
Which epidemiologist do you believe? - akbarnama
https://unherd.com/2020/04/which-epidemiologist-do-you-believe/
======
ljf
I think it is interesting that the discussions are only framed in measuring
deaths, and also focus on deaths of the old.

I'm watching friends and family knocked back by this virus for weeks, and now
pushing into months (36 days and 42 days since first symptoms for 2 people I
know), and research in the US and China points to the increase in long term
health risks in the 20 to 50 year olds that recover from this. I know people
that just walk away from this with no impact, but if we only focus on death we
are likely missing the bigger picture.

~~~
joe_the_user
The "how many time the flu is this" misses how damaging this is beyond it's
potential casualties, how damaging to the health care system this is and so-
forth.

The thing is, I also don't think you can get away from the way that those
pushing for lower-end estimates aren't arguing from pure, selfless virology.
They're arguing from a "this is uncertain, so should we really risk our
economy to avoid potential lives lost?" position. I can see that if you could
translate the lost money directly to other lives lost. But you can't. The
various state could just support people for the period of the lockdown - all
the advanced nations besides the Dysfunctional US are essentially doing this.
So if you phrase things in terms of just paying lives for money, I would
disagree with the article, that is evil. People who actively enable that are
evil. Sweden's policy looks to be baring bitter fruit and I wouldn't forgive
Dr. Giesecke any blame for that if it matures. I could be wrong and I'm OK
risking money on that, it's a better choice imo.

~~~
luckylion
> The various state could just support people for the period of the lockdown

Isn't that just hiding the truth though? After all, what is the state, where
does it get the funds? Whether you take my money today or tomorrow, you've
still taken my money. I don't see any reason to believe that there will be a
magical no-tax funding of government any time soon.

~~~
incompatible
It's not really about money. Money is just bits of paper, or electronic
equivalents, that can be produced in arbitrary quantities. It's about having
sufficient production of food and other necessities to keep people alive,
ensuring that it's distributed to everybody, and finding enough people who are
willing to do enough work to keep the economy going at this level.

~~~
luckylion
Right, obviously when I say money, I don't mean "paper", I mean the equivalent
value that we represent by using money. We're generating a lot less value
today, while spending as if we didn't. Suggestions for the state to pay people
their usual salary while locked down for the next months/years do require some
idea of how to pay for it (again: with value, not with paper). Magic aside,
how will that happen?

~~~
JackFr
Exactly. The estimated $25 billion dollars a day the lockdown is costing the
economy is real economic output not a balance in a ledger.

------
gampleman
A lot of these discussions also sound like lockdown measures are "free". But
in reality it's about balancing two unknowns.

On the one hand we don't know how dangerous the virus actually is. If you look
around you can find very serious scientists calculating the risks both as very
low and very high. There are a number of various complicating factors (like
comorbidity, or lockdown measures) to take into consideration.

On the other hand we have some idea that lockdown is going to be really bad.
We are likely to face a huge economic crisis, except a lot of the outlets for
negative emotion have been cut off. That is going to have a very real death
toll as well. But again, we don't know how bad this is going to be. Will it
cause wars? Perhaps. Will it cause suicides? Definitely.

I am personally fairly surprised that the Giesecke view isn't more popular
around the world. Having a bit more scepticism about the virus before one
decides to also sacrifice a lot of people's livelihoods seems prudent to me.

