There Might Be An App For That (Or Not)

The newly emergent human virus SARS-CoV-2 is resulting in high fatality rates and incapacitated health systems. Preventing further transmission is a priority. We analyzed key parameters of epidemic spread to estimate the contribution of different transmission routes and determine requirements for case isolation and contact-tracing needed to stop the epidemic. We conclude that viral spread is too fast to be contained by manual contact tracing, but could be controlled if this process was faster, more efficient and happened at scale. A contact-tracing App which builds a memory of proximity contacts and immediately notifies contacts of positive cases can achieve epidemic control if used by enough people. By targeting recommendations to only those at risk, epidemics could be contained without need for mass quarantines (‘lock-downs’) that are harmful to society. We discuss the ethical requirements for an intervention of this kind.

In this study, we estimated key parameters of the SARS-CoV-2 epidemic, using an analytically solvable model of the exponential phase of spread and of the impact of interventions. Our estimate of R0 is lower than many previous published estimates, for example (12, 28, 29). These studies assumed SARS-like generation times; however, the emerging evidence for shorter generation times for COVID-19 implies a smaller R0. This means a smaller fraction of transmissions need to be blocked for sustained epidemic suppression (R < 1). However, it does not mean sustained epidemic suppression will be easier to achieve because each individual’s transmissions occur in a shorter window of time after their infection, and a greater fraction of them occurs before the warning sign of symptoms. Specifically, our approaches suggest that between a third and a half of transmissions occur from pre-symptomatic individuals. [ed. Emphasis added] This is in line with estimates of 48% of transmission being presymptomatic in Singapore and 62% in Tianjin, China (30), and 44% in transmission pairs from various countries (31). Our infectiousness model suggests that the total contribution to R0 from pre-symptomatics is 0.9 (0.2 - 1.1), almost enough to sustain an epidemic on its own. For SARS, the corresponding estimate was almost zero (9), immediately telling us that different containment strategies will be needed for COVID-19.

Transmission occurring rapidly and before symptoms, on April 1, 2020 as we have found, implies that the epidemic is highly unlikely to be contained by solely isolating symptomatic individuals. [ed. Emphasis added] Published models (9–11, 32) suggest that in practice manual contact tracing can only improve on this to a limited extent: it is too slow, and cannot be scaled up once the epidemic grows beyond the early phase, due to limited personnel. Using mobile phones to measure infectious disease contact networks has been proposed previously (33–35). Considering our quantification of SARS-CoV-2 transmission, we suggest that this approach, with a mobile phone App implementing instantaneous contact tracing, could reduce transmission enough to achieve R < 1 and sustained epidemic suppression, stopping the virus from spreading further. We have developed a web interface to explore the uncertainty in our modelling assumptions (24). This will also serve as an ongoing resource as new data becomes available and as the epidemic evolves. 

We included environmentally mediated transmission and transmission from asymptomatic individuals in our general mathematical framework. However, the relative importance of these transmission routes remain speculative based on current data. Cleaning and decontamination are being deployed to varying levels in different settings, and improved estimates of their relative importance would help inform this as a priority. Asymptomatic infection has been widely reported for COVID-19, e.g., (14), unlike for SARS where this was very rare (36). We argue that the reports from Singapore imply that even if asymptomatic infections are common, onward transmission from this state is probably uncommon, since forensic reconstruction of the transmission networks has closed down most missing links. There is an important caveat to this: the Singapore outbreak to date is small and has not implicated children. There has been widespread speculation that children could be frequent asymptomatic carriers and potential sources of SARSCoV-2 (37, 38). 

We calibrated our estimate of the overall amount of transmission based on the epidemic growth rate observed in China not long after the epidemic started. Growth in Western European countries so far appears to be faster, implying either shorter intervals between individuals becoming infected and transmitting onwards, or a higher R0. We illustrate the latter effect in figs. S18 and S19. If this is an accurate picture of viral spread in Europe and not an artefact of early growth, epidemic control with only case isolation and quarantining of traced contacts appears implausible in this case, requiring near-universal App usage and near-perfect compliance. The App should be one tool among many general preventative population measures such as physical distancing, enhanced hand and respiratory hygiene, and regular decontamination. 

An App-based intervention could be more powerful than our analysis here suggests, however. The renewal equation mathematical framework we use, while well adapted to account for realistic infectiousness dynamics, is not well adapted to account for benefits of recursion over the transmission network. Once they have been confirmed as cases, individuals identified by tracing can trigger further tracing, as can their contacts and so on. This effect was not modeled in our analysis here. If testing capacity is limited, individuals who are identified by tracing may be presumed confirmed upon onset of symptoms, since the prior probability of them being positive is higher than for the index case, accelerating the algorithm further without compromising specificity. With fast enough testing, even index cases diagnosed late in infection could be traced recursively, to identify recently infected individuals before they develop symptoms, and before they transmit. Improved sensitivity of testing in early infection could also speed up the algorithm and achieve rapid epidemic control. 

