Coronavirus

One does not have to spend a lot of time on political Twitter or following the latest in punditry or among one’s engaged “friends” on Facebook to see that many if not most such people have precisely identified which politicians and which pandemic policy responses and omissions have been catastrophic failures or glorious successes. If you consort with “both sides” and read pundits with whom you rarely agree, you know it when you see it. There has been so much of this that it makes no sense to link examples.

Our own view is that it will be some time — probably after the United States presidential election, unfortunately — before we will know which policies will have worked at an acceptable cost, and which will have worked, or failed, at “too high” a cost. But as early studies do emerge, there will be a meta-struggle, mostly promoted by partisans seeking narrative dominance, about the best way way to measure relative success, failure, and cost.

Herewith, we propose a few measures of ultimate success or failure.

Ultimately, we will know three things in each applicable jurisdiction (itself a hot topic, of which a bit more below): (1) excess deaths (whether from the virus or the stress of the economy and confinement or from local collapse of the healthcare system) over the baseline experience, (2) excess morbidity and mental health problems, and (3) the decline in the jurisdiction’s GDP per capita against the baseline. Those three things in a given country or state will be the indicators of success or failure.

Now, there will be many arguments to be had in that big partisan quarrel to dominate the narrative. How to compare jurisdictions? How to weigh the value of excess lives lost vs. non-lethal physical and mental health and social problems vs. GDP? (And if you are one of those shallow thinkers who recoil with disgust at the idea that we would measure lives in dollars, please go read some other moron’s blog.) How to attribute the effects of public policy to overlapping jurisdiction in a federal system? How much credit should be given to cultural propensity to follow the direction of governmental, business, and social leaders? What was the role of private sector responses and innovation, and should political leaders get the credit for it?

Regarding jurisdictions, we’ve noticed that people who truly hate President Trump without fail want to compare the policy and social responses in the United States, as a whole, to Singapore, Taiwan, South Korea, Iceland and — if the milk of intellectual honesty compels the concession — Germany. Expect Republicans to compare red states with blue states, or the outcomes for Republican governors compared to Democrats (knowing full well that Republican governors preside over more wide open spaces), or New York State to Lombardy. All such comparisons would be — how you say? — rubbish. Or, if you prefer fruity metaphors, “apples to oranges.”

Having dabbled a bit in social science and having, er, gleaned more than enough from an erstwhile mother-in-law who was a professor of sociology, we say with at least the usual blogger’s expertise that the accepted method would be to identify “paired” jurisdictions with similar known parameters that turn out to matter. Competent social scientists can and will identify pairings among relevantly similar states and between countries to measure the effectiveness of policy responses. Suppose (for the sake of argument) it turns out that the attributes in a jurisdiction most closely correlated with excess mortality are average or median age, poverty, obesity, and density of the population in proximity to heavy travel flows from Europe and China. It might be silly to compare New York and Texas, but it might make sense to compare Florida and Texas. It might be pointless to compare Iowa and Illinois avec Chicago, but it might make sense to compare Iowa with Illinois excluding Chicago and the “collar counties.” Or Minnesota and Wisconsin or the Dakotas with each other. You get the point.

As for the rest of our questions and the many more we have not considered, file them away so you can detect partisan nonsense from actual scholarship in the months to come.

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.