As we ponder the tragedies of the US withdrawal from Afghanistan, it is important to also remember the costs of our continuing. An excerpt from the Boston Globe is pasted in below.
The bottom line is that the wars in Afghanistan and Iraq will have cost the US at least $4 trillion dollars (excluding interest costs) which is 4 million million dollars. Given that the US has only 132 million households, this spending averages to over $30,000 per household, all paid for by debt we will eventually have to pay off (unlike previous wars, taxes were not increased).
$4 trillion could have instead been invested in free public university tuition, free health care for all children, reducing climate change, or the $4 trillion infrastructure bill that President Biden is asking for.
I commend President Biden for actually doing what presidents Bush, Obama and Trump all said they wanted to do but did not.
Joy and I have been listening to the audiobook “The Father of All Things: A Marine, His Son and the Legacy of Vietnam” which covers the fall of Saigon in Vietnam and subsequent events. There should be no surprise that the events in Kabul are the consequence of war. Even the speedy fall of the government.
Percentage of US population born since the 2001 attacks plotted by Al Qaeda leaders who were sheltering in Afghanistan: Roughly one out of every four.
The human cost:
American service members killed in Afghanistan through April: 2,448.
US contractors: 3,846.
Afghan national military and police: 66,000.
Other allied service members, including from other NATO member states: 1,144.
Afghan civilians: 47,245.
Taliban and other opposition fighters: 51,191.
Aid workers: 444.
Journalists: 72.
Afghanistan after nearly 20 years of US occupation:
Percentage drop in infant mortality rate since US, Afghan, and other allied forces overthrew the Taliban government, which had sought to restrict women and girls to the home: About 50. (RE note: Statistica still lists the IMR at 5% (“about 46.5 per 1000”) of all live births in 2019. This is still an abysmal rate: 1 in 20 infants are dying.)
Percentage of Afghan teenage girls able to read today: 37%. (RE note: World Bank data show it as roughly doubling since 2011. Still appalling.)
Oversight by congress:
Date Congress authorized US forces to go after culprits in Sept. 11, 2001, attacks: Sept. 18, 2001.
Number of times US lawmakers have voted to declare war in Afghanistan: 0.
Number of times lawmakers on Senate Appropriations defense subcommittee addressed costs of Vietnam War, during that conflict: 42
Number of times lawmakers in same subcommittee have mentioned costs of Afghanistan and Iraq wars, through mid-summer 2021: 5.
Number of times lawmakers on Senate Finance Committee have mentioned costs of Afghanistan and Iraq wars since Sept. 11, 2001, through mid-summer 2021: 1.
Paying for a war on credit, not in cash:
Amount that President Truman temporarily raised top tax rates to pay for Korean War: 92 percent.
Amount that President Johnson temporarily raised top tax rates to pay for Vietnam War: 77 percent.
Amount that President George W. Bush cut tax rates for the wealthiest, rather than raise them, at outset of Afghanistan and Iraq wars: At least 8 percent.
Estimated amount of direct Afghanistan and Iraq war costs that the United States has debt-financed as of 2020: $2 trillion.
Estimated interest costs by 2050: Up to $6.5 trillion.
The wars end. The costs don’t:
Amount Bilmes estimates the United States has committed to pay in health care, disability, burial and other costs for roughly 4 million Afghanistan and Iraq veterans: more than $2 trillion.
Period those costs will peak: after 2048.
Source of the above: Much of the data is from Linda Bilmes of Harvard University’s Kennedy School and from the Brown University Costs of War project. Because the United States between 2003 and 2011 fought the Afghanistan and Iraq wars simultaneously, and many American troops served tours in both wars, some figures as noted cover both post-9/11 US wars.
This blog started as a response to a colleague who was calculating using local community vaccination and positive infection rates, using a 90% effectiveness rate for vaccines, and asking about the risks of singing without a mask outside. He calculated the risk of infection to singers as perhaps 0.15% to 0.31%. Is that reasonable?
Risk of what?
One thing to highlight is that the early effectiveness calculations, and most assertions about the effectiveness of the vaccines being 70-95%, ask whether the vaccines prevented ANY new COVID-19 infections, with or without symptoms, of COVID-19. We now know that if we instead ask whether the vaccines prevent any SERIOUS symptoms (such as a hospitalization or death) of COVID-19 then all three (Pfizer, Moderna, J&J) are well over 99% effective. Here is one link using CDC numbers (red bold text highlights added).
“According to the Centers for Disease Control and Prevention (CDC), 87 million AmericansTrusted Source had received the COVID-19 vaccine as of April 20, 2021. Among vaccinated people, there were 7,157 breakthrough cases, with fewer than 500 hospitalizations and 88 deaths.
Do the math and you can see the cases are about 1/100th of 1 percent of those vaccinated.
“The effectiveness of any vaccine in preventing serious illness is high, and in the case of the COVID-19 vaccines, it’s very high,” Dr. S. Wesley Long, an infectious disease researcher and clinical microbiologist at Houston Methodist in Texas, told Healthline.
“All the data shows that if you’re vaccinated you probably won’t get any symptoms at all, but even if you do, you still probably won’t get full-blown COVID and end up in the hospital,” he said.“
So 87,000,000/7157 = 1/12,000 => a 0.008 percent risk of any detected new COVID-19 infection (presumably found through patients seeking care symptoms or anyone receiving testing), and 87,000,000/588=1/147,000 => a 0.0007 percent or death or hospitalization. So that risk is equivalent to less than one person becoming seriously ill in the city of Newton, where I live. These risks are comparable to the extremely low rates of new infections and hospitalizations found in Israel, the first >1 million population country to achieve over 90% (i.e. universal) vaccination for COVID-19.
CDC?
Here is how the CDC website summarizes this research.
“A small percentage of people fully vaccinated against COVID-19 will still develop COVID-19 illness
COVID-19 vaccines are effective. However, a small percentage of people who are fully vaccinated will still get COVID-19 if they are exposed to the virus that causes it. These are called “vaccine breakthrough cases.” This means that while people who have been vaccinated are much less likely to get sick, it may still happen. Experts continue to study how common these cases are.”
I believe the CDC does not want to make a more precise statement such as “less than 0.1 percent risk” instead of “a small percentage” because the CDC wants everyone to get vaccinated. Plus these low rates are in an environment where most people are still wearing masks and social distancing. The rate of breakthrough infections will go up if people stop wearing masks and gather in crowds. Still, the extremely low rates of SERIOUS illness among those who get infected will likely hold, even if by stopping mask-wearing we increase the number of people infected.
So the risk of something serious happening now for a normal healthy vaccinated person is truly minuscule, and when you also note that the prevalence of Influenza this year has been knocked down to close to zero, singing or exercising outside and not wearing a mask inside among vaccinated people seem like acceptable risks for most of us.
Overall risk versus risk from one activity
The above calculations are averages for very large populatinos over the entire period since they were vaccinated, a span of at least a month after full vaccination. We also do not know how much of the reduction is due to having fewer people infectious around you versus lower risk of getting any symptoms when exposed to some virus germs. One assumption is that it is symmetric, in which case the probability of both goes down equally, and the prob of symptoms if vaccinated when exposed to an infectious germ becomes (0.00008)^.5 = .009 and the probabilty of being infectious when vaccinated also become (0.00008)^.5 = .009. Note that .009*.p009=.00008, the overall risk conditional on being vaccinated and when around others who partially vaccinated. I will use this .009 rate below. The fact that this rate is not observed to be getting better suggests that the probability of symptoms when exposed is what is improving the most, but this only strengthens the calculations below.
The probabilities for a given activity, such as singing outdoors or eating inside a restaurant once a week is different since these risks are included in the overall risk calculations. It is hard to attach a probability to any one of these activities. Before precautions, health care workers in China working many hours on patients with covid had very high rates of infection, 70% or more. Similarly spouses of infected people can also have high rates, 70%. And certain wedding, banquet dinner, and Biogen conference attendees also had very high rates of infections 30-50% from single events, conditional on at least one person being highly infectious. So the right calculation is how many people at a given event (e.g., a group of singers singing outdoors) will be highly infectious and how many will they infect, even if we assume exposure would be say 50%. Almost no one who is vaccinated at such an event should be highly infectious. Lets use the conservative assumption that someone in the choir has a breaktrhough infection with certainty, and that they have a 50% chance of infecting a given person. There is still the good news that for a vacinated other singer, the relative risk of a breakaway infection for a healthy person (see above) remains only 0.009. If we again conservatively assume that 100 percent of the risk from exposure is from this one risky activity, then this 0.009 risk can be assigned to this one risky activity. But we still should assume that there is only a 0.5 probability of infection even if the one assumed person is infectious. So my back of the envelope calculation is that a plausible upper bound on the probability of a vacciated person becoming infected from a moderate risk activity when around a known person in the group who is infectious becomes (.009)*(0.5) = .0045. If instead of being around a person with a known infectious rate of 1, we are around a random person, and the average infection rate is 1.5%, then the risk to a fully vaccinated person would be (average infection rate) * (upper bound on risk from one risky activity) = 0.015*0.0045 = 0.00007 => 1/14,000 an upper bound on risk to a vaccinated person of doing a risky activity around random people. Note that this upper bound calculation is assigning 100% of the risk of infection to time spent singing outdoors in a choiror eating indoors at restaurants, which is likely way above (100times?) the true risk. And the risk will be much lower to the extent that the people participating in the activity have more than the average population level of vaccination.
A useful test of these calculations is to look at rates of infection of vaccinated medical staff who are treating COVID-19 patients, or of spouses with an infected partner. For them, the risk using this calculation would be on the order of 0.009, almost one percent, which is high. There will be a literature on these topics. I just have not explored it. Please send me the link if you find them.
Caveats
Unstated in these calculations is that most of the breakthroughs are occurring in people with compromised immune systems. Conditional on getting a detected breakthrough infection, the probability of getting seriously ill is 588/7157=8.2%, and of dying 88/7157=1.1%. These rates are comparable to early rates for random populations before any social distancing or vaccines. This key group remains at high risk even with the COVID-19 vaccine and is worthy of some extra precautions by all of us.
Another important caveat is that these calculations of risk ignore key correlations. The people not getting vaccinated also tend to be people who are reluctant to wear masks, and also more likely to go to bars and large group gatherings where they are at a much higher risk. Predictions using averages will tend to underestimate the true infection rates since these factors compound the risk. And they tell us to avoid these kind of people.
So enjoy Mother’s Day this weekend. If you are fully vaccinated, your risk of infection is very low from normal activities, but your possible exposure to others when not wearing a mask could still endanger them, especially if they are immune compromised. Wear a mask to be sure when around strangers, especially indoors.
This JAMA research letter came out on March 19, 2021, but it is trending #1 on JAMA, and seems worth highlighting since it gives such hopeful news.
The study compared measures capturing rates of antibodies in three sets of patients: 20 people actively infected with COVID-19, 20 people who had recovered from COVID-19 for 32-94 days, and 14 people who had just finished their second vaccine of Moderna dose 14 days earlier (hence arguably at their maximal responsiveness to the vaccine). Note that these antibody tests are measuring antibodies, related to how well the body is prepared to fight off COVID, not for the virus itself. A higher number is better.
Importantly, the study examined not only the original Wuhan strain that was used to test and approve Moderna and other vaccines, but also three variants that reflect recent concerns, including B.1.1.7. The results are wonderfully summarized in the (Figure) shown below.
The figure makes comparisons across the three types of patients and four strains. Focus on the means and confidence intervals.
Across patient samples:
Not all actively infected are yet protected with antibodies, as expected.
Eventually, convalescent people (recovered infectees) show high rates of antibodies with only one sample showing no signs of being protected, as defined by the low gray line.
All of the Moderna vaccinated sample shows high rates of antibody protection. Scientists are tracking changes in these rates over time, but so far they are encouragingly gradual declines.
Across variants:
More encouraging, across the four COVID-19 strains, there were no statistically significant differences in rates of antibody effects among the two naturally infected groups. ( people infected with A1 appear likely to be almost equally protected against the newer variants. There is a small difference in the strength of antibodies within the vaccinated sample, but the difference is still very small relative to the natural rate of antibody protection observed in the convalescent sample. In short, the Moderna vaccine appears remarkably successful against all four strains considered, even if not exactly as effective against the more recent strains.
This is great news!
