. However, the case count, in and of itself, is not too informative. Testing has increased markedly, so we would expect to see more cases diagnosed. The percent of tests that are positive is a better indicator, and it has flattened at a still uncomfortable 5% for about a month, with a slight uptick in the past few days. Even more telling will be the future path of coronavirus deaths. My expectation is that more recent infections are likely to be less deadly, if only because of the lessons learned about protecting the care-bound elderly. I also believe we’re not too far from what I have called effective herd immunity.

The pandemic has taken a heavy toll, especially among the aged. In fact, total deaths in the U.S. have now exceeded both the Hong Kong flu of the late 1960s and the Asian flu of the late 1950s. Unfortunately, risks will remain elevated for some time. However, any reasonable estimate of the life-years lost is considerably less than in those earlier pandemics due to the differing age profiles of the victims. In any case, the coronavirus pandemic has not been the kind of apocalyptic event that was originally feared and erroneously predicted by several prominent epidemiological models. It can be tackled effectively and at much lower cost by focusing resources on protecting vulnerable segments of the population.

Trump Hates/Loves Lockdowns, Dumps on Swedes

07 Sunday Jun 2020

Posted by pnoetx in Health Care, Pandemic

≈ Leave a comment

Tags

Cholesterol, Coronavirus, Donald Trump, Herd Immunity, Institute for Health Metrics and Evaluation, Lockdowns, Nordic, Rose Garden Briefing, Somali Immigration, Sweden, Vitamin D

President Trump was in a festive mood last Friday, pleased with the May employment report, as he should be. But in his Rose Garden word jam, he made some questionable and unnecessary claims about coronavirus policies in the U.S. and the Swedish experience. I credit Trump for pushing to end the lockdowns as it became clear that they were both unhealthy and unsustainable. However, he’s now way too eager to cover his earlier tracks. That is, he is now defensive about the precautions he advocated on the advice of his medical experts in March and early April.

In the Rose Garden, Trump said that lockdowns were necessary to stop the spread of the virus. But to assert that lockdowns “stopped” or even slowed the spread of the virus is speculation at best, and they had deadly effects of their own. Most of the social distancing was achieved through voluntary action, as I have argued previously. Lockdown advocacy lacked any semblance of geographic nuance, as if uniform application makes sense regardless of population density.

Trump went on to say that Sweden was in “bad shape” because it did not impose a lockdown during the pandemic. This is not a new position for the president, but the facts are anything but clear-cut. Again, there is mixed evidence on whether mandatory lockdowns have a real impact on the spread or mortality of the coronavirus (also see here). That’s not to say that social distancing doesn’t work, but much of the benefit comes from private decisions to mitigate risk via distancing. Of course, that also depends on whether people have good information to act on. And to be fair, Sweden did take certain measures such as banning gatherings of more than 50 people, closing schools, and limiting incoming travel.

While the full tale has not been told, and Sweden’s death rate is high on a per capita basis, several other Western European countries that imposed lockdowns have had even higher death rates. The following chart is from the Institute for Health Metrics and Evaluation (IMHE). It is expressed in terms of coronavirus deaths per 100,000 of population. The orange line is Sweden, the purple line is Belgium, and the light blue line is the UK. Actuals are reported through June 4th. While Sweden’s death toll has a somewhat steeper gradient, the level remains well below both Belgium and the UK. It is also lower than the death rates for Italy and Spain, and it is about the same as France’s death rate. Yes, a number of other countries have lower death rates, including the U.S., but the evidence is hardly consistent with Trump’s characterization.

Sweden’s big mistake was not it’s decision to rely on voluntary social distancing, but in failing to adequately protect highly vulnerable populations. The country’s elderly skew older than most countries by several years. Residents of nursing homes have accounted for about half of Sweden’s coronavirus deaths, an international outlier. Inadequate preparedness in elder care has been a particular problem, including a lack of personal protective equipment for workers. There was also a poorly implemented volunteer program, intended to fill-out staffing needs, that appears to have aggravated transmission of the virus.

Sweden has also experienced a concentration of cases and deaths among its large immigrant population. It has the largest immigrant population among the Nordic countries, with large numbers of low income migrants from Syria, Iraq, Iran, Somalia and parts of Eastern Europe. Earlier in the pandemic, according to one estimate, 40% of coronavirus fatalities in Stockholm were in the Somali population. These immigrants tend to live in dense conditions, often in multigenerational households. Many residents with health problems tend to go untreated. Conditions like Vitamin D deficiency and high cholesterol, apparent risk factors for coronavirus severity, likely go untreated in these communities. In addition, language barriers and traditional trust relationships may diminish the effectiveness of communications from public health authorities. In fact, some say the style of Swedish public health messaging was too culturally idiosyncratic to be of much use to immigrants. And one more thing: immigrants are a disproportionately high 28% of nursing home staff in Sweden, implying an intimacy between two vulnerable populations that almost surely acts as a risk multiplier in both.

It might be too harsh to suggest that that Sweden could have prevented the outsized impact of the virus on immigrants. However, Sweden’s coronavirus testing has not been as intensive as other Nordic countries. More testing might have helped alleviate the spread of the virus in nursing homes and in immigrant communities. But the vulnerabilities of the immigrant population might be more a matter of inadequate health care than anything else, both on the demand and supply sides.

Contrary to Trump’s characterization, Sweden’s herd immunity strategy is not the reason for it’s relatively high death rate from the virus. Several countries that imposed lockdowns have had higher death rates. And Sweden’s death rate has been heavily concentrated among the aged in nursing homes and its large immigrant population. It’s possible that Sweden’s approach led to a cavalier attitude with respect identifying vulnerable groups and taking measures that could have protected them, including more intensive testing. Nevertheless, it’s inaccurate and unfair to scapegoat Sweden for not imposing a mandatory lockdown. The choice is not merely whether to impose lockdowns, but how to protect vulnerable populations at least cost. In that sense, general lockdowns are a poor choice.

Trump and Coronavirus

26 Tuesday May 2020

Posted by pnoetx in Pandemic, Public Health, Risk Management, Stimulus, Trump Administration

≈ Leave a comment

Tags

Andrew Cuomo, Anthony Fauci, Bill De Blasio, CARES Act, CDC, Coronavirus, Deborah Birx, DHS, Disinfectant, Donald Trump, Elective Surgeries, FDA, Federalism, FEMA, Fiscal policy, Hydroxychloraquine, International Travel, Javits Center, John Bolton, John Cochrane, Laboratory Federalism, Lancet, Liability Waivers, Lockdowns, Michael Pence, Mike Pompeo, N95 Mask, NSC, Paycheck Protection Program, PPE, Robert Redfield, State Department, Testing, Unfunded Pensions, UV Light, Vaccines, Ventilators, WHO, Wuhan, Zinc

It’s a bit early to fully evaluate President Trump’s performance in dealing with the coronavirus pandemic, but there are a number of criteria on which I might assign marks. I’ll address some of those below, but in so doing I’m reminded of Jerry Garcia’s quip that he was “shopping around for something no one will like.” That might be how this goes. Of course, many of the sub-topics are worthy of lengthier treatment. The focus here is on the pandemic and not more general aspects of his performance in office, though there is some unavoidable overlap.

