
Medical staff say virus stigma driving Tokyo hospitals to edge of collapse - everybodyknows
https://www.japantimes.co.jp/news/2020/04/24/national/tokyo-front-line-hospital/
======
samizdis
This is the first time that I've read about health/care workers being shunned
and stigmatised, but I can see how it can happen. I can't imagine that this is
a purely Japanese phenomenon, though. Anyone from anywhere outside of Japan
able to point to similar media reports?

Edited to add: thanks for the posters below who pointed me at relevant
articles concerning workers similarly stigmatised elsewhere. Shameful and
depressing are words that spring easily to mind :-(

~~~
HarryHirsch
There are enough reports from the US about physicians and nurses getting
evicted because tenants are getting concerned about coronavirus spreading in
the building.

Daily Beast isn't a real newspaper of record, but I've seen similar articles
in reputable papers: [https://www.thedailybeast.com/coronavirus-nurses-face-
evicti...](https://www.thedailybeast.com/coronavirus-nurses-face-eviction-
housing-discrimination-from-scared-landlords)

~~~
BurningFrog
That does seem like a valid concern.

Not sure what a solution might be.

~~~
toper-centage
How is that a valid concern? The only way the virus could spread would be
through the building door, and maybe elevator buttons. It's a matter of
cleaning those regularly and washing your hands when you get home. It's not
rocket science.

~~~
StanislavPetrov
The virus is airborne and lasts for hours floating in the air, aside from
surfaces. Its not just a matter of washing up.

[https://www.cnbc.com/2020/03/18/coronavirus-lives-for-
hours-...](https://www.cnbc.com/2020/03/18/coronavirus-lives-for-hours-in-air-
particles-and-days-on-surfaces-new-us-study-shows.html)

~~~
runamok
It _can_ last. It's fairly unlikely especially if people are considerate with
minimum precautions.

E.g. If one sneezes uncovered into air with the right humidity, etc. it COULD
survive for a while airborne. That's not to say merely by breathing a person's
usual exhalations they could get it.

The virus is transmitted through droplets, or little bits of liquid, mostly
through sneezing or coughing, Dr. Maria Van Kerkhove, head of WHO’s emerging
diseases and zoonosis unit, told reporters during a virtual news conference on
Monday. “When you do an aerosol-generating procedure like in a medical care
facility, you have the possibility to what we call aerosolize these particles,
which means they can stay in the air a little bit longer.”

[https://www.cnbc.com/2020/03/18/coronavirus-lives-for-
hours-...](https://www.cnbc.com/2020/03/18/coronavirus-lives-for-hours-in-air-
particles-and-days-on-surfaces-new-us-study-shows.html)

------
btilly
In the discussion in
[https://news.ycombinator.com/item?id=22934704](https://news.ycombinator.com/item?id=22934704)
patio11 was pilloried for claiming that, _We project a true count of over
500,000 infections, including more than 5,000 severe cases, and a breakdown in
provision of care (“overshoot”) in Nagoya, Osaka, and Tokyo, before the end of
April._

And yet, according to medical staff, Tokyo is close to a collapse of the
medical system.
[https://www.worldometers.info/coronavirus/country/japan/](https://www.worldometers.info/coronavirus/country/japan/)
says that there are currently over 12,000 reported cases in Japan and this
doubled in the last 10 days. So it is likely to be in the 20-25k range by the
end of the month. [https://www.nbcnewyork.com/news/local/new-york-virus-
deaths-...](https://www.nbcnewyork.com/news/local/new-york-virus-deaths-
top-15k-cuomo-expected-to-detail-plan-to-fight-nursing-home-
outbreaks/2386556/) says that New York reported COVID-19 seems likely to
underreport actual cases by a factor of 10. Which puts Japan at the
200,000-250,000. But as widespread reports say, Japan's testing has been
extremely anemic. That can easily put us back in the ballpark discussed.

You know, that projection is looking reasonably close for having been made
over a month ago.

~~~
danielharan
The NY study is preliminary, not peer reviewed. The sampling strategy used
over-represents people going out, and we have no information on which test was
used or its accuracy.