The economic and social impact caused by widespread lockdowns is severe. Individuals on low incomes may have limited capacity to remain at home, and support for people in quarantine requires resources. Businesses will lose confidence, causing negative feedback cycles in the economy. Psychological impacts may be lasting. Digital contact tracing could play a critical role in avoiding or leaving lockdown. We have quantified its expected success and laid out a series of requirements for its ethical implementation. The App we propose offers benefits for both society and individuals, reducing the number of cases and also enabling people to continue their lives in an informed, safe, and socially responsible way. It offers the potential to achieve important public benefits while maximising autonomy. Specific issues exist for groups within the population that may not be amenable to such an approach, and these could be rapidly refined in policy. Essential workers, such as health care workers, may need separate arrangements. Further modelling is needed to compare the number of people disrupted under different scenarios consistent with sustained epidemic suppression. But a sustained pandemic is not inevitable, nor is sustained national lockdown. We recommend urgent exploration of means for intelligent physical distancing via digital contact tracing.

Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing (pdf). Science.

Luca Ferretti1 *, Chris Wymant1 *, Michelle Kendall1 , Lele Zhao1 , Anel Nurtay1 , Lucie Abeler-Dörner1 , Michael Parker2 , David Bonsall1,3†, Christophe Fraser1,4†‡ 1

Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK. 2 Wellcome Centre for Ethics and the Humanities and Ethox Centre, University of Oxford, Oxford, UK. 3 Oxford University NHS Trust, University of Oxford, Oxford, UK. 4 Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK.
[ed. In other words, total and specific surveillance]

Not Flattening

4/1/2020

[ed. Source: Not Winning This Fight. See also: Infected but Feeling Fine: The Unwitting Coronavirus Spreaders (both NY Times).]

Reflections on a Disaster

[ed. I've only been involved in one major disaster in my life - coordinating and supervising cleanup for the Exxon Valdez oil spill - but the ongoing cornonavirus response has prompted reflection on parallels that might be instructive in our present-day crisis (especially since this time around we're the affected wildlife):

Initially, disbelief followed by widespread horror and panic (in this case, more like a dawning realization of severity). Decisions are ceded to experts (scientists), who themselves are overwhelmed with intense pressure to gather data quickly, disseminate information, coordinate with peers, and interact with the public (media being a constant presence and distracting pressure). Different plans are evaluated and, after many fits and starts, a final approach/strategy is agreed to. Resources (such as they are) are marshalled, checkbooks open, massive dollars are allocated (with flexible terms and wide distribution) and logistics become key. Timelines for securing needed equipment and support facilities become the most important factors driving success of the response going forward. [ed. Where we are now: 4/1/2020.]

At the same time (and throughout the rest of the response), various alternatives and response actions will continue to be proposed, reviewed, tested and modified. Confusion escalates as different players insert themselves into the decision-making process, jockeying for influence. Unsoliticed advice and untested 'solutions' flood in, jamming lines of communication and authority. [ed. Where we are now: 4/6/2020. But expect this process to continue indefinitely.]

As more resources are secured and the response ramps up, focus shifts to execution. But it's execution that's uneven, with different priorities and targets based on different sources of input and pressure. Some areas are hit harder than others. Politicians propose new emergency orders and legislation. Communities and other affected entities become increasingly more vocal and activist. Lobbyists and others (insurers, risk management experts, state and foreign delegations, etc.) descend in droves. Advocacy organizations mobilize supporters.

Then, whatever happens happens, with success (a highly subjective and undefined term) largely dependent upon how closely response efforts adhere to established guidelines (usually, hit or miss); guidelines which themselves are constantly being revised to incorporate new sources of information (leading to more confusion). (ed. Where we are now: 4/16/2020).

This goes on for some time with the system evaluating and re-evaluating various metrics of success while chains-of-command gradually reassert themselves. Prominent players from early in the response (eg. scientists, administrators, technicians) are slowly shuffled back into their established roles so that messaging can be more effectively managed by higher level personnel more attuned to political and PR considerations. The public can only watch and form their own conclusions about decisions that were made, how effective they are, and what it all means, or will mean. Media plays a large role in defining public opinion. (Where we are now, May 2, 2020).

Finally, at some later stage (post-peak, well into the response) as the disaster slowly abates, expect to see growing opportunism, ass-covering, finger-pointing and greed (remember all that money?). This phase was especially grating since nearly everyone involved started with a common focus and unmitigated mutual trust and support. It was particularly instructive to see how the spill destabilized existing power relationships and how those relationships eventually reestablished themselves. Power snaps back.

With this disaster, in an election year, it'll be interesting to see how this all plays out. Especially now that 'disaster capitalism' is a well understood concept (which wasn't the case back then), and also because of the open-ended nature of the problem itself. See also: The Lockdown Is an Opportunity to Redefine What Our Economy Is For (Jacobin). I can only speculate but have a feeling that recovery will be a long and uniquely difficult/different process this time. In many ways, large and small, the world will never be the same again. We'll see what that means.

Note: As the coronavirus response proceeds, I'll link to this post once in a while to see how closely we're following the script. 

See also: What Are The Dying Worth? and Why the Global Recession Could Last a Long Time (NY Times).]

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Food Fight

By now, the sight of ravaged grocery store shelves across the United States has become grimly familiar—and those right-wing memes about food shopping in Venezuela are suddenly as scarce as hen’s teeth—as the country struggles to contain the rapidly spreading coronavirus pandemic. Grocery stores have become ground zero in the battle over social distancing and the site of endless disheartening displays of misguided resource hoarding. Worse, millions of underpaid and overworked grocery store workers are now on the receiving end of the public’s panic over the pandemic—as well as their germs.

