More Thoughts on COVID

Recently a friend asked my thoughts on a podcast from the CATO Institute. CATO is a libertarian oriented think tank. The podcast titled "Following the Science and Pandemic Policy and Outcomes," features an interview with Dr Jeff Singer, MD, FACS. The interview can be heard here: https://podcasts.apple.com/us/podcast/following-the-science-and-pandemic-policy-outcomes/id158961219?i=1000495909421

It is notable that among the physicians who  question the premises underlying current public health recommendations on controlling Coronavirus, how few have epidemiology or infectious disease control credentials. Dr Singer is a surgeon. Donald Trump's COVID advisor, Dr Scott Atlas, is a radiologist, etc, etc. Dr Singer, in the podcast, points out that they learn about viruses in their first year in medical school. They also learn about the anatomy of the heart early on. I'm not going to let an orthopedist do heart surgery on me though.

The false narrative that 85% (or 80%) of people who wear masks get COVID anyway needs to be tossed out. It is a manipulation of a data point in a larger study. Used as a stand alone point, it is misleading and potentially deadly to some. What it refers to is people who wear masks in close-packed environments with other folks, many of whom are doing things that require they be unmasked at least part of the time. Examples are restaurants and bars where you are eating and drinking, churches where there is a lot of singing, or closely packed outdoor events like large outdoor political rallies with lots of shouting and standing in packed long lines to enter. Given the type of activities going on in these environments, I have to wonder how well (and much) those folks who say they were masked actually wore masks and how well.

The other thing about the masking discussion in the podcast is that it's focused on how well masks do at protecting the wearer from others. Surgical and cloth masks worn by the public probably afford, on average, a 50% level of protection.  What makes the difference is how well that same mask protects others from the wearer. And that level of protection is more like 90%, which means if both parties are wearing masks and one is infected, you're still looking at a >95% level of protection. And that, as CDC Director Redfield pointed out in a Senate hearing, is better than you'd ask from a vaccine.

The masking issue, by the way, illustrates why I abandoned libertarianism in my late 30s/early 40s. Libertarianism simply doesn't allow that real life often requires communitarian solutions. COVID and most public health solutions are compelling examples of that.

But the bulk of the podcast dealt with questions of lockdowns, their efficacy, social,  emotional and psychological costs, and economic impacts. And whether a herd-immunity strategy would be better. So, my thoughts on that:

First off: the benchmark for lock downs in popular imagination is NYC, Milan, Rome or Madrid. These were situations where the cities and surrounding regions were taken by surprise by the speed and source of the infections. They also made some initial and serious miscalculations in their response. In fairness health officials had based their pandemic response on influenza and SARS models and Coronavirus turned out to be a different breed of cat. Also, population density, public infrastructure and social and behavioral factors favored explosive growth of the disease.

Most lockdowns throughout the US looked a lot different. Grocery stores, hardware stores and restaurants changed their operations but did not close. Vital services were sustained. A lot of industries were able to modify procedures to keep their businesses viable. And the economic pain was mitigated to a huge degree by economic relief packages pushed through congress in the spring.

We are now  heading into a surge that will likely be significantly worse than this spring's outbreak, certainly in terms of hospitalizations. If numbers of deaths aren't as high, it will be due to a better understanding of what works and what doesn't that we didn't have in March. Still, I don't expect there to be anything like the shut downs we saw in NYC. And, back then, even in NYC and large European cities, there were still measures taken to ensure people could get necessary supplies.

The podcast is largely focused on deaths, which is a horrifyingly large number on it's own, but Dr Singer touches only lightly on  illness that doesn't result in deaths. People who are hospitalized with COVID but don't die -- and even those who don't get hospitalized -- can experience debilitating symptoms and lingering effects that cost them and our economy for years. Many of them will also die years before their time. And those COVID effects will be the co-morbidities this next time around.

About those co-morbidities that folks have been saying are skewing and inflating numbers of COVID deaths, that is another false narrative. Modeling as a discipline is a popular punching bag for many who currently occupy the right end of the political spectrum, because they don't know or don't care what they're talking about. *Prospective* models based on assumptions are tricky and need to be used with caution. Models that are based on well-documented occurrences are a different thing. We know how many folks are going to die this year or next year of heart disease or COBPD because we know how many have. So if there is an increase in death among people with those conditions who get COVID, those are clearly excess deaths due to COVID, they aren't due to greedy doctors tinkering with statistics as Trump and company would like to have folks think.

In the podcast, Dr Singer says -- correctly -- that herd immunity is a phenomenon, not a strategy. Herd immunity can be reached through vaccination programs, and through naturally acquired immunity and usually though a combination of both.

Here's the critical point; no credible public health official would aspire to naturally acquired herd immunity as an approach to resolving an epidemic, certainly not with a disease that has the morbidity and mortality that COVID has. To achieve naturally acquired herd immunity from COVID you probably need a 60-70 percent level of immunity in the population. Some argue it need not be that high, that it might be as low as 40 percent.

Right now, we are recording less than 10 million cases, less than 2.7 percent of the population has been infected. Dr Singer suggests in the podcast  that the actual number of infected persons my be 10 times higher, something less than 27 percent infected. In the best case scenario, a lot more people will have to get sick, and between one and three percent of them die, and many more incur years -- or life -- long disability from COVID, to reach herd immunity. By the way, Dr Singer thinking the actual number  of infections is 10 times higher puts a spotlight on the Trump Administration's utter failure at testing.

In contrast, a nationwide policy of mask wearing, encouraged and modeled by our political leaders, and with policies of closing down or limiting  commercial and public services selectively will still blunt the spread and impact of COVID. Had such been implemented at the outset of the epidemic in the US, our death toll could well have stayed below 50,000. That translates to 180,000 parents, grandparents, children, spouses and siblings still alive. That translates to thousands of "essential workers," school teachers, nurses, physicians, bus drivers, etc still being alive.

What about the schools? Let's not kid around, that is a conundrum. A sizable portion of our population is poorly served by broadband. Service is spotty and ridiculously expensive. Many locations -- and they tend to be where people are less affluent -- don't have broadband at all, or folks have to rely on 4G. Most companies have unofficial limits on "unlimited plans," which means your access slows to a crawl when you pass the limit. That hurts kids who are learning at home.

There is also the reality that teachers and school official are often de facto first responders when it comes to spotting signs of child endangerment in the home. So any policy of closing schools is fraught will direct  and indirect consequences. On the other hand, children above the age of 12 are as capable of harboring and spreading Coronavirus as any adult, which means our junior and senior high schools are able to act as epidemic engines.

For what it's worth, when I drive past schools in West Virginia's Eastern Panhandle and see kids going into school or moving between classes, their mask compliance appears far better than adults in stores around the area.

Years ago, Jerry Pournelle and Larry Niven wrote SciFi novels that became unofficial libertarian manifestos (also vastly superior, literary-wise, than anything by Ayn Rand). The point they made in their novels was that national government could and should, when extraordinary situations arise, be the responder of choice because it is the organization able to muster massive amounts of resources and to deploy them where needed. They further expressed concern that when government intervened when it wasn't needed, it squandered -- and diluted -- its credibility and energy.

The Coronavirus epidemic in the United States is one of those occasions calling for government action and response.