Coronavirus

[Jurgis]

I got an email last night that as of March 23 I have to move my class on-line for the rest of the semester. That means this is our last week of live classes as next week is Spring break.

 

I had emailed our university administration and suggested just canceling Spring break and continue to hold classes. That would have prevented students from scattering all over the world and coming back with the virus. Plus if we had continued the semester next week we would have gotten closer to completing the full semester before any disruption had occurred.

 

MIT moves to all online classes after spring break: http://web.mit.edu/covid19/

 

Students are not going to come back (with virus).

[Cigarbutt]

Disclosure:

-Not planning to use sentiment to guide buy or sell decisions

-As always, triggers will be pulled if external events help to match quoted values with internal evaluations of intrinsic value

 

On the sentimental:

This has most ingredients for excessive sentiment (verbal inflation, irrational behavior, clouded thought process). FWIW, in my socialized medicine area, cancelling elective procedures for flu episodes and related has been a recurrent theme. People adapt in ways that are hard to predict. In my case, last-minute notices of 'free' time resulted in the development of a private business interest to benefit from related (remotely) side effects.

 

On the fundamental:

Much is unknown about the developing phenomenon and I would be careful blindly applying ABC principles or similar (which are based on a large body of previous experiences). Specifically, I wonder if the "whatever it takes" approach may not result in undesirable second or third order effects. However, this seems to be an order of magnitude or two above the typical and variable flu episodes. I get the spreading the pain over a longer period aspect but if people approach this from a long term perspective, people should prepare to run a marathon and not a sprint. For instance (with a potentially weak analogy to the Spanish flu episode), it is possible that a second wave comes at a time when ressources (that are relatively limited in economic parlance) become no longer available, at least to the same extent (opportunity cost point of view).

 

 

With known and developing evidence, it seems that the US is not doing enough. A worrisome aspect is not that the people in charge of the governance want to take a measured, reasoned and rational approach, it's that they seem to hope that the problem will somehow go away.

 

Here are two references for those who want (or have time) to dig deeper, from a policy perspective:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30567-5/fulltext#back-bib13

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037387/

There will be no free lunches.

 

[orthopa]

There is a rule of thumb in medicine when faced with a catastrophic injury or situation, focus on the basics. We call them the ABCs: airway, breathing, circulation. You do not move off of the ABCs until you've made sure that they are all secured and stable. The ABCs of this outbreak would be 1) Identifying as many infected people as possible, 2) Isolating those infected people as quickly as possible, 3) tracing all known contacts of infected people and asking them to self-quarantine; and then repeat. Our governments should be mobilizing any and all resources at their disposal to accomplish 1-3; like the Koreans did in their country. We are not anywhere near doing enough, and time is quickly running out.

 

Not sure why Othopa doesn't understand these basics. I mean the facts s/he is stating are true, but just totally ignorant of basic math. It really boggles the mind.

 

Yeah Im ignorant.

[james22]

Where are my "this is concerning, and we are watching developments with caution" folks?

 

And be thought a fool by everyone with a strong opinion? Better to remain silent.  ;)

[Read the Footnotes]

Is it just me or is the polarization on this thread odd to other people too? It seems like a lot of people are either in the (1) it's just the flu and a nothingburger or (2) omfg this is going to overwhelm everything camps. (I'm throwing out the dude on the other thread who said this is an "extinction level event" because... I mean, come on.)

 

Where are my "this is concerning, and we are watching developments with caution" folks?

 

Though it is unfortunate, I think it is less odd considering the following factors related to how people process information:

 

1) A large number of contributors to the board are US based. Donald Trump was a bit distracted at the time this got started and at that time he felt it was in his interest to minimize and politicize what was then known as Wuhan Coronavirus. Once Trump tells a lie, he NEVER goes back on it. For example, all of his businesses have been great successes and none of them have ever failed, blah, blah, blah. He NEVER admits he was wrong. That's part of his schtick. He just keeps doubling down. It's more important to him to seem confident than to be right or truthful, so he's not going to change his tune.

 

2) Members of this board who started with the attitude of its just a cold and have been arguing that will have difficulty changing their opinion. Some already have but some may have a hard time ever changing their opinion no matter how this ultimately turns out. This is basic cognitive dissonance, anchoring and adjustment bias, etc. The ones who have argued the most strongly and confidently will have the most trouble updating their estimates. To paraphrase Munger they are "pounding in their own stupidity".