My own comment is: The similarity of the effectiveness of the various vaccines suggests similar results are likely with the other vaccines.This is not in the article.
As the article concludes,
“Limitations include the small sample size, possible selection bias, lack of clinical outcomes, and how neutralization titers correlate with protection.”
Research Letter
March 19, 2021
Neutralizing Antibodies Against SARS-CoV-2 Variants After Infection and Vaccination
If you are curious about whether you have already had COVID-19 and would like to find out whether you already have antibodies, it is worth knowing that if you give blood, then the American Red Cross automatically tests donor blood and will tell you if you have COVID-19 antibodies.
20% of American donating blood test positive for COVID-19 antibodies.
CDC estimates that 25% of adults test positive in a random sample.
Do something good for others while you find out information about yourself.
I searched the American Red Cross website for any mention about COVID-19 and found none. The following is from the Washington Post article two days ago.
“If I’ve had covid-19 or taken a coronavirus vaccine, can I still donate blood?
“Of course — but with stipulations.”
“Although certain blood donation centers may have their own rules, at the Red Cross, donors who have been diagnosed with covid-19, the disease the virus causes; tested positive for the virus; or experienced any recent symptoms can still donate blood, but they must wait at least 14 days. Because some centers require longer deferrals, check with local blood banks.”
These two accessible, free JAMA Network articles have excellent answers to some common questions. Below are a few selected quotes with key parts in RED.
My notes are in italics, red italics if important. 2 minutes if you just read the red.
“How well do the COVID-19 vaccines developed so far protect against these novel coronavirus spinoffs?”
“In Scotland, researchers estimated that Pfizer-BioNTech’s vaccine was up to 85% effective and Oxford-AstraZeneca’s vaccine up to 94% effective in preventing COVID-19–related hospitalizations 28 to 34 days after a single dose—the UK policy is to provide the second dose 12 weeks later.”
“The study, posted February 22 but not peer reviewed, found a 70% reduction in both types of infection[UK and SA]21 days after participants received their first dose and an85% reduction a week after receiving their second dose. “Overall, we’re seeing a really strong effect to reducing any infection—asymptomatic and symptomatic,” coauthor Susan Hopkins, MD, PHE strategic response director, said at a press conference. In March, Pfizer and BioNTech announced that non–peer-reviewed data from Israel showed their vaccine was 94% effective against asymptomatic SARS-CoV-2 infection.”
“Fortunately, as the article notes, nearly all vaccines used in humans prevent asymptomatic infection and spread.”
This means that it is most likely that we will not need to keep wearing masks once vaccinated, once the data are in.
“In general, vaccines that are effective in reducing infections do have major impacts on reducing transmission,” said Goodman, director of Georgetown University’s Center on Medical Product Access, Safety and Stewardship. “It is probable that these vaccines will reduce transmission.”
Mounting evidence supports that notion. In a study of UK health care workers immunized with the Pfizer-BioNTech vaccine, participants underwent biweekly polymerase chain reaction testing and twice weekly rapid antigen testing to help investigators determine rates of asymptomatic and symptomatic infections.
Source: JAMA Network Medical News & Perspectives
March 17, 2021
COVID-19 Vaccines vs Variants—Determining How Much Immunity Is Enough
There is continuing concern by some people about getting an allergic reaction to receiving a vaccine. This JAMA article addresses this for Pfizer and Moderna.
JAMA Insights
February 12, 2021
Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US—December 14, 2020-January 18, 2021
“During December 14, 2020 through January 18, 2021, a total of 9 943 247 doses of the Pfizer-BioNTech vaccine and7 581 429 dosesof the Moderna vaccine were reported administered in the US”
No deaths from anaphylaxis after vaccination with either product were reported.
“…mRNA COVID-19 vaccines in the US has confirmed that anaphylaxis [allergic reactions] following vaccination is a rare event, with rates of 4.7 cases/million Pfizer-BioNTech vaccine doses administered and 2.5 cases/million Moderna vaccine doses administered, based on information through January 18, 2021.
Of those with an allergic reaction, 77% of those using Pfizer and 84% of those taking Moderna had a prior reported history of allergies or allergic reactions.
When considered in the context of morbidity and mortality from COVID-19,9the benefits of vaccination far outweigh the risk of anaphylaxis, which is treatable. Because of the acute, life-threatening nature of anaphylaxis, immediate epinephrine administration is indicated for all cases. CDC guidance on use of mRNA COVID-19 vaccines8 and management of anaphylaxis is available.10 All facilities administering COVID-19 vaccines should have the necessary supplies and trained medical personnel available to manage anaphylaxis.
To put this in perspective the annual chance of getting hit by lighting is about 4 per million in Montana and 0.25 per million in California, and averages 1 per million per year nationwide.
About 1 in ten people if hit by lightning die, versus so far 0 in ten million from getting vaccines.
The New York Times had a very interesting article on March 5 which documented differences in rates of vaccination by race across the 50 US states. Whereas some states (Florida, Iowa, Wisconsin and Connecticut (?!?) have vaccination rates for blacks that are less than half of the state average, in Massachusetts the rate for blacks is about 85% of the state average, reflecting the states recommitment to serving needier minorities in the state.
This weekend when I was vaccinated, it was not at my convenient Vanguard primary care provider’s office or at Boston University, which would have mostly served people of privilege, but it was instead provided by a neighborhood community health group in the preschool of a housing project in Brighton MA. Less convenient for me, but much better for the nearby residents.
I am proud of MA for its better-than-average performance on racial equity of COVID-19 vaccinations, even though I know it underlies the enormous dissatisfaction of some of my neighbors and friends of privilege who feel they should have been placed at a higher priority. Being less racist makes some of us uncomfortable, and hopefully also puts more pressure on our government to be sure that everyone who wishes to can get a vaccination. All too often, market systems start by satisfying the needs of the wealthy and privileged (think education, health insurance, zoning, public streets over public transport, etc) and then decide it is not worth doing more for the poor and less privileged. In this case, by vaccinating more minorities, we may also be reducing the overall rates of infection, since infection rates have been much higher in minority groups.
Being less racist makes some of us less comfortable, but in the long run, it may make all of us better off.
A wise friend who read my previous BUHealth post comparing different vaccines warned me that it could be interpreted as saying “Wait to get a vaccine until you get the one you like the most.” I do not recommend that. I care too much about my friends. Instead, you should get a vaccine the first time it is offered to you, whatever one it is. For me, the first offer was yesterday, when a friend alerted me about a small surplus at one community health center. It was Moderna. I had found it hard to sign up via the weblinks. (I am over age 65, which has blanket permission to get a “jab” in the US now.) Look at how happy it made me.
You too could look like this when you get vaccinated.
I did have a little pain in the arm and a low-grade temperature 99.2o F compared to my norm of 97.7 for the first 24 hours. But it ended. And now I can party continue wearing a mask carefully out of solidarity and because of the nasty new strains that are still popping up.
One JAMA Network article this week and an accompanying editorial about COVID-19 are the first I have seen to carefully present the research about recent SARS-CoV-2 strains/variants, different types of vaccines, effects of one versus two doses, advice for people who were previously infected by SARS-CoV-2, what we know so far about their effectiveness against different strains, and what seems likely in the future. I put links in at the bottom after my summary.
The editorial by Drs. Mascola,Graham, and Fauci provides an accessible overview to brush up on your high-school level biology. It starts with a discussion of the distinction between lineage, variants, and strains: new genetic virus variants are organized into lineages when one variant builds upon another, and when the variants become sufficiently different in behavior from the original SARS-2 virus strain – such as by being more resistant to antibodies, or to vaccines, or more infective or fatal – then they are called a strain. There are dozens of new variants of SARS-2 virus, suggesting it is mutating rapidly. The UK, South Africa (SA) and Brazil strains are getting a lot of media attention, as they should. There is also a new variant found in southern California which they are trying to figure out its lineage, but it now represents 44 percent of the cases sequenced. Merely by its rapid appearance as the dominant strain in CA, we know it is a virulent strain.
The article by John Moore (PhD) of Dartmouth was the most relevant to me.
Here are a few quotes from Moore with interpretation in italics.
“Two categories of variants have different implications for vaccine efficacy. …The first category involves variants “…[that]… “spread more rapidly in a population.”
“The second category involves variants that are more concerning, represented by the B.1.351 and P.1 lineages that emerged in South Africa and Brazil, respectively….[that help the viruses resist antibodies created by vaccines or previous infections].
“The combination of a high virus replication rate within an individual (a high viral load) and a suboptimal level of neutralizing antibodies is the exact environment in which resistant viruses are considered likely to emerge and spread.3,4”
In other words, people who have had only one dose of a vaccine are more likely to promote new variants since they do not have enough neutralizing antibodies. This motivates the emphasis in the US for two vaccine doses, close together.
“At present, most scientists active in this area are reasonably optimistic that the efficacy of the mRNA vaccines [Moderna and Pfizer] will not be substantially compromised by the B.1.351 and P.1 [SA and Brazil] variants, …”
This is great news if true, but there is little clinical evidence so far..
In order to reduce the creation of new variants, Moore recommends Pfizer, Moderna, and (when approved) Novavax 2 dose vaccines if available, since they give strong antibody protection.
“The Johnson & Johnson 1-dose adenovirus vector vaccine … is less effective than the Moderna, Pfizer, and Novavax 2-dose designs.”
Moore recommends use of Johnson and Johnson one-dose on younger people (aged <40 years) who tend to have naturally lower “viral replication rates” and hence will not give the SARS-COV-2 as much chance to mutate then they get infected.
“All leading vaccine companies are now redesigning their S-protein components to counter new variants, particularly B.1.351 [SA].”
“Another issue with significant implications involves what happens when a mRNA vaccine [Pfizer or Moderna] is given to a person who has recovered from COVID-19. Small-scale studies have shown that a single mRNA vaccine dose rapidly boosts neutralizing antibody titers to very high levels, perhaps rendering the second dose redundant in this special circumstance.10 … A related issue is that the mRNA vaccines appear to trigger strong (although short-lived) adverse effects (such as headaches and mild fever) in people who have previously been infected with COVID-19.”
In light of this, I am planning to get the Pfizer and Moderna rather than J&J, and await further research for the second dose.
Novovax is a huge potential entrant into this vaccine race with its recombinant protein nanoparticle COVID-19 vaccine. It is not yet approved for use in the US, but is hoping for May. It is gearing up for production at the rate of 2 billion doses per year to be produced in India and Japan. Early clinical results from tests I SA and Brazil are encouraging.
I foresee a long future for vaccines in the world.
free accessis active quizhas multimediaonline first
JAMA. 2021; doi: 10.1001/jama.2021.3465
This Viewpoint proposes ways to maximize vaccine efficacy and allocation given the rise of coronavirus variants and authorization of a Johnson & Johnson vaccine, including reserving the latter for younger healthier populations, boosting it with a single-dose messenger RNA (mRNA) vaccination, and single mRNA immunization of people with prior documented SARS-CoV-2 infection.
Editorial
February 11, 2021
SARS-CoV-2 Viral Variants—Tackling a Moving Target
Despite the abundant evidence2 showing that health care outcomes in the US are much worse than in every other OECD country, I still hear arguments that this is because uninsured, Medicaid, minorities, or low-income people in the US bring down our health outcomes. This myth is repeated3–5, and believed by a majority of Americans.6 This JAMA study shows that this is not true. Even high-income white people get worse health outcomes than the average result in OECD countries. Time to change to a better health care system!
Key Points
Question Are the health outcomes of White US citizens living in the 1% and 5% richest counties better than the health outcomes of average residents in other developed countries?
Findings In this comparative effectiveness study of 6 health outcomes, White US citizens in the 1% and 5% highest-income counties obtained better health outcomes than average US citizens but had worse outcomes for infant and maternal mortality, colon cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction compared with average citizens of other developed countries.
Meaning For 6 health outcomes, the health outcomes of White US citizens living in the 1% and 5% richest counties are better than those of average US citizens but are not consistently better than those of average residents in many other developed countries, suggesting that in the US, even if everyone achieved the health outcomes of White US citizens living in the 1% and 5% richest counties, health indicators would still lag behind those in many other countries.
I greatly enjoyed reading about how BU is using its extensive research laboratory resources to test for the presence of the UK and South African variants at BU. This report includes the 70 cases of COVID-19 detected in members of the BU faculty, staff and students during the week of Feb 17-23. Below are a few selected quotes.