~~~
gizmo
The tail risk angle is pretty interesting. We have a pretty good idea of the
upper bound of mortality of the virus, and we also know that with some basic
precautions the worst case scenario can be avoided. It's worse than the flu,
but not 10 times worse. On the other hand we have no clue what the end result
will be of mass unemployment and food insecurity for millions who used to be
middle class, on top of unprecedented central bank policy. It's pretty
reckless to shut down the world economy and hope it will turn out OK.

~~~
cameldrv
We don't know that it's not 10 times worse. Data is confusing and sketchy, but
there are many datapoints that indicate that the IFR is over 1%, and maybe as
high as 2%.

------
tapland
Being a swede it's hard but I don't know if non-swedish epidemiologists make
the same mistakes and claims.

Giesecke has claimed less than two weeks ago that at least 600k people in
Stockholm (pop 950k) have had it. We did viral and antibody tests that came up
with 11%(and had to be retracted because it was based on blood donors and
included all donors who had recovered and were specifically asked to donate
plasma with antibodies, so 11% is above max) and 2.5% respectively.

This claim and Gieseckes claim that deaths are <0.1% were was then the basis
of a study published to show the Swedish policy was right, which had to be
retracted because it put the population of Sweden to be >3*45million.

Gieseckes claims and articles starting to disappear/overwritten on same URLs
made me back up 4000 news articles yesterday. I think we are close to one of
our famous overnight 180 degree public opinion turns from the media starting
to question any claims at all.

A large anti body study was supposed to be released yesterday, and I'm waiting
to see what it says. We seem to be very far off the herd immunity Gieseckes
strategy is based on.

~~~
matthiasl
I also share your concern about claims made by Gieseke.

The article quotes Gieseke as saying "The real death toll, he suggested, will
be in the region of a severe influenza season — maybe double that at most".

Sweden's official death toll was 2270 yesterday (2020-04-28). The three worst
influenza seasons in Sweden since 1969 killed 807, 674 and 652 people[1]. So
we've already passed his "at most" claim. The only way I can see that working
out is if he feels that none of the influenza seasons in the past 50 years
count as "severe".

[1]: numbers taken from the Swedish wikipedia entry on influenza. I didn't
bother to check wikipedia's source. An average Swedish influenza season kills
about 200.

~~~
alkonaut
> he only way I can see that working out is if he feels that none of the
> influenza seasons in the past 50 years count as "severe".

Or that he doesn't think deaths in past influenza seasons were all attributed
to influenza but rather just "normal" deaths.

The excess all-cause deaths will be the figure to look at, but it will take
quite a while before those numbers are reliable.

~~~
gizmo
But the excess death data will also be tainted because people, especially
older people, avoid going to hospitals out of fear of catching covid19. Cancer
screenings are way down, and fewer people go to the ER with heart attacks and
the like. This will inevitably lead to excess mortality down the road --even
among otherwise healthy people--, but it will be very hard to determine the
magnitude of this second-order effect.

Of course it's also very hard to distinguish between people dying with covid19
and dying because of it. And we've never even made a serious effort to track
the cause of death of the elderly.

Meaning we don't know how many people die each year from the flu, and we don't
know how many people are dying of covid19. When you add it all up, it will be
very difficult to learn the right lessons from this pandemic.

~~~
DanBC
That's not what excess mortality means. They don't say "this many extra people
died, I guess it must be covid" \-- they're not fucking idiots.

When cancer patients die because their cancer treatment was cancelled they die
of a cancer related cause, and that's how their death will be recorded, and
that's how their death will be reported.

> And we've never even made a serious effort to track the cause of death of
> the elderly.

It's hard to understand your "we" here. Which country doesn't try to track
cause of death for elderly people?

> Meaning we don't know how many people die each year from the flu,

But we can count the deaths the same way. We can look at deaths of people
confirmed to have the disease, we can look at death certificates, we can look
at excess mortality combined with community surveillance. The errors for all
three are going to be similar for flu and covid-19.

~~~
gizmo
> But we can count the deaths the same way.

When person in an elderly care facility dies we don't do a forensic
investigation. We just shrug and say "I guess it was their time". So we don't
have an accurate mortality baseline to do any comparison against. And that's
assuming we are accurately distinguishing between those who died of covid19
and those who died with covid19, which we don't.

I'm not suggesting that people who draw conclusions from incomplete data are
idiots, I'm pointing out that the data we have is completely insufficient to
make an accurate assessment of covid19 mortality.

~~~
alkonaut
I think this is why excess all cause deaths will be the best evaluation. Lots
of people who die from Covid in care homes are people who would have died from
this years flu anyway. They aren't excess deaths, they are the baseline
deaths.

~~~
gizmo
I agree that 'excess all cause deaths' is an important metric, but we still
have to correct for clear biases in both directions. E.g. fewer traffic deaths
because of a lockdown.

