Coronavirus

[Read the Footnotes]

 

OK... at least you agree that early travel ban was good decision, which was criticized by press at that time.

 

Coming back to numbers, even in "latest deaths", US is better than Korea.  I guess under your definition, US "rapid exponential growth" is better than Korea "flattened out" death rate. Koreans have more than double US "latest deaths" in per capita terms.

 

Also, setting aside US for a moment.  Japan did much better than most countries.  But Japan did not have heavy testing or lockdowns.

But S. Korea and Italy had heavy testing. 

 

You want to follow S. Korea and Italy with heavy testing rather than look at what Japan did?

 

Yes I want to follow S Korea. Italy did not do a good job of testing. USA is beyond where Japan ever was.

 

This is an infection where it takes ~1 week to show symptoms from catching the virus and maybe ~2 weeks to severe symptoms and mortality. As the U.S. is early in this processes, as I have repeated on here (though some claim it has infected "millions for months" here), the fear is that the deaths are yet to come. S Korea is likely on the tail end so their deaths are probably going to level off.

 

See the exponential mortality graph of U.S. I posted on here a few posts back.

 

You say "Italy did not do a good job of testing." but the truth is that Italy also had bad luck.

Both of you are making a great case for why we don't want to hope for the best or believe "maybe we'll get lucky".

At one point it seemed like USA's approach was going to be that we were going to hope for good luck. We always should have demanded prudence and a margin of safety.

[minten]

forty percent of the population would be sick at once.

 

This seems like a strange model to me to be honest. The total infection rate (as I keep reading) when you do nothing would be 40-60%, spread out over a number of months. Why would everybody be sick at once?

 

Certainly a two week period with forty percent not reporting to work would be disastrous.

 

Well, in a lockdown nobody would be working at all, even worse. Plus apparently large percentages of patients don't have any symptoms at all (which seems to be the problem with this virus), so will be able to work just fine.

 

At some point it'll come to this, especially once we have treatment options. The elderly will be asked to isolate until there's a vaccine next year. If thet do get sick, they can be treated better, while the rest of us go on with our lives. Nothing else makes sense, definitely not an extended lockdown.

[mcliu]

Anyone have a theory on why the curve is so much worse in NYC/New Jersey than Washington/California?

[Castanza]

Anyone have a theory on why the curve is so much worse in NYC/New Jersey than Washington/California?

 

Weather?

[ERICOPOLY]

Testing?

 

https://www.nytimes.com/2020/03/19/nyregion/coronavirus-new-york-update.html

 

A jump in testing finds a spike in new cases.

A few days ago, New York State was testing only a few hundred people a day for coronavirus.

 

On Wednesday night, Gov. Andrew M. Cuomo said, the state processed the tests of 7,584 people.

[Read the Footnotes]

What did you know and when did you know it?

 

https://www.wbur.org/npr/818192535/burr-recording-sparks-questions-about-private-comments-on-covid-19

 

On February 27, Richard Burr (R-NC) was warning donors that Coronavirus was going to rival the 1918 Pandemic. On the same day, Trump said:

"It's going to disappear. One day, it's like a miracle. It will disappear," the president said then, before adding, "it could get worse before it gets better. It could maybe go away. We'll see what happens."

 

My belief all along has been that Donald Trump probably got a fair assessment of the risks in early December. How does that make you reassess his handling of this situation?

[Read the Footnotes]

Anyone have a theory on why the curve is so much worse in NYC/New Jersey than Washington/California?

Population density.

I would recommend physical distancing.

[Read the Footnotes]

forty percent of the population would be sick at once.

 

This seems like a strange model to me to be honest. The total infection rate (as I keep reading) when you do nothing would be 40-60%, spread out over a number of months. Why would everybody be sick at once?

 

Certainly a two week period with forty percent not reporting to work would be disastrous.

 

Well, in a lockdown nobody would be working at all, even worse. Plus apparently large percentages of patients don't have any symptoms at all (which seems to be the problem with this virus), so will be able to work just fine.

 

At some point it'll come to this, especially once we have treatment options. The elderly will be asked to isolate until there's a vaccine next year. If thet do get sick, they can be treated better, while the rest of us go on with our lives. Nothing else makes sense, definitely not an extended lockdown.

