Philip Greenspun’s Weblog

Here are some folks who, had they been listened to, could have saved Americans, or at least Texans, a lot of anxiety… “Stockpiling Ventilators for Influenza Pandemics” (Emerg Infect Dis. 2017 Jun; 23(6)) by Hsin-Chan Huang, Ozgur M. Araz, David P. Morton, Gregory P. Johnson, Paul Damien, Bruce Clements, and Lauren Ancel Meyers.

Some excerpts:

In preparing for influenza pandemics, public health agencies stockpile critical medical resources. [except for masks?]

When severe influenza outbreaks cause high rates of hospitalization, a surge of medical resources is required, including critical care supplies, antiviral medications, and personal protection equipment. Given uncertainty in the timing and severity of the next pandemic, as well as the time required to manufacture medical countermeasures, stockpiling is central to influenza preparedness. However, difficulty in forecasting and limited public health budgets often constrain decisions about sizes, locations, and deployment of such stockpiles.

Mechanical ventilators are essential for treating influenza patients in severe acute respiratory failure. Substantial concern exists that intensive care units (ICUs) might have insufficient resources to treat all persons requiring ventilator support. Prior studies argue that current capacities are insufficient to handle even moderately severe pandemics…

The Centers for Disease Control and Prevention (CDC) manages this Strategic National Stockpile (SNS) and has plans for rapid deployment to states during critical events … However, SNS ventilators might not suffice to meet demand during a severe public health emergency. In 2002, the SNS included ≈4,400 ventilators, and 4,500 SNS ventilators were added during 2009 and 2010. The American Association for Respiratory Care suggested the SNS inventory should increase to at least 11,000–16,000 ventilators in preparation for a severe influenza pandemic.

Our retrospective analysis of the 2009 influenza A(H1N1) pandemic in Texas suggests that hospitals had enough ventilators on hand to treat all patients requiring mechanical ventilation throughout the pandemic. Although these quantities are expected to suffice for a moderate (1957- and 1968-like) pandemic, in which hospitalization rates roughly triple, they would fall far short in a severe (1918-like) pandemic. If we optimistically assume perfect deployment, that is, 0 wastage, by assuming timely delivery, adequately trained and available staff (respiratory therapists, nurses, and physicians), sufficient space to care for a potentially large number of patients, and requisite ancillary equipment and supplies, then even a central stockpile of 8,900 ventilators in Texas—the total number of SNS ventilators in 2010—would fall short, with an expected unmet demand of 576 patients.

Who will vote with me to put these folks in charge of the next plan to fight the last war? And who will bet that if we’d ordered ventilators in 2017 for delivery in 2018-2019 it would have been a lot cheaper?

Note: I found this paper while trying to search for what it might cost to treat a COVID-19 patient in a U.S. hospital ICU with ventilator support. Of course, that was a question that was impossible to answer.

Was this knowledge new in 2017? Has anyone done a study of what it would look like to prepare on a national level, not just in Texas? The Texas paper provides references back to 2006, all coming to the same conclusion: we need to stockpile a bunch of stuff if we want to be ready for a flu or flu-like pandemic.

One of the references from 2015 is “Estimates of the Demand for Mechanical Ventilation in the United States During an Influenza Pandemic”. It is authored by five government workers, four of whom were at the CDC (during the sorely missed administration of Barack Obama!). The authors suggest that more than 60,000 additional ventilators to provide a reasonable assurance of nobody dying for want of a ventilator. What was their conclusion for the administration and Congress of 2015?

The challenge for public health authorities is to plan and prepare how to best respond to the next pandemic that will cause such a rapid and large demand for mechanical ventilation in critically ill patients. Ventilator preparedness planning has to be prioritized against competing influenza pandemic preparedness planning efforts. The time to start planning is now, and the results presented here may help guide such efforts.

What did Barack Obama do in response to the authors’, all of whom worked for him, projection that 308,000 Americans would die if a flu pandemic hit and the ventilators weren’t stockpiled? A month after the paper:

President Obama on Friday hailed a Supreme Court decision legalizing same-sex marriage nationwide, saying justice has arrived “like a thunderbolt” for gay and lesbian couples.

