Cigarbutt

Coronavirus-related news are moving away from headlines, a trend that will likely accentuate overall, despite occasional bumps and absent significant other waves. So, underlying secular trends will continue to play out (global trade, interest rate and debt levels, inequality, institutional erosion etc), integrating what the virus meant for the various hosts and their associated risk factors. It may be a good time for an interim post-mortem and, for those interested, the following paper is quite long but does a reasonable job covering various interesting topics (parallel with 1918 flu epsiode, how regional mortality variations can be explained, effects on fertility, in utero scarring phenomenon suspected after the Spanish flu waves, economic impact, legacy etc). https://www.nber.org/papers/w27673.pdf i would say the utero scarring phenomenon is unlikely to happen from Covid-19 (at least the physical scar) because of various central interventions but the type of institutions that the US still has in place showed that the net effect on functional and effective public policy was mixed. So far, The U.S. has conducted more than 73 million tests (which attests of the great productivity potential) and about 6 million of them have come back positive (which suggests that quality may be more important than quantity sometimes). A summary of the paper can be found in the following graph that is based on the paper with additional data: The graph shows how relatively irrelevant the Covid peak will look like at some point and there is an unusually high overall correlation with the evolution of interest rates. In The Trouble Wtih Prosperity, Mr. James Grant quotes the 19th century economist, Eugen von Böhm-Bawerk who "pronounced that a lower the country's interest rates, the higher its intelligence and the sounder its character." As we're getting back to an ever changing new normal and as we will eventually re-learn how to fail, i submit that the great Austrian economist forgot that a good idea could be taken too far. Some key variables include the presence of risk factors in family members and level of active community spread during opening. All my kids are going back to school but they are relatively older. There is a CDC study that was mentioned above in this thread concerning the risk to younger children. In my area, just like in many other jurisdictions, elementary schools re-opened for a few weeks at the end of the last academic year in most non-urban regions where the community spread was low. There were pockets of resurgence but it was manageable. i happen to think that the cost of school closures, at the population level, is colossal, to use a qualifier mentioned in a title made by The Economist (July 18th edition), a one-page article that is interesting and relevant.

This exchange (my perspective anyways) was very useful and this has become mostly a half-empty or half-full kind of residual question. Thanks. -Historical part The BCS float portfolio's main goal was to match redemption liabilities. The idea is to be in a situation to be able to hold the security (bond or equity) to maturity or for a long time. The equities held had a different risk-return profile (less risk and less return) but the overall float portfolio was a significant contributor to the recurrent annual investment income line and (it seems to me) Mr. Buffett waited (he had the flexibility to do so) until markets recovered after the 73-4 downturn before selling excess float stocks. It became clear then that the redemption liability was on its way to oblivion and those associated (100% association if you insist on that notion) float stocks had their future defined. i would submit that many people don't fully appreciate the genius investment (and the way the transition was handled) that BCS was, despite being literally a target of various lawsuits and dying business model. -Contemporary part If you were responsible for the 100% liability portfolio at BRK now, how would you deal with capital allocation? (would you allocate a portion to gold? :) ) i wonder if one could imagine a float portfolio composed of a significant amount of regulated return equity positions (energy, utility, infrastructure) bought at reasonable prices in exchange for worthless cash, with the intention to hold forever, with the value of the regulated entities growing with the insurance float. Some kind of permanent virtuous circle, of lasting legacy. After all, BRK started out as a textile mill operation.

