Looking back at New York City and the pandemic

(Catching up on posts started a while ago. This one originally written around 6/13/20.)

Hindsight is 20/20, they say, but Google helps sort out what we knew when. I was having an online argument with someone who said that we knew 'within a few days' that covid-19 affected mostly people over the age of 65. But did we? (No, we didn't. There were plenty of younger patients needing hospitalizations, and we didn't have a good idea of who would live and who would die until about March 20, and even then we didn't if it would be different in locales in the US.)

I also decided to check the run-up to the surge in NYC. I found two great contrasting views. The first is that the Health Department in NYC is excellent and has managed so many medical issues, so they will manage well (March 5). The other view, from an ER doctor (March 2), was that they weren't prepared at all. They didn't have tests that they needed, and they were about to be deluged. Hundreds in a few days, thousands by next week. The ER doc was right on the timing, the numbers, and the deluge.

The deluge came March 19. The number of cases nearly doubled that day. It was only one day after Governor Cuomo announced measure for reducing workforce exposure by allowing only 50% capacity at workplaces. Just two days later he announced all non-essential workplaces must close.

So New York went very quickly from a few cases to hospitals being swamped. With so little testing available, they didn't see the growing numbers but in early March, the ER doctor did, but there wasn't proof by testing. A little over two weeks later, there was the surge of admissions of those too sick to weather the illness at home. That was not so different from in Italy, where they were blase about covid-19 at the end of February, and suffered their surge on March 8.

(I may add more later.)

Image: cityandstateny.com

Corona virus pandemic and the US bungled response

This is the biggest contagion of my lifetime. History is unfolding so it's important to pay attention. I have a lot of links below and I don't want to expend the effort to put them into a narrative. The big narrative is countries that handled the situation well versus those that didn't.

Countries like Singapore, South Korea, and Taiwan have handled the epidemic well, with good public health measures to prevent the wildfire spread. The US had a fairly long warning period, but it didn't have the political leadership to put together a good plan to sharply reduce the effect.

Some countries in Europe are in even rougher shape. Italy has had over 2000 deaths and its hospital system was overwhelmed.Today (3/16/20) it appears Spain is headed that way.

The US might be headed that way too. We were slow to identify carriers, don't have an aggressive testing and followup regime, and we have cases spread widely over the country. Perhaps we started some containment/quarantine efforts early enough to prevent an explosion, but we won't know for a few weeks. On 3/8/20, not many news outlets nor the government were closing down crowded venues to prevent the spread. Just 5 days later, many states had closed schools and banned gathering over 100 people.

The change came about because the situation in Italy exploded starting on 3/8/20. Luckily some people in the US paid attention. However a lot of conservative commenters I saw had reasons or excuses why people shouldn't cut back on their socializing. These included: it's only panic; don't be hysterical; what about the waiters who dependent on tips; this is no worse than the flu; and Obama handled the swine flu (H1N1) much worse. These contrary arguments irk me so much. They are stupid and will hurt or kill people if heeded. And they are based on nothing but partisanship and spiting the other side.

I'm hunkering down, everyone is working from home, we've cancelled our RSVPs to parties, and we're limiting our trips to stores. Luckily I realized the situation with certain supplies, and we have enough toilet paper on hand--bought on 3/8/20 before the hoarding started just one day later.

FINALLY, on Monday 3/16/20, Trump sounds like he gets there is an imminent crisis. The covid task force has a long press conference, and the experts are the people talking the most. Thank God there's an end to the denial. Both the New York Times and New Yorker magazine report that the change is due to a major report out of the UK concerning how high the death toll could be. The New Yorker report is more detailed.

The pandemic will affect so many lives and the entire world economy. Smaller than World War II, but possibly bigger than the 2008 recession or 9-11.

