Subjective Probability

Taking a pause from the newsletter

28 May 2020

I’ve been posting infrequently in recent week for two reasons.

First, following a very nice break after my last professional role, during which we moved back to Europe and took several months off as a family, I’ve now started a new role that is consuming all of the time, and more, that I had been dedicating to reading, thinking, and writing about the pandemic. (In brief, I’m leading a new growth equity fund that invests in consumer technology companies; happy to share more details if you’re interested.)

Secondly, I’m finding it harder to find original, value-added things to say about the pandemic. In early March, my modelling provided a quantitative window into the spread of the virus, before professional epidemiological models were being widely shared and discussed. From April, I focused on summarizing the most interesting articles, papers, and blogs I was finding, while still occasionally finding topics where I could offer original analysis that I wasn’t seeing widely discussed. But now, there are so many high-quality sources of information, and excellent summaries of that information, that it seems slightly pointless to summarize great summaries.

So I’m going to pause writing for now. I may come back to this at a later date.

Thank you to the great many people who suggested topics, articles, posts, and papers; who corrected my errors or offered counterarguments to my positions; who commented on drafts; or who sent occasionally encouraging notes.

If you want to get in touch, LinkedIn is the easiest way: https://www.linkedin.com/in/christophernorth/

Thanks & all the best,

Chris

Ninth weekly Sunday off-the-record chat with experts

17 May 2020

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to 500-1,000+ attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the ninth in as many weeks, covered wide ground, albeit largely focused on the US.

As with past conversations, it was held under the Chatham House Rule, meaning I can share a summary of the content but not the names of the participants. I have removed obviously identifying details as well. As with each of these, the notes are as near-verbatim as I can make them, and almost real-time (apologies for typos).

I missed three of the speakers and omit those notes.

In the summary below, note that questions listed at the start of each section were pre-submitted by organizer to the speakers; not all were answered. Questions inline were asked live.

Topic: The ethics of experiments related to Covid19 and what should be the patient’s decision making process be in the hospital for treatments to the pandemic

Bio: Director of Ethics Education in Psychiatry at a medical school; author

Questions:

1. Many people are going into Covid19 hospitals without their loved ones who would normally help them make important medical and life decisions. What is the new decision making process for treatments, such as using a ventilator? If a loved one were to get admitted, what should we do to assist the treatment decisions? On what basis, should we make the decision (ask alternative doctors, weigh more heavily the doctor’s in charge’s opinion, use some other heuristic like NO VENTILATOR no matter what?

2. Some prisons are perfect areas for Covid19 experiments as a majority of prisoners are Covid19 positive (now or will be soon). This would be a great laboratory to determine the impact of viral loads, treatments and even vaccines. There are ethical concerns for experimentation that said a lot is on the line. Given the importance of the answers, would it be ethical to ask prisoners to take additional risks for scientific purposes in exchange for less prison time and/or cash?

3. What’s wrong with paying fully-informed subjects to be challenged in vaccine trials?

4. Everybody says young people should return to work and old people should stay home, and similarly, drug and vaccine trials should be run on young people. But old people have fewer quality-adjusted years left than young people. Shouldn’t that factor in?

5. If a different nation decided to be more aggressive with vaccine testing that violated our medical ethics would it be ethical to use the unethical study’s medical findings?

6.. What do we do if someone is asymptomatic for Covid19 and can infect others indefinitely, should the person be quarantined as long as she is carrying the virus?

7. Some testing methods that use a monitoring device that evaluate your breathing, temperature, and heartbeat, will challenge our sense of privacy. Will there be pushback of the intrusion into your life?

8. How should society deal with the question of keeping criminals in prisons which increases their exposure to the corona virus vs. releasing them which increases society’s exposure to criminal activity?

How we make decisions for COVID patients
- As in any situation, we ask the patient.
- If too sick or not able to understand, look to advance directives
- Usually we look to “substituted judgement” if these are not options — usually we ask their close relatives to try to determine what they would have chosen if they could have.
- Everyone should have an advanced directive, and give copies to loved ones, attorneys, keep copy on yourself, on your cell phone, etc. Having it in a safe deposit box is useless.
Ethics of vaccinations
- Human challenge experiments. In some cases prisoners being offered lower sentences if they take part.
- This has ethical issues. THey are disadvantaged in many ways.
- Slippery slope — what if we ask them to donate blood or organs for shorter sentences?
- On the other hand, this is a way prisons could give back. Plus they might benefit from the experiment.
- Also issue of what happens if we benefit from experiments done on unwilling populations elsewhere?
- Need to be careful not to create incentives for unethical experiments.
- In practice it’s inconceivable that we wouldn’t use a vaccine developed by a foreign country that was tested unethically.
Q: Typhoid Mary was asymptomatic but infectious for a long time. Imagine you were infectious for a very long time. Is it appropriate to quarantine you for a long time?
- If you posed a major threat, most would agree we should both quarantine you and find a way to provide you with a meaningful life. We didn’t do this with Typhoid Mary.

Topic: Uncertainty, Parameter Estimation for Models, and Type 1 and Type 2 Errors for Testing

Bio: Math/Statistics professor

Questions:

How should we estimate the critical parameter estimates for epidemic models? Should we have a confidence interval and then place greater emphasis on the tails?
Humans are bad at estimating uncertainty, but in the real world, we have to make decisions with imperfect information. How would you advise your parents to get from Florida to Chicago in times of pandemic?
If antibody and Covid tests have high false positives and false negatives, how can we interpret the data?

Models
- All models are wrong, some are useful
- Statisticians, like artists, have the bad habit of falling in love with their models
- Some are not accurate, some are pure fantasy
- Think about weather forecasts. Growing up they were pretty bad. In recent years much more accurate. (1) massive amounts of data and (2) really complex models based on physics.
- Econometric models: one professor asked why his forecasts were always wrong. “My job isn’t to make forecasts, it’s to sell forecasts.”
- Models depend heavily on the quality of the models and on the parameters.
- One group at Stanford looked at R and concluded that it is not the same in different places. E.g., compare Japan to Italy in terms of the social norms.
- Always lots of assumptions.
(2) Chance of dying in a commercial air crash is vanishingly small — chance of dying by choking on food is 3x higher. Probability of dying in a crash is also negligible. Call it 1 in 10K for flying. If death rate from COVID is 5%, you’d have to think that the chance of getting COVID is >1 in 4K to make them come out even.
Big problem with false positives. People misunderstand this. Say a test is 100% accurate for positive, but has 10% of negatives that test positive, and say that 5% of all people have the disease, then only ⅓ of people who test positive actually have the disease.

Topic: The Economic collapse, negative interest rates and the end of cash

Bio: Professor of Economics

Questions

In chaotic times like the present, cash is even more important as banks/financial institutions/credit card companies may be unable to function. There has been hoarding of gold and other cash substitutes. Why get rid of cash?
Have there been cases of Covid19 spread from cash?
Do you think this is the time for negative interest rates, and if not, how important is having the option?
You say that recessions with a banking crisis are long and drawn out. Do you think this sort of financial disaster will therefore be short lived?
Could interest bearing T-bills be used as a currency substitute. This sounds fabulous and easy to do as the general ledger gets built. This is fabulous for the citizens who give up seigniorage, why isn’t this the answer to cash? I was thinking of USD interest earning bitcoin, but why isn’t this better?

Worst crisis in a generation.
After great depression took a decade to fully recover, after 2008 4-5 years. Could be around that range in this case too.
Sharply rising US debt?
- Clearly warranted. Output down 25-35%.
- Is it a free lunch? Some people say yes because growth rate greater than interest rate. That’s quite common, but they still run into debt crises
- In the modern state, a lot of the obligation of the government are beneath the table. The headline debt isn’t all of it — there’s “junior debt” like pensions and the senior debt (headline debt) could weigh on it.
- Italy for example is paying 16% of GDP/year in publicly provided pensions and their capacity for borrowing is limited.
- US is quite unique. How unique? In 50s-70s we had the dilemma. Japan and EU were holding more and more $s while the US economy was shrikning in relative terms.
- US market held debt is almost as big as all other economies put together but our share of global GDP is shrinking. One paper shows that if you look at this historically and theoretically, this can be a very fragile situation.
Money
- Fed are heroes for doing wartime finance, guaranteeing credit.
- Where they have commented that they are not thinking about negative interest rates, then they are not thinking clearly.
- EU and Japan haven’t done it write because they haven’t done with cash.
- All new results on Europe is that the slightly negative rates have worked in a modest way.
- To do more negative rates you have to get rid of cash completely so people can’t hoard cash. China is starting to do this with the central bank digital currency.
- You can phase out large denomination notes
- You can set up an exchange rate between electronic and physical currency.
- It’s not difficult to do negative rates.
- Not enough by itself but should be considered.
Economy is in bad shape and I am not optimistic.
Q: Great depression lasted 10 years and 2008 latsed 4-5 years
- If we get back to work and have a V-shapred recovery, great. But think this will drag on, people will not get back to work, will run out of savings, will not be able to pay mortgages, will create financial strain.
- You can guarantee things to a point. The US has great capacity to do this, the ROW less so.. But you can’t guarantee things forever.

Topic: MMT and the global economic challenge of Covid19

Bio: Independent economic consultant, professor, former Global Chief Economist at a major bank

Questions:

Why is MMT going to end badly?
Are there long-term negative consequences to the shutting down the economy?
Do you expect Italy or Illinois to default?
Will there be a U recovery?

The need for debt restructuring as part of the global response is my topic.
Not talking about moratorium, but a jubilee.
At the federal level the US is in the strongest borrowing position, likely to remain that way. But even in the uS, the state and local governments have little fiscal elbow room.
Either they will be condemned to do nothing or engage in risky fiscal operations that put them at risk of default.
Outside the US, other advanced economies are in significantly worse shape.
EU crisis with the DE constituiontla court plus the new Hanseatic league unwillingness to consider debt mutualization. This constraints companies like Italy.
In the US the debt problem is a private sector problem.
For SMEs debt should be forgiven.
For listed companies the debt should be put into equity transferred by central bank into treasury, preferably in non-voting preference shares, but even regular equity is better than being constrained not to issue debt at all.
In emerging markets, little option to do anything without debt forgiveness.

Topic: Which firms will survive the pandemic within an industry?

Bio: Professor of Economics University

Questions:

There is substantial variance in returns on capital within industries. Do you think the weaker firms will be able to raise capital to survive in this recession?
If the strong firms survive and prosper will this mean that they will be getting increasingly greater market power, and if so what are the macroeconomic consequences?
We have had a catastrophic downturn in employment, how will this rectify itself in the short-term?
Will employees drift from the ineffectively managed firms to the best firms within an industry, and will that mean higher long-term productivity?

Constant churn — reallocation — of capital and labor happening all the time.
200K net increase in jobs might mean 6 million hired and 5.8M leaving jobs.
Similarly for company creation and closing.
This process reallocations resources to higher-performing firms.
That’s good when we reallocate to higher productivity firms, that’s good for the world.
Eg hospitals that are better at treating heart attacks over time get a higher share of patients.
Covid will cause a much higher churn than usual. More job losses and more companies going out of business.
Will this be correlated with productivity? In fact, this could be perverse, if good companies can’t get bridge financing; or of companies survive only because they have monopoly power or political connections.
Another problem is if we keep pouring money, out of concern for job loss, into companies that produce products or services that people dont’ want.
We don’t know yet which way it will go.
But we should be concerned on the face of it.
E.g., PPP program isn’t obviously correlated with productivity — we may be rescuing the wrong businesses.
The effect of the crisis on market power and industry concentration is a concern. These have been growing over several decades.
Firms that become big because of high productivity is a good thing. But that works only if growth is related to productivity.
We will definitely see an increase in concentration since small businesses will go out of business at a high rate.

Topic: What are the implications for the Middle Class after the Pandemic?

Bio: Author on global, economic, political and social trends.

Questions

The global middle class was in trouble before Covid, what does this mean now?
Under stress, firms are much more aware of which employees are productive and who are expendable. Do you expect that firms will run much leaner and that employment prospects will be more challenging?
You have written in the past about the benefits of the car and the suburbs. City density and public transportation is dangerous in a Covid world. Do you expect a resurgence of the car, suburban life, and the decline of the city center? Will people want to work in city center office buildings and if not what will happen to real estate prices for these offices?

Tech companies that have an ability to delivery digitally are in a strong position
So to are large chains that can handle delivery, they will gain share.
The oligarchy — Apple, Google, etc — will get more powerful.
Concerned with the Third Estate — e.g., the small business community. They say they can’t get loans, they are hard hit since they don’t have deep banking relationships, sometimes don’t speak English well.
And the “serf class” of people who will never own real estate or a business — very concerned about them. Especially in very expensive areas like CA.
Big concern on Main Street is that Wall Street will step in and buy everything.

Topic: How is Russia and Putin Managing the Pandemic?

Bio: Professor of Government

Questions:

1. Will the much lower oil price undermine the Putin regime? How secure is Putin’s hold on power?

2. What is public opinion of how the Putin government has handled the Covid19 outbreak?

3. Some governments appear to be more aggressive at quarantining, testing and tracing like China and South Korea. Can Russia do this well, or is Russia more like the West with individuals less willing to restrict their movement?

Russia is stronger and can better withstand low oil prices than previously.
Low oil prices will put a strain on the economy
Could contract 10% this year between oil and Covid stresses.
Will it undermine Putin? Depends on a number of factors
Medical capabilities were already very pool, this has exposed and stressed them further.
Public opinion is very low in this crisis.
PM and Mayor or Moscow doing better than Putin
Second to only the US in terms of cases in the world.
10K new cases/day in the last week.
2,300 deaths in the official figures, but FT and NYT says that the deaths are around 70% higher than this.
At lowest popularity rate in his 20-year reign.
He is rarely addressing the population, remaining sequestered.
He has delegated Covid to the PM and the Mayor of Moscow.
The “Putin Forever” project is on hold.
Still, he enjoys support for his constitutional changes that keep him in power.
Can they do testing and quarantine?
- Usually in a totalitarian state you expect that the people accept this.
- But Russians also demand their liberty and are sceptical of the government. Some scattered protests against the lockdowns.
- Unemployment at 11% and gov’t support going to Kremlin-connected businesses.
- Some resistance to obeying government rules.
- Shortage of PPE and testing equipment.

Eighth weekly Sunday off-the-record chat with experts

10 May 2020

Tonight’s installment, the eighth in as many weeks, covered wide ground, albeit largely focused on the US.

I had to drop off the call before the final speaker and the Q&A, so omit those notes.

In the summary below, note that questions listed at the start of each section were pre-submitted by organizer to the speakers; not all were answered. Questions inline were asked live.

Topic: Vaccines

Bio: Physician and scientist involved with vaccines; professor.

1. What types of vaccines are most promising for Covid19?

2. What is the timing?

3. Will we have to make a bet on safety and/or efficacy before taking the vaccine?

4. Should we take shortcuts given the risks from the pandemic?

5. Do you think the first vaccine will have short-term immunity and we will need to take a second vaccine when available?

6. Who should take the vaccine, the vulnerable and/or the young but not vulnerable to get herd immunity?

7. Do you believe that individuals with Covid19 antibodies will be immune from getting sick again, and if you don’t know, then why would a vaccine work if it creates similar antibodies?

Don’t yet have a safe, effective, scalable vaccine.
Three broad areas being pursued in Precission Vaccines programme
- 1. Observational study of 1-2K adult americans with COVID-19, being followed in and after hospitalization for up to a year. Clinical information including background, but also obtaining bio samples at up to 10 time points over the year. Integrate with clinical data / outcomes. Learn about how the immune system integrates with the virus. 10 centres across US participating.
- 2. How to scale vaccine once we have one.
- 3. Repurpose an old vaccine that may cross-protect. It’s BCG, a tuberculosis vaccine that is more than 100 years old.
Q: We’re heard that viral load matters — implications for vaccine?
- There’s an equation that says that the severity of the disease relates to the strain, the amount of exposure, and (inversely) the resistance.
- So yes, the more you’re exposed to, the worse.
- Elderly immune system is different and weaker. We will need vaccine that works for them.
- We see this with flu, where it doesn’t always work for the elderly.
- For some infections, like dengue, a vaccine can make the disease worse!
Q: We’ve been working on vaccine for HIV for 30 years and don’t have a vaccine. IS that a risk here?
- It’s a risk but HIV is a much harder virus. I’m optimistic that we will have one or more. We may get unlucky and discover that the first few don’t scale; aren’t safe in large populations.
- So good that we will have multiple shots on goal.

Topic: Managing a Contemporary Art Museum during a pandemic

Bio: Director of a major contemporary art musem.

Who is your new audience?
If you have a different audience will you adjust your choice of artist, content, subject matter, or method of presentation?
Can you have blockbuster shows with large audiences, or do you have to severely limit attendance?
Your revenues will fall with attendance and your giving will be down, so how will you adjust your expenses?

Museums are powerful economic force as well as being a cultural force.
We welcome over 850M visitors/year in the US.
Annual contribution of sector is $50B to GDP + $12B in taxes.
Over 725K jobs in museums, more than double that of professional sports.
Our museum, and most others, closed in mid-March. For 9 weeks 3 principles:
- Protect staff/public
- Keep public engaged
- Keep organization sustainable
With move to reopening, we’re have two more:
- Museum we closed is not the same one we will reopen on any dimension
  - Financial models will change — much lower earned revenue
  - Our attendance, usually 50% tourists, will be reduced and much more local
  - Our facilities will need to be a socially distant experience which is the opposite of what museums have gone for in the past.
- Question our community will ask: what did you, the museum, do during the crisis to serve the community?
Future of museums. Four outcomes:
- 1. Online museum is here to stay. Many museums established strong platform with stand-alone online offerings.
- 2. Goodbye to blockbuster exhibitions. Had big financial advantage but they will not happen for a while — hard to gather loans, cost of insurance and transportation, lack of attendance. It will mean greater focus on the collection. Also blockbusters crowd out other stories. E.g., attention to emerging artist
- 3. Museums “must double down on being gathering spaces”. We gather people to experience art, so need new way of gathering. Shown people can come together in the crisis. We need to lock in that social fabric. Job of museum is to push against things like xenophobia and racism, make belonging a core value.
- 4. Revive the WPA model! A hope rather than a prediction. Artists have been hit hard. Galleries are closed, museums are laying off freelancers. Our industry is at Great Depression levels of unemployment. New Deal is a template. The WPA put 1,000 artists to work in 800 cities. It kept artists employed but it also changed the course of art history — e.g., great photographers, artists like Rothko and Pollock.

Topic: Will grit improve your odds of success with Covid19?

Bio: Professor of psychology, author.

1. Does having Grit help me get through a crisis relatively unscathed?

2. Can I work on improving my GRIT or am I born with it?

3. Do you think a strong psychological makeup will have a difference when I catch the virus?

No one comes out of this crisis the way we went in, but yes.
Grit = passion and perseverance for long-term goals. Perseverance is an asset; passion could be asset or liability.
A new grit scale, not yet published:
- 1. I’m doggedly persistent
- 2. I never stop working to improve
- 3. I’ve overcome setbacks to overcome an important challenge
- 4. I overcome challenges more than the average
All of these would help. But the passion items:
- 5. I’m working towards a very specific long-term goal
- 6. I enjoy projects that take years to complete
- 7. My interest in work borders on obsession
- 8. Work essential to my identity
- 9. Everything I see, hear or do relates back to my work.
For really passionate people, this could be hard if you are prevented from doing your work.
So what do you do with perseverance and passion?
My advice: reflect on the ultimate purpose of your work, the top-level goal. The trick is to be stubborn about that goal or purpose but to be flexible about how you achieve it.
Can I improve grit? Yes. You’re born with it, but you can also improve it. As a parent, challenge + unconditional support
Does a strong psychological makeup help you if you get the virus? I don’t know. But we know something from related areas that psychological makeup can support physical health.
- Grit is in the family of “conscientiousness” — like self-control, dependability, etc. These are correlated with longer lives.
- Gritty people tend to be optimists, look for the aspect of a situation they can change. Optimists live longer than pessimists.
- Gritty people tend to be motivated by purpose and meeting rather than pursuit of pleasure. This shows the same pattern as optimism in terms of lower incidence of all-cause mortality.

Topic: When can we do elective surgery

Bio: Plastic surgeon, president of a regional society of plastic surgeons.

What should we expect for timing and extent of elective surgeries?
When/How will we get office based cosmetic treatments?

All elective surgeries paused to focus on COVID-19
Loss of $50B/year in the US related to elective surgeries.
At least 2-month backlog of cases.
Surgeons will list cases and they will be done in order of priority.
When it restarts, you will be tested with antigen test before surgery. If positive, you will be reported and asked to quarantine. If negative, you will need to wait 4-6 weeks.
Chinese study of 34 COVID-negative patients who required ICU case where a significant percentage died.
Botox, fillers, laser treatment?
- We don’t think testing is required for these.
- Some disagreement about lasers where some particles could become airborne.
- Expect to wait outside in a car because of social distancing in waiting room.
- Masks etc.
- Some surgeries we won’t do if it requires removing masks.

Topic: Staying Motivated Now

Bio: Professor of Marketing at a business school

Covid19 is disrupting retail, what will the future look like?
There is an ongoing disruption of education, especially college, what does this mean for the various institutions?
How we work will change: Home, office, travel, transit to work, business meetings, distance between desks, etc. Is this temporary?
Work is fun and interaction with peers is motivating. How do we put the joy back in work?

This is more of an accelerant than a change agent. The future is happening faster.
- E.g, specialty stores going out of business, Amazon and Wal-mart consolidating power. Huge stimulus for them!
- Also seeing it in media.
  - Ad supported media being killed — probably bankrupt with 70% decline in revenue.
  - Google and Facebook off in the short run but will have huge increase ,perhaps going from 60% to 70% share of ad spend as many marketers give up terrestrial and print.
- Health care, which has grown prices faster than inflation and has low satisfaction, highly disruptible. Somewhere between 90 and 90% of people who have gone through COVID-19 will never have gone through doctor’s office or hospital. Will create surge of investment in tele-health and remote health care.
- That will be second to disruption in education. We say we’re public servants but we pray on the hopes and dreams of middle-class America, given a mediocre experience for $68K. My students pay collectively $120K/night for school. No one will pay this for Zoom calls. This will create a huge gap year. The better schools will dramatically scale, but the cartel of the education that consist of duopolies will be broken. Several hundred universities will never reopen.
Huge opportunity to create a service industry, to serve in the agency of others.
Distancing, tracing, isolation is the key. Need to dramatically expand the group of tracers, huge army. Big opportunity to put human capital here. Young people could do mandatory or voluntary conscription in this task. “Coronacore”. Pay $25-30K/year, defer their tuition cost.
Variance. Most of us are operating at 60-70% productivity. If you can be productive at home — “functional speed” = knowing when to accelerate or decelerate. Opportunity to make huge relative progress against others if you can find out how to be productive at home.
Also huge opportunity to repair and rebuild relationships. People are suffering emotionally and financially. Can you demonstrate courage, love, and generosity to others?

Topic: Covid19 Treatments: Lessons learned from HIV

Bio: A leading HIV specialist, professor at a medical school, author of many articles.

Why did we need a cocktail to treat HIV?
Are cocktails generally required for deadly viruses?
The medical community is throwing the kitchen sink at Covid19, do you think a cocktail will be required to treat the virus? Do you think the treatment will differ by patient, or by severity of sickness?
If you were to guess what the combination would look like in general terms, what would that cocktail look like?
Why was there no vaccine for HIV?
There is a pill to prevent HIV, do you think this is a possible solution?
I assume you got to the cocktail by trial and error and by using controlled experiments. We don’t have time, so how would we scientifically and statistically prove the worthiness of a cocktail?

Similar in that accelerating science dramatically, setting aside some rules.
HIV was much more difficult to transmit.
- Also struck down younger people, often who were healthy.
Covid symptoms appear quickly and death comes much more quickly, relative to HIV.
Some of the ways we developed treatments can serve as template.
Combination therapy worked much better for HIV than using one. This led to the three-drug combination, “cocktail”.
Lancet study discussed yesterday in NYT looked at treatment with triple-combination. This combo worked better than one alone.
Expect that we will need to develop other antivrals to get better results.
In HIV we learned that prompt treatment led to better outcomes. Not surprising — same with cancer and heart disease.
Our only treatment (Remdesivir) requires treatment via IV. This isn’t practical for early intervention.
We did not succeed in developing HIV vaccine; but we can provide pre-exposure prophylactics.

Topic: Bad Science and Covid19

Bio: Head of Research at a philanthropy organization.

1) Science is normally too slow: In normal times, science is often too slow, incremental, and highly individualistic

2) COVID science is different. — Collaboration is happening in real-time on an international scale, top journals are publishing new work in a matter of days

3) Lots of bad studies still out there. Examples: (A) early studies on hydroxychloroquine and remdesivir; (B) studies purporting to show that 10x-50x more people are infected, meaning the true death rate is much lower than we thought; (C) A recent WSJ op-ed claiming that lockdowns don’t work.

4) Rapid peer review weeds out the bad stuff more quickly than ever. Today, peer review is happening in real-time on Twitter rather than the typical secretive process. In real-time, you can see some of the world’s top scholars dissecting the latest paper, occasionally forcing a retraction or a thorough rewrite just by public scrutiny alone.

Overall, COVID science offers a model for all of science.
Traditional science is too slow.
Better collaboration, open science.
True, there have been some bad studies in the news.
- Eg a paper in France, reported in the Economist, suggested that nicotine had beneficial effects. Methodology was highly suspect.
- WSJ late April opinion piece said lockdowns were not saving lives. But made terrible errors in analysis. Confused correlation and causation, ignored confounding variables.
- Stanford study saying true fatality rate was same as flu. Again made many methodological errors. Group was not a random sample, selected for being interested in and at risk for COVID. Also implausible — more people would have to be infected than exist in NYC.

Topic: Pandemic and the EU

Bio: Professor of International Economic Policy at major graduate school

Is Europe in a different position economically than the US to adapt to the challenges to the virus?
Americans are willing to make sacrifices and make wealth transfers for other Americans, are Europeans will to do that?
So far the damage to Spain and Italy has been different than Germany? Will the Germans be willing to bail out the Spanish and the Italians?
There are fault lines in the Euro experiment, and the Europeans were unwilling to deal with it during the last crisis? Will this economic debacle force the Europeans to fundamentally change the system to make it more robust to an economic shock?
Do you think the Euro experiment will fail and if so when?

Mody Answers

All economic forecasts are optimistic, especially so in Europe, and especially so in Italy.
Northern eurozone economies have the fiscal space for a sizeable stimulus, if just barely.
Southern states—Italy and Spain—do not. They need, between them, at least, 100-150 billion euros in grants.
For now, eurozone authorities are relying on the ECB to buy Italian/Spanish bonds
1. Given Italy’s financing needs, by year end, the ECB will own over 40 percent of Italian bonds
2. That is not stimulus, but will keep the balls in the air.
What then if the Italian government cannot service its debts? That will be Europe’s moment of truth.

Believe it will be a slow recovery WW for many reasons
- Will take time to control disease
- Partial opening will create supply-linked problems.. Mismatch of buyers and sellers internationally
- Uncertaintiy will cause further delays
- Most importantly, we have vast amounts of debt and we will start seeing bankruptcies.
- Europe is worse than the US on all of these.
  - Near-recession prior to the crisis.
  - More tied to international trade
  - Debt levels are high
  - Banks are fragile
- WIll be particularly slow in Itally
  - No growth for 20 years
  - Hit badly by COVID
  - Already in recession pre-crisis
  - Banks are the most fragile in Europe
  - Huge debt (135% of GDP). Could go up to 180% or more.
- In general, northern countries with fiscal room — Germany in particular
  - Even Germany is going through a structural change. Car industry which has been fulcrum of growth for 50 years is going through wrenching transition. NOt prepared for the next IT_based economy.
  - Plus Deutsche Bank is airways on the edge.
  - Probably will do 10% of GDP stimulus, similar to US
- Spain and Italy get almost no stimulus + big recession
- EU is confederation of states. Always a scramble for fiscal resources in such a situation. E.g, NY after the revolution refused to pay for war debt, hoarded tariffs from inbound cargo.
- Joint fiscal response is just talk. A lot of ceremony but not action.
- All of the action depends on European Central Bank. Can in principle print unlimited money and buy up IT and ES debt.
- US central bank (Fed) is buying more than the net issuance of US treasury.
- Bank of England says will buy as much debt as the UK gov’t issues.
- Japan similarly.
- ECB is not a normal central bank. It is the CB of a confederation of states.
- Holds 23% of Italian debt, going up quickly. Will get to 45-50% of Italian debt. Same thing will happen for Spain.
- At that point the ECB will effectively own Italy.
- What if Italy defaults on this debt?
Germany supreme court says cannot buy debt of other countries, puts us (DE) on the hook.
Next 6-12 months, Italians will either default to private investors, or to the ECB.
When this happens, the question will be — WHat is the EU? Will it be a confederation, or a federation? Has never crossed that line before. Only if we have a major miracle or a vaccine will we avoid that.

Topic: How will the furniture industry survive Covid19?

Bio: Chairman and CEO of furniture company

Furniture showrooms are currently closed, how will they reopen?
Is there pent-up demand, or will demand be lower due to lower incomes and reduced home construction?
Will vendors be willing to go to tradeshows?
How will interaction within the trade change because of Covid19?
Do you think there will be any intermediate term problems related to the supply chain?
How will this impact interior design, the purchase of furniture, the relationship between the trade, and the interaction with the end consumer?

Our buildings are showrooms for manufacturers and distributors.
Even prior to COVID19 huge impact on our business from the 25% tarif on furniture coming from China — 75% of all wood products coming to the US come from China. Huge move of supply chain out of CHina. Hit profits..
Most furniture retail shut down except for ecommerce.
The new normal will be driven by the consumer.
Dining room furniture has been only declining category.
Generally optimistic that there will be more demand due to more home-centric lifestyle.

Topic: Senior Housing and Covid19

Bio: Owner of many affordable senior properties

What changes have you made to your assisted living properties to protect the elderly residents?
What legal obligations do you have to the residents so that they protect themselves?
Residents are not prisoners, they can come and go from the property. How do you protect the other residents from bad actors or bad luck?
You have limited common areas but there are still essentials like the laundry (mail room or (food) deliveries). Will these common areas be the weak link and is there anything to do?
How have the economics of the facility changed, is rent being paid, will residents move out to support their kids, are families scared and want their mom with them, or is your facility the safest place for your residents?