Not only does the nature of their work put all grocery store employees—from cashiers to floor workers to those in the warehouse—at high risk of exposure to the virus, they’re also forced to deal with customers’ increasingly nasty attitudes, as supplies run out and shelves sit empty. This added emotional labor is, of course, unpaid, and many hourly workers are braving such conditions without the protection of a union or a living wage, to say nothing of paid sick leave or hazard pay. Through it all, there’s continued pressure coming from above for them to stay smiling as the world around them crumbles. These essential workers are being treated as disposable. As one told me yesterday, “It’s hard to feel like an essential worker when you don’t have health care.”

Even people who work at supposedly more progressive chains like Trader Joe’s and Whole Foods (at least until its Amazon takeover) are anxious, tired, and afraid, and they certainly aren’t being paid enough to deal with these extraordinary circumstances—especially when the hand sanitizer runs out, and emotions at the cash register run high.

“None of us ever expected to be emergency workers; the idea of an ‘essential worker’ is a totally new concept that no grocery store bag boy considers when they drop off an application,” a current Whole Foods worker who prefers to stay anonymous told me. “There’s all of this rhetoric around how we’re just as important as the doctors, and yes, that’s true, but we’re getting paid way less, and medical workers have a little bit more of an idea of the risks that they are setting themselves up for. . . . We’re not used to this shit.” (...)

The lack of safety and support in the workplace is even more of a problem now that the ongoing coronavirus pandemic has thrust Trader Joe’s workers and their fellow grocery store workers onto the front lines of a public health crisis. As a current TJ’s worker based in a Manhattan store put it, “Trader Joes does not give a fuck about human beings; at the end of the day, this is just progressive-themed corporate retail without a soul.”

Trader Joe’s isn’t the only crunchy liberal favorite that has been coming under fire from its frightened and frustrated workforce. Whole Foods—another grocery chain with a notorious allergy to unions—has also failed its workers during this fraught time. The company has taken only incremental measures to protect them, like promising workers up to two weeks of sick leave contingent on a positive COVID-19 test at a time when the vast majority of civilians cannot access them, and offering a $2 hourly wage increase through April. Meanwhile, the chain’s parent company is literally owned by the richest man in the world. (...)

Back in January, Whole Foods cut health care benefits for 1,900 of its part-time workers, a decision that now appears especially cruel. As the Chicago worker told me, “Any kind of argument about money saving or profitability just seems totally absurd when we’re owned by Jeff Bezos. There’s no rationalization for not giving your workers health insurance during a pandemic.”

A group called Whole Worker has since launched a public campaign to hold Whole Foods accountable. They have organized a sickout today in order to bring attention to their demands, which include guaranteed paid sick leave for workers who self-quarantine, hazard pay, proper sanitation procedures, and reinstating the health care benefits that were lost in January. Since Whole Foods has temporarily relaxed its attendance policy, those who participate in the sickout can do so without fear of reprisal, which is a huge advantage when dealing with a company so adamantly opposed to collective organizing.

Matthew Hunt, a former Whole Foods worker who says he was fired in 2017 for trying to start a union, spent several years with the United Food and Commercial Workers International Union (UFCW) before reconnecting with some of his former colleagues and starting Whole Worker. Hunt, who lives in Queens, theorizes that the company is actively trying to cover up the number of employees who have already been exposed. “They’re just protecting their profits. That’s what they do, so I wouldn’t expect anything less from the employing class, especially Jeff fucking Bezos,” he says. “They want people to either quit or to show up to work. They really don’t give a shit about employees.”

by Kim Kelly, The Baffler |  Read more:

Image: Wikimedia Commons

[ed. See also: We Keep You Alive (The Baffler); “Amazon Is a Breeding Ground”; Nationalize Amazon (Jacobin); and We Need Amazon During the Coronavirus. That’s a Problem. (NY Times).]

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Bosses Panic-Buy Spy Software to Keep Tabs on Remote Workers

The email came from the boss.

We’re watching you, it told Axos Financial Inc. employees working from home. We’re capturing your keystrokes. We’re logging the websites you visit. Every 10 minutes or so, we’re taking a screen shot.

So get to work — or face the consequences.

“We have seen individuals taking unfair advantage of flexible work arrangements” by essentially taking vacations, Gregory Garrabrants, the online bank’s chief executive officer, wrote in the March 16 message reviewed by Bloomberg News. If daily tasks aren’t completed, workers “will be subject to disciplinary action, up to and including termination.”

Straight-up Big Brother, perhaps, but it’s perfectly legal for businesses to keep an unblinking eye on employees as long as they disclose they’re doing it. Of course, digital surveillance has been used for years on office desktops, yet it seems a violation of privacy to a lot of workers when they’re required to have software on their computers that tracks their every move in their own homes.

Workers at various companies have complained of excesses, but many of them are new to telecommuting, with its temptations of a midday nap or the demands of children out of school. Employers justify going full Orwell by saying that monitoring curbs security breaches, which can be expensive, and helps keep the wheels of commerce turning.

With so many people working remotely because of the coronavirus, surveillance software is flying off the virtual shelves.

by Polly Mosendz and Anders Melin, Bloomberg | Read more:
Image: Nick Little
[ed. See also: Bigger Brother: The Age of Surveillance Capitalism (NYRB).]

