March 2020

This tweet, which has been passed around a bit in certain circles, reminds us that politicians will be politicians:

There has been a lot of attention directed to Nancy Pelosi’s gambit this week, which aimed at grabbing all the social change territory she could get while the getting was good. Most of her proposals were not to our tastes, but neither would we have handled things as the Republicans have done. Our proposal for economic crisis intervention is sharply targeted to the problem that needs to be solved, rather than rank pandering to constituents who are not nearly serious enough.

Here in Texas, the politicians have been doing the same thing. Since the milk of intellectual honesty flows through our veins, we’ll start with the right, which decided that the pandemic was the perfect moment to make a gratuitous anti-abortion gesture:

Texas Attorney General Ken Paxton on Monday issued the clarification of Governor Greg Abbot’s earlier mandate on non-essential medical procedures.

A statement from Mr Paxton’s office said “no one is exempt from the governor’s executive order on medically unnecessary surgeries and procedures, including abortion providers”, according to the Texas Tribune.

It noted any providers in violation of the order – which expires 21 April – could be fined $1,000 (£853) or jailed for a maximum of 180 days.

Yeah, because the trivial number of abortion clinics in the state are going to be oh so critical to the coronavirus fight.

What a maroon.

Naturally, Paxton’s interpretation got him all the attention that he wished it would, and it drew the required lawsuit in response.

One need not be pro-choice to see that Paxton, by grandstanding on a wholly unrelated issue in the middle of this crisis, is just not being serious.

Here in Blueberry Town, we have seen a similar sort of gesture from the left, although carried off with the liberal’s usual flair for sneaky legalisms. Two days ago, Austin’s Mayor Stephen Adler (who, it should be said, has generally been ahead of most other cities by a couple of days, probably to Austin’s benefit) issued a “Shelter in Place” order, the text of which is here. By and large it works like other cities in Texas, with one big exception: It bans all construction work, except insofar as it relates to “Critical Infracture,” which is defined as follows:

[a. … o.]

Wait. What?

The backdrop, of course, is that the activists on the Austin City Council hate all the luxury housing going up (even as they use it as an excuse to massively jack taxes), but they have been pushing for one or another wholly counterproductive measure to promote “affordable housing,” and massive government spending on “affordable housing,” for years.

What better opportunity than a global pandemic and economic crisis to shut down housing construction in Austin, except “affordable housing”? Are we actually expected to believe that masked and gloved construction dudes working outside on a tear down in Old West Austin pose a greater risk to the public than Team Affordable Housing?

Again, not serious.

We admit to having generally regarded politicians as narcissistic authoritarians whose purpose in life is to boss other people around in the service of some imagined better world. We very much wish that in the current moment, when we actually need our government, they discredited our prejudices rather than confirming them.

As of approximately 4 pm CDT this afternoon, Italy has the highest confirmed per capita infection rate of any substantial country. There are 978 Italians confirmed with COVID-19 for every million people. Switzerland is not far behind, at 864 per million. There are a few micro states, the largest of which is Iceland (which has a smaller population than greater Des Moines), that have higher per capita rates, but the microstates have such low denominators that they are not very useful yardsticks.

New York State has a whopping 810 cases per million residents, closing in on both Italy and Switzerland fast. And the vast majority of those cases are concentrated in the City and nearby commuter counties. Franklin County, in the Adirondacks (and where your Editor has been known to spend some time) has not yet had a single confirmed case.

By contrast, the other 49 states combined, including such hot zones as Washington and California, are at 54 cases per million residents. That puts the per million infection rate in the “other 49” just between Australia and North Macedeonia. Or China, if you care to believe Commie numbers. Which we don’t.

One question, of course, is whether the rest of the country is just “behind” New York by a few days, or whether there are important differences that should inform policy. We suspect some of both is true. Yes, New York is the land of stainless steel subway poles, where the virus once deposited will linger a particularly long time, cheek-by-jowl restaurant tables, and terribly crowded sidewalks. But New York is also testing heaving masses of people, so it may be revealing its own infections more completely than other states that will soon catch up in the world’s most dubious league table.

Regardless, the vast difference in the apparent rate of infection between downstate New York and the rest of the country (and the considerable differences among the remaining 49 states) suggests that we need not apply precisely the same policies in every jurisdiction. Even in New York State, we do not understand the logic, beyond mere political calculus, for imposing the same burdens on the already poor towns of the Adirondacks as are the bare minimum, if that, in the boroughs.