Company does affordable senior housing. These are not nursing homes or assisted living facilities. They are independent living apartments for low-income seniors. While we don’t have a legal responsibility for their health and well being, we feel that we have a moral one.
We had to close all gathering / social places that were non-essential.
Heavy cleaning.
Limiting visitors to essential visitors like care-givers
Low income population, made sure they could get the groceries and pharma that they needed.

Seventh weekly Sunday off-the-record chat with experts

3 May 2020

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to more than 1,000 attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the seventh in seven weeks, covered wide ground, albeit largely focused on the US:

A former senior executive in Medicare/Medicaid talked through what it will take to do test/trace/track/quarantine in the US
A pandemic expert talked about detecting and reacting to pandemics
The president of a top 10 US university talked through expectations for reopening — how and when?
A former National Sercurity Council member talked about preparedness
And many other fascinating conversations.

In the summary below, note that questions listed at the start of each section were pre-submitted by organizer to the speakers; not all were answered. Questions inline were asked live. At the end is a Q&A; I was not able to identify the respondent in each case.

Topic: Testing and Tracing

Bio: Former senior executive in Medicare/Medicaid, involved in Affordable Care Act

What does testing and tracing mean?
Who and how will testing and tracing be implemented?
What is the role of the employer in the process?
How will businesses that interact with consumers be involved with testing and tracing?

Three principles to opening up
- Decline in case load to manageable level
- Testing
- Contact tracing
Status of NY ex-NY, 17% WoW case growth, so not meeting the first critera.
Death rates are crying in 9 out of top 10 cities, ex NY
Rural areas are the new hot spots.
We will need testing to move forward. WIll focus on diagnostic testing [CCN: PCR, not antibodies]. This was not designed to scale, does not have interchangeable parts, and is labor intensive.
Now producing 150-200K tests/day
- But we started late, so that’s not enough
Will need around 3M tests/day. Need abundant, accurate (more than today — high 70s / low 80s currently), and quick.
Not focusing on antibody test which is much less important, highly inaccurate, and with the national immunity level at a few %, will suffer from false positives
First priority is frontline workers, including nursing homes. Also other centers of the pandemic such as prisons, meat packing plants
But everyone will need testing on demand over time.
Without this, economic activity will stall — employment but also consumer activity.
We need this because this is a highly asymptomatic spread with a long dormant period.
Second piece is contact tracing. You find out that you’re infected, who did you come into contact with? Notify them and the people they came into contact with
Working with Scott Gottleib and other experts like Larry Brilliant, Osterholm, and others made proposals to Congress.
The purpose of contact tracing is not to eliminate COVD-19. The aim is to contain it. We have a forest fire right now; need to reduce it to campfires, find those fires, and surround them. Find infected people and isolate them so virus has nowhere to go.
Our plan has 3 components:
- 180K people hired to do contact tracing. Large workforce. Highly manual process. Technology will not be a silver bullet.
- Use hotels/motels for voluntary isolation if they can’t do so safely at home
- Income displacement payment because these people are fulfilling a civic duty to protect the rest of us. We want to pay them daily while secluded– like for jury duty.
I spoke to Google & Apple, had some success to use their technology.
Now I think this isn’t the answer. The public perception is that people are comfortable, in a slight majority, but a large minority are not comfortable.
This will have to be opt in (the apps0. Even with 40% opt-in, it’s not enough. The person infected and their contact both need to be opted in, that’s an effective rate of 16%. The tech can help but it can’t be a substitute for hte labor.
This gives us the time to get to a vaccine.

Topic: Innovative Solutions to Pandemics such as using community based disease monitoring using mobile phones

Bio: Expert in pandemics; former tech executive; formerly of CDC .

How is the technology for Covid19 monitoring?
How invasive of civil liberties is the monitoring?
Will those who have been exposed be willing to quarantine?
How has big data changed the game?
How can we monitor if the epidemic is rising locally and then what do we do other than close the economy locally?
Was the Google Flu trend based on sales of aspirin, cold medicine and relevant searches?

This virus is growing a rapidly growing list of zoonoses that jump from animals to humans
These require serious focus
This is only the latest set. Ebola, Mers, Sars-1, H1N1
I investigated Hantavirus with 75% mortality early on impacting 25-35 year olds in 1993. There were flu-like symptoms, death within 48-72 hours.
Someday, COVID-19 will be a distant memory.
And then we will lose the spirit of cooperation and drive that is happening now. That cannot happen.
Policy and procedure are not always based on the best possible science.
Non-pharmaceutical interventions like lockdown, masks, etc can be done in a systematic way, also to document the intervention so that we learn from the next outbreak.
Any outbreak from an unknown pathogen, speed is of the essence, Reporting and response as well as detection
Any delay in detecting leads to greater spread, illness, deaths, and disruption.
In some countries, farmers and workers in live animal markets are connected to community-led surveillance systems where they report illnesses in animals as well as humans.
Cambodia is an example. There is a free national hotline to get current information on what is circulating in the community. Collaboration of all four major telecoms. 400 calls per day, 20-30 need some intervention
Now they are getting 15-20K calls per day. The ministry of health hired lots more people. It is a way of communicating all things COVID to the public. Most cases identified come through the hotline
Same system gets real-time stats from all of its centres on a daily basis.
In the US: “Flu near you” system — existing users encouraged friends and families to join. We launched COVID Near You to allow “participatory surveillance”.
Brazil implemented this during World Cup, Olympics, and Paralympics.
Social media, ML, AI, etc all offer opportunities to find outbreaks faster.

Topic: Opening up Universities during a Pandemic

Bio: Head of a university

Do you think some universities will choose to be online and others open for business?
Does an urban vs. suburban vs. rural campus make a difference in the opening decision?
How do you protect the two vulnerable populations: faculty/staff and members of the community over a certain age or with certain morbidity?
In your NYT OP-ED you mention that student parties may need to be restricted. Would you consider disciplining students who go to a social gathering off campus?

Although we think of this about bringing students back to classrooms, universities like us are like small cities — lots of departments, staff, etc.
Same challenges that any city or business would face
Undergraduate education poses special challenges
Will some universities open and others be online?
- If it resurges over hte summer as states relax, we will all be online — there will be no option.
- In (one state) right now groups of 5+ can’t be together, and people from out of state have to self-quarantine for 14 days
- We need to be in a position to reopen when possible.
- Where universities are will matter.
- Optimization correlates with location
- One exception: some small colleges far from medical centers will struggle to bring everyone back.
I know of no university that isn’t developing improved online courses, even if they think they can bring students back.
- Many int’l students won’t be able to come back due to travel restrictions
- Students with pre-existing conditions too.
- Large lecture courses will need to be flipped
- So online will be more important going forward.
Young people aren’t at high risk so we’re thinking about how we protect everyone else
Thinking about social distancing, wearing masks, keep people far apart in class.
Faculty who don’t want to teach in person, we can’t force them.
The practices being developed for hotels and restaurants will apply to us.
Students will have more restricted options for community engagement
How do we control students’ social life? Common question
- I hope that students will respond to a good public health campaign
- Can’t be forced on them. They need to understand that they could risk the university returning to remote operation
(Q: What will living arrangements be?)
We’re developing a “medium case” scenario where a lot of distancing is required.
- We will have more semesters and give every student a single room. Can’t put students in doubles. Looking at adding space too.
(Q: Will you defer to the state when deciding whether to open?)
We are willing to set a higher bar than the state, but we are working collaboratively and that is unlikely.

Topic: Will small colleges survive the pandemic?

Bio: Professor of Education at a major university

In your most recent book College Stress Test, you say that 10% of colleges have substantial risk of going under. Do you think the current pandemic increases the risk considerably?
With little endowments and dependence on tuition and kids staying in college, these schools must open in the fall to survive. Will the states allow them and will the faculty be willing to teach?
Colleges are in a dog eat dog battle for the same students. Does the current circumstance force the top schools to take the students away from the less respected schools?
How do you expect the college market to shake-out?

Life neither began nor ended with pandemic
I published a major study around which institutions were likely to close back in February.
There were market flows that told us who was at risk.
The market for higher ed was consolidating anyway. Big were getting bigger, richer getting richer, smaller getting leaner, and underinvolved in trouble.
This was a highly predictable flow.
The pandemic: as a guess, we doubled what we had seen before.
So if 10% of small colleges were previously at risk, we said 20%. But that’s only 2% of total enrollment!
Most students go to big universities, largely public. They will have more pain in the beginning and less at the end.
The private universities will be more calm in the beginning but are in bigger trouble because they don’t have deep pockets.
That diesn’t seem to be the case but it is relative to private universities.
I speak to 5 university presidents every Sunday. All of them say that they will reopen.
- They will also say, “it’s not my decision”
- We have ceded a lot of authority outside of institutions.
- We say “we will be open if the governor lets us” — I have never heard this before.
For institutions at risk, there are high levels of uncertainty. They have not been here before.
I play a game with them. I ask them: will you have your faculty teach with masks? Even two weeks ago, the presidents had often not thought that through. Now they say, “whatever the governor says”
We talk about teaching online. The right way to talk about this is to say that we will teach remotely — like this phone call.
Zoom and other tools, allows a familiarity once you’re used to the tech
So there is a lot of room for innovation around remote teaching
The problem is, where will the revenue come from? At risk of students not on campus.
(Q: You think 2% of the students will have to move if 20% of the schools close. Is that a big deal in the scheme of things?)
1970s — issue of base closing. Took 20 years to work out which ones to close. Colleges are part of the economy — they are like military bases. They play that role (i.e. in anchoring the economy of a small town). The students will do fine.
African American students are more likely to attend an institution at risk than others. So the pandemic will have differential impact on different portions of the population.
So the 2% will cause disruption and consternation.

Topic: Pandemic preparedness

Bio: Formerly of National Security Council.

How should we evaluate US and global preparedness? What are the major gaps?
How should we prepare for bioterrorism? Does that look different from preparedness for naturally occurring pandemics?
What will it take to get prepared for future catastrophic biological events?

Major gaps in preparedness
- We studied preparedness broadly and scored it very low, gave it a low failing grade. That seems accurate now. The US did relatively well but we got a B-. Overall health care, public confidence in gov’t, some metrics around whether capacity is utilized and exercised — these were areas where we scored low. Plus you need to exercise the capability you have and we had trouble there in the US.
- Whether accidental or deliberate, we need to be concerned about biological risk.
- Low capabilitiy to protect lab samples around the world for theft or sabotage.
  - 81% of countries got a low score
- Ability to protect people from pathogens (biosafety)
  - 66% of countries got a low score
- Ability to Oversee dual-use research
  - 99% of countries got low score.
- Our int’l fabric for dealing with pandemics, we look to the WHO — that’s important. We also have one for dealing with deliberate events. But in between those two, there’s nothing to deal with biotech risks –e .g., ability to edit pathogens to make them more virulent; nothing focused on bioterrorism or biosafety. WHO plays a role as does the UN but it’s no one’s first priority. We need to strengthen this.
How should we prepare for catastrophic events in general, including bioterrorism?
What will it take to get prepared for the future.
- We now know where the gaps are. The WHO has done >100 external evaluations. They found similarly low scores.
- No incentive mechanism either to take own actions or leverage donor funding.
- Think we should have a challenge fund to use development loans for preparedness
- Second biosurveillance.
  - Our mechanism is dated.
  - We need an epidemic forecasting capability in the US and a greater global one. We can’t just rely on reports from individual countries.
- Third, we need a supply chain reboot for PPE, for tests, for reagents, for supplies. Everyone is running out of them. Even worse in Africa
We need to be able to pivot in a crisis to make them faster than we can now
Accountability — there is no one coordinator / facilitator. Can’t just rely on WHO. Needs to be someone’s full-time job to think about pandemic risk. That should be at UN. White House also needs a dedicated team.
Hope that when we do the next pandemic preparedness index, we will see increasing scores.
If there’s a silver lining it will be if we focus on these neglected areas.

Topic: Telemedicine

Bio: Primary care physician and healthcare innovator; serial entrepreneur

Why is the future telemedicine?
How has telemedicine worked so far in the pandemic?
To what extent does the insurance industry dictate policy and has their position changed?

Most health systems quickly shut down / minimized F2F visits.
Most doctors are doing 60-100% of visits online (phone, video,, messaging)
Many doctors are working from home. They can because of electronic records.
USually only patients coming into office are those with chronic conditions, need test or exam. They are being seen by skeleton crew. And those who don’t have any symptoms. >50% is being done by telehealth.
For outpatients:
- Those with COVID concerns, being told to stay home and sequester; or based on their symptoms, go to the ER. Not many options in between, triage.
- Quickly seeing a shift from doctors to chatbots or maybe nurses. Doing so to preserve doctor time.
- This will become more important over time.
Still have to take care of those with chronic conditions. Can be done in many cases with home machines (for testing).
Not doing much preventative care. Keeping the lights on
In hospitals, telehealth has become important — e.g,. For specialists.
Even virtual rounds without entering the room in the hospital
What’s happening to help support this?
3Rs:
- Improved reimbursement
- IMproved regulation
- REgularity — people getting used to it.
INsurance companies: being more flexible.
- Doctors can bill at parity for medicare, most followed this. Now that it’s being paid for doctors are more likely to do it.
- Still things to be resolved –video? Asynchronous visits like messaging?
- Signs are that this direction of travel will continue
Regulatory questions
- Waving HIPAA security measures to allow (eg) SKype
- Doctors can now practice across state lines.
We have now crossed the chasm. Nuress love it.
The idea of going to a doctor’s office may be seen as archaic.
But it’s not enough. Goal will be how we really take care of someone effectively, safely, and quickly.
Automation will kick in to support — e.g., data collection.
Automation may manage some patient care if FDA permits. Escalate to doctors for outliers.
Then we will not have a shortage of doctors.

Topic: Medical Restructuring Post-Pandemic

Bio: Board member of a number of companies including health care services; former health care CEO;teaches health care services to MBAs..

Why did hospitals cut back their supplies of masks and gowns?
Who should be responsible for keeping necessary supplies?
Were you surprised how quickly the private sector produced extra supplies?
Who should stockpile medications that are sourced from outside the USA?
How will this financial crisis impact the medical profession, and how would you expect the changes in the capital structure will impact the patient/consumer?

Our prior efforts to continually lower costs in health care led us to be badly prepare for volume.
We saw this in lack of beds. Number of beds per 1,000 has been reduced by 60% in last few decade
We try to lower length of stay for each procedures; move people out of hospitals quickly to ambulatory services (for example)
Like the airline industry where they reduced capacity by stuffing more people onto every plane until there is a large snowstorm.
Extreme measure like cancelling all elective procedures.
That will lead ot a whole new set of problems. 30% of people say they haven’t receive needed medical care either because cancelled or because afraid of infection.
We say we will only reopen cities or universities when we have excess capacity in hospitals — where will that come from once we allow elective surgeries?
Also in the supply chain we did not have the spare capacity. You see that in PPE.
I am experienced with supply chain. How did we not have enough PPE? We can produce it in the US but we don’t ; good at sourcing cheapest possible products. Also moved to just-in-time inventory so no spare capacity.
Supply chain adjusted very quickly, four weeks. In the meantime people worked without the right equipment. They should not have had to risk their lives.
We will need to create a stockpile of supplies to meet future surges of demand. Cannot expect players in the industry to do so.
Likely to be done at the state level.
Finally, we were not prepared with commercial labs and testing. Two players dominate this space. Only recently started finding creative solutions — e.g., deputizing drug stores to draw specimens.
Expect that we will be able to meet demand over the coming months. We will not be limited by lab testing capacity within a reasonable amount of time.
Once we have a vaccine everyone will want one quickly. Think of needles, vials, stoppers, etc. to be able to inject 330M people, maybe 2x. Don’t think we are preparing that now.

Topic: Pandemic and Sports

Bio: Senior executive in sports and entertainment, involved in a future Olympics.

Is it possible for Tokyo to host the Olympics in 2021?
How have your plans changed for the Olympics in 2028?
Will cities be more reticent to bid on the Olympics?
You are involved in almost all sports. Which sports will thrive and which will dive in the post Covid sports world?
How do you think that the public demand for sports will be impacted by the virus? Have we seen the peak of a live stadium audience for sports and maybe concerts, as public gatherings will be too risky/difficult?
Is there enormous pent up demand for sports or has the public moved on?
How do you think this virus will impact the long-term valuation of sports teams?

Tokyo decision based in part on (a) athletes not having access to training and (b) limits of lab capacity meant no ability to test for performance enhancing drugs.
Worst case scenario is domestic-only fans in 2021.
Looking to 2028 LA — adding planning for theoretical pandemic.
Cities will still be ready to bid on the olympics going forward but it will change how it happens and what is considered.
LA is unusual because has capacity for complete games
Most future games will have a single city as the hub, but sports spread all over the country — e.g., Milan won’t host every event. Financially and operationally untenable otherwise.
Big sports will thrive in the future. Marginal sports will be crushed.
BAseball, golf, auto racing will be the first sports to come back. SOccer in Europe.
What about football and college football? Big question marks.
Huge pent-up demand for sports. People miss it.
Huge ratings for anything that is live and real.
May 17th golf match with for players, without fans — there will be much more like this.
New normal: just like after 9/11, there will be a new version of this. E.g., temperature checks, masks and gloves.
Doubt there will be fans in stands in 2020, maybe 2021. Beaches in CA suggests that people would be willing to though.
There will be short-term blip in valuation of franchises but only a temporary blip, unique and valuable assets.
75% (95%?) of NFL fans will never see a live event. Sports are designed to be watched on TV.

Topic: Religious Adaptation to the Pandemic

Bio: Associate Professor of Sociology at major university

Can Orthodox Jews socially distance, or is it too embedded in the religiosity and cultural requirements?
Will Jews follow the models of the Protestant faith and/or transcendentalism?
How should we expect religious communal activities to adapt to social distancing and the rejection of large public gatherings for religious services, funerals and weddings?

In Israel, NY, NJ — male jews > 13 are supposed to be 10 men praying together — “Minyan”. This has been challenged. Many have been cancelled, but there are many cases of secret groups praying together — people go to a pre-set place to pray together. Not keeping social distancing.
Big outbreaks happening in Orthodox community.
Orthodox groups are not always socially distancing — eg, funerals.
We see related issues in some other strict religious groups.
There has been a wrangling over expertise over how we live — whether in science or in religion.
So this should not surprise us. E.g., look at measles vaccinations as a flashpoint for this tension about who has the power to prescribe how we live.
So far this isn’t surprising.
In the Orthodox community there is a lot of cooperation with the medical establishment, both with behavior and religious law.
Pandemic hit during Passover seder. While some large families have come together, rabbinical prescriptions said it was okay to use electricity to have Zoom gatherings. Many rabbis have allowed this. Very unusual.
The other interesting question: what are we seeing in relationship to God with the outbreak? In islam and Orthodox Judaism, based on communal practice — required. Stress is not on personal relationship to God, but on communal practice.
Both in Jewish and Catholic quarters, call to develop private personal relationships with God. very interesting and this is more like Protestantism. In the past this has been the province of the mystic.
Religious adaptations to the situation. Are they a blip or will there be lasting change in practice and expertise? We don’t know. Mahy depend on how quickly the pandemic passes. If it goes on a few years, these practices will become more established.
Q: Given the health risks, why are religious Jews getting too close to each other in minyans?
- Some are trying to do so, keep distance
- Many are very poor, meeting in small spaces — they are trying
- Theologically: they are saying God will protect us. (You hear this from evangelicals too)
Q: Jews believe that if you are put at risk there are exceptions to theological law?
- Yes, we see that with the Zoom exception in some cases (allowing electricity)
Q: Iran, funeral for senior leader, infected many people. In Jerusalem, same thing happening with death of a senior rabbi.

Topic: Municipal Finance and the Pandemic

Bio: Professor at major law school; expert in Puerto Rico

McConnell is proposing a bankruptcy code for states. Is this the time for real?
Can a state bankruptcy code be constitutional?
What have you learned from your Puerto Rican experience?
Do you think there is greater legal protections for American revenue bonds relative to PR/Cofina?

Three things to know about the topic of state bankruptcy
- States currently cannot file for bankruptcy. Cities can (chapter 9 municipal bankruptcy) if state permits.
- If it were permitted, it would have to be 100% voluntary. Illinois is the poster child — they could not be thrown into it against their wishes. If Congress tried to pass involuntary bankruptcy law, would violate 10th amendment. So this is an option
- There are constitutional questions. It would be questioned under the contracts clause of the constitution, and as a violation of state sovereignty. I think it would be constitutional if framed properly.
Quickest way to make the case is to show that the main arguments against it actually demonstrate the virtues.
Democrats criticize the idea, typically because they think it will be used to wipe out pensions and whack public employees.
It’s sometimes pitched that way but entirely a mistaken idea
In fact there would be a more equitable sharing of sacrifice.
What happens without bankruptcy when distress? It tends to get visited upon one or two constituencies, usually beneficiaries of services in that state. That’s what is happening in IL. With bankruptcy,everyone would have to share in sacrifice.
In big city bankruptcy cases so far — Detroit, Stockton -_ Pension holders did okay.
Republicans say it would destroy the state bond market
- Assumes that the bond market can’t tell the difference between responsible and irresponsible states. Market does a good job in fact,
- If there was an impact on bond prices, it would take away the assumption that there would be a bailout.
- If it were terrible, then the municipal bond market would have already been destroyed but it has not.
No one wants a state to go bust but the alternatives are a bailout, or a collapse or default, both of which are worse.
Puerto Rico: the restructuring case has been going on for 3 years. Closest thing to state bankruptcy that we have. I’ve come away thinking it’s messy but actually works pretty well.
Q: Did there have to be a crisis to get state bankruptcy?
- Yes. That’s what we’ve seen with cities.
- No one wants to face up to the reality of what it would be like if there were a massive default. Need a crisis to get a consensus.

Yes, COVID-19 really is dangerous

29 April 2020

There’s a persistent, recurrent idea out there that COVID-19 isn’t really that dangerous after all, and that we are taking economic pain unnecessarily.

I won’t wade into the important and difficult debate about what the right tradeoffs are between minimizing excess deaths and minimizing economic pain, a debate that is becoming more pronounced as many countries see new cases level off and decline and begin to consider next steps.

But I do want to share the best current evidence and logic for why the view that we always could have allowed, or even could now allow,m the virus to run through the population unchecked is wrong.

Yes, it’s much deadlier than the flu

Two weeks ago, I wrote a long post about the question of whether it could turn out that COVID-19 has already infected vastly more people than we think — even the majority of the population in some countries / regions / cities. I concluded that while it’s certain that many more people have been infected than the number of reported cases, it was very unlikely (but not impossible) that, say, 50% of the US or UK has already been infected.

While this point of view appears to be shared by the vast majority of epidemiologists and infectious disease specialists who publish papers or give interviews in the mainstream press, there continues to be a small minority of commentators (some more qualified than others) articulating the alternative view, a view I call the “ubiquity hypothesis.”

For this group, the point of arguing that (in their view) a very large number of people have already been infected almost always follows the following logical path:

If the number of people who have been infected is (say) two orders of magnitude higher than the number of reported cases, the Infection Fatality Rate (IFR) — the measure of the percentage of people who are infected (whether detected or reported or not) who ultimately go on to die — will turn out to be much lower (two orders of magnitude lower) than the Case Fatality Ratio (CFR), which by definition is calculated by dividing the number of people confirmed to have died with COVID-19 by the number of confirmed and reported cases.
If the IFR is vastly lower than the CFR, the disease is less dangerous than we think.
Therefore, we should re-open the economy rapidly and let the virus spread through the population relatively rapidly.

The first point is correct (as a conditional statement by definition).

The second point is wrong, or at least misleading, in two senses.

First, if by “we”, we mean experts, it’s simply wrong. Experts know, and take into account, that crude CFRs are not helpful as a forecast of ultimate mortality. There are a huge number of studies out there that try to estimate the true Infection Fatality Rate, and this is the basis on which professionals are forming a view of how “dangerous” the virus is, and what the risks would be of letting it run unchecked through the population.

Secondly, the point of comparison is almost always to seasonal influenza. The problem is, there’s another logical fallacy that creeps in here. Many people have heard a figure like 0.1% as the fatality rate for flu. And the advocates of the minority view above point out that if many more people have been infected with COVID-19 than we think, then the IFR of COVID-19 could be something like 0.1%, or even lower.

Now, it’s possible that the IFR of COVID-19 could be as low as 0.1%, though recent mainstream estimates typically put it in the 0.3%-0.8% range, with 0.5% probably close to a crude consensus estimate. And of course if it turned out that 100x the number of people have been infected compared to what we thought, the IFR would be even lower.

But it’s important to recognise that isn’t the Infection Fatality Rate for the flu; it’s much closer to something like the the Case Fatality Rate. That’s because the vast majority of cases of seasonal flu are never reported.

The epidemiologist Adam Kucharski explains this very clearly here. If we wanted to estimate the IFR for flu, it would be something closer to 0.02-0.05% of cases are fatal. Order of magnitude, that would make COVID-19 10x more deadly than flu.

Finally, as a sanity check, think what it would mean if the IFR of COVID-19 turned out to be 0.1%. If 60% of the world population ultimately was infected, that’s (60%*7.8B) = 4.7 billion cases. 0.5% of that is 24 million deaths.

Yes, excess mortality is high

I’ve discussed in several earlier posts why there are factors that lead to both over- and -under-attribution of deaths to COVID-19.

At the end of the day, when we talk about “attributing” deaths to COVID-19, what we care about is how many more people die because of COVID-19 than would have otherwise.

On this topic, the evidence is mounting every day that excess mortality is very high indeed. Here are a few examples of the evidence, among many.

Since 2008, the European Mortality Monitoring project (EuroMoMo), supported by WHO and ECDC, has been tracking “excess number of deaths related to influenza and other possible public health threats across participating European Countries.” Their data for 24 EU countries shows significantly higher-than-expected deaths:

In this dataset, the UK looks particularly badly impacted.

I’ve previously shared The Economist’s estimates of excess mortality (article dates from 16 April); this analysis is based on the EuroMoMo dataset as well.

The Financial Times has also been estimating excess mortality for a number of countries.

Looking at the US, the New York Times yesterday reported excess mortality estimates for seven states based on CDC data, suggesting :

The Washington Post published a similar analysis based on a Yale study:

The New York Times also looked at excess mortality in other countries, estimating at least 40K higher deaths, above and beyond those attributed to COVID-19, across just 12 countries.

Of course, there could be other sources of excess mortality besides COVID-19. Some people may be dying of conditions like heart disease or cancer who otherwise would have sought, and been able to obtain, treatment had lockdowns not been in place, had the healthcare system not been overwhelmed in some cases, and so on.

On the other hand, we also have evidence that mortality rates from certain other causes, such as car accidents, are lower — and maybe much lower– because of lockdowns.

So while there’s no way of being certain of the excess mortality that is directly due to the coronavirus, there’s strong evidence that it is significant.

No, the data do not suggest that the majority of people have already been infected.

The limited serological data we have continues to suggest low prevalence in most cases

In my earlier post referenced above, I shared a number of analyses and studies that suggested that the prevalence of COVID-19 was likely still low (<10%, often <5%) in most countries, though there are individual, highly-impacted cities and regions where it is likely higher. The few studies that show higher rates appear to have significant methodological issues.

We’re getting more data by the day from serological studies, and the weight of evidence is adding up against the “ubiquity hypothesis.” Here is a table summarizing findings from a number of studies:

Note that all but one of the cases with prevalence rates above 10% are in highly impacted areas, or small, contained populations.

A study that seems particularly well designed is in Miami Dade County, because it is a random sample of the general population, reasonably large, adjusted statistically for representativeness, and ongoing. This has found 6% incidence.

Still, there are reasons to continue to be sceptical about serological studies of any kind. Many tests appear to be flawed; and even tests that work as advertised suffer from high false positive rates. A good summary of some of the issues is here.

What do other coronaviruses tell us about immunity?

On a different topic, this MIT Technology Review article (paywall, but three free articles per month with registration) worried me. Apparently, for a number of common coronaviruses that cause colds, immunity is only partial and quite short-lived.

Sixth weekly Sunday off-the-record chat with experts

26 April 2020

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to more than 1,000 attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the sixth in six weeks, covered wide ground, albeit largely focused on the US:

A CEO of a major home builder talked about the surprising resilience of that industry
A CEO of a major US oil company talked in detail about the dynamics from the producer’s point of view; contrary to what we’ve read in the media, shale producers are able to shut down and start up quickly and at low cost.
We heard about the impact, and the outlook for, Major League Baseball and for summer camps.
A former head of a major international, multilateral financial institutional talked about the very limited international response to support poorer countries compared to 2008-9.
An expert on the pharmaceutical industry talked about how vaccine development is working, and why he’s both optimistic that we will get one or more vaccines over time, but sceptical that we will have one soon. Even having one early next year would require enormous luck.
We also heard from a sociologist, a practicing doctor, a leading forensic pathologist, a statistician from the pharmaceutical industry.

Topic: Homebuilders and the Pandemic

Bio: CEO of a large US home building company

1. Is construction continuing despite the shutdown?
2. Are subcontractors coming to work?
3. How is the supply chain for equipment and materials?
4. Are customers of homes who put down payments asking you to terminate the contracts?
5. I assume no new buyers have arrived to buy homes, so what do you think your industry’s path to recovery.
6. Do you think the very low mortgage rates will stimulate demand?
7. What happens when someone comes down with the virus who was working on the site?