General “Readiness”

Many have criticized the Trump Administration for not being “ready” for a pandemic. I assign no grade on that basis because absolutely no one was ready, at least not in the West, so there is no sound premise for judgement. I also view the very general charge that Trump did not provide “leadership” as code for either “I don’t like him”, or “he refused to impose more authoritarian measures”, like a full-scale nationwide lockdown. Such is the over-prescriptive instinct of the Left.

Equally misleading is the allegation that Trump had “disbanded” the White House pandemic response team, and I have addressed that here. First, while the NSC would play a coordinating role, pandemic response is supposed to be the CDC’s job, when it isn’t too busy with diseases of social injustice to get it done. Second, it was John Bolton who executed a reorganization at the NSC. There were two high profile departures from the team in question at the time, and one one was a resignation. Most of the team’s staff remained with the NSC with the same duties as before the reirganization.

Finally, there was the matter of a distracting impeachment on false charges. This effort lasted through the first three years of Trump’s administration, finally culminating in January 2020. Perhaps the Administration would have had more time to focus on what was happening in China without the histrionics from the opposition party. So whatever else I might say below, these factors weigh toward leniency in my appraisal of Trump’s handing of the virus.

Messaging: C

As usual, Trump’s messaging during the pandemic was often boorish and inarticulate. His appearances at coronavirus briefings were no exception, often cringeworthy and sometimes featuring misinterpretations of what his team of experts was saying. He was inconsistent in signaling optimism and pessimism, as were many others such as New York Governor Andrew Cuomo and New York City Mayor Bill De Blasio. It shifted from “the virus is about like the flu” in February to a more sober assessment by mid-March. This was, however, quite consistent with the messaging from Dr. Anthony Fauci over the same time frame, as well as the World Health Organization (WHO). Again, no one really knew what to expect, so it’s understandable. A great deal of that can be ascribed to “the fog of war”.

Delegation and Deference: B

Trump cannot be accused of ignoring expert advice through the episode. He was obviously on-board with Fauci, Dr. Deborah Birx, Dr. Robert Redfield, and other health care advisors on the “15 Days to Slow the Spread” guidelines issued on March 16. His messaging wavered during those 15 days, expressing a desire to fully reopen the nation by Easter, which Vice President Michael Pence later described as “aspirational”. Before the end of March, however, Trump went along with a 30-day extension of the guidelines. Finally, by mid-April, the White House released guidelines for “Opening Up America Again“, which was a collaboration between Trump’s health care experts and the economic team. Trump agreed that the timeline for reopening should be governed by “the data”. There is no question, however, that Trump was chomping at the bit for reopening at several stages of this process. I see value in that positioning, as it conveys an intent to reopen asap and that people should have confidence in progress toward that goal.

International Travel Bans: A

If anyone wonders why the world was so thoroughly blindsided by the coronavirus, look no further than China’s failure to deliver a proper warning as 2019 drew to a close. Wuhan, China was ground zero; the virus spread to the rest of the world with travelers out of Wuhan and other Chinese cities. The White House announced severe restrictions on flights from China on January 31, including a two-week quarantine for returning U.S. citizens. In retrospect, it wasn’t a minute too soon, yet for that precaution, Trump was attacked as a racist by the Left. In early February, WHO actually said travel bans were unnecessary, among other missteps. Other bans were instituted on entry from Iran and Brazil, as well as entry from Europe in early March, as countries around the globe closed their borders. Trump’s actions on incoming travelers were prescient, so I’ll score this one for Trump. Some of these travel restrictions can and should be eased now, and certainly that is expected in coming months, so we’ll see how well that process is managed.

Deference to States: A-

As a federalist, I was pleased that Trump and his team left most of the specifics on closures and bans on public gatherings up to state and local governments. That allowed more targeted mitigation efforts as dictated by local conditions and, to some extent, public opinion. This is a classic case of “laboratory federalism” whereby the most effective policies can be identified, though as we’ve seen, there’s no guarantee less successful states will emulate them. I grade Trump well on this one.

On reopening, too, Trump has been a consistent advocate of allowing flexility where local conditions permit, though he wrongly claimed he had “total authority” over ending social distancing rules. It’s hard to square that remark with his general stand on the issue of autonomy except as a tactic to strong-arm certain governors on other points.

CDC/FDA Snafus: D

I applaud the Administration for its emphasis on the salutary effects of deregulation, but Trump went along with some major pieces of “expert advice” that were not only poor from regulatory perspective, but an affront to federalism. One was a directive issued by the CDC to delay “all elective surgeries, non-essential medical, surgical, and dental procedures during the 2019 Novel Coronavirus (COVID-19) outbreak“. (See my post “Suspending Medical Care in the Name of Public Health“.)

This is exactly the kind of “one size fits all” regulatory policy that has proven so costly, sacrificing not just economic activity but lives and care for the sick, creating avoidable illnesses and complications. The idea was to assure that adequate health care resources were available to treat an onslaught of coronavirus patients, but that was unneeded in most jurisdictions. And while the contagion was in it’s early “exponential” phase at the time, a more nuanced approach could have been adopted to allow different geographic areas and facilities more discretion, especially for different kinds of patients, or perhaps something less than a complete suspension of care. In any case, the extensions into May were excessive. I must grade Trump poorly for allowing this to happen, despite what must have been extreme pressure to follow “expert advice” on the point and the others discussed earlier.

That’s not the only point on which I blame Trump for caving to the CDC. In a case of massive regulatory failure, the CDC and FDA put the U.S. well over a month behind on testing when the first signs of the virus appeared here. Not only did they prohibit private labs and universities from getting testing underway, insisting on exclusive use of the CDC’s own tests, they also distributed faulty tests in early February that took over a month to replace. The FDA also enforced barriers to imported N95-type masks during the pandemic. Trump tends to have a visceral understanding of the calcifying dangers of regulation, but he let the so-called “experts” call the shots here. Big mistake, and Trump shares the blame with these agencies.