Let's leave the spacious fiscal room and MMT concepts aside for now (there is a separate contaminated addition inserted at the end) as negative interest rates have entered the territory of casual conversations. --- Two aspects i disagree with concerning the possibility that BRK could become, to some degree, a leveraged (both debt and especially float) play again. On the debt aspect, BRK has used debt opportunistically in the past, under various scenarios. For example, in the early days, Diversified Retailing carried high debt and Blue Chip Stamps (BCS) also, as mentioned above, used debt. While BCS used See's, then Wesco and marketable securities as collateral for the debt, money is fungible and it's helpful to look at the overall picture. BCS, over time, lost its primary stamp mission and became a conglomerate soup, so, for this part, i'll focus on the years 1970 to 1976. Here's the debt to equity ratios for those years: 1970 0.31 1971 0.25 1972(Mr. Buffett appears) 0.94 1973 0.76 1974 0.84 1975 0.10 1976 0.09 In 1972, BCS acquired See's for 25M and debt increased by 32.8M but common stocks in the float portfolio increased also by 45.4M. At that time SE was 46.4M. Up to and including 1974, debt remained high as a % of equity. It's not clear why Mr. Buffett drastically decreased leverage starting in 1975 at BCS but financial leverage was clearly part of the picture for a few years. On the coverage of redemption reserves from "investments", it looks like the float liability measures are comparable but the table you use for "investments" is, on a first-level analysis, like comparing apples to oranges. On a second level, it's like comparing lemons and oranges (explanations below). The major issue is that the Brooklyn Investor site uses cash, cash equivalents and fixed income for 'investments' and your table uses a different definition (same + preferred and common stocks). Here are the adjusted ratios with common stocks removed from the BCS total (preferred stocks included) "investments": 1970 0.98 1971 0.97 1972 0.68 1973 0.42 1974 0.40 1975 0.07 1976 0.35 Some comments. Bonds decreased in 1972 and disappeared after. 1975 appears anomalous as the total float decreased significantly but liquid investments decreased a similar absolute amount as common stocks and financial leverage decreased concomitantly. The most important message is that the coverage of liquid investments and fixed-income-type over float decreased significantly during those reported harem years. There are two factors that help to mitigate some of the decrease in "coverage". First, in those years the common stock portfolio was not exactly composed of nifty-fifty-like holdings; it was a group of "safe" stocks. However, the holdings had equity-like characteristics and it showed, at least temporarily, during the 1973-4 downturn. Second, as you mention, the redemption liabilities, over time, became detached from economic reality so a 1:1 coverage was certainly not essential as future developments eventually showed that the redemption liabilities had been adjusted perhaps too slow, giving rise to some IRS questions and to BRK leaders to dragging their feet for as long as possible. Anyways, during those years, i think it's reasonable to say that the float assets were heavily exposed to stocks. As time goes on, the cash flows become difficult to differentiate as See's was growing significantly but an argument could be made that, BCS, as an investment vehicle originating with significant float, was still a driving force behind the growing Wesco investments etc. In addition to historical interest, what's the point? The point is that BRK has become big and the Fort Knox doctrine is in place so financial leverage is unlikely to become speculative but, given the right assets (ie utility, infrastructure-related), leverage could be part of the picture. The other point is that all this cash and short-term fixed income $ may not be all "worthless" and, given the right circumstances, may hold significant optionality. --- Useless macro addition. Just skip. Japan is sort of a leading light along this low or negative interest rate path. For some time, they've (the central bank) been using a negative rate for some of the cash that the banks park centrally, with the idea to "force" money in circulation for productive purposes, with a euphemistically limited success. With Covid, somebody in the ivory tower recently came up with the idea to pay banks a certain rate in order to encourage lending. The amounts happen to cancel each other. i'm just a noob but it appears to me that the net result should be neutral. No? Well no, after this new creative measure, loan growth has never seen such a rise since 2001 and this is occurring during a massive contraction. Amazing? https://www.reuters.com/article/us-japan-money-boj/boj-paying-banks-to-boost-pandemic-relief-compensates-for-negative-interest-rates-idUSKCN2590SM Anyways, i don' remember seeing Mr. Buffett agitated but he appears to be suppressing a level of excitement that he last openly showed when he made the harem remark: ---

Here is some feedback (and critcism). :) 1- The tax issue is interesting. i guess you'll have to differentiate what you think should be the rate and what it will be and we might as well stay out of this conversation. 2- The basic and fundamental issue is a recurrent theme and is related to the argument about the extent of discounting of the reserves one should apply (and by logical extension, if applicable, what premium on book value to apply with acquisition) when float is expected to grow profitably. So an argument could be made that the pre-tax multiple you are using is too low for the expected performance at BRK insurance subs going forward, in terms of the cash slows that will eventually be generated. 3- You seem to rule out the possibility that the "coverage" of liquid investments to float moves away from 1 (below 1). There is a possibility that this ratio could come to 0.8 or even lower going forward, given the right circumstances. IMO, there is an unrecognized option value on this variable liquidity. On this Board, it's sometimes mentioned that people would use relative valuation in real downturns (those used to happen before) ie they would sell stuff like BRK which, in theory, would resist better in order to buy more undervalued securities. For BRK, this would imply to sell fixed income securities almost guaranteed to maintain (real) value (cash, cash-equivalent, extremely low duration US government debt securities) under any circumstances in order to buy securities on sale. That would certainly act like a multiplier on the change of the "coverage" ratio. 4- You seem to assume that the fixed income part is non-interest bearing and will always be. While this is basically true now, as Mr. Buffett's cash (0 duration) and fixed income (low amount and duration) positions point to the very least as a protection against rising rates (the new Barrick Gold would support this hypothesis as the appearing point of the iceberg), the fixed income side of the portfolio may become a very reliable and enduring source of additional returns on capital. You don't seem to comment on Fairfax but i would say that the historical return on the fixed income part of the portfolio (at least up to the recent period and even if not generally recognized by the investing community) has been a large contributor to the return on equity over time and this could become the case also for BRK if the risk-reward profile becomes favorable. Also, the fixed income portfolio of an insurance firm is a form of a leveraged bond fund. In conclusion, i submit that your 100% non-working capital assumption is too conservative.

Part I ^^High percent positive tests, holding everything else constant, are closely related to the number of deaths projected to happen in the short term. High and rising is a poor indicator if population survival is the aim. Along the same line of reasoning, low and decreasing is the ideal combination. For reference only, current reporting (7-day average) shows a steady low 0.8% in Canada. There appears to be growing test fatigue and the US percent positive rate is still high but declining so there's that. if interested, the following gives a consensus and balanced view on the meaning of the percent positive test results: https://www.jhsph.edu/covid-19/articles/covid-19-testing-understanding-the-percent-positive.html For those who are curious to figure out why the rising testing has not been 1:1 correlated to rising mortality, the following image is instructive. It's from the CDC and shows the commercial testing results. The public health testing is much less significant in numbers but the overall trend is the same. The number of tests in the 18-49 group has gone up significantly which has relatively low impact on the aggregate population outcome (in my province, a 19-year old just died so one has to be careful with population numbers) but there is an unfortunate associated rising percent positive test in that cohort that is closely associated to rising percent positive results in other cohorts, ages 50-64 and 65+ (and therefore higher number of absolute cases with more tests based on simple arithmetic, so given the age-specific CFRs, one can figure out the price to pay resulting from the policies or absence thereof). The CDC also disaggregates the numbers according to race and socio-economic status but it seems this post has enough data as it is. Hint: Well-to-do folks working from home tend to do better. ---------- Part II In seemingly unrelated news, there's been an unusual interest in convalescent plasma lately but the usual process again is being disrupted for the wrong reasons. Isn't this supposed to be about sequential learning? https://www.nature.com/articles/d41586-020-02324-2 Trying to connect some dots between part I and part II, i wonder if this explains that.

