Is shutting down the economy worth it?

[BillE]

We do not know if the Swedish total will be proportionally higher than here or other nations------in the long run. It may just be that some are dying sooner rather than later. The only benefits to social distancing are to flatten the curve, which does not reduce the totals but only spreads cases over time to make them more manageable by the health care system. If Sweden's health care system is not overloaded, then their experiment with quick herd immunity may not be costing them anything in total deaths.
Now delaying potential deaths until there is a vaccine or treatment can save lives, but that may require being locked down for a year or more.
Can any country survive that? I'm not going to knock the Swedish experiment, yet. We just can't tell at this point. Plunging the world into a global depression has costs in human lives too.

 

[ssobol]

I suppose that it might be better than his recent cure-all (drinking Clorox).....

I was floored when I heard that said in the press conference. His actual words were:

"I see the disinfectant, where it knocks it out in a minute, one minute. Is there a way we can do something like that by injection inside or almost a cleaning, because you see it gets in the lungs, and it does a tremendous number on the lungs?"

But as ludicrous as that idea is, his other idea intrigued me even more:

"Supposing we hit the body with a tremendous, whether it's ultraviolet or just very powerful light ... supposing you brought the light inside the body, which you can do, either through the skin or in some other way?"

I just couldn't stop my mind from envisioning how that might work. My favorite image was to imagine American know-how somehow producing tiny nano-LEDs that could be injected into the blood stream to be circulated throughout the body. They could be powered by some kind of magnetic induction coils (something like a MRI machine or an induction cook stove). These nano-LEDs would then bathe all the cells in the body with UV light killing all the bad guys (although it seems like the good guys might get in the way). When I got to the thought of my brain cells being bathed in UV light, I had to stop.....I got too scared because I realized that I don't have that many brain cells to spare -- unlike our President who informed us on Sept 23, 2018 that experts have concluded that China respects him because he has a “very, very large brain.”

Only good thing about Trump's suggestion is that if enough of his followers take his advise, he won't stand a chance of getting re-elected.

 

[dotnmarty]

Regarding Sweden, here's an anecdotal note I got from a Swedish friend who lives in Stockholm'


I live here and I still can't figure it out (though I have to say I experience as very scary and very very cold like we're-willing-to-sacrifice-our-elderly-on-the-off-chance-herd-immunity-is-a-thing cold). I've also been shocked at the number of people willing go to some lengths to shut up critics of the current policy. And I'm surprised at how the democratically elected government has abdicated responsibility to the head of a department who has no democratic responsibilities (ie no accountability) Also the press has been a let down the way they're not being critical (actually I was shocked to hear a slightly critical report this morning on the radio)... frankly the guy heading up Sweden's policy has been wrong SO MANY TIMES but everyone's sticking to his guns. Still, what can I say but say that I hope he's right and that this is the right way to go (since I'm stuck living here for the time being) We're all in this boat and the faster someone finds out the best way to handle it the better

 

[thataway]

Sweden's death rate as a percent of known cases of CV19 is 12.2%, All of US is 5.7% and New York is 7.7%. We know that the total number of infections is not yet known, but probably somewhere between 4% and 20% (Highest number reported by IGG antibody testing.)

The other issue for the US is inflation. We have a probably depression, coupled with massive infusion of "money" into the system. Normally in a depression there is deflation. But in this case, with the sudden appearance of new money (who is buying these bonds--and what will the interest rate be?) Add in the $600 additional to unemployment income, many of low wage earners will not return to work and thus be fired. (compounding the lower income groups woes). Add in those who demand a "livable wage"--today it is $15 and hour, and as inflation runs rapmpid it can soon become $20 or $25 and hour.

Both the economic and scientific outcomes just a speculation. Not sure that we will know the final outcome even in a year from now...

 

[ssobol]

... Add in those who demand a "livable wage"--....

A lot of people in the US think "livable wage" is a dirty word (not necessarily Bob). You pay some one a livable wage (like the EU, NZ, AUST) or you don't (like the US). The difference is that in the US, those not making a "livable wage" end up with subsidies like food stamps, free meals for their kids in school, housing vouchers, welfare, etc. that end up costing society pretty much the same thing. You can pay for their wages at the point of purchase (e.g. higher restaurant prices or service charges) or by supporting welfare programs via taxes.

IMO, the end result is about the same for the people footing the bill (purchasers and tax payers).

