The "Epidemiologic Triangle" and Coronavirus

The epidemiologic triangle is a teaching device to help students think about the elements of infectious disease. The triangle on the left below, is the basic requirement for an epidemic. The one on the right is an example of how changing one part of the triangle can change the course of a potential epidemic and make it less likely, or at least less harmful to the populace.

This image is from Popular Mechanics, a science magazine online, and in it they discuss how the use of masks, physical distancing, isolation, disinfection--all things we've been asked to do--can create a less hospitable environment for the novel coronavirus, and thus "flatten the curve." That is, reduce the number of infections enough so that things don't climb off the charts and overwhelm our medical services.

Our new friend. Artwork: Billboard.com

This is Epidemiology 101. How strong is the germ? What's it do, and whom does it do it to? What sort of environment can it do that in? This model can be abstractly applied to various other health issues, such as tobacco smoking, obesity, and so forth, but here I'm going to limit its use to our new friend The Novel Coronavirus. 

In an article on Fivethirtyeight.com, Maggie Koerth discusses how "Every Decision Is A Risk. Every Risk Is A Decision." As we now emerge from our homes, we're trying to the calculate risk of everyday activities. Koerth details how much is controversial in risk estimation, and how we're learning from the science that is still evolving. But there are things we can estimate generally. I include the link for my readers to check out, because she also writes well about how individuals engage in such calculations.

For example, being at a gathering, outdoors, with maybe eight people you know well, and it's a sunny day...even if no one's wearing a mask, the risk is probably much lower than, say, going to a bar where you're shoulder to shoulder with any number of friends and strangers. 

That's pretty straightforward, and it's intuitive. For some people, though, both prospects are equally "terrifying." What should be an easily guessed risk-difference actually has no difference to some people. Everything is equally (and possibly, maximally) risky. This is important, because as a society our own personal psychology becomes averaged into a kind of public mood. Individual estimates--whether scientifically valid or not--all go into our collective social estimation of risk, and that in turn further adjusts how we end up behaving socially. Each of us feeds that mood, and in turn the mood feeds back onto our behavior, which in turn feeds that mood and so on.

But it's not a cycle, more like a spiral. The process keeps changing with millions of individual adjustments that then alter the next moment in the cycle. This leads me to what was for me the most validating thing about Koerth's article: we're adapting. There may be a terrific vaccine around the corner. We may achieve herd immunity one day--either of these changing the host from "susceptible" to "non-susceptible." Or we may never find a decent, safe vaccine (I, for one, will not be lining up for the "first batch" of whatever soup that is--I've been personally involved in too many drug research studies!), and herd immunity may be years away.

Doesn't matter. I already see signs that people are, individually, beginning to adjust their personal risk calculus in terms that favor other things. How long can I go without visiting my elder parents? How long can my kid miss school? How long can I spin my wheels while my business withers? How long can I put off elective surgery? College? Other plans?

Eventually most of us will begin to reframe risk in broader terms that balance out other needs in our lives. This was true in the Flu Pandemic of 1918-19, and nothing about people has changed so much that this will not be the case today. It will be.

What Else Does the Triangle Tell Us?

Let me pivot to something that may give us a glimpse into this near-future: Host susceptibility. 

When I was working with HIV patients earlier in my career, it certainly looked as if that virus was really deadly. The ravages of AIDS make COVID-19 look like a wimp. Yeah, COVID kills some, but AIDS killed everybody.

Or so we thought. 

Turns out that once we had some drugs available, and we had some time to collect ourselves after losing so many bright lights (sons, daughters, Freddie Mercury, Robert Mapplethorpe, Arthur Ashe, Elizabeth Glaser...) to HIV, and after we had better technology to just understand a germ that was so much more novel than today's coronavirus, we learned that HIV was also subject to the Rule of the Triangle. HIV was not universally virulent and hosts were not universally susceptible.

It turns out that a small-ish fraction of people have genetic mutations in their immune systems that are mostly benign. These mutations may make them a little more prone to get pneumonia or the flu, but they make it really hard for HIV to get into people's immune cells. People who have both mutations (CCR5 and CXCR4) basically can't get HIV. This feature has even been turned to advantage in HIV drugs like Fuzeon. 

I began to wonder about this a few months ago. Basically the thinking has been that all humans are susceptible to COVID. This has led to the belief among many that "If I get exposed to even one viral particle I might die." This is wrong for two reasons.

First, there's dose. We don't actually know what the "dose" of virus is that can lead to a full-blown infection. This is related partly to another aspect of our triangle: virulence. Because humans (and other creatures) are equipped with protective barriers (skin, mucus, little white blood cells that live in tissues), it usually takes more than one little tiny viral particle to get infected. This is being studied, but it's early yet, so we don't have a good sense of how much or how little virus it takes to bring on disease. There are articles out there on this, but the fact is, we just really don't know yet, because there are too many factors to to make study of this easy, and because the studies themselves are very technically difficult.

Second, there's susceptibility. This is a bit easier to guess at, and with time it will become easier to know, because the same approaches we used to study HIV can give us insights into who is more, or less, susceptible to COVID.

We come into the world with trillions of T-helper cells. These cells are by dint of evolution programmed with detectors for thousands of potential infections that live on Earth. When we're exposed to one of these diseases, a subset of T-cells programmed with that pattern begins to genetically transform themselves into even better detectors for that infection that then go after the infection with a vengeance. This is why it takes 7-10 days to get over a cold: it took your T-cells that long to read the new cold virus (they change often), make genetic adjustments, and then to bring in the rest of the players that come rushing in to rid the body of the infection. 