Why use worse-case scenarios when trying to define a gold standard? ... covid one-third death rate of flu in Texas. so hard to understand? Saw that Texas has tragically passed 11,000 covid deaths. Reminded me of this b.s. that you and Abby were spreading a month ago. As the 'story' is evolving, the Texas data is interesting if, for instance, one tries to compare the coronavirus toll to a normalized flu toll. Reminder: most would agree that whatever population immunity concept one adheres to, the Texas population had much lower natural immunity potential to CV compared to the flu and the gap hasn't likely been bridged in a way that would apply under old normal circumstances. Flu mortality trends in Texas, much like the US generally, have been moving down. In some quarters, this is called progress. https://www.livestories.com/statistics/texas/influenza-flu-pneumonia-deaths-mortality The 2017-8 year came with much higher numbers (about 11k deaths, with significant impacts on various population subgroups) but this seems to be an outlier season as it appears that the 2018-9 came back to previous trends. When comparing excess mortality patterns (including the excess in 2017-8 and the slowly crystallizing picture for Covid) for Texas (CDC link mentioned several times above) and integrating a multitude of credible sources of data and analysis, Texas is likely a state that has been, so far, reporting the highest gap between deaths attributed to Covid and total excess deaths. At this point, the evidence points to a 'severity score' of Covid to normalized flu in Texas of about 4 to 8. While it is true that it could have been worse, it's hard to consider these results as a great 'success'. ----- This morning, we listened to the official virtual announcement of our school with our 13-year old. We took notes and i thought about the cost-benefit equation. On the negative side, because of grouping strategies, most enriched classes have been curtailed and the school has suddenly become much less productive. Another negative aspect was the realization that zoom meetings (with other parents) with "chat rooms" for questions have not reduced the number of irrelevant or even stupid questions, in fact quite to the contrary.. For those interested into the question of ongoing community spread when younger cohorts go back towards normal activities: https://www.cdc.gov/mmwr/volumes/69/wr/mm6934e2.htm?s_cid=mm6934e2_x

i wonder if you mean The Innovator's Dilemma by Mr. Clayton Christensen, a rare example of these theoretical books that use real-life examples and that can find practical implications for specific investment theses (long term moat point of view).

Interesting, as always. From the link: "It is amazing to think it was above 100% before the Gen Re merger. BRK back then was a leveraged play on Buffett's stock-picking skills, and any investment in bonds offered free incremental points on ROE above all that. No wonder why returns were so high back then." "So, this piece of evidence doesn't really show any bearishness on Buffett's part, or at least compared to the last 20+ years." i submit that two considerations should be kept in mind: The previous era referred to was before the 1996 irrational exuberance speech. The next twenty years may be very different from the last ones. i don't see why BRK would not become a leveraged play again, given the right circumstances.

As to the source of the health care worker infections, I'd say we'll probably never know... SJ Thanks, i appreciated this exchange. It must be tough for people taking decisions with such wide uncertainty and that perhaps militates for a larger margin of safety. This process is somehow related to contrarian value investing. In the face of uncertainty, coming up with a contrarian opinion is most likely to be wrong and one has to cherish the rare episodes when the 'true' odds are, indeed, favorable. To link back to this thread, these days with all the attention to the virus, many people mention the name Ignaz Semmelweis. https://en.wikipedia.org/wiki/Ignaz_Semmelweis#:~:text=Puerperal%20fever%20was%20common%20in,the%20mortality%20of%20midwives%27%20wards. Based to some degree on intuition, he suggested hand washing in a contrarian way, met unusual resistance, was mocked along the way and did not survive well through the ordeal. But, in his case, he was right. Here's to you, hoping that you find your occasional opportunities to benefit from unique opinions, CF

i think i see what you're getting at but i may have some trouble if you mean to imply that the risk is much ado about nothing. It's been widely recognized (Ontario also) that, due to testing 'strategy' and other various reasons, significant bias can be introduced when analyzing the healthcare worker risk. The main bias risk is the "healthy worker effect". Because testing is typically used proportionally more in frontline workers (mostly for evidence-based reasons and the spreader issue), there is a tendency to report higher absolute numbers of 'detected' cases and to underestimate (vs if that bias were not there, at least temporarily, compared to other population groups) the CFR. When the proportion of testing in the healthcare population vs total population is high, this can introduce bias at the population level CFR also. Having said that, given the use of PPE and procedure adjustments, it appears that most CV+ cases in the healthcare workers result from acquisition in the community but not all. i guess 'we' will find out more precisely over time. In terms of cost effective measures and keeping the precautionary principle in mind, it's probably a good idea for high risk workers to undress in the garage and take a shower before hugging family members even if community transfer in that setting has not been well documented. Interestingly, during the SARS episode (SARS didn't kill so softly so it was more obvious), there were clear and direct links between healthcare workers becoming sick and dying and taking care of SARS-infected patients. An interesting lesson from the SARS episode though was that it was possible to bring the risk of the frontline worker to the same level of the general population, given appropriate measures. From a recent report coming out of the great Alberta province: "It is important to note that evidence from 2003 SARS demonstrated that risk to HCWs could be mitigated by diligent hand hygiene and use of personal protective equipment (PPE)". Not everybody 'believed' that then, in the heat of the action. And some still say it was a hoax.