“Of the positive tests sent to the NEIDL for sequencing since January 25, more than 130 samples have contained enough viral material to allow them to be sequenced.
… thus far, we have detected eight samples containing a COVID variant of concern. Specifically, we have detected two variants of concern: one case of the B.1.351, first detected in South Africa, and seven cases of the B.1.1.7, first detected in the UK. We were not surprised by these results—they confirm what we already suspected, that those two variants have reached our community. “
It was informative to me to learn that BU is not able or allowed to tell people which variant they have if infected.
“For regulatory reasons, BU is not permitted to tell individuals if they have a variant form of COVID-19. The scientists who are doing this study are not even aware of which person the samples they are sequencing came from; they just know the virus sample was collected from someone at BU. “
“… even if we could tell individuals that they had been infected with a COVID-19 variant, that knowledge wouldn’t change our clinical management of that person’s illness.”
I am fortunate to be part of BU’s comprehensive testing. It is available daily on the COVID-19 dashboard, with testing results as of two days ago.
I only wish that more people had such excellent testing available. I have not seen any recent estimates of the cost to BU of doing these COVID tests, but an early guess was $12 per test. I think a lot of people would be willing to pay $12 (weekly) or $25 (biweekly) for careful testing, which is the cost per faculty member or undergraduate of BU’s testing program. BU is continuing its hybrid teaching, with students in many classes allowed to choose between in-class and remote zooming.
Based on these low current testing and vaccination efforts at BU, BU announced this week that it will be holding in-person graduation ceremonies on May 16 (graduates only) as long as the city and state allow it. Link is here and below. Go BU!
In these days when pay-for-performance and value-based payment reform have become the centerpiece of US Medicare payment reform, this short and accessible article in JAMA Health Forum (5 minutes) argues that we implement and evaluate reforms using “policy equipoise” rather than the usual foundational belief – that too many economists adhere to – that these policies must work because the models economists use predict they should because of the incentives they create. The paper provides links highlighting that in many cases these reforms have very mixed or no success. Policy equipoise – the acceptance of true uncertainty about whether one policy is better than another in a given situation – should guide randomized designs to generate more convincing evidence about what works. Check out its links for a systematic review of (y)our favorite US payment reform: VPB, P4P, ACO, bundled payments.
Today is a momentous day for the US and for democracy, so I thought I would comment on it. I did not expect to be so happy today.
The Associated Press has not yet called the second of the two Georgia senate elections but I trust the NY Times report (see article below) that Georgia voters will ultimately elect two democratic senators, which will give the democrats the leadership in our Senate to combine with our democratic majority in the House and allow the Biden administration to negotiate key legislation in coming months.
Also momentous will be when our senate and house today vote to affirm the results of our electoral college, and bring to an end the legislative attempted coup still in play that our current president and a disturbing number of anti-democratic Republicans are still pursuing today.
Today has to be viewed as a success for all who believe in popular democracy in which elections are decided by voters and not just by money and voter suppression, for minorities and other lower caste members* whose voice is too often suppressed and ignored, for citizens who want a congress that debates and enacts legislation rather than simply issuing executive orders that undoes legislation, and for those who want to see government leadership on the environment, COVID-19, immigration, trade, education, racial equality, infrastructure, science-based decision-making, and so much more.
It will not be an easy path forward, but at least it looks like we can move off of the backwards path of the past four years. We will see if our new leadership is up to the challenge, and whether there are spillover effects on the rest of the world.
Happy New Year! Stay healthy! Stay active.
*Read or listen to Isabel Wilkerson’s book “CASTE: The Origins of Our Discontent” to better understand why so many Americans continue to support Trumpism.
Revised new mantra:
Mask, distance, vaccinate, go outside, wash, be patient, be upbeat, be skeptical, pray, believe.
July 20. 2020 Important update on superspreading events.
This article from the Washington Post provides a useful update about how superspreading events account for the vast majority of infection and are driving the pandemic. 3-5 minute read.
I also enjoyed the very accessible video link on the science of COVID-19 which is linked on the first page of this article. (4 minutes.) I could not copy just its link…
The novel coronavirus is a master of disguise: Here’s how it works
By
All is well in my household. Wishing you the same. Randy
July 5, 2020 Hopeful news on speedy SARS-COV-2 testing!
The US federal government is doing a terrible job at tracking cases compared to many other countries. But if some of the fast, low cost technologies for individual testing mentioned in this NY Times Opinion piece actually work, it will make it a lot easier for individuals, schools, firms and motivated local governments to do so. The lead author is BU professor of economist. (5 minute read)
Yale Medicine physicians describe the recovery path they’ve seen for patients experiencing ‘mild to moderate’ forms of the disease.
RE: I would have liked more details about the recovery of people who have more serious forms of COVID-19. This report from Kaiser Health News provides one such glimpse.
By Liz Szabo, Kaiser Health News Updated 9:19 AM ET, Tue June 2, 2020
June 17, 2020 Honor roll of favorite COVID-19 web sites
I often blog about the most recent studies and news reports of interest, but usually it is worth focusing on the best ones. Below is my honor roll of favorite links on COVID-19, all from below.
Sources we’re following. Updated weekly blog by Vivian Ho and staff at the Baker Institute of Public Policy at Rice University
Tomas Pueyo’s March 19 article in the Medium: Coronavirus: The Hammer and the Dance. Dance sequel articles, full of figures are linked here (warning: long, meaty reads).
The best up-to-date statistics on COVID-19 is WorldoMeter.info/coronavirus.with daily updates and documented sources.
New York Times interactive figures are updated regularly for the countries of the world and individual US states and are still the best to me, using log scales.
Covidtracking.com summarizes raw data on COVID-19 for the US, and now includes a new tracking of cases and deaths by race.
July 17, 2020 Western Europe versus US
Just out from the New York Times.
June 17, 2020 Current trends in cases around the world.
Below are charts from 6/16 from WorldoMeter.com/coronavirus for a set of countries I am tracking. Each figure has a story. You can decide for yourself which ones you like.
(Yes, I prefer tracking deaths, but there is also a bias to deaths as well, plus deaths lag reported cases by about two weeks (~12 days), and the last two weeks are informative in many countries, including the US and elsewhere. Rates of testing tend to change only slowly.)
Note that unlike the above, the Taiwan cases is not in hundreds or thousands. (Population 23 million)
It is the start of winter in most of Brazil and Chile. Not a good omen for this fall in the North.
June 17, 2020 World War I and II comparisons
Today’s Boston Globe features the news that COVID-19 deaths in the US – currently 119,000 – now exceed those in World War I. Of course the US population was much lower then. During World War II there were 407,316 service men who died (0.29 percent of the US population). Think of all those flags for WWII veterans you saw on Memorial Day recently. It will take real determination and action to keep US deaths from COVID-19 – currently about 800 per day, or 24,000 per month – below the tragic WWII levels.
June 17, 2020 Be selfish and wear a mask!
Yesterday I ate dinner outside on the main thoroughfare (Moody Street) in Waltham which has been converted into a massive pedestrian way to allow people to eat outside while more than 3 meters apart. I was sad to see dozens of people on the streets not properly wearing masks. I thought of a good selfish reason why everyone should want to do so. Just as high altitude dwellers develop stronger and larger lungs in order to get enough oxygen, securely wearing a high quality mask that cuts off the air flow a bit and results in slightly less oxygen reaching your lungs enables low altitude people to develop stronger and larger lung capacity. The extra effort it takes to breath is no different from lifting more weights or running a bit faster, and builds up your lungs at a time when you may really need them to fend of COVID-19 respiratory failure. I don’t hear weightlifters or joggers complaining about their difficulties: they want the challenge. Wear a high quality mask for your own future health!
June 11, 2020 Words from Michael Osterholm, epidemiologist
I am sharing this informative interview with a very knowledgeable person, even though I disagree with his assessment on several important points.
I have added my comments at the bottom of this summary from the article, while striking out three statements asserted there.
COVID-19: Straight Answers from Top Epidemiologist Who Predicted the Pandemic
By Dan Buettner, Blue Zones Founder [Interview conducted on May 29, 2020. Published on June 6, 2020]
Below is the summary from within that article.
In short, Dr. Osterholm is arguably one of the most dependable, non-political sources for straight answers on what COVID-19 means to us and our world in the immediate future. In his 2017 book, Deadliest Enemy, he correctly foretells a global pandemic and offers the best strategy for fighting it now and avoiding it in the future.
Here are the highlights of our conversation. But if you really want to understand this disease, read the whole interview. This disease may be the biggest event of our lifetimes.
3 months ago, COVID-19 was not even in the top 75 causes of death in this country. Much of the last month, it was the #1 cause of death in this country. This is more remarkable than the 1918 Flu pandemic.
There is no scientific indication Covid-19 will disappear of its own accord.
If you’re under age 55, obesity is the #1 risk factor. So, eating the right diet, getting physical activity, and managing stress are some of the most important things you can do to protect yourself from the disease.
One of the best things we can do for our aging parents is to get them out into the fresh air, while maintaining physical (not social) distancing.
Wearing a cloth mask does not protect you much if you’re in close contact with someone who is COVID-19 contagious. It may give you 10 minutes, instead of five, to avoid contracting the disease.
We can expect COVID-19 to infect 60% – 70% of Americans. That’s around 200 million Americans.
We can expect between 800,000 and 1.6 million Americans to die in the next 18 months if we don’t have a successful vaccine.
There is no guarantee of an effective vaccination and even if we find one, it may only give short term protection.
Speeding a vaccination into production carries its own risks.
The darkest days are still ahead of us. We need moral leadership, the command leadership that doesn’t minimize what’s before us but allows everyone to see that we’re going to get through it.
I strongly disagree with his statement that wearing a cloth mask does not protect you much. It is true that if I were tending a COVID-19 infected patient, it would be highly inadequate, because of the duration of the exposure. But for ordinary activities, even briefly near someone who is infected, then universal mask wearing by both the infected and the rest of the population can bring down the rate of new infections below 1.0, and largely eliminate or drastically slow down exposure in a population. This is why New Zealand has had zero deaths over an extended period, and why rates are also extremely low in Japan, Hong Kong, South Korea and certain other Asian countries. All of these countries have had nearly universal mask wearing, as well as excellent case identification and quarantining.
The research on masks shows that a simple, homemade cotton mask filters out about 70% effective at suppressing germ aerosols, particularly larger particles that can projectile the farthest from a sneeze, cough or singing. Masks also reduce touching your mouth, nose and eyes, even if they don’t eliminate any aerosol contamination. Better “surgical quality” masks can achieve over 95% protection with 99% claimed by N95 masks. (To some degree, the greater risk may be putting on and taking off high quality masks frequently to maintain their effectiveness…) There is no reason we could not all be wearing surgical quality masks when shopping or around others. This would greatly slow down transmission.
If a random COVID-19 contagious person without any PPE protection infects 3 people, then even a 70% effective mask reduces the average number of people infected to .3*3 = .9 newly infected for each person contagious. That is less than 1! So the disease would gradually die out. With a 90% effective PPE, new infection rate would be cut to less than a third, and infections would die out even faster.
PPE is why in Japan millions of people are now commuting daily by public transport on crowded subways and buses with minor numbers of new cases: masks do work. We could do that if we all wore masks, testing was widespread, and we were willing to track cases and enforce quarantines.
I also disagree with the papers blind prediction that COVID-19 will necessarily infect 60-70 percent of the worlds population. The same experience from other countries show that careful testing quarantining, and mask wearing could keep rates below 60% of the population, particularly the at-risk population, for over a year, when hopefully a vaccine will be available for at least high risk people. Recall that until a few years ago flu vaccines were reserved only for older and higher risk segments of the population. This is what will be needed this time as well, when a COVID-19 vaccine is created, since we cannot immediately create 8 billion vaccines for the whole world.
The article starts with a really crazy statement:
“One of the things we have to understand is that this virus is operating under the laws of physics, chemistry, and biology. It doesn’t in any way, shape, or form bend itself to public policy.”
If it were true that science drives everything and public policies do not matter, then why do we even need doctors and hospitals? Or why does physical distancing matter? Clearly public policy AND PRIVATE DECISIONS matter a lot, as the article goes on to highlight.