Could it be that some of us are just better genetically equipped than others to resist cornonavirus? I found an article recently that suggested that this is the case. I include a link here because readers might find it as interesting as I did. It basically reminded me that Nature works in mysterious ways...but it still adheres to rules. In this not-yet-peer reviewed article from a research team in Sweden, we learn that maybe antibodies--whether from prior infection or a vaccine we have yet to invent--may be less important than something we're already carrying around inside us, the valiant T-cell! 

Maybe some will find this reassuring. I do. In the flurry of "information" flooding our TVs, radios, Facebook feeds, and phones, I find it comforting to know that Nature still follows rules, and if we pay attention to those rules, perhaps we'll be able to better understand and apply our own personal risk calculations with less anxiety.

As always,

Be well!

Here it comes...COVID and Schools

Photo: Aha!parenting.com

Well I spent my first day back in the hospital last week, and actually felt pretty safe. Kudos to the Hershey Medical Center for their engineering and environmental controls on COVID spread! And I feel fine--so far, so good. And the students were delighted to be back, even if they were a bit anxious about their skills and knowledge being "rusty." They performed wonderfully.

So there's been some other school stuff in the news this week, as the country's K-12 schools struggle with decisions on when, how, and if they'll re-open. The White House says all schools must reopen fully for in-person instruction in the fall. In interviews on NPR and elsewhere, I haven't heard a single K-12 teacher or union representative say anything other than they don't feel safe to go back to in-person teaching. Some school administrators seem to be putting a hopeful and optimistic face on things, but they admit that there are challenges that include inadequate classroom space for social distancing, the difficulty of policing mask use indoors among very young children, and the costs and time needed to continually disinfect surfaces and equipment.

It would seem that the most common-sense thing to do is simply continue instruction at a distance, using online learning. Why go back at all?

There's the rub.

I myself teach, and I can tell you: online teaching? It depends. I've seen good results from well-designed, sort of "self-study" systems that students do in a guided way on their own, so-called "asynchronus" (at any time) learning. The student isn't "in" a classroom--virtual or otherwise, and studies in a guided way, often interacting in "discussion boards". This is the basis of outfits like University of Phoenix, or Penn State's own World Campus. I feel that this is a good approach for upper division college and graduate students.

"Residence instruction" is the college term for sitting in a classroom or lab. A report by the Department of Education over a decade ago, however, found that neither residence instruction or online learning was as effective as a combination of the two. You take the strengths of one and the strengths of the other and create a "hybrid" experience. I taught this way a lot up until about 2018.

What I experienced in the spring of 2020 wasn't very good at all. It was like the worst of both worlds, at least if the looks on students' faces, the lack of active discussion or questions from students, and the general feedback suggests.

There were some things we designed for our nursing students that were better online. Things like professionally-designed patient care simulations that keep score--the students liked that. They reported that some "virtual clinical" experiences were actually better than some of the observational experiences they'd engaged in prior to the shutdown. Instead of being passive observers of nurses at work, they became active participants in learning that was designed to hit certain key objectives.

There were some things that were worse. Isolated from each other most of the time, that isolation seemed to carry through to the Zoom-classroom experience. Instead of excited chit-chat before and after class, or sudden shares of their own experiences in class, they were mostly silent.

And nursing students not in a hospital seeing real patients? Not only is it counterintuitive (would you want to be cared for by a new nurse who has only ever seen "patients" as robot avatars on a screen? I wouldn't), the students know they haven't been getting the experience they will need in their careers. The feedback I got this week was overwhelmingly gratitude from the students who now have an opportunity to get back into the hospital and see real patients.

I can only guess how this went for K-12 education. From what I've heard, students learned little. And the isolation in those age groups reportedly causes learning delays and mental health problems.

We are a social species, after all.

But one can argue "Well, we had to cobble that together in literally two weeks. We were doing the best we could. We can do better in the fall after we have had time to prepare over the summer." I'm sure that's somewhat true. I know I am planning improvements. (Even though I will be on campus this fall, due to room size and social distancing requirements, every class will have at least some students sitting in front of their screens.)

Sure. It'll be great. Or will it?

The American Academy of Pediatrics has warned that schooling online in isolated settings is likely to cause real harm to the learning and development of the current generation. Less-discussed is their warning that adequate safety procedures and controls need to be in place to assure a safe return to in-class learning.

Charter schools have been doing learn-at-home for maybe 20 years. Many kids get home-schooled by parents and people in their circle of family and friends. The sky hasn't fallen. Although I should mention that most of these cyberschools have extensive experience and have taken the time to address issues of social development and internet access. For example, kids in cyberschools can still participate in local school sports programs. Home schoolers often join co-ops that help facilitate field trips, social activities, and group schooling among home-schooled kids in the same locality.

Will that be possible in just another 5 or 6 weeks as some districts open up?

Parents are split. Having had the spring 2020 experience, many find that there's a reason we have schools and teachers. It works better! Moreover, many parents face choosing between work and looking after their kids who can't go into school. Some families have vulnerable persons in the home, and with their kids in schools with lots of other kids, it's feared that COVID will get passed around to these people.

