Read the Footnotes

Britain is saying some form of lockdown for 9 months. They are a little behind us, but they are saying it will take 3 months to reach peak once the lockdown and that they won't start for another couple of weeks. They will likely increase international travel at the point that on average the US population has equal or greater herd immunity and equal or greater presence of infectiousness. The breakpoints for some of these decisions are probably something like 40% and 60% herd immunity. That will take time and suffering.

Unbelievable. Dalal, I hate to break it to you, but this is the USA's plan too. Britain is being honest. Trump is giving us bread and circus. I suggest you listen to their plan if you want to know what the true plan is here. It's the best we can do given that the federal gov't squandered what time we have. All they can do is try to manage the rate at which people become infected through social distancing. You are thinking about testing from the perspective of the individual. At this point, it's about the herd, not the individual. If I had to choose who would do better? All else equal, the country that communicates honestly, openly, clearly and with one voice would get my vote. On the federal level, My money is on Britain for having better outcomes.

25th Amendment. NOW! Commentator David Brooks makes a pretty solid argument for the removal of Donald Trump in this piece from tonight's PBS Newshour. I would be pretty comfortable with Pence for the next year. I could imagine the cabinet and democrats supporting it. They are mostly in a high risk category and right now Trump seems to be playing Russian roulette with their lives. Many of the cabinet and Congress likely have almost a one in six chance of death based on their age and likely co-morbidity risks. For some of them this virus is likely not that much better odds than Russian roulette with one round in 6 chambers.

not interested in politics now. thanks. Please move to the politics board.

My belief is way may have the Oversight Committee, specifically a REPUBLICAN member, to thank for this happening. He called them out on this. The fact that the administration could not make this happen over months, and it could be that it was done within hours after a Republican committee member to asked some tough, embarrassing questions, is an absolute embarrassment of the Trump administration's management.

Never say never but I don't think they will. I don't think they closed any special days from 2007-2009. Most people seem to be thinking about closure in terms of volatility, but there are other risks. In many pandemic simulations that I have read about, markets or the banking system have become dysfunctional at best. So that is certainly a possibility that planners worry about. I think it is a low probability event in this case. In this particular instance, I think the biggest risk is that about 75% of the US population don't believe much of what comes out of Donald Trump's mouth in the best of times. His poor handling of this situation is probably undermining the confidence of many people who trusted him in the good times. If it was just his political opponents who didn't trust him, that would create less risk, but his own supporters know that what comes out of his mouth has little basis in fact. His supporters were willing to overlook that in the good times, but in the bad times they will worry about themselves and that will increase risk to the financial system. Also don't forget that hurricane Sandy and 9/11 both resulted in the markets closing. SARS 2.0 has more in common with those than 2007-2009 in terms an ability to shut the markets from real world disruptions. Weeks ago banks starting moving staff to their back up disaster locations, separating out different functions, creating redundant teams, etc. So they have been preparing. Assumptions are that without interventions, 40% of the workforce could be out at anyone time. Flattening the curve will help ensure essential functions and the function of the markets. Finally, we shouldn't ignore the risk of disinformation, cyber attacks, etc. Frequently cooperation increases in times like these and countries tend to focus on their own problems too. I have seen some troubling behavior among foreign leader in the past couple of weeks with MBS being among the first to come to mind, but hopefully those risks are low.

not interested in politics now. Thanks.

Bingo. They have to work to maintain critical infrastructure including secret service, military preparedness, etc. None of that will be telegraphed to us. Thank you for your comments. The timing of May makes sense. Some areas of the country have more time to prepare than others. There will be major geographic differences.