Health Resources: B-

The question of disaster preparedness is often characterized as a federal obligation, but the federal government’s role is not to replace state and local efforts, but to backstop them with a form of risk sharing across all 50 states. The obligation to have sufficient medical resources on-hand for a pandemic falls on hospitals, state and local governments, and certain federal agencies like FEMA. In terms of readiness for this pandemic, there were successes and failures at all of these levels.

The first question was having adequate hospital space in terms of the beds and ICU beds to handle a potential surge in coronavirus patients. Again, the CDC directive on elective procedures and non-essential medical care, along with general fear of the virus, helped to empty hospitals across the country. That proved to be unnecessary and should have been suspended in most regions by mid-April. There were a few “hot-spots”, New York City being the most noteworthy. Trump arranged to get Navy hospital ships deployed quickly to NYC and LA. Federal funds were also provided to create a temporary hospital at the Javits Center in NYC and a field hospital in Brooklyn. All of these facilities went virtually unused. Nevertheless, for this I give Trump some credit for effectively responding to requests from state and local leaders.

Another important dimension of preparedness has to do with the availability of personal protective equipment (PPE) and equipment such as respirators and ventilators. On this I give the Administration a harsher evaluation, but many hospitals and states were also culpable for failing to maintain adequate inventories. Even more culpable is China, which did its best to cache supplies before the virus became a real crisis in the West. In an incredible goof-up intended as charity in January, the State Department sent many tons of donated ventilators and PPE to China, leaving U.S. health care workers without adequate protection (Canada did too). On the other hand, Trump arranged to get resources mobilized to produce PPE and ventilators quickly, but on balance, this one gets Trump’s grade knocked down.

Managing the emergency distribution of PPE and ventilators to states did not go as smoothly as might have been hoped. The shortage itself left FEMA with the unenviable task of allocating quantities that could never satisfy all demands. A few states were thought to have especially acute needs, but there was also an obligation to hold stockpiles against potential requests from other states. In fact, a situation of this kind creates an incentive for states to overstate their real needs, and there are indications that such was the case. Trump sparred with a few governors over these allocations. There is certainly blame to be shared, but I won’t grade Trump down for this.

Vaccines and Treatments: C+

The push to develop vaccines might not achieve success soon, if ever, but a huge effort is underway. Trump gets some of the credit for that, as well as the investment in capacity now to produce future vaccine candidates in large quantities. As for treatments, he was very excited about the promise of hydroxychloraquine, going so far as to take it himself with zinc, a combination for which no fully randomized trial results have been reported (the recent study appearing in the Lancet on HCQ taken by itself has been called into question). Trump also committed an unfortunate gaffe when the DHS announced the results of a study showing that sunlight kills coronavirus in a matter of minutes, as do bleach and other disinfectants. Trump mused that perhaps sunlight or some form of disinfectant could be used as a treatment for coronavirus patients. He might have been thinking about an old and controversial practice whereby blood is exposed to UV light and then returned to the body. Later, he said he used the term “disinfectant” sarcastically, but he probably meant to say “euphemistically” …. I’m not sure he knows the difference. In any case, his habit of speculating on such matters is often unhelpful, and he loses points for that.

Fiscal Policy: B

The several phases of the economic stimulus program were a collaboration between the Trump Administration and Congress. A reasonably good summary appears here. The major parts were the $2.3 trillion CARES Act in late March and a nearly $500 billion supplemental package in late April. These packages were unprecedented in size. Major provisions were direct cash payments and the Paycheck Protection Program (PPP), which provides loans and grants to small businesses. The execution of both was a bit clunky, especially PPP, which placed a burden on private banks to extend the loans but was sketchy in terms of qualifications. The extension of unemployment compensation left some workers with more benefits than they earned in their former jobs, which could be an impediment to reopening. There were a number of other reasonable measures in these packages and the two smaller bills that preceded them in March. A number of these measures were well-targeted and inventive, such as waiving early withdrawal penalties from IRA and 401(k) balances. The Trump Administration deserves credit for helping to shape these efforts as well as others taken independently by the executive branch.

Trump’s proposal to suspend payroll taxes did not fly, at least not yet. The idea is to reduce the cost of hiring and increase the return to work, if only temporarily. This is not a particularly appealing idea because so much of the benefits would flow to those who haven’t lost their jobs. It could be improved if targeted at new hires and rehires, however.

Trump’s proposal to grant liability waivers to reopened private businesses is extremely contentious, but one I support. Lockdowns are being eased under the weight of often heavy public and private regulation of conduct. As John Cochrane says in “Get Ready for the Careful Economy“:

“One worry on regulation is that it will provide a recipe for a wave of lawsuits. That may have been a reason the Administration tried to hold back CDC guidance. A long, expensive, and impractical list of things you must do to reopen is catnip when someone gets sick and wants to blame a business. Show us the records that you wiped down the bathrooms every half hour. A legal system that can sue over talcum powder is not above this.”

Indeed, potential liability might represent a staggering cost to many businesses, one that might not be insurable. Accusations of negligence, true or false, can carry significant legal costs. Customers and employees, not just businesses, must accept some of the burden of risks of doing business. I give Trump good marks for this one, but we’ll see if it goes anywhere.

Some of the proposals for new stimulus legislation from democrats are much worse, including diversity initiatives, massive subsidies for “green” technologies, and bailouts for state and local government for unfunded pension liabilities. None of these has anything to do with the virus. The burden of pension shortfalls in some states should not fall on taxpayers nationwide, but on the states that incurred them. The Trump Administration and congressional Republicans should continue resisting these opportunistic proposals.

The Grade

Without assigning weights to the sub-topics covered above, I’d put the overall grade for Trump and his Administration’s handling of matters during the pandemic at about a B-, thus far. When it comes to politics, it’s often unfair to credit or blame one side for the promulgation of an overall set of policies. Nevertheless, I think it’s fair to say that Trump, could have done much better and could have done much worse. We will learn more with the passage of time, the continued evolution of the virus, the development of treatments or vaccines, and the course of the economy.