Teachers seem mostly anxious, anxious that they'll get sick, anxious that the kids will get sick, anxious that the spring 2020 approach isn't working well. But I haven't heard very much about how they plan to improve upon the home teaching experience--in short there's very little enthusiasm for any outcome. They often cite a lack of material support from school districts, and that requires money, and that requires taxes, and tax revenues are way down because of COVID.

And don't even get me started about lack of internet access. I've seen students using their phones as learning platforms. I've heard of people parking all day by McDonald's because their home internet is too slow for Zoom or other class activities (video, learning games, homework completion). Cyber schools make sure their students can access the needed technology, and it may be included in the tuition. But that's not factored into regular districts' budgets--despite scenes this past spring of some districts handing out iPads and Chromebooks to families waiting in line in their cars. A loaner laptop is great--but what if you have dial-up internet?

I don't have answers to these problems. I'm writing this because children's school experience is deeply and profoundly formative, and so I see serious learning and developmental problems ahead if we don't start having less polarized, more productive discussions about this problem. Most of what I hear on the radio or read online in articles or see on TV are really dysfunctional discussions that seem to "spin" concerns toward one outcome or the other.

It's impossible to have it one way. It will not be possible to guarantee that coronavirus will not be spread, no matter what schools do. The novel coronavirus is going to be with us for some time. People are going to die regardless. A vaccine is not "right around the corner," even if many scientists are working on it, and even if some reports suggest a vaccine is possible. Our society was not prepared for this, and no matter how ardently people argue for masks or how much hand sanitizer we use, this isn't over. We cannot keep our kids at home forever--it'll stunt their growth and development.

We can't have business as usual. We can't remain isolated indefinitely.

So we better start having better discussions about how we can all come through this healthier.

Life in the COVID Lane

The moment has come. This is the time when we emerge from our lockdowns, blinking our eyes in the sunlight as we adjust to three months hiding out in our houses (well, I wasn't "hiding out" but many have been). 

Image: Nurse.org

Now in some places, coronavirus cases are down, and in others, cases are up, and there's the sense that we're far from the "other side" of the COVID-19 pandemic. Businesses are reopening, others are having to re-close. Students who spent the latter half of spring term zoning out in front of Zoom classes are soon to return. My own students, who had to settle for seeing virtual patients--basically speech generating avatars--on screen, are keen to get back to seeing real patients with real problems. 

And believe it or not, hospitals are keen to have them back! After all, our students represent their future success. I predict a lot of doctors and nurses are going to retire early, having put in their time in the trenches against the virus since February. I'm already starting to see this, and I wish them well. Having myself spent a bit of time in facilities seeing patients in PPE in this pandemic, I can understand that some folks have put in a lot of hard work and deserve a long rest.

On Facebook and elsewhere I see vituperative, sometimes nasty exchanges about the tension between coming out of our caves to carry on, and staying locked in until all danger has passed. I guess I shouldn't be surprised by the split, but I am a bit disappointed by how strongly (and often meanly) people on either side of this split are with each other. I kind of had to stop following Facebook. 

Here are some of the issues working against staying locked in, and "safe."

• Young students are displaying abnormal adjustment behaviors and early mental health problems related to isolation from peers. They are falling behind in their learning in ways that may be difficult to remedy. 

• Older persons, especially in nursing homes, are showing signs that the isolation is wearing them down. Their mental and physical health is deteriorating. I've seen this up close in my practice. 

• I've seen people putting off getting health problems checked out, sometimes with tragic results, because they're afraid to go to hospitals and some doctors' offices are not yet open or only doing telehealth.

• My nursing students--and health care students elsewhere--want to see patients, learn their craft, and are often being told they cannot by colleges whose faculty fear getting sick, while the hospitals are desperate for new workers to replace those they'll lose. 

• More and more people are becoming hungry and homeless due to prolonged shutdowns. The economic harm from our neglect to plan for such a pandemic will probably last for years.

• I see more and more people unwilling or unable to move themselves from a position of safe isolation to more engagement as they become swallowed up by their anxiety. What will happen to them, safe, but alone and isolated?

I don't have easy answers to these problems. On the one hand, we don't want people getting sick and maybe dying. On the other hand, how far can America decline without some things moving forward? We're kind of stuck.

I've talked to people who say they aren't coming out until there's a vaccine. But there's no certainty we'll ever have an effective vaccine, but if we get one, it's going to be a while. A year is optimistic, because even if one or more vaccines are developed, it will still take time to get it out to people. So here too, they're kind of stuck.

Contact tracing and selective quarantine of infected persons can help, but we have no national strategy for effecting such a plan. States and localities are basically on their own. Some of their plans are working, others, not so much. States open up, others shut down again. Stuck.

So maybe life in the COVID lane right now is just that: "stuck." Can't go forward. Can't go back. 

I have been asked to come back this summer to teach clinical students in the hospital, because we have too many faculty who aren't willing to get back in there, because we all know there's COVID in there. I know it could walk into my office too, but I have kept seeing patients because sometimes "telehealth" just doesn't get the job done. You can't listen to someone's lungs on Zoom. You can't stitch up a wound on Skype. In that vein, I will be going into the classroom this fall as well. I can't teach someone else how to listen to someone's lung on Zoom either. 

Maybe I'm being foolish. Maybe I should stay home.

But I look at it this way: If my work isn't important enough to risk my health and life for, then what is? Why am I even doing this?

Some people may lead lives that will never require such a thing of them, and that is comforting. That is not my life, and so I go into the breech.

Wish me luck!