We are doing enough damage to the economy as it is without doing more than is necessary by treating everywhere, even everywhere in New York State, as if it were the Times Square subway station. Poverty kills as surely as Covid-19, and it may be the one thing we are producing as fast as virus particles.

Fearless state and local leaders, please use a scalpel, not a hacksaw, even if the Manhattan-headquartered national media demands a universal, maximum response everywhere.

Courtesy of a JP Morgan analytical report, see below for a fair use reproduction of a table of therapeutics in development that might attack some or another aspect of the Covid-19 problem. Note that these drugs fall in to three broad categories: Vaccines, direct viral inhibitors, and immunomodulators. In rough terms, vaccines provoke your body to develop anti-bodies to the disease, direct viral inhibitors go after the virus directly, and immunomodulators tune your immune system to go after the virus.

In case you haven’t picked it up elsewhere, vaccines take a long time to develop because they are designed to be administered in massive numbers to theoretically healthy populations. If a vaccine is a little bit harmful to a small percentage of people it can still hurt a lot of people, and in most circumstances that vitiates the benefit. Therefore, the received wisdom and regulatory framework require that vaccines be studied in large clinical trials over a relatively long period of time.

Therapeutics are a different animal. Because we use them to treat people who already have the disease, in rough terms they only need to be less harmful than the disease. That is a much lower bar to prove in the clinic, requiring far fewer patients and much less time.

Of course, we might in the end conclude we were willing to take bigger risks with a Covid-19 vaccine than usual, because of the broader public health and economic consequences of prolonging the pandemic. Stay tuned.

There is, or at least was, a school of thought in some circles that we — meaning virtually the entire global leadership — are overreacting to the novel coronavirus. We should all hope that this is so, and if the infection rate and death toll remains low we can anticipate a robust debate online shouting match between the Covid-19 “deniers” — to borrow a handy bit of opprobrium from the climate debate — and the believers in “science,” to misappropriate another. The deniers will say that our policy response was wasteful in the first place, and the, er, sciencists will counter that the policy response led to the successful outcome and that the heavy interventions saved lives.

That’s one pointless online food fight we sorely hope comes to pass.

In any case, the skeptic/denier predictions are not holding up in these still early days. Just two days ago, we saw this prediction from a conservative whose work we otherwise admire (the author is a friend of mine, so please be gentle):

Here’s what I think you’ll find if you track things for the next week. The number of cases will go up by 500-1000 cases per day for the next couple of days. Then the increase will start to decline. The number of deaths will also go up, but modestly. I suspect that by the end of this coming week the total number of cases will be around 6000, the total number of deaths 100-150. For context, so far this year, the total number of deaths from the common or non-Wuhan flu is about 14,000. (Bold emphasis added.)

At late afternoon today, far from the end of the week and only 2-3 days in to the forecast period, American cases were at 6137 6211, and we had already added discovered 1474 1548 cases today alone. Our guess — go ahead and consider it a stake in the ground — is that we will discover at least 2000 cases a day for the remaining four days in the week, and that we will have between 17,000 and 22,000 cases in the United States by the end of the day Saturday.

Most such skeptic/denier assertions — that the overreaction is the result of “media hype” rather than a genuine threat — lack my friend’s courage to make a numerical prediction, other than to compare the current Covid-19 casualties to those of seasonal flu. See examples here, here, here, and here. And, of course, President Trump at least postured a denialist stance until the last week or so.

We have been predicting a massive problem, far exceeding the seasonal flu, since the end of February, but we absolute understand skepticism. We — meaning all of us — have been warned about something like this for 25 years or more, sometimes in strident terms, without the scary predictions coming to pass. Most people can only take so much crying wolf.

Just remember how that fable ends.

Every time we fight our way through the comments to a Covid-19 story – somebody needs to do – there are more than a few that suggest that the American response is a media-fed frenzy not justified by the cases or casualties to date. There are indeed some otherwise very bright people who have written as much in just the last day.

Sigh.

If you are among those who do not accept that the stakes in the fight against the novel coronavirus are very high, the example of Italy really ought to persuade you otherwise.

Only three weeks ago, the first Italian died of Covid-19. Since then, at this writing, 2158 have, and the death rate is accelerating rapidly.

2158 dead Italians is the proportionate equivalent of 11,760 dead Americans.

In three weeks.

