I’ve heard of a few friends of friends with COVID-19. One of my students at Harvard Medical School believes that he had it, but was unable to get tested. Last night I learned, for the first time, of a friend who almost surely has COVID-19. His wife is the only one who has actually been tested (via lung scan; the RNA test won’t be back until Wednesday). They’re in Michigan and, like Massachusetts, tests are mostly for those who are hospitalized. She is 50 and has suffered from a variety of health conditions, unfortunately, for the past 15 years, that include diabetes and a heart infection. She gets sicker than the rest of the family when there is a cold or flu going around and has had pneumonia a couple of times in recent years. She hasn’t needed oxygen or a ventilator yet.
He thinks that he got the disease on February 19th in New York City. Since then he’s had a cough, occasional chills at night, intermittent fever (never over 100). He’s 56.
Due to living together in a small house, their teenage children must have gotten coronavirus as well. A son was asymptomatic. The daughter experienced it as a cold.
He’s a university professor and has been able to work through all of this, never taking a day off.
So… if you cough and your friends shout out “Coronavirus!” as a joke… they might be right.
They’re projecting roughly 80,000 deaths in the U.S. through August 4, 2020, with a range of 40,000 to 160,000. In other words, about as bad as four years of easily preventable deaths due to driving (assuming that half of driving-related deaths could be prevented with improved infrastructure and technology). The peak will be April 14, 2020, just in time for taxes. We will need roughly 1.2X as many ICU beds as we had before any ramp-up (shortfall of 14,000+ ICU beds divided by about 80,000 total ICU beds in 2018). We need only about 19,000 ventilators nationwide (this is completely inconsistent with New York Governor Cuomo’s statement that his state alone needs 30,000; the “experts” say New York will need closer to 4,000 and, in a worst-case scenario, no more than 10,000 (this is a situation in which we should listen to politicians rather than “experts”?)).
If you’re a New York elite, is it rational to limo out to Teterboro and get into a Gulfstream headed to Florida? Absolutely, says this model. New York has 13,000 hospital beds available and will need 48,000+ on April 6, 2020. The state has 10% of the available ICU beds that it needs. 1/8th of the Americans who are going to die from COVID-19 live in New York (which contains roughly 1/17th of the U.S. population) and presumably the majority of these will be from New York City.
What about Florida, whose tax burden is dramatically lower than New York’s (highest taxed state in the union). In this land of minimal government, they will have 4X as many hospital beds as they need, 2X as many ICU beds. Nobody in Florida is going to die from COVID-19 due to lack of health care availability. With a larger population than New York’s, Florida will suffer only about 3,300 COVID-19 deaths (not everyone can be saved, unfortunately, even with unlimited health care). The peak in Florida won’t come until May 14, 2020 (tough to square with exponential growth).
How about the second- and third-highest tax burden states in the union, Connecticut and New Jersey? Both will be disaster areas, project the data nerds, with demand for ICU beds being 5-7X the supply.
How about Massachusetts, where we pride ourselves on science-informed laws made by a legislature untainted by Republicans (the “science-denial party”)? Demand for beds will be 2X supply. Demand for ICU beds will be more than 5X the supply. Nearly as many people in Massachusetts will die as in Florida, despite that sun-drenched state having a much larger population.
An associated paper explains the model. What’s even worse than 80,000+ Americans biting the dust, many because their state’s government-directed health care system was pushed over by a slight breeze of excess demand?
State governments have cancelled elective procedures (and many hospitals but not all have followed suit). However, this decision has significant financial implications for health systems, as elective procedures are a major source of revenue for hospitals.
The biggest question mark for me is their forecast of ventilator usage (19,000 best-estimate for peak; 40,000 worst-case). If the data nerds are right, we have way more ventilators in the U.S. than we need to handle this challenge. We had at least 62,000 ventilators in service back in 2009 (source), plus another 100,000 older models in storage. Presumably a lot of the in-service ones are tied up with people who are sick with chronic conditions, but all of the older models should be available and that is a more than adequate resource. If these folks are right, everyone who is freaking out about ventilator supply is wrong.
One potential concern for school districts: Because online charter schools already have fully developed curricula that can serve idle students right away, parents of children who attend brick-and-mortar schools might be inclined to transfer their students to the virtual schools.