Marinel Sheu, Home alone
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The Frontier Couple Who Chose Death Over Life Apart

Eric Bealer arrived in Sitka for the last time in a boat weighed down with his art.

It was late March 2018. Bealer, an Alaskan artist who specialized in intricately detailed wood engravings, had just traveled for two days from his homestead on Lisianski Inlet, through the rough winter waters off the west­ern edges of Chichagof and Baranof Islands, to the relative shelter of Sitka Sound. His skiff, built by hand using materials harvested and salvaged from Alaska’s coast, was jam-packed with his work: old prints, new prints, even the ink-stained, delicately carved wooden blocks used to make the prints themselves. There was so much art filling the little boat that, during his overnight layover en route to Sitka, Bealer had no room to lie down. He slept onshore, on the ground.

Eugene Solovyov met him on the dock in Sitka’s Crescent Harbor. Solovyov, owner of the Sitka Rose Gallery, had known Bealer for more than two decades, ever since the artist walked in one day in the mid-1990s, looking to place his work. Solovyov was immediately impressed with Bealer’s depictions of Alaska’s landscapes, the state’s flora and fauna. It wasn’t just the technical proficiency, the fine detail. Bealer’s images, wild and moody, made you feel something. And they were the kind of art almost anyone could afford: prints sold for $25, or $40, or $45. Bealer went on to become the gallery’s most popular artist with both visitors and locals.

In their twenty-plus years of acquaintance, the pair had became much more than gallery owner and artist, vendor and producer. They were close friends. Every couple of years, Bealer would travel to Sitka by plane or boat for a gallery show. He stayed in Solovyov’s apartment, and they’d catch up over a few beers. Sometimes, Bealer’s wife, Pam, came along, too, although her visits were less frequent after she was diagnosed with multiple sclerosis, an autoimmune disease that attacks the nerves in the brain and spinal cord, with effects ranging from manageable problems like pain and numbness to serious physical disabilities. As the years passed and Pam’s symptoms worsened, she and Solovyov kept in touch by e-mail, trading photos and stories.

Solovyov later told me that, when he saw the little boat crammed with art that March day, he should have known. For years, the couple had talked with close friends about their intention to die together when Pam’s time came. She did not wish to see her disease through; Eric did not plan to live without his wife. But it was one thing to talk about this in the abstract. It was another for Solovyov to stand in the harbor and realize that his friend had prepared his last exhibition. “He brought everything with him,” he said.

The show went well. Bealer’s work sold briskly, as it always does, and when he motored out of the harbor and headed home, his boat was a great deal lighter.

Throughout that summer, the Bealers traveled back and forth between their main homestead, a few miles outside the small village of Pelican, and their more remote cabin nearby, on the west coast of Yakobi Island. They planted their vegetable garden and cared for their chickens. They worked on their art. In early September, they headed to the cabin again.

Isolated as the cabin was, they had a neighbor there, and his place had Wi-Fi, which they were able to use even when he was away. So they were generally in touch with people by e-mail. When that communication stopped, in mid-September, their friends took notice. They put the word out to folks in Pelican: If anyone was heading for Yakobi Island, could they look in on the Bealers?

On October 5, a pair of Pelican-area residents, a married couple, made the trip to the island. Leaving his wife in their boat, the husband hiked up a trail to the Bealers’ cabin. The screen door to the covered porch was open. He went in and found a plastic bin filled with packages and letters, and a note taped to the glass window of the main door, which was locked. On one side the note read: “Hello, if you are looking for the Bealers… Please read this. If you found this, please mail the attached packages. It will go to the people who will know what to do next and take care of things. Please accept the cash as a gift to pay you for your trouble, and postage for these packages and envelopes.”

On the back side it said, “To the world and all concerned: This is to officially notify you that Eric and Pam Bealer, by their own choice and free will, have committed suicide. We are dead, gone, and free from this physical world. Free. We have gone to some effort to hide our bodies, as we do not want them found. Please do not waste time and money looking. It would serve no purpose. We are gone, leave us to our peace.”

Below their declaration was a passage attributed to Richard Bach, which said: “Why, instead of suffering and fighting it, don’t people reach a time when they decide, ‘Done! We’ve finished everything we came to do. There are no mountains we haven’t pretty well climbed, nothing unlearned we wanted to learn, we’ve lived a nice life.’ And then they just sit themselves down under a tree or a star, lift themselves out of their bodies, and never come back?”

Underneath the poem was one more note from the Bealers: “Why indeed?” (...)

My thoughts about the right to die be­gan to form in the mid-1990s, shaped by two high-profile Canadian cases. The first was the death of Sue Rodriguez, a woman with ALS who had fought all the way to the Canadian Supreme Court for the right to receive medical assistance in dying on her own timetable. The court turned her down five to four, but Rodriguez found a still-anonymous doctor who was willing to break the law to help her. She died February 12, 1994, from an overdose of morphine.

Around the same time as the Rodriguez case, a farmer in Saskatchewan named Robert Latimer put his 12-year-old daughter, Tracy, in his truck and filled the cab with exhaust, killing her. Tracy had a severe case of cerebral palsy—she couldn’t speak or walk, among other limitations—and over a chorus of outrage from disability-rights advocates, Latimer defended his choice by saying that he was sparing her further agony. He was found guilty of second-degree murder.