Thinking "broadly and deeply..." about COVID-19

That's a quote from my colleague, Dr. Ann Swartz, this morning in a series of group messages we share among our nursing faculty. It was a reference to an article she found, Dr. Peter Piot's interview in Science Magazine online. Piot, a virologist who studied AIDS and Ebola, says in the piece, "Finally, a virus got me." Piot suffered from COVID-19 in a hospital in Britain, and while he is better and recovering at home, he is not completely well. He, like many, was walking around with a low grade pneumonia, and low oxygen levels, until it became too much to bear, and he presented for treatment. You can read his description of the experience in the link above.

Also, this past week I posted on my Facebook page a brief piece on a newly emergent pediatric manifestation, "hyperinflammatory shock" is what the authors of this article in The Lancet call it. It seems some kids, eight patients in this report--most of them otherwise healthy, get a generalized inflammation that can appear like Kawasaki disease or toxic shock syndrome. The New York Times reported on cases in New York, where, at the time of their article, it had caused the deaths of three kids. It's serious. These kiddos need to be in ICU. It seems to be an immune hyper-reaction, maybe related to the "cytokine storm" we've seen in adults with COVID-19 pneumonia, just with a different presentation and timing.

With these developments, is it any wonder that many people want to maintain strict limitations on travel and activity?

So California State University announced closure of campuses in the fall--and we're months from that yet. Dr. Anthony Fauci, in Senate testimony warned that the Winter of 2020-21 could be "the darkest winter in modern history."

So it must seem incredibly rash to want to open our society again! Until one starts "thinking more broadly and deeply."

Julia Marcus, a professor of population medicine at Harvard, writes in The Atlantic that "Quarantine Fatigue Is Real" and argues for "harm reducation"--a long-known theory in addictions medicine that admits that 100% adherence to abstaining from drugs or alcohol or sex is not achievable, because we are human beings, not perfectly disciplined robots. During the pandemic, the message we get is that we must adhere 100% to staying at home, not touching anyone, and so on. A lot of us have been able to sustain that, for a time. But Marcus argues that most of us cannot sustain this behavior forever, and not even for many months on end.

Marcus observes that "pandemic shaming" has become a thing, with people shaming others online --often without full context--for appearing to behave in ways that some of us think are shameworthy. I concur. I've been seeing this online as well. Why aren't those people staying safe? What's wrong with them? This has morphed into Why aren't they protecting me?

Individuals are forming opinions about what they consider "good [pandemic] behavior" and bad. Many say they base their opinions on "science"--but that neglects the fact that even the scientists have a point of view, and unrestrained by the strict rules of scientific writing, those biases can inform their public pronouncements. When Fauci warns of "the darkest winter" the image is evocative, scary, and can influence people to do what he wants: limit disease spread, limit deaths, limit stress on hospitals, and therefore achieve one kind of "good." One can't say that limiting these bad things isn't good.

But are there other "goods" that we want, and other "bads" that we wish to avoid? Perhaps. Dr. Dimitiri Christakis, director of the Center for Child Health, Behavior and Development at Seattle Children's Hospital and the editor-in-chief of JAMA Pediatrics, argues that we need to start thinking about the mental health of children, and balance that with our efforts to mitigate coronavirus, in this article at NPR. Christakis argues that social development, mental health, risk for child abuse, and risk for hunger are all increasing as the lockdowns continue and the economy crashes.

The author of the NPR piece shares examples of children who are depressed, angry, irritable, and who are starting to say things like "I don't care if I die." If I was that parent, that would certainly freak me out.

As I said, I've been seeing this tug-of-war between people who argue that we must continue strict distancing, lockdowns, and school and business closures; and people who argue that all of this is an "overreaction" or that the virus "isn't that bad" or that the "cure is worse than the disease." This is entirely expected, as people en masse tend to dichotomize issues between extreme choices, but I am thinking that these extremes are a false choice. There are others.

I'm doing ok. As a professor, I still have a well-paying job. It's not that difficult for me and my wife, a musician, to stay at home on our lovely property and wait this out. In scanning my feed on social media, I have begun to note that many of the people who argue for continued strict isolation also have the good fortune of working in the knowledge economy where they can work from home. They're still employed...or retired and thus not in danger of losing their lifestyle.

I also notice that many of the people arguing for opening up faster are people who are furloughed or laid off entirely, their jobs never-to-return. Or they're students who face declining educational and social experiences, and future financial uncertainty as the lockdowns start to push into the fall (like this student suing my employer over the spring closure--I'm not sure I disagree with him).

As I thought about what I have been seeing, I began to see that strict lockdown may be a luxury for some, a curse for others, and the inflection point of that divide seems to me related to the balance between competing goods that are individually determined and individually focused. Put another way, rather than asking "what is good for all of us? (even if that comes with risks)" we seem to be asking "what is good for me and the people in my circle?"

I think this pandemic has become an unintended emblem for our times: us against them. The "us" and the "them" simply depends on one's point of view, but in the aggregate these tiny points of view coalesce into shapeless extremes.

Between March and May, the Earth caught fire--"corona" a crown of fire around the Sun--a very apt metaphor for how swiftly and terribly the virus has overtaken us. We have to control the fire, and little fires are probably going to burn on for many months or even years. But we can't let the fire completely overtake our common sense of humanity, and the many needs that humanity requires. We have to change the conversation from "this versus that" to how can we build toward the better things for all of us--even if they aren't individually the "best" things for each of us.