Home builders are building in 45/50 states because deemed an essential service.
This company has > 1K houses being built right now.
Construction continues essentially unchanged.
We and other companies have new rules in place to ensure social distancing
Most workers are coming to work; they are paid hourly or by task and need the paychecks. They’re happy that they can work.
Supply chain is a “new adventure every day”. Had shortages and delays originally.
Large manufacturers built up inventory in Q1. Not yet a problem but we worry about it.
We’ve seen cancellations increasing, but not as much as feared. Highest and lowest price points hit the most.
We have low cancellations from job loss; job loss is concentrated in low-wage jobs who don’t typically buy new homes
Greatest rate of cancellations comes from the mortgage market where there is significant tightening of standards.
New buyers? Yes, every day.
Path to recovery? We started from a strong position, so there was a significant pre-sold backlog.
Large builders have strong balance sheets and low leverage.
We will see some declines in revenue.
Path to recovery is consumer confidence, which requires that unemployment decline.
Strangely, COVID has helped our industry. It messed up the used market where there is a severe shortage so pu
Shelter in place meant that illegal to have open house, so used home sellers withdrew listings; shortage helped home builders
People spending a lot of time in their residences and many will want to move.
We think people will move back to the suburbs.
Blizzards, shelter in place result in a mini-baby boom which helps home builders
Mortgage rates do stimulate demand but they’ve been low for a long time. The main question is qualification for mortgages.
What if someone gets the virus on a site? We usually only have one trade on site at a time, and people are being good about social distancing. If someone got sick we might not even hear about it from the subcontractor. Have heard of very few cases so far in our teams or our subcontractors.
Q: The CARES act has a mortgage forebearance provision, and you say that that has scared lenders. What kinds of applicant is facing pressure?
A: Through FHA, you could have gotten a loan with a 580; now that’s 620. Debt-to-income ratios have been reduced. Hitting first-time buyers and lowest-income buyers.
Q: You mentioned that existing home sales are down; isn’t that a temporary phenomenon? Will home building have a problem after we reopen?
A: Big question, People wanted to sell in spring, the traditional selling season, who have not been able to . But COVID won’t end overnight. The supply will come back over time. Eventually there will be a lot of sellers, but not a spike.

Topic: The energy market and the pandemic

Bio: Board member of an international information company; author of books on energy.

What does this mean for the future of oil and the future of fracking?
Is it true if we shut down a fracking well, the economics make it nearly impossible to reopen?
Is the WTI contract broken and how would you fix it? Should we say it has some minimum value like $0?
What are the political implications for lower oil prices on the regimes in Saudi Arabia, VZ, and Russia?
What does the future of energy market look like? Has oil fallen in price enough to make alternative energy sources unattractive or not?
What are the implications of cheap, readily available energy on how the world functions?
Historically global oil demand has increased 1-2% a year, global depletion rates run approximately 5%. So global oil industry demand growth is really 6-7%. Big oil cap ex typically rises to meet this demand. However due to covid, global cap ex has been slashed to maintenance levels. What is the risk that the price of crude hockey sticks in 2021-2022? What is your prediction for the price of oil in the intermediate term?

Today a CEO of a major oil company said to me that what has happend was not within anyone’s imagination of what wa spossible.
Phase 1: shutdown of China. 6M out of 100M b/day disappeared of demand. Then the OPEC meeting in Vienna — thought this would hurt US shale
Phase 2: now. We think world oil demand is down ⅓ , 30M b/day. Gasoline down more than down 97% in the US.
US Senators no longer willing to fund Saudi Arabia
Big exporters couldn’t sell oil
Trump used his influence to get the 9M b/day cut in place. There will be other cuts and declines
But that only addresses part of the problem.
We’re running out of storage. Big problem. That’s what happened last week to someone who had to pay $40/b to get rid of their oil.
22 Tankers off the coast of Long Beach are full.
Production will start shutting down.
Then there will be a natural decline in the US, around 3M b/day. In Feb we were at 13.1M b/day, more than Russia and Saudia Arabia — a record. We will still be a major producer but it will be a decline.
Future for US shale industry? Access to capital will be a big issue.
Now it’s Russia + US + Saudia Arabia who are the big three; it’s not about OPEC vs non-OPEC anymore
Q: 97% reduction in air travel. So there will be lots of jet fuel with no demand. Is that hard to store?
A: Creates a problem because you’re producing a bunch of different products. These companies have to think about employees getting sick too. Refiners are cutting back on output.

Topic: The Oil Market

Bio: President of major oil company

Given the massive decline in oil production, there is a glut and a demand for storage. WTI futures for May delivery traded as low as MINUS $40 per barrel. What do you think caused this negative spike? Is marginal storage unbelievably expensive? Does this mean that production needs to be curtailed immediately?
Some experts have said that it is very expensive to shut down some fracking sites and too expensive to reopen, is this true and what does it mean? Will non-fracking sites be closed first?
What are the implications for the short, medium, and long-term for US production?
Is oil going to stay inexpensive for a long-time and what does this mean for oil substitutes?
How is Hunt Oil going to take advantage of these market inefficiencies?

Private company
Negative WTI? Most oil and gas companies are paid on a 30-day average of monthly prices. So few companies actually had to pay $40/b. It goes into the average.
People who were trading in future contracts lost out.
Futures prices are set for delivery of oil at a specific location. When prices are very low, <$30, and you take it back to the wellhead, even the most profitable welljheads are only making a few $ per barrel. And then you have storage costs.
People will have to decide whether to pay for storage or shut wells.
Take a specific field that is a mature field where we have reduced production dramatically. We have some storage on site and can make it through May and then decide whether to sell or shut the well. Some we will shut in because not economic; most will operate at reduced capacity.
Storage and curtailment — want to avoid making large generalisation and large policy decisions about across-the-board cuts. Producers will make individually rational discussions.
Unconventional wells? Shutting them? They need help to produce (e.g., fracking); they don’t flow on their own. Mechanical pump or some other activity to cause it to continue to pump. Makes it easy and inexpensive to shut off and to turn back online. We do this all the time, on a daily basis.
Q: We sometimes hear that it is expensive to restart? A: That’s not true. As a general rule, it’s more expensive to shut a conventional well since they’re large and they flow naturally on their own; risk of blowout because of pressure.
Q: Natural gas prices are going up. They are a by-product of oil being produced.
A: The idea is that there is so much natural gas that is a by-product of west texas production, but you still need demand. Don’t think the price will move that much.

Topic: The Pandemic and Major League Baseball

Bio: Senior executive at a MLB team in a hot state

1. Do you think you could have a baseball season without fans, played in AZ or Florida?

2. What would it take to reopen the ballparks and have fans in attendance?

3. Would you consider spacing out the seating?

4. The world is not a safe place and never can be, but we want to watch baseball and eat hot dogs, so what do you think will be an acceptable risk for our society?

5. Should we replace the umpire with a machine?

6. There is little league, high school ball, college ball, minor leagues and major league baseball Should there be different criteria for each to play? And why?

Need better testing — more and better accuracy
Governor will decide who can open
Not optimistic. In June/July temperature is too high for day games. Few covered stadiums.
A more likely plan is three central locations across the US, that would make start times work for TV.
But more likely, teams play in home ballparks. Will happen without fans
California is not moving quickly, they might have to play away.
To reopen with fans? Would require serological tests to be better and easier to get to. We can’t put fans there unless we know they have tested positive and had some kind of an all-clear.
Safety of players and support staff is critical.
Don’t want a situation where the champion team is the luckiest team rather than the best team — in terms of which players can play.
Replace umpire with machine? Mostly, yes — certainly automated strike zone. Still need an umpire for other reasons. The technology is getting more precise.

Topic: Summer Camp and the pandemic

Bio: Camp Director and Owner

Why is camp more important than ever?
Are kids going to go to camp this summer?
How can we keep campers and counselors safe?

Camps are >100 years old. Were a way to get kids out of unhealthy areas in poor urban areas, the polio scare too..
We need a sense of returning to normalcy. Camp could be part of that.
Also a place to heal. “Emotional restoration”
Camps are also small businesses, an $18B industry that employs lots of people in rural areas.
Will kids be able to go to camp this summer? Fluid situation.
CDC doctors were working on schools, now working on camps. We will hear in the next week from them and from our governing body, a set of initial guidelines.
Can we create a safe baseline, e.g., bring in staff 20 days ahead of time? Antibody testing? Testing kids as they arrive? Ability to isolate kids if necessary, send them home, etc?

Topic: Multilateral Institutions Response to the Pandemic

Bio: Former Chief Economist at major investment bank ; former senior executive at a major international financial institution

Questions:

Any progress on what the IMF plans to do to help out the emerging market economies?
Do you think there is US political interest in helping out developing countries in this crisis, or do we want to spend the money closer to home?
There are complaints by the administration that China has co-opted multilateral institutions like the WHO, do you expect similar complaints about the IMF and World Bank? What are these institutions doing to insulate themselves from the Chinese? Is there anything nefarious out there, is it a witch hunt, or do the Chinese and the Americans have different objectives for these multilateral institutions?
We expanded the swap lines at the beginning of this crisis? If the President or leaders of the Republican congressional teams become aware of the unlimited exposure to the swap lines, will they be pulled or limited? How did these expanded swap lines get past the politicians? And do you think there is general public support for unlimited swap lines? What do you think happens if we expand the swap lines to a non-creditworthy nation?

Contrast GFC actions to today. In 2008, $1T in new resources for the IMF and multilateral development banks. $250B SDR, special drawing rights, new funds to IMF membership and useful to low-income countries. New facility, flexible credit line, cautionary facility used right away by Mexico and Columbia, successfully. Zero-interest rate loans for poor countries.\
This time around? No new regular resources for IMF or MDBs. Some pre-existing facilities were extended. The new facilities were very limited. The only new thing was that two pre-existing trust funds that subsidize borrowing from the IMF by poor countries — the 76 poorest countries. No actual new funds provided, just suggested that folks donate. The US is “considering it.”
So nothing like the interest in helping out like what we say in 2008-9
G20 ministers endorsed a debt service moratorium on debts to the IMF and other MDBs. Similar recommendation to private lenders.
The US mainly helped via the Fed: Swaplines to 14 countries, “favored friends of the Fed.” Only the Fed board knows which countries are members and what the critera are. Emerging markets: Brazil, Korea, Singapore, Mexico (?).
Most interesting is two things:
- G20 ministers pushed back meeting to 2023 the next IMF quota adjustment, previously agreed in 2010, was supposed to be done by 2012. Important because the US has the biggest quote followed by Japan and China. China doesn’t want to be 2 but they will become that next time.
- Largest single lender to low-income countries is China. China has always taken the position that this is a sovereign issue for them. Eg debt restructuring through the Paris club, which gives transparency and pari passu terms when restructuring is necessary. China is not a member of the Paris club, and their attitude is that they do it bilaterally and in secret.

Topic: Sociology and the Pandemic – Who is most at risk and what are the implications of people living alone and in isolation.

Bio: Professor of Sociology; author.

What lessons from the Chicago heatwave can we apply to the Covid19 pandemic?
There are always different subgroups that will have worst mortality, in the Chicago heatwave it was African American men living alone in SROs. I would suspect that this cohort is probably doing relatively poorly today. What can we do to help our most risky populations, or do you believe the dye had been cast and there is little public policy can do. This isn’t like asking the mayor to open up move theaters so that the men without air-conditioning wouldn’t die from heat exhaustion.
In your book, you discuss the implications of more people choosing to live alone and not couple up. You describe the choice as both informed and for the better for those who make the choice. One potential surprise of the pandemic is that if we enter into a long-term shelter in place this might result in greater isolation for the solo population. How do you think that the pandemic is affecting the solo-crowd and have they adapted in other ways to deal with the crisis?

In many extreme events, our failure to take early warnings seriously and rely on the best science to guide policy has hurt us. In the heatwave local leaders failed to react despite clear early warnings.
Heat kills more people than all natural disasters combined.
1995 heat wave was a catastrophe.
What killed people in the end in 1995 was social isolation.
There was enough cool water and airconditioning. Lack of social connection and support killed people. Isolation meant people were overwhlemed and didn’t have support.
Early in this crisis the WHO and other bodies told us that the way we needed to survive was social distancing. I think it’s a horrible idea.
We need *physical distancing*. Social distancing implies hunkering down and turning our backs on others. We need social solidarity.
Subgroups with vulnerability? African Americans, Latinos having terrible experience. High incidence and high mortality.
Extreme events are important to sociologists–they are like particle accelerators.
NY: hard-hit populations have difficulty sheltering in place, stocking up, finding private space. Crowded housing units where even if you can stay home others are going out and putting you at risk. Higher use of public transit, which is still very crowded in NY. Least likely to have access to routine health care. High rate of underlying conditions.
Disparity between public and private hospitals.

Topic: How to keep running a doctor’s office for children despite a pandemic

Bio: Board certified in 5 fields including immunology; runs a doctor’s office.

Why is your office safe? And why is this a model for other service businesses and other doctor offices?
Implicit in your doctor’s office analysis reflects your belief in the value of masks, temperature taking, and good cleaning of surfaces. Why do you think these methods have real value and how much does it truly reduce the risk of infection.
No office environment can be riskless, how should we evaluate what is the appropriate risk? Is a doctor’s office a more necessary place than say a hardware store or a school? And should be willing to take more risk in a doctor’s office because of the benefits to health that accrue to patients?
There was a study of asymptomatic cases in a grocery store in NY that suggested that 20% of NYC residents have been exposed to the virus? What do you think of these sort of studies, and if so why do you think the number of asymptomatic cases is so high?

Built large facility with >10K patients. Many fly in.
Starting in first week of March, started putting out timeline of what would happen next.
Developed SW to track the screening of each employee and patient.
Changed physical environment of our physical facilities to reduce risk.
Haven’t let go any employees.
100% patient retention. They are still flying in to keep their children’s appointments.
Hope to be back at normal capacity next month.
Think it is possible to remove COVID risk in the workplace.
Asymptomatic cases in NY? Very common to see people shedding viruses on a regular basis. Need to patient large groups of individuals to know true shedding risks.

Topic: What can pathology teach us about Covid19?

Bio: Leading forensic pathologist in the US; prolific author

1. In 1918, the medical community did not understand what killed the Spanish Flu victims, and it was the pathologists who were able to provide an explanation.

2. What can pathologists teach us about Covid19 that might be helpful in either treatment or prevention?

3. What have you heard from the overseas pathologists, and is there a difference in the autopsy results in Wuhan vs. Italy vs. USA?

5. There are a lot of theories about how Covid19 is killing its victims, but can pathologists tell us what is precisely causing the death? Can pathologists detect or determine the mechanism of injury?

6. Why are Kidneys getting injured? And do we understand the process of why kidneys are damaged?

7. Are we treating the injury improperly as if it were ARDS with ventilators and if it is not ARDS what is it?

8. Can pathology point us into a different therapy or different mechanism of action for Covid19?

Spanish Flu: pathologists, as today, study cases in autopsies. The techniques are largely the same.
What can we learn? We apply gross + microscopic inspection, correlate it with clinical information, and put together the CPC. No difference in how this is pursued in other countries. Same process in China.
How does COVID19 kill? It’s different. I have a lot of data on this. We are seeing changes that are different than with bacterial and viral pneumonias. We get a lot of cytokines, huge outpouring. They do damage because they result in damage cells accumulating in the alveolar sacs. This is where the O2/CO2 exchange is made; when the wall is damaged, it compromises things.
We’re learning that the virus can attack organs directly — the kidneys, even the heart. One report of the eyes as well. Extremely contagious, and can damage various organs.
Use of respirators helps in many cases, in others it does not.
As the denominator increases, the mortality rate will be lower than predicted.

Topic: How can we make good estimates of the parameters of the epidemic?

Bio: Retired statistician from major pharma company; author.

Questions:

We are throwing the kitchen sink at the virus, how can we tease out what is working when we are using so many different combinations of treatments?
Is the medical community keeping track of what treatments that we are using, and also aware of what morbidities the patients have?
The hospitals are chaotic, can we be sure that record keeping is sufficient?
Are we going to be using the law of large numbers and regressing the inputs?
To what extent will the studies show treatments that have been proven helpful purely by anecdote?
How will Bayesian priors play into observational studies as doctors will tend to move in the direction of what appears to be working?
Cochran talks about using blocking, which he means that when two patients enter the hospital with similar general characteristics (age, morbidity, and extent of virus infection) you split the two and give them different treatments. The other concept is to use randomization for minor sources.

How do we know if a given drug is helpful? Traditionally we run large-scale double-blind clinical trials. That takes a long time; and patients are dying now. Is there another standard?
1952, Willian Cochran faced a similar situation. Noticed that many families that moved from the slums to a new housing development were breaking up. There was a new measurement of “family cohesiveness” that they wanted to use; but they could not assign homes at random. Families that moved into new housing first would by definition be different than families who moved later — more aggressive etc. So developed the idea of an “observational study” where you don’t randomize in advance, just observe, and then try to create groups after the fact that differ only in outcomes but are the same in every other way. [CCN: this is like synthetic controls.] This has produced useful results in medical field and in others. Dedicated journal.
Has been used to examine value in seat belts, for example.
For COVID, we have one study which shows that more patients died when treated with chloroquine than those who were not; but they might differ in essential ways such as how sick they were.
Q: Can you vary treatments to tease out covariance?
A: You don’t intervene at all in Cochrane’s method. After the fact, you look at the characteristics of each patient. No random assignment. There is a Bayesian interpretation of this.

Topic: Survey of Progress in Vaccines for Covid19

Bio: Blogger on the pharma industry

Questions

Which type of vaccine can get to market the fastest?
Do you think, human trials will all be in developed countries, or do you think that experiments will be conducted in the developing world to cut corners, or has the developed world decided that the virus is dangerous enough to clear any reasonable vaccine for human trials?
When would be the earliest we might have a workable vaccine with unknown side effects? And do you think we will allow vaccinations before we know the side effects?
Do you think that the fastest to market vaccines can be mass produced in sufficient volume to help the most at risk patients and first responders?
Do you see chaos around the fact that there will be small initial supplies of the vaccine? And will that cause an international incident if the country that is producing the vaccine will not share it with other countries before vaccinating all of its own citizens?
Do you think we will have different vaccines for different groups of patients?
How important is Bill Gates in the vaccine production process? How difficult is large scale production and does it make sense to follow 7 different vaccine paths to be precautionary, and do you think the large drug companies will end up producing their own vaccines without Gates’s help?
Will the vaccine race be profitable for the manufacturers or will it be a charitable exercise, and is this fundamentally why vaccine production is suboptimal?
Do you think that all the work on Covid19 will accelerate the research to have a universal flu vaccine? And do you think it will result in better vaccines for other corona-like viruses?

We are trying every known vaccine technology simultaneously now; large number of studies. Hope a few will make it through.
The mRNA might be the fastest but we don’t know if it works — no human vaccines yet developed this way.
We’ll get through Phase 1 safety trials quickly and getting into at-risk populations.
Earliest we can see even an emergency use authorization would be early next year. That would break every known speed record. That will only happen if everything works perfectly the first time, which it rarely does.
That sort of vaccine would only have been roughly tested for safety. No time to do the multiple, wide-ranging vaccine tests that we usually do. That could take 4-8 years!
Whatever comes out first will also be in short supply at first. We will have to plan for how we roll it out and to whom.
Will it give enough immunity? Can we deliver it via manufacturing?
Bill Gates is trying to fund a number of different types of manufacturing facilities, which is a great idea, particularly if we need to go to a different technology.
Some larger producers may be able to handle it; they are ramping manufacturing.
Don’t think anyone will make money on this. J&J has said they are doing it on a not-for-profit basis.
This won’t help that much with flu or HIV — very different types of virus.
Incentive is to find something that works to get the world back to normal.
Could be more than one vaccine. Consider Polio where there were two vaccines, was unclear for some time which way to go.
Expect high profile failures. Hard to predict.
Optimistic that we will get something but don’t know when.

Estimating the effective reproduction number; looking ahead

21 April 2020

Here are some of the most interesting posts, articles, papers, and resources I’ve come across recently, organised by theme.

How close are we to R=1?

You’ve probably heard about the basic reproduction number by now, R0 (R-naught). This is the average number of people infected by each infected individual a situation in which the entire population is susceptible (no immunity) and no measures have been taken to reduce the spread.

The number that matters most now is the effective reproduction number, often simply called R. This is the average number of people infected by each infected individual in a given population, at a given point in time, taking into account the actions taken to reduce the spread.

Studying the paths of different countries, and talking to epidemiologists, one very simple but very important rule is clear: If R<1 (and remains below 1) in a given population (say, a city or a country), the pandemic will gradually die out in that population. If R>1, the epidemic is still increasing exponentially.

Of course, it also matters if R is a little more than 1 or a lot more than 1.

One of the best explanations of how important this concept is, and how much depends exactly where we are relative to that threshold of 1, comes from none other than German Chancellor Angela Merkel. Below is an excellent video, subtitled in English, where she explains this clearly (and here is the link if the embed below isn’t working for you).

This is how Angela Merkel explained the effect of a higher #covid19 infection rate on the country's health system.

This part of today's press conf was great, so I just added English subtitels for all non-German speakers. #flattenthecurve pic.twitter.com/VzBLdh16kR
— Benjamin Alvarez (@BenjAlvarez1) April 15, 2020

While there are more and more individual studies trying to assess what R is in a given location at a given time, the most useful general resource I’ve found for looking at this globally is the Epiforecasts site from the Centre for the Modelling of Infectious Diseases (CMMID). The good news is that R is trending down towards, near, or possibly even slightly below 1 in a number of countries (six shown here, many more available on the site):

Figure 2: Time-varying estimate of the effective reproduction number (light ribbon = 90% credible interval; dark ribbon = the 50% credible interval) in the regions expected to have the highest number of new confirmed cases. Estimates are shown up to the 2020-04-11. Confidence in the estimated values is indicated by translucency with increased translucency corresponding to reduced confidence. The dotted line indicates the target value of 1 for the effective reproduction no. required for control.

The site also helpfully presents the number of daily cases both with the date on which they were reported, and on a time-adjusted basis where they use some fancy mathematical tricks to try to map cases to the most likely date of infection; this can present a very different picture:

Looking across a number of countries (not just those reproduced above), a few things stand out:

Control measures have clearly been very effective at reducing R, albeit at high cost.
Few countries that experienced a large outbreak have gotten R significantly below 1. France, Austria, and South Korea stand out as having significantly reduced R below R.
A number of countries that imposed strict control measures continue to have R very near 1, including the US, the UK, Italy, Germany, and Spain. These countries may have trouble relaxing control measures significantly (as Merkel discusses).
Many countries that have not yet had large outbreaks have R meaningfully above 1; it may be that they have not yet felt the pressure to impose significant control measures, or that they have taken very effective preventative measures.

Still on the topic of R, and for geeky voyeuristic value, I particularly enjoyed this debate between Nobel Laureate in Economics Paul Romer (whom, for the record, I think is an extraordinary thinker), and mathematical epidemiologist Adam Kucharski, about whether a given set of measures would likely be sufficient to get R below 1. (Spoiler alert: Paul gracefully backed down from his claim that these measures would suffice after Adam publicly walked him through a simple framework that demonstrated that they likely would not.]. The important point, though, was that even assuming we had sufficient testing capacity, periodic testing (e.g., fortnightly) is unlikely to be sufficient to keep R below 1 given a high rate of asymptomatic transmission.

Finally, one recent study looking just at France estimates that R0 was 3.3 and that lockdown has taken France to an R of 0.5. Note that one result of slowing the spread of the epidemic so effectively, in order to preserve health care capacity and avoid Lombardy-type situations, is that we are very far from herd immunity. This study forecasts that only 5.7% of the total French population will have been infected (those currently infected as well as those who have recovered) as of 11 May, the target date for relaxing control measures.

Dancing towards the exit?

You may remember Tomas Pueyo’s early, influential Medium post from 10 March which warned what was coming, with great data and charts. His latest post, Learning How to Dance, takes an approach I like a lot: it looks at what we can learn from successes and failures around the world.

Most significantly, he compares Singapore and Japan, early success stories that originally contained the pandemic successfully and more recently have seen accelerating infection rates, with Taiwan, South Korea, and Hong Kong, who have managed to allow some degree of reopening without resurgence.

The detailed description of how Taiwan’s highly centralized, mandatory, police-state like approach to contact tracing and quarantine is impressive; but also depressing, as it’s hard to imagine that approach being accepted, let alone being implemented successfully, in the West.

Similarly, South Korea reportedly has tracked travel and contacts centrally, coupled with extensive testing and mandatory quarantine in government-run shelters for those who test positive.

By contrast, Singapore made critical mistakes: they allowed European travelers in for too long, permitted seeding of new cases; started with under-resourced manual contact tracing; and achieved low opt-in for automated contract tracing.

Apparently, adoption of masks has been another point of difference:

Until April 3rd, Singapore only recommended masks for the sick. As we saw before, that contrasts with both Taiwan (with masks managed centrally) and South Korea (with 98% of people wearing masks at least sometimes and 64% all the time outside).

If you’re a fan of Tomas’s essays, you’ll also want to read his extremely depressing post about the pandemic in the US. He concludes that the US will only succeed in having an effective response if it centralises many aspects of it (e.g., healthcare supplies, contact tracing, setting guidelines for social distancing measures, testing initiatives); exactly the opposite direction that the US is currently going.

More generally, I am a big fan of comparing the approaches taken in different countries to see what is effective. To that end, I found the Oxford COVID-19 Government Response Tracker very helpful. It provides a quantitative way to assess, report, and compare how stringent the measures being adopted by different countries are, and how those are evolving over time.

The data show that in most countries, responses have lagged (and presumably been in response to) outbreaks:

(I know correlation doesn’t prove causation, but I’m pretty sure that higher stringency doesn’t cause more cases, so I’ll go with escalating cases causing stringency.)

The year ahead, according to the NYT

The New York Times’ recent feature on the outlook for the next year, summarizing the views of around 20 experts, was excellent and (I’m sorry to keep using this word) sobering. Some key points:

Many experts are pessimistic about the ability to reopen the economy without a re-acceleration of the pandemic. “Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding. If Americans pour back out in force, all will appear quiet for perhaps three weeks.”
“Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.”
Although the actions taken will reduce the death toll from what it would have been, COVID-19 is still likely to be the leading cause of death in the US and could kill more than the 420,000 Americans who died in WWII.
There are emerging templates for what it would take to reopen the economy safely, but their criteria seem very difficult to meet anytime soon: “Resolve to Save Lives, a public health advocacy group run by Dr. Thomas R. Frieden, the former director of the C.D.C., has published detailed and strict criteria for when the economy can reopen and when it must be closed. Reopening requires declining cases for 14 days, the tracing of 90 percent of contacts, an end to health care worker infections, recuperation places for mild cases and many other hard-to-reach goals.”
Those certified immune will have great advantages in their ability to participate in the economy, which creates perverse incentives to seek to be infected.
Mandatory quarantine of infected individuals (a cornerstone of some effective responses such as Taiwan and South Korea) is controversial in the US; and contact tracing efforts are not being scaled up rapidly.
Vaccines are unlikely to arrive soon.

Testing capacity?

Every proposed path to reopening relies on scaling testing capacity. But where will that capacity come from?

This epidemiologist from the Johns Hopkins Center for Health Security points out that the US has plateaued at 1M tests/week but needs 3.5M/week.

This article in StatNews discusses a global shortage of relevant reagents.

A long road ahead?

Here’s a small selection out of many articles suggesting that the path ahead is a long one. Harvard Professor of Epidemiology, Dr William Hanage, writing in The Guardian:

This crisis is not close to over, quite the reverse. The pandemic is only just getting started.

In order to get really depressed, read this article in Science, co-authored by Marc Lipsitch, projecting multiple years of recurrence. It takes the approach of assuming that, without a vaccine, we have no choice but to achieve herd immunity through infection and recovery, and tries to model what that will take, using as a constraint that we do not want to exceed critical care capacity. The paper is very clearly written and worth reading in full.

We projected that recurrent wintertime outbreaks of SARS-CoV-2 will probably occur after the initial, most severe pandemic wave. Absent other interventions, a key metric for the success of social distancing is whether critical care capacities are exceeded. To avoid this, prolonged or intermittent social distancing may be necessary into 2022.

Naturally, there is a lot of attention (as discussed above in relation to Tomas Pueyo’s post) on contact tracing and quarantine. Adam Kucharski points out that it would take extremely highly adopted tracing programmes and high compliance with quarantine for this to be sufficient to completely exit other control measures (though of course, even partial adoption and compliance would help). The key challenges are that even with much more testing, a lot of spreading would still happen prior to testing picking up new cases; and enormous effort would be required to manually trace large numbers of contacts (in the absence of near-universal adoption and acceptance of technical measures as in Taiwan).

Fifth weekly Sunday off-the-record chat with experts

19 April 2020 (minor typos corrected 20 April)

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to more than 1,000 attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the fifth in five weeks, covered very wide ground: the likely duration and path of the pandemic and our reaction; the historical context from the 1918 pandemic; political and economic considerations; what we’re learning from serological testing; the perspective from small business; what’s coming in therapeutics; implications for medical education; ethical considerations; and more. We had a range of prominent speakers including a superstar public health expert frequently quoted in the press.

As always, the conversation was fascinating and wide-ranging. Here were a few of the most important takeaways for me:

Without exception, all speakers agreed that there was a very long road ahead — 12-18 months or even more. No speaker thought we could return to normal quickly.
We had one of the authors of the Santa Clara serological study I mentioned earlier this week on the call. She cautioned that because of the high rate of false positives of the test they used, and the real possibility of selection bias of who volunteered to participate in the study, that the results were very likely not indicative of the overall prevalence of infection in the broader population. While some are trying to interpret the study as meaning that many more people have been infected than was previously thought, she does not believe that that is the case.
There appeared to be a consensus that not more than 5% of the US population had been infected so far (though of course rates could be higher in some places). So a long way to go to herd immunity.
Similarly, several speakers thought that herd immunity (whether achieved organically or with the help of a vaccine) was the only route out of this. One prominent public health official pointed out that the virus is like water — it seems to find holes and start new waves every time a country relaxes its measures. We don’t yet have a playbook other then lockdown or letting the virus spread rapidly.
Testing & contact tracing as a strategy is challenged by a WW shortage of reagents for testing.
One way in which this is more challenging than the Spanish Flu is that it is likely more infectious, and that the incubation period is much longer so it takes longer for the pandemic to spread through a given community.
While no speaker thought we were likely to have an active vaccine prior to 12-18 months, and some were more pessimistic than this, having a passive vaccine (i.e., using antibodies produced from outside of the patient’s body, perhaps from blood serum) could be as soon as 3-6 months away.
Several speakers discussed open questions around the duration of infectivity, and about immunity. Some COVID-19 patients who appear to have recovered, in terms of symptoms, are still shedding virus up to six weeks later! We don’t think this is reinfection but we don’t fully understand it. Most were convinced that some, but not all, recovered patients had gained immunity.
In the US, the fact that the outbreaks happened first in blue states combined with political polarization has influenced the (slow) response to the pandemic. Now it is spreading to red states; that may again change the response.
Current incentives in the US are for a huge number of people not to go back to work even when they can, because they get more money for not working than they earn working. This needs to be fixed.

