Some basic economics of the covid-19 pandemic

In 2007, the St. Louis Fed summarized research about the 1918 influenza pandemic and used it to predict what would happen in a pandemic like the present covid-19 crisis. Their predictions have been pretty accurate. For example, the report predicted that low-income and minority households would have higher mortality rates than households with more resources. The report also made some predictions about the urban/rural divide:

• Given the positive correlation between population density and influenza mortalities, cities are likely to have greater mortality rates than rural areas. Compared with 1918, however, urban and rural areas are more connected today—this may decrease the difference in mortality rates between cities and rural areas. Similarly, a greater percentage of the U.S. population is now considered urban (about 80 percent) com-pared with the U.S. population at the time of the pandemic (51 percent in 1920)…

• Urban dwellers are likely to have, on average, better physical access to quality health care, though nearly 19 percent of the city population in the United States has no health coverage compared with only 14 percent of the rural population.28The question remains as to affordability of health care and whether free-service health-care providers, clinics and emergency rooms (the most likely choices for the uninsured) are able to handle victims of the pandemic.

The report warns about the need to “flatten the curve” to slow the rate of infection to prevent the healthcare system from becoming overwhelmed because, “Health care is irrelevant unless there are systems in place to ensure that an influenza pandemic will not knock out health-care provision”. This is much more important than it was in 1918 because of the dramatic improvements in the health care technology and epidemiology since 1918. In 1918, medical science didn’t even know that the pandemic was caused by a virus nor did they understand that it was spread by airborne droplets. It is amazing that even in 1918 the support of health care to take care of hydrating patients and keeping their body temperature in a safe range was extremely helpful. That was about all doctors were able to do in 1918 and the average household didn’t have the capability to do that kind of care well. The Fed report paints this picture of the limited ability of the healthcare system in 1918:

In 1918, the world was still engaged in World War I. Movement and mobilization of troops placed large numbers of people in close contact and living spaces were overcrowded. Health services were limited, and up to 30% of U.S. physicians were deployed to military service.3

In addition, medical technology and countermeasures at the time were limited or non-existent. No diagnostic tests existed at the time that could test for influenza infection. In fact, doctors didn’t know influenza viruses existed. Many health experts at the time thought the 1918 pandemic was caused by a bacterium called “Pfeiffer’s bacillus,” which is now known as Haemophilus influenzae.

Influenza vaccines did not exist at the time, and even antibiotics had not been developed yet. For example, penicillin was not discovered until 1928. Likewise, no flu antiviral drugs were available. Critical care measures, such as intensive care support and mechanical ventilation also were not available in 1918.4 Without these medical countermeasures and treatment capabilities, doctors were left with few treatment options…

In 1918, there was very little shared information about efforts to combat the flu so local officials couldn’t learn from the public health and medical efforts of other regions. World War I led to formal or informal censorship in most nations that would otherwise have had freedom of the press. In fact the disease misleadingly became known as the “Spanish Flu” simply because Spain happened to be a neutral country during the way and it was about the only nation with an unfettered press that was able to freely report about the unfolding disaster. The earliest known case of the pandemic was in Kansas and France was an earlier epicenter before it spread to Spain. Even though scholars are unclear about the origin of the flu, they agree that it did not begin in Spain and it was less severe in Spain than in many other areas. Because there was so little information sharing about the epidemic, nobody could learn from other nations about how to respond to the crisis and every local authority could only guess about what to do. For example, the Fed argues that, “complete quarantines worked (i.e., no activity allowed outside of the home) whereas partial quarantines, such as closing schools and churches but not public transportation or restaurants (as done in Philadelphia, St. Louis and Washington, D.C.) did little to stop the spread of influenza”, but the data gathering was primitive and even today there are uncertainties about what approaches worked best .

In the current crisis, public health experts have learned from experiences in other nations with social distancing and quarantine which has been more effective than most predicted. Although they failed to predict that social distancing would be so effective to combat the corona virus, this is partly because we have never had these kinds of public health measures in the history of the world and it is partly because science takes time to come to conclusions and we still don’t have enough data to understand what kinds of social distancing measures work best nor what vectors are most important in spreading the virus.

Despite the uncertainty, most experts in both public health and in economics agree that our shutdowns have been well worth it. The shutdowns worked a lot better than expected at reducing mortality so the advice of the experts worked out even better than most people would have hoped.

The University of Chicago’s business school regularly polls elite economists about a wide variety of topics and economists overwhelmingly agree that a lockdown is better for ‘the economy’ than letting the disease spread because the mortality and healthcare costs of a pandemic cause even more economic disruption than a voluntary lockdown. In effect, the fear and illness of widespread infections would cause the economy to shut down worse than what we have with deliberate stay-at-home strategies to slow the spread.

Abandoning severe lockdowns at a time when the likelihood of a resurgence in infections remains high will lead to greater total economic damage than sustaining the lockdowns to eliminate the resurgence risk.