Updates, and "New Normals"

Here's an update of the graph shown on April 10th, with an end date of April 26th:

Graph: Author

The growth of new "test-positive" cases of coronavirus infections has continued its trend downward to reamain consistently less than 5%. In the next graph, check out the purple line, which represents the number of new cases day by day.

Graph: Author

Note that it has been flattening out since about April 2nd. The anticipated "peak" for Pennsylvania was at that time April 15th. On that date I checked and the peak was moved to the 18th. Whatever the case, the trendline from April 10th to date is flat to slightly negative, and that means we're coming out the other side. Of course, these changes are sensitive to how much we're testing, which has gone up and down daily, but averaged about 5,200 new tests reported per day.

New Normals?
In a press conference, Dr. Deborah Birx announced that social distancing would continue through the summer. A journalist on NPR speculated that things like telehealth would become the norm, even beyond the epidemic. These bits, and more this morning just teed me off and I switched of the radio!

There were protests in a number of state capitals last week, including in Harrisburg. A minority of people want some of the restrictions to end, and for more businesses to be allowed to open as long as precautions to limit disease spread are put in place in their workplaces. Georgia has started to allow a number of social-contact businesses (eg, barbershops) to open. Most Americans, according to polls, say it's too soon to do so, and many in those opening areas plan to keep their distance from others anyway. No one ever promised that social distancing and lockdowns would stop the virus; the intent was to "flatten the curve" so as to avoid overwhelming hospitals with very sick patients.

Sweden is an experiment that studies a different approach. The BBC reports that the Swedish government has not locked the country down, rather allowed people to continue to mix, with recommendations for keeping distance, and Swedes have mostly gone along with this. The policy is broadly popular, as is the government's epidemiologist, Dr. Anders Tegnell. Sweden is in the top 20 for deaths, and most of those are very old folks in nursing homes, but the death rate is a concern to the government. It has been suggested that Sweden is seeking to improve herd immunity through this policy.

So how is this going? Here are the deaths in four countries in Europe, compared to Sweden:

Graphic: BBC

What's interesting to me is that all of these graphs appear similar, that Norway and Denmark have fewer weekly average deaths, but Britain has more--and Prime Minister Boris Johnson took a lot of heat for this, and coincidentally got COVID-19 himself!

Herd immunity is something we've all heard a lot about, and a number of folks I know have publicly mused about it. What can we expect? We don't know yet, but if the virus--SARS-CoV-2 is similar enough to its brother, SARS-CoV-1 in 2002, then immunity after exposure probably lasts about 1-3 years. So maybe it'll be more like the flu than chicken pox, which confers life long immunity. A vaccine is likely to come into the equation in the next 12-24 months.

So what's the deal with Sweden, and why are so many countries so different from them? I suggest that both the protests here in Harrisburg and elsewhere, and many people's expressed desire to continue some social distancing despite an imminent opening up of society, are two touch points for understanding what is going on.

Swedish scientists knew there was no stopping the virus, and they also knew that no matter what was done, people would die, although most of those deaths would be among people who were quite frail, and who would die of something soon in any case (flu, a bad cold, bacterial pneumonia, urinary tract infection, etc.). It's a risk-based management strategy, and to some probably seems cruel, but in fact it simply reflects the reality of the situation. It does not ignore that younger people and health care workers would also die, but it frames all of this in a context of building herd immunity. It depends on the natural tendency of individuals to avoid danger; many Swedes are exercising a complex personal calculus that includes their own risk tolerance, and they practice social distancing voluntarily for this reason. Sweden's death rate is high, but their herd immunity after this passes may exceed 50% of its population.

Interestingly, the Swedish government has allowed schools to remain open. Special needs students still get in-person services. People are out exercising, "It’s good for their physical and mental health," says Johan Carlson, head of Sweden's Public Health Agency. Their hospital beds are not full to capacity. They have not run out of ventilators. There's evidence that Sweden's economy has not been hit as hard. Shops can still do business--less business--but keeping the doors open. In short, Sweden's approach may be more sustainable and lead to less disease and death--of all kinds and all sources--than may be the case where strict lockdowns have been instituted. Time and study will tell.

From this I think it's reasonable to conclude that we could open up the country more quickly, and rely on individual risk estimation, continued, aggressive testing, contact tracing and selective quarantine to allow people to begin to transition to a real "new normal. What's that look like?

Who knows? It irritates me when journalists, policy makers, and talking heads breathlessly speculate extremes (as I mentioned above). But I think a few things are likely:

• Some people, but by all means not all people, will decide to keep employing some distancing behaviors indefinitely. But evidence from other epidemics (Spanish flu, Ebola) don't point to people en masse giving up on handshakes, hugs, and sharing a tasty dessert. People haven't changed that much in 10,000 years.
• Telehealth will become more common, and be better paid for, but it will not become the "new normal" since talking to a patient on the phone or via Skype is only a "second best" way to really evaluate health and disease. I speak from experience. Just because a health system decides it's more efficient to "see" patients on Zoom, doesn't mean it's a good idea. Look for a generation of lawsuits to emerge over cases that should have been seen in-person.
• Funding for public health, disease surveillance, and stockpiles of medical gear, and calls for changes in health care system design, are likely to be demanded by the public as a means of forestalling a similar crisis in the future. We got caught with our pants down once. I doubt people want that again.
• Tolerance for "lockdown" in the US will begin to fade very quickly in the next month, but even then individual behavior is likely to moderate what society looks and feels like to people. When, and if, we see another outbreak of this new virus in the fall or later, the response to it will be different, less intense, more modulated to local conditions, and reframed to a risk model that looks more like Sweden's. 
• Public health scientists have become heroes of a sort, but I think that fame has led to a kind of desire to keep the power that heroism confers--maybe for the "best" of motives, but still one-sided. I don't wish to indict anyone in particular. I just understand how people are. That power will fade, because it will be moderated by other considerations: you can't keep an economy on hold forever, and at some point people will begin, on their own, to engage in the same complex decision-making that Sweden already has, and that we've seen in other parts of the world, like Africa.