I was in junior high when these stories played out. I didn’t have any strong feelings about Rodriguez’s case, just a vague, unexamined sense that she was right. Tracy Latimer, unable to speak for herself, was much more complicated. But I latched on to something I’d heard on the radio: that she suffered as many as a half-dozen seizures a day.

At the time, I was newly diagnosed with epilepsy, and the three full-body seizures I’d experienced before medication brought them under control were the worst experiences of my young life. I remember sitting at a table at school with a few friends, talking about the Latimer case, and while I didn’t pretend to know what Tracy thought or felt, I knew one thing for sure. “If you told me I’d have six seizures a day, every day, for the rest of my life,” I said, “I would beg you to kill me.”

So I grew up broadly sympathetic to the idea of choosing one’s own time and place. But on three occasions I also felt the particular, sickening sadness of learning that a classmate has died by suicide. I’ve read about suicide clusters and suicide contagion. I know that it can be a corrosive act, leaving grief and anger in its wake. Our choices can have ripple effects far beyond our own lives. (...)

Assisted suicide is not yet legal in Alaska, and Pam Bealer wouldn’t have qualified for it anyway—most legal frameworks require the patient’s death to be imminent. Eric’s choice goes beyond what most right-to-die advocates envision. I wasn’t sure how to feel about what they’d done.

by Eva Holland, Outside |  Read more:

Image: uncredited
[ed. I predict someday we'll look back on our current end-of-life policies with something like horror. Speaking only for myself, the way I'll die scares me a hell of a lot more than the when.] 

John Prine

[ed. Good luck to John.]

Where We Are Today: 3/30/2020

[ed. Professor Kim Woo-joo from Korea University Guro Hospital. In Korean, with subtitles. Generally known information but with some specific details. Excellent interview. Update (Uh-oh): Mystery In Wuhan: Recovered Coronavirus Patients Test Negative ... Then Positive (NPR).]

Alberto Magnelli (Italian, 1888–1971.)
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Bob Dylan

[ed. Trump Extends Social Distancing Guidelines Through End of April. Something finally got to him (which is scary in itself). See also: Coronavirus Slowdown in Seattle Suggests Restrictions Are Working (NY Times).]

"Citing figures from his advisers that showed that as many as 200,000 people could die from the virus even if the country took aggressive action to slow its spread, Mr. Trump said the restrictions must continue, even if it meant more sacrifice in the days ahead.

“During this period, it’s very important that everyone strongly follow the guidelines. Have to follow the guidelines,” Mr. Trump told reporters, with members of the government’s coronavirus task force nearby. “Therefore, we will be extending our guidelines to April 30 to slow the spread.”

Getting Through, Making Memories and Being the Grown-Ups

I’m not here to tell you what the “good thing” is about the coronavirus situation, because there is no good thing about a pandemic, not ever. That doesn’t mean there won’t be acts of heroism, because there will be, and heartwarming stories, because we’ll have those too, and even — if we’re lucky — moments of scientific brilliance. But we still have to get through the bad stuff. And getting through the bad stuff with your kids may be your act of heroism, your heartwarming story, and even your moment of scientific brilliance.

What I’m here to tell you, you already know, but even so, it’s always a hard thing to hear, at any age: we — the grown-ups — have to be the grown-ups here. And for those with young children, especially those at home now for the foreseeable future with those young children, with schools and day care centers closed, with “social distancing” the order of the day, I want to talk about getting through, making memories and being the grown-ups.

First a disclaimer: I’m a pediatrician and a mother of three, but I’m not particularly good at spending long periods of time with young children — or elementary-school-age children. I like children, and I think they’re interesting, and I’d certainly rather have them as my patients than adults, but I have always understood that I do not have what it takes to be even a decent day care teacher, or kindergarten teacher, or grade school teacher.

My kids had plenty of decent teachers, and not a few brilliant teachers, with all the energy and creativity and endless patience that I don’t have, and I worshiped them with the grateful fervor of the parent who knew that she paled by comparison. And certainly we should all acknowledge how much skill goes into doing these jobs well — and as we yearn for the world to start up again, maybe we’ll spare some energy to do that.

But here’s the thing — in addition to everything else that you are doing, if you are unexpectedly home with your kids right now, in addition to trying to work from home, and tracking all the worrisome news, and hoarding toilet paper (just kidding), not to mention looking up recipes for making your own hand sanitizer — in addition to all that, you are also making memories, and helping your kids lay them down.

This is going to be an event that defines their childhoods. It’s going to be a touchstone for the little kids whose schools have closed just as it is for the college students sent home when they expected to be spring breaking and senior springing. Decades from now, at their college reunions, this will be one of the things those students remember, what they hark back to, what they have in common.

It will be like the memories of where you were and what you understood on 9/11, or (for people my age) where you were and what you understood when John F. Kennedy was assassinated — but it will be more than that, because it will not just be about where you were and what you did at one defining point in time, but instead a memory of a long, strange interlude, when the world was interrupted. And heaven knows, there are many things about that future memory that are out of our control. So let me acknowledge the many levels of uncertainty, anxiety and catastrophic thinking that are gripping us all.

by Perri Klass, MD, NY Times |  Read more:

Image: Getty

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[ed. Sheltering in place.]

The Korean Clusters and Patient 31

The Korean Clusters and Patient 31 (Reuters)
Image: Korea Centers for Disease Control & Prevention (KCDP)
[ed. See also: The Missing Six Weeks (The Guardian).]