Given antibody testing done in places like Vô, the NY results seem a bit of a
stretch.

Hopefully Japan gets it together and starts testing properly, though.

~~~
rbritton
The NY study does align fairly well with similar studies done in Santa Clara
County and Los Angeles County in California, though. All three indicate a
significantly lower IFR than previously expected.

~~~
rallison
> All three indicate a significantly lower IFR than previously expected.

The NY study, if it holds up, suggests an IFR in the 0.8-1.0% range for NYC
(depending on whether or not you include the additional excess deaths), which
is in the range most experts have been assuming (0.5%-1.0% has been a common
range that's been tossed around). For example, the Imperial College model used
0.9% IFR as an input. Additionally, a 10x confirmed cases to actual cases
ratio is in the range most experts were assuming.

The two CA studies were outliers (and, had significant and substantive
critiques), and suggested an IFR as much as 10x lower than the NY study
suggests. I wouldn't call those two studies as aligning with the NY study.

~~~
rbritton
Do you have any links handy discussing the issues? I have not come across
anything like that in my reading and would like to read more on the critiques.

~~~
rallison
Sure!

Andrew Gelman (Stats at Columbia) had a commonly shared piece:
[https://statmodeling.stat.columbia.edu/2020/04/19/fatal-
flaw...](https://statmodeling.stat.columbia.edu/2020/04/19/fatal-flaws-in-
stanford-study-of-coronavirus-prevalence/)

Also a good dive into the issues: [https://medium.com/@balajis/peer-review-of-
covid-19-antibody...](https://medium.com/@balajis/peer-review-of-
covid-19-antibody-seroprevalence-in-santa-clara-county-
california-1f6382258c25)

Mercury News also had a good article covering a lot of this:
[https://www.mercurynews.com/2020/04/20/feud-over-stanford-
co...](https://www.mercurynews.com/2020/04/20/feud-over-stanford-coronavirus-
study-the-authors-owe-us-all-an-apology/)

And yes, lots of twitter discussions from folks in the field, e.g. Natalie
Dean of University of Florida
[https://twitter.com/nataliexdean/status/1251309217215942656](https://twitter.com/nataliexdean/status/1251309217215942656)
and Trevor Bedford (Fred Hutchinson)
[https://twitter.com/trvrb/status/1251332447691628545](https://twitter.com/trvrb/status/1251332447691628545)
and others.

~~~
timr
The most interesting thing (to me) about the Gelman page is that by the PPPS,
he's hedging all of his most significant criticisms:

 _" The data as reported are also consistent with infection rates of 2% or 4%.
Indeed, as I wrote above, 3% seems like a plausible number. As I wrote above,
“I’m not saying that the claims in the above-linked paper are wrong,” and I’m
certainly not saying we should take our skepticism in their specific claims
and use that as evidence in favor of a null hypothesis. I think we just need
to accept some uncertainty here. The Bendavid et al. study is problematic if
it is taken as strong evidence for those particular estimates, but it’s
valuable if it’s considered as one piece of information that’s part of a big
picture that remains uncertain. When I wrote that the authors of the article
owe us all an apology, I didn’t mean they owed us an apology for doing the
study, I meant they owed us an apology for avoidable errors in the statistical
analysis that led to overconfident claims. But, again, let’s not make the
opposite mistake of using uncertainty as a way to affirm a null hypothesis."_

The twitterthink reaction to this study has been vicious, mostly based on
amateur re-hashes of the Gelman critique, which even Gelman himself doesn't
really believe.

~~~
Karrot_Kream
The study pre-print is published and some of the numbers are publicly
available, we don't need to play a game of revelations here between one person
and another, or incorporate Twitter users into the mix. (I didn't even realize
this was being criticized over Twitter, as I don't really use the service.)
Gelman's critique is quite substantive, and commenters on Gelman's post have
created Bayesian analyses which incorporate the uncertainty from test
sensitivity and specificity.