For newer research that supports this conclusion, see Pandemics Depress the Economy, Public Health Interventions Do Not: Evidence from the 1918 Flu

In addition to the economic effects, the mortality would be shocking.  The pandemic would infect at least half of the world without social distancing efforts and even for people in their teens and twenties, the mortality rate is about 1 in 500. 

That sounds small until you think about other comparable mortality risks in a given year.  For example, would you be willing to go on a roller coaster ride that ‘only’ kills 1 in 500 riders?  Most people would pay thousands of dollars to avoid being forced on such a ride and yet the corona virus is a lot less fun than a roller coaster.  Even if you don’t die many more people get lung scarring and reduced lung capacity that is likely to be permanent. 

The University of Chicago’s poll also supported the idea that the government isn’t doing enough spending on testing, treatment, and searching for a cure:

Optimally, the government [should] invest more than it is currently doing in expanding treatment capacity through steps such as building temporary hospitals, accelerating testing, making more masks and ventilators, and providing financial incentives for the production of a successful vaccine.

Another poll also showed that economists strongly agree that more testing is required before we can reopen the economy. This is what South Korea, Taiwan, Singapore, and China did. They used a massive testing program (relative to the total number of infections they had) to identify people who were sick and trace their contacts so that other people with possible infections could be identified and isolated until testing proved that they were virus free. As a result, these nations have been relatively successful at containing the outbreak and most of these nations avoided a lockdown. China has been successfully easing restrictions and restarting their economy as can be measured from satellite data showing a resurgence of air pollution as China’s industry restarts:

In order to get the economy back to work, America needs much greater investment in testing and contact tracing. There are many think-tanks and panels of experts who have come up with various plans for what it would take to successfully reopen the economy and they all agree that America needs to at least double our testing capacity (and get faster and more accurate at it) and we need to dramatically expand our public health infrastructure for tracing contacts for potential spread. That infrastructure has withered over the past decade and America is behind the Asian nations that have been more successful at limiting the spread of coronavirus without shutting down. Some states like Massachusetts are doing well at this, but to be successful, it needs to be a national effort. If any area of America lets down its guard, covid-19 will come roaring back and it will spread to the states that have been successful at keeping their own population safe. It is too hard to shut down state borders to prevent reinfection coming from out of state.

The consensus of The University of Chicago’s poll of elite economists is that the best way to stimulate the economy is a massive moonshot push to improve testing and tracing the coronavirus until we have a cure (or herd immunity) and we should be also investing massively in the effort to develop vaccines and/or treatments. Epidemiologists are divided about what percent of the population would need to get infected in order to achieve herd immunity, but most expect that at least 50% would need to get infected and that would result in millions of deaths, and worse economic disruption than our voluntary shutdown so it is a terrible option. There are a number of conspiracy theories circulating on social media about speculation that we have already achieved herd immunity because those conspiracy-theorists believe that the disease has an extremely low mortality rate and has already infected most people without them experiencing any symptoms. But that rumor is false. There is lots of evidence from random testing and from genetic studies that suggest that the percent of Americans who have been infected is closer to 1% than the 50%-80% required to achieve herd immunity.

Here is an estimate for European nations:

Long-term effects of the pandemic

There has been a lot of economic research about the effect of the black plague upon the economies of Europe, and the big conclusion is that it reduced inequality by reducing the labor supply when it killed “an astounding one-third to two-thirds of the population of Europe”. This caused wages to roughly double and rents to roughly drop in half and it reduced real interest rates. This radically reduced inequality except in places where elite property owners banded together to essentially enslave their workers by inventing serfdom in Russia and other parts of Eastern Europe to keep wages low.

I doubt the coronavirus pandemic will cause significant changes in the labor supply because modern public health measures will keep the mortality rate much lower than even the 1918 flu pandemic and unlike the 1918 pandemic which disproportionately killed the age group that was in their prime working years, this pandemic disproportionately kills retired people, so the demographic effect will be tiny and it will mostly just cause a small reduction in the dependency ratio by reducing the number of retired people the economy supports.

Posted in Health, Labor

Bush and his team was SOOO much better than Trump and his team.

Once again I find myself longing for the good old days of the George W. Bush administration which was so much more honest and competent.  And they weren’t racist nor corrupt.

Here is Bush’s chief economic advisor on what should be done today. I wish he still had the ear of the President.  Greg Mankiw:

…my thoughts about the current economic situation in light of the ongoing pandemic. Here they are, in abbreviated form:

  • A recession is likely and perhaps …the best we can do under the circumstances…
  • Mitigating the health crisis is the first priority. Give Dr. Fauci anything he asks for.
  • Fiscal policymakers should focus not on aggregate demand but on social insurance. Financial planners tell people to have six months of living expenses in an emergency fund. Sadly, many people do not. Considering the difficulty of identifying the truly needy and the problems inherent in trying to do so, sending every American a $1000 check asap would be a good start. A payroll tax cut makes little sense in this circumstance, because it does nothing for those who can’t work.
  • There are times to worry about the growing government debt. This is not one of them.
  • Externalities abound. Helping people over their current economic difficulties may keep more people at home, reducing the spread of the virus. In other words, there are efficiency as well as equity arguments for social insurance.
  • Monetary policy should focus on maintaining liquidity. The Fed’s role in setting interest rates is less important than its role as the lender of last resort. If the Fed thinks that its hands are excessively tied in this regard by Dodd-Frank rules, Congress should untie them quickly.
  • President Trump should shut-the-hell-up. He should defer to those who know what they are talking about. Sadly, this is unlikely to occur.