I really think that the suddenness, the surprise at the numbers of deaths, and the realization that we had really neglected disease surveillance, led to what we're seeing now--and its economic fallout. So I know everyone's hungry for predictions of the future, but I would caution: be patient. Understand that we're figuring this out together, and as such we do have a voice in the conversation, and we're not just to be herded into our pens. I was neither in favor of the protests, nor was I critical of them. It's just another part of the conversation that needs to happen.

Otherwise we'll spend the next 20 years isolated in our closets, waiting for inevitable death.

How are we doing today?

According to modeling at National Public Radio yesterday (the site is here, just scroll down and click on the blue "SHOW ALL (ORDERED BY PEAK DATE))", Pennsylvania is due to peak April 15th. This accords strongly with my own data from the PA-HEALTH case website:

Graph: Author

This shows that our daily new case rate has dropped below 10% (yay). I just came from the grocery store, where most customers and about half the staff were wearing masks. Wearing masks does work to prevent the spread of influenza-like illnesses. According to the CDC "Most experts think that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often, a person might get flu by touching a surface or object that has flu virus on it and then touching their own mouth, nose, or possibly their eyes." This reach extends about 6 feet. (Hence, all the yellow tape marks 6 feet apart on the store's floor!)

However, with the novel coronavirus, this is less clear. The World Health Organization still lists this virus as being spread by droplets and contact. They are aware of some studies that suggest it can be breathed out, even while talking, but also note that this research is still in progress and is not conclusive, and they stress that personal protective equipment is in short supply, so masking by ordinary folks might not be a good use of that PPE.

Of course, the directive from the Governor's Office that all people should mask reflects the thinking that "Well what if is does turn out to be airborne? Why not be careful?" Urging people to "make their own" masks--sewing them, or wearing scarves or bandannas--addresses the PPE issue. The idea is not to be protected from inhaling COVID-19, rather to avoid breathing it out.

My graph above displays a consistent decline in new cases since the outbreak began and some precautions were started, and a continued decline since social distancing and stay-at-home orders were rolled out. It's possible that that masking directive will lead to an even sharper decline, but it's also possible it won't.

There are several reasons for this:

1. It's possible that most transmission is not airborne, even if some is. Statistically, it could be difficult to impossible to see this come through the numbers.
2. It is likely that little things, like picking up things at stores, which can involve contact with stuff that settled out of the air, is a cause of transmission, but again, statistically that would be hard to see in the numbers.
3. It may be that there isn't any airborne expression of virus, except when someone coughs or gets a COVID-19 test (which involves sticking a swab up the nose--really far!), or gets a respiratory procedure like intubation. This would mean airborne transmission mainly happens in hospitals, but not the community.

When I was out just a while ago I saw many creative masks! It's a fun way to do something that may or may not help, so why not? On the other hand, I found it hard to feel critical toward the people I saw not wearing masks. Masks can be hot. They fog people's glasses. And they aren't 100% effective in controlling the expression of very tiny aerosol particles. They are fairly ineffective at keeping those very tiny particles out.

I also think there's something else going on. I think masking creeps some people out. It visually reinforces our fear of one another. I did see a lot of fear in people's eyes in that store--both among the people wearing masks (afraid of the virus), and those not wearing masks, afraid of what we are becoming--perhaps a society of individuals, separated permanently from one another, driven by a fear of our instinctive social, "touchy" nature.

So looking ahead, I will be watching for this. Are we to become a society of germaphobes, living in fear of one another, forever bathing in sanitizer? Looking back over the last 20 years and the proliferation of germicidal hand soaps, wipes, and a commercial emphasis in TV ads on being absolutely clean, I have every reason to believe that the trauma of coronavirus on our collective mind will lead to exactly that.

Interestingly, as I have discussed elsewhere in this blog, there's good reason to suspect that this obsession with "sterile-clean" home environments has been partially responsible for the explosion of auto-immune diseases like rheumatoid arthritis, ulcerative colitis, and other conditions.

What will happen? Too soon to tell...but when we begin to know, you can be sure I'll be talking about it!

Do what you need to do to be comfortably safe!

Credit: rockpaperthis.com

(Another) COVID19 Update

We're not out of the woods yet.

On the other hand, there is hope. I have been compiling data from the Pennsylvania Department of Health from the first day of regular reporting, March 4th. It was the first of two days which would report no cases. The clouds were still just coming over the horizon then. Today, we had the second highest daily increase in deaths, 240, or 32.5%.

Rest their souls.

It may be darkest before the dawn, and that's what I wanted to share tonight. This is the main graph, which shows the number of total (cumulative) number of cases to date (red), cumulative deaths (orange), and the daily death rate (pink).