“Enrollment of new students to virtual public charter schools during the closure would impact school funding for districts across Oregon and therefore may impact the distribution of state school funds and delivery of services as directed under the executive order,” the [Oregon Department of Education] said in its guidance to districts.
Sweden is geographically close to and tightly connected via commerce and tourism with some of the world’s coronavirus hotspots, e.g., Italy, Spain, and Germany. Yet the government in Sweden hasn’t closed the schools or done much of anything else about coronavirus. Why don’t the WHO COVID-2019 situation reports show a dramatic upward trend for Sweden compared to its European neighbors?
While every other country in Europe has been ordered into ever more stringent coronavirus lockdown, Sweden has remained the exception. Schools, kindergartens, bars, restaurants, ski resorts, sports clubs, hairdressers: all remain open, weeks after everything closed down in next door Denmark and Norway.
Universities have been closed, and on Friday, the government tightened the ban on events to limit them to no more than 50 people. But if you develop symptoms, you can still go back to work or school just two days after you feel better. If a parent starts showing symptoms, they’re allowed to continue to send their children to school. [!]
Anders Tegnell, Sweden’s state epidemiologist, believes it is counterproductive to bring in the tightest restrictions at too early a stage. “As long as the Swedish epidemic development stays at this level,” he tells the Observer, “I don’t see any big reason to take measures that you can only keep up for a very limited amount of time.”
His team at the Public Health Agency of Sweden is critical of the Imperial College paper that warned this month that 250,000 people in the UK would die if the government failed to introduce more draconian measures. A week later Johnson ordered the police to implement a partial lockdown to combat the virus, telling people they “must stay at home”.
“We have had a fair amount of people looking at it and they are sceptical,” says Tegnell. “They think Imperial chose a number of variables that gave a prognosis that was quite pessimistic, and that you could just as easily have chosen other variables that gave you another outcome. It’s not a peer-reviewed paper. It might be right, but it might also be terribly wrong. In Sweden, we are a bit surprised that it’s had such an impact.”
Is it that the Swedes have so much hospital capacity they don’t care how quickly the patients come in? No need to flatten the curve (or remind everyone you know on Facebook to flatten the curve) if an infinite supply of universal health care is available. The World Bank says that Sweden has 2.6 hospital beds per 1,000 population, less than the U.S. (2.9), Italy (3.4), Germany (8.3), or Japan (13.4). Has Sweden been hoarding ventilators? Exactly the opposite: “Sweden’s Getinge to deliver 500 ventilators to Italy as demand rockets”.
If you believe that hot/humid weather helps keep the virus in check that can’t be a factor for Sweden (high of 39F tomorrow in Stockholm). Here they are wearing jackets in summer (from my Sweden photos):
Maybe they’ve just given up? From the above article:
Tegnell even questions whether stopping the progress of the virus is desirable. “We are just trying to slow it, because this disease will never go away. If you manage, like South Korea, to get rid of it, even they say that they count on it coming back. Stopping it might even be negative, because you would have a pent-up possible spread of the disease, and then once you open the gates, there is a possibility that there would be an even worse outcome.”
While Tegnell understands that he will be blamed if Sweden ends up in a similar situation to that of Italy, he refuses to be panicked. “I wouldn’t be too surprised if it ended up about the same way for all of us, irrespective of what we’re doing,” he says. “I’m not so sure that what we’re doing is affecting the spread very much. But we will see.”
Why haven’t we seen the effects already? If a shutdown works, Sweden should have a higher infection rate per capita than Denmark, right, since Denmark is shut down. But WHO reports show Sweden with a lower infection rate (Sweden has twice the population of Denmark).
Why don’t we read about overwhelmed hospitals in Sweden? With exponential growth, we’ve had enough time to see a difference between Germany and Denmark (schools shut afternoon of March 13) and Sweden, no?
(Maybe two weeks isn’t enough if Denmark and Sweden are like Massachusetts and don’t test people until they’ve been admitted to the hospital and are at death’s door. And then the tests don’t get reported out to the public until after they’ve come back from the lab (can take 2-4 additional days). So Sweden could have been experiencing far more infections during the last two weeks, but it wouldn’t show up in the data just yet. Though you’d think we’d see hysterical articles about the hospitals filling up, as we have been getting out of New York.)