When I made one in PyMC3 (which lined up with a commenter's approach with
PyStan), the 97% CI for the prevalence based on the non-poststratified data I
got had the prevalence between (-0.3%, 1.7%). What does that mean? The test
just isn't certain enough to allow us to make any conclusions, not that the
null hypothesis is correct or that we can reject the null hypothesis.

There's nothing wrong with performing the study. Indeed, the publishing of the
study allows us to have these vigorous debates about methods and informs
future trials from being more exact and not suffering from the same problems
as previous studies. But trying to extrapolate a conclusion for something as
important as COVID based on studies with extremely high uncertainty is highly
irresponsible. Sometimes we have to accept that coming up with statistically
significant conclusions is difficult.

~~~
timr
_" When I made one in PyMC3 (which lined up with a commenter's approach with
PyStan), the 97% CI for the prevalence based on the non-poststratified data I
got had the prevalence between (-0.3%, 1.7%). What does that mean? The test
just isn't certain enough to allow us to make any conclusions, not that the
null hypothesis is correct or that we can reject the null hypothesis."_

Yeah, that doesn't sound substantially different than Gelman's frequentist
intuition in the blog post. I'm not sure the more complex methods are adding
much here, except that you can now examine the posterior, and see what portion
of the density lies below zero (i.e. probably not much of it).

IMO the "CI includes zero" was weak when Gelman advanced it, because even
though it's _possible_ , it was clear from the assay error rates that the
outcome was on the tails of the distribution; even if 95% of repeated samples
_may include_ zero, very few of them actually would. So at the end of the day,
as you have demonstrated, you get a non-post-stratified posterior that
encompasses the point estimate they gave (1.5%), but your confidence interval
is different, and perhaps the mean is lower.

Now you're just left with debating the validity of the bias adjustments they
made.

That said, it's wrong to frame this in terms of a "rejecting the null
hypothesis". There's no hypothesis in an observational study like this.

~~~
Karrot_Kream
> So at the end of the day, as you have demonstrated, you get a non-post-
> stratified posterior that encompasses the point estimate they gave (1.5%),
> but your confidence interval is different, and perhaps the mean is lower.

You cannot use confidence intervals to argue the validity of a point estimate
inside of the CI. When using frequentist methods, we usually have some sort of
control group where we can use a paired test to compare sample means in order
to reject a hypothesis.

I wanted to use Bayesian methods not because they were more complex, but
because I felt that when a control group is not available, a Bayesian analysis
would be a lot more obvious about surfacing uncertainty. Bayesian methods also
allow us to actually simulate P(prevalence | data). And no, just because 1.5%
is in the 95th percentile of the posterior prevalence, does not mean you can
say that 1.5% is a valid estimate. What the CI shows is that, with 97%
confidence, the prevalence is somewhere between -0.3% and 1.7%. Additionally,
the mean of this posterior came out to 0.8% prevalence, which to me is good
as, to me, saying it's inconclusive. In fact, if we use the median of
P(prevalence | data), then we get very close to 0.8%, so this test is
basically showing that the prevalence in this population is negligible.

~~~
timr
_" You cannot use confidence intervals to argue the validity of a point
estimate inside of the CI."_

You're using a Bayesian method, so you have a posterior distribution. You can
sample from it.

 _" And no, just because 1.5% is in the 95th percentile of the posterior
prevalence, does not mean you can say that 1.5% is a valid estimate."_

You told me that was the confidence interval on the parameter. The confidence
interval contains the point estimate for the original study. It's as valid as
any other point within the confidence interval. As you say: "you cannot use
confidence intervals to argue the validity of a point estimate inside the CI".

 _" What the CI shows is that, with 97% confidence, the prevalence is
somewhere between -0.3% and 1.7%."_

Which includes 1.5%.

~~~
Karrot_Kream
> You told me that was the confidence interval on the parameter. The
> confidence interval contains the point estimate for the original study. It's
> as valid as any other point within the confidence interval. As you say: "you
> cannot use confidence intervals to argue the validity of a point estimate
> inside the CI".

> Which includes 1.5%.

And everything else in the CI. If we're treating this like a CI, then it's
like saying a dice will land on 1, just because it's equally likely to land on
6.