Suspending Medical Care In the Name of Public Health

23 Saturday May 2020

Posted by pnoetx in Health Care, Pandemic

≈ 1 Comment

Tags

Asian Flu, Comorbidities, Coronavirus, Covid-19, Get Outside, Hong Kong Flu, Imperial College Model, Italy, Lockdowns, Mortality by Age, Mortality Rates, Neil Ferguson, New York, Organ Failure, Pandemic, Public Health, Slow the Spread, South Korea, Spanish Flu, Suicide Hotlines, Vitamin D Deficiency

Step back in time six months and ask any health care professional about the consequences of suspending delivery of most medical care for a period of months. Forget about the coronavirus for a moment and just think about that “hypothetical”. These experts would have answered, uniformly, that it would be cataclysmic: months of undiagnosed cardiac and stroke symptoms; no cancer screenings, putting patients months behind on the survival curve; deferred procedures of all kinds; run-of-the-mill infections gone untreated; palsy and other neurological symptoms anxiously discounted by victims at home; a hold on treatments for all sorts of other progressive diseases; and patients ordinarily requiring hospitalization sent home. And to start back up, new health problems must compete with all that deferred care. Do you dare tally the death and other worsened outcomes? Both are no doubt significant.

What you just read has been a reality for more than two months due to federal and state orders to halt non-emergency medical procedures in the U.S. The intent was to conserve hospital capacity for a potential rush of coronavirus patients and to prevent others from exposure to the virus. That might have made sense in hot spots like New York, but even there the provision of temporary capacity went almost completely unused. Otherwise, clearing hospitals of non-Covid patients, who could have been segregated, was largely unnecessary. The fears prompted by these orders impacted delivery of care in emergency facilities: people have assiduously avoided emergency room visits. Even most regular office visits were placed on hold. And as for the reboot, there are health care facilities that will not survive the financial blow, leaving communities without local sources of care.

A lack of access to health care is one source of human misery, but let’s ask our health care professional about another “hypothetical”: the public health consequences of an economic depression. She would no doubt predict that the stresses of joblessness and business ruin would be acute. It’s reasonable to think of mental health issues first. Indeed, in the past two months, suicide hotlines have seen calls spike by multiples of normal levels (also see here and here). But the stresses of economic disaster often manifest in failing physical health as well. Common associations include hypertension, heart disease, migraines, inflammatory responses, immune deficiency, and other kinds of organ failure.

The loss of economic output during a shutdown can never be recovered. Goods don’t magically reappear on the shelves by government mandate. Running the printing press in order to make government benefit payments cannot make us whole. The output loss will permanently reduce the standard of living, and it will reduce our future ability to deal with pandemics and other crises by eroding the resources available to invest in public health, safety, and disaster relief.

What would our representative health care professional say about the health effects of a mass quarantine, stretching over months? What are the odds that it might compound the effects of the suspension in care? Confinement and isolation add to stress. In an idle state of boredom and dejection, many are unmotivated and have difficulty getting enough exercise. There may be a tendency to eat and drink excessively. And misguided exhortations to “stay inside” certainly would never help anyone with a Vitamin D deficiency, which bears a striking association with the severity of coronavirus infections.

But to be fair, was all this worthwhile in the presence of the coronavirus pandemic? What did health care professionals and public health officials know at the outset, in early to mid-March? There was lots of alarming talk of exponential growth and virus doubling times. There were anecdotal stories of younger people felled by the virus. Health care professionals were no doubt influenced by the dire conditions under which colleagues who cared for virus victims were working.

Nevertheless, a great deal was known in early March about the truly vulnerable segments of the population, even if you discount Chinese reporting. Mortality rates in South Korea and Italy were heavily skewed toward the aged and those with other risk factors. One can reasonably argue that health care professionals and policy experts should have known even then how best to mitigate the risks of the virus. That would have involved targeting high-risk segments of the population for quarantine, and treatment for the larger population in-line with the lower risks it actually faced. Vulnerable groups require protection, but death rates from coronavirus across the full age distribution closely mimic mortality from other causes, as the chart at the top of this chart shows.

The current global death toll is still quite small relative to major pandemics of the past (Spanish Flu, 1918-19: ~45 million; Asian Flu, 1957-58: 1.1 million; Hong Kong flu, 1969: 1 million; Covid-19 as of May 22: 333,000). But by mid-March, people were distressed by one particular epidemiological model (Neil Ferguson’s Imperial College Model, subsequently exposed as slipshod), predicting 2.2 million deaths in the U.S. (We are not yet at 100,000 deaths). Most people were willing to accept temporary non-prescription measures to “slow the spread“. But unreasonable fear and alarm, eagerly promoted by the media, drove the extension of lockdowns across the U.S. by up to two extra months in some states, and perhaps beyond.

The public health and policy establishment did not properly weigh the health care and economic costs of extended lockdowns against the real risks of the coronavirus. I believe many health care workers were goaded into supporting ongoing lockdowns in the same way as the public. They had to know that the suspension of medical care was a dire cost to pay, but they fell in line when the “experts” insisted that extensions of the lockdowns were worthwhile. Some knew better, and much of the public has learned better.

Covid Framing #6: The Great Over-Reaction

16 Saturday May 2020

Posted by pnoetx in Pandemic

≈ 2 Comments

Tags

Asian Flu, California, Colorado, Confirmed Cases, Coronavirus, Covid-19, Death Toll, Florida, Georgia, Germany, Great Over-Reaction, Hong Kong Flu, Italy, Nate Silver, Neil Ferguson, New York, Pandemics, Spanish Flu, Sweden

I visited my doctor last Wednesday. He’s a specialist but also serves as my primary care physician, and we share the same condition. He’s affiliated with a prestigious medical school and practices on the campus of a large research hospital. First thing, I asked him, “So what do you think of all this?” Without hesitation, he said he believes we’re witnessing the single greatest over-reaction in all of medical history. He elaborated at length, which I very much appreciated, and I was gratified that much of what he said was familiar to me and my readers. The risks of the coronavirus are highly concentrated among the elderly and the already-sick, and the damage that the panic and lockdowns have done to the delivery of other medical care is probably a bigger tragedy, to say nothing of the economic damage. Furthermore, the Covid-19 pandemic is certainly not more threatening than others the world has experienced since WW II.

But did we know all that in March? No one with any sense believed the low numbers coming out of China; major flip-flops and mistakes by public health officials in the U.S. did much to confuse matters and delay evaluation of the outbreak. Nevertheless, there were reasons to proceed more deliberately. The explosion of cases in Italy and elsewhere consistently indicated that risk was concentrated among the elderly, so a targeted approach to protecting the vulnerable would have made sense. Still, individuals took voluntary action to social distance even before governments initiated broad lockdowns.

The lockdowns, of course, were sold as a short-term effort to “flatten the curve” so that medical resources would not be overwhelmed. There was, no doubt, great stress on front-line health care workers in March and April, and there were short-term shortages of personal protective equipment as well as ventilators for the most severe cases (but it’s possible ventilators actually harmed some patients). But whether you credit government action, private action, or the fact that so much of the population was not susceptible to begin with, mission accomplished! The strains were concentrated in certain geographic regions, especially the New York City metro area, but even there, the virus is on the wane. There is always the possibility of a major second wave, but perhaps it can be handled more intelligently by the public and especially public servants.