Related:
From 2018: “Denmark plans to house the country’s most unwelcome foreigners in a most unwelcoming place: a tiny, hard-to-reach island that now holds the laboratories, stables and crematory of a center for researching contagious animal diseases. As if to make the message clearer, one of the two ferries that serve the island is called the Virus.” (nytimes)
getting to the same place, but perhaps from a less-obviously-informed-by-epidemiology perspective, “Brazil’s Bolsonaro makes life-or-death coronavirus gamble” (Associated Press): “Brazilian President Jair Bolsonaro has staked out the most deliberately dismissive position of any major world leader, calling the pandemic a momentary, minor problem and saying strong measures to contain it are unnecessary. “The Brazilian needs to be studied. He doesn’t catch anything. You see a guy jumping into sewage, diving in, right? Nothing happens to him. I think a lot of people were already infected in Brazil, weeks or months ago, and they already have the antibodies that help it not proliferate,” Bolsonaro said.
… they’ll get it while shopping at Whole Foods instead, according to my friends there.
Last night I managed to FaceTime with some friends who live in Greenwich Village. They’re locked down in a 19th floor 4BR apartment with a 20-year-old daughter home from college, a boy who is a high school junior, and a daughter in her last year of middle school.
Thus far, the online education efforts of New York Public Schools consist mostly of homework assignments. There is little attempt made to provide instruction via video.
The family leaves the apartment only every other day for a walk outside. The kids are on Zoom with their friends all day, but do not socialize with other children in person. The primary coronavirus exchange points in NYC right now seem to be grocery stores. Mask-wearing is not that common for either customers or staff. In this family’s opinion, at least, whatever spreading of the virus that would have happened if New York had kept the office buildings open is occurring just as effectively in the grocery stores. Whole Foods in their neighborhood is crowded enough for a disease to spread.
In their opinion, it would be much smarter in New York had kept its economy going, but given everyone a mask and gloves for use in public.
Related:
“Mount Sinai hospital leaders holed up in Florida vacation homes during coronavirus crisis” (New York Post): Dr. Kenneth Davis, 72, the CEO of the Mount Sinai Health System who pulled down nearly $6 million in compensation in 2018, is ensconced in his waterfront mansion near Palm Beach. Davis has been in the Sunshine State for weeks and is joined by Dr. Arthur Klein, 72, president of the Mount Sinai Health Network, who owns an oceanfront condo in Palm Beach.
The Gates Foundation‘s main message is “All Lives Have Equal Value” (secondary message: send $billions in Microsoft profits over to Africa without it ever being taxed!).
Bill Gates is a righteous opponent of Donald Trump’s hopes to reopen the U.S. economy. From The Hill:
Asked about suggestions being floated in the U.S. about relaxing social distancing measures to avoid severe economic damage, Gates said there is “no middle ground” between the virus and the cost to businesses.
Gates, who did not mention Trump in the interview, said that “it’s very irresponsible for somebody to suggest that we can have the best of both worlds.”
Are these positions consistent? If some of the most pessimistic epidemiologists are correct, shutting down the U.S. economy might save a few hundred thousand American lives. For this to be true, the virus has to thrive in hot/humid weather, the Army Corps of Engineers has to be incompetent at setting up field hospitals, all drug therapy attempts have to fail, etc. But maybe all of those worst-case assumptions will be correct.
For every saved American, though, aren’t we guaranteed to cause more than one death in a poor country? The U.S. is 15 percent of the world economy. Our shutdown is going to make us poorer so we’ll buy less from the world’s poorest countries. People in those poorest of countries who were at a subsistence standard of living in 2019 are going to be without sufficient funds for food, shelter, and medicine in 2020. Even citizens of medium-income countries, e.g., those who work in industries that are tied to trade with the U.S., might be unable to afford previously affordable life-saving medical interventions.
So if Bill Gates actually believes that All Lives Have Equal Value, shouldn’t he be saying “keep the the U.S. economy open, sweep up any dead bodies, and keep buying stuff from countries where they desperately need the cash”?