 

3) Some people spend a lot of time arguing in the politics section and that has probably changed the way their brains work with respect to issues like this. Do something enough and it rewires your brain.

 

There are also issues related specifically to understanding this virus such as:

 

1) A lot of people are not well educated about how healthcare actually works.

 

2) The other big issue is that you really need to slow down and use the slow logical part of your brain and really look at how easily the medical system can be overwhelmed.

 

3) In many cases both sides are right. The true distribution of fatality rates around the world will probably end up being roughly bi-modal. Some countries like South Korea will likely end up clustered around 0.5% other countries are going to end up clustered around 4%. For each developed country there was a point at which they could chose which group they would join.

 

Finally, I think there are issues around communication:

 

1) We are all making a living investing or doing something else. Time for posting is limited

 

2) Communicating complex thoughts and being well understood in writing is more time consuming for most than verbally in person.

 

3) This topic is new to many and that may make it harder to communicate effectively.

 

4) For members of this board this is a matter of personal health, public health and investing opportunities. In haste, it is probably being lost at times which element posters mean to emphasize when making their comments. Some people are also thinking about politics, but hopefully they will take that to the politics section.

 

5) This is the first time I can think of when there are investment decisions to be made and large geographically diverse portion of this board is facing a certain major change to their lives due to the disruptions and a high likelihood of local health emergencies. All of those things at once complicates things. Some people are emphasizing making a buck, others are emphasizing their own health.

 

Merket, you've been a good friend in real life, as have many others on this board. I suspect the fact that many of us are friends in real life is causing some of us to be concerned for each others portfolios and health. As a result, some of us are probably pushing harder than we would otherwise.

 

[orthopa]

 

 

There is a rule of thumb in medicine when faced with a catastrophic injury or situation, focus on the basics. We call them the ABCs: airway, breathing, circulation. You do not move off of the ABCs until you've made sure that they are all secured and stable. The ABCs of this outbreak would be A) Identifying as many infected people as possible by testing symptomatic patients regardless of travel history, B) Isolating those infected people as quickly as possible, C) tracing all known contacts of infected people and asking them to self-quarantine; and then repeat. Our governments should be mobilizing any and all resources at their disposal to accomplish A-C; like the Koreans did in their country. We are not anywhere near doing enough, and time is quickly running out.

 

M.

 

Interesting strategy. Couple questions for you.

 

1. As I'm sure you know symptoms are cough, difficulty breathing, fever, as well as common cold symptoms. We are still in cold and flu season as you know. That means since symptoms are similar we would need to test 10s of millions of people over the period of a couple of weeks with cold symptoms, pneumonia symptoms, strep throat symptoms, mono symptoms, asthma symptoms, COPD symptoms, flu symptoms, CA, viral URI symptoms, etc etc. You laid out your ABCs, how do you plan on doing this? Honestly? You guys are worried about overload of the medical system with ventilators, ICU beds etc. Jesus Christ. Its not feasible.

 

2. Im assuming you mean isolating those that test positive. Not above, not realistic.

 

3. How do you trace the known contacts of someone who traveled with virus? Who is doing this? The physician? The DOH? the CDC? The family? Your going to call the airline?, the hotel?, the restaurant?, etc and trace all known contacts? Honestly?  I could see friends and family, but those are not all known contacts.

 

Great idea but what your suggesting is impossible.

 

These are great questions, and this is how I would approach them.

 

First, concentrate on the states with the currently highest known case loads (I know this is a moving target), but let's say Washington, Oregon, California, NY, MA.

 

In these highest risk states, public health officials should be out in the hot spots testing anyone who is symptomatic - just like they did in Korea with their road side checks.

 

Everyone who presents to a doctor with Upper respiratory tract infection symptoms anywhere in the country, who also does not have another proven diagnosis (i.e. Strep Throat, Flu, bacterial pneumonia, etc) should get a nasal swab sent for Covid-19 PCR. This would add a total of 15 seconds to the patient encounter while you uncork the swab stick it up their nose and apologize for the discomfort. There is already an infrastructure in place for flu PCR testing and surveillance across the country, you would basically bolt on the covid-19 testing to the flu surveillance network.