Obama opposed same-sex marriage when he was first elected president in 2008. He backed it before the 2012 election, saying his views had been “evolving” during his time in the White House.

“Today, we can say in no uncertain terms that we have made our union a little more perfect,” Obama said from the Rose Garden.

From July 2015:

“What I found during the course of the presidency, and I suppose this is true in life, is that investments and work that you make back here sometimes take a little longer than the 24-hour news cycle to bear fruit.”

Well, he was right about this particular investment decision! (to not purchase PPE)

He had developed clairvoyance by November 2015:

“There’s no doubt that the longer I’m in this job, the more confident I am about the decisions I’m making and more knowledgeable about the responses I can expect. And as a consequence, you end up being looser. There’s not much I have not seen at this point, and I know what to expect, and I can anticipate more than I did before.”

Was there any politician that saw this coming? George W. Bush!

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Some countries are suffering more from the coronaplague than others. Italy, for example, is a hotspot while Greece is scarcely touched. Parishioners in the worldwide Church of Shutdown would say that this shows the excellence of the Greek government’s early and eager shutdown (they are not afraid to relax at home and borrow some more money that the Germans can work extra hours to pay off?).

What if we are celebrating the lucky rather than those with special insight?

A map of influenza in Europe for 2015-2016 shows apparently similar countries with radically different levels of flu. Greece was slammed while Italy was barely scratched. Portugal was flu-free compared to adjacent Spain. Ireland suffered much more than adjacent Wales/England/Scotland. Finland had more flu than adjacent Sweden.

The 2016-2017 map, on the other hand, shows no difference between Portugal and Spain. France was hit hard. Greece was hit hard again.

If we step back one year, to 2014-2015, we find that Sweden and Finland have swapped places. Germany and Italy are hit hard while Greece is comparatively better off.

How about within the U.S. states? The CDC offers a map of “Influenza/Pneumonia Mortality by State”, adjustable by year. North Dakota and South Dakota may have dramatically different rates, despite being similarly situated. Vermont is always lower than New Hampshire, despite the geographic and demographic similarities (maybe southern NH gets infected by commuting into Boston?). Nevada is bad in most years, but not all. Florida seems never to be touched by flu and Colorado hardly ever. (It can’t be Florida’s tropical climate that saves it, however, because Hawaii usually has a high prevalence.) It seems that there is a significant amount of random variation and also a consistent pattern for some states. We could certainly look at this map and say that Florida, Vermont, and Colorado are examples of superb governance. Washington and Oregon are always much better off than California. What are they doing right?

If COVID-19 behaves like the flu, are a lot of the policy attributions that we’re making the result of accidents of fate?

Related:

• “Coronavirus’s ability to mutate has been vastly underestimated, and mutations affect deadliness of strains, Chinese study finds” (SCMP): The most aggressive strains of Sars-CoV-2 could generate 270 times as much viral load as the least potent type; New York may have a deadlier strain imported from Europe, compared to less deadly viruses elsewhere in the United States

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“Study finds no benefit, higher death rate in patients taking hydroxychloroquine for Covid-19” (CNN) is discouraging. We’re apparently not on track to have a better drug treatment for coronavirus infections any time soon, thus potentially casting doubt on the value of “flatten the curve”. If we should be unfortunate enough to get seriously ill from COVID-19, we’ll get the same drugs next month that we would have gotten last month.

(Maybe flattening the curve is still worthwhile because then everyone can get onto a ventilator if necessary? “Nearly all Covid-19 patients put on ventilators in New York’s largest health system died, study finds” (CNN) says that 88 percent of patients on ventilators died. The true number is probably higher, since a lot of patients suffer so much organ damage that they die after being discharged from the hospital where they were on the ventilator. This number is consistent with what my physician friends had told me and what the Chinese found; see April 2 post.)