The forty percent statistic is a basic rule of thumb. Go check out the CDC's planning documents, or review the research literature in the field and you'll see it over and over again. Also, if you play around with exponential growth for just a little bit and you'll see that it is possible.

 

Isolating vulnerable people, social distancing, herd immunity all accomplish the same thing through different mechanisms. They are all levers to pull upon. Finding the correct mix is the challenge.

 

You also need to remember that there will be a huge variation by location. 40% is an average. What is more likely is that entire essential service departments could be simultaneously taken out in one town, and another town might have good luck. One town could be a disaster area and the other could have no cases at all and on average maybe you only have 10% out sick at one time. Do you really want to roll the dice?

[rolling]

One town could be a disaster area and the other could have no cases at all and on average maybe you only have 10% out sick at one time. Do you really want to roll the dice?

Over here we are still in the beggining but that already shows. A small town has been declared a disaster area, nobody goes in or out, people must stay at home but for a few exceptions. What happened? A 17 year old girl contacted with some friends that had been to Italy and were assymptomatic. A few days later she started symptoms, went to the primary care, went to the emergency deptartment went home and only when she was getting seriously ill did someone make the diagnosis. In the mean time her mother had caught the disease and also had tons of contacts with other people. So simple, yet so devastating (they closed the town at the 30th case, recognizing it was now a community spread disease over there).

In the meanwhile, much bigger cities only had their first case later: chance happens

[Spekulatius]

It is still calm where ai live (MA/ NH) border. No known cases in my town yet. Hospitals are empty (my wife works in a couple) as they cleared out patients that don’t have to there and procedures elective or can wait are delayed. In one hospital, they have crated an extra ICU an “droplet Control” zones.

 

It will come, but it’s not there yet. Based in my Nextdoor local feed, I still estimate that at least a third of the local population thinks it’s media induced hysteria.

[Dalal.Holdings]

I still estimate that at least a third of the local population thinks it’s media induced hysteria.

 

Not surprising since that was pretty much the case on places like this website as well. It's all hysteria until it hits home. Just ask Sean Hannity.

[StubbleJumper]

forty percent of the population would be sick at once.

 

This seems like a strange model to me to be honest. The total infection rate (as I keep reading) when you do nothing would be 40-60%, spread out over a number of months. Why would everybody be sick at once?

 

Certainly a two week period with forty percent not reporting to work would be disastrous.

 

Well, in a lockdown nobody would be working at all, even worse. Plus apparently large percentages of patients don't have any symptoms at all (which seems to be the problem with this virus), so will be able to work just fine.

 

At some point it'll come to this, especially once we have treatment options. The elderly will be asked to isolate until there's a vaccine next year. If thet do get sick, they can be treated better, while the rest of us go on with our lives. Nothing else makes sense, definitely not an extended lockdown.

The forty percent statistic is a basic rule of thumb. Go check out the CDC's planning documents, or review the research literature in the field and you'll see it over and over again. Also, if you play around with exponential growth for just a little bit and you'll see that it is possible.

 

Isolating vulnerable people, social distancing, herd immunity all accomplish the same thing through different mechanisms. They are all levers to pull upon. Finding the correct mix is the challenge.

 

You also need to remember that there will be a huge variation by location. 40% is an average. What is more likely is that entire essential service departments could be simultaneously taken out in one town, and another town might have good luck. One town could be a disaster area and the other could have no cases at all and on average maybe you only have 10% out sick at one time. Do you really want to roll the dice?

 

 

People should keep in mind that 40% is a hell of a distance to haul.  Take Italy as a the worst case currently out there.  If you add up the new known cases over the past 7 days what do you get?  It is 25,000, 30,000 over the past 7 days (today was particularly bad)?  Okay, assume that the asymptomatic and mild cases are 10-for-1 to the known cases.  So, if that heroic assumption is true, there were only perhaps 300,000 total new cases in Italy.  Well, the population of Italy is 60 million, and 40% is 24 million.  You need 80 weeks that are just like this past week to achieve herd immunity across the country.

 

It's a hell of a miserable distance to haul to achieve herd immunity.

 

 

SJ

[LC]

Colorado: about 3K tested, 275 positives, 4 deaths.

[Read the Footnotes]

forty percent of the population would be sick at once.

 

This seems like a strange model to me to be honest. The total infection rate (as I keep reading) when you do nothing would be 40-60%, spread out over a number of months. Why would everybody be sick at once?