 

People who are symptomatic with no known cause should self-isolate while they wait for their test results. Those who test positive go into quarantine and the source contact tracing and testing pathway.

 

To answer your second question, I would only quarantine folks who tested positive, not all symptomatic people.

 

To answer your 3rd question, the Department of Health should be tracing contacts of known infected cases. This is of course an inexact process, but we should try. There is a well established methodology for doing this and we've been systematically doing this as a society for a couple of hundred years - https://www.theguardian.com/news/datablog/2013/mar/15/john-snow-cholera-map

 

The Koreans were publishing infection travel patterns on a public health website and sending push notifications to phones of folks in the effected areas. For example, "A patient with Covid-19 was identified who was at Jim's Bar at 11pm, and at a Conference in 'So-and-So' building this morning at 8am. If you were at either location and have upper respiratory tract infection symptoms, please present to medical care for testing".

 

I understand this might all seem overwhelming, but it is manageable. The government recently announced $8.5billion in emergency economic aid around Covid-19. All of the measures I describe above, would cost less than half that much money, and would have cost even less if they were started earlier.

 

M.

 

PS. Let's assume it costs $100 per test to test all 10 million folks in the US who currently have upper respiratory tract infections. That would still only cost $1billion, but as I mentioned above, likely less because those with obvious clinical explanations for their symptoms like Strep Throat, Ear infections, Pneumonia, flu, etc would be exluded.

 

 

So you want to start by testing states with 75 million people? Yikes.

 

The covid-19 nasal swab doesn't exist yet, you know this. Secondly. That would have been great, back in December.

 

Whats your plan for asymptomatic patients and children who show no symptoms? Surely they have to be tested too. Otherwise they become an immediate vector. We just let them go?

 

This all sounds great on paper but just very unrealistic.

 

 

[orthopa]

Great idea but what your suggesting is impossible.

 

In the "greatest health care system in the world", basic public health containment measures are impossible? If so, how did the Koreans manage it with less resources per capita than the US has at its disposal?

 

M.

 

The greatest heathcare system in the world to contain this virus would need the cooperation of every citizen, all 372 million of them, as well as the say 1, 2, 3 Billion people who continue to have access to this country via plane, train, foot, boat, etc. Its impossible, you know this.

[Read the Footnotes]

So you want to start by testing states with 75 million people? Yikes.

 

The covid-19 nasal swab doesn't exist yet, you know this. Secondly. That would have been great, back in December.

Looks like they have it in WA

 

https://www.npr.org/2020/03/08/813486500/coronavirus-drive-through-testing-centers

[orthopa]

Contact tracing will obviously no longer work in the US. That is an opportunity the US has missed. 

 

We must start social distancing immediately, including cancelling public events, and reducing exposures to large groups.

 

Marc Lipsitch, the Harvard Epidemiologist has a thread here:

 

 

Weren't we just arguing about this in my example of extended contact at airport ? Now because he says it, its true? LOL

[merkhet]

Is it just me or is the polarization on this thread odd to other people too? It seems like a lot of people are either in the (1) it's just the flu and a nothingburger or (2) omfg this is going to overwhelm everything camps. (I'm throwing out the dude on the other thread who said this is an "extinction level event" because... I mean, come on.)

 

Where are my "this is concerning, and we are watching developments with caution" folks?

 

Though it is unfortunate, I think it is less odd considering the following factors related to how people process information:

 

1) A large number of contributors to the board are US based. Donald Trump was a bit distracted at the time this got started and at that time he felt it was in his interest to minimize and politicize what was then known as Wuhan Coronavirus. Once Trump tells a lie, he NEVER goes back on it. For example, all of his businesses have been great successes and none of them have ever failed, blah, blah, blah. He NEVER admits he was wrong. That's part of his schtick. He just keeps doubling down. It's more important to him to seem confident than to be right or truthful, so he's not going to change his tune.

 

2) Members of this board who started with the attitude of its just a cold and have been arguing that will have difficulty changing their opinion. Some already have but some may have a hard time ever changing their opinion no matter how this ultimately turns out. This is basic cognitive dissonance, anchoring and adjustment bias, etc. The ones who have argued the most strongly and confidently will have the most trouble updating their estimates. To paraphrase Munger they are "pounding in their own stupidity".