And now for some charts. Due to day-to-day volatility, and because the data on case numbers and deaths fluctuate on a weekly frequency, the charts below are on a 7-day moving average basis. It’s clear that the peak in U.S. daily confirmed cases was over five weeks ago, while the peak in Covid-attributed deaths was about three weeks ago.

Unfortunately, there is more doubt than ever about the legitimacy of the numbers. New York keeps “discovering” new deaths in nursing homes, a situation aggravated by a statewide order in March prohibiting homes from rejecting new or returning patients with active infections. There are reports from across the country of family deaths that were imminent, yet officially attributed to Covid. In one case, a death from severe alcohol poisoning was attributed to Covid. Colorado announced today that it was revising its death toll downward by about 24%.

The data on confirmed cases are elevated because testing keeps expanding. The first chart below shows that the number of daily tests has more than doubled over the past 3½ weeks. At the same time, the second chart below shows that the rate of “positives” has declined steadily for over six weeks. That is likely due to a combination of expanded testing for screening purposes, as opposed to testing mainly individuals presenting symptoms, and fewer individuals presenting symptoms each day.

As Nate Silver said on Saturday:

“There are still *way* too many stories about big spikes in cases when the cause of those spikes was a big increase in tests. And remember, it’s a good thing when states start doing more tests!”

One commenter on Silver’s thread pointed out that more testing is likely to lead to more confirmed cases even if the true number of infections is declining.

I’ll highlight just a few individual states. Missouri’s peak in cases appears to have occurred several weeks ago, though a spike at the end of April interrupted the trend. The spike was partly attributable to a flare-up at a single meat-packing plant (facilities that are particularly conducive to viral spread due to close conditions and aerosols).

Here is Georgia, which began to reopen its economy on April 24. The pro-lockdown crowd confidently predicted the reopening would lead to a spike in cases within two weeks. Georgia is conservative in its reporting, so they don’t extend the lines in the chart beyond 14 days of the most recent reports due to potential revisions. Nevertheless, it’s clear that the trend in cases is downward.

The pro-lockdown contingent predicted the same for Florida, but that has not been the case:

The next chart shows seven-day moving averages of deaths per million of population for four states: CA, FL, GA, and MO. The labels on the right might be hard to read, but MO is the green line. Deaths lag cases by a few weeks, and Missouri’s death rate was elevated more recently, again owing partly to the meat-packing plant. These death rates are all fairly low relative to the northeastern states around New York.

Finally, here are death rates per million of population for a few selected countries: Italy, Germany, Sweden, and the US. Italy had the large early spike, while Germany lagged and with a much lower fatality rate. The U.S. suffered more than twice the German death rate. Sweden, which has pursued a herd immunity strategy, has come in somewhat higher. The Italian and Swedish experiences both reflect high deaths in nursing homes, which might indicate a lack of preparedness at those institutions.

Here is a post from just a few days ago with a nice collection of charts for various countries.

Returning to the main gist of this “framing”, the Great Over-Reaction, the predictions setting off this panic were made by a forecaster, Neil Ferguson, who has had a rather poor track record of predicting the severity of earlier pandemics. The model he used is said to have been poorly coded and documented, and it is underdetermined such that many multiple forecast paths are possible. That means the choice of a “forecast” path is arbitrary.

Make no mistake: Covid-19 is a serious virus. Ultimately, however, the Covid-19 pandemic might not reach the scale of a typical global flu: the current global death toll is only about two-thirds of the average flu season (global deaths from Covid-19 are now about 312,000—the chart below is a few days old). In the U.S., the death toll is modestly higher than the average flu season, but that is largely attributable to the New York City metro area. Worldwide, Covid19 deaths are now about 30% of the toll of the Hong Kong flu in 1969-70, 28% of the Asian flu in 1957-58, and far less than 1% of the Spanish flu at the end of WW I. Neither the Hong Kong flu nor the Asian flu were dealt with via widespread non-prescription health interventions like the draconian lockdowns instituted this time. The damage to the economy has been massive and unjustifiable, and the effective moratorium on medical care for other serious conditions is inflicting a large toll of its own.

Again, we can identify distinct groups that are highly vulnerable to Covid-19: the aged and individuals with co-morbidities most common among the aged. A large share of the population is not susceptible, including children and the vast bulk of the work force. The sensible approach is to target vulnerable groups for protection while minimizing interference with the liberties of those capable of taking care of themselves, especially their freedom to weigh risks. Nevertheless, those facing low risks should continue to practice extra-good manners…. er, social distancing, to avoid subjecting others to undue risk. Don’t be a close talker, don’t go out if you feel at all out of sorts, and cover your sneezes!

Cuomo Denies Tradeoffs, Cries Scarcity

12 Tuesday May 2020

Posted by pnoetx in Pandemic, statism, Virtue Signaling

≈ Leave a comment

Tags

Andrew Cuomo, BMI, Coronavirus, Cost-Benefit Analysis, Covid-19, Economic Value of Life, European Virus, Javits Center, Lockdown, New York Virus, Shadow Price, statism, The Nation, Ventilators, Who Shall Live?, Wuhan Virus

Here’s an all-time dumbass bromide: “If it saves only one life, it’s worth it.” New York Governor Andrew Cuomo said it last week in a bit of sanctimonious posturing intended for consumption by the unthinking. A variant on this is, “You can’t put a value on a human life,” and Cuomo said that too. But of course we do that every day. Yes, we weigh lives against costs, and we must. Each and every decision involving any personal or public health risk entails an implicit and sometimes explicit valuation of human life. There are few costless decisions in a world of scarce resources, and lives are often one of those costs. These might be matters of probability in an ex ante sense, which might make it more palatable. Ex post, they add up to real lives.

Imagine a world in which we spared no expense to save lives. We’d shift massive resources into health care to the detriment of all production and consumption that does not save lives. No precaution would be too conservative. No driving or biking, because those prohibitions would save many lives. Many risky construction and maintenance jobs would be off limits. No smoking, of course, and no drinking! No chips! Every BMI greater than 25 and you’re off to mandatory fat camp. Sadly, the effort to save a life is sometimes fruitless, but as long as there’s a chance, we’d try and try, providing mechanical life support to every patient hanging on by a tattered thread. No, we don’t do these things because it’s too damn costly.