 

Certainly a two week period with forty percent not reporting to work would be disastrous.

 

Well, in a lockdown nobody would be working at all, even worse. Plus apparently large percentages of patients don't have any symptoms at all (which seems to be the problem with this virus), so will be able to work just fine.

 

At some point it'll come to this, especially once we have treatment options. The elderly will be asked to isolate until there's a vaccine next year. If thet do get sick, they can be treated better, while the rest of us go on with our lives. Nothing else makes sense, definitely not an extended lockdown.

The forty percent statistic is a basic rule of thumb. Go check out the CDC's planning documents, or review the research literature in the field and you'll see it over and over again. Also, if you play around with exponential growth for just a little bit and you'll see that it is possible.

 

Isolating vulnerable people, social distancing, herd immunity all accomplish the same thing through different mechanisms. They are all levers to pull upon. Finding the correct mix is the challenge.

 

You also need to remember that there will be a huge variation by location. 40% is an average. What is more likely is that entire essential service departments could be simultaneously taken out in one town, and another town might have good luck. One town could be a disaster area and the other could have no cases at all and on average maybe you only have 10% out sick at one time. Do you really want to roll the dice?

 

 

People should keep in mind that 40% is a hell of a distance to haul.  Take Italy as a the worst case currently out there.  If you add up the new known cases over the past 7 days what do you get?  It is 25,000, 30,000 over the past 7 days (today was particularly bad)?  Okay, assume that the asymptomatic and mild cases are 10-for-1 to the known cases.  So, if that heroic assumption is true, there were only perhaps 300,000 total new cases in Italy.  Well, the population of Italy is 60 million, and 40% is 24 million.  You need 80 weeks that are just like this past week to achieve herd immunity across the country.

 

It's a hell of a miserable distance to haul to achieve herd immunity.

SJ

SJ, to be clear, I was talking about 40% simultaneous illness, not 40% cumulative infections, or 40% herd immunity. Just wanted to make sure since those could easily be confused, and are frequently associated with 40%. I realized from your response that quick read might have resulted in confusion.

 

I'll inject a bit of optimism by saying that if you study complex adaptive systems, you will realize that there are better outcomes possible than what has been discussed here recently.

 

The secret is having good leadership and multiple levers to pull. If you can optimize for the system and get lucky, then a few weeks of shelter in place could pay huge dividends.

 

The recent Bill Gates Reddit AMA to gives a sense of his optimism and some hints at how decisive action and a multi-pronged approach could be so much better than relying on a single tool in the tool kit.

[LC]

What did you know and when did you know it?

 

https://www.wbur.org/npr/818192535/burr-recording-sparks-questions-about-private-comments-on-covid-19

 

On February 27, Richard Burr (R-NC) was warning donors that Coronavirus was going to rival the 1918 Pandemic. On the same day, Trump said:

"It's going to disappear. One day, it's like a miracle. It will disappear," the president said then, before adding, "it could get worse before it gets better. It could maybe go away. We'll see what happens."

 

The best part? He dumped his portfolio on 2/13:

 

https://www.propublica.org/article/senator-dumped-up-to-1-6-million-of-stock-after-reassuring-public-about-coronavirus-preparedness

 

Oh and he's on these committees:

 

Committee on Finance

Subcommittee on Energy, Natural Resources, and Infrastructure

Subcommittee on Health Care

Subcommittee on Taxation and IRS Oversight

 

Committee on Health, Education, Labor, and Pensions

Subcommittee on Children and Families

Subcommittee on Primary Health and Retirement Security

 

Select Committee on Intelligence (Chairman)

 

 

[EliG]

What did you know and when did you know it?

 

https://www.wbur.org/npr/818192535/burr-recording-sparks-questions-about-private-comments-on-covid-19

 

On February 27, Richard Burr (R-NC) was warning donors that Coronavirus was going to rival the 1918 Pandemic. On the same day, Trump said:

"It's going to disappear. One day, it's like a miracle. It will disappear," the president said then, before adding, "it could get worse before it gets better. It could maybe go away. We'll see what happens."