Greg Mankiw also served as Romney’s chief economic adviser.  Too bad Trump would never pick an economist like Greg. Instead Trump has only had flaky economic advisors that are either obscure or well known for bad reasons.

#MAGNA → Make America’s GOP Normal Again.  Please.

Posted in Health, Macro

America’s covid-19 testing fiasco

Investigative journalists and at least one think tank are putting pressure on the American government to improve our shameful coronavirus testing capability. There is a great article by Brian Resnick and Dylan Scott this morning about it with this new data:

The USA is in trouble because we have a LARGE population and almost no testing compared to the size of our need. Taiwan, by comparison, has done the best job preventing the crisis. They started disease surveillance and testing early, so they haven’t needed to do that much testing because they have very few cases even though Taiwan has the highest risk of exposure given it’s location and economic ties. Taiwan has done the best job of diagnosing infected people and keeping them from infecting others. That should be our model for how to prevent and slow the pandemic.

Brian Resnick and Dylan Scott‘s article also tells stories about Americans who need testing and meet obvious risk criteria but haven’t been able to get it.  Meanwhile, American politicians who had been denying that we have a problem were able to cut in line and get tested even though they obviously don’t meet the CDC’s criteria for testing.  With such limited testing capability, America needs better triage.

The conservative/libertarian think tank the AEI has also prioritized tracking America’s testing problem to help show that it is a problem that needs to be fixed. They are disseminating their findings on twitter and this is the current state of their investigation into the theoretical capability of American labs to conduct testing:

That is the claimed capability of America’s labs to conduct testing. It is pretty pathetic compared with what China and Korea and many other nations have been doing and worse yet, it is only a fiction. It is propaganda that is completely out of touch with reality. In TOTAL, since testing began in America last January, we haven’t even tested half what the AEI claims we are capable of testing daily. I know why politicians like Mike Pence have been putting out ridiculously rosy lies about our testing capabilities, but ‘m not sure why AEI is putting out this sort of propaganda.  It is useful to see how pathetic America’s theoretical testing capability is, but the AEI should emphasize that even our pathetically small wished-for capability is outlandishly inflated compared with our testing reality.

The Atlantic magazine has been tracking the covid-19 testing reality on a daily basis and the reality is that the US had only tested 8,900 people TOTAL as of yesterday.

The CDC shamefully stopped tracking how much testing has been done in America when Pence took over leadership of our pandemic efforts.  After a lot of criticism, they finally resumed reporting test totals yesterday and their current count is 7,288 (the numbers for yesterday).  Regardless of whether The Atlantic’s numbers are right or the CDC’s, either way, our testing shortfall is pathetic and will cause unnecessary suffering and deaths.

America’s testing snafu is why the disease is currently spreading more rapidly in America than in other nations we have data for:

At this rate, the US will be have the second biggest covid-19 infection after China within 10 days of any nation in the world.

Meanwhile, Trump’s big idea does what a successful reality-TV star does best: theater. His biggest announcement in his national address last night was shutting down travel with Europe. If that hinders our testing capacity by reducing international cooperation, it will make things worse.  It already caused the stock market to tank which doesn’t help anything.  It will do nothing the slow the pandemic in the US because our cases are mostly home grown already. He is shutting the doors after the foxes are already in the henhouse. And some hens are still outside too. It is the kind of dramatic, theatrical move that Trump understands better than any other politician, but it is a pathetically weak way of stopping people from bringing the virus. First of all, probably less than a thousandth of one percent of European travelers have the virus, so it is almost like shutting down all travel to prevent a tiny number of terrorists who might try to come to the US. It would make more sense to try to identify and stop the tiny fraction of individuals who might cause a problem than to stop the 99.999% who have legitimate and important reasons to travel.

Plus, anyone in Europe can just spend $30 and fly to Britain or Morocco or any number of other third nations and then get a free pass into the USA from there, so it does nothing to stop virus carriers from coming. It just slows them down by a few hours. Imagine using this policy to stop terrorists. It would have zero effect. It will have almost zero effect on stopping infected people for the same reason. To stop the virus, we need to identify the tiny fraction of the population that has the virus just like the only way to stop terrorists is to identify the tiny fraction of the population that are terrorists.

To stop the virus we need diagnosis and testing. Let’s focus our resources on that, not on the distractions of political theater.