 

3) Some people spend a lot of time arguing in the politics section and that has probably changed the way their brains work with respect to issues like this. Do something enough and it rewires your brain.

 

There are also issues related specifically to understanding this virus such as:

 

1) A lot of people are not well educated about how healthcare actually works.

 

2) The other big issue is that you really need to slow down and use the slow logical part of your brain and really look at how easily the medical system can be overwhelmed.

 

3) In many cases both sides are right. The true distribution of fatality rates around the world will probably end up being roughly bi-modal. Some countries like South Korea will likely end up clustered around 0.5% other countries are going to end up clustered around 4%. For each developed country there was a point at which they could chose which group they would join.

 

Finally, I think there are issues around communication:

 

1) We are all making a living investing or doing something else. Time for posting is limited

 

2) Communicating complex thoughts and being well understood in writing is more time consuming for most than verbally in person.

 

3) This topic is new to many and that may make it harder to communicate effectively.

 

4) For members of this board this is a matter of personal health, public health and investing opportunities. In haste, it is probably being lost at times which element posters mean to emphasize when making their comments. Some people are also thinking about politics, but hopefully they will take that to the politics section.

 

5) This is the first time I can think of when there are investment decisions to be made and large geographically diverse portion of this board is facing a certain major change to their lives due to the disruptions and a high likelihood of local health emergencies. All of those things at once complicates things. Some people are emphasizing making a buck, others are emphasizing their own health.

 

Merket, you've been a good friend in real life, as have many others on this board. I suspect the fact that many of us are friends in real life is causing some of us to be concerned for each others portfolios and health. As a result, some of us are probably pushing harder than we would otherwise.

 

Thanks for taking the time to write the longer version of what I’ve been thinking myself!

 

I think the bi-modal distribution is a really important thing to keep in mind. Policy decisions/actions are going to be the thing that determines the difference between a South Korea-like situation (likely the “natural”* CFR) or an Italy-like situation (overwhelmed healthcare system “exacerbated”* CFR)

 

Hope you’re staying safe up there in Boston!

 

*natural/exacerbated are not quite the right words here but the best I can come up with at the moment

[arcube]

Nice Summary +1

 

Is it just me or is the polarization on this thread odd to other people too? It seems like a lot of people are either in the (1) it's just the flu and a nothingburger or (2) omfg this is going to overwhelm everything camps. (I'm throwing out the dude on the other thread who said this is an "extinction level event" because... I mean, come on.)

 

Where are my "this is concerning, and we are watching developments with caution" folks?

 

Though it is unfortunate, I think it is less odd considering the following factors related to how people process information:

 

1) A large number of contributors to the board are US based. Donald Trump was a bit distracted at the time this got started and at that time he felt it was in his interest to minimize and politicize what was then known as Wuhan Coronavirus. Once Trump tells a lie, he NEVER goes back on it. For example, all of his businesses have been great successes and none of them have ever failed, blah, blah, blah. He NEVER admits he was wrong. That's part of his schtick. He just keeps doubling down. It's more important to him to seem confident than to be right or truthful, so he's not going to change his tune.

 

2) Members of this board who started with the attitude of its just a cold and have been arguing that will have difficulty changing their opinion. Some already have but some may have a hard time ever changing their opinion no matter how this ultimately turns out. This is basic cognitive dissonance, anchoring and adjustment bias, etc. The ones who have argued the most strongly and confidently will have the most trouble updating their estimates. To paraphrase Munger they are "pounding in their own stupidity".

 

3) Some people spend a lot of time arguing in the politics section and that has probably changed the way their brains work with respect to issues like this. Do something enough and it rewires your brain.

 

There are also issues related specifically to understanding this virus such as:

 

1) A lot of people are not well educated about how healthcare actually works.

 

2) The other big issue is that you really need to slow down and use the slow logical part of your brain and really look at how easily the medical system can be overwhelmed.

 

3) In many cases both sides are right. The true distribution of fatality rates around the world will probably end up being roughly bi-modal. Some countries like South Korea will likely end up clustered around 0.5% other countries are going to end up clustered around 4%. For each developed country there was a point at which they could chose which group they would join.