We face an infinite number of tradeoffs in medical care and in public health more generally. The question “Who Shall Live?” must be answered every day when deciding how health care resources are to be allocated. No matter how you answer that question, certain lives will be lost as the cost of meeting your preferred medical objectives. You can’t meet them all. Resources are scarce — or in more everyday language, budgets are tight.

So human life is often assigned an implicit or shadow value in decision making. But even explicit assignment of economic value to human life is not uncommon. Valuing lives is a standard practice in cost-benefit analysis. It’s also quite common for life values to be estimated as part of forensic analyses in support of legal proceedings.

Andrew Cuomo surely knows all this. That makes his statements all the more disingenuous. This article in The Nation from the end of March implies that Cuomo has valued life all too cheaply in light of his past budget proposals for health care programs. Along the same lines, see this eye-opening critique of the policies Cuomo has pursued that left NY poorly prepared for a pandemic. And now, he’d like to keep his costly lockdown order in place even if it saves “just one life”.

Beyond all that, Cuomo is a stupendous hypocrite, asserting that life is too precious to spare any expense after signing an order in March requiring nursing homes to accept individuals with active Covid infections. Nursing homes have been the very hottest of spots for Covid infections and deaths, so the order was glaringly dismissive in valuing the lives of vulnerable nursing home residents. The rationale for the order was to save hospital beds, but there was no shortage.

In fairness, Cuomo was also clamoring for assistance to add hospital capacity. Millions were spent to convert the Javits Center to a temporary field hospital and to bring a U.S. Navy hospital ship up the Hudson, but they went almost completely unused. Why not send the elderly patients there, instead of back to the nursing homes?

Finally, he pouted for weeks about his state’s shortage of ventilators, only to quickly reverse course as it became apparent that the state had a surplus of ventilators.

Recently, Cuomo felt it necessary to demonstrate his anti-Western bona fides by labeling the coronavirus the “European Virus“. He must think that’s a clever poke in the eye to those who prefer “Wuhan Virus”, though it is quite correct (and not the least bit “racist”) to note that the virus originated in Wuhan, China. For what it’s worth, the genome of the European strain, like the others that hit New York, differs by less than 12 out of 30,000 base-pairs of DNA from the original Wuhan strain. And of course the New York metropolitan area has made a massive contribution to the U.S. case load and death toll from the virus. Travelers from New York did much to spread Covid-19 to the rest of the country. So, as some have suggested, perhaps a better name might be “New York Virus”.

Andrew Cuomo is nothing if not a politician, and I suppose he’s just behaving like one. I probably wouldn’t gripe were it not for the minions who fall for Cuomo’s sham virtue. But it’s worse than that: the claim that public intervention at any cost is worthwhile if it saves “just one life” is a deeply statist sentiment.

On the Meaning of Herd Immunity

09 Saturday May 2020

Posted by pnoetx in Pandemic, Public Health, Risk

≈ Leave a comment

Tags

Antibody, Antigen, Carl T. Bergstrom, Christopher Moore, Covid-19, Herd Immunity, Heterogeneity, Household Infection, Immunity, Infection Mortality Risk, Initial Viral Load, John Cochrane, Lockdowns, Marc Lipsitch, Muge Cevik, Natalie Dean, Natural Immunity, Philippe Lemoine, R0, Santa Fe Institute, SARS-CoV-2, Social Distancing, Super-Spreaders, Zvi Mowshowitz

Immunity doesn’t mean you won’t catch the virus. It means you aren’t terribly susceptible to its effects if you do catch it. There is great variation in the population with respect to susceptibility. This simple point may help to sweep away confusion over the meaning of “herd immunity” and what share of the population must be infected to achieve it.

Philippe Lemoine discusses this point in his call for an “honest debate about herd immunity“. He reproduces the following chart, which appeared in this NY Times piece by Carl T. Bergstrom and Natalie Dean:

Herd immunity, as defined by Bergstrom and Dean, occurs when there are sufficiently few susceptible individuals remaining in the population to whom the actively-infected can pass the virus. The number of susceptible individuals shrinks over time as more individuals are infected. The chart indicates that new infections will continue after herd immunity is achieved, but the contagion recedes because fewer additional infections are possible.

We tend to think of the immune population as those having already been exposed to the virus, and who have recovered. Those individuals have antibodies specifically targeted at the antigens produced by the virus. But many others have a natural immunity. That is, their immune systems have a natural ability to adapt to the virus.

Heterogeneity

At any point in a pandemic, the uninfected population covers a spectrum of individuals ranging from the highly susceptible to the hardly and non-susceptible. Immunity, in that sense, is a matter of degree. The point is that the number of susceptible individuals doesn’t start at 100%, as most discussions of herd immunity imply, but something much smaller. If a relatively high share of the population has low susceptibility, the virus won’t have to infect such a large share of the population to achieve effective herd immunity.

The apparent differences in susceptibility across segments of the population may be the key to early herd immunity. We’ve known for a while that the elderly and those with pre-existing conditions are highly vulnerable. Otherwise, youth and good health are associated with low vulnerability.

Lemoine references a paper written by several epidemiologists showing that “variation in susceptibility” to Covid-19 “lowers the herd immunity threshold”:

“Although estimates vary, it is currently believed that herd immunity to SARS-CoV-2 requires 60-70% of the population to be immune. Here we show that variation in susceptibility or exposure to infection can reduce these estimates. Achieving accurate estimates of heterogeneity for SARS-CoV-2 is therefore of paramount importance in controlling the COVID-19 pandemic.”

The chart below is from that paper. It shows a measure of this variation on the horizontal axis. The colored, vertical lines show estimates of historical variation in susceptibility to historical viral episodes. The dashed line shows the required exposure for herd immunity as a function of this measure of heterogeneity.

Their models show that under reasonable assumptions about heterogeneity, the reduction in the herd immunity threshold (in terms of the percent infected) may be dramatic, to perhaps less than 20%.

Then there are these tweets from Marc Lipsitch, who links to this study:

“As an illustration we show that if R0=2.5 in an age-structured community with mixing rates fitted to social activity studies, and also categorizing individuals into three categories: low active, average active and high active, and where preventive measures affect all mixing rates proportionally, then the disease-induced herd immunity level is hD=43% rather than hC=1−1/2.5=60%.”

Even the celebrated Dr. Bergstrom now admits, somewhat grudgingly, that hereogeniety reduces the herd immunity threshold, though he doesn’t think the difference is large enough to change the policy conversation. Lipsitch also is cautious about the implications.

Augmented Heterogeneity

Theoretically, social distancing reduces the herd immunity threshold. That’s because infected but “distanced” people are less likely to come into close contact with the susceptible. However, that holds only so long as distancing lasts. John Cochrane discusses this at length here. Social distancing compounds the mitigating effect of heterogeneity, reducing the infected share of the population required for herd immunity.