Posted in Health

How the US should have responded to covid-19… For next time?

If you are scared of the coronavirus and you want to travel somewhere in the world to escape it, ironically, you might want to book a ticket to the Republic of China, more commonly known as Taiwan because Taiwan has demonstrated a way to effectively prevent the pandemic.

Taiwan is a capitalist democratic island nation (colored orange on the map) just off the coast of China (colored purple). Taiwan is completely independent of the communist Chinese dictatorship based in Beijing. Oddly both Taiwan and China insist in claiming that they are one unified country due to their shared history and cultural ties, and they are very economically integrated these days, but they have completely different political and economic systems.

Both nations are Chinese linguistically, culturally, and historically, and given their closeness and asymmetrical sizes, Taiwan has a lot of interchange with China (as predicted by the gravity model of globalization). Taiwan had more than one visitor from China for every ten Taiwanese residents just last year alone! Taiwan is simply flooded with Chinese people and probably the number of trips that Taiwanese people make to China every year is over 10% of the Taiwanese population too.  Heck, 3.7% of Taiwan’s population even has residency in China.

Taiwan is very densely populated with more people than the continent of Australia all crammed into an island that is about the size (and climate) of Florida, but unlike Florida, most of Taiwan is uninhabitable because Taiwan is full of steep, cold mountain ranges.

So if there is one nation in the world outside of China that should have the worst odds for getting the corona virus, it is Taiwan. It’s people live in one the highest population densities in the world and per capita it probably has more visitors to and from China of any independent nation in the world.

But Taiwan has only 45 corona virus cases total so far.  That is only about half the number in Australia and about a fifth the number in the Netherlands. All three nations are of comparable size and levels of economic development, so given Taiwan’s much higher risk of exposure, they must be doing something right.

Stanford Health Policy researcher Jason Wang wrote a new article in the Journal of the American Medical Association about Taiwan’s success and Kelsey Piper intervened him:

The most important thing about crisis management is to prepare for the next crisis. [Taiwan] started to do that. [in 2004, after the last SARS epidemic] They set up a command center, the National Health Command Center, and integrated different agencies.

It was a 24/7 command center. There’s the media room, there’s the data room where the data from different local governments could come in, there’s a place for people to rest, so you could actually sleep there. And so you get data analysts there, you have different experts there, you have people talking to the media, the information center, people managing logistics.

The lesson for the US is… We need to test people for Covid-19, and refer that data back to [a] command center so we have real-time reporting for action…

when there were only a very few cases reported in China, [Taiwanese health authorities] already went onto every airplane that came from Wuhan. Health officials came on the airplane and checked people for symptoms.

Here in the US and elsewhere, we’re now seeing community spread [people getting the virus with no international travel and no links to known cases, implying they were exposed locally by an unknown source]… And so now we’re trying to see, “Oh how many people should we test?” [Now] you really need to have a very large capacity [whereas] in the beginning [it would have been easier].

… They were testing on December 31. As soon as they heard there were suspicious cases of a new type of virus, they were nervous. They were like, “Oh, we wonder if this is SARS again.” And so they were proactive. I think that’s the way we ought to treat these kinds of epidemics. It’s okay to be overly cautious… You can relax afterward, if it turns out to be nothing. But when you don’t know what something is and how serious it is, you want to be very cautious…

The [public didn’t panic because the] government very quickly began hosting a press conference every day, sometimes more than once a day. They would tell people we’ve identified one case and then we’ve identified two cases, and they were all travelers from Wuhan.

…So we knew which ones were imported cases and which ones were domestic cases that were contracted from the traveler. You could track everybody. So then you’re not that nervous because you can say, “Oh yeah, she got it because it’s her husband. He’s case number 10, and she’s case number 11.” So you will know [for each case in Taiwan, how they contracted the virus]…

I think the US has enormous capacity that’s currently not being used. We have big tech companies that really could do a lot, right? We ought to get the big companies together. get the governors together, get the federal government agencies to work with each other, and try to find innovative ways to think about how to best do this. We’ve got the smartest people here in the US because they come from everywhere. But right now those are untapped resources. They’re not working together. And the federal government, the agencies, they need to collaborate a little more closely.

If you are able to pull the data together from all the states, and the federal government agencies are working together, then the big tech companies can help predict the next hot spot. So that’s what you want to do — you want to predict the next hot spot. And then just work on it…

We need to educate the public, communicate with the public a lot more… Because… If you ask [people where] there have been cases [near] their community, they say, “Oh, maybe, I don’t really know.” So you really need to have people be more knowledgeable — and look, it’s quite possible. For example, text people, and say, “There have been three cases where you live.” It’s quite possible, right? We all have phones, right? If there is some burglary, a fire, or something like that, I get a message, I get Amber alerts and all that.

Well, why can’t we create some alert system like that where you say, “Look, there’s been a hot spot in this mall. Try not to go there”?…

I wrote the article, so that other people could look at the list of 124 [action items that were elements of Taiwan’s response] and say maybe we could do these three or four.