 

The best part? He dumped his portfolio on 2/13:

 

https://www.propublica.org/article/senator-dumped-up-to-1-6-million-of-stock-after-reassuring-public-about-coronavirus-preparedness

 

https://twitter.com/lachlan/status/1240802700171849731?s=20

 

"Sen. Kelly Loeffler sold between $1.2M and $3.1M worth of stock in the three weeks beginning on Jan 24 — the day of a closed-door, all-Senator briefing on the coronavirus"

 

[EliG]

 

He *still* thinks he can fool capital markets. The last two weeks haven't been enough of a lesson.

 

[orthopa]

Have been just sitting back and reading everyone's thoughts on things which is interesting for sure. My attention has turned more from what I think will happen with the virus (I think I have made my thoughts very clear). Some of my predictions so far have been close which feels good I guess but means nothing in the mess the world is today. Especially in light of the sick people, fear, society shut down and all the angst the market falling is causing many I'm sure.

 

Like everyone here (except for Viking you bastard! ;) ) it blows watching the market implode unless short or all cash. Long term investing is not easy thats for sure. But what I am really starting to get worried about is what this will do to many, many, small business, restaurants, franchisees, bars, etc. This 15 day gov shut down and multiple state shut down is going to kill businesses, confidence, sky rocketing unemployment etc. I would like to think and hope it is a V or U shaped recovery but if your a business owner that goes out of business how long is it going to take your confidence to come back, workers etc? I would love to have a quick rebounding economy but if enough people get laid off, enough businesses bankrupt this could be a long time mess.

 

I think Ackmans idea makes some sense but hes a billionaire. Sure you can have rent holidays, mortgage forbearance, don't pay your utilities etc but this is already crushing airlines, hotels, small business, restaurants and we are a couple days in. Some states want a month or more. Whats the unemployment rate after this month? That drops down fast? Idk. And sending 1-2k checks wont cut the mustard for many

 

At some point I think you start to see people who say fuck it, enough. Stress levels and tension are extremely high. First it was fear, and still is, but in social media circles I have seen many start to question what we are doing and for who? That can get dangerous. Throw in not working, no money coming in, your kids not going to school driving you up the wall and every day you get up and the death rate in the US is at 100-125-150.

 

I'm not saying we should get to a point where we choose who lives and who doesn't but at some point I think you have to look at the broader picture. I brought this way up earlier in the thread and some commented on it as the owns persons fault but some things to just consider.

 

As of right now fear still predominates in the greatest economy in the world as well as other nations in the world. In every sense of the word we are in this together and I think fundamentally doing the right thing, but....we have shut down essentially the world, ruined daily lives, scared the ever living shit out of people. We will have bankrupted people. Some may commit suicide  seen with financial crises, many other making huge sacrifices some of which will never recover from. Businesses will close. We will add trillions to the debt, the fed taking extraordinary actions to prevent the economy from seizing. Scrambling in chaos to find solutions with amounts of money that no one can comprehend for the millions, and millions of people who will be affected, emotionally, mentally, financially etc. Bankrupting our airline industry, possibly hotel, travel, leisure, restaurant, banking?? industry. Its turned into absolute chaos.

 

And what are we afraid of ? A disease that we know may have an 86% as symptomatic rate, that so far has killed 8784 people out of 7.8 Billion people,  .000116%. People who we know on average are nearing the end of their lives. People who succumb every day to diseases we are numb to. I know many are aware of the flu data on deaths but some aren't on the most common every day killers in the US. Every year in the US alone;

 

674,000 people die from cardiovascular disease

607,000 from cancer

170,000 from accidental deaths

 

In the world;

 

17.65 million heart disease

8.93 million from cancer

3.54 million from respiratory disease

 

My point is not to sacrifice people for money, and I am aware obviously the death rate world wide would be much higher if the above was not done in the US, China, Italy, Europe etc. But why is it ok for all of these people to die from the above? Are we just numb to it? Since the first corona case in the US 2 months ago based on the above data 112,333 people have died from heart disease. Every day we look at the Johns Hopkins map checking deaths and each day 1846 Americans and 48,356 in the world have died from heart disease. We are killing ourselves over ICU beds for Mary for Covid, while her friend from the Senior Center dies downstairs in the same hospital before they can get to the Cath lab. We want a vaccine in months for corona but are willing to go through multiple year trials for anticoagulants, cholesterol meds, and hypertension meds.

 

That being said, do we really care as country how many people die? And who and how old they are?