I agree that each country needs a leader like Franklin Delano Roosevelt who is unselfish and totally committed to leading the public sentiment in a positive direction. A few countries have been blessed with this, and we should be learning from their successes.
My own wish is that more attention would focus on the following facts.
The death rate is not some constant for each health care system, but rather it will go up if a health care system gets overcrowded and cannot keep up. It could be that with optimal treatment in a well-endowed health care system, the death rate is only 0.5% of those infected (across the whole population). But if there are not enough hospital beds, trained doctors, staff, ICUs and ventilators, then the death rate could be 5%. This is the great value of policies to slow down rates of infection.
A significant part of the burden of high rates of COVID-19 is the consequences of all the avoided preventive and curative treatment of OTHER diseases. Heart conditions, cancer, vaccine preventable infections. This is another reason to want to keep the flow rate of new infections manageable.
While everyone is focusing on when there will be a vaccine, of greater likelihood is that we will develop treatment strategies that can further reduce mortality and serious illness. This is what is more likely in the near term.
I think it is too early to tell whether death rates by the rest of the world are much better than in Sweden, which has encouraged private actions but not shut down and mandated self-quarantines. We have so far DELAYED infections and deaths meaningfully in the US and many other countries, but whether we have prevented them over say the next year will depend on what happens this fall and winter.
There is far too little effort and research discussing how to better target social distancing and public polices to people at greatest risk. Shutting down all businesses is a very blunt tool for doing this.
The findings that high altitudes have lower rates of infection is likely not the result of the virus not finding conditions less hospitable at low air density or humidity, but rather that at high altitude people develop larger lungs and stronger lung muscles that make them better able to fight off the virus. Working out hard can do much the same thing for many of us.
Obesity affects heart and circulatory diseases in part because the fat clogs up arteries and veins. For COVID, a different mechanism may be that obesity increases the weight that the lung muscles have to raise and lower with each breath, which leads to faster respiratory failure and requires the really nasty ventilators that replace muscles and cause all kinds of problems of their own. We all know that repeatedly raising your arms while holding even a one pound weight soon wears your arms out. The same must be true for breathing with extra pounds of weight on your chest and stomach. The shrotness of breath symptom of COVID-19 can force you to breath hard for hours or days at a time.
There is evidence in JAMA just out from China that shoes spread around germs all over the floor when people walk in areas around infected people, even if those people are not showing any symptoms. Most of us don’t touch the floors much, but infants do. While symptoms are concentrated among the old populations, US studies show that infection rates are pretty uniform across all ages. Parents should not let very young children crawl on floors in public places.
Teens and college age students are especially prone to large gatherings (sports, concerts, bars,…) in which people mingle with strangers, and many infected do not display symptoms. While serious cases are rare, they are also likely to be a very strong source of new infections.
Randy Ellis
June 8, 2020 More on Race and likely futures
Covidtracking.com is an new source of raw data on COVID-19 statistics for the US, and now includes a new tracking of cases and deaths by race.
This source is the new standard being quoted by the media, including by the White House and CDC. I have not compared it to the NY Times and WorldOMeters.com sources that I have previously linked.
I am not sure I agree with the consensus, but this survey out just today of epidemiologists by the NY Times gives a very sobering overview of when we might expect to return to a wide range of normal activities.
RE: This is a reassuring article to me. We should not become paranoid over the very low risk of contamination from touching surfaces, which is dealt with effectively by frequent hand washing. (Three minute read.)
May 21, 2020 more from the U Mass Dartmouth biology professor.
Erin Bromade PhD. has an excellent 4 minute CNN interview on outdoor barbecues, shared bathrooms for dinner guests, and swimming pools. With his Australian accent, it is a fun listen. Very specific. Watch it here.
May 21, 2020 Steps hospitals use to minimize COVID-19 and more
Excellent article by Atul Gawande in the NYTimes magazine. Probably a 20 minute read.
“Is there any place that has figured out a way to open and have employees work safely, with one another and with their customers?” Yes. Mass General Brigham, … seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. Not zero: we’ve been on a learning curve, to be sure, and we have no way to stop our health-care workers from getting infected in the community.”
“Its elements are all familiar: hygiene measures, screening, distancing, and masks.”
“Toughing it out is now a shameful act of disloyalty.”
“Surgical masks are made of a melt-blown polypropylene fibre fabric, which, under magnification, looks like cotton candy. Most of the filtration this material provides isn’t from direct blockage but from an electrostatic charge applied to the fibre using a machine called, aptly enough, a corona charger. The static electricity captures viral particles the same way that a blanket in the dryer catches socks. This allows the material to breathe more freely. Cloth masks feel warm and smothering by comparison, and people tend to loosen them, wear them below their noses, or take them off more frequently. The fit of improvised masks is also more variable and typically much worse. A comparison study found that surgical masks did three times better than homemade masks at blocking outward transmission of respiratory viruses.”
I also enjoyed the following link on the value of face masks. The comments on this are indicative of how a strong, well organized contingent in the US is arguing against masks.
As before, Vivian Ho’s weekly blog is full of many great links. Including recent work by Erin Bromage.
May 21, 2020 Sad humor: some governments are distorting with statistics.
See this post on Andrew Gelman’s blog. Ten minutes. See if you can see what is wrong.
That article is foundational and is still be essential reading for everyone.
I have been remiss in not revisiting and following Puyea’s subsequent work, which contains an excellent Learning How to Dance series. He has just released Part 5. I recommend all of them, although there is some overlap, as there should be in any “Learning how to…” series.
We should particularly avoid allowing very large gatherings such as sporting events, conconcerts, crowded churches, restaurants with no spacing, because these are the worst hazards to the Dance.
Several countries have successfully quashed the infections, but will have to continue to restrict outside visitors and even regional travel.
Some countries and some US states have taken few precautions and will end up needing to get to herd immunity to stop the spread. This will take about two thirds of the population getting ill before infections quiet down, at a fatality rate of .5 to 1.5 this would kill 1 to 3 million Americans. there are many excellent figures and simulations that highlight all that can be done without totally closing down the economy
28 percent of infected people infect their spouses, 14% infect other people they live with, and 4% infect their children. Social distancing within the household is very challenging.
Opening schools while managing interactions to be only among smaller groups and having monitoring is proving successful in many countries.
South Korea never really shut down, but has extraordinary public effort, public information and intrusive quarantining.
International and even regional travel will likely have to be restricted for a very long time, such as until an effective vaccine.
There is still no guarantee that a vaccine or immunity will be effective for more than two years.
My own thoughts to add: There is very little in Puyeas work about the role of weather. Colder, drier areas do seem to have greater exposure.
I see a great need to highlight that even vacation travelers can stay in hotels and summer rental housing if they are willing to leave an interval of 3-4 days between guests. Similarly mail, store purchases, and food, that has not been touched for a few days is inherently safe. Things stored outside in UV light including picnic tables and benches and rocks and trees are also extremely low risk because of this natural healing.
The findings discussed in Erin Bromage (see May 11 blog summary below) that only 0.3 percent of all infections have been traced back to someone getting infected outdoors speaks volumes to me.
We will have to give up not only handshaking, but also hugs, social kisses, and close encounters among family and friends. Italian and Spanish traditions, young people in clubs and others who believe in extensive close social contacting will need to change.
The latest antibody test in the city of Boston found that about ten percent of the population has been infected so far. So Boston is about 1/7th of the way to herd immunity.
COVID-19 antibody test results from Santa Clara (1.5% of population testing positive), and from Denmark (1.8%) taking antibody tests of random samples find that overall infections are approximately uniform by age. Children are just as likely be become infected as adults, but they are much less likely to show symptoms or become highly contagious.
Future costs of all the medical complications of people who recover from COVID could be very serious.
I can’t resist including an extended quote describing Taiwan’s response to COVID in March. This is taken from Part 1. All highlights were in the original article. They have only had ~500 cases and 46 deaths so far. Population is 24 million, more than New York State (19 million). Enjoy.
“Taiwan’s level of preparedness is jaw-dropping. This is a list of over 100 measures they took before March. Here are some examples, from the list and othersources:
Early and strict travel bans, updated every day.
They centralized the management of mask production, starting at 2.4 million per day (twice their need of 1.3 million at the time).
They set the price to avoid profiteering, initially at USD $0.50 per mask.
The penalty for price gouging for masks and other key items became 1–7 years in jail and a fine up to USD $167,000.
The spread of fake news could be fined with USD $100,000.
Proactive detection of cases: They tested all people who had previously had flu symptoms but tested negative for flu, finding some coronavirus patients.
All of the above happened BEFORE Wuhan even shut down! Then, they continued:
Soldiers were mobilized to produce masks.
The official price of masks was eventually down to ~$0.20 by the end of February.
Eventually, they ramped up production to 10 million masks per day (for a population of 23 million) before the end of March. Masks were rationed and their export banned.
Travel and healthcare databases were connected, so healthcare professionals could know who was at a higher risk of being infected. The Taiwanese CDC could track what was happening on the field in real time.
It triaged travelers based on their risk, from free to enter the country with self-monitoring to mandated quarantines.
Quarantine support with food and encouragement.
Enforcement of the quarantine through people’s existing phone signals. If they don’t have a phone, the government provides them with one. An alert is sent to the authorities if the handset is turned off for more than 15 minutes.
Persons who were not compliant with home quarantine orders were turned over to law enforcement and tracked by police officers. A couple was fined USD $10,000 for breaking the 14-day home quarantine rule.
If the world was a class and each country was a student passing a coronavirus exam, Taiwan is acing the test. And it’s offering to help. If I were another student, I would take that offer.
That it for now.
May 13, 2020 Hopeful article about the search for effective drugs
By Kim Tingley, New York Times, Published May 13, 2020
The article highlights the extraordinary level of cooperation internationally, as well as the dangers of the US claims that China is stealing US secrets. This is not a time for the US to interfere with science because of worries about who makes the billions of dollars a new drug will be worth.
New York Times Interpreter by Max Fisher and Amanda Taub
It reminds us that the successes of South Korea and China were “test, trace, and mandatory quarantine with fines” and not just “test and trace.”
May 11, 2020 Hot off the presses from U.Conn., MIT-Sloan Harvard, and collaborators
Weather Conditions and COVID-19 Transmission: Estimates and Projections
Ran Xu, Hazhir Rahmandad, Marichi Gupta, Catherine DiGennaro, Navid Ghaffarzadegan, Mohammad Jalali
The attached paper was just posted today on SSRN with coauthors from UConn, MIT-Sloan and Harvard. It has over-the-top modeling of daily data from every county in the US, plus cities, states or countries worldwide rates of COVID-19 infection based on weather, humidity, air pressure, geography, wind, sunlight, and even the phases of the moon! (This last one has to be considered the werewolf effect, which they omitted from their final model even though statistically significant.) I saw the write up about it in the Boston Globe yesterday but the actual paper was only posted on May 11.
They do not forecast rates of disease but only relative rates of infectiousness and how they are affected by weather. They have only a few months of data from a wide range of worldwide cities.
They have a really cool graphics generated here, including the ability to generate weekly forecasts of relative rates of infectiiousness by city, county state and country worldwide. You can play with it to look at patterns by state, simulated by week across the year.
They get that favorable weather can reduce rates of infection by about 40 percent, or worsen it by about the same. Given that the rate is about 2 overall, then this means it will slow down in many parts of the US this summer, but then come back strong next fall or winter. It is worse in cold, dry areas.
May 11, 2020 Best overview of COVID infectiousness
I have read a lot of articles about COVID, but this paper, by a professor of biology of U Mass Dartmouth, is the best so far at signalling how different activities and situations vary in their riskiness. I recommend it highly to everyone.
Shopping in an uncrowded large store for a short time is relatively safe, as is jogging and brief contact while social distancing. In contrast indoor in-person meetings, especially in small areas, parties, church gatherings, concerts or other large gatherings, or other events that last for an hour or more and include talking, singing, eating, exercising, or touching shared items are the most risky.
Here is the direct link. It is a 12 minute read. Do it now!
I especially like that this article is by an ordinary professor, who has just done an extraordinary synthesis of German case studies, epidemiology and other diverse scientific sources. It highlights that all of us can play a role in fighting this virus.
Also, I also recommend this article by the same author, which covers events in China, the origins of the virus, and descriptions of various tests and vaccines.