[Update, 4/9: I have supplied this post to friends on Facebook who are most zealous regarding “saving lives” via a U.S. economic shutdown. Although in pre-plague times these same people were generally huge advocates for “thinking globally” and advocating for the vulnerable anywhere on Earth, they are hostile and confused when told that their shutdown might be an inconvenience or worse for someone in another country. It has proven to be an interesting window into the logic of the American Righteous. Planet Earth is exquisitely interconnected such that bringing a reusable shopping bag to the Columbus Circle Whole Foods will stop global warming and thus keep the seas from inundating Jakarta. On the other hand, we can stop trading with a country where people are living on $2/day and there will be no adverse consequences for those people.]
Related:
Preston curve (Wikipedia): the poorer the country, the shorter the life (effect is dramatically larger for poor countries)
“For life expectancy, money matters” (Harvard Gazette) says that we might not need to look at poor countries to find a counterbalancing burden of shutdown-related mortality. “The only thing [life expectancy] seems to be correlated with is how educated and affluent the area is” (i.e., by shutting down schools that will result in young people having less education and by shutting down the economy that will result in the country having less affluence, life expectancy for Americans without serious COVID-19 problems will fall)
“Researchers Link Deaths to Social Ills” (New York Times, 2011): For 2000, the study attributed 176,000 deaths to racial segregation and 133,000 to individual poverty. The numbers are substantial. For example, looking at direct causes of death, 119,000 people in the United States die from accidents each year, and 156,000 from lung cancer. … “In some ways,” Dr. Galea added, “the question is not ‘Why should we think of poverty as a cause of death?’ but rather ‘Why should we not think of poverty as a cause of death?’ ”
“Shelter in place” orders may be a bit unpleasant for the typical American suburban family or those Americans wealthy enough to have their own apartments. But what about for densely packed roommates in our cities where housing costs far outstrip median incomes?
Consider four young people in New York City who are sharing a $3500/month two-bedroom apartment. On entering this arrangement they may have said “I don’t really need to know or like these other people because I’m never going to be here. I work 10 hours per day and then I’m out in the city until bedtime.” Now they’re together with these virtual strangers 24/7.
New York is the epicenter of the U.S. epidemic. The “how full” percentage can be teased out of a CNBC article from yesterday:
New York coronavirus cases continue to surge, topping 37,258 on Thursday as the state scrambles to find enough hospital beds and ventilators to handle the coming onslaught of patients, Gov. Andrew Cuomo said.
More than 5,300 residents have already been hospitalized and the state is projecting that will climb to 140,000 over the next two to three weeks, he said. At least 1,517 people have been discharged, he added.
In other words, there are about 3,800 COVID-19 patients in New York hospitals right now. What’s the capacity? A separate web search yields the answer: 57,261. So roughly 6.6 percent of New York’s hospital beds are occupied by COVID-19 patients.
The situation is described in our media as a crisis, e.g., “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital”. Maybe that’s not an exaggeration, though. If the system into which we pour 17 percent of GDP (maybe more like 25 percent in 2020!) was already stretched, perhaps the breeze of 6.6 percent additional demand blew it over.
Will the surge of 140,000 show up? If these are mostly in the same week that would certainly be ugly in a state with 57,261 hospital beds (the president that New Yorkers hate is sending one of the Navy’s two hospital ships to NYC, but that will add only 1,000 beds). But why do they have to stay in New York? U.S. case statistics show that Pennsylvania has only 2,218 cases (1/20th as many as New York) and 42,817 beds. Even if coronavirus were to affect all states equally it won’t affect them all at the same time, right? Could this be a case where diversity is our strength? Prepare some ambulance buses to take 10-20 patients at a time to wherever there is significant excess capacity, even if that is across a state line. If Pennsylvania ever does get into a Wuhan-on-the-Hudson scenario, New York’s peak demand will be over at that point and New York hospitals can return the favor by taking Pennsylvania residents in.
As of today, we have no idea what the prevalence of coronavirus infection is in the U.S. Out of every 100,000 people we have tested fewer than 600 (nytimes). This is not a random sample either, but typically people who are hospitalized (or elites with the sniffles!).
Tokyo 2020 has fallen victim to coronavirus. What happens to all of the T-shirts and other gear printed with “Tokyo 2020”? Will these be valuable collector’s items for those with a black sense of humor? Or discounted and/or shredded in favor of “Tokyo 2020 in 2021” (they’re still trying to call it “Tokyo 2020”?)?
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?
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))