------
throwaway936482
The problem with the Giesecke approach is that it relies on 2 assumptions
being true. 1) that infection brings long term immunity to the currently
circulating strains. 2) that covid-19 will not mutate into a new strain with
equivalent pathogenicity to which those with immunity to the current strain
are no longer immune. If either of these are false then you will not get a
meaningful form of immunity in the population. Currently we don't have any
evidence that either assumption is true so pursuing this approach carries an
increased risk for very little benefit.

~~~
BBergdahl
On the other hand, if we don't get long term immunity from the virus we wont
get it from a vaccine either. In my opinion there is three paths through this.
Two of them depends on immunity. 1\. Slow down the spread with soft lockdown,
let it pass and get immunity. Will take a long time. 2\. Try to severly limit
spread with hard lockdown. Either to open up and do lockdown again as
necessary or stay in lockdown. Untill vaccine. This is a long road. Optimistic
figures is a vaccine somewhere second half of next year. 3\. Contact tracing
and severe quarantine for infected and contacts until the virus is eradicated.
Quick, only possible if the spread is limited. You can't open your country to
others until they have done the same or a vaccine is here. The unicorn exit is
of course every county doing this and a total eradication of the virus. A
country could possibly change track from strategy 2 to 3 if the spread is down
really low and contact tracing is in place. Testing without tracing wont do
it.

So soft lockdown in maybe a year or more, deaths will be in the 0,5% vicinity,
more in some countries, less in some. Hard lockdown in the same timespan as
above. Less deaths but will you have any society to return to? If you do hard
lockdown for a while and then lighten up you're in situation 1 basically or
forced to lock down soon again. Number three is very attractive. Had we all
been prepared and had plans for this like South Korea and being island nations
with easily shut borders like NZ it would have been simpler. But most
countries were not and are not any of that.

~~~
SiempreViernes
South Korea is effectively a island nation in this context: ain't nothing much
passing over their land border unless something goes severely wrong in North
Korea.

~~~
BBergdahl
Very true

------
yokaze
How is Giesecke's approach of "so we should do what we can to slow it so the
health service can cope, but let it pass" different than what is currently
happening?

As I understand it, that is what most countries do and achieve with various
success. And as soon as there is any respite in the load of the hospitals,
people are already pushing for a easing of restrictions in place.

~~~
joe_the_user
A few countries have eliminated the virus entirely. Most other countries are
in lockdown as more or less a desperation move and effectively have no
articulated plan. Maybe they'll get infection rate down and can get testing
and contact tracing working enough to do elimination in heavily effected areas
but in the US, certainly, all plans are vague and the authorities seem to be
reacting to events rather than planning. I think WHO articulated the
elimination path but again, who knows.

But with all that, Giesecke's approach is more like getting the whole thing
over with quickly, which would have brutal effect on the health care system,
to say the least. IE, once this is done, all the doctors and nurses in the
emergency care system are going to quit.

~~~
bsder
> But with all that, Giesecke's approach is more like getting the whole thing
> over with quickly, which would have brutal effect on the health care system,
> to say the least. IE, once this is done, all the doctors and nurses in the
> emergency care system are going to quit.

The point of lockdowns wasn't to stay locked until total control. That simply
will not happen in the US, at this point. (And I'm not sure it's feasible
anywhere other than South Korea, now.)

The point was to give everybody time to react and get ready. It's been almost
45 days since the lockdowns started--healthcare workers should have all the
gowns, wipes, masks, etc. that they need, by now.

The fact that they don't is an indictment of most of the governments of most
of the countries.

In my opinion, we stay locked down until healthcare workers have what they
need _even if a gigantic wave hits_. If enough healthcare workers die, we're
all in deep shit even after Covid-19 reaches herd immunity.

Want to unlock things? Start smacking some idiot leaders around about giving
equipment to healthcare workers.

When I see healthcare workers saying "Please, stop, we have all the equipment
we need and then some," _then_ I'll believe we can come out of a lockdown.

