Monday, April 27, 2020

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.

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