Topic: “Federal polarization”

The ideological and partisan disagreements across states and between states and the federal government. Federal polarization has grown dramatically over the past 20 years and has clearly been the major impediment to a coordinated public health response. I will also talk about the election as the two are related.

Bio: Professor of Political Science at a major university

Questions:

1. Chris DeMuth in this Weekend’s WSJ Op-Ed mentions that this Administration is acting differently than previous administrations in that it is focusing on a decentralized and deregulatory response. It is not centralizing authority but is instead empowering local and state government and encouraging private enterprise responses with less than normal regulatory oversight. Do you think this will continue? Is this the future Federal government? Or will this be unique to this administration?

2. What will happen when Trump wants to open the economy and the governor does not? Do you think that when Trump calls upon the public to make demands on the governors that this political and democratic process is the right way to handle the problem?

Focused on partisanship
Four-decade long increase in ideological polarization
Republics & Dems vote less together than in the aftermath of the Civil War
Focusing now on state government. OVer last 20 years it looks like this in most states as well. Half of states are more polarized than the US legislature
More ideological variation across states (between states) than previously.
Three trends at the Federal level
- 1. Polarization as per above.
- 2. Increased propensity for a single party to win both legislative chambers
- 3. Increased propensity for Governor to be in the same party as the legislature.
So moving towards 50 one-party enclaves, state by state. Highly divergent choices.
Also greater difference between “out party” states and the Federal government.
This is visible in this crisis.
Crisis like this requires high coordination between states and federal, but not happening.
High disagreement across states about the right decisions.
Liberals and conservatives view the tradeoffs differently, and this shows up in different views about re-opening the economy.
Misiformation that preys on confirmation bias exacerbates it.
One clear manifestation: very different plans about reopening, appearing in cross-state pacts. Three such: NE, Midwest, PAcific coast. 17 states in all. 14 of the 17 have Democratic governors.
Federal polarization in an election year heightens the stakes.
Federal relief efforts in natural disasters can be exacerbated by politics. Worse than usual here, administration encouraging voters to see this through a political lens.
Also biggest outbreaks in Democratic states.
This incentivizes administration on quick economic reopening.
Huge gamble that outbreak doesn’t spread to the red states.
Now that it’s in Michigan and Penn, seems to have been a miscalculation.
Huge challenge we need to confront.

Topic: The Pandemic and Future Legislation

Bio: Republic politician with medical background in emergency care

Significant body of work suggesting that there is a genetic difference in people that influences response to virus. This may hold the key to who gets sick.
My network includes many medical providers.
We may have misread the [angiotensin] receptor. Sample sizes too small to draw population conclusions. SUggestion is that hte virus is creating something like pulmonary edema, so patients don’t respond to ventilation. High-flow oxygen may be better. In one study 68% of patients on ventilators died.
[How will Congress respond?]
Three bills: one focused on testing, one Families First to help small businesses, one CARES act. On latter we will be focused on fixing holes in earlier CARES Act.
In 14 days SBA loaned 14 years worth of loans. $36B loaned out.
President wants $251B, Senate tried to just add that amount, Democrats blocked it in the Senate. Negotiations have been going on all weekend long. (This is on the PPE program which is depleted.) The other aspects of the CARES program are not yet depleted.
The Left is trying to add to it, focused on areas like more money for hospitals.
Democrats are not making the same push for things like the Green New Deal or the Kennedy Center for the Performing Arts (pork). Good negotiations are going on now on substantive topics. We will vote by Tuesday or Wednesday.

Topic: Santa Clara Randomized Study of Covid19

Bio: Medical researcher

Questions

1. What does the high asymptomatic rate mean for the expected death rate from the virus?

2. Does this mean that we should open the economy?

3. Will there be frequent random surveys in the same county to better evaluate rate of increase of exposure under both lockdown and free movement with some social distancing?

4. What do you suspect will happen when asymptomatic patients are exposed to the virus again?

5. Why do so many people who take the Covid19 test are negative even with symptoms, is it because they have a different variant of the flu?

I was on the call last week and was careful not to give out numbers for how many people had immunity in a random community study. That’s because I was waiting for our paper to come out.
It’s not out and it’s not peer reviewed. There are a lot of criticisms about it. I shared the critique.
We used Facebook questionnaires to get 3K people to take finger prick tests for serological tests.
We used a toolkit that might not be idea but is what we had at the time. There are three other toolkits now available that are probably better in terms of precision and accuracy, but this is what we had three weeks ago.
The test has a false positive rate. When you look at the data in a population, the random population could have had a different coronavirus previously, not COVID-19.
There could be a cross-reaction.
So we need to be very careful in drawing conclusions given false positive rate.
Clear lesson from his study that we need better tools and larger population
They came across with a rate that 1 in 100 in the Bay Area had been infected.
But if you look at the trends, we thought i would be 1 in a 1000 to 1 in 2000. So this was surprising.
What does it mean? It means we need better tools to test; we need to understand if someone is immune, — “titers” — whether someone has enough immunity to fight the virus if they had it again
South Koreans have done a lot of long-term monitoring of those who had it originally.
A lot of them are still shedding virus 6 weeks later!
Reports of patients having positive results, then going negative, then going positive again.
We think that reflects the tools not that they have been reinfected but we don’t know enough.
We don’t know if people can go back to work.
We don’t think there’s enough to get to herd immunity.
We need therapeutics.
[Q: one complaint about your study is that it wasn’t random enough, that people who had symptoms would be been aggressive in trying to get onto site because of lack of general testing]
You always have to wonder about who signs up to a study and why. It’s possible that they were incentivized by having symptoms, having someone they know have COVID-19, etc.
This is not a large enough sample to know if it was random the way we wanted it to be.
It seems like this was not a random population.

Topic: Comparing Covid19 and the 1918 Flu

Bio: Author, historian

Questions:

1. How would you contrast the government response of 1918 and Covid19?

2. How do you think the education of the current heads of the CDC and public health officials plays a part in the current decision making process? And does it matter that medical technology and knowhow is progressing at such a fast rate?

3. Communication is so much faster and doctors can communicate the world over to make contributions in the race against Covid19, what do you make of the international medical response to making better informed clinical decisions?

Viruses tend to be seasonal. DOn’t think this wil lbe the case here. The issue is susceptibility.
In 1918 the population was highly susceptible. Second wave started in July in Switzerland. Australia, 1919 was the last place in the world to be hit because they had a rigid quarantine. That hit in summer.
At least 95% of the US population has not been exposed. Modellers think there are at the extreme, up to 20x infected who have been exposed — that is the outside estimate. THat will prove much more important than seasonality.
Predict we will see swells, not peak and trough.
Second big difference is the incubation period. This is much longer. Flu is 1-4 days, median 2. This one is 1-14, most people sick at 5-6 days.
It is in the body longer as well. Each generation of transmission takes much longer.
Flu will go through a community, seasonal or 1918m, in 6-10 weeks and then largely gone unless another wave comes.
That will not be the case here.
[Q: How does the education of the relevant officials impact their response?]
Totally different situation. In 1918 it was the Surgeon General of the Army.
Today we have every nation in the world with top-flight scientists and biotech industry who are cooperating to a remarkable extent instead of competing. Good information sharing.
Controlling this medium-term is therapeutics, vaccine long-term.
Expect immune systems to be more effective the 2nd or 3rd time around.
The Virus is here to stay but may not be a serious threat in the future.

Topic: Treatment and Testing of Covid19

Bio: Professor of Anesthesiology at a major hospital

Convalescent plasma at our hospital, in 120 patients so far. This is immunoglobulin therapy, taking from people at least 3 weeks out from COVID disease.
We have a world-class virology lab and were able to more the research assay into our clinical laboratory. We got qualitative approval from the FDA.
We’ve identified patients who are “high titers”.
We don’t know if it will work.
Have had a lot of support from the FDA.
Not clear what the role of Immunoglobulin will be.
Many of us are working on creating a consortium to work on
Seems that the virus is injuring lining of small blood vessels and then activating the coagulation system. Clotting is part of the mechanism of the disease causing injury to lung and other organs.
Attempting to block the coagulation.
Sickest patients: also trying research protocols to use other drugs like EPA.
Very intense disease, frightening to treat.
About 5% of people who enter hospital will become long-term ventilator dependent. That has long-term implications for capacity across the country, for inpatient rehabilitation, etc.
[Q: COuld there be 40K patients on long-term ventilators?]
Depends on how well we do as a nation in controlling disease. It could be.
People don’t come off ventilators with high frequency. 50% of patients intubated are still intubated. A proportion do very well, a proportion die rapidly.
Remdesviir, some other inhibitors, we’re hoping some cocktail will help us improve the clinical course and the survival rate.

Topic: How will the biotech industry, pharmaceutical firms, and medical supply companies respond with new products in the pandemic?

Bio: CEO of a therapeutics company

Questions

1. How rapidly can private firms provide testing, treatments and vaccines?

2. Are you pleasantly surprised at the change in the FDA regulations during the crisis and do you think it will last?

3. How can biotech specifically improve the situation? What does it mean for drug, testing, and vaccines?

Most laypeople believe that one therapy is as good as another
Three types:
- 1. What can be used to prevent the infection in the first place. E.g., vaccine. Active = you take the virus, attenuate them = partially kill them, inject, expect patient to develop antibodies. Passive = could include convalescent serum, antibodies are manufactured externally. Either could prevent infection. Active is 12-18 months away, passive could be 3-6 months away. For disclosure, I am on the BoD of a company developing one such.
- 2. How do you control the spread of the disease? Viruses turn the host into a virus factory. Antivirals come into play, goal is to stop the virus from replicating. There are several antivirals under exploration including remdesivir. Early, encouraging population data for remdesivir that it can shorten the period.
- 3. Not targeted, but prevent or reverse end-organ damage. We think this virus creates a significant inflammatory response. Some therapies will try to mute this response. One drug approved for arthritis is being tested.
[Q: FDA has changed process to encourage quicker applications of drugs and treatments. How will that deregulatory process will speed things up?]
This is the fastest I’ve ever seen industry respond with clinical trials.
May have an answer for remdesivir very soon, and for passive vaccine by end of summer which would be a record.
Then need to cooperate with regulatory agencies around the world to get approval.
FDA seems open to it, and to processing applications quickly if effective and safe. Expect this to be similar around the world.

Topic: Medical School Education and the Pandemic

Bio: Professor of Medicine at a major medical school

Questions

1. What are medical schools teaching methods and content that do not belong in medical schools?

2. What is the appropriate role for a medical school teaching hospital in a pandemic?

3. Should medical students be shipped out to hot spots in the pandemic?

4. How do we bring pandemics into the medical school curriculum?

My discussion is more theoretical.
My ideas are somewhat controversial.
Medical schools have decided to reduce basic science and clinical science compnents of education, to emphasize social and organizational aspects.
Required clinical now just 1 year, basic science just one year. Lots of electives.
Insufficient time to hard science, almost no time to disaster preparedness like epidemics.
I supervisted my school’s curriculum so I take some blame.
Some want to more education even further away from science to focus on social inequalities. So they think we should focus on “Intersectionality”; e.g., racism.
My view is that medicalization of social problems is a profound error.
Our true role is to care from those suffering from illness.
Of course inequalities exist and this impact outcomes.
But physicians have little to contribute in correcting these problems. This distracts from the required political and economic solutions.
My view is that this shows we need more rigorous training including learning about epidemics.
That does not denigrate the courageous work of the frontline healthcare works who have been spectacular.
But we have a shortage of those trained in critical care.
Sending medical students into hotspots would be a terrible mistake. It was done in WWII. But they are not ready for this intense work without a lot of supervision. Might be required in a crisis but would be dangerous for patients and clinicans.
Impact on African Americans has been blamed on the care they receive. But the same disproportionality has been seen on people of African origins in the UK. So can’t just be the US system. More likely it’s about poverty.

Topic: Medical Ethics and the Pandemic

Bio: Director of Ethics Education at a medical school

Questions:

1. In a world of scarcity, finite ventilators and finite masks and finite nurses, who should get the hospital care? And who should be the decision makers?

2. Should we give out the vaccines if we do not how safe it is?

3. We are going to violate a number of FDA protocols, should we do so if the risk/reward in public health demands it?

4. Should we force certain citizens to be vaccinated if we do not know if is safe for those supporting an at risk population like nursing home workers?

All evidence suggests that my field has not contributed as much as it should have.
Rationing fortunately didn’t come to pass, but this could resurge or there will be a new one.
So we have to think about how to improve bioethics going forward.
Rationing of ventilators, ICU beds, etc — we lack a consistent national policy about how to allocate resources in a crisis.
Only 26 states have publicly available standards of care. And they differ hugely across states.
This isn’t necessarily because of federalism or a difference of cultural values.
We have uniformity in the definition of death in almost all states. Same for the standards for qualifying for organ transplants. So it’s possible.
Not clear who should establish guidelines or what criteria to use.
Some lessons. Clearly physicians in the field should not be asked to make the judgement. That could have devastating effects on their long-term mental well being; and it would lead to very different rules being applied.
Whatever policy we choose it should be applied blindly — without knowing who the patient is. By an independent party. This prevents ratinoing from undermining relationship with doctor.
We also need community buy-in including underrepresented communities and those with underlying conditions.
Will be important for vaccination decisions.
Two unresolved questions:
1. What test to use? Assume not first come first serve; is it life expectancy?
2. Needs of COVID vs non-COVID patients. E.g., some patients who require ventilators may not be able to get them.
[Q: Does it matter who had the ventilator first?]
Maybe we want to have a a system which allows us to take people off ventilators so that we are not reluctant to put them on in the first place.
[Q: we’ll have vaccines at some point, we may want to release them before we know that they are safe. Thoughts?]
1. For the system to work well we need collective buy in.
2. Some people will be serving vulnerable populations, we may have to have higher standards for them.
3. Should we mandate flu shots going forward?

Topic: Battle Plan for the Pandemic

Bio: Professor of Public Health at major university, prominent thinker on the pandemic.

1. Are you optimistic about vaccines – quality and timing? In your book you mention that you were particularly concerned about not getting an HIV vaccine, do you think there is significant risk of no vaccine in the foreseeable future?

2. What are your thoughts on the efficacy of the treatments?

3. What is your view of the large segment of the population who appears asymptomatic?

4. Do you think that asymptomatic patients will not have sufficient antibodies in case they are exposed again?

5. Do you think the CDC did a good job?

6. Do you see more pandemics coming or is this a once in a 100 year event?

7. Testing has its flaws, do you think that it is critical to opening the economy, or do you think it is bogus due to high error rates?

8. An Israeli mathematician, Isaac Ben-Isreal, who holds some positions of importance has been claiming that the data from Sweden, Taiwan and Singapore show that the virus might be following a pattern of peaking after 40 days and going away after 70 days in a manner that seems to be independent of how much a society has locked itself down. This theme has been getting picked up and amplified. Is it quackery, or might this perspective have merit as policy makers try to figure out the path forward?

9. There is a growing chorus of experts (Josh Mitteldorf being one) who suspect that the virus has characteristics that make it plausible that it was genetically engineered and didn’t arise naturally in the bat population, possibly coming out of some Bio-warfare research, which is supposedly illegal in the US. Is this also quackery, or is there a decent probability that this story is accurate. Some interesting implications for the future if this is what happened.

Thoughts about where we are going in the coming months.
We have been preparing for a long time, but we don’t know how it will end.
“We’re not at the end, we’re not even at the beginning of the end, we’re at the end of the beginning.” At best.
No more than 5-7% of the population has been inefected, even in hotspots. Much lower in some parts of the country.
This virus is going to spread until we get to 60-70% range to get to herd immunity.
We have a long ways to go.
I worry about, as a nation, that we want to get back to normal. We never will; there will be a new normal.
We are considering policies not in our best interest.
We can look at models; I think of them — whether Imperial College or U Washington — they are black-box analysis with assumptions that vary a lot.
Regardless of what your estimates are, 320 million Americans, say half will be infected. Even consider those who will be clinically il.. 80% will be mild to asymptomatic. 20% will seek medical care. 10% of those could be hospitalized, 5% will need intensive care, 1% will die.
0.5-1% of 160M = 800K – 1.6M people who will die if you believe that. So we have a long way to go.
Two lanes of decision making.
1. Shutdown like Wuhan. It took that incredibly draconian limitation of population movement to get to where they are now. As they go back to workplace, in multiple countries, seeing
We may or may not get a vaccine, we don’t know timeline.
Shutdown isn’t a good long-term model, will destroy the economy.
2. We could just let it go. The implications on health care system — NY, Italy, etc — have dramatic implications. Impacts all patients not just COVID-19.
Trying to figure out how to thread the needle.
How can we allow those who have lower risk to be active part of society & economy?
At the same time protect those who are at higher risk? Try to stave off infection until we have a vaccines.
We odn’t have many tools.
We have suppression.
We have testing and trying to do contact tracing. Many chalalnges to that including a major shortage of reagents WW.
Some challenges about the predictive value of positives.
You would get as many false positives as true positives with antibodies today.
In next 16-18 months or more we will face many more challenges.
There may be many more curves to come.

Topic: How Mid-Sized Companies in Construction are Faring in the Pandemic

Bio: President of a construction supplier

Questions:

1. What were the challenges for the NJ hospitals to create negative pressure rooms for Covid patients?

2. Cuomo’s decision to close all work sites in NY was hugely problematic for you. How did this impact supply chains, working capital, and warehousing? Can NYC construction reopen without a hitch?

3. Working Capital Problem. You used Wells before the 2008 crash and Wells not only did not extend credit, but they withdrew it in last financial crisis. You switched to a small local bank, how responsive have they been, and did they get your SBA PPP loan immediately? Do you think the ever greater concentration of deposits and corporate lending hurts small business?

4. We need to figure out how to use your labor force in this intermezzo period?

We are 3rd generation small business
45 employees
Commerical building supply in tri-state area.
First two weeks of March were business as usual.
Started getting emergency calls from hospital to create negative-pressure rooms.
We were furnishing lights and view panels into flush doors, plus automatic door closeres to keep doors closed. Plus lots of plywood and plexiglass to install HEPA filters where there had been windows — to create positive pressure. Also to be able to keep an eye on patient from outside room.
Last two weeks were very hectic. Then all non-essential construction was shut down.
We had a lot of orders coming in for NY and NJ for major clients. They were all shut down.
This created a warehouse problem as we have lots of things waiting to go to job sites. Had to rent trailers to store material.
Creates potential cash flow problem for us. Vendors want to be paid. Don’t know if customers will pay for stored materials prior to being shipped.
On April 3 applied for our PPE loan. On April 15 received funding.
Felt fortunate to be working with a small bank where I feel valued.
Worked with a big bank previously and they were difficult on our industry. Very happy that I moved to a small localbank.

Topic: Unemployment Insurance and Getting Back to Work

Bio: Professor of Labor Economics at major university.

Questions:

1. How will we get people back to work if we pay them more than their daily wage?

2. Would you propose that workers earn both unemployment insurance and a wage for a period to encourage work?

3. How do we decrease unemployment insurance payouts to achieve our objective of more work?

4. How will labor markets adapt

We’re getting a better estimate of the labor and economic depression.
Expressed annually, $7 trillion, or $15K/household PER QUARTER. Employment has fallen 28 million.
Scholars have the well-developed national accounts.
Calendar years have a varying number of workdays which let us estimate what a quarter would be like if it had just weekends and holidays.
GDP would be 25% below normal, hours worked 28% below.
28% below normal work hours is exactly what we are seeing in the data.
Capital utilization is 30% below normal. So real GDP is around 28% below normal.
The published data does not express data like this. This data is talking about what Would happen if there was no change for three more quarters.
Economic pie has shrunk in unequal way.
But legislatinos does not produce goods and services.
The legislation further shrinks the pie.
This is equity/efficiency tradeoff.
There are 9 separate provisions. Each of them is large by historical standards.
$600/week for unemployed on top of normal benefits.
Over 100M people are eligible for this assistance.
Don’t see we can have a recovery when most people can make more money not working than working.
Policy options:
Wait for privions to expire
- Let people going back to work to keep some benefit
- Inflation
- Somebody put some sand in the system.
Employee retention tax credit appears to subsidize employees on the payroll, but another provision offsets this negatively and removes the incentive.
“Human capital” accumulation is important. Not all accounted for in GDP. Schooling is not happening, also young adults at early stages of the career. $100B less human capital for each quarter.
Civil liberties are not included in that $7 trillion cost.
Is the cure worse than the disease?
It will get worse before it gets better. Recovery will be slow as long as there are artifical incentives in there. Either money will run out or washington will realise that it is time to get back to work.

Topic: Conflict between Civil Liberties and Public Health

Bio: Professor Emeritus at a Law School, author

Questions

1. What is the inherent conflict between civil liberties and public health?

2. China and South Korea are using cell phone data to track your whereabouts. Do you think this is a good idea if it saves lives? Do you think if we start doing it, the government will track you in times where there is no public health demand?

3. Why are you so worried that government powers can be limited to national emergencies?

4. How do you feel about federalism and the role of the states in handling local public health problems?

5. Should the federal government executives issues orders that undermine FDA regulatory authority during a pandemic?

If this goes on a long time the civil liberties issuse are even more urgent.
1905 decision Jacobson vs Mass., Supreme Court, a man who refused to be vaccinated for smallpox. Court said: Police power of the state to protect public is within the discretion of the state if not exercised in an arbitrary measure. No absolute right in each person to be free of restraint.
So the States have tremendous powers to impose the kinds of regulations we are now living under –stay at home, masks, gloves.
But over time people worry that the cure is worse than the disease.
People will start violating regulations; can they be stopped? Punished? Told they can’t congregate in a political protest or in their churches?
These issues will be coming up in lawsuits.
Last 3-4 years, huge assault on 1st amendment rights — speech, press, assembly. This is exacerbating that. Hostility to the press as “enemy of the people”, deplatforming attempts.
The next few months we need to think more about the obvious public health needs of the country with individual rights.

Topic: Solidarity

The surge of social solidarity that we are seeing and its consequences for the near future. The consequences will include support for universal assistance such as universal child care, wage subsidies, etc. The length of the crisis means that our social relations and politics may be changed for a year or more.

Bio: Professor of Sociology at a major university

1. Why do you think that the social solidarity will increase during this crisis? We are seeing pushback for a demand to work in Michigan and elsewhere, why can’t we see the opposite impact?

2. There may be winners and losers in the pandemic, are you concerned about this causing a rift?

3. Why do you think that if there is a work stoppage and the Federal government has the largest near term deficits since WW2 that the government will use this as a chance to expand entitlements and new social programs? The states are going to be under enormous budgetary conflicts, my expectation is that services will be cut, won’t this issue of scarcity drive us apart and not closer?

4. Basic family solidarity will be under stress from long-term quarantines. Do you expect an increase in divorce, spousal abuse, alcoholism, depression as well as an increased temporary birth rate (like in previous blackouts),

Will talk about social consequences of the crisis
Cold War: 1950s and 60s, Civil Defense AGency focused on how Americans could survive a nuclear attack by Soviet Union. Duck & cover.
Officials feared anarchy like Cormac McCarthy’s The Road.
Gov’t funded study to see what usually happens after disasters. In fact, people pull together, volunteer, surge of solidarity.
But the surge didn’t last. It declined to usual levels after a time. Empathy lessened.
Disasters also uncover hidden inequalities and provide opportunities for actors to advance their own interests.
We’ve already seen a sharp rise in solidarity.
Lots of focus on those who are most impacted, least protected.
We’ve seen a run on guns.
Some states have tried to push prolife agenda
But what is different than all prior disasters is length. Solidarity is highest in the period when people are suffering and dying. But this could go on for a year or more.
The floodwaters of this disease may not recede for some time.
COuld have one of two possible effects.
Optimistic: could prolong the period of solidarity. Maybe support for extending health insurance could expand.
Pessimistic: Or solidarity fatigue will set in soon. Hoarding could grow. Interest groups could try to use this to their advantage.
We don’t know what will happen.
1918 flu epidemic didn’t lead to much social change.
Will charitable giving increase?
Will other states follow CA in assisting undocumented immigrants?
The silver lining would be if we narrow the social divisions of pre-COVID America.

Topic: The Pandemic and Religious Faith

Bio: Rabbi, author

1. Some governors are banning religious services even in parked cars in the church parking lots, do you think this is appropriate?

2. Minyans have to be done in person. Have orthodox shuls adopted appropriate social distancing in the pandemic?

3. There is a reason that Jews use minyans as prayer is a social activity. Should we undermine these norms in this risky time?

4. Telereligious services are taking off. Do you think this is where Reform Judaism is headed? And will this be a net harm?

5. Shivas and funerals have to be sparsely attended. How do you think this harms the surviving family?

I was on the way to Morroco in March, leading a mission. At that point Africa virtuall untouched. A few days later, borders were closed and I got the last plane out.
We were debating how to manage at the synagogue — e.g., minimizing physical contact.
My colleagues studied it and decided to shut down completely, even before this being suggested by the CDC or the government.
We canceled weddings, bar mitzvahs, etc. Shut down all buildings.
The highest Jewish value is saving lives, it is above all mitzvahs.
When we left Morocco, there was an outbreak immediately afterwards traced to a single wedding that had 200 French who had flown in — this became the nexus of the contagion.
So it was a good thing that we shut down such celebrations.
We also cut down funerals. We made them small, outdoors — e.g., 10 people.
In those for days my colleagues transformed our synagogue, one of the largest, into a virtual community.
It’s been amazing. Our attendance soared.
When we do a Passover seder (meal), we get typically 600 people. Our virtual seder had 15,000 people.
It’s also my biggest worry. I worry that our success may end up killing us.
My congregants may like it too much. They like the idea that they can sit at home.
I’m pessimistic about the short & mid term in terms of our ability to gather.
We will create an amazing High Holy Days with high production values and it will be more convenient for everyone..
Will this become a replacement for gathering?
Gathering is a high Jewish ideal — we are meant to be 10 or more gathered together to pray.
I believe people will come back to their religious institutions because of the innate spiritual need to be with other people.
May it be your will, oh God. Amen.
[Q: Will it be different for Reform vs Orthodox?]
Orthodox community is tech savvy. We [Reform] also have the need to get together. The question is how to we get back to gathering in person. Will be true for all religions.

Q&A among speakers

Q: How will families adapt to confinement?

A: Two phases: things will be fine or will even get better. People pull together for a while. But if it lasts too long we will see problems. So far reports of domestic violence are down. Could be that people are not reporting it. Long-term, if it’s a long time, not all families will be able to.

Q: (to economist) Hidden tax in the employee retention tax credit? I didn’t understand.

A: It is phased out with the revenue of the company. They get a good tax refund on their return, but they lose it as revenues return to normal. That’s a problem.

Q: You mentioned that the unemployment insurance is more than some workers earn, and hinted that Congress might change thet terms?

A: In prior stimulus, only 4-5 million people could earn more on unemployment than in their jobs. Now it’s 10s of millions. In some countries like DE they are going to bear the costs for some time of letting people work and get these benefits.

Q: (to construction company) What is your plan in terms of keeping your workers?

A: I got the loan on Wed night, on Friday met all hourly employees, said we were fortunate to get PPE loan. I’m not going to lay you off. We have 8 weeks to clean things up since we’re not doing our normal work. We will find things to do. They were very happy to hear that. I said, I don’t know what will happen in 8 weeks. Hopefully things will relax and we can return to almost normal.

Q: (to epidemiologist) We’re seeing the number of infections declined dramatically in China and South Korea. Why is that? Will they too have ⅓ to ½ the population get the disease? Why aren’t we seeing a rekindling?

A: People are making conclusions on data today where we see something very different the next week. E.g., Singapore in a state of public emergency. Japan is in state of emergency as well. In Korea, active transmission happening there. The virus is highly contagious; if you let up to allow the economy to return, the virus escapes.

Concerned about the numbers in China, they have been reporting 20+ cases of transmission per day and 1 clinical case; that can’t be right.

Will take time for these outbreaks to build.

If any country can contain it China can, because of what they can bring to bear.

Over and over again we find the virus in places that thought they didn’t have it.

Q: Will the draconian policies reduce the total attack rage? Could we reduce it to 5-10%?

A: We don’t have clear lessons from the past. We’re making assumptions that this is highly infectious and a long incubation period. It is like water, it will find the holes and leak out, until we have herd immunity. It will be like whack-a mole.In 2918 we had some peaks that went away on their own too. Nature plays a role. But it can cut both ways. You have to prepare for the worst. It will keep burning until you get to herd immunity or a vaccine.

Q: You’ve talked about HIV where there was a lot of optimism about a vaccine. Might we not find a vaccine?

A: HIV was very unusual situation. Our vaccine technology at the time couldn’t do it. There may be challenges here too. One is the effectiveness of the vaccine. Looking at SARS and MERS, it may be hard. But some work is more optimistic. One issue we have to resolve is the safety issue. Antibody-dependent Enhancement (ADE). Sometimes if you make a little bit of antibody and get infected, you create an immunological cascade that can be fatal. We saw a bit of that with SARS research. This is also why the Dengue Fever vaccine was removed from the market. We need to understand ADE more before we put a vaccine out.

Q: (to ethics expert) During Obamacare the Republicans were concerned about death panels.

A; Needs to be broad consultation. This would apply if someone was going to die because there weren’t enough ventilators.

Q: Will Congress try to fix the incentives in the legislation?

A: Will be challenging. The idea of continuing the $600 bonus once someone is on employment is an interesting idea. We face similar challenges when someone on welfare goes back to work and loses money. We need to work on this; clearly want people to return to work.

Q: If disease is here 18-24 months should we change medical school curriculum right now?

A: Classes are shut down, online only right now. Students aren’t involved in clinical activities. There will be a dramatic change. The response will be about how to protect yourself, isolate patients, treat patients. It will happen in a dramatic way.

Q: Is quarantining 14 days enough given evidence of shedding beyond that period?

A: (University researcher) We don’t know, we need to get the data. Some people have become immune and gone negative permanently. We’re studying health care workers. I’m optimistic that we’ll have better data. We don’t understand why some people have not gone negative.