 

[colbysmith]

The only benefits to social distancing are to flatten the curve, which does not reduce the totals but only spreads cases over time to make them more manageable by the health care system

Billie. I think you may completely misunderstand exactly what flatten the curve means. I'll leave it to Dr. Bob, or one of the others that is better at explaining it, but what I understand is that social distancing does reduce the number of deaths.

I found this article easy to read. https://health.usnews.com/condition...al-distancing-is-important-to-combat-covid-19

 

[BillE]

Colby, I read it, understand it, and it was pretty much what I said. Flattening the curve is not reducing the number of total cases, it is spreading them out over time. That is not just my take on it, that is the consensus view. The goal is to not overwhelm the medical facilities by having everyone get sick at the same time, but the result is that we still get sick, but over a longer period of time. And IF there is any effective medical intervention then yes, some lives will be saved. But since 80% of those going on ventilators die anyway, the number of lives saved through medical interventions is just not that high. Beyond ventilators, about all the hospitals can treat is dehydration and fever. Our immune system can either fight it off, or it can't. The gloomy news is that anyone with compromised immunity had best plan on social distancing and wearing masks for the next year or so, while hoping that some effective treatment or vaccine is developed.

 

[thataway]

You are both correct: But in some instances flattening the curve does decrease the number of deaths. The hospitals which are overwhelmed will probably have a higher death rate. There are some "experimental" techniques and drugs--esspecially involving those who need ventilators and those who need only oxygen and some ventilatory assistance, such as a CPAC machine (slightly modified) can give. If this is not recognized, the outcome will not be as good. For example if you have the manpower to turn the patient form prone to supine and back every few hours, this helps the outcome.

Right now there is "no drug" which clearly benefits the outcome. But in some cases where there is "Cytokine storm" (over whelming response; hyperinflammatory syndrome) where some drugs used in cancer therapy and immunosuppression seem to help the outcome.

Thus I would not say that there is noting which can be offering by hospitalization:
Only about 15 to 20% require hospitalization at initial ER visit. Some of those may later in the disease process. Oxygen often helps. A DDS friend of my asked me today should he buy a pulse oximeter, because there are many patients who seems to not be in respiratory distress, but have blood oxygen levels of 70 to 80%.

Below is the "Curve" theoretically the area under the curve, is the same number of people.



In the 1918 Flu there is a tale of two cities: Philadelphia, whose officials didn't believe in social distancing, and encouraged the population to attend a crowded parade (shades of Wuhan and New York or Sweden), vs St Louis, where all gatherings were canceled and people were told to social distance. Philadelphia who encouraged the gatherings had a higher death rate. We won't know until this is over. But it seems to be playing out similarly in the US currently.

"Living Wage". One of the issues is a "living wage" is not the same in New York, Los Angeles or San Francisco as it is in Piper City, Illinois or Pensacola. FL. Just housing alone is a fraction of the cost in the more rural areas.
Those who depend on "Tips" often are paid below the "living wage" standard, but in fact make far more when tips are included. Increasing the minimum wage can be inflationary, and in the long run hurt those it was intended to help. There are many minimum wage business which will probably not re-open after this pandemic subsides. It is a very complex issue.

 

[hardee]

Just conjecture here, but I have a hypothesis about the curves. The "Without Precautions" curve, in reality is not probably a true symmetrical "Bell Curve" as it looks in the diagrams. I would put my money on the after slope being a less steep retreat to baseline, with a prolonged descent, increased infected and mortality numbers. I'm basing this on the fact that the virus attack and spread is much quicker than the decline. (Some patients -- from the Lakewood facility -- went from no cough or fever to coughing, dyspnea and hypoxic with oxygen saturations in the, low 70's in 3 hours.)

I am also in the ring with the social distancing as a method of decreasing both the infected and the mortality rate, but I think that is also improved with proper masking in public, and a judicial use of gloves and disinfectant as well.

Bob, There are (and have been for some time now) variations on CPAP devices that are capable of noninvasive ventilation. These could be used as invasive ventilators with the proper circuits and intubated or trached patients. I have not seen any numbers indicating differences the outcomes of trach vs ET patients. Standard practices were 5 - 10 day maximum for intubation before the patient was trached. Traching a covid patient would be adding a whole next level of risk.

AS to buying an oximeter, they are cheap and may be helpful but there is a level of education that makes them useful and some of the numbers I have been hearing about show that the education part is very sadly not in hand in most cases.