The actual P(1.5% | prevalence) is quite low at 3%.

~~~
timr
_" And everything else in the CI. If we're treating this like a CI, then it's
like saying a dice will land on 1, just because it's equally likely to land on
6. The actual P(1.5% | prevalence) is quite low at 3%."_

You _just said_ that you can't use a CI to estimate the likelihood of any
point within the CI (you actually can, for well-behaved problems, but I
digress) when I commented that 0% isn't a likely outcome within the interval.

Literally the same argument. If you want to argue that 1.5% is unlikely, then
you have to accept that 0% is unlikely for the same reasons.

------
Jeema101
"At the hospital, about 10 nurses and other staffers have left since the first
COVID-19 case was found on the medical staff. The list included clerical
workers."

I fear this is going to be an increasing problem if we continue to rely on the
belief that medical personnel can be abused indefinitely.

~~~
TeMPOraL
That's actually the nicer side of the problem. Given current conditions pretty
much everywhere, doctors and nurses that don't run away end up overworked to
the point of exhaustion. Some of them die, rest are left with PTSD. Healthcare
systems worldwide are bleeding medical staff, and unfortunately, training a
new medical professional takes many years (more than a decade if you want them
to be any good).

~~~
ISL
If we're hemorrhaging healthcare workers, it is because we're not giving them
enough support.

We're spending $2+T on keeping everyone afloat in the US. We can spend a lot
of that money encouraging everyone to pitch in to fight Covid.

We need ~hundreds of thousands of contact-tracers. If that were our only need,
we could offer $1,000,000 to everyone who works as a contact tracer and have
money left over.

I'm already volunteering ~70% of my time on FindTheMasks.com. I can only
imagine how much more work could be done if unemployed people were given the
opportunity to work on _fixing the root cause of unemployment_!

~~~
TeMPOraL
I'm not sure what contact-tracers do (seriously, I don't know, and I'd love a
description of what this job entails), but I assume they'd need PPE and tests,
both of which are generally unavailable due to insufficient manufacturing
capability, supply chain issues and bureaucratic blunders.

> _We 're spending $2+T on keeping everyone afloat in the US._

I think it's best to consider this as less "money to help fight the pandemic",
and more as "money to save everyone from starvation", or alternatively "money
to have a country to save from the pandemic".

> _I 'm already volunteering ~70% of my time on FindTheMasks.com._

My strong and sincere thanks for the hard work you do!

~~~
SyneRyder
Contact tracing is about asking the patient where they have been in the last
few weeks, identifying (tracing) every person they've been in contact with
during that time, finding out where and how they caught the virus (ie the
specific person they caught it from), and also finding and immediately
quarantining everyone the patient has had contact with. It's not a process
that necessarily needs PPE, more the ability to go through someone's Google
Location History data and make lots of phone calls to people.

Australia is even introducing an open source app next week (like Singapore
has) to automatically collect Bluetooth IDs of nearby devices as a person
walks outdoors, so people can be more easily traced & notified / quarantined
if they've been in contact with someone who has been infected.

Here's one of our Australian state government's explanation of contact
tracing, in this case for Tuberculosis:

[https://www.healthywa.wa.gov.au/Articles/A_E/Contact-
tracing...](https://www.healthywa.wa.gov.au/Articles/A_E/Contact-tracing-for-
tuberculosis-TB)

(Edit: and here's some info about the Australian and Singaporean contact
tracing apps, if you haven't heard of them before)

[https://www.theguardian.com/world/2020/apr/17/australias-
cor...](https://www.theguardian.com/world/2020/apr/17/australias-coronavirus-
contact-tracing-app-what-we-know-so-far)

------
jefftk
This is described as "stigma", but it looks like people making reasonable
decisions trying to avoid getting sick. The child of someone who works in a
hospital really does bring higher than normal risk to their daycare.

People with medical jobs not being able to get childcare is a serious problem,
but we need dedicated separate childcare if we're going to keep the spread
down.