Then, let me start with a related challenging question: In the US, if one lets the virus spread and not encourage or adopt appropriate population protection measures, "shouldn’t we expect more deaths" compared to other countries where such measures are applied? Answer: yes, a lot more :( Back to your specific question, the short answer AFAIK is 'we' don't know. There have been cases and deaths in healthcare workers having direct contact with patients but testing is said to be high and, at this point, it's hard to be precise. Eyeballing it (and using reference below), it seems that working directly with patients (even with precautions, protocols and equipment) means higher risk to catch the disease. In your country and various jurisdictions, criteria have been relaxed to accept the link between a Covid diagnosis and the job status as a healthcare worker (workers comp) which, it seems to me, is the reasonable thing to do at this point. It seems that mortality profile adjusted for risk factors is similar to the population in general except for the unusual cases early on (people not aware or accepting the risk anyways) and when protective equipment has been insufficient. i think your wife works in a neonatal ICU so this was not (per se) a high risk area but maybe she heard how people tend to avoid "red" zones in certain hospitals even if they say that it's no big deal when writing posts on the internet. There is no doubt that the viral loads involved in high-risk and repeated exposures without protection would have resulted in a healthcare workers' hecatomb in high risk areas. The key was the rapid (although disorganized and confused at first) definition of risk stratification and application of protocols (with appropriate level of equipment). Low risk required simple adjustments and high risk required complicated and often cumbersome requirements. Aerosol management has been a key aspect. Here's a video from China (they describe the protocol to put a tube down one's throat) that looks like it's coming from a bad movie but is quite representative of what has happened in various global emergency rooms, operating rooms and ICUs. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30164-X/fulltext This virus is not equipped with a shotgun. It uses a musket but it's awfully good at replicating and getting close to you (or your threshold), if you let it.

Post delivered in 3 parts. Part 1 The Who did rectify the information after (it was some kind of misunderstanding). The simple answer is that 'we' don't really know the extent of asymptomatic transmission at this point. It appears that 20% of spreaders may be responsible for 80% of the cases and asymptomatic is probably less than symptomatic transmission. In the meantime, you have to deal with incomplete information unless you possess magical thinking abilities. https://globalnews.ca/news/7043306/coronavirus-asymptomatic-spread-who/ Part 2 If you want to go fundamental, i would read the following. TL;DR: It appears that asymptomatic carriers develop similar viral loads and so, in theory and potentially, could spread the virus but asymptomatic people, by definition, don't sneeze or cough. But they can sing, yell, shake hands, ride the subway etc. If interested, in my area, asymptomatic (or minimally symptomatic) transmission was likely a significant killer of older and institutionalized people. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769235 Part 3 It seems to me the best way to deal with those questions (bullshit or Nobel Prize idea) is to do a fundamental analysis first and then to look at the sources (the driving force). i couldn't resist doing some limited digging. It looks like the interviewee is a prostate specialist spreading some controversial theories whose main claim (shame) to fame has been an unusual ability in creative billing. Not that it's relevant to you, at some point in my life, in order to self-regulate and to efficiently but fairly maximize profit potential, i was responsible, within my organization to periodically team up with the main payer with the goal to identify aberrant payments. The payer had great AI-type tools but a very rewarding area to look at involved the "high flyers" (it looks like your referenced urologist was one of those). In that group, one would find extremely hard-working or very well organized and productive individuals. But investigations sometimes revealed individuals billing in a way that could not be reconciled with human abilities (ie doing procedures simultaneously in various locations etc; it looks like your referenced urologist may have been one of those). i always wonder about opinions formulated by super-humans, they simply know too much. Edit: @Castanza: i suspect i finally made it to your ignore list which is fine. Just in case though, if you formulate a more precise question about frontline healthcare workers' exposure, i may potentially be of limited help.