Harvey
SleepyC:moon

 

[RobLL]

As this all was beginning I bought an oximeter, mostly because people were getting sick, and it was one way to convince ERs, Docs, etc that a family member was very sick and needed to be seen. Plus they were cheap and available. It has been somewhat of a toy fortunately.

A friend's kid, and their family of four, hunkered down - all working, schooling by phone, super isolating. All the correct things plus. They were wondering about kid's bright red toes at the very beginning of all this. Did you know about Covid-19 toes? Truly weird and eerie. Who knows what happened until serum testing comes along.

Res inflation: Paul Krugman has been looking at Japan ever since their great crash in 1990. They need a little inflation (generally agreed that 2-4% inflation acts like a lubricant to keep the economy going). Their deficit spending now has reached national debt 250% of GNP. No inflation in sight, esp that little bit that is needed. It is called, no racism intended or perceived, the Japanese Disease. It affects developed economies, typical symptoms are low growth, deficit spending, no inflation, aging population. At this point no cure is known. Oddly, immigration relieves some symptoms, but we all knew that (hint,lower paid farm, construction, restaurant workers.)

google search: Covid-19 toes, economics The Japanese Disease

 

[westward]

The hospitals which are overwhelmed will probably have a higher death rate

Dr. Bob nails the value of quarantine in overall death reduction. Think: availability of ventilators and nursing help vs. triage in the hallway or parking lot.

As a health care professional, I happen to feel we can keep hospitals below capacity and still begin to open things up. (Indefinite shutdown will cause increased death and degradation in its own way, through the backdoor)

The key is robust education and practice of infection control, distancing, and testing. For example: folks still go to the grocery store, Home Depot, the gas station. They generally wear masks, wash their hands, and maintain social distance, working from home where possible. This behavior could be expanded to include retail, construction, transportation, etc.

Until we get out of the "full-open don't tread on me" vs. "don't open until we have a vaccine" battle we're unfortunately stuck.

 

[kennharriet]

A VERY thought provoking read!
Copied from a friend.

I am just sharing this post to see people’s thoughts and opinions.

I was reading some posts for and against reopening the country. One was talking about being selfish and it got me to thinking.

There are those wanting to reopen yet they’re being classified as selfish. There are those that rely on all kinds of people to supply them while they cower in fear at home. Isn’t that being selfish too?

You expect your garbage to be picked up, you expect the grocery store to be open so you can get milk, you expect truck drivers to supply the stores, you expect farmers, meatpackers, fruit and vegetable pickers all to keep food in that grocery store.

You expect Amazon to still ship all the things you’re ordering while you sit at home shopping. You expect the delivery driver to leave it on your doorstep. You expect your phone to work, your power to stay on, and your mail to show up rain, sleet, or shine. And most important, you expect the doctors and nurses to be there if you need them although many of them across the country have been furloughed because their units and services have been shut down while the entire system focuses only on COVID19.

The whole premise of shelter in place is based on the arrogant idea that others must risk their health so you can protect yours. There is nothing virtuous about ignoring the largely invisible army required to allow people to shelter in place.

I know there are some of you that are screaming mad about what I just said but stop and really think about what is allowing you to stay safe in your home.
I truly believe that with some common sense on my part, I could easily go back to life as it was. I want to go to restaurants, I want to shop at the little store just up the road.

And yes, I could catch COVID-19. I could also catch the flu or a cold. I could get run over by a bus. I could get struck by lightning. We take risks everyday. If you choose to stay home, that is absolutely your choice. And please don’t start screaming at me about how I’ll just spread it. Why are you worried? You won’t get it because you’re staying in your home. Are you going to shelter in place every time a new strand of the flu happens?

Our economy can’t withstand much more of this. If our economy collapses, so will the rest of the world’s. If that happens, you will see the rise of tyrants.
I absolutely don’t want people to die...from COVID or anything else. I want people to live.

But sheltering in place is not living.

 

[RobLL]

I have generally been reluctant to use a mask because N95s are not available, and surgical/home made ones are not all that effective. If you consider the old standard of a contact is being close to one person for 10 minutes, my wife and I have not had one contact. We have been closer to other persons for handing off or receiving things, but cumulative times, maybe a minute or so.