~~~
akiselev
For a disease as transmissible as Ebola or the flu that might be true, but for
a brand new highly transmissible disease like COVID-19 with limited testing
supply, it might be safer to live near someone who might actually have access
to regular testing. Do the people stigmatizing healthcare workers have the
data to back up your theory?

Trying to explain away prejudice with science requires actual science.

------
nwatson
Japan already has formal stigmatizing of groups:
[https://en.wikipedia.org/wiki/Burakumin](https://en.wikipedia.org/wiki/Burakumin)
... this is how caste systems develop.

Burakumin: "They were originally members of outcast communities in the
Japanese feudal era, composed of those with occupations considered impure or
tainted by death (such as executioners, undertakers, workers in
slaughterhouses, butchers, or tanners), which have severe social stigmas of
kegare (穢れ or "defilement") attached to them."

Add to this now "medical professionals".

~~~
masklinn
This specific issue is hardly limited to japan. You can sadly find this sort
of cases in the US, in India, in Germany, in France, in Belgium, Australia, …

From cars getting degraded to harassment to eviction to assault and battery.

~~~
viklove
I don't think the US has a history of confining them to villages though...

~~~
masklinn
It certainly didn't call them villages. Rather preferred "plantation",
"ghetto", "reservation", "inner city", "hazardous housing inventory".

It also has a history of owning them as furniture, of killing them in many
manners, of breaking treaties with them, of hanging them as town event, of not
treating them, of banning them from states, cities, neighborhoods, of
excluding them from society, public places, social benefits, … and I'm sure
I'm forgetting a bunch.

~~~
viklove
Are we still talking about doctors and medical staff here? Sounds like you
just want to drag a whole host of other issues into this conversation, but I
urge you to try and stay focused on the discussion we're having, and not the
one you seem to want to have...

~~~
masklinn
> Are we still talking about doctors and medical staff here?

I assumed not since Japan does not have “a history of confining [doctors and
medical staff] to villages” So your comment could only apply to the treatment
of burakumin.

> Sounds like you just want to drag a whole host of other issues into this
> conversation

You’re the one who made mistreatment of minorities the issue, it’s not really
my problem if it also makes you uncomfortable.

------
ericmcer
In the USA most doctors doing residency would get an immediate pay bump if
they went on unemployment.

~~~
kingkawn
A quick search says the average us residency salary is $61,200 as of 2019,
which is above the unemployment maximum even taking into account the
additional $600 a week in pandemic funding.

~~~
skellera
I think they’re going off a per hour basis. If a resident is working an 80
hour week, they aren’t getting paid much per hour.

------
InfiniteRand
I know in some places the hospital workers are given decent hotel
accommodations, that seems to be a pretty reasonable compromise for medical
workers in dense living situations, in some places that would require building
some additional places or taking possession of some, but given the amount of
slack resources right now that also seems reasonable

------
mensetmanusman
Humans are irrational fear driven creations.

Only institutions (involving decision making by multiple humans) can help in
these circumstances, because we need each other.

------
arkitaip
This isn't really surprising in a country where saving face, social standing
and collectivism is everything. Other horrible consequences of these deeply
embedded social systems are "evaporated people" [0][1] and the terrible
treatment of single parents [2][3].

[0] [https://www.pri.org/stories/2017-04-25/japans-evaporated-
peo...](https://www.pri.org/stories/2017-04-25/japans-evaporated-people-have-
become-obsession-franch-couple)

[1] [https://www.businessinsider.com/evaporated-people-
disappeari...](https://www.businessinsider.com/evaporated-people-disappearing-
from-japan-2017-4?r=US&IR=T)

[2]
[https://www.theatlantic.com/business/archive/2017/09/japan-i...](https://www.theatlantic.com/business/archive/2017/09/japan-
is-no-place-for-single-mothers/538743/)

[3]
[https://www.youtube.com/watch?v=PYmivmkZvIg](https://www.youtube.com/watch?v=PYmivmkZvIg)

~~~
sebwi
Do you have any insight on what differentiates Japan from other Asian
countries like South Korea? Collectivism is not a unique characteristic to
Japan and South Korea has arguably done a good job.