Annualized, assuming no acceleration from the average Italian Covid-19 death rate of the last three weeks (and we know it is accelerating rapidly), the equivalent in the United States would be 200,000 Covid-19 deaths, multiples of any normal flu season. And if it gets out of hand, it probably really gets out of hand. That is the rough basis for the CDC model you have seen that shows potential deaths north of a million Americans.

So, we definitely don’t want to turn out like Italy.

The good news is that our deaths are not, at least yet, rising as quickly as in Italy. Two weeks after Italy’s first death, 233 people had died (scroll through the link for the daily Graph o’ Death). Two weeks after our first death (eight days after Italy’s) we only had 57 deaths. We do not know the reason for the difference, but various learned pontificators have pointed out that Italy’s median age is seven years older, and its social circumstances are quite different, and maybe some of its hospitals are now being overwhelmed.

Those factors and more may explain the difference in the death rates.

Sadly, our trajectory in cases seemed very similar just five days ago. See below. Therefore, we Americans may have to rely on our lower Covid-19 death rate to keep our casualties in the thousands — like a seasonal flu — rather than in the hundreds of thousands.

We will learn soon whether the aggressive American response in the last few days is enough to bend the curve favorably. You are not going to win a lot of friends, though, arguing that the potential benefits are not worth the game.

And, in case it isn’t clear, if you do this you are a giant bag o’ douche who might possibly actually cause somebody else to die.

A lot of people are arguing for their favorite health care policy in the middle of the national response to the novel coronavirus pandemic. If you have politically engaged friends the left, as we do, then you’ve seen no end of claims that the solution is single-payer healthcare “for all” (Taiwan has it!), never mind that the four countries with the highest per capita infection rate, at least as of this writing, all have universal health care. On the right, people are passing around this article, which points the finger at state “certificate of need” laws.

There is no doubt a legitimate argument to be had about the correct balance between the capacity of the nation’s hospitals and the cost of that capacity. Of course, if we are all in the moment focused on flattening the curve because of capacity constraints, then we are all — in this moment — going to wish we had more of it, never mind the cost during all of those times when there is no global pandemic.

The national numbers do not answer the question of the right balance, but they do suggest that — nationally — we are in good shape compared to most other countries hit with Covid-19. See the chart below, and then multiply the beds per 100,000 by 10 to get the beds per 1,000,000, which aligns it with the column on this table.

Source.

OK, we’ll do the math for you. As of today, Italy and Spain have many more Covid-19 cases than their total critical care capacity (recognizing both that there are many people in hospitals for other reasons, but also that most cases of Covid-19 do not require hospitalization). Germany and the United States are still far below capacity, at least measured against known Covid-19 cases, with the United States in very good shape.

On the national numbers.

The issue for all actual people, of course, is that the local burden on the system might well be far above, or far below, the local capacity to deal with them. If Seattle’s many great hospitals are overwhelmed, it will not matter that there are plenty of beds in Tulsa or Wheeling. Look at this map. The national policy and national capacity barely matters to the discussion.

So, whether or not we have “enough” critical care capacity as a nation, and whether or not there is an obvious public policy solution that would have provided more, it is impossible to know whether any such policy would have allowed for more, or less, in the places that will turn out to need it.

Ranked by cases of Covid-19 per million people, the bottom countries — meaning the worst — as of this afternoon, are as follows (cases per million people are the far right column):

Marshaling all our personal knowledge of the world and, even, our offensive but perhaps relevant prejudices, we struggle to see a useful pattern here. Indeed, in these admittedly early days these data would seem to mock the hope that rising temperatures might contain the virus.

Damn.

Yesterday our vast network of spies sent us an interesting analytical report from JP Morgan. Sadly, we cannot link it since it came by email. Strictly in the interests of the public health, however, we share this interesting fair use excerpt relating to the prospects for relief from the novel coronavirus as the northern hemisphere warms up:

Update: tracking COVID-19 outbreaks and geographical vulnerability bands (March 12, 2020)
This is controversial and many scientists are still uncertain about it, but there has been some research on COVID-19 outbreaks as a function of latitude, temperature and humidity. A paper just released from the Institute of Human Virology at the University of Maryland [(link to pdf)] which makes the following observations:
• The most severe community outbreaks have occurred in regions along a narrow east-west distribution roughly along the 30-50 N” corridor at consistently similar weather patterns (5-11°C and 47-79% humidity). Cities at greatest risk below are on the border of the yellow zone and the green zone
• Average temperatures (5-11°C) and relative humidity (47-79%) in affected cities are similar to each other, and also similar to laboratory conditions conducive to coronavirus survival (4°C and 20-80% relative humidity). None of the infection concentrations have occurred (yet) in places with minimum temperatures below 0°C either.
• Outbreaks have been lower (so far) in places with large populations and substantial travel connections with China, such as Bangkok