Have you considered the possibility that the reason why things are going okay in Lombardy these days is because they actually made significant progress towards herd immunity during their atrocious outbreak in the spring? Lombardy is a region where the official numbers state that there have been 97k diagnosed cases and 17k deaths recorded for a region of 10m people. With a ~17% calculated CFR, clearly the official statistics are drastically under-counting the true number of cases in that region. So, run the calculation backwards, beginning with the number of deaths to infer a plausible number of infections in the region. If you are in the camp that believes that the IFR is likely around 0.5% or 0.6%, then the 17k deaths implies about 3 million infections. A region of 10m people with ~3m infections could be quite far advanced along the path to herd immunity. So, are the current daily numbers in Lombardy indicative of good management in the present, or poor management in the past? SJ Specifically around this exchange about herd immunity, in early June, the Bergamo province reported population antibody levels at 57% which would clearly not support the notion that much lower antibody levels prevalence would be sufficient herd immunity under any circumstances. However, the numbers suggest that herd immunity had become a contributing variable going forward, at least for those who could mount one (immune response). ... Even though the value in the hotspot is 57%, Italy as a whole is far from herd immunity with only 2.5% antibodies overall. https://medicalxpress.com/news/2020-08-italians-covid-north.html Another tidbit, for whatever it’s worth. Italiy’sVOVID-19 fatality rate is 586/1M. When the US reaches 198k death (we are currently at 177k and increasing by almost 1k/day) we will be just as bad as Italy. That should occur around mid September at latest. I recall folks talking on Italy’s incompetence back in February. Well, it took a while but we have beaten them to it. That's what the serology testing might suggest. But, if you believe that the serology results are true, then you must also believe that the IFR for Italy is a shade higher than 2%. Never say never, because the elderly population was hit particularly hard in Italy. But, generally, it seems that IFR estimates are mostly coming in at about 0.6%, which would suggest a much larger portion of the population has probably already had covid (maybe about 6% of the population). Or maybe some of Italy's 36k deaths have been misclassified as covid deaths? SJ @Spekulatius You are correct in underlining the territorial disparity of antibody levels but i just wanted to suggest that the herd immunity-lockdown question is not a binary one. Taking figure 1 of the study mentioned below, one can suggest that herd immunity relatively and gradually played a larger role in the north while herd immunity's contribution remained low in the south. @StubbleJumper Some of your concerns have been discussed elsewhere and the beat way to summarize a short piece is to include it: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31357-X.pdf Italy was hard hit relatively early, healthcare capacity was massively overwhelmed where huge (excessive excess) mortality occurred and the virus ended up in agglomerations where a high proportion of elderly and sick people were meshed into their communities---)unusually high fatality rates which, even as "local" and "regional" numbers, had a huge impact on overall national results. A lot of work is coming out suggesting that under-reporting of covid deaths (deaths reported as a result of another cause but more likely, in fact, resulting from Covid) is significant. The under-reporting appears to be more significant in areas that have been characterized as hot spots. In these cases, many deaths occurred at home and simply bypassed hospitals, testing etc. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09335-8 This may not be purely luck as the Queens' sector is populated by relatively poor people, recent immigrants, people living in cramped apartments who need to move around to get $, the land of the poorly documented, the informal job owners and the holders of questionable health coverage. From the WSJ (two days ago): "Among people in the U.S. who died between their mid-40s and mid-70s {my edit: skewed curve to the older} since the pandemic began, the virus is responsible for about 9% of deaths. For Latino people who died in that age range, the virus has killed nearly 25%, according to a Wall Street Journal analysis of death-certificate data collected by federal authorities". For Gregmal if he reads this: If looking for a business opportunity in that area, i hear that food banks are doing great.

Have you considered the possibility that the reason why things are going okay in Lombardy these days is because they actually made significant progress towards herd immunity during their atrocious outbreak in the spring? Lombardy is a region where the official numbers state that there have been 97k diagnosed cases and 17k deaths recorded for a region of 10m people. With a ~17% calculated CFR, clearly the official statistics are drastically under-counting the true number of cases in that region. So, run the calculation backwards, beginning with the number of deaths to infer a plausible number of infections in the region. If you are in the camp that believes that the IFR is likely around 0.5% or 0.6%, then the 17k deaths implies about 3 million infections. A region of 10m people with ~3m infections could be quite far advanced along the path to herd immunity. So, are the current daily numbers in Lombardy indicative of good management in the present, or poor management in the past? SJ Specifically around this exchange about herd immunity, in early June, the Bergamo province reported population antibody levels at 57% which would clearly not support the notion that much lower antibody levels prevalence would be sufficient herd immunity under any circumstances. However, the numbers suggest that herd immunity had become a contributing variable going forward, at least for those who could mount one (immune response). ----- Bergamo has meaning here because it's a nice city perched on a hill that marries well the ancient with the modern and is a great example of the mixed human nature of the Piedmont region. Its geographical features also make it an ideal place for the start or the finish of cycling race. It's also relevant because this CV threat, for me, became really real when first accounts (early March when choices had to be made for survival and when army trucks were handling coffins) of what was happening in hospitals made it to my email box. This is when i decided to establish a scorecard looking at the effectiveness of various national public health organizations and leaders across the world in dealing with this phenomenon.. The Bergamo province and Northern Italy had a similar experience compared to various areas of Spain, New York and my jurisdiction with a large spread occurring before the actual implementation of measures (spontaneous, encouraged and imposed). In hindsight, whatever the causes (close to high volume international airports, large events as super-spreading catalysts, older and more fragile population etc), it looks like every day counted and it is reasonable to suggest that the outcome would have been a 100x better if measures that were actually applied had been applied about 2 weeks earlier (with obviously a much lower cost). It's been shown that the viral load is highly determinant as to whether one catches the disease or not and how sick or dead one can become. The viral load concept can be applied to the population level and is one more argument suggesting that herd immunity is a dynamic concept. Bergamo showed that a high population viral load will drive up the population herd immunity required to contribute to flattening the curve. There are several quantifiable and sophisticated ways to report on what happened in Bergamo. Here's one example (and i'm sorry to say a preventable one): Note: to understand, there is no need to speak Italian or for fancy statistical knowledge. -----