~~~
taneq
> In my opinion, we stay locked down until healthcare workers have what they
> need _even if a gigantic wave hits._

Do you think that's practical? This virus has a hospitalisation rate of
somewhere between 10% and 20% and an ICU rate of 4-10%, and people who are
hospitalised need to be in there for 2-4 weeks. If a 'gigantic wave' is even
10% of your population (which realistically it would far exceed, given how
contagious the virus is) you need 10-20 free hospital beds per 1000 population
of which 4-10 are ICU beds.

The United States has 800k hospital beds of which ~100k are ICU beds, for a
population of 330 million (source: [https://www.aha.org/statistics/fast-facts-
us-hospitals](https://www.aha.org/statistics/fast-facts-us-hospitals)) That's
2.4 hospital beds per 1000 population, of which 0.3 are ICU beds.

You're gonna need at least 10x as many additional beds as you currently have.
At _least_. And that's for only 10% of your population getting sick.

Edit: To be clear, I'm not saying that lockdowns are pointless. I'm saying
that they need to be longer and more thorough to get to the point where the
virus is entirely eliminated, or they need to remain at current levels
indefinitely until an effective vaccine or other treatment is available.

~~~
argonaut
> This virus has a hospitalisation rate of somewhere between 10% and 20% and
> an ICU rate of 4-10%

Part of the reason there is even a debate is because we don't know this for
sure.

~~~
taneq
I've seen a lot of discussion about a "submerged iceberg" population of
asymptomatic or lightly symptomatic infections that haven't been picked up by
testing, but IMO this doesn't pass the sniff test when considering populations
like Australia / NZ / South Korea. Any such population should cause a steady
stream of serious cases popping up that can't be traced back to known sources,
along with random community testing seeing an unexpectedly high positive rate.
We're seeing no such thing.

The few studies where a large population was tested and shown to be widely
infected but largely asymptomatic seem to fall into one of two camps: They
used immunological tests (which are now under serious suspicion don't seem
reliable) or they tested a newly infected population after the first cases
were found (before the majority of infections had time to manifest symptoms.)
They've also been reported misleadingly (eg. the aircraft carrier case where
it was reported "80% of the crew were infected but asymptomatic" when actually
80% of the crew _who tested positive_ were asymptomatic.)

~~~
argonaut
I'm also not asserting we know for sure that there is a 20-50x (or something
along those lines) undercount in cases. Just that there is a huge amount of
uncertainty with IFR and hospitalization rates, and none of your points really
rule out that uncertainty.

~~~
taneq
Also true, and there's a chance I'm wrong and most people have already had a
mild version and everything will be fine. There's enough evidence suggesting
that the rates of severe complications and death are far higher than we're
comfortable with, though, that I, for one, would prefer to err on the side of
caution rather than run with "well, it _might_ not kill 10% or more of the
population."

------
alkonaut
An interesting aspect is that the authority where the Swedish State
Epidemologist works is the "public health agency". That is: the agency
responsible for the health of the whole population. That's not irrelevant
here. Their mission is always the _long term_ health of the population. They
are _not_ in a position to recommend actions that they belive will reduce
deaths from Covid if they simultaneously believe that e.g the economic effects
on the healthcare system will mean it is a net negative for the public health
long term.

Meanwhile in other countries perhaps some authorities are working from shorter
term ethical guidelines.

Using different views and optimizing for different goals isn't necessarily
wrong. There is no "right" here. Everyone realizes that thousands will die in
the coming years from things we can afford to treat today, but that we won't
be able to afford if we have 15% unemployment. Whether that's part of the
equation or not varies between countries and experts. In many places these
decisions aren't even left to relevant expert authorities but rather to
politicians who have an additional set of concerns (such as popularity) to
deal with.

Note: Johan Giesecke is no longer working as State Epidemologist but his views
are rather consistent with those of the current authority and the current
State Epidemologist Dr Tegnell, so his views are probably shaped in this
framework.

------
noizejoy
I doubt there’s a _single_ best way of dealing with this crisis across the
entirety of our planet, given the incredible diversity in demographics,
cultures, population density, wealth, health care systems and dna.

EDIT: should have added politics as another differentiator

~~~
weddpros
and diversity in politics... don't forget politics

Korea "should" be comparable to western countries if it wasn't for politics.
But they have 100x fewer deaths. They're not trying to reach herd immunity,
it's a political choice.