A: (From major hospital) Looking at 5,000 people including titers, after 21 days almost zero, at 28 days 100% zero — but small study still. We’re all being cautious for now. We cannot 100% guarantee that reinfection is not possible, but patterns suggest that when the virus disappears, after 21-28 days immunoglobulin is appearing.

Q: Substantial errors in testing with false positives. In your study showing 5% of population having antibodies, what proportion do you think that are false positives?

A: We need to be very careful. When false positive rate is what we think, we’re worried that a large proportion of the positives could have been false positives.

A seductive idea that’s probably (but not definitely) false

It’s unlikely, but not impossible, that many or most people have already been infected

16 April 2020 (minor updates 17 April 2020)

Contagious (and possibly dangerous) memes

Many false and/or dangerous memes have spread about coronavirus (SARS-CoV-2) and COVID-19. These include that 5G cell phone towers cause COVID-19, that people of certain ethnic backgrounds don’t get sick, that certain drugs are miracle cures, that the virus was deliberately created by [China to attack the US / the US to attack China], and more.

(As an aside, mathetmatical epidemiologist Adam Kucharski’s The Rules of Contagion is a great and highly topical read, though more about the application of epidemiological concepts to spaces other than infectious diseases, including to meme propogation.)

One framework for thinking about these memes is against a two-dimensional space, with one axis being how likely they are to be true, and the other being how helpful or dangerous they would be if they gained widespread acceptance.

Obviously false but harmless ideas can be laughed at; obviously false but dangerous ideas should be argued against using data and logic; and true, useful ideas should be widely propagated.

The most concerning memes are those that meet all of the following criteria: they’re likely to be false (but can’t be demonstrated to be false); people are inclined to believe that they’re true; and their widespread acceptance could be dangerous. We can’t yet definitely disprove them, and need to study them dispassionately, but we don’t want everyone to change their behavior under the assumption that they are true.

With that in mind, there’s an idea that has been circulating for at least a month, and appears to be gaining momentum, that really concerns me.

The idea is this: that the rate of SARS-CoV-2 infection is much, much higher than we currently think, in some or in many countries.

For simplicity, I’ll call this the “ubiquity hypothesis.”

By the way, if you’re not already familiar with the definitions of and the differences between Case Fatality Ratio (CFR) and Infection Fatality Ratio (IFR) read this. In short, CFR measures the fatality ratio among confirmed cases of COVID-19; IFR measure the fatality ratio among all those infected (including asymptomatic or otherwise unconfirmed / unknown). We can approximately measure CFR, but we really care about IFR.

The argument for the ubiquity hypothesis

Here’s the logic for this idea in a nutshell.

We don’t yet have a definitive way of knowing who currently has COVID-19, or has previously had it and recovered.
- That’s both because the rate of PCR testing (tests for who is currently infected) has been so low in most countries,
- and because we don’t yet have widespread, reliable serological testing (tests for who has previously been infected).
What we do know with a somewhat higher degree of confidence (but still very significant error bars) is how many people have died while infected with COVID-19.
But the data on reported, confirmed cases and of deaths attributed to COVID-19 are in theory consistent with two very different scenarios.
The first is (I’m pretty confident) the mainstream, consensus view among epidemiologists and public health officials: in most countries and most locales, only a relatively small percentage of the population (usually <10%, sometimes much less than this, with a few notable exceptions in certainly highly impacted regions like Lombardy in Northern Italy) has been infected so far. Yes, there is significant underreporting, but this position takes that into account. I’ll call this the “mainstream view.”
The second view, a minority view which appears to be gaining some momentum, is that a much higher rate of the population has already been infected. (One blog I follow and (usually) respect argued that 30% of the US population may have already been infected.)
On this view, the vast majority of cases are asymptomatic or at least very mild, and therefore don’t get tested or picked up.
An important consequence of this second view, the ubiquity hypothesis, would be that the Infection Fatality Rate would be at least an order of magnitude lower than the kinds of figures we hear for the Case Fatality Rate (see here for definitions) — potentially as low as for seasonal flu or even lower.

I want to pause to outline a few things to consider here.

Who actually holds the ubiquity hypothesis?
What evidence is there for and against the ubiquity hypothesis, and how can we decide if it’s true?
How should we proceed given that there is uncertainty?

Who actually holds the ubiquity hypothesis?

Here are just a few.

The blog I mentioned above, arguing that >100M Americans have already been infected is here. Dr Baker (whose blog I read, admire, and sometimes cite) posted a follow-up here; I was one of the people who wrote to him to argue against his view and to whom he was responding in that post.

The epidemiologist Marc Lipsitch (who I do not think subscribes to the ubiquitous view) wrote an excellent opinion piece for the New York Times this week (13 April), primarily focusing on the question of immunity. Dr Lipsitch’s article, while apparently subscribing to the mainstream view (underreporting is up to 10x), allowed that at least one paper — a pre-print here — argues for the ubiquitous view. This paper argues that CDC data on “Influenza-Like Illness” correlates with COVID-19 clusters, and is consistent with “at least 28 million presumed symptomatic SARS-CoV-2 patients across the US during the three week period from March 8 to March 28;” it then argues that the number of cases could have continued to double every 3.5 days from there. If that’s true, we could have well in excess of 100 million cases (current and recovered) in the US.

(Here is an Economist article about the same pre-print.

In late March, there was a much-cited pre-print from modeling group at Oxford arguing that as much as half of the UK population had already been infected. (This paper was also much-criticised; Adam Kucharski’s article and this article from LiveScience are worth reading.)

This video from a German doctor has been making the rounds, arguing that we are over-reacting and that if we let the disease rip, we’ll face at worst 30 extra deaths per day in Germany versus a baseline of 2,200.

This video from a Swedish epidemiologist claims that 50% of UK and Sweden have already been infected, that COVID-19 is a “mild disease”, and that we should just let it rip.

What evidence is there for and against this view?

Current estimates of CFRs might overstate the IFR significantly, because CFRs decline over time

The excellent and cautious Our World in Data (who does not argue for the ubiquity hypothesis) points out that estimates of Case Fatality Ratios usually decline over time as we learn more about the true extent of infection, and that estimated CFRs have declined in some cases for COVID-19. Other sources discuss how this has been true in past epidemics.

But most commentators agree that currently measured CFRs (sometimes called the “crude” rate) are too high, both because we don’t know the true size of the denominator, and because there is a lag between infection and death.

Thus, everyone acknowledges that the true denominator is higher than the reported case count, and therefore that IFR will be lower than measured CFRs. So this doesn’t argue in favor of either view.

Many studies that try to estimate the true incidence of the disease are consistent with the mainstream view, not the ubiquity hypothesis

One such study — very good, and regularly updated, from the CMMID — is here.

Most estimates of the true rate of infection for a given country (and therefore the rate of underreporting) that I’ve come across are based on the assumption that the fatality rate is known and more or less constant in most situations.

But of course risks having an element of circularity to it. If we use an estimate of the IFR and the attributed deaths to estimate the true incidence of the disease, then our estimate of the incidence is only as good as our estimate of the IFR. And we can’t estimate IFR without estimating the true incidence.

One way out of that problem is to look at special situations where we can estimate the IFR with high confidence. Several examples where a high percentage of the relevant population was tested, or where there was a meaningful random or quasi-random sample, include the Diamond Princess cruise ship; early evacuation flights from China; and extensive analysis of how the disease evolved in Wuhan.

These tend to converge on estimates of Case Fatality Ratios (calculating based on those who calculate symptoms) of 1.0-1.5%.

We also know much more now about the ratio of cases that are asymptomatic. I’ve seen recent estimates in clustering in the 40-50% range, though some estimates are lower. Even if 50% of cases were asymptomatic, this would put the IFR at 0.5-0.75%. Those figures are consistent with the mainstream view, not the ubiquity hypothesis.

A study in the Lancet (summarized here) tries to adjust for asymptomatic cases, and concludes that the IFR is 0.66%.

One very recent study from Iceland, published in the New England Journal of Medicine, is particularly valuable because it is one of the only one I know of to try to estimate the incidence of infection in the general population. There were three groups in this study: one drawn from high-risk individuals; and two drawn from the general population using different strategies (not strictly random since individuals could choose to participate or not.). For those two groups selected from the general population for PCR testing, the incidence rate was well under 1%, and rate the did not increase over the 20-day duration of screening. Other nuggets from the study:

57% of those in the overall population group reported symptoms. 29% of those who tested negative reported symptoms.
43% of participants who tested positive (across the three groups) reported no symptoms.

Reportedly, a study using serological tests against 500 residents in Gangelt, Germany — hit hard by COVID-19 after many were exposed at Carnival — found that 15% of residents had antibodies and therefore had had COVID-19 at some point. This study found a 0.37% IFR (note that Germany has consistently had a lower CFR than most countries, discussed here.)

On a smaller scale, and earlier, doctors tested all 3,000 inhabitants in the town of Vo, in Northern Italy, and found 66 positives (2.2% attack rate).

Are we under- or over-attributing deaths to COVID-19?

Another source of uncertainty is that the reported deaths from COVID-19 may, for various reasons, over- or under-attribute deaths. (I discussed this in some detail here.)

We know the official statistics often exclude deaths that did not occur in hospitals; and almost always exclude deaths where there was not a positive COVID-19 test (perhaps no test was administered, or there was a false negative). These are reasons to believe in under-attribution.

There are arguments for over-attribution too. For example, those who die in a hospital with a COVID-19-positive test might have died in any case; we know that there is a high incidence of co-morbidity, often with serious pre-existing conditions.

One way to try to get to the bottom of this is to look at the overall death rate in a given population and see if it is higher or lower than normal.

Two articles that try to do this in different places: the New York Times article, Deaths in New York City Are More Than Double the Usual Total; and the Economist article, Covid-19’s death toll appears higher than official figures suggest.

Here is a very good Twitter thread making similar arguments and estimating true IFR at 0.5%: “…numbers aggregated by country can be very misleading and mask the severity of #COVID19 in heavily affected communities. A community doing well is likely due to at most a few percent having been infected so far. More viral spread means more morbidity.”

While this evidence doesn’t definitively say that we are under-attributing deaths, it makes me very wary of arguments that claim that there are far fewer “real” COVID-19 deaths than we think.

How should we proceed given that there is uncertainty?

I’ve argued above the reasons that the ubiquity hypothesis is unlikely to be true. But it’s impossible, at this point, to say that it definitely isn’t true.

I think that points to several conclusions.

First, even those who hold the ubiquity hypothesis must admit (and many do, to be fair) that there is a reasonable chance that it is false; and vice-versa. So we need to acknowledge, as with so many aspects of this pandemic, that we need to be humble about the degree of uncertainty we face.

Second, if there is a good chance that the true IFR is even 0.5%, let alone 1-2%, we can’t allow the disease to run unchecked through the population. Say the final attack rate to achieve herd immunity is 50% (and there are arguments for 20%-70%); 8 billion * 50% * 0.5% = 20 million deaths.

Third, this uncertainty — and the growing pressure to ease control measures and allow a significant degree of economic activity to resume — makes it all the more urgent that we have not one, but many serological testing-based studies to get a better understanding of the true rate of incidence.

Fourth weekly Sunday off-the-record chat with experts

12 April 2020

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to hundreds of attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the fourth in four weeks, was quite simply outstanding — the best so far. Speakers included a half a dozen household names, including economists, psychologists, social scientists, doctors, a CEO of a testing lab, a fashion brand CEO, a leading Private Equity investor, a political scientist, and famous authors. I was particularly delighted to hear from several personal intellectual heroes.

As with past conversations, it was held under the Chatham House Rule, meaning I can share a summary of the content but not the names of the participants. As with each of these, the notes are as near-verbatim as I can make them, and almost real-time (apologies for typos).

Topic: Pandemic Challenges for Economy, Industry and Sports Management

Bio: Co-Founder of a major private equity firm, sports investor

The massive US stimulus isn’t going to propel the economy; it’s not enough. $20 trillion US economy, $2 trillion stimulus, economy down 25-30% in Q2. Global GDP down around 5%, $5 trillion. This fiscal stimulus won’t get far.
We need to get people back to work.
No one thinks a vaccine is ready in the next 12 months though there will be treatments.
Massive testing will be critical.
Think gov’t will try to get people back to work between May and July 4th. But people are nervous. Hard to see how this will work.
Looking at the markets and credit markets, the technicals have gone way ahead of fundamentals. We don’t think the markets are fathoming the depth and severity of the problem and how hard it is going to be to get people back to work.
We aren’t very active right now; watching the markets. Don’t think the fundamentals are there. Need to be cautious.
We’ve been involved in the Fed’s actions. It’s helping.
But for non-investment grade companies, middle market, smaller companies: it’s going to be much harder to reach them.
In PE, we invested early and now we are more muted. The alternative space is holding together well. We think most companies will be down the same amount as the S&P.
LP are still funding capital calls. Money for branding players is still being raised. So our space is in reasonable shape.
As the Q2 and Q3 numbers roll in, it could put a damper on PE.
Looking at sports, everyone is focused about whether we can play this season, and how. It would be a big lift to the country. Decisions are being deferred through May.
Leagues need to be sensitive.
Lots of incentives to play and desires to play. But quite complicated to play even without fans. Health & safety of players and coaches is paramount. There’s a large entourage around the players who have to travel with them, so it’s complicated & unclear. A lot will depend on the next few months.
With our players, the massive media footprints of the players have allowed us to give back to the community in an effective way. It’s helped via charitable giving for example.

Q: From your portfolio companies, what are you hearing?

A: Businesses that are based on in-person crowds are completely dark. E.g,. big hospitals: elective surgeries are gone. Energy (sector) is uninvestable. The economy being down is going to impact companies with leverage. Some companies (<25%) are not paying their leases anymore. It’s company by company. Our companies had a lot of liquidity and had debt structures to give them flexibilty.

Topic: A perspective from positive psychology: the psychology of growth through adversity, how this could be the best thing to happen to gen Z, and how the sources of happiness change in quarantine.

Bio: Well known professor in social psychology.

Two powerful concepts are important: re-appraisal, and anti-fragility

Corovirus might be the best thing to happen to humanity in the 21st century!

Chinese folk table: Favourite stallion ran away. Neighbors came to comfort him. He said, too soon to know. Horse came back with a mare. Still: too soon to tell. Son rides mare and hurts his leg. Still: too soon to tell. (Etc.)

When you look at the things that could wipe out humanity, it’s bioterrorism or a pandemic respiratory virus. Now they are much less likely because we’re learning from our mistakes in this situation; we’ll have better systems. Looks like a disaster now, but might be too soon to tell.

Re-Appraisal: “There’s nothing good or bad but thinking makes it so.” (Shakespeare) “Life itself is what we deem it.” (Marcus Aurelius) We see things through mental filters. This is the biggest opportunity in our lifetime to reframe and lower our expectations.

When we grow accustomed to a situation we feel entitled, lose a sense of gratitude, etc. Now we can realize how much our success depends on many other people. We can cultivate a sense of gratitude.

Recommend two practices. (1) keep a gratitude journal. (2) read the Stoics, esp. Marcus Aurelius.

Anti-fragility: here’s how to think about it. A wine glass is fragile so we don’t give it to toddlers, so we give them plastic cups. Taleb made up this concept. E.g., “viral dose” — small amount causes immune system to respond and develop antibodies.

For children under 18, opportunity for them to become stronger.

Need to get these two principals working for us and then this will turn out to be great.

Topic: The politics of the pandemic

Bio: Professor of Political Science at a major university.

3 things are chronic features of politics.

Few incentives for politicians to engage in long-term planning. Read Andrew Healy: Myopic voters and natural disaster policy. Spending for disasters is not rewarded by voters. Disaster relief spending is rewarded. More than 10:1 ratio of rewarding the latter than the former. You see this in climate change, pension planning,etc. This is another example (COVID).
American federalism. Challenge in coordinating action in response to a pandemic. National, state, local gov’ts share power. Useful experimentation, but a challenge when states are asked to coordinate on a national problem. Competition among states. Probably what it was like 250 years ago under the Articles of Confederation. Each state’s policy creates externalities for other states — e.g., if I don’t do social distancing, people can cross state boundaries and infect other people. Federal gov’t not coordinating, deliberate decision?
Political polarization in US politics. Mixed messages by party. Equivocation by president & republicans on this topic. When states adopt social distancing is a function of party & closeness to Trump. Republicans are less concerned about the virus than Democrats; and they are distancing less. Their communications make it harder for governors to take a stand. Famous article from 1956 from Charles Lindblum: policymaking is the “science of muddling through.”

Topic: the nature of the bias including the inability to understand exponential growth of COVID19

Bio: Professor or Risk Management at major business school.

Why do politicians and the general public not pay attention to risk of pandemics?

Failure to understand exponential growth
1. Experiments in 1975 by William Wagenaar. People do not focus on these risks and misinterpret what will happen with something like coronavirus. Article by Megan McArdle about this: a lilly pond where you would see how quickly would be filled if you doubled leaves each day. After 47 days, assume half filled. On 48th day will be fully filled. On 40% day only 0.4% of pond is filled.
Risk perception: Paul Slovic has done a lot of work on this. Features of risk perception that get people to pay attention were not there in the first months. No dread, no worry about catastrophic potential.
Cognitive bias and heuristics. Myopia, focus on short-term horizons. Politicians don’t pay attention and we don’t either. We forget lessons of the past, no one thinks about 1918 until now.. Optimism: we estimate the future based on current data.

[Lost the line for one minute]

How can we adapt to avoid this in the future?

We need to listen to the scientists early in the game. They were worried about this ealry.
Look at countries like SK that have done a good job: testing, contact tracing, quarantine
Impose strict regulations at the national level based on success in other countries.

Topic: Covid19 Forecasting

Bio: Professor of Psychology, expert on forecasting.

Human judgement under uncertainty is topic.
Who are good forecasters? Self-critical, Bayesian belief updaters.
Bad forecasters: opinionated twits, blur judgement of facts & probabilities with values.
Good forecasters: the heroes are the microbiologies. They applied base risks and updated from there. Science journal in 2007: presence of a large reservoir of virus in bats + culture of eating exotic mammals is a time bomb. They put probabilities of 1-7%. But over years that adds up.
Others are in the intelligence community, eg CIA in Nov ‘19 who talked to president about what was happening in Wuhan. President did not move, but some in Congress sold stock!
This was a predictable surprise: a chronic low-probability event. Minor outbreaks over the years. But also many false positives, which makes it hard to hold policy makers perspectives.
Forecasting tournaments
Historical counterfactuals and looking forward. We are testing this idea. If you answer quickly questions that are highly political (e.g., if Hillary were president fewer people would be dead) then you are probably not a good forecaster.
Cognitive reflection test: measure of cognitive impulsivity. COVID19 forecasting looks like forecasting in other areas; the correlates of better & worse judgements are similar here as in elsewhere.

Topic: Challenges of being a mayor of a city at the center of the storm

Bio: Mayor in the Greater NY area.

We have 2,500 active cases, > 100 fatalities
Enforcement of shelter in place? Same as every other city. Things you won’t read about in the paper because we are making decisions about policing. Of 900 police officers, ⅓ are home because they or a colleague are COVID positive. Hard to enforce. We have limited choices; we won’t put someone in jail because counterproductive. Poor populations are less responsive to summonses or tickets. And every time we have a close contact with someone we have a risk that they ID themselves as positive and we lose 1-2 officers. Very hard to police.
Municipal budget? We have $600M usually. We expect $70M gap because of COVID. We have no taxes from hotels, payroll taxes are low, we don’t know what receivables will be from property taxes, we lose $1-1.5M per week from tickets, permits, etc. Will be big gap come August/Sept. Not getting any help yet from State or Fed.
Q: You’re a very diverse city. How do behaviours vary?
A: Hard to do outreach in some ethnic communities. Not so much a racial disparity as an economic one. Where there is more poverty, much more COVID19-postivei and fatalities. Probably 20-30% of “DOA”, someone dead in their house, not necessarily suspicious. Probably COVID but not counted that way.
Q: Opening economy? A: No good plan yet that we could implement. How to persuade challenging communities? Use conduits, leaders, religious leaders ,etc. Not everyone from tough backgrounds is afraid of Coronavirus.

Topic: Covid19 and the South Korean Response

Bio: Professor of Government

If US wants to open economy, needs mass social testing and distancing even if it infringes on privacy. Has been shown to work in SK.
SK is the model for flattening the curve.
From outset, only 10K cases with slowing rate of infection around 1st week of march. US and SK discovered first cases around the same day.
Per capita SK is 2-3x the testing rate of the US.
The real question is whether testnig is available on demand. In SK, yes — there is a phone app that will take you to the closest place. Not in the US.
How?
- Moved early. From Jan 20th first detected case, less than 1 week to have a meeting with 20 medical companies for response including test kits and rapid regulatory approval. Feb 23rd was declared national emergency — US was 3 weeks later.
- Premium on speed, 9 days after first case, established national call centers. 10 days provided masks to vulnerable cases. 22 days after first case, self-diagnosis mobile app available. Also ramped manufacturing of masks.
- Gov’t led from the front. Brought together public and private to produce kits and to grant regulatory approval quickly.
- DS system = designated covid and non-covid health facilities to reduce incidental spread.
- Mask shortage; when there was hoarding and price gouging, the gov’t bought 80% of national production and held prices constant. Distribution system through pharmacies, agricultural cooperatives, etc. Depending on your birth year you could buy masks on certain days. Held prices around $1.xx per mask.
To reopen, need a phone app. Absent a vaccine or universal testing, no other way to get effective social distancing. Privacy is a concern. SK is a democracy too.

Topic: How to Reopen the Economy

Bio: Professor of Economics

Dark days are ahead.
At our university, technical developments:
First test: We have FDA approval for an antigen test, hoping to have it done within a week. We will make 100K per day but can scale up to 4M/day. Test costs $10, done at bedside, does not need lab, get result in 15 minutes — a pregnancy test for COVID19. Everyone should take this test every day before going to work. Project is fully funded, first 1M sold, dep’t of homeland security trying to buy everything we can produce. This has been key in SK
Track and trace systems? Lots of competition. Project coming out of one of our labs on this.
- Problem is adoption. Like Facebook, you need large network of people using it. How drive adoption? Give the rapid antigen test away for free if they opt in.
Third piece: IGM/IGG test (antibody tests). This is some weeks away … not too many. Fully funded. We don’t know how long you are going to be immune but should be at least a few months, and almost certainly you are not currently positive or shedding virus. Will make it easier to figure out who can work in critical roles like food services.
Look at Germany. We are level 5 lockdown, they are level 3. How do they do it so selectively? Many shops are closed, but white collar workers go to work with some distancing and some warnings about hotspots — “selective social distancing”. Cannot be done at a federal level but can be done at a state level, or even regional. Maybe New England? The federal government isn’t going to solve this.
We have the capital we need.
If you want to buy the tests, get in touch … we might be able to help. Not private firms for now but the private sector will lead the country back to reopening.

Topic: The pandemic and the macroeconomic implications

Bio: Professor of Economics and Law

Projections that US federal deficit will reach levels not seen since WW2 — maybe 20% of GDP. In 1943-45 we had larger.
Many ways in which current situation is more like WW2 than a recession.
Not a typical recession: bigger employment drop, faster. But there are other differences.
Different: In WW2 we had high employment. But think of soldiers as not being employed but doing something else not for consumption or export — something like the industries that can’t function right now. During war we had no new cars, homes, white goods. Then autoworkers made tanks not ventilators, but still not cars.
Service industries are hit, that’s a difference.
Think of a soldier of unemployed and then you have unemployment at more like 25% than 0%.
Then as now we couldn’t use stimulus to create demand of services that are not happening.
When we return to normal, as with war, we expect transition period to normality. May even be booms in certain activities like auto and house purchases, family formation, fertility.
Different than WW2: now it depends on how much gov’t support.
Fiscal contraction at state and local level is severe.
Debt to publicly held GDP ratio was 106% at end of WW2, highest ever. We will reach or surpass that.
Gov’t yields are very low now. Were higher (not high) and rising in the1940s.
Our federal gov’t picture is very different today. Social security etc will be 12% of GDP and rising. High deficits. We will need to make serious adjustments to the budget.
Low interest rates are not always a good thing . State and local governments will have trouble covering unfunded liabilities like public employee pensions. These are already way underfunded. Low interest rates make this worse.
Finally, inflation. We had price controls at WW2, the inflation as pent-up demand was released. Some worry about this now. But I think unless we have strong income replacement for industries that are hit, not obvious that we will have a concern about inflation.

Topic: The Pandemic and US Labor Markets and Labor Statistics

Bio: Professor Public Policy and Economics

Two sources of data on the labor market: initial claims for unemployment insurance, and data on first half of March.
Last two weeks on insurance claims of 6.6 and 6.9 million. This tells us about the limits of our processing capacity in the system. Prior to that was 200K/week. Impressive that system ramped up as fast as it did.
16.8M applicants in 3 weeks so far. Compared to 2008, 2 years of claims at 500K/week — an excess of 300K/week. Vastly lower. But over 2 years, 2008-2009, 30M more people applied than usual. So I expect to see over a few more weeks we will work through the backlog.
Employment report in March, unemployment higher than I expected. Employers told us 700K fewer people on payroll. Households said 3.1M people became unemployed. But 3M fewer people were employed. Not only are people losing their jobs, but we’ve frozen their ability to start new jobs. Usually lots of people start new jobs every day. This will add up.
We might see 20-30% unemployment rate. But we care about the number of jobs preserved that people can go back to. And we don’t have this data. Most employers don’t know what their “recall rate” will be . The idea that we’ve just hit pause and people will go back to jobs, that’s just wrong. We will see massive sectoral re-alignment. Some jobs will be destroyed. It will be like a regular recession in that way.
9-10% unemployment rates are on the horizon for a while.
Biggest warning: as we see job growth start to surge as people move off of temporary layoff, realize that that is not real job growth; it’s people restarting their old jobs.
To return to 2019 level of GDP and production will be what the unemployment rate after that surge. What will be the sectoral realignment? (Dining out less, fewer concerts, live life differently …)
Maybe we will recover faster, but I fear that the permanent job destruction will be higher than people expect.

Topic: Medical Treatment and Testing of Covid19

Bio: Works on Allergy and Asthma Research at a major university

Our focus right now is on outpatients.
People are doing very well with social distancing, hand sanitizer.
Once shelter in place was in place, look at CA. We are seeing a decrease in numbers. It did what it was supposed to do.
We’re careful because that could change.
We’re only as good as our data and tools.
We think the plateau is real because at our university we are testing people with and without exposure, tested 7K people randomly. We try to quarantine immediately.
Developing an immunity test, very important for the workforce.
We need data rather than opinions on the science around the testing.
Our university is doing 3K tests including those known to have been tested. We will learn from this.
If we can get to this at the home level, microsampling — we are doing 2-3K this weekend! — hopefully this data will help inform when people can go back to work.
New paper this week saying we need randomized control trials.
FDA doing a great job fast-tracking diagnostic and therapeutic tests.
One drug might not work but we need a combination of therapies.
Those with vascular disease are often hit the hardest — smokers, vapers, etc.

Topic: Issues related to testing for Covid19

Bio: Many years in the clinical laboratory industry, currently CEO of a diagnostics company.

Rapid antigen test that is low-cost? Would have said before this call that we are weeks away but this call makes me think we are closer than I thought.
Where did things go wrong in the lab industry? Why do we have shortages?
Hundreds of high-complexity labs across the country.
A well coordinated rollout could have created enough capacity.
Planning for pandemics was going on for years.
Was always assumed that we would have a high quality lab test available in sufficient quantities, but was not the case.
The CDC put out a bad test at the start.
Gov’t did not marshall the full capacity of the labs at the start.
We thought the large labs would be able to ramp and they have not.
Individual labs like mine assumed that and it was wrong, so we fell behind and have been playing catch-up.
Backlog is mounting at the national labs
Capacity is finally growing daily by the 1000s.
Governors are still saying not enough capacity.
One challenge: no effective way to understand capacity at a national level. No centralized place to find out availability. So a wild west of matching supply and demand.
We could have used better coordination at a federal level early on.
Antibody testing: need to understand how the disease confers immunity. We need studies to answer this. There is some presumed immunity, perhaps 6 months to 2 years — antibody tests will help.
Caution: there are issues with accuracy. PCR test (ID the virus) is the most accurate, but even that has 20-25% false negative rate. That is because of the challenge of working with the specimen types; mucus and sputum, collecting a good sample, is important.
Antibody tests will likely be blood tests. Blood is the best specimen type. But antibody tests can have widely varying accuracy levels.
Q: You say hard to get good specimen. How will it be done in the future? Self-service? A: FDA allows for self-collection for nasal samples (think Q-Tip). Our lab is running a study where we take health care worker collected specimens and we compare it to those collected by patient (PCR test), happening this week. Blood-based antigen test, also an antibody test, those will be important. If rapid, cheap, and self-administered, that will help a lot.

Topic: How will the pandemic impact retail and the clothing business

Bio: CEO of several retail and apparel brands over the years.

We are a major apparel brand in a number of countries.
Majority of sales have been in brick & mortar, shut down for one month.
Initially we were worried about supply chain since 90% of manufacturing comes from China.
We are solely focused on getting through this crisis.
Ecommerce continues to be strong and has picked up some drop. But it is at a discount — typically 25% off. Affluent customer will shop with a discount.
Work from home / video, people are focused on topics not on bottoms!
Warehouse & fulfillment centers, needed these deemed
Most brands are not paying rent while stores are closed. Initially landlords asked for this even though centres were closed. Now landlords are looking to defer rather than abate rent; not realistic, but at least shares burden. Long-term perhaps we will share the cost or add on more months at the end of the lease.
Typically we would get monthly deliveries. Now we are scrambling for whatever deliveries we can get.
Most cancellations are around August- January receipts.
Maybe there will be a small holiday collection.
We will be selling summer collections through Thanksgiving — hope for a long fall!
Long lead times in supply chain are a problem. Our teams are working remotely and that is hard for some roles.
We had no choice but to do mass furlows. All store employees and half of corporate, 75% in total. We are protecting their benefits. The rest of us have taken salary reduciton sand deferments.
Don’t think it changes our long-term path but will accelerate the move to ecommerce.
Will there be as many stores? Must increase direct-to-consumer.
Will people return to malls? Restaurants are an important source of foot traffic.
Our space is about emotional relationship to clothing, not functional need.
Rental could become more important. We have our own site which is doing well.
Will people have the disposable income to shop? Important question for low-price space. Luxury has been resilient through last crises.
Will be less competition.
Most important leadership lessons: be honest, and empathetic.