The mask question, from a policy standpoint, is not simple. The propensity to wear masks is highly cultural and contextual. Globally, one of the most significant incentives to wear mask has been related to circumstances where hospitals (and morgues) were overwhelmed (ie mask wearing habit acquired too late). Interestingly, from the data i've seen, the propensity to wear masks in Nordic countries is only marginally different despite a perception that Sweden's policy choice is significantly different in that regard. https://www.euronews.com/2020/07/14/coronavirus-how-the-wearing-of-face-masks-has-exposed-a-divided-europe Disclosure: i think mask wearing should be encouraged using various tools (clear message, even requirements) taking into consideration where the population stands and the known risk factors (proximity, promiscuity, enclosed spaces etc) as the most important cost to the measure is inconvenience.

i do 'believe' that the 'real' % is higher but likely not much higher, because of the methodological limitations. An input that strengthens this belief is the recent data published in the UK. The method of study was much stronger but, as you likely know also, the social method involved, at least for some time and to a relative degree, involved to "take it more on the chin", and it may be reasonable to raise the possibility that the different approach is correlated and perhaps more to the more elevated morbid statistics. So, they reveal a slightly less than 6% prevalence overall (3 to 13%, according to the regions, by the end of June). https://www.imperial.nhs.uk/about-us/news/largest-home-antibody-testing-publishes-results Your points about sustainability and 'fatigue' are well taken. What i know is that my area seems to be better prepared (actions already taken and others ready to be deployed) in the event of a second wave towards chronic care and retirement homes.

Not true. Ontario's data is much more recent than most of the serology reports in that thread. Based on his chart, he seems to by using NY serology from mid-June. But this is irrelevant since Ontario's epidemic was crushed by the end of June (a few deaths per day since). There is no problem with the Ontario analysis due to recency or lack of recency. Essentially, what the data show is that about 0.4% of Toronto residents were officially diagnosed as being infected with covid up to June 30, but about 1.5% of people in Toronto who submitted a blood sample to the health system showed the presence of antibodies. On the face of it, the ratio between people carrying antibodies and those officially diagnosed is a bit low compared to other seroprevalence studies (ie, ~3.75:1), but on the other hand people who are young and healthy do not generally submit blood samples to health care system, so it is quite possible that the blood samples were biased to those who had existing co-morbidities and who were quite rightly taking their own social-distancing measures to avoid the virus. SJ Yes, since June 30th, in Ontario, standard measures such as daily new cases per million population have remained very low (even lower than British Columbia) and the positivity rate has stayed below 1% and has been declining. There is no evidence that community spread has continued to any significant degree, enough to materially alter the conclusions that could be obtained from using antibody levels during the study period, as an input. To be clear, the methodology used by the Ontario public health is not perfect but is quite robust: "Specimens tested to generate seroprevalence estimates were originally submitted to PHO Laboratory for clinical testing for antibodies to a variety of infectious diseases (but not COVID-19)". They had to make some adjustments for various reasons but their method is quite dependable. No, things have been quite impressive in Ontario, but that is largely due to the Draconian measures that were put in place by governments during the lockdown (some aspects were more severe than in Quebec, some less). Now, you are a medical practitioner, so you can tell us. How many perfectly healthy people are asked to provide blood samples? How many diabetics are asked to provide blood samples? How many people with coronary difficulties are asked to provide blood samples? It is a physician-selected group of people who *already* have interactions with the health care system, which generally would exclude the healthy population under age 50 and would particularly exclude the healthy population under age 40. Ontario does not need to apologize for using existing samples of blood, but let us not pretend that it was in any way random (remember the non-random sample of Manhattan denizens who were tested when they went out for groceries?). These were probably sicker than average people. So is this better or worse than using blood donors? The blood donors are probably healthier than average people. But, let us not pretend that they are random either. In any case, the recency or non-recency of the sample is not particularly problematic. The seroprevalence work in Ontario is directionally consistent with that done for other populations, but I remain hesitant to accept the magnitude. SJ From old and recent knowledge, i gather that the methods of these serosurveillance investigations done at the population level will depend on what you want to achieve and compromises have to be made between the 'investment' required and the precision and generalization of findings. You need to decide if the study will be cross-sectional (performed once) or longitudinal (follow-up). You also need to decide how to sample the population. The Ontario method used above and blood donors (convenience sampling) are not truly random but are relatively simple to design, to do and to analyze compared to fancy random selection of different population stratas. Blood donors tend to participate well but tend to be different from the general population (often healthier and other factors). The Ontario study design is interesting because it likely represents fairly well the general population. Random sampling is more complicated, more expensive and takes longer to perform so there is a price to pay for precision that may not be critical for population level measures that may be helpful during the acute decision making process. Also, people that get randomly sampled have to consent to the lab test etc and this is a source of efficiency and statistical problems. There is a more complex project going on: https://abcstudy.ca/about/ The seroconversion data at large has been a bit of a cold shower if the hope was to rapidly get to herd immunity (whichever form or definition that you adhere to) i would like to hear from cherzeca, yourself or others about how a such a low seroprevalence in Ontario (or Toronto) could be reconciled with herd immunity under any circumstances going forward. Hope this helps in your thought process.