CoronaLinks 3/27/20: We're Number One

The United States now has more coronavirus cases than any other country, including China, marking a new stage in the epidemic. As before, feel free to treat this as an open thread for all coronavirus-related issues. Everything here is speculative and not intended as medical advice.

Hammer and dance

Most of the smart people I’ve been reading have converged on something like the ideas expressed in The Hammer And The Dance – see this Less Wrong post for more.

[ed. For summaries of these links, see the following posts.]

Summary: Asian countries have managed to control the pandemic through mass testing, contact tracing, and travel bans, without economic shutdown. The West lost the chance for a clean win when it bungled its first month of response, but it can still recover its footing. We need a medium-term national shutdown to arrest the spread of the virus until authorities can get their act together – manufacture lots of tests and face masks, create a testing infrastructure, come up with policies for how to respond when people test positive, distribute the face masks to everyone, etc. With a lot of work, we can manage that in a month or so. After that, we can relax the national shutdown, start over with a clean slate, and pursue the Asian-style containment strategy we should have been doing since the beginning.

This is the only plan I’ve heard from anybody that doesn’t result in either hundreds of thousands of deaths, or the economy crashing so hard we’re all reduced to eating weeds and rocks.

I relayed some criticism of a previous Medium post, Flattening The Curve Is A Deadly Delusion, last links post. In retrospect, I was wrong, it was right (except for the minor math errors it admitted to), and it was trying to say something similar to this. There is no practical way to “flatten the curve” except by making it so flat that the virus is all-but-gone, like it is in South Korea right now. I think this was also the conclusion of the Imperial College London report that everyone has been talking about. (...)

Japan and other mysteries

Japan should be having a terrible time right now. They were one of the first countries to get coronavirus cases, around the same time as South Korea and Italy. And their response has been somewhere between terrible and nonexistent. A friend living in Japan says that “Japan has the worst coronavirus response in the world (the USA is second worst)”, and gets backup from commenters, including a photo of still-packed rush hour trains. Japan is super-dense and full of old people, so at this point the living should envy the dead.

But actually their case number has barely budged over the past month. It was 200 a month ago. Now it’s 1300. This is the most successful coronavirus containment by any major country’s, much better than even South Korea’s, and it was all done with zero effort.

The obvious conclusion is that Japan just isn’t testing anyone. This turns out to be true – they were hoping that if they made themselves look virus-free, the world would still let them hold the Tokyo Olympics this summer.

But at this point, it should be beyond their ability to cover up. We should be getting the same horrifying stories of overflowing hospitals and convoys of coffins that we hear out of Italy. Japanese cities should be defying the national government’s orders and going into total lockdowns. Since none of this is happening, it looks like Japan really is almost virus-free. The Japan Times is as confused about this as I am.

Some people have gestured at the Japanese being an unusually clean and law-abiding people. Maybe the government has just sort of subtly communicated “don’t do anything that will mess up our Olympics chances” and everyone has been really good at not touching their face. Maybe widespread use of face masks is much much more important than anyone has previously believed. I don’t know.

One way this should affect us Westerners is by making us worried that an Asian-style containment strategy wouldn’t work here. The evidence in favor of such a strategy is that it worked in a bunch of Asian countries like South Korea, Taiwan, Hong Kong, and Singapore. But if there’s something about wealthy orderly mask-wearing Asian societies that makes them mysteriously immune to the pandemic, maybe their containment strategies aren’t really that impressive. Maybe they just needed a little bit of containment to tip them over the edge. I don’t know, things sure seemed bad in South Korea a few weeks ago (and in Wuhan). I am so boggled by this that I don’t know what to think.

Also, what about Iran? The reports sounded basically apocalyptic a few weeks ago. They stubbornly refused to institute any lockdowns or stop kissing their sacred shrines. Now they have fewer cases than Spain, Germany, or the US. A quick look at the data confirms that their doubling time is now 11 days, compared to six days in Italy and four in the US. Again, I have no explanation.

Takeout

So far every US state and local self-isolation order has included exceptions for getting takeout or delivery food. I’m sure restaurants appreciate the business and consumers appreciate getting to keep that particular aspect of a normal lifestyle. But is it actually safe?

All the big organizations say yes. From Forbes:

“Takeout food seems to pose a very minimal risk of passing on coronavirus. Here, virology experts explain why….”There is no evidence that SARS-CoV-2 can be transmitted by eating food. I imagine that if this is possible, the risk is extremely low,” said Angela L. Rasmussen, PhD, a virologist in the faculty of the Center for Infection and Immunity at the Columbia Mailman School of Public Health, adding that she is not aware of any human coronaviruses that can be transmitted through food.

And the San Francisco Chronicle:

With dining in restaurants off the table, many Americans are wondering if take-out and delivery food options are still viable in the age of coronavirus. Luckily for people tired of their own home cooking, the answer is, by and large, yes. 

According to the CDC, transmission of COVID-19 primarily happens person-to-person, so your largest risk is not in the food but in human interaction. Keep your distance as much as possible when picking up food, or request that delivery workers leave the food on your doorstep. As with other in-person interactions, remember to avoid touching your face and be sure to wash your hands thoroughly as soon as you can. 

“It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads,” the CDC says.