Image: euronews.com

Extras. Trump's misinformation machine. Drezner on Trump's incompetence and predictable consequences. Politico also discusses this with a lot of detail. Some of the failures of the administration. Administration hampered Washington state when they had known cases. Trump makes himself irrelevant. Governors move ahead without him. This might be another reason why Trump changed his tune. The House, Senate and administration can't write a bill. Oh well, they'll get to it eventually. Days later (3/17/20) and still no new bill.

Hong Kong and Singapore handled it much better. South Korea too, which improved after being badly hit by H1N1. The UK had a plan that they dropped. Act now before it's too late.

What China did to slow it down. Readable with plenty of data.

Fast worldwide overview. Hospitals in the west likely to be overwhelmed. Another overview. The dashboard I'm using. It's got daily new cases and new deaths which is info I really want.

Doctors in Italy give accounts. Focus on Italy and why it happened there. Summary of the situation in Italy. By March 7, there were approximately 550 people in ICU beds. The projection for March 20 to April 3 ranged from 900 to 14000. Yikes. More from Italy. More.

Scroll down to see graphic on which ages are dying.

Biogen company meeting that spread the virus. Ohio, with a Republican governor, gets honest and makes a painful guess about its situation. A brief overview of their plans.

Trump Jr. knowingly lies about Dems, again. What a weasel.

Update 3/18/20. A bunch of info from an ICU doctor in Seattle. The course of the disease and some of its quirks. What Fox News said then versus now. Fucking hypocrites. Trump's nonchalance. Trump finally starts to get it... after ignoring experts and the evidence but getting an intervention from Tucker Carlson. Oy vey. We're dependent on Fox News anchors doing the right thing. That's not good. Upon further research, I'm not sure Carlson had that big an effect. His meeting with Trump was 3/7/20. The tone started changing 3/13, with the biggest change coming on 3/16. So perhaps it was the projections from Britain.

A small Italian town stops it by doing 100% testing and lockdown. Not applicable to most of the US. For posterity, a typical daily news update. Will this Lancet report be born out? We shall see.

Update 3/23/20. Straight talk and no whitewash from NIH director. Warning signs that were missed, including those from a pandemic exercise. Trump isn't following through on defense authorization to direct industry to make needed equipment; governors are scrounging as best they can. Florida waited too long to shut down social venues. Trump touted a particular drug as a treatment, incorrectly. Turns out it's rather dangerous, not safe as he claimed. Bad details lead to bad outcomes. Trump and Fox News are already tiring of the lockdown and don't understand why it's important. Short attention span isn't good.

My predictions. There should already be a surge in hospital admissions but information is being held  tightly. On or around 3/26/20, we should have a surge in deaths, which will be reported. By 3/30/20, we should be seeing over 400 deaths per day in the US. This level of deaths will probably last at least 8 weeks. Since the level of deaths will be high, the lockdown won't be cancelled after the initial 15-day period.

Update 3/25/20. Two stories from ProPublica: how covid-19 is different from the usual winter pneumonia by an overworked respiratory therapist in New Orleans. Doctors are writing prescriptions and hoarding chloroquine, the medicine that may fight the virus. A slice of life with the pandemic--a nursing home in New Jersey with 94 patients evacuated. New Jersey is beginning a steep rise in deaths. NIH technical description of covid-19.

Update 4/6/20. I stumbled on an explanation for the run on toilet paper. It started on 2/26 in Hawaii with a message to stock up because of the spread of the virus. This might make sense if Hawaii doesn't have paper mills, and it seems (per a Google search) that maybe they don't. From Hawaii the panic buying migrated to Japan and Australia, then Europe and the US.

The state intervenes... too much

The Alfie Evans scandal didn't get a lot of news site attention from the MSM, but it did in the conservative media. A bit of background if you don't know the story (which means that you follow the MSM and thus miss some news stories):

Alfie was born in Britain about 23 months ago. About 6 months after his birth, his health was declining and he was found to have some unknown wasting disease that was shrinking his brain. He's been on life-support since December 2016. The doctors decided treatment was futile, and removed life support. A hospital in Italy offered to take him, which the parents wanted, but this was blocked by the British courts, who also posted guards to prevent his parents from removing him from the hospital. He died at the hospital on 4/28/18 approximately 5 days after being removed from a ventilator.