Another compounding effect on heterogeneity arises from the variability of initial viral load on infection (IVL), basically the amount of the virus transmitted to a new host. Zvi Mowshowitz discusses its potential importance and what it might imply about distancing, lockdowns, and the course of the pandemic. In any particular case, a weak IVL can turn into a severe infection and vice versa. In large numbers, however, IVL is likely to bear a positive relationship to severity. Mowshowitz explains that a low IVL can give one’s immune system a head start on the virus. Nursing home infections, taking place in enclosed, relatively cold and dry environments, are likely to involve heavy IVLs. In fact, so-called household infections tend to involve heavier IVLs than infections contracted outside of households. And, of course, you are very unlikely to catch Covid outdoors at all.

Further Discussion

How close are we to herd immunity? Perhaps much closer than we thought, but maybe not close enough to let down our guard. Almost 80% of the population is less than 60 years of age. However, according to this analysis, about 45% of the adult population (excluding nursing home residents) have any of six conditions indicating elevated risk of susceptibility to Covid-19 relative to young individuals with no co-morbidities. The absolute level of risk might not be “high” in many of those cases, but it is elevated. Again, children have extremely low susceptibility based on what we’ve seen so far.

This is supported by the transmission dynamics discussed in this Twitter thread by Dr. Muge Cevik. She concludes:

“In summary: While the infectious inoculum required for infection is unknown, these studies indicate that close & prolonged contact is required for #COVID19 transmission. The risk is highest in enclosed environments; household, long-term care facilities and public transport. …

Although limited, these studies so far indicate that susceptibility to infection increases with age (highest >60y) and growing evidence suggests children are less susceptible, are infrequently responsible for household transmission, are not the main drivers of this epidemic.”

Targeted isolation of the highly susceptible in nursing homes, as well as various forms of public “distancing aid” to the independent elderly or those with co-morbidities, is likely to achieve large reductions in the effective herd immunity ratio at low cost relative to general lockdowns.

The existence of so-called super-spreaders is another source of heterogeneity, and one that lends itself to targeting with limitations or cancellations of public events and large gatherings. What’s amazing about this is how the super-spreader phenomenon can lead to the combustion of large “hot spots” in infections even when the average reproduction rate of the virus is low (R0 < 1). This is nicely illustrated by Christopher Moore of the Santa Fe Institute. Super-spreading also implies, however, that while herd immunity signals a reduction in new infections and declines in the actively infected population, “hot spots” may continue to flare up in a seemingly random fashion. The consequences will depend on how susceptible individuals are protected, or on how they choose to mitigate risks themselves.

Conclusion

I’ve heard too many casual references to herd immunity requiring something like 70% of the population to be infected. It’s not that high. Many individuals already have a sort of natural immunity. Recognition of this heterogeneity has driven a shift in the emphasis of policy discussions to the idea of targeted lockdowns, rather than the kind of indiscriminate “dumb” lockdowns we’ve seen. The economic consequences of shifting from broad to targeted lockdowns would be massive. And why not? The health care system has loads of excess capacity, and Covid infection fatality risk (IFR) is turning out to be much lower than the early, naive estimates we were told to expect, which were based on confirmed case fatality rates (CFRs).

Private Social Distancing, Private Reversal

04 Monday May 2020

Posted by pnoetx in Liberty, Pandemic, Uncategorized

≈ 1 Comment

Tags

Andrew Cuomo, Anthony Fauci, Apple Mobility, Bill De Blasio, Centre for Economic Policy Research, Donald Trump, Externalities, Forbes, Foursquare, Heterogeneity, John Koetsier, Laissez Faire, Lockdowns, Nancy Pelosi, Points of Interest, Private Governance, Safegraph, Social Distancing, Social Welfare, Stay-at-Home Orders, Vitamin D, Wal Mart, WHO

My original post on the dominance of voluntary social distancing over the mandated variety appears below. That dominance is qualified by the greater difficulty of engaging in certain activities when they are outlawed by government, or when the natural locations of activities are declared off-limits. Nevertheless, as with almost all regulation, people make certain “adjustments” to suit themselves (sometimes involving kickbacks to authorities, because regulation does nothing so well as creating opportunities for graft). Those “adjustments” often lead to much less desirable outcomes than the original, unregulated state. In the case of a pandemic, however, it’s tempting to view such unavoidable actions as a matter of compromise.

I say this now because the voluntary social distancing preceding most government lockdown orders in March (discussed in the post below) is subject to a degree of self-reversal. Apple Mobility Data suggests that something like that was happening throughout much of April, as shown in the chart at the top of this post. Now, in early May, the trend is likely to continue as some of the government lockdown mandates are being lifted, or at least loosened.

An earlier version of the chart above appeared in a Forbes article entitled, “Apple Data Shows Shelter-In-Place Is Ending, Whether Governments Want It To Or Not“. The author, John Koetsier, noted the Apple data are taken from map searches, so they may not be reliable indicators of actual movement. But he also featured some charts from Foursquare, which showed actual visits to various kinds of destinations, and some of theoe demonstrate the upward trend in activity.

In the original post below, I used SafeGraph charts lifted from a paper I described there. The four charts below are available on the SafeGraph website, which offered the services of the friendly little robot in the lower right-hand corner, but I demurred. You’ll probably need to click on the image to read the detail. They show more granular information by industry, brand, region, and restaurant categories. The upward trends are evident in quite a few of the series.

I should qualify my interpretation of the charts above and those in my original post: First, nine states did not have stay-at-home orders, though a few of those had varying restrictions on individuals and on the operation of “non-essential” businesses. The five having no orders of any kind (that I can tell) are lightly-populated, very low-density states, so the vast majority of the U.S. population was subject to some sort of lockdown measure. Second, eight states began to ease or lift orders in the last few days of April, Georgia and Colorado being the largest. Therefore, at the tail end, a small part of the increase in activity could be related to those liberalizations. Then again, it might have happened anyway.

The authoritarian impulse to shut everything down was largely unnecessary, and it did not accomplish much that voluntary distancing hadn’t accomplished already (again, see below). Healthy people need to stop cowering and take action. That includes the non-elderly and those free of underlying health conditions. Sure, take precautions, keep your distance, but get out of your home if you can. Get some sunny Vitamin D.

Committing yourself to the existence of a shut-in is not healthy, not wise, and it might destroy whatever wealth you possess if you are a working person. The data above show that people are recognizing that fact. As much as the Left wishes it were so, government seldom “knows better”. It is least effective when it uses force to suppress voluntary behavior; it is most effective when it follows consensus, and especially when it protects the rights of individuals to make their own choices where no consensus exists.