On the other hand, all of my friends who are actually worried about getting the condition are avoiding delivery food like, well, the plague. Their argument is that we know the virus can survive on surfaces for a while, so all you need is one food worker to cough on your food after it’s been cooked (or on food that doesn’t get cooked at all), and you’re screwed. Restauarants are supposed to follow sanitary precautions, but people familiar with the industry say these precautions are not so strong to 100% (or even an especially high percent) ensure you get un-coughed-on food. The CDC telling food workers they don’t need face masks does not exactly inspire confidence here.

I am really craving something other than the three or four things I can cook myself, and I have a lot of mutually-quarantined housemates to convince, so if any of you have any clearer estimate of the risk situation, please share.

Ventilator numbers

Britain has 5,000, or one per 12,000 citizens. The US has 160,000, or about 1 per 2,000 citizens (why are these numbers so different?). The head of a small ventilator company says they usually “sell 50 in a good month”.

Elon Musk recently delivered 1,255 ventilators to California from some of Tesla’s Chinese contacts, and promised to make more. Dyson, the British vacuum manufacturer, says it will be able to make 10,000 ventilators in time to help with the crisis – remember, that’s twice what the whole UK has right now. The American Hospital Association says 960,000 Americans may require ventilators during the pandemic – hopefully not all at once.

Ventilators also require trained staff to operate. I never know how far to trust medical people when they say something requires training. You would think doing a lumbar puncture requires training, but the training I received for this in residency was watching one (1) guy do it one (1) time, and then them saying “Now you do it” – which by the way is exactly as scary as you would expect. This is an official thing in medical education, called see one, do one, teach one. So when people say some medical task requires training, I don’t know if they mean “ten years’ experience and a licensing exam”, “watch it once and then we throw you in the deep end” or “we’re going to make you go through the former, but the latter would have worked too”. Hopefully ventilators are more like the latter and someone can train new people really quickly.

If you’re confused about the difference between ventilators, oxygen concentrators, etc, or you have clever questions like “can we repurpose CPAP machines as ventilators?”, you might like Sarah Constantin’s Oxygen Supplementation 101.

The British reversal

A UK critical care doctor on Reddit wrote a great explanation of their recent about-face on coronavirus strategy.

They say that over the past few years, Britain developed a cutting-edge new strategy for dealing with pandemics by building herd immunity. It was actually really novel and exciting and they were anxious to try it out. When the coronavirus came along, the government plugged its spread rate, death rate, etc into the strategy and got the plan Johnson originally announced. This is why he kept talking about how evidence-based it was and how top scientists said this was the best way to do things.

But other pandemics don’t require ventilators nearly as often as coronavirus does. So the model, which was originally built around flu, didn’t include a term for ventilator shortages. Once someone added that in, the herd immunity strategy went from clever idea to total disaster, and the UK had to perform a disastrous about-face. Something something technocratic hubris vs. complexity of the real world.

by Scott Alexander, Slate Star Codex |  Read more:

Covid-19 Points of Leverage, Travel Bans and Eradication

#Don'tFlattenTheCurve

The optimal strategy to defeat the disease is currently the subject of much debate. Several strategies have emerged, and a popular meme right now is #flattenthecurve. The idea of flattening the curve is that if we increase the duration of the pandemic, the number of people infected at any one time will be lower and our ability to treat people properly will be increased. People put a lot of time into creating convincing memes and diagrams showing how this works:

Unfortunately people didn't put much effort into getting the numbers right. Every single one of these diagrams is a steaming pile of nonsense because the line for "Healthcare System Capacity" is about 20-50 times too high, which was first pointed out by Joshua Bach. That tiny red line right next to the x-axis is our health system capacity:

(taken from The Imperial College COVID-19 Response Team's latest report ).

The UK government's "herd immunity" strategy was another possible way forward, but the government reversed course on this when they realized it would involve at least a few hundred thousand deaths.

Contain and Eradicate

In my opinion, the correct strategy to beat covid-19 whilst minimizing losses from this point forward is a contain-and-eradicate strategy. The New England Complex Systems Institute's writeup on this, written by Nassim Nicholas Taleb of Black Swan fame outlines the strategy:

Since lockdowns result in exponentially decreasing numbers of cases, a comparatively short amount of time can be sufficient to achieve pathogen extinction, after which relaxing restrictions can be done without resurgence. ... 

Finally, the use of geographic boundaries and travel restrictions allows for effective and comparatively low cost imposition and relaxation of interventions. Such a multi-scale approach accelerates response efforts, reduces social impacts, allows for relaxing restrictions in areas earlier that are less affected, enables uninfected areas to assist in response in the ares that are infected, and is a much more practical and effective way to stop otherwise devastating outbreaks. ... 

A few other issues are of importance: They ignore the possibility of superspreader events in gatherings by not including the fat tail distribution of contagion in their model. This leads them to deny the importance of banning them, which has been shown to be incorrect, including in South Korea. Cutting the fat tail of the infection distribution is critical to reducing R0.

Basically:

- Close borders and limit internal travel, lockdown and hygiene to drive R0 below 1

- Ban large events to cut off the long tail of the R0 distribution

- Use aggressive testing and contact tracing to clean up any remaining holdouts, and eradicate the virus on a region-by-region and country-by-country level.

- "Green" regions can return to mostly normal life, albeit without large events and travel. That means that people can go back to work and we can reverse the economic damage.