And maybe, they should share with other people what other strategies work. This is a global epidemic. We all live in a global village. And we need to be more proactive because you can’t just be like, “Ah, we’re safe, we’re in the United States.”

Extensive testing has been essential to Taiwan’s success in limiting the spread according to Stanford Professor Jason Wang who said, “The authorities in Taiwan …also proactively find new cases by retesting those who tested negative,” and Kolas Yataka explained that the financing of testing, healthcare, and quarantine are provided for free to encourage testing by preventing financial burdens due to the illness:

“Taiwan’s health insurance lets everyone not be afraid to go to the hospital. If you suspect you have coronavirus, you won’t have to worry that you can’t afford the hospital visit to get tested… You can get a free test, and if you’re forced to be isolated, during the 14 days, we pay for your food, lodging and medical care,” Kolas said. “So no one would avoid seeing the doctor because they can’t pay for health care.”

In contrast, the news media in America is full of stories about the high cost of getting a coronavirus test.  A man in my home town of Newton, Kansas was reported today to have been charged nearly $1,000 for the test and others have been billed over $3,000.  Given that half of American adults said that they postponed or skipped medical care last year due to cost, many Americans might hide from testing because they are afraid that a doctor visit will cause financial ruin.

As Yascha Mounk observed, the only measure that has been effective against the coronavirus has been social distancing and there are two ways that can work.  Taiwan put extreme effort into screening and testing so that they haven’t needed extreme social distancing so far.  They had just isolated 2,291 people (as of March 1) while the individuals were tested until they could be cleared.  The contacts of the few people who tested positive were aggressively investigated. Because America has failed at testing efficiently we don’t know who has the virus.  So whereas Taiwan has limited the spread to very few cases and thereby limited social distancing, America will probably need extreme social distancing.

As a Homeland Security expert advises in The Atlantic, extreme social distancing will disrupt nearly everything:

If Americans conclude that life will continue mostly as normal, they may be wrong. The United States is far less prepared than other democratic nations experiencing outbreaks of the novel coronavirus. Low case counts so far may reflect not an absence of the pathogen but a woeful lack of testing. Disruptions are almost certain to multiply in the weeks to come.

China’s government has been ruthless in stopping the virus.  In contrast, Taiwan is a free democracy, not an autocratic dictatorship like China, so its success in limiting the spread of the pandemic is a model that other free democracies like the US could emulate.  It helps that they have a expert team of public health professionals running their pandemic response rather than a Vice President Pence (who is patently unqualified in health).  In contrast, Trump disbanded America’s pandemic response team.  And even if Taiwan did appoint their Vice President to manage the crisis, he’d probably do well because he has a doctorate in epidemiology from Johns Hopkins University!

The Trump administration took the unusual step of declaring the public health meetings about the coronavirus classified which meant that many scientists were barred because they lacked security clearance and the public cannot legally learn anything about what they decided in the meetings.  That is the opposite of Taiwan’s communication approach.

I’ll give you one more hint about Taiwan’s success. Taiwan didn’t achieve it’s pandemic success by keeping Mexicans out.  Today Trump tweeted that the wall is an integral part of his coronavirus crisis strategy. Trump’s ongoing obsession with travel restrictions has been a distraction from the hard work of pandemic preparation that he should have been doing all along.  Rather than investing in early preparation like Taiwan did, he tried to slash the CDC budget by 16% in the middle of the epidemic.

Taiwan has succeeded without closing schools and other extreme social distancing measures.  Here is a video of schools reopening after their long winter holiday.  Note that Taiwanese people have been wearing facemasks routinely in public for decades, mainly due to a myth that they filter out pollution, and the covid-19 risk undoubted increases that tendency, but it is pretty normal behavior for Taiwan.

Italy has had the worst response to the epidemic so far.  Italy went from only having three cases three weeks ago to the second most outside of China today and the virus continues to grow exponentially there and has paralyzed the country.

The US is probably going to look a lot more like Italy than like Taiwan partly because the US is:

severely lagging in its testing capacity. As of March 8, only 1,700 Americans had been checked for the virus — a number that pales in comparison to the 50,000 who have been tested in Italy or the 23,000 tested in the UK, according to an analysis by Business Insider

“Looking at all the signs, and there are many, it would be shocking to me if [the USA] didn’t have large numbers of cases undetected, silently transmitting in the community, in multiple countries and regions,” said Lawrence Gostin, a Georgetown University global expert.

If cases more than double every week — like they appear to being doing now in Italy — the US may soon be facing its own crisis.

“…if the virus had a chance to spread undetected, it’s hard to make up that time,” said Hodcroft. “The Italian situation should be a big wakeup call to the rest of Europe and the US.”

Posted in Health

How do people get the coronavirus?

There are two likely ways that infected people transmit the virus to infect healthy people.

