Tag Archives: New York

Hooray For Florida!

22 Monday Feb 2021

Posted by in Coronavirus, Public Health

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It’s been said that many of the so-called “heroes” of the COVID pandemic who’ve been celebrated by the media are actually villains, and perhaps Governor Andrew Cuomo of New York should top the list. He saw to it that retirement homes were seeded with infected patients by ordering them returned their care homes rather than admitted to hospitals. Deaths in these facilities mounted, and they mounted faster than Cuomo’s administration was willing to admit. But the media and even Democrat state legislators have begun to take note, which is practically a miracle!

It seems equally true that some vilified by the media for their COVID response are actually heroes. Governor Ron DeSantis of Florida might deserve top honors here. Having spent the last month in Florida, I can attest that the business and social environment here is quite open compared to my home state (despite the presence of a few freaked out northerners who can’t quite fathom how stupid they look wearing masks on the beach). Florida’s infections, hospitalizations, and deaths have been lower than in California, New York, and many other states where lockdown measures have been stringent. (The first chart below is just a little busy…)

As I’ve written for much of the past year, COVID is far more dangerous to the elderly than anyone else, particularly those with co-morbidities. It’s also true that blacks (and some other minorities) are more vulnerable than whites, but if we want to save more black lives, we’re still better off prioritizing the elderly than racial groups. DeSantis understands this, and Florida is among the leaders in vaccinating the elderly population. (States don’t report this data on a uniform basis):

This approach to saving lives is obvious, yet critics at outlets like NBC News insist that DeSantis must be pandering to the senior population in Florida. Well, one wouldn’t want to be responsive to voters who happen to face high mortality risks, right? Others such as horror writer Stephen King have jumped onboard to offer their bumbling public health expertise as well.

There were many experts and the usual collection of numbskulls on social media who were wrong about Florida. DeSantis handled the pandemic as it should have been handled elsewhere. But the propaganda to the contrary goes unabated. For example, this article is pathetic. Can these people be serious? Or are they really that stupid? This goes for the Biden Administration as well, which had entertained the notion of imposing federal travel restrictions on Florida!

The political attacks on Florida and its governor reveal the extent to which opponents wish to ignore the evidence in plain sight. The data on COVID outcomes put the lie to the narrative of a public health emergency requiring massive restrictions on personal liberty. We know those policies are powerless to control the course of the contagion. The pandemic, however, was the key to convincing the public to accept a more authoritarian role for government. It’s a blessing that not everyone bought in, and that there are places like Florida where you can still go about your business in approximate normalcy.

COVID at Midsummer

04 Tuesday Aug 2020

Posted by in Pandemic, Public Health

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It’s been several weeks since I last posted on the state of the coronavirus pandemic (also see here). The charts below show seven-day moving averages of new confirmed cases and reported C19 deaths from the COVID Tracking Project as of August 3. Daily new cases began to flatten about three weeks ago and then turned down (it can take a few days for such changes to show up in a moving average). Daily C19-attributed deaths began climbing again in early July, lagging new cases by a few weeks, and they slowed just a bit over the past several days. Obviously, both are good news if those changes are maintained. The other thing to note is that deaths have remained far below their levels of April and early May.

The daily death count is that reported on each date, not when the deaths actually occurred. Each day’s report consists of deaths that were spread across several previous weeks or even a month or more. That makes the slight downturn in deaths more tenuous from a data perspective. There are sometimes large numbers of deaths from preceding weeks reported together on a single day, so reporting can be ragged and the final pattern of actual deaths is not known for some time. More on that below.

States

The increase in cases and deaths during late June and July was concentrated in four states: Arizona, California, Florida, and Texas. Here’s how those states look now in terms of cases and deaths, from the interactive COVID Time Series site:

 

New cases began to flatten or drop in these states two to three weeks ago, driving the change in the national data. Daily deaths have not turned convincingly, but again, these are reported deaths, which actually occurred over previous weeks. One more chart that is suggestive: current hospitalizations in these four states. The recent declines should bode well for the trend in reported deaths, but it remains to be seen. 

Meanwhile, other parts of the country have seen an uptrend in cases and deaths, such as Illinois, Missouri, South Carolina, and Tennessee. Here are new cases in those states:

It’s worth emphasizing that the elevated level of new cases this summer has not been associated with the rates of fatality experienced in the Northeast during the spring. There are many reasons: better patient care, new treatments, more direct summer sunlight, higher humidity, and tighter controls in nursing homes.

More On the Timing of Deaths

Back to the discrepancies in the timing of reported deaths and actual deaths. This is important because the reported totals each day and each week can be highly misleading, even to the point of frightening the public and policy makers, with consequent psychological and economic impacts.

The latest summary of provisional vs. reported deaths is shown below, courtesy of Kyle Lamb, who posts updates on his Twitter feed. This report ends with the last complete week ending August 1. It’s a little hard to read, but you might get a better look if you click on it or turn your phone sideways. Some of the key series are also graphed below. 

The table shows the actual timing of deaths in the fourth column, with dates alongside. The pattern differs from the statistics reported by the Covid Tracking Project (CTP) in the top row (shaded orange), and from the totals of actual deaths by reporting day in the third row (shaded gray). The reporting dates are always later than the dates of death. This can be seen in the chart below. The most obvious illustration is how many of the deaths from around the peak in mid-April were reported in May. In March and April, the daily reports were short of the ultimate actual death counts because so few deaths with associated dates were known by then.

 

The right-hand end of the red line shows that many deaths reported by CTP have not yet been placed at an actual date of death by the CDC.  At this point, the actual date of death has not been placed for over 10,000 deaths! Again, those will be spread over earlier weeks.

The blue line is dashed over the last four weeks because those counts are most “highly” provisional. Small changes in the actual counts are likely for dates even before that, but the last four weeks are subject to fairly substantial upward revisions. Eventually, the right end of the blue line will more closely approximate the totals shown in red.

To get an indication of trends in the actual timing of deaths, I plotted the weekly actual deaths reported for the last four reporting weeks going back in time. In the table, those are the four lowest, color-coded diagonals. In the graph below, which should include the qualifier “by recency of report week”, actual deaths in the most recent report week are represented by the blue line, the prior weekly report is red, followed by green (three weeks prior), and purple (four weeks prior… sorry, the colors are not consistent with those in the table). The lines extend farther to the right for more recent report weeks.

The increase in actual deaths occurring in July has declined or flattened in each of the four most recent report weeks. Only the second-to-last week increased as of the August 1st report. On the whole, those changes seem favorable, but we shall see.

Closing

It’s getting trite to say, but the next few weeks will be interesting. The increase in deaths in July was a sad development, but at least the extent of it appears to have been limited. Even with a somewhat higher death count, the fatality rate continued to decline. Let’s hope any further waves of infections are even less deadly.

Suspending Medical Care In the Name of Public Health

23 Saturday May 2020

Posted by in Health Care, Pandemic

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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 in Pandemic

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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!