 

Finally, I think there are issues around communication:

 

1) We are all making a living investing or doing something else. Time for posting is limited

 

2) Communicating complex thoughts and being well understood in writing is more time consuming for most than verbally in person.

 

3) This topic is new to many and that may make it harder to communicate effectively.

 

4) For members of this board this is a matter of personal health, public health and investing opportunities. In haste, it is probably being lost at times which element posters mean to emphasize when making their comments. Some people are also thinking about politics, but hopefully they will take that to the politics section.

 

5) This is the first time I can think of when there are investment decisions to be made and large geographically diverse portion of this board is facing a certain major change to their lives due to the disruptions and a high likelihood of local health emergencies. All of those things at once complicates things. Some people are emphasizing making a buck, others are emphasizing their own health.

 

Merket, you've been a good friend in real life, as have many others on this board. I suspect the fact that many of us are friends in real life is causing some of us to be concerned for each others portfolios and health. As a result, some of us are probably pushing harder than we would otherwise.

[thowed]

Poland just closed all schools, museums, and cinemas.

 

https://www.dailymail.co.uk/news/article-8099501/Poland-closes-schools-museums-cinemas-amid-coronavirus.html

 

with only 25 confirmed cases this seems like a very proactive approach that the US and Canada are not implementing and I think they will pay a price.

 

(I'm on the "this is a significant event but we will get through it" camp)

 

I don't know the context, but just to say that while this is probably fine, I'd generally be wary of using the Daily Mail as a news source.  It is not the most objective of papers, if fun for gossip & stuff.

 

 

[Castanza]

Just an observation:

 

It seems a lot of individuals greatly underappreciated the scale of the Interstate and road systems in the US. Not to mention the sheer land mass of this country.

 

Comparing the lock down of a country the size of Minnesota (that heavily relies on public transit) to the US is apples to oranges. Containment in the US is magnitudes more difficult.

[orthopa]

So you want to start by testing states with 75 million people? Yikes.

 

The covid-19 nasal swab doesn't exist yet, you know this. Secondly. That would have been great, back in December.

Looks like they have it in WA

 

https://www.npr.org/2020/03/08/813486500/coronavirus-drive-through-testing-centers

 

Well its not available in New York. Where can we source them? NY will need about 40 million of them.

[Read the Footnotes]

Contact tracing will obviously no longer work in the US. That is an opportunity the US has missed. 

 

We must start social distancing immediately, including cancelling public events, and reducing exposures to large groups.

 

Marc Lipsitch, the Harvard Epidemiologist has a thread here:

 

 

Weren't we just arguing about this in my example of extended contact at airport ? Now because he says it, its true? LOL

 

Orthopa, do you think you can slow down a bit and try to communicate a little more clearly? I think you are making some good points, but it seems your points may not be getting across clearly or that you may even be misunderstood. This post in particular makes me think that is the case.

 

I also thought your earlier point about testing the role of testing in a diagnosis is likely a good point, but was probably too hasty to get your point across. Maybe some other medical professionals could weigh in on that, especially if you're to busy to respond.

[Guest Schwab711]

Where are my "this is concerning, and we are watching developments with caution" folks?

 

And be thought a fool by everyone with a strong opinion? Better to remain silent.  ;)

 

I'm not saying "I think the world is ending" or "this is GFC" when I'm saying there is going to be (let's ignore what I think for a moment) prolonged periods of containment. The market is trading at 17x 2019 earnings right now (S&P 500 is ~2800). That's not exactly cheap when you consider risks to near-term and intermediate earnings (the latter being some sort of economic contagion from global economic slowdown). From the human side, lowering the number of sick at any given time means better healthcare outcomes. That's the ultimate goal. As some skeptical have identified, the disease will be passed to many before it ends either way. If 10m are sick in the US at one time for months on end, many will die. If 100k are sick at one time for 1+ years, relatively few will die. It's a semi-controllable variable.

 

 

@orthopa

I think what folks are saying when saying testing is important is that identifying as many spreaders as possible is key to containment. You can't catch them all. Don't let perfect be the enemy of the good. Some folks spread to 1 person. Some spread disease to dozens. You want to eliminate as many spreaders as possible so that the disease population can't reach escape velocity. Basically to the point above about the number sick at any given time being semi-controllable.