  1. Mucus like saliva and snot. These are primarily expressed two ways:
    1. As droplets that spray into the air when people cough and sneeze. This is thought to be the primary way that people transmit the virus, but we don’t know for certain yet. Viruses have evolved to force your body to cough and sneeze uncontrollably. They have evolved to spread and reproduce by modifying your behavior!  The CDC thinks this is the main way that the disease is spread and although infected people can spread it when they are asymptomatic, the CDC believes that that is rare.
    2. Onto the hands (primarily) after touching the nose or mouth or after sneezing onto the hands. Again, viruses have evolved to force your nose to produce a stream of virus-laden snot that you will have the impulse to wipe away thereby spreading itself to your hands.
  2. Through poop. At least two studies have found the virus in human poop and many viruses and bacteria exclusively transmit this way which again can get into the bodies of new hosts via two main vectors.
    1. As droplets that are sprayed into the air by toilets or faulty sewage pipes. These droplets are then inhaled. A major outbreak in the SARS epidemic happened in a housing estate in Hong Kong called Amoy Gardens where over 300 people caught the virus via the fecal-air route.
    2. The fecal-oral route which usually means that people aren’t washing their hands completely after using the toilet. Almost nobody lathers soap over their for the full 20 seconds recommended by the CDC. Brian Resnick wrote a great explainer about why soap is “a brutally effective coronavirus killer.”  In countries without proper sewage treatment, most fecal-oral transmission happens when water sources are contaminated.

There are three main ways that you could get infected:

  1. Getting the virus on your hands (as described above) and then touching your mucus membranes like those of your eyes, mouth, etc.
    1. You prevent this by:
      • Washing your hands properly. Ordinary respiratory illnesses are reduced 15-20% simply by washing hands!
      • Stop touching yourself!  It is hard to avoid unconsciously touching vulnerable bodily openings such as on the face. One way to help remember to not touch your eyes and mouth is to wear ordinary cloth gloves. They should be laundered regularly to prevent them from becoming sinks of virus, but at least they could help remind you not to touch your eyes and mouth and food because it would be weird to feel the fabric of gloves on the face (or have it touch your food).  It is possible that the virus doesn’t survive as well on fabric as it does on skin, but we don’t know that yet, so if gloves don’t help you remember to stop touching yourself, then they probably aren’t worth wearing.
  2. Breathing in the virus of which there are two possibilities:
    1. droplets of virus-laden moisture.  This is thought to be the most common route of infection.
      • It is surprisingly easy to guard against breathing in droplets because they generally only travel less than three feet horizontally and they soon fall out of the air (where they can contaminate surfaces that lead to the next route of infection) and the Taiwanese authorities are recommending that everyone always try to maintain one meter of “social distance” from others. The CDC recommends that if you stay six feet away from infected people, you can nearly eliminate this risk. A surgical mask or cloth over your mouth and nose could help reduce this route of transmission, but droplets can still be inhaled if a mast is not well-sealed on the face and that is usually impossible with most designs because they aren’t designed to protect the wearer. Surgical masks are designed to prevent droplets from spreading from the people wearing the masks, such as surgeons, to others, such as their patients who have open wounds that are literally right under the surgeons’ noses in operating rooms. They are not designed to protect the wearer of the mask. But if someone gets sick, then by all means, they should wear a mask at all times to protect others around them.
    2. dried airborne viruses.
      • Moisture droplets rapidly desiccate in the air leaving the remaining solids such as virus particles. We don’t know if (nor how long) the corona virus can survive in the air after the moisture evaporates out of droplets, but if it can survive as a dry particle in the air, it would be very difficult to stop because it airborne viruses are so small that they can float on air currents indefinitely and only high-performance HEPA filters can screen them out of the air. Ordinary surgical masks are completely useless to stop dried airborne virus particles. In actuality, some airborne viruses are not completely dried out because the viruses form a little wall that retains a tiny amount of protective moisture around them, but the effect is the same. It becomes dry particles that don’t stick to the fibers of surgical masks and which are tiny enough to float on the air currents for hours or days. Airborne viruses cannot survive indefinitely, particularly when exposed to sunlight which typically kills them rapidly with ultraviolet light, but they only need to survive long enough for someone to inhale them back into the hospitable habitat of the lungs.
      • So far there is no hard evidence that airborne transmission is happening, which is good because it is very hard to prevent. You prevent airborne transmission by breathing outside air, using high-efficiency HEPA air filtration or staying out of buildings that share air with infected people.
  3. The oral route whereby the virus gets on your food, typically after hitching a ride on someone’s hands, but also possibly as a result of sneeze droplets that fall onto food.
      • You prevent this by properly washing hands and making sure your food is never around sick people after it is cooked.

Although a few bacteria and fungi can directly inflect people through unbroken skin, it is highly unlikely that the corona virus can. Most viruses die harmlessly after only about 20 minutes on the skin which is less hospitable to viruses than non-porous surfaces like stainless steel and plastic where viruses stay moist longer than on cloth or dry wood which tends to suck out the moisture which sustains them. So cleaning hard surfaces that people often touch could help. Be particularly aware of things that you touch frequently like your phone. It might be a good time to break that habit of using your phone while on the toilet unless you are going to wash your phone along with your hands afterwards.