I haven't listened to the whole thing because I'm not that in to podcasts, but this podcast supposedly does a good job of explaining how China and Korea's successes depended on testing. https://www.nytimes.com/2020/03/12/podcasts/the-daily/coronavirus-pandemic.html

But this is one of the most important thing we can do - to buy as much time for both research into treatment, and to ease the burden on the healthcare system. In addition to treatments and vaccines, there are a couple of things that people have not mentioned: 1) Standard of care will likely improve over time and a delay could make a difference. In each new area doctors are being quoted saying "I didn't believe the reports were accurate" or "I've never seen anything like this" or "we have no idea what to do" or "it turns out ____ is true after all". None of those are things you want to hear a doctor say when that was so easily fixed through communication and time. I'm not quite sure that I quite understand this one. Are you positing that a better treatment might be developed (eg, the use of HIV antivirals), and therefore if you are forced to choose, you'd be better to catch Covid in October rather than April because you will benefit from cumulative learnings? This is definitely a large threat. IMO, the focus should have shifted weeks ago towards developing contingency plans for temporary facilites. I am really hoping that my province has some sort of plan to close down schools and convert them into temporary Covid clinics. But is it happening? Who knows. We are banging away on the politicians about testing and travel restrictions, but I don't seem much banging being done about developing surge capacity. If you were a 70 year-old retired doctor or nurse and you took the time to pull up the morbidity and mortality numbers by age group off of the WHO's website (or other websites) would you come out of retirement? If I were 70 years old, I'd be trying desperately to dodge this one... I am guessing that, as a group, retired health professionals are not in desperate need for an extra $10,000, so it's a bit hard to imagine that they would be motivated to expose themselves to a bunch of sick people. Responding to your responses: 1) Exactly: a) I would hope to do everything I can for myself and anyone I can tell to delay getting it. Especially if you're in a risk group. Remember some of us might not realize we have underlying commodities. b) Also, check the probabilities of risks other than age. Statistically, hypertension, diabetes, smoking is about as bad statistically as being 70+ years old. c) If you smoke, quit immediately. Smoking kills your cilia, which appears to be the same primary method of action on COVID-19. d) Also, eliminate all risk during periods you suspect your local services will be overwhelmed. 2) Agreed 3) I have heard from many people in North America that their hospital colleagues were oblivious, or actively denying the threat. We are just seeing tents put up in many cases. I haven't spoken to anyone that is starting to reorganize their hospital or change schedules. Most have already had protocol discussions, some specialty hospitals haven't even done that. I am not speaking about backwater locations. Some backwater places have discovered they are more connected than they realized and were completely unprepared. 4) Yes, that could be an issue, but: a) unlike finance the psychopaths are usually concentrated in a limited number of specialties. Volunteers and conscripts will probably be more common in other countries that are showing a more coordinated response and preparation. At risk workers can be assigned to low risk duties. Remember, there are still going to be people getting in car wrecks and chronic conditions aren't going away either. b) There will be heroes all over the world. China doesn't have a monopoly on heroes.

But this is one of the most important thing we can do - to buy as much time for both research into treatment, and to ease the burden on the healthcare system. In addition to treatments and vaccines, there are a couple of things that people have not mentioned: 1) Standard of care will likely improve over time and a delay could make a difference. In each new area doctors are being quoted saying "I didn't believe the reports were accurate" or "I've never seen anything like this" or "we have no idea what to do" or "it turns out ____ is true after all". None of those are things you want to hear a doctor say when that was so easily fixed through communication and time. 2) Healthcare providers are already getting infected and quarantined. Estimates are that without good management 40% of healthcare providers could be sick at the same time. At that point, ventilators and beds will no longer be the bottleneck in the system. 3) Temporary facilities can be erected, equipment repurposed, procedures rescheduled, etc. 4) If 40% are out sick (which is also a typical rule of thumb) then we would typically try to draft health workers out of retirement and issue them temporary licenses, which takes time. And given that they are likely in the high risk category for this virus (sometimes it is the young or the particularly fit instead who are at risk of death due to cytokine stormc) that may not be as good of an option.

Korea is spending less than $15/test. Korea's tests are provided by Roche. In testimony before the oversight committee yesterday, the CDC head was loathe to acknowledge we could likely have just bought the test from Roche, or even who the maker was. Eventually he mumbled some stuff about Roche and having to get back to them.