Q&A Session

Q: For apparel CEO. How will people be rehired?

A: We hope to bring them all back, that’s a openly stated goal. But things will evolve, we may need to reallocate resources.

Q: For economist. You used to work at a federal statistics agency. Given the difference in this recession vs prior ones, does it change what data we collect? How hard is that to change to find out the questions we want to know?

A: Would be great to get a survey into the field; but they will not be able to change it quickly – -not this week or next month. Maybe there could be some private efforts to add to the baseline questions. What do we need to know? What are people’s expectations as to their future jobs, as to whether they will go back to the same thing, their financial situation. Some we will get from public data but not enough.

Q: Small business loan to stop hemorrhaging of jobs. Will it work?

A: Unemployment system is good way to get money in people’s hands. But won’t make a big difference either way in terms of whether people will be recalled. Paycheck Protection Act — will be helpful for some businesses, those which do not see revenues go to zero, where this help will let them maintain payroll. But for a business that has to go without revenue for 6-8 months, what do they do after two months? They don’t think this is enough. Works better for those businesses that have a decline but not a stop to revenue.

Q: Asymptomatic population, how large is it? How will we know?

A: Our testing at our university — data will be published soon — that are asymptomatic in the community. It’s a pandemic in CA. We’ve traced immune system of individuals over time. It’s true, many people were asymptomatic. Young and without vascular disease yes, but even some people with immunodeficiency. Shelter in place helped California a lot.

Q: If it turns out that the death rate for the pandemic was not that much from the flu, but much more contagious?

A: Diagnostics that can be done quickly, especially at home. The PCR test: people were questioning it. Depending on the primer used, the kit — if it’s used well, the data is that it is over 90% accurate. But if you don’t go deep enough in airway you might not find virus.

Q: Worried about the behavior. Say you take the test, negative, but it’s a false negative. What if you then take risks? What should the social norms be?

A: Think the PCR test and the serology tests in conjunction will be important. This is what will let people get back to work. We are already doing it. 40% of our workforce (hospital) had to stay at home, now coming back. But we don’t know enough about viral shedding. We see it in saliva up to 6 weeks after infection, in stools as well. More work to be done.

Q: Reasonable to quarantine people at risk and the elderly and allow kids to go back to school?

A: Some countries are trying something like that. Need to look at the data to see the extent to which closing schools helped plateau the curve. Shelter in place, not school closure, looks to have been critical.

Q: Treatments — what is working, what isn’t?

A: Lots of different possible approaches. One is prophylactic — try to keep it from becoming symptomatic. But Tamiflu didn’t really work for flu. Lots of investigations under way. Duke is testing 15K people on chloroquine. Probably combination therapies will be needed, we’ve seen this in other viruses.

Q: We have to make tradeoffs. Given large deficits, what will have to give? E.g., social programmes like Social Security — we could defer 12 months?
A: You answered yourself, not politically feasible near-term. Generational justice has come up: how older cohorts are more at risk. Social distancing has a generational aspect. The young are being asked to sacrifice to help the old. One could argue that once this is past, the old have disproportionately benefited and the young will have suffered. That could be a political argument for attacking infeasible entitlements. But in our current political climate? I don’t know, but it can’t happen now.

Q: Success and failure of policies in China. What do you believe?

A: I have the same scepticism as most people about death rates and about the infection rate. Are they counting asymptomatic cases? It’s a problem. Korea has been fairly transparent. They learned after the MERS outbreak where the gov’t was not as transparent at the start.

Q: North Korea? What are you hearing?

A: They won’t be able to handle it. They have reported zero infections but that’s impossible, since they are sandwiched between China and SK. `they allow border travel with China. They were reported to be locking down and quarantining where they suspect that there are cluster outbreaks. Very little information about Pyongyang. An outbreak there could cause instability. They are requesting test kits from NGOs.

Q: How should we speak to children?

A: There’s a sensitive period during which adversity is maximally beneficial. Very young and middle-aged, no. But teenagers (for example) can benefit from adversity. Short-term stress is very good for kids, chronic stress is very bad. I haven’t seen data about what is happening at home. Are kids anxious or is it like a snow day? If they feel less entitled, many will grow from it.

Q: What did we get right and wrong in this situation?

A: We got things right but too late in the US. The South Korean model was better. Biggest challenge has been on testing side. We don’t know the denominator. Will make it harder to reopen the economy.

Thursday roundup

9 April 2020

I didn’t publish an update yesterday, and in the near future my updates will be less frequently than daily given other commitments.

In general, there are so many sources doing a good job of synthesizing the latest data that my focus will be less on quantity/frequency than quality. I’ll publish fewer updates, and they will be increasingly orineted towards “insight and analysis” more than reporting the latest information.

Underreporting deaths

In the last post I discussed the underreporting of deaths and the difficulty in comparing data on deaths across countries, and asked:

I am not certain, but think that “deaths in hospitals for confirmed COVID-19 cases” may be something like a standard for at least ECDC data. (Does anyone have a source that can confirm this?)

Helpfully, several of you (thank you!) confirmed that this is indeed the case. My friend C pointed me to a transcript of the UK Chief Scientist addressing a question on this here (bold emphasis mine):

Sir Patrick: (24:16)
I’m happy to do that. The international reporting standard for death, all the other countries are based on hospitalized deaths confirmed and that’s the same as the data that you’re seeing. The ONS data, which are important look at overall deaths on death certificates where coronavirus is mentioned so that they are not confirmed deaths necessarily. It’s important to have both of those, but that’s what the difference between the two numbers is.

Tying up loose ends on masks

I discussed masks in some detail on Sunday 5 April. In the update I noted that the WHO were not yet recommended widespread use of masks. Almost as though the WHO were reading these posts (hah!), they updated their recommendations the next day. The updated advice, in typically WHO cautious and heavily qualified language, moves towards the emerging consensus view I described in that earlier post: that widespread use of (homemade, not medical) masks might reduce transmission by reducing the distance droplets travel — but carefully noting that there is a lack of evidence and that medical masks should be reserved for medical use.

Other articles (too many to link) note increasing frequency of masks being required, and increasing voluntary mask adoption. In my extremely limited sample (one trip to the grocery store per week here in France), I’ve noted week-on-week adoption going from 80% to 100% of people working in the grocery store, and from 10% to 70% among customers, even though masks are voluntary (though now gently encouraged) in France.

Ventilator best practices?

There is a growing chorus challenging the ways in which ventilators have been used in many situations so far.

StatNews reports that ventilators may be overused: that they may be of limited benefit, may in fact do harm in many cases, and that other, less-invasive approaches like nasal cannula may have better outcomes for some subsets of patients.

There has been a lot of attention in the UK on the statistics for patients who are placed on ventilators, when Prime Minister Boris Johnson was moved to an ICU to make ventilation possible if required. (Thankfully, earlier tonight we learned that he has now left the ICU.).

What statistics there are make for grim reading. An anaesthesiologist in the US I spoke to reported that 80% of the patients in his hospital who went on to a ventilator ultimately died. This NPR article summarizes several small studies that all report high fatality rates for those COVID-19 patients placed on ventilators. This article in the German press (FAZ) from a pulmonologist argues that ventilators are overused.

This is clearly a space in which the best practices are evolving rapidly. What is definitely clear is that being placed on a ventilator is a very bad sign and indicates that the chance of recovery is fairly low. What we don’t yet know is the extent to which this is because only the sickest patients are placed on ventilators, or because ventilation is the wrong treatment.

Underreporting update

I’ve previously discussed (in a “Resources” post, not yet updated with latest figures) the issues of underreporting of cases.

A study I like (though it has its limitations) has updated its estimates. See here, and the table below. The right way to think about this data is not as a highly accurate estimate of underreporting, but an answer to the question, “If fatality rates are relatively consistent, what would that imply about how many cases there must be as compared to the number of reported casts?”

The chart below shows the 95% confidence interval by country. Here, 100% means that (according to this estimate) all cases are being reported; and 10% that only 1 in 10 are being reported.

False negatives

A recent pre-print analyses the risks of false negatives in PCR tests based on throat and nasal swabs.

The bad news? As epidemiologist Adam Kucharski summarises, “The authors estimated that in a single test of some who first had symptoms 10 days ago, there’s a 33% chance of a false negative with a nasal swab, and 53% chance with a throat swab.”

The probability of a correct positive test decreases rapidly with time from the onset of symptoms. Given this, PCR tests will be less helpful in assess the overall attack rate of the disease in a population.

These false negative rates are higher than I expected and could further contribute to undererporting.

Summer may not help

On the question of whether seasonal effects may reduce the reach or severity of the epidemic in the summer, this study is cautious that we should not expect it to.

Children; deaths and data; Rt

7 April 2020

Correction

Mea culpa: Yesterday’s post contained a math error in, well, my math example. (Thanks to P for pointing it out!). It’s now updated with the correct figures. Importantly, in my made-up example about the risk of false positives from serological tests, 50% (not 8%) of all positives would be false positives.

COVID-19 in US children

From the Johns Hopkins Center for Health Security newsletter (emphasis in bold mine):

COVID-19 IN CHILDREN The US CDC COVID-19 Response Team published a study of COVID-19 disease presentation and severity in US children. The study, published in the CDC’s Morbidity and Mortality Weekly Report, analyzed clinical data for 149,082 COVID-19 patients in the United States reported between February 12-April 2, including 2,572 pediatric patients. Pediatric patients represented only 1.7% of those patients. Compared to adult COVID-19 patients, fewer pediatric patients experienced fever, cough, or shortness of breath (73% vs 93%). With respect to disease severity, only 5.7% of pediatric patients were hospitalized, compared to 10% for adult patients. Three deaths were reported among the pediatric patients, but investigation is still ongoing to determine if COVID-19 was the likely cause of death in these patients. The study also provides analysis of underlying conditions in pediatric patients. Among those with available data (345 cases), 23% had at least 1 underlying health condition, with chronic lung disease (including asthma), heart disease, and compromised immune system being the most commonly reported. These data support the current understanding that COVID-19 disease tends to be more severe in adults than in children; however, severe disease and death can still occur in pediatric patients.

Are death counts commensurable?

We already knew that it was misleading to compare the count of confirmed cases across countries, both because the standards and lags for reporting vary by country, but also because the degree and criteria of testing, and therefore the degree of underreporting, varies widely.

Increasingly, it seems like this could be the same for the death toll — which until now has been taken by many epidemiologists and modelers as a more reliable figure. (For example, several papers try to estimate the true number of cases per country by backing it out of the reported death toll and applying estimates of lag time and fatality rates.)

For example, the FT reports today that the death toll in England may be 76% higher than previously reported:

The daily death toll in England from coronavirus was almost 80 per cent higher than the hospital figures reported during the accelerating phase of its spread across the country. Even these figures, running up to March 27 and verified by the Office for National Statistics, are an underestimate as they do not capture the total number of those who died with Covid-19 symptoms outside hospitals.

Chart showing coronavirus deaths have been rising faster than reported, cumulative deaths by date, England

For what it’s worth, when I checked the various UK sources today (7 April 2020, at 8:46pm UK time), as a case study, I found the data on deaths to be consistent where it should be consistent, and the distinctions between sources clearly called out.

The Department of Health and Social Care data (on www.gov.uk) stated that this was deaths that had occured in hospitals with a positive test for COVID-19. The ONS data clearly includes deaths in nursing homes, so naturally is higher.

There have similarly been reports that Italy is not counting a significant number of deaths outside of hospitals; e.g., here.

I am not certain, but think that “deaths in hospitals for confirmed COVID-19 cases” may be something like a standard for at least ECDC data. (Does anyone have a source that can confirm this?)

It’s also worth noting that when Our World in Data compared three of the primary data sources for confirmed cases and deaths (WHO, Johns Hopkins, ECDC), they found that over time the discrepancies were very small.

So it seems to me that what is happening here is easy to understand, but important to remind ourselves of frequently: in the important effort to have data that is as comparable across countries as possible, the data of necessity becomes less comprehensive: we need to work to something like a lowest-common-denominator data set.

Even considering these limitations, I do think that comparing deaths across countries is helpful, once the important caveats are in place. That said, in the future, as we start to look at developing countries alongside wealthier countries, these definitions will not give as useful a comparison.

On a separate but related point, we also need to remind ourselves that the way we are attributing deaths to COVID-19 today will both understate and overstate the death toll, and is inconsistent with how we think of a disease like seasonal flu.

The attribution methodology will overstate deaths due to COVID-19 because many people who die with COVID-19 would have died in any case, some within a relatively short period. Some studies have found high rates of comorbidity with COVID-19.

It will understate deaths due to COVID-19 in cases where we did not have a test, where the test was a false negative, if the death was not recorded at all, or if the death was excluded from official statistics (for example, because it took place outside of a hospital).

Longer-term, what we really care about with a disease like COVID-19 (or seasonal flu) is excess deaths: deaths that we should causally attribute to COVID-19, because we believe that in the absence of the disease the death would not have taken place. This, as I understand it, is how we talk about deaths from seasonal flu.

This Economist article, which I’ve linked to before, gives reasons to believe that the excess deaths could be significantly higher than the reported deaths. It tries to identify excess deaths by simply comparing actual trends to expected trends in impated areas.

There’s another sense in which the deaths causally attributable to COVID-19 could be understated. Some people will die of unrelated conditions that might otherwise have been treated successfully, but were not treated because of the strain on the health care system or because of the lockdown.

How is the effective reproduction number evolving?

I found this new resource, from the CMMID Covid working group, fascinating. It attempts to estimate how the effective reproduction rate, Rt, is changing over time by country. (See here for a definition of Rt vs R0.)

When looking at the charts, keep in mind that an Rt over 1 means exponential growth, and an Rt under 1 means the epidemic is declining. Yes, a lower Rt is always better than a higher one, but we need to get, and stay, under 1.

These charts say that the vast majority of countries are either likely or very likely to be above 1:

In general, the country-specific charts demonstrate real progress, but also that we still have a ways to go in some countries.

Hard choices

Original published 6 April 2020; updated 7 April 2020 to correct an error

Exit strategy or roadmap to recovery?

I wrote about exit strategies four days ago, on 2 April. In the last week, it seems like this has become a dominant topic of conversation in “quality” media. And no post I’ve written has generated more feedback from friends, many of whom felt that I was being too pessimistic.

Many commentators are suggesting potential exit strategies, or what the American Enterprise Institute (AEI) calls a “roadmap to reopening.”

I want to share a few arguments that have partially moderated my view about how hard / long / fraught such a roadmap might be (though not fully).

My view on the likelihood of a vaccines in the near-term may be too pessimistic.

In my post, I argued that a widely-deployed vaccine in 2021 or even 2022 was unlikely:

First, we’ve tried for many years, and spent a lot of money, to develop vaccines against other viruses (common cold, AIDS, SARS, MERS) without success.
Secondly, if the true IFR (infection fatality rate) really is 1% or less, as seems likely, we will need to have confidence that severe side effects occur in well below 1 in 100 people who are vaccinated. It will take human trials of significant scale and time to conclude that.
Third, we need to overcome the challenge of manufacturing, distributing, and administering billions of doses around the globe; and we also need to get high (probably >2/3) compliance; something that we struggle with for some vaccines.

The two best arguments I’ve heard against this are as follows:

We will deploy talent and resources on an unprecedented scale, and bulldoze any regulatory or even normal safety hurdles, to get a vaccine done — think Manhattan Project — because an effective vaccine is literally worth trillions of dollars of economic benefit (leaving aside the health benefit). Looking at the success of prior vaccine development attempts is irrelevant; it would be like trying to form your base rate of the chances of putting a man on the moon by looking at past attempts.
We don’t need a perfectly effective, perfectly safe vaccine to make a difference. Say a vaccine had a 2% severe side effect rate. It would be certainly rational for at-risk people (e.g., elderly, significant pre-existing conditions, health care workers) to take it, which could contribute significantly to building herd immunity. Also, with a good serological test, we don’t need everyone to take it; only those who don’t have acquired immunity.

I’m not completely won over by either argument, but they are both make me realise that the right question isn’t, “When will we have a vaccine that we know with near-certainty to be safe, that everyone in the world will have taken;” to, “When will we have vaccine that we have good evidence is safe enough for at-risk populations to take, and in sufficient quantities to begin to make a difference in reopening the economy?” The likely timeline to the latter is faster than that to the former.

The economic vs health tradeoffs will shift over time to a new equilibrium

I made this point partially in the last post, but the argument has become increasingly compelling in my mind.

Many countries today, when faced with the choice between terrible health outcomes and terrible economic impact, have chosen to improve health outcomes at the expense of economic outcomes. But that calculus is not static.

There are two components to the argument.

First, economic costs (and the associated political costs) are increasing over time; and the damage done to an economy by shutdown is not linear with time. This is obvious when considering the limit cases: an extra one-day national policy does little harm, and asking everyone to stay home for the next decade would be economic suicide. While there are many different guesses about how long a shutdown we can weather before long-term damage is done to the productive capacity of an economy (it surely varies widely under different situations), conversations with economics, policymakers, and business leaders all converge on anything much more three months at the outside, being severe and lasting.

Lost GDP, lost wages and profits, personal and business bankruptcies, and the like are not the only source of increasing damage over time. Many emerging markets, and some developed countries (Italy at almost 150% debt-to-GDP ratio? Greece at 180%?), face severe constraints and potential future default or devaluation.

So for these reasons and more, economic pain goes up over time, likely at an accelerating rate.

At the same time, the health consequences of at least partially reopening the economy go down over time. We’re building more health care capacity (beds, ventilators, professionals), replenishing PPE, building testing capacity, adding serological testing to PCR testing, and developing better treatment protocols. We’re better able to identify and isolate vulnerable populations. We’ll likely have better therapeutics quickly. The chance of a vaccine goes up over time. Herd immunity is building, albeit slowly; and if we can reliably identify those with acquired immunity, we can allow them to return to work or to the frontlines without significant restrictions. On top of that, we can build effective contact tracing and quarantine approaches.

As a result, it’s quite possible to imagine a time in the near future when a healthy, younger individual could rationally assess his or her chance of dying of COVID-19 if infected as being at the level of seasonal flu.

As health costs of reopening go down, and economic costs go up, we will surely reach a new equilibrium. The open questions in my mind are two:

How quickly?
Might we reopen too quickly, experience a serious second wave, and have to shut down again?

Faced with unaccepted health versus economic choices, we may be willing to sacrifice more privacy and liberties

My thinking is less developed here, but the general argument is that we have examples from China, Singapore, and South Korea of how a combination of (a) strong technological surveillance, control, and communications technologies (e.g., apps that notify everyone about nearby confirmed/suspected cases; apps that publicly share your green/yellow (amber)/red status), and (b) invasive policies (e.g., forced quarantine, removal of infected family members) might allow for an equilibrium of greater openness with acceptable health risks.

I want to do more work to understand exactly what these measures are and how they are working, and will reserve that for a future post.

Hard choices for policymakers

On this topic, The Economist has an outstanding Briefing in the 4 April edition: The hard choices covid policymakers face. I highly recommend reading the full article, which is not behind the paywall as of now.

The article takes head-on the question of the tradeoffs between health and economic considerations, and how these may evolve over time. A few of the most salient points:

Policymakers in practice had no choice but to put in place strict control measures. The examples of China and Italy, in addition to epidemiological models, made it clear that how bad the possible, or even likely, outcomes could be without action. It many cases, it would have been politically impossible to allow the epidemic to continue without significant action.
Epidemiological models have severe limitations in their ability to accurately forecast the future, but allow us to ask “what-if” questions. They can’t answer hard policy questions on their own.
Governments will increasingly come under pressure to balance the health benefits and the economic costs of strict controls. How should they do this?
Even without policy changes the economic impact would have been significant in the early stages, and taking action was the right thing to do:

“[I]in the acute phase of the epidemic, a comparison of costs and benefits comes down clearly on the side of action along the lines being taken in many countries. The economy takes a big hit—but it would take a hit from the disease too. What is more, saving lives is not just good for the people concerned, their friends and family, their employers and their compatriots’ sense of national worth. It has substantial economic benefits.

At the same time, the economic impact will be severe, leading to lost income, individual and business bankruptcies.
Some fear that the economic impact will have its own severe impact on health, and even cause a higher rate of death. This is not clear from past downturns: “mortality is procyclical: it rises in periods of economic growth and declines during downturns.” Overall mortality fell during the Great Depression.
But economic costs will increase over time and individuals’ may be less willing to accept the impact over time as well. So we should expect greater pressure to restart the economy over time.
Vaccines are not the only path to relaxing constraints:

The rudiments of such a plan would be to ease the pressure step by step, not all at once, and to put in place a programme for picking up new cases and people who have been in contact with them as quickly as possible.

Some evidence from the flu pandemic of 1918-19 suggests that cities that worked longer and harder to step the spread of the flu performed better economically.
But there are fears that longer shutdowns could do greater structural damage.

Immunity passports vs false positives

I’ve been guilty (though in good company) of discussing serological testing as though it would be a panacea; of suggesting that once someone tests positive for the antibodies that we think confer resistance, she could resume any activity as though an immune superhero.

Indeed, the UK’s plans apparently include the idea of “immune passports.“

A lot of the discussion around serological testing has focused on how quickly they can be deployed at scale, and whether or not they are accurate enough.

But I have bad news. Serological testing will likely not be as useful as I had thought in the near term, for obvious reasons that I’m ashamed not to have thought through.

The reason is the same reason that tests for breast and prostate cancer are often not regarded as that helpful: the ratio of the rate of false positives to the rate of the disease in the population.

As epidemiologist Zachery Binney explains here, even a test with high sensitivity (the percentage of positives that are reported as positive) and high specificity (the percentage of negatives that are reported as negatives), if the true rate of the positives in the population is low, the test may produce a high ratio of false positives and not be very predictive.

This is really counterintuitive for most people, even those who like math. It’s worth working through an example to make the problem clear; but if you prefer, you could read the Wikipedia article or (even better) Zachary’s powerpoint.

[Note: math error corrected in the example below on 7 April 2020]

To make the math easy, let’s say our serological test has 95% sensitivity, 95% specificity, and that 5% of the population (say, in the US) actually has had COVID-19. Now we test 1,000 people. What happens?

50 people actually have it; 950 do not.

The test has 95% sensitivity, meaning it correctly detects 48 of the 50 people who have had it (“true positives”), but misses 2 of them (“false negatives”).

The test has 95% specificity, so it correctly detects that 902 of the people have NOT had it (“true negatives”), but it incorrectly reports that 48 people have had it who did not (“false positives”).

So (48)/(48+48) = only 50% of the time does a positive result actually mean that you have had COVID-19!

Now, this gets better over time for several reasons. Serological test will improve; there may be multiple kinds of tests that give uncorrelated results, in which case we could administer more than one; and the actual prevalence of immunity in the population will. be increasing over time.

But the key point is that serological testing, while potentially useful, is far from a panacea today.

The third instance of Sunday private conversation with experts and investors

5 April 2020

Each Sunday, a friend has been organising a two-hour call for friends (mostly from the finance, economics, and policy world) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to hundreds of attendees, with a consistently all-star cast of speakers drawn from many different fields. and a fascinating conversation.

Tonight’s installment, the third in three weeks, was no exception. We had professors, historians, economists, working doctors, a data scientist, investment bankers, experts on the developing world, a great urbanist, and more.

If I had to pick out a few highlights:

A major media CEO talked about how re-starting is going to be much harder than shutting down was. He also pointed out that for his business (and this will apply to other businesses as well), they are still getting revenues from prior projects (rights in this case) but have slashed cash expenditure in new projects. This means cash flow is good right now in that business. But next year there will be a double-whammy as they start putting out cash again for new projects, and don’t have cash flow from projects they would ordinarily have launched in 2020.
Several speakers discussed the impact on the developing world, which was sobering. “There, it’s not economic impact vs health impact; it’s health vs health. Starvation has a high fatality rate.”
Another speaker talked in stark terms about how different the experience of quarantine was for the poor vs middle class/wealthy in the US and other developed economies. How would a family of 9 sharing one bathroom, or three generations in a trailer, shelter in place for months? What about laundry, for example? He sees significant political consequences.
We heard form a number of historians and economists who took a broad, historical view. The key message was that the battle between humans and microbes/viruses has been waged throughout human history, particularly since we settled in towns and cities; and that humans are gradually winning the battle. We have knowledge and tools today that we have never had before, and we will win.
One speaker discussed the stark difference in fiscal support between the US, at 10% of GDP so far, and the Eurozone, where France, Italy, and Spain have pledged around 1.5% of GDP. He was concerned about Italy in particular, with debt-to-GDP at 150%. “Too big to fail and too big to bail.” Italy doesn’t have its own monetary policy and can’t devalue.
An. anesthesiologist talked about how mechanical ventilation may be doing more harm than good. 80% of people put on ventilators go on to die. Now experimenting with high-flow nasal cannula as an alternative.

Topic: How will pandemic impact the automotive industry?

Bio: Executive Director of HIS Markit Automotive Advisory

Expect major consolidation with those with strong balances sheets acquiring. Auto parts companies in particularly will consolidate. Larger companies will do okay. We worry about the deeper supply chain, tier 2. Mom & pops will have a lot of difficulty.
New business models will arrive. Used car market will be a focus
Rental car companies? There will be consolidation. They will not replenish fleets until sometime next year when travel restarts.
What about majors? Will they go bankrupt? GM? Stock has fallen by half. They will be fine. We are most worried about people like FCA and Ford who are exposed to North America. Nissan also, they entered pandemic in bad shape.

Topic: How will the pandemic impact TV, Entertainment and Theme Parks

Bio: CEO of a large media company.

Vast majority of our team are working from home
Those who come in are either news people or technical people getting signal out there.
We’ll never go back to the old way of operating — it’ll be some hybrid.
Our internet provision business will do well assuming the network stays up. Some of those who are on auto pay are switching it off which suggests they will have trouble paying the bills.
Sports: no sports events happening anywhere. The chain of payments from consumer all the way to player will at some point cascade, hasn’t happened yet.
Our TV & Movie cash budget has been cut 90%. So that is helping cash flow since we’re still being paid on catalogue. But that will be a double-whammy next year when we don’t have revenue from what we would have produced this year and have the cash expenditure out next year
People are watching more TV, more linear, more news — that’s a positive on advertising; but the economy is tanking which is a negative
Theme parks are shut almost everywhere. However, in Asia, construction is going on full steam — but with extensive testing, quarantine, etc. Have to operate in a secure bubble.
It’s going to be much harder to start up than to shut down.
For theme parks I asked whether we could open July 1 and test everyone, 5-minute test, but once you’re in you’ll know everyone was negative. There were 35 good, complex reasons why that wouldn’t work. This business is hemorrhaging profitability.

Topic: The pandemic and urbanization

Bio: Economics Professor

Unprecedented body blow to the urban world
Density helps trade, F2F collaborations, but there are demons
Crime, traffic, and contagious disease are the demons.
If you’re close enough to exchange ideas you can exchange viruses.
This was true in Athens & the Peloppenesian war, and again stopped Justinian in Constantinople
Until recently disease was the main problem of big cities. City children lived much shorter lives than those in the country.
The prosperity of the last century came about from sewage, fresh water, and some restrictions on freedoms.
NY continued to have cholera epidemics for 25 years — e.g., 1849 epidemic — afterr fresh water arrived. Poor neighborhoods wouldn’t pay.
If you don’t have fresh water you don’t wash your hands.
NY only became healthier after 1866 after the board of health came in and fined tenements that didn’t connect to the sewers.
Cities spent as much on water in 1900 as the federal gov’t did almost in total!
This solved most pandemics except for droplet-borne ones.
To stop pandemics of the future we will have to spend billions, but it will be worth it.
Possible to imagine a world that will be less urban and less connected.
But for much of the economy can’t imagine a prosperous world without F2F interactions.
Farms & factories have great output but highly mechanised
Low skilled employment is largely in services in urban oe
1/3 of our labor force in the US is in F2F activities like hospitality.
43% of businesses in our sample have closed.
Retail armaggedon. Job numbers will get worse.
Firms are running out of cash quickly. Many only have 2.5 weeks of cash.
Many firms are optimistic about being able to reopen, but they may be optimistic.
CARES act is not stimulus, it’s insurance.
In developing world this will be deadlier. More people died from starvation in the plague of Athens than from disease.
Economic vs health tradeoffs in the developing world are really health vs health. Starvation has a high fatality rate.
Investment in science is necessary to let us reopen the cities.
Big Q: is this once every 100 years, or once every 3 years? It’s within our power.

Topic: How will the pandemic effect the Developing and Emerging Markets

Bio: Former Emerging Markets Chief Economist at major investment bank, now at think tank

Could problems abroad cause problems in the developed world?
Three big problems:
- 1. Eurozone area problems — could be a debt crisis
- 2. China could slow down a lot like Japan did
- 3. Emerging market debt defaults, they are half of the global market.
Eurozone
- France, Italy, Spain being hit worse than the US. Not only manufacturing, but tourism — will not recover quickly. Italy: 7% of GDP is tourism. It’s another major shock for them.
- Euro straightjacket limits ability to jumpstart economy — constraints on their ability to take fiscal measures. US has taken 10% of GDP in measures. It, Es, Fr — 1.5% of GDP.
- Italy has huge public debt. 150% of GDP, weak banking sector. Will need to be propped up by the ECB. 10x the size of Greece, too big to fail, too big to bail.
China
- Already had problems with a credit bubble, excess capacity all over, too many houses, too much real estate.
- This will trigger defaults, clog up banks with bad loans. Won’t be a collapse, but will be like Japan in 2000 after their boom — zombie companies. Too much credit. Wills slow growth. Big impact on commodity prices. That also will hit EMs hard.
Emerging markets
- Perfect storm. Commodity price bust; now record pace of capital repatriation, marketing coming at — $100B out in a single month. Huge pressure on currencies. Also weak demand from advance countries.
- Corporate sector have borrowed too much, much of it in USD-denominated debt. Brazil, South Africa, etc. currencies have already depreciated 25% —makes it hard to repay the debt.
- Will see wave of defaults, e.g., in Turkey, but could see them in Latin America as well.
This all makes it hard for the US economy to recover.
Q: what if world restarts in 2-3 months? A: damage already done. US collapse provoked collapse in Europe. How did they get the economies going? Say, Italy. Can’t devalue, doesn’t have own monetary policy … deep in recession and stuck, don’t have a mechanism for external stimulus

Topic: The need for global data on the pandemic and what we can and cannot say based on the available data

Bio: Founder of a website providing rich data on many key topics including COVID-19. Data scientist, academic, researcher.