But here is an interesting Science Daily article - we have the material and my wife's major was clothing construction, she graduated with honors. She would enjoy making several.

https://www.sciencedaily.com/releases/2 ... 081648.htm

 

[westward]

Kennharriet:
I have wondered myself how grocery, delivery, health care, home improvement, auto repair, cannabis, etc workers can successfully function but somehow well- situated folks must shelter in place.

I’ve also wondered what states are going to do when, in financial dire straits from a combination of reduced revenue and increased public assistance expense, they are no longer able to provide basic healthcare in public safety services?

I wonder how it is that countries like Germany are able to successfully begin opening up but somehow we can’t? In Germany even the schools are opening up, the restaurants and bars are still closed. I think the Germans are doing it based on scientific risk assessment and behavior modification, where we are still doing it based on politics, ego, and blame.

 

[RobLL]

Those of us sheltering in place are helping those providing essential services, we are just one more contact that may be safe. That girl (60 years younger than me) checking out my groceries is hoping that I am not the one to infect her. The nurse or doctor who has to see me is hoping that I will not infect them.

Washington state is starting to return people to work including construction workers. Those people returning are hoping their fellow workers have not partied and will infect them. Those kids working in restaurants and at stores are hoping their fellow workers and the customers have been following the rules, and will not infect them.

You really just have to think these things through.

 

[ssobol]

... I’ve also wondered what states are going to do when, in financial dire straits from a combination of reduced revenue and increased public assistance expense, they are no longer able to provide basic healthcare in public safety services? ....

It's not just states that have problems. The healthcare systems themselves are in a financial crisis. The hospital where my sister works is losing $2M/day because all elective procedures are cancelled. Even the number of people they see due to car accidents (lots less driving) and cardiac issues (no one wants to go to the ER and get the corona virus) is way down.

The result is that even with a nationwide health crisis, the hospitals are reducing staff hours and/or laying health workers off.

 

[thataway]

Personal compliance with regulations:
One aspect in come countries is compliance. (not the lung type). Some societies (for example Japan) are extremely compliant. Others (The US) are not. There are many who don't think the virus can affect them adversely--or really don't give a darn. Germans, are generally pretty compliant. They will follow the orders that the government gives. I believe (and most medical sciencests agree) that if we distance, mask wipe down surfaces and glove, that going back to work and Liesure activities are acceptable. Crowds (take Disney World) for example, would have to make radical changes if they were to reopen. We must differentiate and open sectors of the economy which are relative safe--as well as "essential"--that should have been considered from the "get go", and would have alleviated some of the economic stress.
Essential and safe occupations.
The truck driver, Auto repair and even grocery stores etc. can operate safely. A dentist would require full hood, and positive pressure apparatus for himself and his assistant. Vets, outpatient medical care and surgery, most small businesses can be "safe". It took me a week to find a dog groomer who was open and willing to take new pets. Yet veterinary care and grooming can be practiced safely.

Masks: My daughter is using hot glue, because she does not sew. She makes a basic 3 layer mask--with a pocket. In the pocket she inserts anti allergen vacuum bag layer. HEPA would be better and that was the model we started with, but they are not available. The anti allergen bags close in the $1.20 range, and can give 4 or more mask inserts. The outer masks are re-washable and the insert is discarded after a few uses. Any fabric or mask you can see thru is not going going to give much protection. The Allergan filters are slightly less than 0. 1 micron and the HEPA are 0.3 micron. So the protection is somewhat less, but far greater than a "gator" or bandana.
Graphs vs reality
Hardee, you are probably correct--the graphs are only to illustrate a point-not necessary what will be retrospectively discovered. As for the compliance issue (scientific term which I am putting out the definition for those who are not in the medical field.)

compliance of a system is defined as the change in volume that occurs per unit change in the pressure of the system. In layman terms, compliance is the ease with which an elastic structure can be stretched. Compliance is, therefore, basically a measurement of the elastic resistance of a system. Pulmonary compliance (C) is the total compliance of both lungs, measuring the extent to which the lungs will expand (change in volume of lungs) for each unit increase in the trans-pulmonary pressure (when enough time is allowed for the system to reach equilibrium) [1]. It is one of the most important concepts underpinning mechanical ventilation used to manage patient respiration in the operating room (OR) or intensive care unit (ICU) environment

Overview of the disease
Medscape, a log in site.
Dealing with Lung compliance types: L low lung compliance and High lung complieance
Here is an article in JAMA released yesterday dealing with the two different types.

?another Medscape article citing the Italian sturdy.