 

This has become an irrational obsession for the world, and with this virus. When you really look at what will kill you living in this country, and who we should be saving, the sooner you realize this has become insanity.

 

According to a key part of your thesis, the virus has infected millions for months here. Strange why deaths are just now rising, then. Unless you propose that people died in January but we had no idea what the true cause of death was. Strange too that ICUs in NYC are just now starting to get loaded...

 

Attached is a graph of U.S. mortality thus far from COVID. If I saw such a trend for cancer deaths, cardiovascular disease, or accidental deaths, I WOULD be concerned about those things.

 

Not to mention the fact that none of these things that you mention that cause deaths are systemic, multiplicative (i.e. none of them are contagious) processes. A BIG difference.

 

Im surprised your allowed in the ICU's in NY. I assume you have been to the ones in Kings county and LA too huh? ::)

 

So its the graph that does it huh? Fuck the 1800 a day dying from heart disease? 179 so far from Corona virus. Avg 3.4 per state. You are not concerned about the other because you went your entire life not being aware 24 hours a day of cardiovascular disease. Your numb to it. This is new and exciting. Death does not concern you. You seem to relish in the fear, we all have our thing.  You should make a graph from the start of the year to now, 1800 a day of cardiac deaths and map those out vs corona. That would be fun to watch.

 

Oh, its how these people die, not that they die. Ok. I just think you get off on the fear, cool whatever.

 

Its still coming huh? When will you be wrong? My early assumption already is if/when the deaths fail to take of exponentially you will pivot to the flattening the curve is working.

[orthopa]

 

OK... at least you agree that early travel ban was good decision, which was criticized by press at that time.

 

Coming back to numbers, even in "latest deaths", US is better than Korea.  I guess under your definition, US "rapid exponential growth" is better than Korea "flattened out" death rate. Koreans have more than double US "latest deaths" in per capita terms.

 

Also, setting aside US for a moment.  Japan did much better than most countries.  But Japan did not have heavy testing or lockdowns.

But S. Korea and Italy had heavy testing. 

 

You want to follow S. Korea and Italy with heavy testing rather than look at what Japan did?

 

Yes I want to follow S Korea. Italy did not do a good job of testing. USA is beyond where Japan ever was.

 

This is an infection where it takes ~1 week to show symptoms from catching the virus and maybe ~2 weeks to severe symptoms and mortality. As the U.S. is early in this processes, as I have repeated on here (though some claim it has infected "millions for months" here), the fear is that the deaths are yet to come. S Korea is likely on the tail end so their deaths are probably going to level off.

 

See the exponential mortality graph of U.S. I posted on here a few posts back.

 

My local DOH is no longer testing in my county. I talked to the epidemiologist today and new recommendation is anyone with symptoms to quarantine for 14 days. No more tests for community unless pt is admitted.  Give me your information so you can talk to this guy. Im sure he would love to hear from you.

[ERICOPOLY]

Last year, it is estimated that 38,800 died in the US from auto crashes, and I'm guessing that the average life is cut short by 30-40 yrs in a car crash.

 

So I guess that automobile crashes cost the US population 1,164,000 - 1,552,000 years of life annually.

 

In terms of years of life lost, that is equal to losing 582,000 to 776,000 lives to COVID-19, assuming it cuts short the average life of it's victims by 2 years.

[Guest cherzeca]

I hope everyone by now has noticed the resemblance between modeling in the finance world (for example structured finance) and the modeling being done by epidemiologists today in our world.  we have epidemiologists with models and assumptions, telling the country what we should be doing in response to a novel virus.  resembles to me a bad trade in the finance world.  cant we fire the epidemiologists like we can some wayward financial analyst?

[TwoCitiesCapital]

I hope everyone by now has noticed the resemblance between modeling in the finance world (for example structured finance) and the modeling being done by epidemiologists today in our world.  we have epidemiologists with models and assumptions, telling the country what we should be doing in response to a novel virus.  resembles to me a bad trade in the finance world.  cant we fire the epidemiologists like we can some wayward financial analyst?

 

Not sure I understand this. A month ago, no one was dead in Italy. Now 3000+ plus are dead with an additional 400-500 coming in daily despite the fact the entire country has been shut down for 9 days.

 

Similar numbers in the US would be 15,000 dead in 2 weeks time with a full shutdown - but we haven't done that yet. LA just announced it. Nowhere else has and we have over 100k confirmed cases w/o testing.