Figure credit: Author

The average death rate is 1.10, although today it really spiked a bit. I don't expect that to continue, but it is hard to be certain. What is encouraging is the declining upward curvature of cases. There is an interesting correlation with the graph below, which is the rate of change of new cases--or, day by day, is the number of new cases higher or lower, and how does this compare to the previous day's number?

Figure: Author

For example, March 20th and the 26th weren't so great, with pretty big spikes in new cases. Look at the trendline--the black line--from the beginning of full reports with coronavirus testing, the overall trend is for slower growth.

The first closure order was March 16th, but it was advisory, and limited in scope, and this may account for why, from March 18th to the 23rd it kind of bounced around 27%, then spiked on the 26th. The hard order for the urban counties was on that date, and then the line really starts sinking. Interesting the highest numbers are in urban parts of the state (at 155 cases and 1 death, Dauphin County doesn't quite qualify).

The message: "Social distancing" is working--although I still prefer the far sunnier "healthy distancing."

The learning: I wonder what this would look like if we had tested more aggressively? This we will only be able to speculate about using modeling after the whole thing is over.

Finally, what's this mean for all of us? It means that we're not out of the woods yet!--but there is a light over the hill. Stay strong and let's hope that we get over it soon. (And if any of you feel guilty about making an extra grocery trip just to get out of the house, take heart: we're all just human).

Peace

An Epidemic and The Psyche

Much is being made to night of this photo, and others like it, as the people of New York City gather to watch The USNS Comfort glide into New York Harbor.

Credit: New York Post

I write this because I am dismayed at the responses I've seen in the press--from Reuters to Breitbart to the Post--that these "bone headed" people are ignoring social distancing rules. I don't know how many ordinary people, who aren't internet pundits, feel.

Then I saw this on the evening news tonight, and I have to say I was moved at the spectacle of help on the way to a city that is literally (and perhaps justifiably) freaking out. Can you imagine, living in such a concentrated hub of humanity, thousands of cases, hospitals filling up. And then a white ship of hope arrives.

Credit: The National Review

Is it any wonder people broke out of their self-imposed isolation for a moment to welcome the help? I fear it is a peculiar disease of mankind that criticism comes easier than kindness. There has been kindness aplenty, and that feels like something healthy. This collection of masked and fearless New Yorkers is seen looking on, an old man grasping the barrier as if he were looking out of prison bars. 

I don't know. I just couldn't muster up any criticism of these people, clutched in this malignant grasp.

Credit: WBFO

The Pandemic, So Far

Speaking of malignant forces, how's this virus doing? I have reviewed the statistics from various locales and so far there is a consistent 1 to 1.4% mortality rate. There are outliers like Italy and Louisiana, but most experience run to about 10 to 14 people in 1000 will die. This breaks down to maybe 4 people older than 80, 2 or 3 aged 65-80, maybe 1 or 2 from my age group, and the rest lightly scattered in the remaining groups. 

Of course, we still don't know how many people get the virus and never get sick. They are carriers in many cases, but how would they know when testing is in such short supply? I think once we can estimate the number of people infected but not sick, plus those plausibly afflicted and perhaps tested, the illness rate and death rates will be lower. It's the contagiousness of this thing that got us discombobulated. Contagiousness is thought of as "R-naught"--R0. I've seen R0 rates of 1.4 to 3.7--that is, one person can infect 1.4 to 3.7 people, with the average settling in at about 2.5. Now this can come down if people, don't...um, congregate. But baseline, its R0 is higher than the flu (which we have a vaccine for, so, just sayin'). People who want to bring this thing under control want the rate to be less than 1 (then the number of cases will go down).

Social distancing is an imperfect tool to limit any epidemic. South Korea used a better tool: aggressive testing, selective quarantine, and contact tracing as a means of limiting the damage. Another shortcoming of social distancing and general area lockdowns is the social isolation it can lead to. Just because it is an imperfect tool, doesn't mean it shouldn't be used, especially if the better approaches, well let's just say it's too late for those. 

So one has to wonder: who should we really be pissed at? Our fellow, desperate citizens? Or the people who govern them? It is said that the people rule, but: leaders must lead. Our politics these days doesn't seem to lend itself to that. So the morgues get a little bit fuller, the dying die without family, we grow farther apart in both space and mind, and once again we're humbled by the power of Nature to impose her brand of reconciliation on a careless species. This can be expected to focus our attention.

Maybe the catastrophe is being pinned on the wrong culprits.  

Wash your hands and touch your face :)

Coronavirus Update

So it's been a while, because I teach a very intensive course until Spring Break. What better time than now to dive back into the blog?

I won't rehash the usual advice or news, since there's a constant fire hose of these all day long. I'm sure any readers of this blog are up to speed on hygiene, and of course what coronavirus is, and why people are worried about it. There's a lot of speculation out there: When will it peak? When will it decline? How many people may die of COVID-19? When can we go back to back to "normal" (whatever that ends up looking like)? But speculation is mostly a waste of time. Most experts will be wrong, either by a lot of a little. A few will say they "called it," but mostly they'll have just gotten lucky.

If it sounds like I'm a bit jaded by this experience, I am. In the middle of the chaos, there's no time to ask the deeper questions that need to be asked. Those deeper questions are what interest me the most, though, perhaps because I am only mildly inconvenienced by this catastrophe. There are many folks who are a lot worse off than just "inconvenienced," so I've mostly kept my thoughts to myself.

So, in no particular order, I'll go ahead. Perhaps it's time to share.

The Silence of an Early Spring
This was the parking lot at Target. On a Tuesday. At 11 AM.