Which cities are most at risk? The table below show cities with community spreading and those deemed at risk by the authors of the study using their (in my view highly simplified) approach, simply due to the latitude and average temperatures/humidity of each. The authors note that the cities below will experience rising temperatures and humidity in the weeks ahead, and if temperature and humidity do affect the transmission of the COVID-19 virus, the passage of time could help. As the “ideal temperature/humidity” zone for the survival of the virus moves further north over time, the authors believe it would overlap with population centers with much lower density.

However, let’s be cautious here. The authors cite the decline in Wuhan infections as possibly being related to warming weather when there are many other factors involved: the rising effectiveness/severity of the quarantine, increased knowledge of the virus and social distancing by citizens, and “herd immunity” once a large percentage of the population has already been exposed to the virus. This paper makes an important contribution to virus severity tracking and suggests that weather may play a role, but the results are far from conclusive this early in the outbreak (for example, the only cities circled on the map are ones with >6 deaths as of March 5; there are a lot more cities that would have circles today, and I do not have an updated map overlaying these circles on latitudes/temperature zones). To me, the primary value of the paper is to highlight cities with potentially high risk, and secondarily, that we wait and see if weather may mitigate it. I would NOT recommend any reduction of density reduction and social distancing simply out of the view that weather will solve the problem. [Bold emphasis added.]

The same report, which is regularly updated, had an earlier bit that suggested the mechanism.

Update: Could the onset of spring and summer slow virus transmission rates? (March 4, 2020)
There have been press articles and government statements on the possibility that COVID-19 infection rates could fall as the winter comes to an end. There are three main theories as to why the flu season in temperate regions peaks in winter months:
• More clustering of infected and uninfected people indoors due to colder temperatures
• Colder, drier air is more conducive to airborne travel of viruses; colder air allows viruses to survive for longer periods and to travel longer physical distances
• Lower levels of winter sunlight may play a role given the ability of UV light to sterilize surfaces and kill both viruses and bacteria
Some details:
• Scientists have found that influenza peaks in periods of low humidity, low temperatures, low solar radiation and low precipitation. In other words: in cold, dry winter months
• In lab studies using animals, scientists also found that high temperatures and high humidity slowed the spread of influenza sharply, and at very high humidity levels, the virus stopped spreading completely
• During the SARS epidemic in 2003, infection rates declined from March to May as temperatures rose. However, there were other factors changing at the same time (changes in hospitalization rates, greater provision of gear to medical personnel, higher quarantine rates and the natural erosion of epidemic severity over time) so results were not conclusive with respect to weather in isolation. Even when combining all these factors, researchers were only able to explain two thirds of the change in SARS infection rates
• Why might infection rates be impacted by temperature?
o Low winter humidity might impair the function of mucus, which traps and expels foreign bodies like viruses or bacteria. Cold, dry air can render mucus drier and less efficient at trapping a virus
o In addition, influenza “virions” (an infective virus outside a host cell) appear to be much less stable in conditions of higher humidity, when respiratory droplets fall to the ground more quickly
• It’s not just the heat, it could be the sun as well. Direct and scattered radiation from the sun can break down viruses that have been transmitted to surfaces (“fomites”), but is much less abundant in winter. UV light is so effective at killing bacteria and viruses that it’s used in hospitals to sterilize rooms and equipment
o One study found that in Brazil, there’s a correlation between increased influenza hospital admissions and solar UV-blocking by smoke during the burning season
o The US military reported that UV radiation sterilization virtually prevented the spread of influenza among patients in a veterans hospital, during the same time that an epidemic of influenza ravaged similar patients in nearby non-irradiated rooms
• However, COVID-19 is not the same as influenza and SARS, and its reaction to changes in temperatures, humidity and sunlight is still unclear. SARS did not completely subside until late May 2003, which suggests that temperature factors, if they did mitigate the disease, took time to work
• If weather DOES play a role in COVID-19, then infection rates could FALL in the Northern Hemisphere as temperatures rise, but RISE in parts the Southern Hemisphere in June/July/August when temperatures fall there (i.e., what happens with the flu each year)

Read the underlying paper here.