Contain-and-eradicate probably results in both less loss of life and less economic damage than any other strategy, and we can see this as a consequence of taking an exponential process and fighting it in the low orders of magnitude rather than the high ones. Flatten-The-Curve is bad because a flat curve that lasts for a long time is still, in log-terms, almost at the maximum power of the virus and therefore it can do huge amounts of damage. Herd-Immunity and Deliberate-Infection are bad for the same reason. The only other sensible plan I have seen is the idea of rushing a vaccine as quickly as possible, but that is beyond my expertise.

by Roko, Less Wrong |  Read more:

Images: CDC/The Economist; The Imperial College COVID-19 Response Team report

Coronavirus: The Hammer and the Dance

This article follows Coronavirus: Why You Must Act Now, with over 40 million views and 30 translations. If you agree with this article, consider signing the corresponding White House petition. Over 30 translations available at the bottom. Running list of endorsements here. Over 10 million views so far.

Summary of the article: Strong coronavirus measures today should only last a few weeks, there shouldn’t be a big peak of infections afterwards, and it can all be done for a reasonable cost to society, saving millions of lives along the way. If we don’t take these measures, tens of millions will be infected, many will die, along with anybody else that requires intensive care, because the healthcare system will have collapsed.

Within a week, countries around the world have gone from: “This coronavirus thing is not a big deal” to declaring the state of emergency. Yet many countries are still not doing much. Why?

Every country is asking the same question: How should we respond? The answer is not obvious to them.

Some countries, like France, Spain or Philippines, have since ordered heavy lockdowns. Others, like the US, UK, or Switzerland, have dragged their feet, hesitantly venturing into social distancing measures.

Here’s what we’re going to cover today, again with lots of charts, data and models with plenty of sources:
What’s the current situation?
What options do we have?
What’s the one thing that matters now: Time
What does a good coronavirus strategy look like?
How should we think about the economic and social impacts?

When you’re done reading the article, this is what you’ll take away:

Our healthcare system is already collapsing.
Countries have two options: either they fight it hard now, or they will suffer a massive epidemic.
If they choose the epidemic, hundreds of thousands will die. In some countries, millions.
And that might not even eliminate further waves of infections.
If we fight hard now, we will curb the deaths.
We will relieve our healthcare system.
We will prepare better.
We will learn.
The world has never learned as fast about anything, ever.
And we need it, because we know so little about this virus.
All of this will achieve something critical: Buy Us Time.

If we choose to fight hard, the fight will be sudden, then gradual.
We will be locked in for weeks, not months.
Then, we will get more and more freedoms back.
It might not be back to normal immediately.
But it will be close, and eventually back to normal.
And we can do all that while considering the rest of the economy too.

Ok, let’s do this.

1. What’s the situation?

by Tomas Pueyo, Medium |  Read more:

Life Will Eventually Go Back to Being Normal-Bad Again

In a matter of weeks, the coronavirus outbreak has fundamentally changed American life. Businesses and schools have closed indefinitely, and hundreds of thousands of people have lost their jobs. As the economy continues to crash, everyday life feels more precarious than it ever has before. To help, government officials across the country are proposing a slew of benefits, such as a moratorium on evictions and mortgage payments, student loan deferments, releasing prisoners from crowded jails, moving unhoused citizens into hotels and unused apartment buildings, and sending a check to every American citizen for as long as this pandemic lasts.

These unprecedented actions have bipartisan support, as both sides of the aisle understand them to be necessary to address this national emergency. And while I know how scared Americans are feeling, I want to make one thing clear: we will weather this storm. Once the quarantine is lifted and a COVID-19 vaccine is developed, it will once again be business as usual. All the benefits you’ve come to rely on will go away, we will cut the social safety net we hastily assembled, and life will return to normal. As terrifying as things are now, we will persevere and return to the normal terror we’re used to.

We are not underestimating the devastating effects of COVID-19. We are taking this virus seriously, and help is on the way. We are in the process of implementing many left-wing policies — universal income, debt relief, free healthcare, reducing the prison population — that were unfathomable just a month ago. But I want to stress to all Americans that these policies are only temporary. While we might make coronavirus testing, and possibly even treatment, free of charge, rest assured, once this blows over, you will continue to go into debt for any other health issue. Nothing can stop the American way of life, not even a pandemic. We will not let this virus prevent our insurance companies from gouging us for basic services the way our Founding Fathers intended. (...)

Some of you might be wondering, why can’t we take this opportunity to address our country’s issues, create a strong welfare state, and change society for the better? I hear your concerns, but it’s a slippery slope. Once we start being decent, there’s no going back. If Americans aren’t one missed payment away from losing their home, people are going to be kind to one another on a scale we’ve never seen before. Neighbors will help neighbors. Young people will look after older people. Quality of life could skyrocket to levels we haven’t seen since before the invention of capitalism. It’s complete and utter altruism, and it will tear us apart. The sooner we go back to fucking each other over, the better.

by Matthew Brian Cohen, McSweeny's |  Read more:

Image: Andrew Harnik/AP via ABC
[ed. See also: How We're Keeping Up the Fight (Elizabeth Warren); The Novel Coronavirus has a Well-Known Left-Wing Bias (Juan Cole); and The World Is Changing — So Can We (David Byrne).]