How long did that take? Is now the time to do this nationwide? Should Trump issue that recommendation to all governors? Or is that an overreaction? Some local people where I am are acting like idiots and not taking it seriously. In these situations you don't want people to panic, but there are plenty of people who still are anchoring to the "it's just the flu" statements from weeks ago. Maybe we have not yet reached an appropriate level of fear.

I agree with you in spirit, but take a look at my post above and tell me if I'm missing something. I think we're just a bunch of blindfolded analysts feeling around an Elephant. Orthopa may have just been too busy hanging around down there by tail to get around and explore the other parts. I don't think your post (which is good IMO) contradicts what Schwab711 is saying. The problem is that we cannot prove the "more testing does not help" people wrong, since we don't have two parallel universes where US tested in one but not tested in another and results are clear. We can point to S. Korea, but the answer from no-testing-benefit camp is "but that's not US... and they all gonna die/recover anyway". I don't think it contradicts what what Schwab is saying. I wholeheartedly agree with Schwab. Orthopa has told us he is an ER Doc. His job is basically to stabilize patients. To the best of my knowledge he's not an epidemiologist, or specialist in infectious diseases, or a specialist in infectious disease surveillance. There is a fascinating literature on the difficulties of infectious disease surveillance. Statistics nerds will enjoy a trip down that rabbit hole. The problem is that the sample size tends to be too small for each individual doctor. When the data is aggregated and in the hands of a specialist, that helps a lot. Frequently in the past, we have gotten lucky when several otherwise healthy patients with severe, troubling illnesses present to the same doctor with the same symptoms at the same point of progression at roughly the same time. If you don't have a lot of those qualities present at the same time, a single individual will usually miss the signs of an outbreak because the number of observations is too small to catch their attention. In Orthopa's case, if he does not take this seriously enough it could be because he does not believe the reports of disease progression from China or elsewhere and is discounting the risks if 15% of his patients return in three weeks with serious symptoms and the population is doubling every three to four days or less.

I agree with you in spirit, but take a look at my post above and tell me if I'm missing something. I think we're just a bunch of blindfolded analysts feeling around an Elephant. Orthopa may have just been too busy hanging around down there by the tail to get around and explore the other parts.