We are an open access scientific project. Mission is to study the large global problems, to bring together best research and best data, present as clearly as data, and how we can make progress.
We have a wide scope, but we focus a lot on disease and health. We are global and long-term.
For a small science publication — we had 20 million visitors last month, and many more use it for their research.
On pandemic, we started in February. Our team of <10 focused all efforts on it.
Goal is to provide the data to allow everyone to understand what is happening. Help people understand how different companies are doing relative to one another. The differences will become broader. Learn from the ones doing better.
Early on we focused on getting the media’s reporting right — BBC, FT, newspapers around the world. A crucial mistake early on was to focus on the current numbers of deaths and cases. But the right focus was on the growth rate.
Now we are shifting to work on testing data and on the poor data on the pandemic globally. A crucial problem now is undercounting. We know the total number of cases is much larger than reported cases. We know this from research that looks at the ratio of deaths to cases. We think only 16% of cases in the US are reported — real number 6x higher. In Italy, only 6% are reported. Not even the number of deaths are right in Italy. We see this from the excess mortality statistics.
Testing data is crucial. Everything we see has to be interpreted relative to the level of testing. Iceland for example has tested 6.5% of the total population. The US is 20x behind Iceland. Poor countries are doing almost no testing. Indonesia has done 26 tests per million! No wonder we don’t see cases or deaths.
Korea, Singapore, Norway; also Veneto in northern Italy — did well because they tested early and extensively.
Vaccines might be far away but testing is available now.
We want to put pressure on the gov’t to increase testing.

Topic: News and Market Reaction

Bio Professor Business and Economics, author

Value destruction is already at level of GFC and early depression.
What is new is the role of coronavirus.
We are looking at next-day reporting of stock market falls, to understand how people are understanding it.
If you look since Feb 24 — 90% of big moves were attributed in next-day accounts to the economic fallout or to policy responses.
Prior to Feb 24 to 1900, how many such big moves were there attributed to the coronavirus? Zero. The last several weeks are extraordinary in that way.
The point is that flu and influenza never, in the contemporaneous perception, caused the market movements.
Paper looking back to 1985: we had computers read articles. No prior virus (SARS, H1N1) registered as a perceived reason for volatility.
Why? The human health impact can’t be all of it.
Unlikely the mortality rate in the developed world will exceed the Spanish Flu.
But Spanish Flu had little visible impact on markets or market volatility at the time.
Why? One reason might be that info difuses more rapidly than back then. Is that really it? Don’t think so.
One way to see this is to look at movements over weeks and months during Spanish Flu. Nothing like this back then.
Two other explanations which I give much more weight to.
1. Interconnected nature of modern economy. E.g., F2F interactions, personal services, for much our economy. Not a manufacturing or agrarian economy anymore.
2. Dramatic policy response. Voluntary and compulsory efforts to social distance. This has shut down most of the economy.
Q: In 1918 people kept going to work to factories. Is it because we’ve changed our behavior? A: yes, very different economy today.

Topic: The pandemic fallout on municipal bond credit

Bio: Former head of municipal bond research at a major investment bank

We’ve seen centuries of pandemics
Muni market will survive, with pain
State & local revenues will mirror economic performance
Great Recession did not produce waves of defaults.
V-shaped vs U-shaped recovery is the bid question.
The colonies issued their own currencies, was a disaster. States gave up the right to print money but not to borrow money. That is muni market. States can borrow.
There are around 80K muni issuers.
No state has defaulted since 1937.
Many states are like nations-states — e.g., California, 40M people.
Most states are AAA, all investment grade though IL close to the edge.
Many kinds of bonds, more than in corporate, lots of structures.
On the governmental side, there are tax/revenue-supported credits, primary user in the public, bonds are publicly owned.
Privately-owned families are financed by non-gov’t bonds. These can borrow via a public conduit.
If a city shuts down, everything shuts down. So very few defaults in the muni market. Expect that to continue.
That said, pandemics are negative for all bonds.
Ratings agencies are giving warnings which is to be excepted.
Consumption declines impact state tax revenues. Income tax receipts are going down, The rich have stock market launches. Delay of state taxes by 3 months doesn’t help.
State of NY’s new budget is probably already $10B in the hole.
Looking at Munis, worry about how essential they are, worry about whether pensions are funded, worry about travel and entertainment.
But the Fed is buying bonds, increasing liquidity, possibly another stimulus bill.
There will be defaults. They will be a small % of the market, mostly private purpose. Unrated bonds, around 10% of the market, will have credit problems.
If state or local gov’t it’s Chapter 9 not Chapter 11.

Topic: Logistics prevents quarantine for poor Americans and urban poor in EM mega-cities – What Happens?

Bio: Author

The pandemic gap: most discussions in the media are viewed through the lens of the wealth.
This will hit the poor much harder. IN the US and globally.
This will evolve into a disease of the poor. Economic and moral consequences.
Big political consequences as well.
In the US, we are talking about this by people like us, people who are sheltering at home in nice homes, able to work.
The reality for many Americans is that you can’t quarantine. Not everyone can continue to do it. There will be pushback. The logistics are too awful. Look at Patterson Houses in the Bronx for example.
“Shelter in Place”: if 9 people share 1 bathroom in a fourth-floor walkup, will you spend three months?
Home life is complex for poverty. You don’t have deep freezers for storage or green spaces to escape for. What about laundry? Laundromats are not an option.
The wifi gap. People go to McD’s for wifi. Many poor Americans don’t have wifi, don’t have cars to drive to go to parking lots with wifi.
If you live in trailer with three generations there? Will you stay there?
This will have political consequences. Especially if this goes into May.
Look at Jakarta to see how almost 1 billion people live. They can’t socially distance. Sanitation isn’t there.
This will be disastrous morally and politically.
Our inequality is rarely so exhibited as it is now.
The wealthy are generally surviving and getting on.
The poor are having to work to keep it going. It will kill them because of lower health quality.
Also these will be reservoirs of the disease that can carry it back into the developed world.

Topic: What are the pandemic’s implications for international relations

Bio: Professor at Stanford University

It doesn’t change things all that much.
Cold War was very unusual.
Looking at different kinds of countries today:
Consolidated democracies. Europe other than Germany haven’t done that well as far as I can tell. US in in the middle; worse than Korea, better than Italy and Spain. US is neither leader nor inept.
US has not been leading effectively since the Cold War. A book, Deaths of Despair — declining life expectancy for uneducated whites. People without college degrees seeing life expectancy go down — same as Soviet Union in 1980s.
Upcoming election: these are not great candidates on either side.
We can see that even Spain and Italy, democracies, didn’t react well.
No indication that we have a leader who will deal with deaths of despair, or deal with this crisis in the US.
Consistent with the last speaker.
For 40-50 years we had a system that worked, since US had effective leadership. It depended on the US functioning effectively internally. We don’t have this today.

Topic: How are ventilators working to save Covid19 patients?

Bio: Anesthesiologist in the US

Ventilators may be doing more harm than good.
Very fluid situation.
Poor data collection, no studies, no science. Disjointed treatment plans.
Fragmented processes with bad outcomes.
Ventilators are a prime example.
Difference between life and death is being placed on a ventilator.
7-10 days after infection
This is our last line of defence, big bazooka.
If you fail the ventilators, very few solutions left.
Looking at NY and NJ, the ventilators may be causing some kind of trauma or progression of the disease in the lungs.
When the virus replicates in the lungs you get a significant immune response.
Thick layers between lungs and blood stream, oxygen having trouble passing through.
Ventilators may be causing the thick layers to become scar tissue.
High death rate if put in ventilator.
Equivalent or higher than if you were infected with Ebola in 2014.
ICUs and anaethetisioligsts are revoking at this.
How to ventilators help? Breathing tube, you can provide more oxygen, and you are pushing it through the thick better to get the O2 into the blood.
What seems to be happening, changing treatment modalities to use high-flow nasal cannula, keep patients off of ventilators, may have better outcomes.
We are considering dual therapies but info so far the results do not appear promising.
Waves of patients requiring intubations, setting new records every day.
You never hear about the anaesthetist equipment shortages, we need to use specialised equipments. The source of our equipment is Wuhan! Significant lag time to get the batteries we need for example.
They are being allocated to hotspots in the US.
Mentally has been very difficult.
At time of incubation we are speaking to families to ask where they would like remains stored, since 80% will die.

Topic: How are major hospitals dealing with the Pandemic?

Bio: Cardiovascular Surgeon in the US

I work at a large suburban hospital near a major hotspot.
Lots of sick patients
We expected to peak in the next two weeks.
We couldn’t have imagined this.
Entire hospitals are devoted to COVID, everything else has come to a complete halt.
Resource allocation of PPE: you need an extraordinary amount. A single round uses a huge number of gloves, gowns, masks.
Many doctors around the country are sick,I know many of them. Some mild, some in ICU, some on ventilators.
Once patients have been triaged, ICU specialists take on the patients.
Some need immediate incubation & placement on ventilators; others are more stable. Usually admitted to a floor just for COVID patients.
On ventilators: treating huge cytokine release, inflammatory response. Requires high dose steroids.
Renal insufficiency, some renal failure.
Risk of multi-organ system failure which causes death.
We are treating so much at once we don’t know what is working.
Broad set of symptoms. Sometimes first admitted to non-COVID unit, then become COVID positive, and can infect a “clean” unit.
Some hospitals plan to transfer patients who are stable to field hospitals. But will only work if the appropriate patients are sent there.
Large hospitals have surge plans for catastrophes.
Most have put these plans in place.
Elective surgery has been cancelled across the country. Only dealing with emergencies.
We have not converted every OR in my hospital to an ICU. We do have enough resources right now.
Our patients are avoiding coming in if they can.
Testing has continued to improve almost daily.
Inpatients and health care workers get results quickly.
Highly persistent, even on surfaces. Highly contagious.
Greenlight in early May to begin operating again.
1/3 of patients who go on ventilators come off of them.

Topic: Pandemics in Economic History

Bio: Professor of Economics and History, author

Go back to William Mcneil, U Chicago historian. He pointed out that we can look a a long struggle of people vs microbes and viruses throughout history.
Once in a while a plague changes the course of history.
Roman times, Justininan plague; black death.
Much of pre-columbian population of the Americans were destroyed by pandemics brought by Europeans — smallpox and measles.
How have pandemics changed as a result of economic development?
Bad news: Higher integration of the world means microbes get around the world faster.
Every pandemic we know about is the result of two societies being in contact which were not previously.
Now they can spread simultaneously globally. Three months is a very short time in history compared to past epidemics!
Possible that viruses and microbes are mutating faster, not sure.
Good news is that we are finally learning. This pandemic is very different, even than the Spanish Flu. In 1918 people did not understand at all, did not know it was a virus.
We are so good at handling infectious disease that this pandemic is a surprise!
Deaths from infectious disease had fallen from 800 to 60 per 100K people.
Dangerous to generalise from history here. Despite all of the problems, we are much better equipped to deal with this than anyone ever was before.
We are throwing everything at it.
We will have vaccines faster than every before.
The techniques we develop will prepare us for the next one.
Over the long run we are winning the long-term battle of people against microbes!
This isn’t going to be the Black Death or the Justinian plague.
We sequenced the virus within a few weeks. We know the enemy.
May be some good results.
May get better at working from a distance.
Once we have a vaccine, hopefully will end the anti-vax movement.

Topic: How does the current pandemic resemble the 1871 Horse Epidemic

Bio: Professor of History

Started in Toronto, spread rapidly throughout NA, hit every city. Took one year to burn out.
Horses got very sick, many collapsed.
No social distancing for horses!
95% of animals got sick quickly.
Those that had to work anyway often died.
75% of horses and mules died
Most of them were unable to work for 3-6 weeks.
Caused economics and social shock.
Revealed dependency of supply chain on horses: coal, fuel, harvests were rotting.
Railroads relied on horses to take material to/from depot.
Railroads wouldn’t even stop because they ran out of places to put packages that had piled out.
People didn’t catch it but economic anxiety caused people to stay at home. Bankrupted many people.
Some people think it caused the panic of 1873, a major recession.
People couldn’t congregate because they had to walk everywhere.
Wedding and funerals were disrupted.
Had it lasted, could have cut off heat and food for the winter.
Anti-cruelty movement came out of this.
Confused national debate among scientists and doctors. What caused the disease? What was it? How could you prevent it?
We’ve come along way since then. Easy to map the spread. Each newspaper discussed it. It was national news.
Early epidemiology could see that it was spreading radially from Toronto along the main transit routes.
Germ theory was in its infancy. Microscopes weren’t strong enough.
We don’t know what the disease was for sure.
This focused national attention on the problem and it led to the first vet schools.
This in part led to the replacement of horses with machines. Cities encouraged that transport companies experiment with steam, hydraulics, cable cars. This accelerated trends that were already underway.
It didn’t last long enough to cause lasting change. The duration of the epidemic matters to know if it will cause long-term change.

Topic: 1918 Flu

Bio: Author, works in emergency care research funding

Happened in the pre-antibioitic period. Although they don’t treat viruses, they do treat the secondary bacterial infections. It is these that cause pneumonia and were likely responsible for mosts of the deaths.
Even today, secondary pneumonias are an issue.
We have tools they did not, antibiotics, against secondary complciations.
We are in a very different state. Today we have >100 drugs in trials.
Doctor back then would have arrived on horseback; was the same doctor who would deliver your baby or set a broken bone. Today we have specialists.
Fear is a big factor. Back then people didn’t know what was killing them. Experts gathered to discuss it after three months of deaths. Famously, the Chicago health commissioner said that people should be kept from fear.
People are afraid today too.
We are around 325K infections in the US, 9K deaths. This is around 3% crude death rate. That’s up there with the 1918 death rate. That will fall as we discover more asymptomatic carriers, discover more cases through testing. Still a staggering number. In 1918 it was 2-3% death rate; some saw 80% (e.g., in one town in Alaska with elder population).
The fear is common to the two epidemics.
What happened in Fall 1918, when it came back, it was much more deadly. Don’t know if that will happen here.
Other coronaviruses are “winter viruses” and subside, are less transmissible, in warmer & more humid summer weather. We’ll see what happens, and then what happens in the autumn.
Q: Does that mean in places like Florida and Indonesia will have lower transmission. A: In general, yes. But many other factors at play. Density of population is very important. A lot of people in a small area, may transmit even in a climate poor for transmission.
MIT paper in the last week says less of a problem in warmer climate but data still Evolving. Need to look at the data on a per 100K population basis.

Topic: How literature can help us make sense of crises like now.

Bio: Professor of Slavic Literature
Requirement: Please read short story The Bishop by Anton Chekhov.

Putin might be thinking that this is relatively minor compared to what Russia has been through.
Bleak House by Dickens would be good to read. The wealthy people ignore the slum going through a disease. The heroine catches it, comes close to dying, is marred by smallpox.
I asked you to read this story to understand the psychological aspects.
When reading reporting, big picture are statistics not individuals.
Hero doesn’t know he’s ill at first. Experience of the illness merged with his loneliness.
Great literature lets you experience what others are from within.
He dies of typhoid.
I don’t agree that the hero is unsympathetic.
His relationship with his mother is because after being abroad for 9 years she can’t relate to him any more. People stand up in his presence because he’s a bishop. He doesn’t know how to overcome it, despite trying.

Sunday roundup

5 April 2020

Just wear it

The topic of masks seems relatively simple; here’s the emerging consensus (but note some dissenters):

Everyone in a significantly impacted area should wear one in public.
The main reason is to reduce the risk of infecting other people.
You should do it even if you don’t have symptoms, because it seems like many more people may be both asymptomatic and contagious than we thought.
A surgical mask, a homemade cloth mask, or even a scarf helps for this purpose.
These simple masks might or might not protect you, but it doesn’t see like they could hurt.
They could have a side benefit of keeping you from touching your face (not clear that there is evidence for this).
In terms of social signalling, until recently wearing a mask in the west (not Asia) might have been stigmatised as signalling that you were sick; but quickly it will come to signal that you are a responsible citizen.
P95 masks definitely offer more protection, and if there were unlimited supplies I would recommend wearing one in public. But for as long as there are PPE shortages, you should instead see if you can donate them to a local hospital or nursing homes.

What do experts say?

The case for: The New York Times’ roundup is helpful. Here’s the CDC’s advice: wear a mask, even a homemade one. Austria now requires them in grocery stores. These experts say you should.

This roundup of recommendations from health authorities around the world in the Lancet tips cautiously in favour of wearing masks. (Dated 20 March, somewhat out of date.)

The case against?

David Heyman, professor of infectious disease epidemiology at the London School of Hygiene & Tropical Medicine (that’s way up there in terms of credentials), is sceptical. His arguments for caution: (a) We don’t have strong evidence to support a recommendation one way or another. (b) It’s possible (again, little evidence) that in removing a mask you could increase your risk of infection. (c) Encouraging mass adoption of masks could reduce the supply available to hospital workers. (d) Wearing a mask could give a false sense of security and cause us to take less care elsewhere (e.g., in washing hands).

Also note that the WHO has not updated their advice as of today, 5 April 2020: “If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.”

(As an aside–though I come out in favor of wearing masks in public for those in impacted areas, I love arguments like Heyman’s, which are brave enough to question the conventional wisdom and, with cool rationality, consider the potential counterarguments.)

I also appreciated this post by Ed Baker: https://medium.com/@esbaker/homemade-face-masks-could-be-the-silver-bullet-for-defeating-covid-19-5ed96d61544b

Asymptomatic transmission

I’ve heard increasing numbers of claims about asymptomatic transmission recently, which is a really important topic.

As a matter of definition, I’m using “asymptomatic transmission” to include two types of situations: transmission during a pre-symptomatic period of a case that later goes on to develop symptoms; and transmission from a case that never develops symptoms.

It’s also worth noting, as this New York Times article does, that there is no standard definition of “asymptomatic.” It often turns out to mean “pre-symptomatic.“

Before considering the current evidence, let’s also distinguish between two questions.

Are a significant proportion of those infected with COVID-19 mostly or completely asymptomatic (to the point that they might not even know that they were infected)?
Are a significant proportion of instances of transmission coming from infected individuals during a period in which they are asymptomatic?

The second is the important question in the near term. Lots of asymptomatic transmission would be bad news for our ability to control the spread; and in turn, that makes it harder to return to normality. We would need stricter control measures for longer. And subsequent outbreaks (e.g., from imported cases) would be harder to detect and contain.

On the other hand, if little asymptomatic transmission is happening, but there are significant number of asymptomatic cases, that would (strangely enough) be really good news. It would mean that there are likely many more cases than we know about, which would mean that the IFR (the true fatality rate) is much lower, since the denominator of the CFR (the measured fatality rate) would be understated–i.e., that the virus is less deadly than we currently think. And it would mean getting to herd immunity faster.

What does the evidence say so far?

In this NPR interview, the head of the CDC, Robert Redfield, says that as much as 25 percent of people infected with the new coronavirus don’t present any symptoms but can still transmit the illness to others. And even those who do go on to present symptoms can be infectious 48 hours prior to symptoms.

This Business Insider article lists many examples of studies (some small-scale) consistent with either asymptomatic cases, asymptomatic periods of a case, or asymptomatic transmission (they don’t always distinguish among these).

This New England Journal of Medicine paper says, “The viral load that was detected in the asymptomatic patient was similar to that in the symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients.” Note that this was one patient out of 17, so a tiny sample.

This paper looks at the population of a nursing home in Washington State, and finds that roughly half of the 76 who tested positive were asymptomatic on the day they were tested.

At the same time, the WHO’s situation reports continue to say (quoting 2 April 2020 sitrep), “There are few reports of laboratory-confirmed cases who are truly asymptomatic, and to date, there has been no documented asymptomatic transmission. This does not exclude the possibility that it may occur. Asymptomatic cases have been reported as part of contact tracing efforts in some countries.”

Because of the vagueness about what “asymptomatic” means, one academic argues that the distinction between symptomatic and asymptomatic transmission is unhelpful, and should be replaced by “documented” vs “undocumented.” Using this distinction, he and collaborators published a paper that estimated that 86% of infections in China were from undocumented cases.

My conclusions are as follows:

There are almost certainly asymptomatic periods of cases that go on to be symptomatic.
There are probably fully asymptomatic cases (which could just mean: really mild symptoms).
There’s increasingly strong evidence that transmission can occur in the absence of symptoms.
I haven’t found any good sources to enable us to estimate the proportion of transmission that is asymptomatic.
There are surely many instances of transmission from undocumented cases–perhaps even the majority of all transmission.

Why is Germany’s fatality rate so low?

A good New York Times article on this topic. The key points:

Germany’s CFR is 1.4% vs 14% in Italy, 10% in Spain, France and Britain, 4% in China, 2.5% in the US, and 1.7% in South Korea.
The main reason is probably a statistical one: Germany’s exceptionally high rate of testing likely means that the denominator of the CFR calculation is less understated in Germany than elsewhere. (A good reminder that what we care about is IFR, not CFR, and that CFR’s can’t be compared across regions with different testing rates.)
Germany’s infected population (at least the population we know about) is unusually young:
- “But the average age of contracting the disease [in Germany] remains relatively low, at 49. In France, it is 62.5 and in Italy 62.”
- Why? “Many of the early patients caught the virus in Austrian and Italian ski resorts and were relatively young and healthy.”
- (But note that these average ages are among detected cases; probably places like France and Italy, which test a far lower proportion of the population than Germany and focus testing on serious cases, have many more cases among young people than they have detected or reported.”
Germany may be doing a better job treated patients which would reduce the fatality rate. “But there are also significant medical factors that have kept the number of deaths in Germany relatively low, epidemiologists and virologists say, chief among them early and widespread testing and treatment, plenty of intensive care beds and a trusted government whose social distancing guidelines are widely observed.”
- “The reason why we in Germany have so few deaths at the moment compared to the number of infected can be largely explained by the fact that we are doing an extremely large number of lab diagnoses,” said Dr. Christian Drosten, chief virologist at Charité, whose team developed the first test.
- “When I have an early diagnosis and can treat patients early — for example put them on a ventilator before they deteriorate — the chance of survival is much higher,” Professor Kräusslich said.
Germany started with a higher ICU capacity and built more capacity quickly. “All across Germany, hospitals have expanded their intensive care capacities. And they started from a high level. In January, Germany had some 28,000 intensive care beds equipped with ventilators, or 34 per 100,000 people. By comparison, that rate is 12 in Italy and 7 in the Netherlands. By now, there are 40,000 intensive care beds available in Germany.”

Overall, it appears that the German approach is a role model that should be widely followed.

Robert Schiller on economic impact

Nobel laureate Robert Schiller is a hero of mine; a great, long-term, big-picture thinker. SO I was excited to see his opinion piece in the New York Times on the stock market.

Key excerpts:

“[I]s the market cheap today? Is it expensive? Here’s my equivocal answer: It’s not as highly priced as it was just months ago.” […]
I worry that the present anxious situation may stay in the collective memory for decades, much as the stock market crash of 1929 did. That could make people more risk-averse, possibly portending lower valuations on the stock market. […]
Based on history we would expect to see it to be a reasonable long-term investment, attractive at a time when interest rates are low. […]
As a practical matter, my advice is to look at your portfolio to make sure that it is not so heavily weighted to stocks that further losses would be unbearable. Otherwise, I’d try not to worry too much about the stock market.”

Modeling humour

Roundup of worthwhile reading for Friday

3 April 2020

Here’s the best of what I’ve been reading recently.

Bill Gates: How to make up for lost time

Adopt a consistent approach to control measures nationwide; otherwise those areas with relatively lax measures put everyone at risk.
Ramp testing faster; prioritise those on the frontlines, symptomatic people in high-risk groups, and those who may have been exposed.
Stop having states compete for scare masks and ventilators.
For therapeutics and vaccines, “stick with the process that works: Run rapid trials involving various candidates and inform the public when the results are in. Once we have a safe and effective treatment, we’ll need to ensure that the first doses go to the people who need them most.” Start ramping manufacturing capabilities now to be ready.

Might the death toll to date be higher?

We have strong reason to believe that the data we have on reported cases understates actual cases significantly, as I discuss here. What about the death toll? These are taken by most epidemiologists and modellers as a more reliable source, but have the disadvantage of being a lagging indicator.

The Economist presents data that suggest that the actual death toll so far could be significantly higher.

There are good reasons to be concerned about under-attribution of deaths:

“Official death tolls for covid-19 may exclude people who died before they could be tested. They also ignore people who succumbed to other causes, perhaps because hospitals had no room to treat them. The latter group has been large in other disasters.”

In a few regions, journalists have been trying to estimate the total number of deaths, from any cause, and to compare those figures to the number of deaths we would ordinarily expect in the absence of COVID-19. Here are the results:

There are two important caveats to this approach.

First, estimating the counterfactual of what deaths would have happened without COVID-19 is just that, an estimate. We can’t know for sure what it would have been. That said, if you look at the supplemental charts in the article, you’ll see that the weekly number of deaths in the examples given have been consistently within one range, and then jumped far outside of that range. So estimates of the baseline level of death seem reasonable.

Second, even if we’re confident in our estimate of the number of excess deaths, above that baseline, we can’t know that all of them are directly as a result of COVID-19 infection. There could be other reasons, even reasons related to our response to COVID-19. Perhaps it was harder for people with other illnesses to get medical help. Perhaps they were less likely to seek help. Perhaps social isolation has put more people at risk.

Still, the overall point is very clear and compelling: in the five regions the Economist article looked at, if all excess deaths were due to COVID-19, we could be underreporting COVID-19 deaths by something like 100%. And that could be consistent either with a higher Infection Fatality Rate than we think, or a higher attack rate in the population.

What are models good for?

Zeynep Tufekc’s measured and intelligent piece in The Atlantic, Don’t Believe the COVID-19 Models (That’s not what they’re for) is exactly how I think about modelling. The key points;

So if epidemiological models don’t give us certainty […] what good are they? Epidemiology gives us something more important: agency to identify and calibrate our actions with the goal of shaping our future. We can do this by pruning catastrophic branches of a tree of possibilities that lies before us.
The most important function of epidemiological models is as a simulation, a way to see our potential futures ahead of time, and how that interacts with the choices we make today. With COVID-19 models, we have one simple, urgent goal: to ignore all the optimistic branches and that thick trunk in the middle representing the most likely outcomes. Instead, we need to focus on the branches representing the worst outcomes, and prune them with all our might.

If you’ve been reading these updates for a while, you’ll know that I’m a committed Bayesian, and like to think about a range of potential outcomes and the probability of each (what in the statistics world are called probability density functions). Modelling, or more simply, asking “what if” questions and trying to estimate the chances that each scenario comes true under certain circumstances, is an indispensable tool for this.

But there are some subtle concepts that get completely lost in the reporting of modelling efforts like the influential Imperial College work.

The first is exactly the point made in the article above. The goal of modelling is not to be correct; it’s to inform policy decisions. At the extreme, as in the case of the Imperial College paper, a model can change policy response in such a way as to ensure that it is incorrect.

The second is that when using models in this way, there is an uncomfortable fact that our simplistic notion of what it means for a model to be correct or accurate isn’t that helpful. Ordinarily, we say a prediction is correct if it accurately predicts the future. But sophisticated models like those epidemiologists are using, particularly those that use Monte Carlo (random) simulations, or consider a range of possible inputs and the corresponding range of outputs, don’t make a single prediction; they make a range of predictions and assign probabilities to them. So how can we say if they are right or wrong after the fact? I’m not going to try to answer that question in detail here; it would require pages of statistics and philosophy. But to say that a given model didn’t correctly predict the actual outcome in our actual universe doesn’t mean the model wasn’t “right”.

Here’s perhaps a simpler way of thinking about this. When you flip a fair coin, you know that there’s a 1 in 2 chance of it coming up heads. Say you flip a coin twice and get two tails. Should we say your model, which forecast a 50% chance of heads, was wrong? What if you flip it 100 times and get 52 tails? What if you flip it 1 million times and heads comes up 50.532% of the time? There’s some complex math we can do that lets us estimate the chance that the coin is in fact biased based on the number of trials and the distribution of outcomes; but in general, in ordinary language, we wouldn’t say that our forecast of a 50% probability of heads was wrong at least in the the fits two of these three cases.

Bringing these points close to home, I made a prediction back in early March that we would see 1 million confirmed cases outside of Mainland China on the 3rd of April, based on an extremely simple model. It looks like my forecast will be right to within one day (will report back on 4 April). Does that mean my model was right?

I don’t think so. I knew, and advertised, that my model was overly simplistic in many ways. By design, it will be useless at predicting when the epidemic will turn. It was trying to forecast confirmed cases, not actual cases, and so to the extent to which it got the growth rate roughly right, there is some unearned “luck” (bad luck for humans) that we have been so bad at detecting and reporting cases.

But the model did do the one thing it was designed to do. It answered the what-if question, “what if confirmed cases around the world continue to grow exponentially at the same doubling time we saw in late February?” The fact that this came true is not a reflection of the quality of the model, but our collective failure to act more quickly and decisively.

Are viruses alive? And how did SARS-CoV-2 evolve?

Two recommendations via the excellent blog Pandemic Pondering (by a professor of immunology).

Dr. Baker linked to this classic Scientific American article, Are Viruses Alive?. It’s a quick and worthwhile read.

I was also fascinated by his summary of a recent paper in Nature on the evolution of SARS-CoV-2 (the virus that causes COVID-19). Key points:

“COVID-19 did not just appear but has aggressively evolved to infect humans. This has been a progressive process that has led to a virus very efficient in infecting human cells.”
The evolutionary history may explain why the virus infects and replicates in the nose and the throat, which may encourage asymptomatic transmission.
“Another piece of bad news is that the high affinity binding of the virus to target cells may make it harder to develop a vaccine. Very strong antibodies would be necessary to block the virus binding to the cell, so the vaccine would need to be very potent to induce a protective immune response.”
“The somewhat good news is that the virus has evolved so well it may have reached its zenith! Any further mutations in the spike binding protein would likely make the virus less virulent (potent). This may protect us from the development of other, more severe strains of COVID-19 and explain why more virulent strains have not developed thus far.”

