Cardiology Shutdown in Massachusetts

I met with a cardiologist friend last night. He says that he is working roughly 60 percent as much as he was pre-coronapanic. “Where we would do five procedures per day, we can now do only two,” he said. “That leaves enough time for deep cleaning between patients. Also, they’re reserving 20 percent of the rooms in the hospital for Covid patients, just in case.”

He and his colleagues have already had multiple patients die while waiting for heart valve procedures that were considered “elective”. (see “StayHomeSaveLives or #StayHomeTradeLives?” and the link to the NEJM article) He gets paid in full despite the reduction in work and billing, and is at a vulnerable age for Covid-19 (70s), but is nonetheless anti-shutdown: “It was only a few years ago when parents were supposed to make sacrifices for their children. Now it is the other way around.”

Today is #ShutDownSTEM day. Plenty of righteous posts on Facebook from friends who are professors of various flavors of nerdism. They’ve been sitting on their butts for three months now, taking baby steps in the direction of online teaching (nowhere near as competently as faculty at Western Governor’s University, which has been online since the mid-1990s). Today they will sit on their butts even more firmly? It has been a struggle for me to refrain from asking “How could you possibly do less than you’ve been doing since mid-March?”

(Not all professionals are idle. A friend Facebook messaged me today about some divorce litigators who are fully engaged on an issue of life insurance. The defendant father wants to have the beneficiaries of his life insurance be a trust for the children (tweens). The plaintiff mother wants to ensure that the life insurance cash is paid to her, to compensate her for any reduction in profits from alimony and child support. The parties are divorced, but the litigation lives on (legal fees on both sides paid for by the father’s earnings that would have been the children’s inheritance).)

Speaking for myself, I participated in a Zoom meeting regarding some health records data analysis today, but all of the coding was in SQL so I am not sure if that qualifies as “STEM”! Later today it will be time to fly the helicopter, which can be considered a “STEM” activity by American journalists when a member of an officially recognized victim group is at the controls. One of the participants in the call is a third-year medical student. He won’t be able to do a clinical rotation until about a month from now (i.e., he will miss at least three months of clinical training).

From a neighbor’s front yard, “Science is Real” (but also not so important that you’d want to do it every day?):

From a recent visit to the doctor’s office in Concord, Massachusetts to get some blood drawn in advance of a regular checkup:

(any of 50+ gender IDs is okay, but we will depict, recognize, and give priority to only two?)

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Ebola vaccine: 43 years after first outbreak

A righteous Church of Shutdowner on Facebook regarding the infidels of the frozen north:

The Swedish approach makes sense if and only if you are certain that everyone is going to get the virus in the end. If you think there is going to be a vaccine available within 18 months, it means far more deaths than necessary.

[“far more deaths than necessary” in Sweden to date translates to half as many as in Massachusetts (adjusted for population size). Their failure with continuity looks pretty good compared to our success with shutdown!]

I asked why he was confident regarding vaccine development:

We produced a vaccine for Ebola within months of the disease appearing. And right now we have every vaccine lab in the world and more looking for the COVID vaccine. The question hasn’t been time, it has been whether immunity was possible. If you have thirty world class labs each taking a shot at producing a vaccine that has a 10% chance of success, you are pretty much certain to succeed if it is possible with that approach.

I certainly hope that he is right (he’s a computer programmer, not a virologist, so he is guessing just like the rest of us!), but I decided to check out Wikipedia on Ebola and discovered that it first broke out within humans in 1976 and an approved vaccine become available 43 years later, on December 17, 2019 (i.e., we were perfectly set up to fight the last war almost to the day that the next war broke out).

(The press release might have to be walked back a bit, given recent events: “The first-ever FDA approval of a vaccine for the prevention of Ebola is a triumph of American global health leadership.”)

Related:

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Medical doctors stopped meeting in huge conventions on March 10

A friend in medical research and I were joking about people who claim to have hindsight regarding coronavirus. I said that I alternate between bragging about my garage full of N95 masks and ventilators and, if someone else says that it should have been trivial for Donald Trump to foresee, if I can come over to his/her/zer/their house to borrow some of the stockpiled N95 masks and ventilators.

He said “We were actually the worst.” What could that mean? “We [doctors] were still holding huge conventions, flying on packed airline flights, meeting by the thousands in hotels, and then returning home with whatever we’d caught to our patients, often some of the sickest and most immune-compromised people in the U.S.” Until when? “March 10.”

(note that the typical school system in Massachusetts shut down on the afternoon of March 12 or 13 and a lot of companies went to work-from-home after March 13)

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Will cigarette and marijuana smoking become less popular in the Age of Corona?

For decades the government has been telling people that smoking cigarettes is bad for their health. For about a decade, the government has been telling people that smoking marijuana is good for their health (cures most illness!).