 

This is already on course to be way worse than the 30k annually from the flu even w/ the shutdown which hasn't been implemented yet. I'm not trying to fear monger - just extrapolating the data that's available

[ERICOPOLY]

I hope everyone by now has noticed the resemblance between modeling in the finance world (for example structured finance) and the modeling being done by epidemiologists today in our world.  we have epidemiologists with models and assumptions, telling the country what we should be doing in response to a novel virus.  resembles to me a bad trade in the finance world.  cant we fire the epidemiologists like we can some wayward financial analyst?

 

Not sure I understand this. A month ago, no one was dead in Italy. Now 3000+ plus are dead with an additional 400-500 coming in daily despite the fact the entire country has been shut down for 9 days.

 

Similar numbers in the US would be 15,000 dead in 2 weeks time with a full shutdown - but we haven't done that yet. LA just announced it. Nowhere else has and we have over 100k confirmed cases w/o testing.

 

This is already on course to be way worse than the 30k annually from the flu even w/ the shutdown which hasn't been implemented yet. I'm not trying to fear monger - just extrapolating the data that's available

 

Not only did LA just announce it.

 

All of California did!  40 million people.

[LC]

I hope everyone by now has noticed the resemblance between modeling in the finance world (for example structured finance) and the modeling being done by epidemiologists today in our world.  we have epidemiologists with models and assumptions, telling the country what we should be doing in response to a novel virus.  resembles to me a bad trade in the finance world.  cant we fire the epidemiologists like we can some wayward financial analyst?

 

Not sure I understand this. A month ago, no one was dead in Italy. Now 3000+ plus are dead with an additional 400-500 coming in daily despite the fact the entire country has been shut down for 9 days.

 

Similar numbers in the US would be 15,000 dead in 2 weeks time with a full shutdown - but we haven't done that yet. LA just announced it. Nowhere else has and we have over 100k confirmed cases w/o testing.

 

This is already on course to be way worse than the 30k annually from the flu even w/ the shutdown which hasn't been implemented yet. I'm not trying to fear monger - just extrapolating the data that's available

 

What I find mind-boggling is that the first confirmed case in Italy was on Jan 31.

The first confirmed case in the USA (WA state) was on Jan 21.

 

Obviously the two areas are different, but to date there are 74 coronavirus deaths in WA, versus 3,400 in Italy.

 

On the flip side, let's compare Italy vs NYC:

 

Italy first case: Jan 31

NYC first case: March 1

 

NYC has about 4500 cases and about 30 deaths.

 

When Italy had about 4600 cases, deaths were around 175.

 

 

[TwoCitiesCapital]

I hope everyone by now has noticed the resemblance between modeling in the finance world (for example structured finance) and the modeling being done by epidemiologists today in our world.  we have epidemiologists with models and assumptions, telling the country what we should be doing in response to a novel virus.  resembles to me a bad trade in the finance world.  cant we fire the epidemiologists like we can some wayward financial analyst?

 

Not sure I understand this. A month ago, no one was dead in Italy. Now 3000+ plus are dead with an additional 400-500 coming in daily despite the fact the entire country has been shut down for 9 days.

 

Similar numbers in the US would be 15,000 dead in 2 weeks time with a full shutdown - but we haven't done that yet. LA just announced it. Nowhere else has and we have over 100k confirmed cases w/o testing.

 

This is already on course to be way worse than the 30k annually from the flu even w/ the shutdown which hasn't been implemented yet. I'm not trying to fear monger - just extrapolating the data that's available

 

What I find mind-boggling is that the first confirmed case in Italy was on Jan 31.

The first confirmed case in the USA (WA state) was on Jan 21.

 

Obviously the two areas are different, but to date there are 74 coronavirus deaths in WA, versus 3,400 in Italy.

 

On the flip side, let's compare Italy vs NYC:

 

Italy first case: Jan 31

NYC first case: March 1

 

NYC has about 4500 cases and about 30 deaths.

 

When Italy had about 4600 cases, deaths were around 175.

 

I mean NYC went from 2k to 4k overnight after only testing 8k people....it's only just become an issue for them and I started heard stories of some hospitals being overwhelmed just a day or two ago.

 

Generally the demographic is younger than Italy, but the real risk is overwhelming the healthcare system which is only just now happening in NYC.