Erin S. Bromage, Ph.D., is an Associate Professor of Biology at the University of Massachusetts Dartmouth. Dr. Bromage graduated from the School of Veterinary and Biomedical Sciences James Cook University, Australia where his research focused on the epidemiology of, and immunity to, infectious disease in animals.
May 9, 2020 Good signs.
Today (Saturday) I ventured out out to a local hardware store to get a few gardening items and to CVS to pick up a few health items. Among the many encouraging signs were:
Everyone I saw in either place was wearing a mask,
Social distancing was marked on the floor and adhered to.
CVS was actually selling nursing quality masks (not N95, but at least with metal strips around the nose) for $2 apiece, limit of 4
The hardware store was selling hand sanitizer and bulk packages of 100 gloves at a normal price.
Everyone was friendly and happy.
There is hope for a more pleasant existence in our future together, even if things will remain different for a while now. Keep your hopes up!
May 8, 2020 Careful statistical model of COVID-19 fatality rates
Anirban Basu, an exceptional econometrician (with 9252 Google Scholar citations) at the University of Washington who is personally known to me, published an article that just appeared in Health Affairs yesterday.
Using daily county-level data on deaths and new cases from the US up through April 20, 2020, he estimates Bayesian models of the infection fatality rate among symptomatic cases (IFR-S) which give a point estimate of 1.3% of all people with COVID-19 symptoms dying.
The Health Affairs article is heavy reading for a non-statistician. To give you a flavor, here is the key sentence about methodology: “The mean of this Binomial model, p_jt, represents the probability of death, and is expressed as a Bayesian random-coefficients exponential decay model within a logit link framework so that the predicted rates remain within 0 and 1.”
Here are the first few sentences from the abstract.
“ABSTRACT: Knowing the infection fatality rate (IFR) of SARS-CoV andSARS-CoV-2 infections is essential for the fight against the COVID-19 pandemic. Using data through April 20, 2020, we fit a statistical model to COVID-19 case fatality rates over time at the US county level to estimate the COVID-19 IFR among symptomatic cases (IFR-S) as time goes to infinity. The IFR-S in the US was estimated to be 1.3% (95% central credible interval: 0.6% to 2.1%). County-specific rates varied from 0.5% to3.6%. The overall IFR for COVID-19 should be lower when we account for cases that remain and recover without symptoms.”
This segment was also highly informative to me.
“Results from sero-testing from the Diamond Princess outbreak suggests that about 17.9% of infected persons never developed symptoms.10 Consequently, a reasonable estimate of the overall IFR would be about 20% lower than our estimated IFR-S.”
In the conclusion:
“If we carry out a thought experiment where 35.5 million individuals would contract COVID-19 illness this year in the US (i.e., the same number as flu last year)19 then, in the absence of any mitigation strategies or social distancing behaviors and the supply of health care services under typical conditions, our IFR-S estimate predicts that there would have been nearly 500,000 COVID-19 deaths this year. To the extent that COVID-19 is more infectious than flu and does not have any protection from a vaccine or treatment, the number of infections, and hence the number of deaths, would be higher. Certainly, with mitigation strategies, the death toll will be lower.”
My interpretation: The paper is very open about biases upward and downward. One bias not discussed is the number of deaths unreported in the data, which now appears to be significant. Death rates in the US are likely to be higher than in other countries, for many of the reasons discussed in the Boston Globe article linked here. Still, these are very sobering numbers for the US.
May 7, 2020 – EXCELLENT Boston Globe article on diet and its link to COVID-19.
“Only about 12 percent of Americans are metabolically healthy, without a large waist, high blood pressure, high blood sugar, or high cholesterol.”
“The sad reality is that 75 percent of Americans are overweight, and more than 42 percent are obese. Chronic disease affects 6 out of 10 Americans. Also 20 percent of normal-weight people have prediabetes. These shocking rates of poor metabolic health — with nearly 9 out of 10 American adults unhealthy — is a major reason the COVID-19 crisis is so much greater than it needs to be.”
My interpretation: Just like a marathon race, winning against the coronavirus requires a strong immunity system, strong lungs, and a healthy heart. Americans, and particularly poor Americans, are compromised in all three with their diet, lifestyle and environment more than the rest of the world. I invite you to read the article.
Fortunately, for many of us with increased free time, the inconvenience of buying large quantities of food, and greater motivation, now is a good time to do something about it.
May 1, 2020 NY Times links below are useful for data updates.
The most telling thing to me is the lack of confidence and incredibly negative consumer expectations. People are only buying necessities, and that will not fuel the economy. Even food production (meat, fresh vegetables) is now uncertain. On April 10, a poll of sports fans found that 72% would not plan to go to a sporting event even if they resume in September. (What about children in schools or universities or any public entertainment, or restaurants?) Even the workers getting government aid want to save it since they realistically fear that the worst is yet to come. The ridiculous epidemiological model from U. Washington predicting a nice bell-shaped declines in rates of infection with the shutdown are not even close to the persisting rates of new cases, and the very gradual, flat persistence. Deaths are being grossly undercounted, and we are still less than 10% of the way toward herd immunity. Reopening the economy fully will I believe likely cause many areas to overload their hospital capacity in about three weeks: the average time from new infections to death (two to three weeks) plus a week for a renewed doubling in cases because we still have high fundamental infection rates to start from.
I am not a macro economist, but we now have a shock where earned income has dropped about 40% (Ellis and Marcolongo, April 17, 2020, with a new draft out next week), and more in the most vulnerable occupations. Current PPP loans are not reaching the neediest, and $1200 per person will not last long. Cities and states will soon be going bankrupt and start having to lay off public workers unless the federal government acts very quickly, which they can’t. Even people who have income, like me, are perhaps spending less than half of what they would usually spend, hording food, but not spending anything on travel, transportation, other consumables or durable goods. We are just spending more on personal delivery services and internet services. Health care spending will be strong, however, given the resources spent on COVID, but offset by canceling most elective and preventive care. I can easily see a more than 50% decline in consumption spending in the economy. Something similar is happening in the rest of the world, plus trade is also collapsing. I don’t see why the stock market is still acting like we will come out of this quickly. (Remember, the Dow Jones lost 75% of its value in the Great Depression. We are a long way from that now.) The economy is so dreary that I have pretty much stopped blogging about my predictions in the last week.
I am enjoying bird photography, vegetable gardening, and baking bread. I recommend these activities highly to you. It is nice to fall asleep thinking about gardening or how to zoom about birds instead of about COVID-19.
The state of Maine started reopening as of today. Lets see what happens.
Have a good weekend!
Randy
April 23, 2020 Science article about COVID-19 effects
This Sciencearticle has an excellent overview about the complex medical challenges from COVID-19.
I recommend it to anyone interested in clinical manifestations, rather than economics or epidemiology.
By Meredith Wadman, Jennifer Couzin-Frankel, Jocelyn Kaiser, Catherine MatacicApr. 17, 2020 , 6:45 PM
_____________________________
April 23, 2020 Increased death rates, increased cases
Today’s newspapers are full of angry reports about how cases and deaths could have increased so rapidly, while what is actually happening is improved testing of people – living and dead – not previously identified as having COVID-19. I believe it will get much worse before it gets better. Particularly in nursing homes, dormitories, and other places where close-quarters living and working has continued.
April 22, 2020
The New York Times just updated their web site showing rates of reported COVID-19 cases and deaths by country, state, and city (MSA) which is updated daily. This is my go-to location for up to date rates. They are now using the most recent week of data (versus five days, previously) and recentered all their plots to start when a country or state had 200 cases (or 100 deaths) instead of ten.
There is an excellent overview of sources by Vivian Ho, Kirstin R.W. Matthews, and Heidi Russell, from the Rice Baker Institute. I first learned about this from The Incidental Economist blog by Austin Frakt. I recommend you choose which sources you want to review for your update.
One anecdote reflecting my own experience is revealing:
Yesterday I spoke for 20 minutes with someone working closely with an estate attorney. Several things surprised me. This person (“Jane”) said that the lawyer in the Boston area was swamped by demands for living wills and do not resuscitate (DNR) orders (covering what to do when faced with the choice of being on a ventilator, for instance), updated wills, trust tax forms (no extension granted for these) and particularly assistance to households trying to get death certificates from the state.
Jane revealed two nursing homes in the area that have not yet gone public with the surge of deaths they have experienced because of fears over negative publicity.
Jane spoke of several people who died in nursing homes who were not yet reported to the state because when a death occurs at home or in a minimal care nursing home a death certificate requires verification by a coroner, and coroners are overwhelmed just now. The coroner must decide whether an autopsy is needed, and what samples should be taken before determining the cause of death. This is causing a serious delay. This leads me to believe that deaths in total and deaths attributed to COVID are being understate in some places in the US, and that more reliable estimates will want to look at deaths by age this year versus over past years.
These unreported deaths are consistent with recent reports in the media about new tests of samples from deceased bodies are turning up new cases of SARS-COV-2 not previously recorded.
April 22, 2020 Nursing home rates skyrocket.
Yesterday, April 21, the Boston Globe published a site for Massachusetts nursing homes that reporting confirmed cases by named. Unfort6unately they only have three tiers: <10, 10-30, and 30 or more. The results are stunning. A total of 228 Nursing homes are reporting cases of COVID, out of 338 in the state (56%). The data is to granular to calculate
My own calculations using the Massachusetts nursing home data as of April 22, 2020 posted on the Boston Globe web site suggests that among those reporting at least one confirmed COVID case, the average rate of confirmed cases is 15% or more of all residents, much higher than the population averages reported for older age groups.
I commend the Massachusetts Department of Public Health for publicly posting its rates of testing, new cases, rate of hospitalization, and deaths each day. Rates by race and place of death are reported. Also interesting is the detailed PPE supplied by region. Rates of N95/KN95 and other masks still seem distressingly low in the state.
I will mention that the number of COVID tests done per day has remained constant at approximately 5,000 since March 24, and that the very high positive test rate – average of 26% over the past five days – suggests that there remains a very large number of infectious cases not being identified at existing test levels.
April 22, 2020 Humor and misinformation
I was trying to track down a legitimate post mentioned on Facebook and had reason to view a variety of Facebook sites ridiculous postings. Some of the claims so outrageous as being hilarious. Here is one of my favorites:
“It will be extremely important for the truth about the events of September 11th, 2001 in New York to come out one day, including the truth about the use of a Directed Energy Weapon to “Dustify” the buildings. I hope and pray.”
I was originally going to post several more ridiculous claims. but they were gone!
When I went back to Facebook to copy them, they had been removed. Plus, in two cases, I saw notices from Facebook that they had fact checked some consumer posts, and inserted a link to discuss why certain key statements were false. Hallelujah! Great to have Facebook start actually policing postings and repostings for accuracy.
April 21, 2o20
I was forwarded an interesting article about hypoxia in the NY Times that is worth a read.
It describes how COVID19 induces hypoxia and recommends the use of a pulse oximeter as a low-cost route to early identification of COVID pneumonia. One of the striking findings in the article is that the normal signal of breathing problems (a build-up of CO2) doesn’t happen with COVID-19, so that hypoxia can progress quite far, without the person realizing that anything is wrong – hence the value of proactive monitoring of blood oxygen levels.
Widespread pulse oximeter testing could be very significant for our ability to manage COVID-19 during the ‘dance’ phase, by changing the ratios at several important points:
Reduced R: Earlier detection of COVID19 cases through early identification of hypoxia, even before other symptoms have developed has the potential to increase the ability to isolate earlier and reduce the infection rate.
Reduced % of cases needing ICU beds or ventilators. Earlier detection of hypoxia would allow more routine treatment and less need for oxygen or intensive care, reducing the pressure on ICU beds and on ventilators. The NYT article suggests that better treatments alone – e.g., better positioning of the patient for better breathing could reduce ventilator need in the first 24 hours by 75%.
Reduced mortality rate. The NYT article doesn’t speak to this directly, but it is suggestive that a major reason for the high mortality rates for individuals without other underlying conditions is that the hypoxia has progressed to dangerous levels before seeking treatment. If so, avoiding dangerous levels of hypoxia might dramatically reduce mortality rates for otherwise healthy individuals without underlying conditions.
April 20, 2020 UK report on exit strategy
Interesting UK report from Ian Mulheirn, Executive Director and Chief Economist, Institute for Global Change.