We know that coronavirus attacks smokers. Americans right now are as scared of coronavirus as they’ve ever been of anything. Could it be that the coronaplague will get people to stop smoking both tobacco and marijuana?

Cigarettes are taxed at the federal level, right? So we should be able to get clean data on how many are sold, no? All that I could find was a December 30, 2019 report on tobacco sales in 2018 (i.e., it took a year to get the data and report together).

Readers: Predictions?

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Invest in Estonian-style e-governance to be ready for the next plague?

Quite a few Boston-area businesses have shut down their physical offices. Employees of Amazon, for example, are working from home. Towns and cities, however, can’t close down their respective Town Halls and City Halls because the only way to access quite a few government services is to show up in person. The same enterprise of state/local government that tries, via its public health department, to get everyone to stay home, may ironically end up being one of the only information processing operations that insists that everyone show up and get within contagious distance.

Supposedly Estonia allows citizens to do almost anything that they’d do at a city hall from the disease-free safety of their own homes.

The U.S. track record for government-run IT is admittedly mixed, e.g., with the $1 billion healthcare.gov insurance site. But maybe if we could adopt the Estonian system unmodified for state and local transactions we would be able to save time in non-plague periods and save lives in plague periods.

Readers: What do you think? Should people have to brave coronavirus to get (or issue) a building permit?

Related:

  • “Estonia, the Digital Republic” (New Yorker, 2017)
  • e-Estonia (Wikipedia)
  • e-governance (from Estonians themselves): “Estonia is probably the only country in the world where 99% of the public services are available online 24/7. E-services are only impossible for marriages, divorces and real-estate transactions – you still have to get out of the house for those.” (don’t get too excited about those family law transactions; they are not as lucrative as in the U.S. From a 2017 post: “In all three Baltic countries I learned that having sex with the richest person in the country would yield only about 200 euros per month in child support” (similar to nearby Sweden))
  • “Estonia: Tough campaign stop for Bernie Sanders”
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Undocumented migrant population of U.S. jumps from 11 million to 19 million due to Coronavirus

For about 20 years, our official media tells us that there are 11 million undocumented residents of the U.S. But last week I was listening to NPR (temporarily bored by a lecture on 11th century Japanese history so tuned into the Channel of the Righteous as a last resort) and they casually used the number “19 million” in the context of how many people should get amnesty for violating U.S. immigration laws so that they would be encouraged to seek treatment for coronavirus and not kill all American natives. The 19 million number isn’t that different from the 22 million that Yale estimated in 2018, so it is not the number that is interesting but the radical jump from 11 million (when telling Americans not to believe Trump) to 19 million (when telling Americans about the risk of Trump policies designed to discourage the undocumented from getting on health care welfare).

Separately, as there is no treatment for coronavirus and hospitals at the time of the interview couldn’t order tests, it is unclear why anyone would want 19 million undocumented Americans to go to their nearest hospital.

(Is a constant number of undocumented plausible? To some extent, it might be. Most migrants arrive and have children in the U.S. Thus, 18 years later, the parents are entitled to a green card via chain migration (each legal immigrant will bring in an average of 3.45 additional migrants). On the other hand, with the recent migrant surge, the constant number over decades seems less plausible.)

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Coronavirus is a national emergency, but let’s not do anything drastic

Email from the president of Harvard University:

I write to follow up on the message you received Wednesday from HUHS Executive Director Giang Nguyen regarding two members of our community who have been tested for Coronavirus Disease 2019 (COVID-19). One individual received a presumptive positive test and is receiving medical care off campus. We await test results for the second individual. Additionally, a third individual who had close contact with the person who tested positive, is now being tested.

Ensuring the anonymity of these individuals is paramount. If you are aware of their identities, please respect their privacy so that they can focus completely on their health. The last thing they need—or any of us would want for them—is public attention and scrutiny.

So… it is an emergency, but preventing millions of deaths is not as important as keeping the names of the infected anonymous? If we’re in an actual emergency and lives are at stake, wouldn’t it make more sense to abandon the standard procedures and publish the names of the infected so that people who were with them can self-quarantine? Or, if anonymity is actually more important than stopping the spread of coronavirus, should we choose some description softer than “emergency”?

[Follow-up from March 15, after the governor of Massachusetts had declare a State of Emergency, ordered all restaurants and schools closed, etc.: “I write to follow-up on President Bacow’s recent message to the community. While we wait for additional test results, I continue to emphasize that the anonymity of these individuals is paramount. If you know their identities, please respect their privacy so they and their loved ones can focus completely on their health.”]