I have said it before, and I'll say it again. I think it is very easily explained that there are multiple sides to this and each side is right. I'll explain in a moment. First a question. Orthopa, what percentage of the beds in your hospital are available on an average day? What about ventilators? Also, how many total patients have you personally seen that you believe have COVID-19? Were any diagnosed as COVID-19? I just called the hospital and talked to the charge nurse on each floor. Hospital is ~ 85% full but that is very fluid and changes by the hour as people are admitted and discharged. Ventilator only used in ICU. 80% full. Don't know any of the diagnoses though. Now mind you this is a suburban hospital in town with 9 other hospitals within 20 miles. That could vary in each one. In that data I suggested I saw 165 of those patients. None were tested for corona. All in the group looked at were diagnosed with viral illness. Thank you Orthopa for the response and for going above and beyond and getting us up to date numbers. Orthopa's stats match what I have heard from numerous doctors around CAN and USA. First a note in case anyone is incredulous. Many doctors I spoke with said they tend to operate close to 90% all the time. From operations management, you might think that operating at 90% sounds insane and you never want to operate at that level, but the real limiting factor under normal conditions is the practitioner error. Under the best case scenario, you want your doctor to seem mildly bored or slightly engaged. The best case possible is that your doctor is skipping to work and experiencing flow, but has seen it a million times. If you think of things that way for a while operating at 90% capacity starts to make more sense. Here's a simply capacity model using the numbers Orthopa provided to us: If we adjust the number of beds and ventilators to reflect the actual capacity rather than the total number, things make more sense. Inputs for the USA: 2.8 beds/1,000 people 333,000,000 total population 20 full featured ventilators per 100,000 people Orthopa's Utilization Rates: 85% bed occupancy 80% ventilator utlization Experience in China: 15% were hospitalized 5% were put on ventilation American Hospital Association Assumptions: 5% of cases require hospitalization 1% require ventilatory support Simple point estimate of capacity: 2.8 beds/1,000 people * 330,000,000 total population = bed estimate for the USA = 924,000 beds in the USA 15% free X 924,000 beds = estimate of beds currently available in USA = 138,600 beds available 20 ventilators/100,000 * 330,000,000 total population = ventilator estimate for the USA = 66,000 total full featured ventilators 20% availability rate of ventilators * 66,000 total ventilators = 13,200 available ventilators Using Experience in China: 138,600 beds available/15% hospitalization rate = 924,000 cases before we run out of beds 13,200 ventilators/5% on ventilation = 264,000 cases before we run out of beds (this is not good and US have more per capita than most) Using Experience in China and Orthopa's utilization rates: 138,600 beds available/15% hospitalization rate = 924,000 cases before we run out of beds 13,200 ventilators/5% on ventilation = 264,000 cases before we run out of beds (this is not good and US have more per capita than most) If we have 1,319 cases as I write this and the number is doubling every three to four days, how long before we have 264,000 cases? What if today's real number of cases is more like 20,000? We will be above the number of cases in which we would have to ration resources in less than three weeks. Now why wouldn't this look bad at this point from Orthopa's perspective on the front lines? If he has seen 160 cases so far, and it is doubling every three to four days, then three weeks ago he would have seen less than 20 COVID-19 patients. With serious cases representing 15% of cases and serious cases frequently taking multiple weeks to progress to hospitalization, it becomes very believable that Orthopa has seen 165 diagnosed COVID-19 patients, none of whom have required hospitalization, yet. This simple model would indicate he only saw his hundredth patient within the last week, and that 88% of the patients he has seen were not in that cohort of the first 20 I mentioned who have had the most time to present with serious cases. I think this makes explains why it is very believable that Orthopa is seeing lots of COVID-19 patients. That they will increase every day, and that in a couple of weeks, Orthopa's hospital and surrounding hospitals may be overwhelmed with returning patients who have deteriorated very quickly. Reports are that this disease progresses very slowly compared to the flu. Being sent home doesn't mean that a number of them wont return very ill in a few weeks. I'd be interested to see someone else play around with growth rates patients, and play around with other assumptions. I provided the AHA's assumptions from a presentation. Feel free to use other assumptions.

For Trump's sake, I hope that doctor wasn't lying about Trump's health. On Monday, Trump met with someone who has tested positive. Governor Rick Scott of Florida and the Mayor of Miami announced self-quarantines as a result of meeting. https://www.nbcmiami.com/news/local/florida-sen-rick-scott-in-self-quarantine-after-potential-contact-with-brazilian-official/2204541/ Hopefully Trump will set a good example for the country and self-quarantine.

I have said it before, and I'll say it again. I think it is very easily explained that there are multiple sides to this and each side is right. I'll explain in a moment. First a question. Orthopa, what percentage of the beds in your hospital are available on an average day? What about ventilators? Also, how many total patients have you personally seen that you believe have COVID-19? Were any diagnosed as COVID-19?

History shows that a second wave is all but guaranteed if controls are lifted too early. Hopefully decision makers around the world have good models and good data and will make decisions for the right reasons.

This is well done. Thank you for sharing.

Based on the number you listed, if there are 2.8 beds per 1k people, there would only be around 1m beds in total. Where did you get 4.6m beds from? Thanks for finding the typo. That should have read "without exceeding capacity, we can have at most 4,620,000 people sick simultaneously". That is 5x the number of beds, which as you stated is just under 1 million, using the estimate of 20% hospitalizations. I think my writing regarding ventilation was bit more free of typos, and hopefully more clear. Of course the assumption that there are tons of empty beds and excess ventilators is a bit ridiculous, but is easily dismissed because if we are in trouble with unreasonably optimistic assumptions, we will be in trouble with more realistic capacity assumptions, which is now consistent with messaging pretty much around the world.