The US continues to be woefully unprepared for the volume of personal protective equipment (PPE) needed and is still totally failing to keep up with the urgent need. Here is one telling quote from Dr Steve Corwin President and CEO of New York Presbyterian Hospital speaking to CNN on April 6, 2020:
“We can’t make that mistake again. I know the next crisis will be different than this one. But let me just give you a statistic, pre- crisis, we were using 4,000 masks a day of all sorts. Now we’re using 90,000 masks a day.”
Given that there are 2650, staffed beds at NY Presbyterian, that implies 34 masks per bed per day. Official guidelines are for hospital workers to put on a new mask each time you enter a patient’s room, which is a lot of masks for each health care worker and each patient. Fortunately some areas have figured out how to sanitize and reuse some N95 masks, but the costs of doing this may exceed the costs of making a new mask, which with bulk production are fundamentally very inexpensive. The magnitude of the need is still unprecedented.
This following table calculates the magnitude of the mask problem for New York state, Massachusetts, and the nation assuming the same rate of need as NY Presbyterian Hospital in early April, before the peak need in NYC.
Governor Cuomo has asked new York hospitals to add another 20,000 emergency beds, which increases the demand even more. These calculation suggest a need for more than a billion masks per month to meet the US hospital demand for masks.
Notice I am not talking about N95 masks, but “all sorts of mask”, just like Dr. Corwin. This calculation ignores the additional masks needed for dozens of other occupations (police, firefighters, public health, pubic transport, food workers, pharmacy workers, and other essential workers). Given their numbers, this easily adds another billion masks per month. Then there are ordinary citizens: if each citizen wanted to use new three masks per month, that would add another billion face masks. These uses quickly triple the number demanded nationally: 3 billion masks per month, or 100 million masks per day.
These levels of demand would require a thousand plants each producing 3 million masks a month, just for serving the US. While a charity event like the Boston Patriots owner flying home 1 million masks from China that were shared between hospitals in NYC, Rhode Island, and Massachusetts, was helpful, achieving a day’s supply at best for the three regions, a much bigger concerted effort is needed. Masks are not expensive, this could be done for perhaps a billion dollars per month once scaled up. That is only $3 per American per month. We can do that.
Obviously a great deal of other PPE equipment is also needed. I need not make the calculations here.
We need the federal government to immediately use its emergency wartime powers to ensure that US industry is turned to producing these supplies at prodigious rates, not just rely in imports and voluntary private businesses to supply the need. After resisting the need for widespread mask wearing, it is time for the US to take this step before we consider partially reopening the economy.
April 19, 2020 COVID
It is clear that the US is not yet testing enough people for COVID-19 virus or antibodies. Here are two good links on the subject.
THE EARLY TOLL OF COVID-19 ON JOB AND INCOME LOSSES: VULNERABILITY BY OCCUPATION
Randall P. Ellis and Giovanna Marcolongo
Boston University, Department of Economics
April 17, 2020
Key message: Early PPP funding does not target the occupations most affected by the COVID-19 shutdown
Figure 2 summarizes the key findings of a new poll of 13 labor and health economists from April 3 to April 10 conducted by the authors about rates of job and income loss of employees by occupation (including seasonal and less than full time workers).
Overall, we calculate that the two-month income losses from the pandemic are $485 billion and argue that the most impacted occupations may be least able to benefit from the PPP loan program.
The best source of up-to-date statistics I have found is on COVID19 is WorldoMeter.info/coronavirus. which gives daily updates and documents its sources.
New York Times interactive figures are updated daily for the world and individual US states.
April 14, 2020 Herd immunity
Jeff Howe from the Boston Globe on April 11, 2020 summarized Harvard epidemiologist Marc Lipsitch modeling in a very direct, if unpleasant way. It is worth a read if you want to know what a top epidemiologist thinks.
“This is the simple, scary math that Harvard epidemiologists Marc Lipsitch and his colleague Yonatan Grad have tried to convey in a series of recently published papers: If each person infected with COVID-19 disease in turn infects three more, as we now think, then in order to bring the disease to heel, Grad says, two of those people must already be immune.”
Currently we are hunkering down with less than 3% of people ever infected everywhere.
The figures in the Boston Globe article are easier to interpret than the three linked academic papers. Worth a sobering read if you care to.
This opinion piece by Marc Lipsitch in the NYTimes on 4/13/2020 is on a similar vein, and also presents evidence on how well people acquire immunity from exposure. Immunity appears not to be complete but only 80 – 90%.
My own belief is that the epidemiologists are perhaps too pessimistic about the assumption and implications. My reading is that good masks (see earlier posts below on Stanford study) reduce infection rates by 70 to 95%, so if everyone wore masks routinely, and also washed hands regularly, the infection rate need not multiply as rapidly as modeled for much of the population, which they max out at a 60% reduction. This points to the importance of high quality, comfortable and hence widely worn, personal protective equipment (PPE).
The biggest short run hope is not vaccination, but PPE, physical distancing, crowd avoidance, and above all effective palliative and treatment drugs so that the infectiousness and death rates can be brought way down. As an analogy, we have never found a fully effective vaccine for malaria, and malaria is still a potential risk even in the US (and Spain and Italy), but we now have very effective prevention methods and treatments for it, so that rates of reinfection are low here and deaths and serious cases rare. The Jeff Howe 4/11 Boston Globe article mentions that 40 different drugs have been approved for clinical trials in the US. These are treatment drugs, not vaccines. If at least one of them is highly effective, then we would free up a lot of ICU beds, reduce pain and deaths, a make us all a lot less fearful of the disease. By focusing on already existing drugs, we have a much better chance of one becoming available sooner. This give me hope, because the infection simulations and impacts on the economy do not look good without this.
Also giving me hope is that several health economists are coming out with behavioral models that may do a better job at building in feedback loops than the existing epidemiological models that I have seen.
Today my wife and I took our dog for a walk at Brayburn Country club and saw eighteen species of birds. Most notable were a pair of bluebirds, a pair of green-winged teal, and two magnificent male wood ducks. Also seen today were turkey vulture, red-tailed hawk, mallard ducks, Canadian geese, chipping sparrow, house sparrow, grackle, starling, mourning dove, chickadee, robin, goldfinch, white-breasted nuthatch, red-bellied woodpecker, chestnut-sided warbler, and at our feeder pine warbler, two turkeys, (including a Tom on full display), cardinal, junco, blue jay, house finch, gray squirrel, and chipmunk. Fun to see 20+ species on a casual day near home. Our winter viewings since COVID-19 quarantine is now 36 species.
I pass along the holiday greetings of my friend Shuli Brammli of Israel
Dear Friends,
This week we are entering a period when the three religions are celebrating their spring holidays. One by one we celebrate Passover, followed by Easter and then by Ramadan Kareem of our brothers the Muslims. We don’t know much yet about the consequence of this Epidemic that we all experience. But one fact is undeniable. We all live in one small world and there is no other world for us. It is too small to be ignored. I hope that we will be smart enough to learn the lesson from this, and that we will be kinder to each other and compassionate, promote social support and mutual guarantee within our society as well as between our countries. I wish you all the best for you and your beloved ones.
I was proud to see BU offering their empty dorms to the homeless shelter staff, some of whom are themselves homeless.
Now is a good time to give to Pine Street Inn (homeless shelter) and the Greater Boston Food Bank (wholesale food pantry) donations or your own local shelters and pantries.
April 10, 2020 More on job impacts of COVID pandemic
There is an important article by Noam Levy at the LA Times that is worth a careful read.
“Primary care doctors have seen a big uptick in telehealth visits — a move widely hailed by public health experts. However, the fees for these services are often lower than for office visits. Many physician practices have seen in-person patient visits drop 50% or even 75%. That has left physicians struggling to stay afloat and forced growing numbers to consider laying off staff or even closing their doors. Nearly 8 in 10 primary care clinicians in one recent survey reported their practice is under “severe” or “close to severe” strain due to COVID-19, the disease caused by the coronavirus.
“Seventy-two percent of Americans said they would stay away from a sports event if it were held before a vaccine is developed. Even if the seating arrangements allowed for social distancing, just 12 percent would be comfortable with that setup.“
“Toast, the maker of popular software and systems used by the restaurant industry, said late Tuesday that it was laying off over 1,000 employees, reducing its workforce by about half through layoffs and furloughs. The company said that restaurant revenues have declined by 80 percent since state and local officials began shutting down businesses nationwide, and “our success is tightly coupled with the success of the restaurant industry.”
“Lola.com, Zipcar, Hopper, and Wanderu have all cut back workers as travel restrictions have decimated the industry. At Logan Airport, the number of passengersfell by 93 percent between March 23 and 29, compared to the same period last year, according to the latest Massport data.”
Although tangential to this COVID blog, the big news for me on April 8 was the appearance of my first first-authored paper in JAMA. It is worth a click if you understand the importance of disease tracking over time.
JAMA Network Open (Open means it is free to all viewers)
Original Investigation Health Policy April 8, 2020
Randall P. Ellis, PhD; Heather E. Hsu, MD, MPH; Chenlu Song, MA; Tzu-Chun Kuo, PhD; Bruno Martins, PhD; Jeffrey J. Siracuse, MD, MBA; Ying Liu, MA; Arlene S. Ash, PhD
Question Was the US transition from ICD-9-CM to ICD-10-CM in October 2015 associated with dramatic changes in diagnostic category prevalence in various classification systems?
Answer: YES. See the paper’s figures to see how much.
It has been a long time coming, but here it is! We didn’t like the title either, but JAMA insisted. This is the first publication from our ICD10 project. We use 1.2 billion data points for the figures, which are the best thing to look at.
There is now significant evidence that pets, such as dogs and cats can become infected with SARS-CoV-2, however no evidence yet over whether they can infect humans through the air. But it seems likely. Here is the evidence from the American Veterinary Medical Association (AVMA). I personally will not stop petting our dog, and will consider her part of the family who is at risk of exposure if any of us become ill. We no longer let her get close to any other dogs or people, so she is like other members of our family.
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April 6, 2020 Effectiveness of different types of homemade mask materials.
April 6, 2020. How to sanitize masks against viruses.
The link on the previous posting from Stanford includes advice for achieving medical quality sterilizatoin of N95 masks. Here is the key table.
Their key finding is don’t use bleach or alcohol to sterilize masks since it can change how well they filter or the difficulty breathing. heating anything in an oven to 160 for 30 minutes will kill the virus.
My reading is that for cloth masks, where you want adequate but not surgical safety, any of the following should work
Running them through a load of wash, where the soap will remove the germs to practical levels.
Put them in a dryer at high temperature for ten minutes.
Put in hot or boiling (not recommended for many rubber or stretchy attachments, however).
Leaving things out in the direct sun for a half hour works because of UV light.
Or leaving them unused for a five days will also kill COVID germs (but not necessarily other germs).
The other key advice is not to reuse or handle used masks. Treat them as if they are used tissues. If you have been around anyone who is infectious, and your mask has done its job and filtered/caught any bad germs, then you don’t want to be touching the germs or reattaching them to your face. best is to have several and just routinely use a different one once you have been out with one.
This requires having a sewing machine to make several well.You probably have a friend or neighbor happy to give or sell you one for a donation to a good cause.
In a pinch, the following simple technique could also be effective if bulkier in areas where it is not too hot.
Find a 100% cotton T-shirt and a black binder clip. Put the whole T-shirt over your head and use the binder clip (or a safety pin) to shrink the size of the head hole to be snug around your nose and mouth, leaving the rest of the shirt just hanging around your neck. When done visiting the store, throw shirt in a plastic bag, wash your hands, and be sure to launder the t shirt before the next use. Keep several T-shirts handy.
Any face mask will only work if you actually wear it… Half (?) of its effectiveness is probably from the reduced ability to touch your mouth and nose. Wear glasses or goggles to also reduce eye touching.
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April 4, 2020
The media is full of predictions of the date on which rates of hospitalizations, and deaths will peak. Many of them are informed by the model from IHME, the Institute for Health Metrics and Evaluation, which is led by Christopher Murray, a well regarded health economist and MD, now an adjunct professor at the University of Washington. He is best known for his work calculating the burdens of disease for WHO and the World Bank. IHME are updating their predictions for COVID-19 every few days.
There is a research paper in draft form linked here.