Similarly, on Friday, March 13, the Boston Public Schools decided to close for six weeks… but not start the closure until the following Tuesday (today, March 17). If the problem is serious enough to require a six-week closure, why open the schools on a single Monday after everyone has had a chance to pick up the virus somewhere over the weekend (if anyone needed to come the school to retrieve an item, that could have been done over a period of days, without gathering everyone together in close quarters for 6+ hours).

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Will the human race be more susceptible to obsessive compulsive disorder going forward?

What do you call someone who washes his hands 30 times a day? “OCD,” right? As the coronaplague spreads, what do you call someone who washes his hands 30 times a day? “Alive”?

If it turns out that OCD is protective against coronavirus and the virus mutates such that it can kill a significant number of reasonably young people (i.e., not well past their child-producing years), could it be that OCD will become a significantly more common human characteristic?

Even without coronavirus, if the world population expands to 11 billion or more and the trend toward urbanization continues, will the dense living conditions favor those with OCD habits? There are plenty of existing diseases that are transmitted from person to person and that can be stopped with OCD-style hand washing, wearing of obsessively-fitted face masks, etc.

Related:

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More from the British on coronavirus

From three days ago: “If the British are right, everything the U.S. is doing about coronavirus is wrong”. If you’re not like my friends on Facebook who get all of their scientific, technical, and medical information from Donald Trump (and then complain that it isn’t accurate), you might be interested in “Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand” from Imperial College. It seems that the UK government policy is to some extent derived from this research.

It is tough to summarize, but the authors say that both “mitigation” and “suppression” are required. Mitigation is the “flatten the curve” idea that we’ve seen. Suppression is Asian-style crush: “the aim is to reduce the reproduction number (the average number of secondary cases each case generates), R, to below 1 and hence to reduce case numbers to low levels or (as for SARS or Ebola) eliminate human-to-human transmission.”

The optimum strategy seems to be to turn suppression on and off depending on how many ICU beds are occupied. The authors expect this fight to last roughly two years. If everything is done perfectly and the baseline transmission (R0, an assumption) is 2.4, deaths in the U.K. will be cut from a baseline of 510,000 (do nothing but sweep up bodies) to around 30,000. The authors are expecting social distancing policies to be in place for about 2/3rds of the time.

Some unwelcome news for a country that takes 100 years to build a subway line and maybe 1,000 years to build high-speed rail:

Perhaps our most significant conclusion is that mitigation [as opposed to mitigation plus suppression] is unlikely to be feasible without emergency surge capacity limits of the UK and US healthcare systems being exceeded many times over. In the most effective mitigation strategy examined, which leads to a single, relatively short epidemic (case isolation, household quarantine and social distancing of the elderly), the surge limits for both general ward and ICU beds would be exceeded by at least 8-fold under the more optimistic scenario for critical care requirements that we examined. In addition, even if all patients were able to be treated, we predict there would still be in the order of 250,000 deaths in GB, and 1.1-1.2 million in the US.

So a country like China that can throw together and deliver emergency hospitals may be able to get away with comparatively lightweight social distancing measures. But for countries that are mostly paralyzed with red tape and therefore that have to “go to war with the hospitals they have”:

We therefore conclude that epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound. Many countries have adopted such measures already, but even those countries at an earlier stage of their epidemic (such as the UK) will need to do so imminently.

Sobering. The only thing that would potentially save us from these shutdowns is a vaccine, say the authors. But other sources are saying that a vaccine probably won’t work, right? The virus evolves so fast that last month’s vaccine won’t help with next month’s infection.

Even more sobering…

we emphasise that [it] is not at all certain that suppression will succeed long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time. How populations and societies will respond remains unclear.

Related:

  • The hospital that the Chinese built in 10 days is 645,000 square feet (Business Insider). How big is that? The Blue Origin rocket factory at Cape Canaveral is 750,000 square feet (Florida Today). (anecdote: A program manager at Blue Origin told our aviation group about making a bet with the general who runs the nearby U.S. Air Force base. A base guard shack had been wiped out by a hurricane. Blue Origin was beginning work on their factory as the Air Force was planning the new guard shack. The Blue Origin guy said he’d get his rocket factory built before the Air Force guy had his new guard shack. 18 months later… the Air Force won, but only by a couple of weeks.)
  • “Flattening the Coronavirus Curve Is Not Enough” (MIT Press), by a University of Toronto professor, who says that we need surge capacity like the Chinese that our military and government will deliver it (after all, we mostly won the Afghanistan and Iraq wars in slightly less than 20 years while spending less than $1 trillion per year on our military, right?): “Building out that capacity requires a new mindset and it requires it quickly. The great news is that we — and by we I mean the generation who were adults in World War II — have done this before. Entire economies were shifted over to military production. This was done by abandoning market processes of resource allocation and moving to a planned economy.”
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