Not true. Ontario's data is much more recent than most of the serology reports in that thread. Based on his chart, he seems to by using NY serology from mid-June. But this is irrelevant since Ontario's epidemic was crushed by the end of June (a few deaths per day since). There is no problem with the Ontario analysis due to recency or lack of recency. Essentially, what the data show is that about 0.4% of Toronto residents were officially diagnosed as being infected with covid up to June 30, but about 1.5% of people in Toronto who submitted a blood sample to the health system showed the presence of antibodies. On the face of it, the ratio between people carrying antibodies and those officially diagnosed is a bit low compared to other seroprevalence studies (ie, ~3.75:1), but on the other hand people who are young and healthy do not generally submit blood samples to health care system, so it is quite possible that the blood samples were biased to those who had existing co-morbidities and who were quite rightly taking their own social-distancing measures to avoid the virus. SJ Yes, since June 30th, in Ontario, standard measures such as daily new cases per million population have remained very low (even lower than British Columbia) and the positivity rate has stayed below 1% and has been declining. There is no evidence that community spread has continued to any significant degree, enough to materially alter the conclusions that could be obtained from using antibody levels during the study period, as an input. To be clear, the methodology used by the Ontario public health is not perfect but is quite robust: "Specimens tested to generate seroprevalence estimates were originally submitted to PHO Laboratory for clinical testing for antibodies to a variety of infectious diseases (but not COVID-19)". They had to make some adjustments for various reasons but their method is quite dependable.

-On the many definitions of herd immunity International comparison is fair game but there are limitations. The Twitter thread seems to base its analysis on a binary definition of lockdown: no lockdown versus full lockdown. There is indeed a wide gap in perception about the actual impact of government measures but even if many (reasonably comparable otherwise) countries have been defined as adopting widely different approaches, in reality, the differences are much less significant than some suggest (ie Sweden versus Michigan) and, on the ground, individuals use rules and guidelines, to a significant degree, to fine-tune behaviors that they were already ready to implement. Also, assuming natural immunity has been reached suffers from a major flaw in the sense that it is a dynamic number (concept) and that the functioning of society is still far from normal (whatever your individual beliefs or ideologies). -On herd immunity in Georgia This (below link) is an interesting example showing how dynamic the concept of herd immunity is. When social measures are modified (government, individuals or anywhere in between), suddenly you find out that the level of immunity required becomes different (both a the individual and collective levels): https://www.forbes.com/sites/nicholasreimann/2020/08/16/third-high-school-in-one-metro-atlanta-county-is-closing-after-coronavirus-outbreak/#5e4a1d041809 BTW, this is not submitted to suggest that a major resurgence of hospitalizations and deaths are about to occur in Georgia. For a variety of reasons (both knowns and unknowns), the trajectory of the virus is clearly down (at least for this wave). It just seems that Georgia will "succeed" in maximizing (under given circumstances) the area of the curve (size and time) describing mortality and morbidity for a given population. -On the 'real' excess mortality from Covid https://www.ft.com/content/a2901ce8-5eb7-4633-b89c-cbdf5b386938 https://www.ft.com/content/6bd88b7d-3386-4543-b2e9-0d5c6fac846c Both links offer good quality data concerning international comparisons and the relative marginal differences in timing and extent of "government stringency measures". Although there are factors that point to under-reporting of deaths. Evidence suggests that, at least so far, on a net basis, excess mortality from Covid has been somewhat under-reported. This is worth following as virus-induced inflammation (direct or indirect) is for real but there is an awful lot of attention given now to anything related to Covid. The interest here is similar to what happened at some point with the growing concerns about Kawasaki-like presentations in children. Time will tell i guess. I'll provide the link in exchange for more insights from KCLarkin and you.. https://www.publichealthontario.ca/-/media/documents/ncov/epi/2020/07/covid-19-epi-seroprevalence-in-ontario.pdf?la=en

Saliva testing comes with potential advantages but there are residual questions about the ideal collection technique and method as well as sensitivity. Also, even if the saliva process can remove one step (finding a test center that provides the testing material and performs the actual test), my understanding is that people who obtain the home kit still need to send the material to a lab (often by mail...) so it's unclear if this is an avenue that will improve the turnaround time significantly. Also, from a larger perspective, if the idea is to effectively contain or eventually trace, the last numbers show that states that contribute to 28.9% of US GDP still have positivity rates above 10% and states that contribute to an additional 46.6% of US GDP still have positivity rates between 5 to 10%. Background info: https://www.frontiersin.org/articles/10.3389/fmed.2020.00465/full

Fair enough. Looking at this from the perspective of core values and efficient application of policies is relevant. For the efficiency part, which comes after the definition (negotiation) of core values, i would say that despite the real-time concerns that you mention, governance is important in terms of the capacity to articulate and coordinate the application of policies, the way a competent CEO would do it (financing, capital allocation and especially operations). For the core values part, leaders of democratic countries have to take into account where the critical mass of constituents are and only (only is a relative word here) have a marginal effect on where the current should go (right, wrong or no direction). This is even more important with unexpected shocks and during critical junctures. Covid is small change compared to your Civil War, but the point is that, then, President Lincoln was able to lead and guide (with a component of 'price' discovery in the process) in the right direction despite a divided house. This is also why i think the Sweden posture is interesting. Sweden has been wrong on many things for Covid so far but the plan has resulted from a reasonable collective discussion and gave way to a relatively efficient way to deliver on this plan (process vs outcome). One way to assess how core values were defined and applied is to do international comparisons. Apologies for using the US again as a reference point but with responsibilities come power and expectations (my jurisdiction did very poorly on some important parameters). The following link comes from the Washington Post (i use the Post as an input source despite some limitations because it tends to produce good work and it tends to moderate my spontaneous conservative opinions on various topics). They do mention the obvious limitations when comparing countries but there may be something to learn vs core values and efficiency. Interesting comparisons: Michigan vs Sweden, Colorado :) vs Denmark, New Jersey vs Austria, Virginia vs Israel. So, it's not reasonable to expect Wisconsin to 'perform' similarly to Singapore for a variety of reasons including some very positive aspects of American exceptionalism but the size of the discrepancy suggests that your Great Country can do better. https://www.msn.com/en-ca/news/world/how-the-pandemic-in-each-state-compares-to-countries-of-equal-size/ar-BB17YGD2?ocid=msedgntp BTW, in this thread, you were early in identifying the usefulness and relevance of the excess mortality statistics (and how to interpret them) and i thank you for that. Excess mortality tends to be more objective and is a useful springboard for discussion (core values and efficiency). Excess mortality may have two meanings. Excess mortality versus the years before. And excess mortality that was/is preventable in a 'cost'-effective way.