 

 

@RTF

Agreed with arcube. Good post.

[orthopa]

Uh oh, another spike in cases in N. Korea. Will need another response model to slob on next. Germany? France? Uk?

[Read the Footnotes]

Thanks for taking the time to write the longer version of what I’ve been thinking myself!

 

I think the bi-modal distribution is a really important thing to keep in mind. Policy decisions/actions are going to be the thing that determines the difference between a South Korea-like situation (likely the “natural”* CFR) or an Italy-like situation (overwhelmed healthcare system “exacerbated”* CFR)

 

Hope you’re staying safe up there in Boston!

 

*natural/exacerbated are not quite the right words here but the best I can come up with at the moment

Thanks, Merket.

 

Some good news is that our interventions can impact BOTH the CFR and the R0. That's good news, but I probably should have included that in my list of things that make this more difficult for some people to understand without spending a lot of time on it.

 

South Korea's CFR may rise. There seems to be a long delay in case progression, so it will be a while before we will know that.

 

Also, I should have emphasized that an advanced understanding of probability and statistics will make this easier for some people to understand. There's probably a little bit of Duning-Kreuger going on here in this discussion.

 

A final complicating factor I should have included is that even within countries there will be a wide dispersion of experiences. Some local geographic areas will do much better than others for various reasons:

 

1) how connected they are to other parts of the world (from and epidemiological perspective, Manhattan may have more ties to Milan and Wuhan than it does Bridgeport, CT.)

 

2) There will also be a lot of variation based on population differences, cultural differences etc

 

3) public health preparedness and local leadership

[alwaysdrawing]

Weren't we just arguing about this in my example of extended contact at airport ? Now because he says it, its true? LOL

 

In many many areas, contact tracing will still be useful.  In a number of areas where spread has become endemic, that's impossible.

 

Slowing the spread through NPIs has always been part of what I've been saying.  At this stage in the United States, we will likely need a major shutdown of events, schools, churches and more to prevent hospitals from being overwhelmed.  Some still likely will, but our ability to spread out cases is key to keeping the hospitals from being overrun.

 

I have skin in the game--my wife is a health care worker.  I have a child who I have already kept home from school.

 

We all need to brace for what's coming.

[Jurgis]

This was posted in another thread, but I think it should be posted here too:

 

https://www.nbcnews.com/news/us-news/young-people-capitalize-cheap-coronavirus-flights-if-i-die-i-n1154326

 

YOIO

 

Containment be damned.

[muscleman]

In case you want some real stories:

My relative who was cured 3 weeks ago now has the symptoms again and CT shows lung infections. My mom’s neighbor was recently cured and discharged from hospital and died the next night.

[matts]

In case you want some real stories:

My relative who was cured 3 weeks ago now has the symptoms again and CT shows lung infections. My mom’s neighbor was recently cured and discharged from hospital and died the next night.

 

sorry to hear that. Do you know their ages?

[Kaegi2011]

This is interesting, and I think highlights several issues being talked about here:

 

1) unless we somehow eradicate the virus or find a cure, it'll be with us for a while

2) the importance of social distancing and containment early on in terms of the growth rate of the virus

 

I think this is a good example where doing something is better than doing nothing, but even if we do something it's unlikely to change the terminal trajectory of the virus until the cure is found.  Bending the curve still seems appropriate where possible. 

 

https://www.bloomberg.com/news/articles/2020-03-11/singapore-warns-of-complacency-while-new-virus-infections-surge

[muscleman]

In case you want some real stories:

My relative who was cured 3 weeks ago now has the symptoms again and CT shows lung infections. My mom’s neighbor was recently cured and discharged from hospital and died the next night.

 

sorry to hear that. Do you know their ages?

Both in the 50s.

[Kaegi2011]

In case you want some real stories:

My relative who was cured 3 weeks ago now has the symptoms again and CT shows lung infections. My mom’s neighbor was recently cured and discharged from hospital and died the next night.

 

sorry to hear that. Do you know their ages?

Both in the 50s.

 

Which area, if you're ok disclosing?