Could you share the logic please to those who are less informed? :) If you've studied operations management or even just managed a team or operation, you will know that you want to focus on the bottleneck. As soon as you eliminate that bottleneck another will appear, so then you need to deal with that. So a fast way to identify that we could have a problem is simply identify the bottlenecks and then see how easy it is to exceed capacity. Obviously the easiest healthcare capacity numbers to come up with are aggregate numbers for the whole country and things will vary a lot by region, but capacity is so easily exceeded that doesn't really matter (even those making television appearances for the Trump administration have started saying that in the past 24 hours). Here's a logic problem that's even faster. Another way of looking at it is that the USA's population is growing and healthcare capacity has been declining, in large part due to legislation and administrative action or inaction. The USA has less capacity per capita than China or Italy. China is historically ground zero for this type thing and has more experience with it than the USA. Why would we handle it better than them and what are the odds of that happening? P.S. The WHO finally declared it a pandemic. Got it, thanks. I thought you were talking about the modeling that SJ was referencing, so was curious to see if there was another approach. Appreciate you typing it out. I found my previous relevant posts from a few days ago. It will give you a point estimate. The important thing to note is that many hospitals have gone bankrupt in the past three years, or have been shutdown due to the removal of subsidies. Some have extra capacity, some have a lot of elective procedures, many today are operated toward maximum efficiency during the good times and cannot easily generate extra capacity. Keep that in mind when you read the comments below. https://i.insider.com/5e62a449fee23d58c83a9e62?width=1300&format=jpeg&auto=webp

You weren't asking me, but I will answer anyway. 1) If there were 1,000 undetected cases in the USA 4 weeks ago, some of them could have easily presented to the hospital by now. Since our healthcare system would have been functioning extremely well, they would have received excellent care and the chance of any of them dying would be less than 1%. So even if it is possible that there was 1,000 cases a month ago and severe cases had enough time to progress to death, we would expect to see less than 10 deaths at this point across the entire nation of 370 million people. Plus doctors who know that they are dealing with COVID-19 are flummoxed by how to respond. What are the odds that it catches their attention if they don't realize it's COVID-19? 2) There will definitely be a wide range of regional outcomes and population density is just one of many factors that will influence it. Wuhan is definitely on the less desirable end of the distribution of population densities if you're shopping for a nice condo with a low chance of epidemic. 3) There are believed to be two different strains already with differing virulence. But the most important thing to understand is the bimodal distribution of outcomes depending upon whether local hospitals are overwhelmed or not. A system that could have a CFR < 1% in the best of times, could have a CFR of 15-20% during the worst of times.

Could you share the logic please to those who are less informed? :) If you've studied operations management or even just managed a team or operation, you will know that you want to focus on the bottleneck. As soon as you eliminate that bottleneck another will appear, so then you need to deal with that. So a fast way to identify that we could have a problem is simply identify the bottlenecks and then see how easy it is to exceed capacity. Obviously the easiest healthcare capacity numbers to come up with are aggregate numbers for the whole country and things will vary a lot by region, but capacity is so easily exceeded that doesn't really matter (even those making television appearances for the Trump administration have started saying that in the past 24 hours). Here's a logic problem that's even faster. Another way of looking at it is that the USA's population is growing and healthcare capacity has been declining, in large part due to legislation and administrative action or inaction. The USA has less capacity per capita than China or Italy. China is historically ground zero for this type thing and has more experience with it than the USA. Why would we handle it better than them and what are the odds of that happening? P.S. The WHO finally declared it a pandemic.

sorry to hear that. Do you know their ages? Both in the 50s. @Muscleman , very very sorry to hear. Reoccurring infections have been reported in China (my wife told me about it) and so far seem inexplicable and scary. Probably different strains of the Virus ( solely my conjecture). Thank you for contributing, Muscleman and sorry for your continued loss due to this terrible illness. Stories of reinfection, and stories of lung damage are very concerning and are probably not factored in to most people's mental models.