Superficial review and reaction

Initially I viewed this case of one of people blindly holding on to hope, screaming for everything possible to be done, and ignoring the evidence that it was hopeless. I think most of the news stories played out this way, along with most of the comments. So my initial reaction was to back up the scientific findings and stress the reality of the situation. Alfie was not going to recover. He was not conscious at all, and would never become conscious. He had no prospect in life except being connected to life support and having seizures as they gave him therapy in trying to keep him alive. That was the hard truth that so many people seemed unable to accept.

I agreed that hospital was right to declare treatment futile. I disagreed with the British court preventing the parents from taking Alfie to Italy. There seemed (to me) little chance of significant harm to Alfie. But the judge was overly concerned that he'd die in transit, and that seemed appalling to the judge. I disagree, but at least I understood the rationale, and I didn't think the judge was a monster. Many others did.

The public outrage at the hospital and the British courts was huge, which I didn't understand. Now I do.

When should courts overrule parents?

If you look at the story through the lens of what was good for Alfie and what was medically possible, the parents seem out of touch, and the hospital and courts seem sane, realistic, and reasonably kind.

However, if you look at the story through the eyes of Alfie's parents, it appears very different. They want to do whatever they can for their son. The hospital says they can't do anymore. The parents are distraught, seek other opinions, but are legally and physically blocked from taking their son to another location for treatment.

This is the outrage. They love their son, want to care for him, have never been abusive to him, but their rights as parents were shut down in favor of the court's opinion. I felt this was wrong, but at first I didn't feel the outrage of it.

The mistake of the court was to take away the rights of the parents to decide the child's treatment. Almost all parents will consider carefully, help, nurture, notice how the child responds, comfort, and minimize suffering. Most parents can do this better than a judge can because they are intimately connected to the child.

Not all parents are like this, however. Some are abusive or negligent. For those parents, it makes sense for the courts to intervene. However, Alfie's parents were neither abusive nor negligent. They cared more than anyone else. But at the end, these parents, who dearly loved him, were barred by police from caring for their son in the way they desperately hoped to.

That was the wrong. Not against Alfie, but against his parents. And it was a fairly grievous wrong, to take the decision away from them in such desperate circumstances.

Media focus

Media tended to focus on how it wasn't certain what caused Alfie's decline, and how his last hope relied on getting care elsewhere. Some attacked the British National Health Service (NHS) for its policy to withdraw life support. Some didn't attack the NHS, but faulted the courts for siding with the NHS against the parents and the child's 'last hope.' It became a cause within Britain, but perhaps even more among American conservatives. Their spin, motivated by animus against socialized medicine such as the NHS, regularly contained lies and didn't accurately report the reality of Alfie's condition. The media regularly used words like 'murder' and conservative commenters copied that. Very few gave consideration to the personal, ethical, moral, and financial issues in giving life support for extended periods.

The American Conservative is typically a more thoughtful source of the conservative perspective. But even here, Dreher puts his thumb on the scale. When the NHS wants to end artificial life support, it's described as "forcibly euthanizing the disabled." But should his parents make the decision, it's letting "Alfie die a natural death." Interesting difference in wording considering the actions are the same.

The American Spectator is probably more typical in its invective. The doctors are incompetent and the state is tyrannical. This isn't measured analysis, it's war against tyranny. It's no wonder so many echo these arguments when they're not presented with any counterarguments. Just one side of the story. If you're not practiced in questioning, it's not going to happen.

Luckily, the comments section for the Dreher argument had other thoughtful alternatives. Another columnist for the American Conservative focused more on the parents, and was also fair to the doctors. In the comments section for the American Spectator, anyone dissenting was blasted. Well, that's just another week in the culture war. I wonder what this week will bring?