I think this comment below on that paper sums up well the weaknesses of this method. Murray uses a simple parametric model, and assumes that the rate of new infections will be a symmetric Gaussian sigmoid function. There is no evidence that the decline will be symmetric with the rise, and indeed the evidence from South Korea is that it does not return to a zero rate, but rather to a low, but still growing rate of growth. So I do not place a lot of faith in the predictions other than that in the short term we are in for some very difficult times. States that started lock down earlier will face less exposure. Those that have yet to start, could be in for a much higher mortality. For reasons discussed below, I do not believe the China rates of extremely low deaths recently are entirely reliable. There is reason to believe that they have been concealing deaths.
This is seriously just a three-parameter model fitting a transformed sigmoid to the extant data?! On one hand I appreciate the simple model, but who came up with the idea that the data was well approximated by a sigmoid?! pic.twitter.com/7KUeGVE0jA
While it is easy to be critical, no one really knows what the right hand tail will look like, and I do not know any other model that is worried about short term forecasts as much as this one.
The bottom line of their model, as of today 3/4/2020 at 12:49 pm EST is that they forecast that the US hospital bed demand will peak on April 15, 2020
Resources needed for COVID-19 patients on peak date
All beds needed: 262,092beds implying a Bed shortage of 87,674 beds
ICU beds needed: 39,727beds implying an ICU bed shortage of 19,863beds
Invasive ventilators needed: 31,782 ventilators
He forecasts that the number of deaths will peak one day later at 2,644 per day. With eventual deaths by August 4 of 93,531.
At his last update three days ago, he raised his estimated beds needed and deaths. the web site says that it will be updating its model and predictions today, April 4.
April 4, 2020
It is only a newspaper report, but the 3/4/2020 Boston Globe had an interesting article about funerals in China, which has been receiving some attention. China is making it hard to attend an count deaths through this normal means. So people have been using other methods.
Below is the relevant text to me. Two different estimation techniques both give much higher estimates of death. Note that the current death count in China is still only 3,326. Only slightly more than Iran, another country that people question: how could they be so successful?
“Long lines have been forming at funeral homes in Wuhan over the past two weeks, as family members have been informed they may collect their loved ones’ remains ahead of Tomb-Sweeping Day. Some waited six hours to collect an urn, then the ashes.
The Hankou Funeral Parlor’s crematorium was operating 19 hours a day, with male staff enlisted to help carry bodies. In just two days, the home received 5,000 urns, the magazine Caixin reported.
Using photos posted online, social media sleuths have estimated that Wuhan funeral homes had returned 3,500 urns a day since March 23. That would imply a death toll in Wuhan of about 42,000 — or 16 times the official number. Another widely shared calculation, based on Wuhan’s 84 furnaces running nonstop and each cremation taking an hour, put the death toll at 46,800.
Wuhan residents say the activities belie the official statistics. ‘‘It can’t be right . . . because the incinerators have been working round the clock, so how can so few people have died?’’ a man, identified only by his surname of Zhang, told Radio Free Asia.
US intelligence agencies have reportedly concluded that China’s numbers are much lower than they are in reality.”
Let me note that these reports on urns and cremations might also be biased, reflecting misinformation. I won’t speculate on how or why.
I myself look at South Korea as the country most likely to have a reasonable trend. They are showing a reduction to less than new 100 cases a day, with deaths hovering around 10 per day. Even scaled up for the US, that is a level that buys us time until we get a virus. That seems credible to me.
April 3, 2020
This 8 minute video produced gives the best scientific overview of COVID19, and I am sending it out to my full set of BUHealth recipients. It is accessible and would be understood even by an intelligent child, although complex topic.
As before, I am posting my other updates on a single blog site to not overwhelm people
Yesterday was a day of much bad news. First an Italian colleague and health economist stated and provided further support today, that there is evidence from Italy that health care workers who are believed to have had COVID and recovered, have become reinfected and showing new symptoms. This was also supported by news in the NY Times (source not provided) of reports coming in from Wuhan that an estimated 5-10 percent of people are becoming reinfected with the virus, after seemingly recovering.
The other bad news is that the articles in today’s papers that the current COVID test used for current infections appears to have a 30% false negative rate. This is really bad because it means that after testing and sending people home, 30% may still have COVID.
More bad news is that two people I spoke with in our summer town in Maine thought that the presidents financial stimulus would not be of any value to them, for different reasons. So as I have worried, the very lowest income citizens may not be helped meaningfully by the measures taken to date.
My own “back of the envelope” calculations using my own guesses about rates of job loss and lost income suggest that US income during the shutdown may have fallen by 40%, with an even larger drop in spending. This is unheard of in previous recessions.
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April 1, 2920
This posting from “TheLawyerBubble”, which I do not know, focuses on cited quotes by Donald Trump over time which clearly show that Trump repeatedly lied to the US public and caused delay which is very costly to the US. It will mostly interest Americans, but highlights the importance of good leadership.
John Burn-Murdock has been generating a series of excellent figures on COVID trends by country. There is a rich set in this series of Twitter feeds today. I recommend them to you.
This confirms what others have said, that there is no relation of infection rates to size of population across countries, at least for the low rates now. Ultimately population size will matter, but recall that even in the three countries with the highest rate of infections (Italy, Spain and Switzerland), the rate is only just over 150 per 100,000 which is .15%. So the saturation that slows down the rates of growth is not yet in effect. The US rate is only 39 per 100,000, which is .039%.
It is not the absolute levels that should make us scared but rather their rates of growth. If they double every 3 days, then in 30 days they will have doubled ten times and 2^10=1024. Multiply the above percentages by 1000 twice and you have everyone infected. Burn-Murdochs figures show no slowing down by population size, only by actions taken in some countries.
March 30, 2020
In case any readers are interested in doing your own empirical analysis of county rates of infectoin with COVID, the NYT might pick up if well done, they have just posted their entire dataset of county level cases and deaths from January 21 to at least March 29, 2020. Look here.
An article describing what has been posted is linked here.
Others have documented states and cities who have implemented guidelines and lockdowns. There are dozens of papers eventually to be written about all of this information.
RE
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March 30, 2020
These New York Times interactive figures and interpretation from today’s Upshot are excellent.
It is clear that Korea and China have done something critical by slowing the doubling rate to once per month or less.
The US is now the laggard. But the disease always spreads faster when entering a new area and rates are low. So what will matter is how they look in areas where there has been time to respond. In a few states there is encouraging news in that the rate of doubling has slowed down to about once every month instead of every two days in the worst cases.
RE
March 30, 2020 RE
I want to retract some of my enthusiasm in light of a link from a BU colleague.
While the news is on a larger sample of N-80, an article in today’s Science Magazine questions the reliability of the finding. It is still not a randomized controlled trial, and was done on a sample with a median age of 54, where a lower complication rate would be expected anyway.
My previous post is below.
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March 30, 2020
Fabulous news just in from France. If validated, this could be a game changer for this COVID battle. N=80.
There is also a key literature on the effects of hospital strikes on mortality. Cancelling all elective procedures and non-urgent care for COVID is a similar impact to a MD strike. This study from 2008 did a meta analysis of 156 studies of strikes from around the world, of which only 7 studies were considered high quality. These seven suggest that in every case an MD strike in the short run resulted in the same or lower overall mortality. They acknowledge that this is only the short run effect. But the cancellation of elective surgeries in the developed world tends to reduce other causes of death in the short run. Hard to build into models, but very real. Assuming zero or small negative change in the short run seems credible. More than a few weeks, who knows.
Growing evidence that masks are key to containment. thank you BU alum Jing Guo for these links and text.
Wearing mask also helps us to dance well in the long run before we all can get effective vaccine. I’m glad to see more articles about wearing masks these days:
Everyone should be wearing masks when out of the home or around people at home who might be infected. Most of the west has been in error about not advocating their use. Here is a good video.
BEST OVERVIEW.
Tomas Pueyo’s COVID:Hammer and the Dance is the best overview of the issue from early this week.
The following University of Chicago article is also interesting and has much higher costs of the pandemic than some others. It does a cost effectiveness using the value of a statistical life.
In WorldoMeter, I especially recommend the figures using the log scale on the vertical axis, so that you can quickly calculate the days before doubling or sadly the days before a ten fold increase.
As of March 27, the World is doubling every six days in terms of cases and deaths, while the US is doubling every 3.5 days. If this pattern continued for two months (60 days), then the cases and deaths from COVID19 in the US would exceed the US’s population. If we slow down to the world rate of increase the US rate would still increase by the multiple 2^10 = 1024. If the US continued at this rate, every American would be infected in 60 days (A 32,000 multiple). If we assume the US only slows down to the current world rate then the following numbers emerge. This is not a prediction, only a calculation.
World
USA
Doubling time (T) in last week
6 days
3.5 days
Times doubled in 60 days (50/T)
10
Multiple after 60 days (2^(60/T))
1,024
today
60 days
Today
60 Days
cumulative cases
596,366
610,678,784
104,126
106,625,024
cumulative deaths
27,345
28,001,280
1,696
1,736,704
Calculations based on extrapolating most recent growth paths for 60 days
Source: Worldometer
In all of World War II, there were only 405,000 American deaths.
For President Trump to assert that the worst is over and that we should reopen everything on Easter would be equivalent to announcing that WW II was over two months after the US entered the war.
3/27/2020
Best humor.
God only brought one guy back from the dead on Easter. Trump is here to bring back the whole economy on Easter 2020. Enjoy this clip (possibly, like, the best ever), share and be sure to subscribe to Making Podcasts Great Again (@TrumpPod) – new every week! pic.twitter.com/aUifVWRzfh
I am impressed with how the Atlantic is publishing great overviews of this pandemic.
The four possible timelines for life returning to normal
The coronavirus outbreak may last for a year or two, but some elements of pre-pandemic life will likely be won back in the meantime. Read in The Atlantic: https://apple.news/AxwhNr30XQiWDDkWSUTvJFw
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There has been a lot of misinformation about how seasonal COVID19 is likely to be. We have no prior information, so many are looking to the seasonality of Influenza (the flu). But more informative may be that of pneumonia, since COVID mostly causes lower respiratory infections (pneumonia), not upper respiratory ones, like the flu. Some work I am doing with a team has looked at monthly diseases rates per 10,000 people on 1.2 billion US monthly observations. These four pictures tell an important story.
If it were in our data, COVID would likely be classified into this CCS disease category and are likely to have similar seasonality.
Age patterns of prior high cost pneumonia cases also display a pattern similar to COVID, and seasonality by age would be possible with our very large datasets. The following figure is based on old data, and shows rates per 100,000 people. Something similar could be done with our newer data. It would be even more interesting with All Payer Claims data, which we hope to have available for a sample of states already. Notice that older Americans have much higher rates of treated infection, and this is much more likely to be high cost when they are infected.
I took time to make the following game board because I greatly love bird-watching and also love games. I invite you to view it. School teachers or parents might enjoy it as well.
I admit that our bird-watching is much better through having a bird-feeder in the back yard, which accounts for probably half of the species we have seen.
Each picture is of a bird or animal seen, heard or smelled in Newton Massachusetts in March 2020.
Options:
Study it to learn the local birds and common mammals.
Print it out and see if you can see five in a row, column or diagonal.
See how many species you can see, hear or smell.
Click on the links to listen to the sounds, and then listen for them outside.
Print out the second page and see how many names you can remember.
Have someone tell you a name, and see if you can find it on the second page.
Try taking your own pictures or make your own recordings.
Learn the differences between male and female books. Look at the Cardinals! How different is the male and female house sparrow? Which one is shown here?
Use the embedded sounds to listen and learn, and then have someone else play them to see if you can identify them. How many can you guess correctly?
If you play all of the sounds quickly in sequence and on a recurring loop, you can turn your room into a bird sanctuary with all the sounds going at once. See if you can recognize them as they a sung.
These are mostly winter and year round birds just now. Soon arriving will be many migrants, including the red-wing blackbirds, kinglets, flycatchers, warblers, owls, hawks, ducks and geese. Then come the summer resident birds. See how many you can find on your own!
I have personally seen 15 wild mammals in Newton MA. Can you think of what they might have been?
If needed, send out one person every three days to buy food. Wear a mask if you go out. It need not be perfect, but any mask or scarf is better than nothing when around other people.
Maintain 2 meter distance if you do go outside. Jogging is fine.
Wash hands and things you touch compulsively. Wear gloves of any kind when you go out to stores.
Stay connected online to stay socially connected. Don’t watch too many news broadcasts.