Endgames

I’ve previously linked to this well-written Atlantic article, How Will the Coronavirus End? But I should have re-linked to it in yesterday’s post on the same topic, as it’s so good. If you haven’t read it, do.

Ken Rogoff on the economic crisis

I’m a huge fan of Kenneth Rogoff’s work on the history of financial crises. So it was with some trepidation that I watched his brief interview on PBS (full transcript available here). Highlights; or lowlights, in this case:

It is really hard to think of a historical parallel.
We are going to see a recession, at least in the short term, the likes of which we have not seen at least going back to World War II.
But I think what we do know is, the short-term drop in output and quite possibly in employment could be worse than 2008.
If the virus can be conquered, and we can reach a stable situation, I’m very optimistic that we will be able to do that.
But it will be different for different countries. Italy’s in trouble. I mean, they have big pension problems, big debt problems, growth problems going into this. Emerging markets are in trouble. We’re actually already seeing emerging markets start to fold under the weight of this.
(Q: You are someone who’s worried about governments taking on too much debt. That’s now not a consideration anymore?)
No, absolutely not. I mean, there’s never been a concern about our government’s defaulting. The concern is being able to borrow massively when you need to. That’s the whole point of saving for a rainy day. When it rains, you want to really open up the floodgates.
And, here, I just — there’s no limit. We’re in a war. You have to win the war. I would have no problem with the government debt magically going up $5 trillion in the blink of an eye, if we could get out of this in two or three months healthily.

Per-capita infection and death rates in the US

A useful, interactive map showing infection rates and deaths per 10K residents, based ont the New York Times dataset.

A quibble: areas with a single death but very low populations look misleadingly bad.

Takeaways: the New York City area and greater New Orleans have clear clusters.

Adding to the Resources section of the blog.

Few patients requiring mechanical ventilation recover

NPR reports on several small studies. This 5 March 2020 Lancet paper gives details based on 52 patients given assisted ventilation (out of 710 confirmed COVID-19 patients admitted), of whom 79% died.

Clearly, the claim isn’t that mechanical ventilation causes fatalities; patients who require mechanical ventilation are the sickest.

But if ventilation is consistently this ineffective, it raises questions about the relative priority (given finite resources) that should be put into increasing ventilator capacity, vs other interventions that may be more impactful. (Of course, more ventilators are good; but at the limit there may ways to use the same resources that would save more lives.)

The studies are very small so we should be cautious about drawing conclusions at this point.

Prospective vaccines and therapeutics

I haven’t written much about the many prospective vaccines and therapeutics in the pipeline, mostly because I feel completely unequipped to say anything intelligent about them.

A friend shared this resource, which is apparently trying to track everything in the pipeline and has some interesting metrics.

Niskanen’s Live Video Briefing Series

I’m a great fan of the Niskanen Center, a centrist think-tank in Washington DC. If you’re not familiar with them, take a few minutes to read their conspectus (not COVID-19-related).

They have just announced a free, live video briefing series via Zoom, which looks very interesting. Below are the announced events. I’ll be joining several of them, particularly those featuring my friend Steve Teles and his co-author Brink Lindsey, co-authors of the outstanding book The Captured Economy.

LIVE VIDEO BRIEFING SERIES
PHASE III STIMULUS—A REVIEW OF THE CARES ACT
Hosted by Niskanen’s Sam Hammond
Friday, April 3, 2020, 10 AM EST [https://zoom.us/j/838085907]The $2 trillion coronavirus aid package offers relief to several groups impacted by COVID-19, including state and local governments, businesses, public health, and education. But individuals will (arguably) be the biggest benefactors of the bill, receiving approximately $560 billion in aid. Niskanen’s work on child benefits crystalized this month when Republican Senators Romney, Cotton, and Hawley all voiced early support for emergency cash payments to every adult and child in the country. Niskanen’s Director of Poverty and Welfare Sam Hammond will discuss details of the package, and the important changes Niskanen advocated for to reduce the paperwork required to apply for recovery rebates, enhance fiscal stabilization for states amid falling sales revenue, increase SNAP benefits, and expand health coverage for COVID-19. Hammond will discuss the development of the CARES Act, details about the relief package, and how Niskanen plans to impact multiple aspects of the next phase of recovery.
ELECTION SECURITY AND COVID-19
Hosted by Niskanen’s Geoff Kabaservice, Kodiak Hill-Davis, and Kristie De Peña
Thursday, April 9, 2020, 2 PM EST [https://zoom.us/j/855576028]COVID-19 has propelled the discussion on election security to the forefront of efforts to prepare for 2020 general elections. In the $2 trillion coronavirus aid package, $400 million was dedicated to “Election Security Grants” to prepare for, and respond to, coronavirus domestically or internationally. The CARES Act makes progress in ensuring the states are able to effectuate fair and reliable elections, but the changes are just the first step. Niskanen’s Vice President of Policy Kristie De Peña will review the provisions of the CARES Act and broadly highlight what improvements should be a part of a “Phase IV” package; Niskanen’s Director of Political Studies, Geoff Kabaservice will highlight specifics about proposed solutions, like mail-in voting, and additional voting modalities; and Niskanen’s Director of Government Affairs, Kodiak Hill-Davis, will review how Capitol Hill is responding to changes in policy and how politics will—as always—play a critical role in reform.
COVID-19 IMPACTS ON THE IMMIGRANT COMMUNITY
Hosted by Niskanen’s Kristie De Peña and Matthew La Corte
Wednesday, April 15, 2020, 11 AM EST [https://zoom.us/j/637086349]COVID-19 affects everyone, regardless of their immigration status. It is more critical now than ever that all individuals have access to testing and treatment that will help America overcome this crisis, and are not subject to treatment and conditions that will increase their likelihood of exposure or needlessly risk their health and safety. Niskanen’s Vice President of Policy and Director of Immigration Kristie De Peña will review the multitude of impacts COVID-19 is having on immigrants’ ability to seek treatment and care, and where changes must be made in order to keep them—and the American public—safe. Niskanen’s Governmental Affairs Manager for Immigration, Matthew La Corte, will detail changes that would help protect the health and safety of key immigrant employees in the United States, and how we can capitalize on the role of immigrants in critical healthcare and essential jobs.
CLIMATE CHANGE AND COVID-19—WHAT WE CAN (AND CAN’T) LEARN
Hosted by Niskanen’s Joseph Majkut and Nader Sobhani
Monday, April 20, 2020, 3 PM EST [https://zoom.us/j/191421236]The global pandemic and resulting economic shock will have implications for every issue in public policy, including climate change. In the next few months, government investment in clean energy and infrastructure will be positioned as a necessary economic stimulus, and bailouts for high-carbon industries could come with conditions for future environmental performance. In the medium term, climate advocates need to develop saleable plans for long-term recovery. Niskanen’s Director of Climate, Dr. Joseph Majkut, and climate policy associate Nader Sobhani, will discuss why COVID-19 reveals how poorly our society has prepared itself for predictable risks and how poorly designed government regulation can impede an effective response. It is essential that both climate advocates and skeptics learn from this experience and commit to not repeating them in our own domain.
BREAKING BARRIERS—REGULATIONS DURING A PANDEMIC
Hosted by Niskanen’s Brink Lindsey and Daniel Takash
Tuesday, April 28, 2020, 9 AM EST [https://zoom.us/j/217777108]COVID-19 and our country’s faltering early response exposed a number of dysfunctions and rigidities in the American regulatory state, and thereby created openings for larger structural reforms that go beyond the current short-term waivers. First, the debacle over shortages of the delayed rollout of testing and shortages of PPE and ventilators highlights larger problems with the FDA’s highly risk-averse and slow-walk-everything institutional culture. In addition, various problems with the state licensing of healthcare workers have cropped up. State-based licensing has created obstacles to both telemedicine and moving healthcare workers across state lines to where the outbreak is most severe. Moreover, the scope of practice restrictions on nurse practitioners and physician assistants reduce the availability of primary care options at a time when all resources are under heavy strain. Niskanen’s Vice President Brink Lindsey and regulatory policy fellow Daniel Takash will discuss these and other issues and the prospects for constructive policy change in the wake of the crisis.
ELECTION FORECASTING AND THE ROLE OF MODERATION IN A BIDEN ADMINISTRATION
Hosted by Niskanen’s Steve Teles, Brink Lindsey, and Rachel Bitecofer
Tuesday, May 5, 2020, 11 AM EST [https://zoom.us/j/963351859]Niskanen’s Senior Fellow Rachel Bitecofer will lead off with an in-depth review of her election forecast, the methodology and assumptions that underlie it, and the various factors—including the pandemic—that could influence turnout and results in November general elections. Assuming a victory for the presumptive Democrat nominee, Joe Biden (for purposes of this discussion), Niskanen’s Vice President Brink Lindsey and Director of Political Studies, Geoff Kabaservice will discuss various scenarios for the correlation of political forces in 2021, and how that may influence the direction of the Biden administration. In particular, Lindsey and Kabaservice will consider factional rivalries between moderates and the progressive left in the Democratic party, and the possibility of some Republicans joining with moderate Democrats in a centrist coalition.

Updating priors; what are the exit strategies?

2 April 2020

Updating my priors

I haven’t publicly updated the distribution of my current, subjective probabilities, against the three high-level scenarios I’ve previously described (which I call “expected, better, worse”), in a while. If you haven’t already read that post, you might want pause and skim through it to have context for what comes next. I also updated my thoughts on these scenarios a few days later, here.

As a reminder, “expected” is the still-unhappy case where, in many wealthy countries, we go through a period of lockdown for (what I previously called) 4-12 weeks (but now seems like it could be longer); where the lockdown is ultimately successful in slowing/controlling the epidemic; but where we still say large-scale, if temporary, economic disruption, a final attack rate of 25-40% of the population, and a Infection Fatality Rate of 0.5-1.0%. So there are a huge number of cases, and a significant number of deaths, but we can look ahead to a time, a year or two from now, when things are mostly normal. (Emerging economies are likely to suffer a much worse path.)

“Better” and “worse” do what they say on the tin; see prior posts for more detail.

On 19 March (the first post linked above), I put the distribution of probabilities as 60% expected, 20% better, 20% worse.

On 23 March (the second post linked above), I concluded that the tails had grown fatter: that the chances of better and worse outcomes were higher than I’d thought, and moved to 50% expected, 25% better, 25% worse.

In the last 8 days I’ve see-sawed between greater optimism and greater pessimism, but not shared specific updates to my priors. Today, I want to share what has behind the see-sawing, and why I significantly updated my views today in the last 24-hours.

Until a few days ago, I was concluding that Europe was on a high-probability path for Expected with a chance of Better, given the strong flattening of the curve, discussed here. At the same time, I feared that the risk of Worse outcomes in the US was rising rapidly, as discussed here.

This week, we’ve seen the US not only demonstrate a willingness to deploy unlimited (and steadily increasing) firepower on the economic front, but also radically shift both rhetoric and behavior towards stricter, medium-term control measures. That made me upgrade the chance of the US having an Expected outcome versus Worse.

If you’d asked me even two days ago, I would probably have been around 65% Expected, 25% better, 10% Worse for rich Western countries. (Rich Asia as well as developing economies are in different situations, where I’m largely more optimistic about the former and extremely pessimistic about the latter.)

Yesterday and today, I’ve been thinking and reading about exit strategies, and ended up depressed again. Depressed not because I concluded that I should increase the probability of Worse outcomes — I am moving even more strongly towards Expected — but because I realized that my thinking about the Expected case was sloppy (to the point of hand-waving) on the question of exit strategy, and that Expected cases are likely quite a bit more painful that I had thought.

My thoughts are very much in formation on this, but I’ll share my updated thinking about why I fear the most likely exit strategies are painful.

Exit strategies

When I talk about exit strategies, I mean paths, post-lockdown, to outcomes where life can mostly return to normal: where most economic activity resumes, and where the risk of serious adverse health consequences from COVID-19 for most people has decreased to a level where it is not much greater than the risks that we accept every day, without radical intervention, from diseases like seasonal flu.

(As an aside, it’s remarkable that so many of us would rather accept somewhere between a 1 in 10,000 and 1 in 100 chance of dying from the flu, as a rough order of magnitude and excluding 65+, than get a flu vaccine. In the US, less than half of the <65 population was vaccinated in a 2018 survey. We don’t shut down nursing homes, let alone the entire economy, in a worse-than-average flu season. There is something extraordinary about the salience, the perceived threat, the alienness, and the many unknowns around COVID-19 that makes us think about it in an entirely different way.)

What I’ve said previously, in an extremely hand-waving way, is that once the epidemic is under control, we can move to a different stage of aggressive contract tracing, quarantine of infected and suspected infected individuals, and tight border controls including quarantine for new entries. In other words, we can try to be China, South Korea, Hong Kong, or Singapore.

I’ve now realised that this is very naive for a few reasons.

Before I go there, let’s remind ourselves of how an epidemic of a highly contagious virus ends. There are really only four ways:

The virus for some reason becomes less contagious, or so much less lethal that we accept the risk of infection as we do with more familiar infectious diseases. The lower risk (or perceived risk) could be because of mutation or because of response to changing weather, for example.
We develop herd immunity because a high enough proportion of the population acquire immunity through being infected and recovering, assuming that immunity does indeed result and last. (For basic reproduction number R0, we need (R0-1)/(R0) to be immune; so for R0=3, that’s 2/3 of the population.)
We develop herd immunity through developing and globally deploying an effective vaccine that (combined with acquired immunity) results in the level of immunity described in (2) above.
We drive Rt (the effective reproduction number at time t) down to below 1, and keep it there for an extended period of time. This could be through some combination of lockdowns, behavioral changes like hand-washing and voluntary social distancing, as well as extensively testing for COVID-19 and quarantining those who are infected.

I don’t know any scientist who thinks we should count on (1) above.

Despite the vast resources being put towards developing a vaccine (3), I’m sceptical that we will have one in 2021, or even 2022, for three reasons.

First, we’ve tried for many years, and spent a lot of money, to develop vaccines against other viruses (common cold, AIDS, SARS, MERS) without success.
Secondly, if the true IFR (infection fatality rate) really is 1% or less, as seems likely, we will need to have confidence that severe side effects occur in well below 1 in 100 people who are vaccinated. It will take human trials of significant scale and time to conclude that.
Third, we need to overcome the challenge of manufacturing, distributing, and administering billions of doses around the globe; and we also need to get high (probably >2/3) compliance; something that we struggle with for some vaccines.

(2) is clearly the scenario we’ve been trying to avoid, or at least to delay: overwhelmed hospitals, higher-than-necessary death rates.

And so the question is, if the least bad options are (4) or a very slow version of (2) — which I think at some level are almost equivalent — what do they look like?

Nicholas Davies, along with the influential epidemiologist / modeler Adam Kucharski and colleagues from the Centre for Mathematical Modelling of Infectious Diseases COVID-19 working group have just published a really depressing paper focused on the UK; and although it is UK-specific, the conclusions will directionally apply in many countries.

The paper appears designed to demonstrate to UK policymakers that they have made the right decision to go down (however slowly) the lockdown route versus other options. And to that end, the lockdown option in this set of simulations is shown to be less bad than other options.

What really hit me in reading the paper is how bad the lockdown option is in reality.

The problem is that after an intense lockdown of, say, two months, what happens? As we’re starting to see in Asian countries that initially controlled the virus, new outbreaks begin to appear, either because there are a significant number of infected people in the population whom have not been detected, or because new cases enter from outside the country.

This new paper suggests that the least-bad option requires us to “pulse” in-and-out of strict control measures in order to keep demand for ICU beds within supply, even if the supply of ICU beds doubles.

*Figure:* Projected impact of intensive control measures with reactive lockdowns. (a) Dynamics of the epidemic under different triggers for introduction and lifting of lockdowns (median timing of lockdowns shown as grey shaded areas). Bolded lines show ICU bed occupancy in the median run under each scenario. Horizontal guides show the estimated number of ICU beds in the UK as of January 2020 (solid line) and with a hypothetical doubling of capacity (dashed line). Blue shaded regions show school closures, while the pink shaded region shows a background period of intensive interventions. (b) Summary of epidemic runs. (c) Estimated distribution of R0 under three different interventions: intensive social distancing with schools open and closed, and lockdown.

In the charts above, the “Lockdown 1000-bed trigger” (top row, second chart from the left) is the least-bad scenario when measured by total deaths, peak ICU beds needed, and for staying closest to within ICU bed capacity (though note that to do so the number of beds needs to double). (The name of the scenario comes from the idea that we would relax lockdowns whenever we brought active cases within then-current health-care system capacity — double todays’ — but would re-impose them to avoid breaching that capacity.)

But note that the lockdowns need to recur, albeit with decreasing frequency, through the summer of 2021! And that we are more often in lockdown than not for the rest of 2020. In this scenario, we are in lockdown for 5 of the next 8 months, and for 7 of the first 8 months of 2021; and “intensive interventions” (social distancing) are a constant through March 2021.

Needless to say, the economic impact of (taking this “Lockdown 1000-bed trigger” scenario as a specific example) would be extreme; much more than the already-dire forecasts you’ve been hearing anticipate.

Now, the authors are very careful to make clear that this is only one modeling study; that there are important assumptions made that may not obtain in real life; and that other outcomes are possible.

But at the same time, other researchers are reaching similar conclusions as well. So to is the Harvard epidemiologist Marc Lipsitch (a very accessible article worth reading).

So the question we need to ask is: what are the alternatives, and how likely are they?

The best alternative

The best alternative, I think, goes something like this — effectively the China / Hong Kong / Singapore / South Korea strategy:

Take a lot of pain up from to get new cases very near zero.
Do extremely broad, mandatory testing in the population to detect new cases, and force-quarantine those suspected or confirmed of being infected, including removing them from their families.
Close the borders except to small numbers of people, and require long quarantine periods for those who do come in.
When in doubt about whether an individual might have been exposed, enforce quarantine.

But as I understand about how this has been implemented in some Asian countries (and about the potential limitations on the effectiveness of the strategy), I’m growing increasingly concerned about whether such a strategy is feasible in a country like the US (it might be in some European countries, especially smaller and highly cohesive ones).

Any country will find it hard to impose the economic and social pain from on-again, off-again lockdowns for an extended period.

But is it possible to imagine the compliance, the perceived invasion of privacy, the separation of families in such an individualistic culture? Would we submit to an app that rated us as red/yellow (amber)/green and imposed restrictions on our movements as a result? Would we permit a family member showing symptoms to be removed to government-run quarantine?

Immune superheroes

Another, potentially complementary path, is through serological testing.

Assuming immunity sticks, widespread, inexpensive, accurate serological tests (as I wrote about recently) would make a big difference.

(This free-to-read FT article gives a good and recent summary of testing.)

If we acquire immunity after recovering, and if we can detect it broadly and reliably, we will have an increasing number of “superheroes” who can (in theory) return to work, work on the front lines, etc. without significant risk to themselves or to society. In this scenario, we can permit more and more of the economy to ramp as the proportion of society known to have immunity increases.

This is clearly a better scenario than shutting down the economy for most of the next 16 months. But even in this scenario, a significant proportion of the population is subject to strict control measures for most of the rest of 2020, and parts of 2021 as well.

Other possibilities?

I shared a draft of this post with a few friends, and thought this was an interesting way of looking at it (minor formatting edits are mine):

[Could] therapeutic (non-vaccine) medical developments [change] society’s calculus on the issue? Surely there has to be some fatality/severe case rate that is tolerable, and this will not only go up over time as economic damages mount; but also the actual data on the fatalities can be pushed down if a therapeutic development manifests (which I believe is much more probable in the next 6-12 months than a vaccine).
Maybe that is one ‘better’ equilibrium here that doesn’t solely involve the ‘R’s – between some measure of social distancing and the like we bring attack rates down from a hypothetical X to a hypothetical X -20% and then we have a therapy that reduces fatality from 1-2% to .5% or something like that.

My friend is making two points that both seem highly relevant.

First, as therapeutics get better (and I am much more optimistic that we will have helpful therapeutics quite soon, than that we will have a vaccine within a few years), the Infection Fatality Rate will come down, and COVID-19 will look more like familiar infectious diseases like seasonal flu.

Secondly, in some countries, over time we might choose a different balance between health outcomes and economic outcomes, particularly as the economic costs mount and as the potential health impact reduces thanks to effective therapeutics.

Among all of the posts I’ve written so far, I feel the least confident about my thinking this one. I’d really appreciate hearing reactions, and in particular ideas about better exit strategies.

(Correction) Use Kinsa data with caution for COVID-19

2 April 2020

In a post on 31 March 2020 I linked to a New York Times article about US data and estimates based on Kinsa Health’s internet-connected thermometers, which showed a significant drop in fevers vs Kinsa’s forecast. I did say that we should be “cautious about concluding that this represents a decrease in COVID-19 infections.” It turns out that I should have put even more caveats when I shared this article.

A friend who knows much more about Kinsa’s dataset and methodology, and is close to the company, recommends even greater caution. He does not want the comments attributed to him but gave me permission to summarize them; what follows is my summary and any errors are my own:

The data has been historically accurate on broad trends, correlates with the CDC data, and has the advantage of being released earlier.
Using the data more precisely — for example, at a narrow geographical level — is more challenging.
By way of background, there is no precise baseline (“ground truth”) against which to train models. We don’t know exactly who has the flu. So the “percentage of people who are sick” is at best an estimate, which is designed to correlate with the CDC’s metric. It’s consistently calculated so is probably a reasonable proxy for the flu at a national level.
However, there are a lot of challenges in extrapolating from this to what we want to know about COVID-19.
First, it is much harder to be accurate at a local level. CDC data is not published locally so the model can’t be changed; and some locations have very few thermometers.
Secondly, users are not representative; they tend to be younger and tech savvy. That poses a big problem in trying to extrapolate to COVID-19.
Third, user usage patterns can change over time. Worse yet, they can change in reaction to new stories like this one! So even if past correlations were pretty good, they might not be the same today.
Finally, flu incidence is more random than one might think, meaning that it’s hard to say what “atypical” levels of fever are.

It’s a helpful reminder that at a moment when more data, more studies, and more so-called experts are being thrust at us than ever before–and when many scientific papers are being distributed as pre-prints before going through the peer review and publication process–we need to be extra-cautious when looking at data and claims.

Control measures are working

31 March 2020

(Reposted 1st April as due to human error — mine — this didn’t make it into the newsletter.)

On 30 March 2020, researchers at Imperial College published a paper, discussed in this article, assessing the effectiveness of control measures put in place in 11 European countries.

The model uses the now-familiar method of looking at reported deaths and inferring the infections that must have existed several weeks prior. The conclusion?

We find that the slowing growth in daily reported deaths in Italy is consistent with a significant impact of interventions implemented several weeks earlier. In Italy, we estimate that the effective reproduction number, Rt, dropped to close to 1 around the time of lockdown (11th March), although with a high level of uncertainty. Overall, we estimate that countries have managed to reduce their reproduction number.

It estimates the lives saved as a result:

With current interventions remaining in place to at least the end of March, we estimate that interventions across all 11 countries will have averted 59,000 deaths up to 31 March [95% credible interval 21,000-120,000]. Many more deaths will be averted through ensuring that interventions remain in place until transmission drops to low levels.

The paper also tries to estimate the percentage of the population that is infected in these countries.

We estimate that, across all 11 countries between 7 and 43 million individuals have been infected with SARS-CoV-2 up to 28th March, representing between 1.88% and 11.43% of the population.

Here is the key table, presenting ranged estimates at a 95% confidence interval:

I would be cautious with these figures as the study had to make a number of important assumptions (including that the impact of control measures was roughly consistent across these countries). Still, it gives us a sense of what the possible ranges might be.

A very different approach in the US also gives hope that control measures and behavioural changes are slowing the spread, reported in this New York Times article:

The article reports that a manufacturer of internet-connected thermometers, Kinsa Health, has been monitoring atypical fevers across the US, and identified a clear trend.

Kinsa has more than one million thermometers in circulation and has been getting up to 162,000 daily temperature readings since Covid-19 began spreading in the country.

The company normally uses that data to track the spread of influenza. Since 2018, when it had more than 500,000 thermometers distributed, its predictions have routinely been two to three weeks ahead of those of the Centers for Disease Control and Prevention, which gathers flu data on patient symptoms from doctors’ offices and hospitals.
Since 2018, when it had more than 500,000 thermometers distributed, its predictions have routinely been two to three weeks ahead of those of the Centers for Disease Control and Prevention, which gathers flu data on patient symptoms from doctors’ offices and hospitals.
To identify clusters of coronavirus infections, Kinsa recently adapted its software to detect spikes of “atypical fever” that do not correlate with historical flu patterns and are likely attributable to the coronavirus.

Here’s a link to the results, and here’s the key chart:

I’d be cautious about concluding that this represents a decrease in COVID-19 infections. “Atypical” here means simply “an unusual incidence of elevated flu-like illness levels.” It’s entirely possible that this trend primarily represents a decrease in seasonal flu, since social distancing and other control measures would also impact flu transmission. As the company says in its description of its technical approach, “It is also important to note that this method identifies anomalous ILI [Influenza-Like-Illnesses] events, not COVID-19 in particular.”

Still, it’s a fantastic example of the use of both big data and connected devices, and could be helpful in monitoring, predicting, and surgically responding to outbreaks going forward.

How healthy people die, negative oil prices, serological tests, and more

1 April 2020 (promise: no April Fools’ jokes today)

Epidemiological modeling is hard

A friend sent me this excellent FiveThirtyEight post, Why It’s So Freaking Hard To Make A Good COVID-19 Model. It’s an accessible read that gives real insight into why different models give such different results, and why even the best epidemiologists are constantly changing their forecasts. I wrote related posts, here and here, about why simple approaches to modelling have been the best approach so far (but have limited future use).

How healthy people die from COVID-19

From the excellent blog Pandemic Pondering: Why totally healthy people die from coronavirus:

[Y]oung people who die from COVID-19 infections have a very different illness. They seem to get acutely ill and develop a systemic attack on many of their organs. While these patients can also die from respiratory failure, there is no predisposing illness. They often have failure of the other organs. This is been ascribed to an acute inflammatory response, now being called “cytokine storm.”
[…]
People who die from acute coronavirus infection seem to have an exaggerated innate response and a delayed specific response, so that they fail to clear the virus. The body continues to flail at COVID-19 with inflammation in an attempt to wake up the immune system. However, this causes organ damage and can lead to death.

Should we be worried about oil prices?

A few days ago, a friend shared Goldman Sachs’ report on oil prices, which made my head spin. I had no idea that oil was so complicated, or the predicted near-to-medium-term future so counterintuitive.

I can’t share the report, but here is an article summarising the key points; and here is blog making similar points. Here are my highlights:

Demand for oil has cratered, which obviously drives prices down.
What is driving prices down even further is the lack of storage. Many oil wells are expensive to shut down and restart, so they keep pumping despite the lack of demand. But the world will quickly run out of storage given continued (even if reduced) supply and much lower demand.
We are already hitting these storage constraints.
The impact is different on different kind of oil producers. “Waterborn” oil producers (e.g., oil platforms in the North Sea) having direct access to tankers, which are an ample source of storage; while landlocked producers (e.g., the Permian basin in the US, Canada) face extremely limited storage.
As a result, in some locations the price of oil could go negative as producers without access to storage pay others to remove it rather than shutting down their wells.
So in the near term oil prices could be even more impacted.
As if that wasn’t complicated enough, the report further predicts that oil prices will go up very significantly post-crisis–and that we will even face potential oil shortages.
The reason is that the economic shock will take some of the world’s production capacity permanently off-line; and some of that capacity, once offline, will be uneconomical to bring back online. We believe the upstream sector could lose as much as 5.0 million b/d of oil supply capacity.”
Goldman’s conclusion is that we could in fact face an oil shortage as a result, in 2021 or beyond, which could impact the economic recovery:

“This will likely be a game changer for the industry,” the bank said.
“Big Oils will consolidate the best assets in the industry and will shed the worst … when the industry emerges from this downturn, there will be fewer companies of higher asset quality, but the capital constraints will remain.”
“Paradoxically, this will ultimately create an inflationary oil supply shock of historic proportions because so much oil production will be forced to be shut in,” it added.

Potential good news on serological tests?

A friend shared a Citi research report, published today (1 April 2020), with a positive outlook for the speed with which widespread serological (antibody) testing will be available in the US. I can’t share the report itself, but this article summarises the key points. Here are a few takeaways:

From the article:

“Citi’s global health-care, strategy and economics teams say governments and health-care providers will be able to supply 60% of U.S. individuals of working age with antibody tests by the end of April, and 95% by the end of May.”

“Individuals with elevated antibody levels will then be able to return to the workforce with minimal risk of reinfection or transmission, they say. How many? Such tests could enable between 20,000 and 400,000 of sidelined U.S. workers with previous exposure to COVID-19 to cease lockdown and immediately and safely return to work. Soon after, 90 million workers, representing 60% of the U.S. workforce, could return.”

Additional key points from the report (my summary of what Citi says, not my point of view):

This would be a significant positive for equity markets.
There could be 160K and 3.2M undiagnosed cases of COVID-19 in the US.
“Antibody based testing for COVID-19 is inexpensive, rapidly scalable: [A]ntibody based SARS-CoV2 testing requires small volume blood sampling either by a pin prick or phlebotomy. It has zero operator error (such as poor sampling through incompetent nasopharyngeal swabbing required for PCR). The currently available point of care tests indicate after 15 minutes whether a patient has detectable antibodies to SARS-CoV2.”
If so, the healthcare sector could be significantly undervalued at the moment.

Citi envisions four main benefits:

Lower COVID-19 and non-COVID-19 related fatalities by allowing sidelined
healthcare professionals and key personnel to return to work.
Restart the economy.
Shift back to contact tracing using PCR testing.
Longitudinal sampling to determine durability of resistance.

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Yes, it’s much deadlier than the flu

Yes, excess mortality is high

No, the data do not suggest that the majority of people have already been infected.

What do other coronaviruses tell us about immunity?

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How close are we to R=1?

Dancing towards the exit?

The year ahead, according to the NYT

Testing capacity?

A long road ahead?

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Q&A among speakers

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Contagious (and possibly dangerous) memes

The argument for the ubiquity hypothesis