Alfie on a ventilator, with his dad

Image: dailyrecord.co.uk

Don't worry about Ebola in Atlanta

Two American missionaries who were treating the Ebola outbreak in Africa have contracted the disease. One has already been transported back to the US, and the plan is to transport the other also. They will be treated in a special isolation unit at Emory University Hospital in Atlanta.

How dangerous is it to bring these patients into the US? That's a good question. However, there are some very bad answers to this good question, like these:

"Martial law is what we risk if an epidemic of something like Ebola were to break out here. Far better to prevent its entry to begin with. Not understanding that is moronic."

"This should not and cannot be allowed; that plane should be shot out of the sky; that hospital, burned to the ground; the unelected bureaucrats and plutocrats behind this decision publicly executed as traitors and tyrants; along with and including our President, who could have stopped this and did not due to this personal hatred of the citizens and dedication to the destruction of the United States." --comments here

So, doom predictions from the peanut gallery aside, how worried should we be? Let's think about it.

Ebola hasn't spread worldwide, unlike various forms of flu. Why? Because it doesn't spread as easily as flu. The disease is spreading on the ground in West Africa, but it hasn't gotten into a major city, even with the traveling that people tend to do. Supposedly, people can't pass it on until they're showing symptoms, so you can't pick it up easily or randomly. It doesn't spread via the air. That's very good, and is probably why it hasn't spread throughout the world.

The usual method of infection is from handling the fluids from a person with symptoms, so the visitors and caregivers are the ones who are being infected. Again, it's not random people down the street.

With this limited mode of infection, it won't be hard for a well-prepared hospital to contain the contagion. They will limit the people who have contact. The air from the isolation unit won't be circulated elsewhere. Caregivers will be gowned appropriately and will disinfect appropriately. The staff will be monitored closely, and any sign of illness will be scrutinized, not ignored. Finally, two patients will not overwhelm the resources of the hospital or the special isolation unit.

Am I worried? No. These people are experts in dealing with communicable diseases. This is their expertise, and they practice it a lot. It's the first time they've had an Ebola patient, but hardly the first time they used these procedures. So if you're worried, calm the heck down.

The Ebola patient arrives. No zombies. No martial law.

Image: cnn.com

Extra. Idiot-in-Chief Donald Trump weighed in on the idiot side, of course.

Medical miracle in Maryland

On a radio show this week, I learned that Maryland is the only state with cost controls on hospital charges. The speaker told about how New York once had controls... until a GOP governor put an end to that. Of course I was curious about how cost controls have worked for Maryland, so, as always, I did some research.

Maryland is quite proud of its system. They have their white paper bragging about the results, particularly the lower rate of increase in hospital costs. Their medical system has been more stable too, but perhaps the biggest feature is that there's no cost shifting. That sounds great to me because of the resentment that cost shifting causes. If you're unlucky to work for a small company with a weakling insurance plan, you pay more in the hospital. The government makes this a necessity by being miserly in its Medicare and Medicaid reimbursements--those whales of cost shifting.

In Maryland, all payers pay the same rate, even Medicare and Medicaid. So in one way, the entire nation supports Maryland by paying more there. However, this deal was negotiated decades ago when Maryland's hospital costs were 23% more than the national average. The deal remains in effect because Maryland has done well in lowering its costs and keeping them below average. So it hasn't been a bad deal for the taxpayers either.

Because all payers pay the same rate, the rates are known at hospitals. No insurer wangles a sweet deal at the expense of others. Some hospitals get higher reimbursements, but only due to higher local cost-of-living. That's a consistency I'd love to see. Just imagine, a hospital could easily post its rates in a list, not a complex table accounting for many different classes of insurers or patients.

All this good news was seconded by a (probably) independent review, but what is the bad news? Maryland still has higher than average medical spending than its neighbors. Some costs are displaced from hospitals to outpatient facilities. But I've never heard that Maryland is a hell-hole for medicine, so this cost control approach hasn't ruined life in Maryland.