This at home quarantine may only have to last for two months if we continue the dance well.
Low cost antibody testing kits are rapidly becoming available and will greatly help the dance.
Randall P. Ellis, Ph.D.
Professor, Department of Economics, Boston University
I started listening to Audiobooks while commuting, which lets me get in at least 45 minutes of audio listening a day during my round trip commute, which is wonderful.
My most recent favorites are
Talking to Strangers: What We Should Know About the People We Don’t Know. Malcolm Gladwell. 2019. Just as I have loved Blink, Outliers and The Tipping Point, I really like this book. Gladwell makes his discussion so vivid with lots of concrete examples. I have actually been enjoying the free Audiobook version, which is free to you if you have not yet downloaded the Audible app. The audiobook has recordings from actual police stops and court proceedings that make it incredibly interesting. Along the way you will appreciate differences by race, sex, foreigners, law officials, liars, cheaters, and above all understand people and make better decisions. 10/10
So you want to talk about race.Ijeaoma Oluo.2018. I was inspired to read this book on systematic racism in the US by Austin Frakt’s Incidental Economist blogs about it. I was delighted with the Audiobook reading of it which was both deep and easy to follow. It will make you feel uncomfortable, particularly if like me you are a white, high-income male of privilege. I feel like I learned a lot, even if it is hard to change even a little. The image of blacks walking around and getting a constant series of “punch in the arms” from systemic racism is something that will stick with me and perhaps help me pause to try to recognize and minimize the many “mini-aggressions” that she documents so well. Low-cost paper copies are here. I rate it 9.5/10
The Silent Patient. Alex Michaelides. This bestseller is a psychological thriller about art, psychology, and murder. It is rich in details about love, betrayal, evil, and the ills of psychiatric hospitals. You will be both happy and sad as you listen. I think the book is probably almost as good as the audiobook, although I really liked the voices and emotions of the audiobook. The audio is 8 hours long, but it flies by. I rate it 9/10, leaving me room to have other books above it.
Break Shot, James Taylor. 2019, is only available as an audible book, is an autobiography of his first 21 years of this folk/rock singer’s life, which features stories about his struggle with addictions and depression, six months in McLean psychiatric hospital, the origins and meanings of favorite songs, and how the Beatles and Apple records befriended him to give him the Break Shot of his life, giving him a wonderful opportunity after a childhood of challenges. At only 1:30, it is a quick listen. It is a wonderful audiobook with his singing and his own voice. I rate it 8/10.
Caffeine: How coffee and tea created the modern world. Michael Pollan. 2019.This fascinating overview of the history and uses of coffee and tea is light listening. I learned a lot from it, including that England was once more addicted to coffee than tea, and made the switch to tea because it was less expensive. More importantly, it highlights the role of caffeine in furthering the industrial revolution! Only on audiobook, and only 2 hours long. 7.5/10.
My reading recommendations from last summer were located here.
I also list my favorite reads on my favorites page here.
This NY Times column 12/18/2019 summarizes a British Medical Journal article about bias in medical abstracts, but the same could be done for economics journals, I am sure. Worth the five minutes to read. Bottom line: Women should brag more, and editors and reviewers should get men to tone it down.
Figure 2 ranks individual positive words in descending order in terms of prevalence and compares the proportion of articles using each word in which the first and last author were both women with the proportion of articles in which the first and/or last author was a man. The most commonly used positive word was “novel” (used in 44.8% of positively framed articles). Articles with a male first and/or last author used the word 59.2% (95% confidence interval 48.8% to 69.6%) more often than articles with female first and last authors.
Gender differences in positive presentation of clinical research articles according to specific positive words, based on 101 720 articles during 2002-17.
This blog contains the excellent advice of Nancy Rose to MIT faculty and students, along with my own two addenda on Etiquette and Advice to Presenters. Here is a pdf version if you wish to print and post or forward it.
Subject: Some guidance for our upcoming seminars
Date: Tue, 22 Jan 2019 10:11:02 -0500
From: Nancy Rose <nrose@mit.edu>
To: All faculty, visitors and graduate students
Dear Faculty and Student Colleagues,
Many of us have been thinking about how we can respond, individually and as a department, to concerns about the climate of the economics profession, and how best to affirm our mutual commitment to a supportive environment that empowers each of us to realize our full potential and contribute the best of our talents.
As one step in that ongoing effort, I am writing to share with you some guidance in advance of our department’s job market talks, which begin tomorrow. These are not meant as rules written in stone. But I hope they will prompt each of us to reflect on how we can ensure – in seminars and in our departmental interactions more generally – that MIT Economics combines intellectual vitality with an inclusive and respectful environment in which to exchange ideas and advance knowledge.
I hope that each of you will join me in making sure that our department’s seminar culture not only achieves our shared goals for job market seminars, but also serves as a role model for others. I welcome feedback at the conclusion of our hiring season, as we continue our efforts to sustain a welcoming environment for all.
Thank you for your engagement on this important issue–
Nancy Guidance for a Constructive Culture of Exchange in MIT Economics Seminars
Research seminars are one of the highlights of our department’s academic life. They provide opportunities for participants to learn about and probe the boundaries of new research, for presenters to gain the benefit of constructive feedback, and for students to develop skills as participants in research discussions. All of these are best achieved when the seminar environment is respectful and inclusive, and when all participants keep these goals in mind.
Building on recent discussions at the AEA meetings and elsewhere on the culture of seminars in our profession, and informed by a number of conversations with our faculty and students, this memo shares some guidance for “best practices” to help ensure that department seminars promote an open and vibrant exchange of ideas within a positive environment for both presenters and participants.
1)Allow presenters time at the beginning to frame their talk without interruption. A “10 minute rule” has been successfully implemented in several field seminars, allowing only brief clarifying questions during this initial period. And as that leaves 70 more minutes, please don’t feel you must get all your questions in at minute 11!
2)Share the floor. Please remember seminar time is a scarce resource. If you haven’t had a chance to read the paper, please try to determine whether the paper addresses your question before you ask it. If you have already asked several questions, you might consider allowing a bit of time and space to see if others wish to contribute.
3)Raise your hand to indicate that you wish to ask a question or contribute to the discussion. This gives the presenter agency to mediate the discussion by calling on audience members, and avoids interrupting the presenter mid-thought, a courtesy that may be especially appreciated in job talks. If the presenter doesn’t see someone’s hand, the organizer can help by pointing that out. A question or comment often leads naturally to some back and forth exchange with the speaker. But if you continue to be dissatisfied with a response, please don’t hold the talk hostage. Instead, allow the presenter to move on, and follow up offline. Please make every effort not to interrupt or talk over the presenter or another participant.
4)Avoid sidebar conversations with other participants. Keep whispers to no more than a short (clarifying) question or response. Anything more should be deferred or asked publicly; please raise your hand and share your question or concern for the benefit of all. Even quiet sidebar conversations between participants rarely are as unobtrusive as intended, and distract the speaker and others in the audience.
5)Strive for fair and equal treatment. Many studies suggest that women are likely to be interrupted more often than are men in settings like this. The same may be true for softer-spoken participants regardless of gender. Resist contributing to that disparity!
6)Organizers: Please be prepared to intervene in real time if necessary to call attention to someone whose raised hand has been overlooked, to return the floor to the presenter, or to remind participants of our norms of courtesy and respect.
Thank you!
Nancy L. Rose
Department Head and Charles P. Kindleberger Professor of Applied Economics
MIT Department of Economics
The Morris and Sophie Chang Building, E52-318A
50 Memorial Drive, Cambridge, MA 02142
(617) 253-8956
https://economics.mit.edu/faculty/nrose
Addendum to Nancy Rose’s excellent email. Randy Ellis, March, 2019
Common Courtesies
7) Show up on time for the seminar.
8) Stay until the end of the seminar. If you must leave early, it is much more polite if you arrive early and privately tell the speaker that you have another commitment and will have to leave promptly at time X:XX.
9) Mute your cell phone. (If you are presenting, you could intentionally do this just before your talk, even if it was already mute, to signal to others that they should remember to do that as well.)
10) No answering phone calls in the seminar room. If you do answer a cell phone call (from vibrate mode!!!) never talk until you have left the seminar room. Mute or hang up and call back later, or make the caller wait ten seconds while you leave the room.
11) No email or web surfing in the front three rows. If you plan to be looking at your cellphone or laptop or read papers during a talk: a) try not to, or b) sit in the back of the room.
->I was at a seminar in Spain given by a woman, and every man in the room was checking their cellphone or laptop for messages, while only one of the ten women were. This was not a coincidence.
12) No napping. If you are prone to napping or had a bad night’s sleep, sit in the back of the room or don’t come.
13) Keep questions brief. Many professors think they are making brilliant comments, which others feel are bad or unnecessarily long. Err on the side of too few, and ask questions instead of giving advice.)
14) Write down your thoughts. If you have a lot of comments or uncertainties about a presentation, write them down. Discuss or give them to the presenter at the end of the talk. Most presenters are delighted to get constructive comments after their talk.
->I have always been immensely grateful to Daniel McFadden, who instead of interrupting my job market paper presentation, gave me a page of very high-quality comments.
15) No questions during the final three minutes. Let the presenter summarize and conclude the presentation.
Advice to presenters facing inappropriate, intrusive or awkward questions, by Randy Ellis November 2019
Don’t recognize any hands up or intrusions when still on your introductory few slides or five minutes. Nod them away or if rude, say “Please let me finish my overview first.” Then finish your overview while trying to anticipate questions.
Never interrupt your talk in the middle of a sentence to react to a person raising their hand. Finish your sentence.
Nod at someone who has their hand up to recognize them and then return later (hopefully soon) to let them ask their question.
Try to give succinct answers, saving your own time.
It is OK to say “I don’t know” for a factual question. Just not too often. Avoid speculation.
If lots of hands go up, try to choose someone who has not already spoken. Also, take it as a signal that you have just said something confusing and try to clarify it.
Learn to distinguish a comment (or suggestion) from a question.
Try to have the confidence to move on with a comment rather than a question. Just say “Interesting comment” or “Thank you.” Others who agree that the comment is a tangent or of secondary importance, or rude, will respect, not disrespect, you for this.
Take the comments and questions of junior faculty and people in your field more seriously than those of old farts.
Restate a question if it is unclear and answer your version. Also, restate it if it was said too quietly.
Be willing to repeat something you have already said, in a slightly different way, to try to improve comprehension.
Try to use specific examples to motivate concepts: Pizza rather than good Q, Bart instead of Agent J.
Pick on someone in the audience if it will add humor and concreteness.
Feel free to say “That is a good question. I will get to that in a few more slides. Ask again if I don’t.”
If the question is tangential to the point you are making in your paper, consider saying “That is an interesting point, perhaps we can discuss it after the seminar.”
Writing down new ideas is a good idea, but not if the point is something obvious you should have already thought of, which makes you look foolish. Even if you already know about the idea, acknowledging the idea, such as by writing down a single word, may be good.
Ask a coauthor, colleague, or friend in the audience to take notes. Tracking your time on the intro/data/ methods/results/extensions/conclusions is also helpful.
Don’t say too often: “That is a really good question.” If so, you should have answered it already.
If someone else is giving a very long speech, and you think others will recognize that it is inappropriate or too long, be willing to interrupt or cut it short. “I think I get what you are saying…”
Don’t allow faculty sitting in the front row to ask you private questions that everyone can’t hear or understand. Interrupt them and say “Could you please speak up so that others can hear you.”
If you feel that the questions have interrupted you too much to finish your talk, say “I see my time is running short. I need the next few minutes to cover XXX (my methods or results or conclusions or whatever) without interruption and get back on track.” You can do this before the final five minutes.
Try not to be snarky, dismissive or rude. Strive to be gracious and open to suggestions.
Assume you will have intrusions and plan a shorter talk with extra bonus slides if you have time.
Assume you won’t have enough time to cover sensitivity analysis and extensions and plan accordingly.
Always take your final three minutes without interruptions. Tell the audience you need to do that to finish your talk. Have a strong conclusion to use, even if you didn’t finish your results.
Be sure your name is on the final slide. Don’t just show “Thank You,” but rather show your name. affiliation and paper title, as on your first slide. If you end on your conclusions, include your name. It is the single most important thing you want people to remember.
Pay attention to other strong presenters (men and women) and try to imitate them.