Should we abandon hope for hydroxychloroquine? A doctor friend responded to my questions with, essentially, “not on the basis of this VA study”:

• It didn’t fail for indication / mechanism of its action
• It’s a study done at the wrong stage of disease for the drug to work
• So much garbage published
• It works at very early stage of disease to block viral replication
• If you give it to people who are dying in icu from cytokines storm it’s useless
• They didn’t separate the patients

(she had only skimmed the paper, so might be wrong about some details)

Not everyone is upset at the failed outcome of this study. My Facebook feed has been alive with glee that the drug does not help people who are suffering and dying from covid-19. They write posts highlighting Donald Trump’s expressed enthusiasm about the drug back in March and then linking to articles about the VA study. Oddly, these expressions of delight come from the same people who are most vocal in their demands for additional shutdown because suffering and dying from covid-19 must be avoided at all costs. This is consistent with my April 7 post:

As much as I want this whole Covid-19 thing to be over, my biggest fear is that it will abate and the stock market/economy will rebound in time for the November election and Trump will claim credit and be re-elected.

Yet I was still unable to think of any situation in which so many people have been happy about a failed drug trial.

Readers who know more about medicine and pharma: Based on the trials that have been done, do we know whether hydroxychloroquine helps covid-19 patients? Anything else that seems promising for the near-term?

Related:

• Dr. Betty Light explains how to protect yourself and others during the shutdown
• “New data on Gilead’s remdesivir, released by accident, show no benefit for coronavirus patients. Company still sees reason for hope” (STAT, 4/23)
• Bill Gates’s April 23 coronaplague post: “Another class of drugs works by changing how the human body reacts to the virus. Hydroxychloroquine is in this group. The foundation is funding a trial that will give an indication of whether it works on COVID-19 by the end of May. It appears the benefits will be modest at best.” Gates also notes that poor Americans are being destroyed: “The heavy cost of the pandemic for lower-paid and poor people is a special concern for Melinda and me. The disease is disproportionately hurting poorer communities and racial minorities. Likewise, the economic impact of the shutdown is hitting low-income, minority workers the hardest. Policymakers will need to make sure that, as the country opens up, the recovery doesn’t make inequality even worse than it already is.” (Maybe it would help the American poor and dark-skinned that Gates purports to care about if rich people, instead of paying taxes on capital gains from their appreciated stock, funneled the money overseas via a charitable foundation.)

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Considering joining an anti-lockdown protest? The official Massachusetts coronaplague report is now in a new format that is much more helpful.

Although it is heretical Sweden that is featured in our media for having a “high” death rate, the Church of Shutdown Massachusetts death rate is yet higher (about 1.7X; see tracking post). This is unfortunate, but it gives us enough data to produce statistically interesting charts. The average age of a COVID-19 victim is 81. Just one (1) person in Massachusetts under the age of 30 has perished from COVID-19. Twenty one out of 1,809 have been under age 50:

You’ve heard that it is people who identify as “men” who are more likely to be killed? (I heard that too and have been identifying as a “woman” since mid-March.)

Wrong, then! There was no need for me to change my gender ID in order to survive this pandemic. Or was there? COVID-19 is primarily targeting Massachusetts residents age 70-100+. There are more elderly people who identify as women than who identify as men. So, in a pie chart of 50+ gender IDs, we would expect to see more “women” than “men” if the death rate is uniform among gender IDs.

The heart-wrenching U.S. media story of a young fit completely healthy person who failed to social distance and was dead from COVID-19 three days later? That story seems not to have come from Massachusetts:

So… should you have been persuaded by the Swedish infidels, call up Masterpiece Cakeshop to buy a T-shirt, put on your MAGA hat, and drive your planet-destroying negatively-priced-gasoline-burning Toyota Camry down to the State House for the next anti-lockdown event (as explicitly not seen on Facebook) iff you’re under age 50 with no underlying health conditions.

[Separately, the new report format shows hospital utilization. We had approximately 15,000 hospital beds before coronaplague descended on us. For the past week, roughly 3,800 of those beds have been occupied by COVID-19 patients.

In other words, locals shouldn’t worry about not finding a place in a hospital should one be required.]