Now would also be a fantastic time to quit smoking:

Among Chinese patients diagnosed with COVID-19 associated pneumonia, the odds of disease progression (including to death) were 14 times higher among people with a history of smoking compared to those who did not smoke. This was the strongest risk factor among those examined.

In fact, a HEPA air purifier to clean indoor air might even help. They can actually filter out some fraction of airborne viruses and even if that doesn’t help, there is some evidence that just getting rid of particulates in the air could help reduce the risk of respiratory infections, at least for people living in polluted areas.

Given that it is possible that people could get their initial infections through different organs, such as via the lungs or the eyes or the digestive track, it would be interesting to see if the mortality of the disease is different for people who are initially infected in different places on their bodies.  Most people who have died of covid-19 were killed when the virus invaded the deep lung tissues and if the virus were to initially infect the lower part of the lungs, perhaps it’s symptoms might become more severe and life-threatening than when it begins somewhere else such as in the digestive track and only later finds a way to the lungs after the body has already begun to develop defensive antibodies which could help protect the lungs which is the organ that is the most vulnerable to covid-19.

Julia Belluz has even more information and recent research about how covid-19 is spread.

Posted in Health

Mike Pence promised 1.5 million coronavirus tests by today. We only got 2,000.

Over a week after I first became alarmed at how shockingly inept America’s covid-19 testing has been, today I’m finally seeing a lot of journalists investigating the problem. As Brian Resnick and Kylan Scott report:

Here’s a big, discomforting fact about the current coronavirus outbreak in the United States: We have no idea how large it is.

We don’t know because the US has been extremely slow to roll out diagnostic testing for the Covid-19 disease. It’s unclear if there’s a specific policy or decision to blame for the current situation. It arose from a combination of manufacturing problems, chronic underfunding, and an apparent lack of foresight. But no matter the specific reason, the testing challenges, scientists tell us, make us less prepared to deal with this unfolding public health crisis that will probably get worse before it gets better.

“I think that we could have probably controlled this, if we had effective testing,” Angela Rasmussen, a Columbia University virologist, says.

Accurate testing is critical to stopping an outbreak: When one person gets a confirmed diagnosis, they can be put in isolation where they won’t spread the disease further. Then their contacts can be identified and put into quarantine — so that they don’t spread the virus if they’ve become infected, too. That’s particularly important for a virus like this one, which seems able to spread before people show symptoms, or when their symptoms are mild.

Better testing, paired with aggressive public health actions — like social distancing, isolation of those who are sick, and tracing those who sick people made contact with — can still help save lives in the United States.

But it starts with testing…

Evidence is mounting that early in the outbreak, in January and February, China bought the world time with its aggressive action to contain the viral outbreak in its borders. The testing fiasco in the US indicates we didn’t use that time well.

“There was clear lack of foresight,” Nathan Grubaugh, an epidemiologist at the Yale School of Public Health, says. “We were very slow to roll out testing capacity to individual places — wherever that came from, it was a very bad strategy.”…

Making matters worse, some people who have sought tests in the past few weeks have been turned away. And these shortcomings make it harder for the public health community to react to a virus that spreads quickly and easily.

Many people don’t really show symptoms of Covid-19, or their symptoms are very mild, but you want them to be tested anyway if there is an opportunity… As cases of Covid-19 in China were increasing dramatically in January and February, a lot of the US response was focused on travel restrictions and travel-focused testing. In retrospect, there should have been more planning for a pandemic… We don’t need testing just to diagnose sick people coming into doctor’s offices and hospitals. We also need testing to do surveillance out in communities. “You actually have to go out like now in many places in the US and start taking samples from people,” Grubaugh says… Again, without testing, we’re in the dark. And while we’re in the dark, the virus can spread.

The public relations effort of the administration has tried to focus not on actual testing, but on how many “test kits” will be produced. Pence promised that 1.5 million tests would be going out this week, but that is misleading in two ways. First, they won’t have but a small fraction of that number ready and second, the number of “test kits” doesn’t matter at all unless they are actually used and very very few have been used. The actual testing is what we need and it is still a trickle. For example, The Atlantic reported that only 1,895 Americans had been tested as of this morning after surveying the health authorities of all 50 states, the District of Columbia, and the federal government. This is embarrassing compared with any reasonable standard:

In South Korea, more than 66,650 people were tested within a week of its first case of community transmission… The United Kingdom, which has only 115 positive cases [compared with 322 in the USA as of now], has so far tested 18,083 people for the virus…

Normally, the job of gathering these types of data in the U.S. would be left to epidemiologists at the CDC. The agency regularly collects and publishes positive and negative test results for several pathogens, including multiple types of the seasonal flu. But earlier this week, the agency announced that it would stop publishing negative results for the coronavirus, an extraordinary step that essentially keeps Americans from knowing how many people have been tested overall…

It has not always been so challenging to get estimates of the number of Americans tested. Throughout February, the CDC published a regular tally of Americans who had been tested for the pathogen. Last Saturday, several days after the country’s first case of community transmission was confirmed, that figure was 472.