[Dr Gattinoni characterised Type L phenotypes as having low elastance, low ventilation-perfusion ratio, low lung weight, and low recruitability]. Others may present late through A&E and are on the point of collapse, and can be more like the Type H or ARDS patient [Type H is characterised by high elastance, high right-to-left shunt, high lung weight, and high recruitability]. Similarly, others who have stayed on the ventilator for some time and become more like an ARDS patient with poor compliance are Type H. Others fall between the categories with many changes on chest X-ray.

Proning::

In the Type L patients we find proning also helps patients who are spontaneously breathing. We normally consider proning for patients on ventilators and less so in those who are spontaneously breathing and awake. These patients have shown improved oxygenation when they self-prone. Proning helps by improving VQ relationships [ventilation-perfusion ratios] in Type L patients, and also helps by opening up closed air passages in Type H ventilated patients

pulmonary micro thrombosis:

There could be something else going on in COVID-19 lungs in that we suspect microthrombi, which affects the way blood flows through the lungs. Knowing how to manage this is the next problem. Rather than giving our normal dalteparin dose we are deciding on doubling it in patients with high d-dimers. Most don’t seem to have pulmonary emboli but there is more general clotting.

I have read the original Italian Article, and can go back and look for it if Harvey wants.

 

[Da Nag]

I must say...I've gotten to the point where the minute I see/hear "Covid/Corona" anywhere on the Internet or radio - I immediately change the channel. I'm so thoroughly sick of the topic, for so many reasons.

This thread however, has been a breath of fresh air. It's a welcome respite from the idiocy being shared most everywhere else. Both from those issuing mandates, as well as those thinking it's "no big deal".

I'm not about to offer up thoughts of a medical nature with respect to Covid - that's well beyond my pay grade. Rather, when it comes to this topic I concentrate on things I feel I do have an above average understanding of. Common sense, human nature - and as is worded far better than I ever could, the cut/paste below on perspective. I liberated this literary gold from a friend ...

“This is not to say that we should just throw out the wise things we are doing: social distancing, wearing masks in public, sheltering in place as much as possible. And yet, here are some thoughtful words from one of the greatest minds of the 20th century, C.S. Lewis, in similar times:

"In one way we think a great deal too much of the atomic bomb. 'How are we to live in an atomic age?' I am tempted to reply: 'Why, as you would have lived in the sixteenth century when the plague visited London almost every year, or as you would have lived in a Viking age when raiders from Scandinavia might land and cut your throat any night; or indeed, as you are already living in an age of cancer, an age of syphilis, an age of paralysis, an age of air raids, an age of railway accidents, an age of motor accidents.'

In other words, do not let us begin by exaggerating the novelty of our situation. Believe me, dear sir or madam, you and all whom you love were already sentenced to death before the atomic bomb was invented: and quite a high percentage of us were going to die in unpleasant ways. We had, indeed, one very great advantage over our ancestors—anesthetics; but we have that still. It is perfectly ridiculous to go about whimpering and drawing long faces because the scientists have added one more chance of painful and premature death to a world which already bristled with such chances and in which death itself was not a chance at all, but a certainty. This is the first point to be made: and the first action to be taken is to pull ourselves together. If we are all going to be destroyed by an atomic bomb, let that bomb when it comes find us doing sensible and human things—praying, working, teaching, reading, listening to music, bathing the children, playing tennis, chatting to our friends over a pint and a game of darts—not huddled together like frightened sheep and thinking about bombs. They may break our bodies (a microbe can do that) but they need not dominate our minds."

 

[westward]

Ssobol:

Absolutely. My employer , a major teaching hospital and research center, is at way less than capacity, is re- purposing or furloughing employees, and going broke. It happens to be a State hospital as well. I wonder where the $$ will come from (local, state or federal) to proceed to recovery if the revenue stream doesn’t turn positive soon.

Europe has recognized this reality and is in the process of reopening, with sensible risk management. Our process seems much more piecemeal and frankly arbitrary. Here in Washington there is no coherent plan, timeline, metric for judging success, or comprehensive system for infection control education. Just intermittent proclamations re: this or that industry being allowed to open “with strict safety measures “, together with statements concerning how we will be guided by science. Not very reassuring

 

[kennharriet]

Thank you Will and Steady Eddy for sharing your perspectives. Bob, thank you also for your experienced judgment on the medical front. Very refreshing after listening to politicians and others running around with their hair on fire. Ken