Related:

• “Two E.R. Workers Worry: If They Died, Who’d Take Care of Their Son?” (New York Times): A few nights ago, after their 18-month-old son, Nolan, went to sleep, Dr. Adam Hill and Neena Budhraja sat down on the living room couch in their apartment in Greenpoint, Brooklyn. Pen and paper in hand, they turned their attention to a pressing need: figuring out who would be Nolan’s legal guardian if the coronavirus swept them away. They aren’t just anxious parents. Adam, 37, is an emergency room doctor at Elmhurst Hospital Center in Queens. Neena, 39, is a physician assistant in the emergency room at Woodhull Medical and Mental Health Center in Brooklyn. [Not-very-empathetic friend’s comment on the article: “They are not even fat. What’s the probability they both die from COVID-19? Should we plan now in case we win the Mega Millions lottery?” What would the probability be, you might ask (if you are similarly lacking empathy)? They fall into an age range with roughly 12 deaths per 100,000 people within NYC. They’re slender and health, which is in their favor, but they get more exposure to coronavirus than the typical New Yorker and, once one is infected the other would have exposure at home. Let’s assume these factors wash out. So we just divide 12 by 100,000 and square it. The chance that the child becomes an orphan due to COVID-19 is therefore 1 in 70 million. You’d have to buy roughly four Mega Millions tickets to get to the same probability event. Compare to the child’s 1 in 15,000 lifetime risk of being struck by lightning.]

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Journalists around the world love to condemn the Swedes for their refusal to attend the Orthodox Church of Shutdown while instead following the false prophet (former chief scientist of the European CDC). Example: “Graph shows Sweden’s coronavirus death toll rapidly increasing compared to other countries” (Independent). (When writing this kind of story, it is best to avoid comparing Sweden with shut-down Massachusetts!)

Today’s New York Times, however, gives us the data that are least likely to be subject to variation from recording: total deaths by country. From “28,000 Missing Deaths: Tracking the True Toll of the Coronavirus Crisis”:

Sweden actually seems to over-reported their COVID-19 deaths (see “Sweden may be recording COVID-19 deaths differently than other countries”), the only country in the survey to have done so.

The reporters and editors who worked on this story somehow neglect to mention that the country with the smallest increase in deaths is still running its schools, restaurants, offices, nightclubs, gyms, etc.! (Maybe this didn’t seem significant to them, despite the 12% versus 298% discrepancy. For True Believers in the Church of Shutdown, what Sweden is doing is merely a variant form of their own religion, just as Hinduism was for the Portuguese who spent an entire summer on the west coast of India in the late 15th century. So strong was their belief in Christianity that they believed Hindu temples to be churches (and Ganesha was Jesus with a big Jewish nose?). They attended Hindu religious rituals and believed that they were observing Christian practices.)

[How did New York City get to be such an outlier? A friend’s wife’s theory is that it was the three shopping days between when the governor announced a lockdown and when the lockdown actually began (Friday morning to Sunday at 8 pm). “I have never seen stores so crowded in Manhattan,” she explained. “People were panic-buying everything that they thought they might need over the next three months. Bed, Bath, and Beyond was so jammed you could barely move. Nobody was wearing a mask. I think most of the infections in New York City happened during those three days.”]

Related:

• https://philip.greenspun.com/blog/2020/04/12/everything-the-gleeful-journalists-said-would-happen-to-sweden-has-happened-to-massachusetts/
• https://philip.greenspun.com/blog/2020/04/14/swedes-persist-in-refusing-to-die-from-covid-19/

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One of my Facebook friends, a guy closing in on Medicare eligibility:

I was almost 13, standing before my temple congregation, and I still remember reading these words from my Torah (bible) portion, “Choose life — if you and your offspring would live” It was somewhat random that of all the dates for me to be born and selected for my Bar Mitzvah, this would be my portion to read. If you know me, you know I don’t preach, I do think people should make their own choices. So these days, I can’t stop thinking about these words, and the choice we all make every day. Choose life over the alternative.

In other words, we can choose to stay home and save lives or go out and party (where, exactly?) and kill people via covidiocy.

In a previous post, I pointed out that, even if the Swedes are wrong and our quasi-lockdown has some effect on transmission rate, we can’t “save lives” by shutting down the U.S. economy because the resulting poverty will kill Americans (2011 NYT article) and kill poor people in trading partner countries, e.g., some of the hungry among the 200 million in Nigeria now that we’ve driven the price of oil below their production cost. The Earth can sustain a population of 8 billion only with a functioning modern economy of trade. If that weren’t necessary, the human population would have hit 8 billion before the birth of Jesus. The best that we can do is “save older richer American lives” by trading them for deaths among the poor. (But probably we won’t succeed in saving any rich old Americans.)