Last week’s post follows:

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

How much did state and local governments accomplish when they decided to issue stay-at-home orders? Perhaps not much. That’s the implication of data presented by the authors of “Internal and external effects of social distancing in a pandemic” (starts on page 22 in the linked PDF). Social distancing began in the U.S. in a series of voluntary, private actions. Government orders merely followed and, at best, reinforced those actions, but often in ham-handed ways.

The paper has a broader purpose than the finding that social distancing is often a matter of private initiative. I’ll say a bit more about it, but you can probably skip the rest of this paragraph without loss of continuity. The paper explores theoretical relationships between key parameters (including a social distancing construct) and the dynamics of a pandemic over time in a social welfare context. The authors study several alternatives: a baseline in which behavior doesn’t change in any way; a “laissez faire” path in which actions are all voluntary; and a “socially optimal” path imposed by a benevolent and all-knowing central authority (say what???). I’d offer more details, but I’ll await the coming extension promised by the authors to a world in which susceptible populations are heterogenous (e.g., like Covid-19, where children are virtually unaffected, healthy working age adults are roughly as at-risk as they are to the flu, and a population of the elderly and health-compromised individuals for which the virus is much more dangerous than the flu). In general, the paper seems to support a more liberalized approach to dealing with the pandemic, but that’s a matter of interpretation. Tyler Cowen, who deserves a hat-tip, believes that reading is correct “at the margin”.

Let’s look at some of the charts the authors present early in the paper. The data on social distancing behavior comes from Safegraph, a vendor of mobility data taken from cell phone location information. This data can be used to construct various proxies for aggregate social activity. The first chart below shows traffic at “points of interest” (POI) in the U.S. from March 8 to April 12, 2020. That’s the blue line. The red line is the percentage of the U.S. population subject to lockdown orders on each date. The authors explain the details in the notes below the chart:

Clearly POI visits were declining sharply before any governments imposed their own orders. The next two charts show similar declines in the percent of mobile devices that leave “home” each day (“home” being the device’s dominant location during nighttime hours) and the duration over which devices were away from “home”, on average.

So all of these measures of social activity began declining well ahead of the government orders. The authors say private social distancing preceded government action in all 50 states. POI traffic was down almost 40% by the time 10% of the U.S. population was subject to government orders, and those early declines accounted for the bulk of the total decline through April 12. The early drops in the two away-from-home measures were 15-20%, again accounting for well over half of the total decline.

The additional declines beyond that time, to the extent they can be discerned, could be either trends that would have continued even in the absence of government orders or reinforcing effects the orders themselves. This does not imply that lockdown orders have no effects on specific activities. Rather, it means that those orders have minor incremental effects on measures of aggregate social activity than the voluntary actions already taken. In other words, the government lockdowns are largely a matter of rearranging the deck chairs, or, that is to say, their distribution.

Many private individuals and institutions acted early in response to information about the virus, motivated by concerns about their own safety and the safety of family and friends. The public sector in the U.S. was not especially effective in providing information, with such politicos as President Donald Trump, Nancy Pelosi, Andrew Cuomo, Bill De Blasio, and the mayor of New Orleans minimizing the dangers into the month of March, and some among them encouraging people to get out and celebrate at public events. Even Anthony Fauci minimized the danger in late February (not to mention the World Health Organization). In fact, “the scientists” were as negligent in their guidance as anyone in the early stages of the pandemic.

When lockdown orders were issued, they were often arbitrary and nonsensical. Grocery stores, liquor stores, and Wal Mart were allowed to remain open, but department stores and gun shops were not. Beaches and parks were ordered closed, though there is little if any chance of infection outdoors. Lawn care services, another outdoor activity, were classified as non-essential in some jurisdictions and therefore prohibited. And certain personal services seem to be available to public officials, but not to private citizens. The lists of things one can and can’t buy truly defies logic.

In March, John W. Whitehead wrote:

“We’re talking about lockdown powers (at both the federal and state level): the ability to suspend the Constitution, indefinitely detain American citizens, bypass the courts, quarantine whole communities or segments of the population, override the First Amendment by outlawing religious gatherings and assemblies of more than a few people, shut down entire industries and manipulate the economy, muzzle dissidents, ‘stop and seize any plane, train or automobile to stymie the spread of contagious disease,’…”

That is fearsome indeed, and individuals can accomplish distancing without it. If you are extremely risk averse, you can distance yourself or take other precautions to remain protected. You can either take action to isolate yourself or you can decide to be in proximity to others. The more risk averse among us will internalize most of the cost of voluntary social distancing. The less risk averse will avoid that cost but face greater exposure to the virus. Of course, this raises questions of public support for vulnerable segments of the population for whom risk aversion will be quite rational. That would certainly be a more enlightened form of intervention than lockdowns, though support should be offered only to those highly at-risk individuals who can’t support themselves.

Christopher Phelan writes of three rationales for the lockdowns: buying time for development of a vaccine or treatments; reducing the number of infected individuals; and to avoid overwhelming the health care system. Phelan thinks all three are of questionable validity at this point. A vaccine might never arrive, and Phelan is pessimistic about treatments (I have more hope in that regard). Ultimately a large share of the population will be infected, lockdowns or not. And of course the health care system is not overwhelmed at this point. Yes, those caring for Covid patients are under a great stress, but the health care system as a whole, and patients with other maladies, are currently suffering from massive under-utilization.

If you wish to be socially distant, you are free to do so on your very own. Individuals are quite capable of voluntary risk mitigation without authoritarian fiat, as the charts above show. While private actors might not internalize all of the external costs of their activities, government is seldom capable of making the appropriate corrections. Coercion to enforce the kinds of crazy rules that have been imposed during this pandemic is the kind of abuse of power the nation’s founders intended to prevent. Reversing those orders can be difficult, and the precedent itself becomes a threat to future liberty. Nevertheless, we see mounting efforts to resist by those who are harmed by these orders, and by those who recognize the short-sighted nature of the orders. Private incentives for risk reduction, and private evaluation of the benefits of social and economic activity, offer superior governance to the draconian realities of lockdowns.

Sacred Cow Chips

Category Archives: Pandemic

Unfortunate COVID Follies

Trump Hates/Loves Lockdowns, Dumps on Swedes

Trump and Coronavirus

Suspending Medical Care In the Name of Public Health

Covid Framing #6: The Great Over-Reaction

Cuomo Denies Tradeoffs, Cries Scarcity