The Bad News

For a more brutal critique, I had to read a report from the Heritage Foundation. First is a spiel on why cost controls never work. Then the terrible examples from Japan and the Netherlands. Finally, they detail the considerably fewer complaints against Maryland. Cost controls are said to stifle competition and create shortages, yet Johns Hopkins in Maryland has managed to set up surgical centers that allow "the hospitals to circumvent many of the shortages associated with price controls." I read that as saying, well, they don't have the shortages you were warned about. The biggest complaints in the Heritage report are the higher total costs than neighboring states, the waiver from Medicare and Medicaid, and a loss of "care coordination." Weak sauce.

A better critique comes from this healthcare blog. I learn the Maryland has managed to strike a good balance between hospital and taxpayers. Not so with Massachusetts (my state), where "hospitals are so powerful that they ... capture the regulators." The author also tells the history of how other states (all but Maryland) abandoned their cost controls under the illusion of competition between HMOs. Remember how they were supposed to keep medical inflation in check? What went wrong there?

I have to agree--state cost controls sound like a good idea to me. No other method has worked to reduce the inflation in medical spending over the long term. And Maryland provides an example of how to avoid the disadvantages of cost controls. I tend to like market processes, but they haven't worked in healthcare. They may never work in healthcare because it's not your normal market. Let's finally admit that.

Image: northwestern.edu

Success against nasty infections

I work in healthcare, so this topic is on my mind all the time. People go into hospitals where they are exposed to and infected by some very nasty bugs. These bugs, as biological things, evolve. However, they also do it very quickly because they have rapid reproduction rates. So they've been evolving to survive our arsenal of antibiotics, and they can be very hard to kill.

These infections, sometimes called superbugs, aren't new. I'm pretty sure that my mother-in-law died from one in 1998 (but I was a layman then). However, there has been a lot of attention to these superbugs in the past decade. That's part of the reason we have anti-bacterial wipes at the entrances to our supermarkets and anti-bacterial gel dispensers in hospitals.

I have a particular sensitivity on this issue, because healthcare personnel have been blamed for the spread of the superbugs. Supposedly we don't wash our hands often enough or well enough. Being among those personnel, I know that I don't wash as much as expected because I don't have time when I'm caring for over a dozen patients an hour. Telling me to "make time" assumes I can manufacture extra minutes, which I assure you I CANNOT.

So I'm intrigued by this news story of an approach that has reduced hospital based infections by over 60%. But get ready--it's not easy and it doesn't involve hand washing. To do this, the pilot project used:

• Robots that spray hydrogen peroxide.
• The hydrogen peroxide disinfects the surfaces of the hospital room.
• It takes 30 minutes of spraying, not counting the setup time.
• The ventilation system has to be closed off and door to the room taped shut because...
• Humans can't breathe or open their eyes in the room during the disinfection process.

This is what it takes to make a large dent against these superbugs. I'm relieved to find out that loading another requirement on overworked staff wasn't the solution. But just try telling that to the administrators who don't work on the units and don't directly care for those 12-20 patients an hour. One thing this study tells me is that the infection problem wasn't due to staff, but was due to the surfaces in the hospital. It takes a whole lot of effort to get those surfaces safe.

One of the most well-known articles on the subject, published in the Atlantic, tells the story of how a TV executive's father died from several of these infections. (Here's a shorter youtube version if you don't have time for a multi-page article.)

The author describes a lot problems, not many solutions, and puts faith in the idea that health care needs to be overhauled to become responsive to patient needs. How exactly do we do that? Clearly, I'm not a fan of this author's sincere but ultimately incoherent ideas. As a country, we obviously have to overhaul our health systems. This robot story shows just one small aspect of the changes we need, and also shows how complex the situation is. Don't kid yourself that it's not.

Hail our robot saviors

Image: wbur.org