@LC Around 1988, as part of some kind of training, i had to spend some time in public health, to assist in a few projects. One of the projects was to determine how to improve a road intersection (investment versus utility) which had been associated with quite a few accidents. Sounds simple enough. The team had to come up, in the end, with an NPV which, as an input, used the ‘value’ of a life. How do you value a life? Politics is about the messy application of core values around complex trade-offs. But it’s also about the efficient deployment of ‘capital’ around compromises. One difficulty with Covid is that many people (especially if one distrusts sources of data, experts, in general etc) who don’t see it firsthand conclude that it doesn’t really exist. Same with the unintended consequences from collective actions. Last spring, when some hospital resources came close from being overwhelmed in my area, a decision-making blueprint was produced in order to prioritize the use of life-saving equipment. The committees were to use best evidence and principles recognized by peers and outside people acknowledged for sound judgment. I would say that those who say it’s easy don’t understand it. There is still so much to learn and adapt. Thanks for the inputs. Answers tend to form out of constructive discussions.

LC's and KCLarkin's inputs are appreciated. (time saved) Pseudoscience and especially the growing impact of pseudoscience is fascinating and it appears that counter-arguments with facts and rational analysis may be counter-productive. On top of the fundamental inputs mentioned above, it is reported that the author is a controversial naturopath who claims vastly superior results in cancer patients over the traditional approach. The founder of the site itself is also controversial (anti-vax movement...). It is reported that his training is in philosophy. The greenmedinfo site implies the possibility to filter the literature for relevant articles about certain topics. Respected sources reveal that the site is deeply affected by confirmation bias. Being controversial, they often react to criticism with lawsuits based on the freedom of speech and it's been mentioned by some that the site is part of the empire of misinformation. Isn't there some kind of responsibility to check basic facts, analysis and source(s)? Here's a list inspired by a site that i consult frequently (often for contrarian opinions; i have a feeling the site's line of thought (ideology) correlates with yours quite significantly): http://www.econ.ucla.edu/tvwachter/papers/sullivan_vonwachter_qje.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202979/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070776/#!po=2.00000 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831278/ TL;DR: The cost is huge and efforts should be made to minimize the cost (both short and long term). However, i'd like to leave you with another study that suggests that the reaction to COVID was more "due to individuals’ voluntary decisions to disengage from commerce rather than government-imposed restrictions on activity". https://www.nber.org/papers/w27432.pdf i think that political leaning and government actions (or inactions) will have a marginal impact but humans are humans and their destinies are often historical path-dependent, at least to a significant degree. Let's focus on what 'we' can control and that may be why drifts can be so significant.

Thankfully there's no libido in there. There's no questioning of personal tastes but somehow the combination of Orthodox Jews and libido doesn't really do it for me. If interested in the topic with time restraint, here are two useful references: http://faithandworklife.org/wp-content/uploads/2010/12/faith_and_fortune.pdf https://financialpost.com/opinion/a-hard-look-at-paul-reichmanns-long-goodbye Paul Reichmann was a true genius but was also a gambler. In the end, this was about financial libido. A potential problem occurred when the collateral that banks relied on was substantially related to the reputation of a single individual. The best ways to 'kill' a man is to prevent him from working or to give him unlimited credit.

-On the management of tests as a useful resource and the intent of letting the disease run its course towards herd immunity. The strategy of producing an ever increasing amount of testing lagging behind spread is indeed questionable. If acquiring natural herd immunity is the goal, testing should be kept to a minimum. BTW, the positivity rate looks like it's finally coming down which finally points to the end of this wave given the actual situation (combination of 'social' (imposed or self-induced) measures and present level of herd immunity). The strategy is like when (as an ER doc), you 'miss' an infection and let the disease run its course for 24-48h towards septic shock (microbe spreading throughout the body system with the risk of multi-organ failure) and start antibiotics late. By bypassing the application of timely intervention, attempts to compensate and to catch up by giving more antibiotics for longer while exposing potential mortality and morbidity does not represent the best use of resources. The following link explores the area between the "this is the flu" crowd and the "we're all going to die" crowd". The UK has recently produced an interesting population report showing the heterogeneous levels of exposure across their territory. It points to the possibility that natural herd immunity, on a relative basis, has not been reached. https://www.technologyreview.com/2020/08/11/1006366/immunity-slowing-down-coronavirus-parts-us/ i love and admire America and keep looking for exceptionalism. The photo included at the top of the article (taken beside the Animal Kingdom's Tree of Life) reveals the bipolar nature of exceptionalism. Laissez-faire and individual sacrifice for the greater good do not reconcile very well. But it can be done and even mixed with the secret sauce, somehow.