~~~
noizejoy
> and diversity in politics

Agreed and I amended my comment accordingly - and thanks for pointing out my
oversight!

------
throw93232
If Covid19 is 10x deadlier than flu, they both say the same thing.

> it’s like a tsunami sweeping across Europe.” The real death toll, he
> suggested, will be in the region of a severe influenza season

>UK fatality rate of Covid-19 is likely to be 0.8-0.9%,

------
hackeraccount
"Whether you’re more Giesecke or Ferguson, it’s time to stop pretending that
our response to this threat is simply a scientific question, or even an easy
moral choice between right and wrong. It’s a question of what sort of world we
want to live in, and at what cost."

That right there is the thing. I think there are a lot of questions that fall
into this catagory. People want them to be questions of science but they are
fundamentally political questions. You can use science - in ways that are fair
or unfair - but at heart science can't answer them.

------
smitty1e
I take the editorial stance that we should only use "believe" in a religious
context, so that we tag the thought as something subjective and unprovable in
the mathematical sense.

Instead put a Figure of Merit against the idea.

I 30% buy off that covid-19 is a nasty virus that one Does Not Want, and that
precautions are in order to protect those with compromised immune systems (my
wife).

I 70% think that a variety of leaders on all levels and parties are not
"letting a crisis go to waste" here, and purging the backlog of items that
they don't care to discuss in detail.

------
2019-nCoV
History won't be kind to Giesecke.

Deaths are almost an order of magnitude higher in Sweden v the rest of
Scandinavia: [https://ourworldindata.org/grapher/covid-daily-deaths-
trajec...](https://ourworldindata.org/grapher/covid-daily-deaths-trajectory-
per-million?yScale=linear&country=NOR+SWE+FIN+DNK)

~~~
alkonaut
What do you think the goal is of any strategy? Minimizing deaths from Covid-19
in the 2020 spring season? Minimizing deaths from Covid-19 overall (until the
disease is "over")? Minimizing all-cause deaths this year? Minimizing some
more abstract thing like "quality adjusted lives lost" over many years ahead?

I'll let you know which one it _isn 't_: the first one.

~~~
2019-nCoV
Currently all that is certain is the Swedish gov has gambled with their
citizens lives and in doing so they've done horribly in contrast with
comparable countries. And the number of fatalities continues to grow.

How is Sweden in any better position to minimise total (lifetime) C19 deaths?
Or all-cause deaths this year?

~~~
alkonaut
> How is Sweden in any better position to minimise total (lifetime) C19
> deaths? Or all-cause deaths this year?

One strategy is ensuring you have some protection from immunity in the
population (e.g. 20%) when the first wave is over, so that together with other
measures (testing, contact tracing, quarantines) you have a chance to control
the virus until a vaccine is found in say 18 months, while also allowing the
economy to function. That is to say: flatten the curve but not too much. You
_want_ some percentage of immunity too.

The effects on deaths from the economy will take years to manifest. What
quality of cancer care can be offered in a country in 5 or 10 years can
definitely depend on how this situation is managed now.

------
pinkfoot
Not this bunch for sure:

[https://calmatters.org/health/2020/04/debunking-
bakersfield-...](https://calmatters.org/health/2020/04/debunking-bakersfield-
doctors-covid-spread-conclusions/)

~~~
pinkfoot
To which ever rational scientist downvoted me, here are the good doctors'
claims from 26th [1] :

"So if you look at California—these numbers are from yesterday—we have 33,865
COVID cases, out of a total of 280,900 total tested. That’s 12% of
Californians were positive for COVID. So we don’t, the initial—as you guys
know, the initial models were woefully inaccurate. They predicted millions of
cases of death—not of prevalence or incidence—but death. That is not
materializing. What is materializing is, in the state of California is 12%
positives. You have a 0.03 chance of dying from COVID in the state of
California."

Even a child can figure out why this is not even wrong.

[1] [https://www.aier.org/article/open-up-society-now-say-dr-
dan-...](https://www.aier.org/article/open-up-society-now-say-dr-dan-erickson-
and-dr-artin-massihi/)