So we don’t have a choice to save lives, only, if the Swedes are wrong, whom to kill.

A physician friend said, “I agree with you on the poverty. That’s the biggest single determinant of clinical outcomes. However, you’re missing two big factors.” He pointed out that all clinical trials are currently shut down. If you were hoping to survive heart disease, diabetes, or cancer with the assistance of a new drug, you’d better come up with a way to survive an extra 6-24 months with the old pharmacopoeia. Any innovations will now be delayed by however long the coronapanic lasts.

He also directed me to “The Untold Toll — The Pandemic’s Effects on Patients without Covid-19” (Lisa Rosenbaum, M.D., New England Journal of Medicine, Apri 17). The author points out that a postponed “elective” treatment may result in death:

Although canceling procedures such as elective hernia repairs and knee replacements is relatively straightforward, for many interventions the line between urgent and nonurgent can be drawn only in retrospect. As Brian Kolski, director of the structural heart disease program at St. Joseph Hospital in Orange County, California, told me, “A lot of procedures deemed ‘elective’ are not necessarily elective.” Two patients in his practice whose transthoracic aortic valvular replacements were postponed, for example, died while waiting. “These patients can’t wait 2 months,” Kolski said. “Some of them can’t wait 2 weeks.” Rather than a broad moratorium on elective procedures, Kolski believes we need a more granular approach. “What has been the actual toll on some of these patients?” he asked.

[Note that NEJM makes this article available for free because it is COVID-19-related. Consistent with “Why do we care about COVID-19 deaths more than driving-related deaths?”, they want to make sure that all doctors worldwide have access to information that could save a COVID-19 patient, but they don’t care if a patient dies from some other preventable cause because the doc couldn’t afford a subscription!]

This death toll is in addition to deaths from patients who try to avoid going to the hospital in the first place because they’ve read that it will be a Fall of Saigon situation and they will get coronavirus during their 14 hours in the ED waiting room.

Finally, if you were hoping to be cured by a well-trained physician a few years from now, you might be disappointed to learn that all medical student clinical training has been suspended (and classroom training for years 1 and 2 has become a less effective virtual experience). It doesn’t matter to that our future doctors will miss 3-6 months of training? If so, why not cut medical school to 3.5 years?

Separately, but also on Facebook, there seems to be a rich vein of social distancing scolding. Here’s one from a nowhere-near-old-enough-to-be-at-risk guy who married the daughter of a rich guy and thus lives in a big beautiful custom-built home on a large suburban lot:

As of yesterday, 4.2% of Massachusetts residents who contracted Covid 19 died.

Today on my solo bike ride, I observed PACKED parks, with zero social distancing measures.

We can do better than this. I’m beyond ready to get back to work.

(He doesn’t have a W-2, 9-5 job, thanks to the father-in-law’s success, so “work” is creative, rather than oppressive.)

From a nurse in the Bay Area, regarding an outbreak in Truckee:

Wtf?!! What don’t people get? Stay the F* home!! Do not go to your 2nd or 3rd homes/ski leases!!! They don’t have the medical facilities/ICU capabilities for Bay Area people going back and forth and potentially spreading the virus!! All of us Bay Area/ SC/ Monterey 2nd homeowners are SIP at our PRIMARY homes… not escaping to our 2nd/3rd homes (Kirkwood) to “get away into the high altitude wilderness”. It’s ABSOLUTELY F**** selfish!!!!

Here’s one posted by a friend, in which the Seattle Parks & Rec folks tell the rabble “Enjoy Your Backyard”:

Nobody on either coast seems to be thinking about Americans who aren’t rich enough to have a backyard!

Related:

• “COVID-19 Is Likely to Lead to an Increase in Suicides” (Scientific American)
• Fun, even if the Swedes say it won’t make much difference: Sound of Music “Do Re Mi” remixed for Covid-19
• “‘Instead of Coronavirus, the Hunger Will Kill Us.’ A Global Food Crisis Looms.” (nytimes, April 22)

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