Then the agency stopped updating the tally… Since the CDC’s pullback, it has become extremely difficult to track the nation’s growing capacity to test for the coronavirus.

Today the CDC resumed reporting how many tests that they have performed after a week of negligence. In the week since they last reported testing, the CDC has performed only 1,102 additional tests.  And it isn’t like we couldn’t see the pandemic coming.  The US was one of the first countries to get the disease way back in the beginning of January:

COVID-19 cases in the United States by date of illness onset, January 12, 2020, to March 5, 2020, at 4pm ET (n=67)**

covid19

Because the CDC is woefully unprepared to deal with all the testing America needs, a few days ago the FDA implemented a new Emergency Use Authorization which allows labs across the country to begin testing without submitting for prior approval. Better late than never. Now several state public health departments such as California, Washington, and New York have already developed their own testing capabilities and state universities and private medical labs are also rapidly ramping up testing capacity. The Atlantic again:

As more laboratories join in the effort, quality control will become more difficult… These types of measures are necessary because the United States’ response to the coronavirus is far behind the spread of the disease within its borders. Testing is the first and most important tool in understanding the epidemiology of a disease outbreak. In the United States, a series of failures has combined with the decentralized nature of our health-care system to handicap the nation’s ability to see the severity of the outbreak in hard numbers.

Today, more than a week after the country’s first case of community transmission, the most significant finding about the coronavirus’s spread in the United States has come from an independent genetic study, not from field data collected by the government. And no state or city has banned large gatherings or implemented the type of aggressive “social distancing” policies employed to battle the virus in Italy, Hong Kong, and other affluent places.

If the true extent of the outbreak were known through testing, the American situation would look worse. But health-care officials and providers would be better positioned to combat the virus. Hard decisions require data. For now, state and local governments don’t have the information they need.

Whereas the US did a great job testing for H1N1 and Zika using exactly the same technology, the covid-19 test has had numerous errors. Some people have argued that the quality is so bad that it isn’t worth doing until the quality is fixed. But China used some low-quality tests in its massive testing program which missed up to half of sick people and it helped them stop the growth of the epidemic anyhow despite a 50% false negative rate. That’s because they caught half of the sick people on the first test. Diagnosing half of the people with the virus is a whole lot better than none. And they retested people as symptoms got worse or when there were other signs of risk which meant that they could get 75% accurate on the second round (assuming independent probabilities) and some information is clearly better than none. Plus they also used chest CT imaging which was more accurate than the PCR test which is what most people mean when they talk about testing. The combination of chest CT and PCR test gives useful information even when both are imperfect by themselves.

Americans may already be dying unnecessarily because our lack of preparation to be able to do adequate testing.

Posted in Health

Other countries can keep track of coronavirus testing. Why can’t the USA?

Here is a table from Karen Hustler showing how many people have been tested in a selection of nations. The USA is at the bottom of the list having done the worst job (as far as we know from the available statistics).

Even though most nations have been testing way more people than the US, they have managed to keep track of how many tests are completed. The US can’t even keep track of the miniscule number we have done! We were able to keep track for a month until Pence took over the leadership of the effort and now our government won’t say how much testing we have done. The only testing-related statistics that Pence and his officials talk about is the number of test kits that they have or that they will have soon, but that is irrelevant to the facts on the ground right now because the bottleneck has never been the number of kits, but rather the amount of tests that have been done. Is the testing problem fixed? We can’t know until we see some numbers.

So far the available evidence suggests that it isn’t fixed. First there is the fact that the government is touting misleading, irrelevant propaganda about test kits rather than about completed tests. Secondly, the case fatality rate (CFR) in the US is 7% which is over double the case fatality rate in the rest of the world at 3.4%. The virus probably isn’t more deadly in the US. The most likely reason that the US has such a limited testing ability that we have reserved testing for the most critically ill patients who are on the verge of death. That means we haven’t detected very many cases and the ones we have detected are the most severe ones.

Countries that have done the most testing like China and Korea have a much lower CFR than the world average and the countries with the least testing (like the US presumably) have the highest CFR. In China, as the amount of testing increased, the CFR predictably declined because more and more people with less symptoms were detected as carrying the disease.

The failure to fix the testing problem is just one more sign of the failure of leadership in America in response to this crisis. Instead of fixing the problem, our leadership is denying that it is a problem and hiding information about it and our media is letting them get away with it so far.

Call your congressperson and ask them to pressure the White House to fix the problem and keep calling until they give us evidence that verifies that the problem has been fixed.

Posted in Health

Enter your email address to follow this blog and receive notifications of new posts by email.

Join 59 other followers

Blog Archive