Credit: Author

My spouse desperately need a new computer in order to teach from home, so we went forth. Nothing available. Here's what we found inside, at the Starbucks entrance inside Target.

Credit: Author

This is certainly the most closed down we've been since 9-11. Maybe more so. So far it's been difficult for people, but I haven't heard about any adverse health effects, such as suicides, homicides, relapse of depression, violence, or health problems directly attributable to the closing down of America. Perhaps my readers have, and perhaps I'm not paying enough attention. I am hearing about a lot of people turned away from hospitals, ERs, and doctors' offices because of the perception--I think--that it's just too risky to do your job in a time like this. 

The counter-argument: It is too risky to see anyone but the sickest COVID-19 patients right now!

But it isn't.

According to NPR, a Dutch researcher found that many health care workers were already infected with the novel coronavirus. So a lot us may already have had it--and not known it. No symptoms. Yet it's changing how we work. Just today a colleague of mine had to take her husband back to the hospital for readmission, because he was discharged--just days ago--"too soon" with a major kidney problem, because of the collective organizational worry about what's coming. 

I get it: How bad can it get? is the question that troubles hospitals, who are trying to create capacity for anticipated thousands of very sick patients, even though these acute shortages are only being really being seen in major cities. In the rest of Pennsylvania, the numbers suggest that while growth is geometric, some of this owes to increased testing. Deaths remain modest, with 6 out of 644 cases as of 2 PM Monday (most in the Philadelphia area), 1%, twice the rate death from the flu, but the flu has caused 128,000 cases and 100 deaths in Pennsylvania so far, and the season isn't over yet. 

So one question that I look forward to answering after we all head back to the Starbucks, when this is over, will be: What was it about this thing made it seem like a coming apocalypse? We don't take flu, or tuberculosis, or HIV seriously enough to devote efforts to limit their spread (or we'd already have enough masks and gloves in a stockpile somewhere). Why this?

Hydroxychloroquine

This is an antimalarial drug, but it's also used for autoimmune diseases like lupus and rheumatoid arthritis. A nationwide shortage of the drug now exists because prescribers are hoarding the drug for themselves and their families. I have a family member with lupus who is on this drug, and although I haven't heard from her yet, I have heard about numerous cases in which people with these serious diseases cannot get it, because it's been hoarded by the very people charged with helping the sick.

Perhaps the shortage of personal protective equipment has led to this behavior. Maybe not. Perhaps it's just self-centeredness, a doppleganger of the "self-ism" of many of our societies  in the West, in which individual "freedom" is believed to eclipse the common good.

Anyway, I found it interesting that in just a few days of this behavior, several people have died from taking this drug. (The link is just a couple of the cases reported so far--maybe this will cause people to rethink taking medical advice from a real estate developer.)

If you are considering, I would not recommend it. I myself would use a homeopathic remedy--at least the cure won't kill me.

Panic Buying

Or is it something else, maybe boredom? After all, we're pretty much left with just the grocery stores for outside entertainment in the presence of others of our kind. Here's an example:

Credit: Julie Moffitt

The pasta aisle at a local supermarket. I do hope none of this ends up in a landfill when it's too stale to eat. Maybe people will donate to food banks, especially with all the unemployed now coming online.

I understand. We're freaking out. But why? Should seem obvious, one could say. Deaths, lockdowns, mysterious, invisible invaders among us (sound familiar?), and all sorts of disruption with no clear end date. If I examine the real data so far, I can conclude that we have a serious health problem on our hands that mostly afflicts people 50 and older, that it seems alarmingly contagious but modestly fatal--the vast majority live when circumstances allow, such as healthy food supplies, clean water, avoidance of well-known bad habits (In China 52% of men smoke), and exercise some healthy behaviors, the fatality rate seems a modest 1%--and will probably be lower once we have a real denominator. We don't actually know how many people even are infected with the novel coronavirus.

Today I began to wonder Did we need something to happen? Were things too easy? Were we somehow bored? Did we need "a kick in our complacency," as Jean-Luc Picard put in Star Trek?

Things were not great for a lot of people, but we were tolerating it. This communal freak out accomplishes laying bare the inequities and poverties of many parts of the world, thus to inspire better discussions about how to fix those inequities. 

I mean, people are gettin' an education about their "health insurance". Am I right?

I'm not sure that I would say that people are somehow "causing" this. But this epidemic was probably influenced by the growing power of Chinese agribusiness, which like America's, forces the less wealthy to find other means of support, when they see a market to over-exploit.

In other words: systems move as an interconnected wave. It's not possible for me to imagine that this is objective decision-making in the face of limited data; rather it is the collective psychic seizure that for a moment frames everything into such relief, it can no longer be ignored. So...

• We should have been better prepared for this.
• Politicians politicizing catastrophe should be publicly flogged.
• Individuals should have been better prepared, both by equitable wealth-structures and personal effort.
• We need to have a real conversation about what's possible and what's desirable, real soon.

So that's going to mean new discussions. I kinda hope it upends the current political stalemate. That's what I'm thinkin' about. How about you?

Special Thanks: to Julie Moffitt. I love bouncing ideas around with you. Inspiration.

UPDATE 3/25/20: COVID-19 cases in U.S. 55,000; deaths, 801. From the CDC: "CDC estimates that so far this season there have been at least 38 million flu illnesses, 390,000 hospitalizations and 23,000 deaths from flu." Context.