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Covid-19: the harms of exaggerated information and non‐evidence‐based measures (wiley.com)
249 points by tomerico 8 days ago | hide | past | web | favorite | 435 comments

Firstly, there is 10 weeks of evidence on what other countries have done to avoid transmission. Taiwan, Vietnam, South Korea, China, and Japan all show a variety of strategies and have some successes under their belts. Sure, it’s messy social data, and they have systematic differences from other countries, but it’s real data about what is working.

Ioannidis says: “If we assume that case fatality rate among individuals infected by SARS-CoV-2 is 0.3% in the general population — a mid-range guess from my Diamond Princess analysis — and that 1% of the U.S. population gets infected (about 3.3 million people), this would translate to about 10,000 deaths.”

The Diamond Princess data shows deaths with a functioning health system. From WaPo: “a doctor at Papa Giovanni XXIII Hospital in Bergamo, where he said there are 500 patients in need of intensive care and just 100 ICU beds”. The deaths in Italy are often due to an overloaded health system, which can easily double the number of deaths. Why ignore that? Italy has 6000 deaths already with 1/5th the population of the US: you need some powerful evidence to assume the US should expect to have a different path to end up with a total of 10k (by say the end of the year).

I think John has good reason to desire evidence based decisions, but sometimes you have to make decisions without enough data and change your game as it develops e.g. look at what effective entrepreneurs do in uncertain times?

> “If we assume that case fatality rate among individuals infected by SARS-CoV-2 is 0.3% in the general population — a mid-range guess from my Diamond Princess analysis — and that 1% of the U.S. population gets infected (about 3.3 million people), this would translate to about 10,000 deaths.”

Why would we use the Diamond Princess CFR instead of China's, or Italy's, or South Korea's? Where does the idea of 1% come from? Both of those numbers sound ridiculously optimistic to me. Furthermore, death isn't the only negative outcome - what do we know about permanent organ damage (lungs, heart, liver, kidneys) in survivors?

>Why would we use the Diamond Princess CFR instead of China's, or Italy's, or South Korea's?

because everyone on the diamond princess was tested. So we know for sure how many cases we are dealing within the sample.

~0.3 and ~0.9% are also not optimistic guesses but the current numbers for Germany and SK. Italy sits at 9%. So the situation is either that Italy is vastly underestimating cases, or Germany and South Korea have lost a magnitude of corpses somewhere. I find the latter less likely than the former.

0.3% & 0.9% are optimistic.

South Korea's naive case fatality rate (CFR) is already 120 deaths/9037 cases = ~1.3% today, gradually going up from ~0.5-0.6% a few weeks ago. Why? People in a functioning healthcare system take time to die and these people were infected during an expansion phase of spread which rapidly increases #cases (denominator).

SK's cohort CFR is even higher. More properly, we should use the infection number from 3 weeks ago because it takes 3-4+ weeks from exposure to death: 120 deaths/4335 cases = ~2.8%

Germany's current naive CFR at 0.4% will also rise in a similar manner for the same reasons. (You can bookmark this.)

https://www.worldometers.info/coronavirus/country/south-kore... https://www.worldometers.info/coronavirus/country/germany/

South Korea has the 2nd highest number of hospital beds per capita in the world and 4 times the US number. Germany: 4th and almost 3 times.


South Korea's and Germany's hospitals were never overwhelmed in the same manner as Italy's. A major reason Italy's fatality number is so high is because doctors there cannot save everyone anymore.

>South Korea's naive case fatality rate (CFR) is already 120 deaths/9037 cases

But the denominator in this formula strongly depends on who and how often you test. In other words: You don't know the number of cases.

Obviously, people who are severely affected are tested more often. People with mild or no symptoms might never be tested, even if they want to (I'm not sure about South Korea but for sure this is happening in Germany).

Based on people in the German parliament and the German soccer league, you can currently guestimate that 1% of the population is already infected (1% of the parliament and 1% of the premier league players are infected. I suspect that they are tested more often and even without symptoms. Maybe they have more contact to other people - maybe not).

Yes, this is a wild guess, but much better than taking the confirmed cases which are heavily biased towards people where the infection causes problems.

Yes, all my figures above are Case Fatality Rate (CFR) and not Infection Fatality Rate (IFR), which includes people with mild or no symptoms. It's much harder to estimate the latter unless one conducts antibody tests on a sufficient sample of a population. South Korea's extensive testing program should bring their two figures closer than those of other countries.

Credible estimates of IFR from noted epidemiologists I've seen are around 1%, assuming that the healthcare system still functions, and much higher otherwise.

COVID-19's CFR & IFR might not even be the biggest problem. High rate of hospitalization and broken healthcare system, with all their ramifications, could be considered even worse.

IFR early estimates from Wuhan are at 0.04-0.12%:


There is no real consensus regarding IFR yet. I think the best data we have is from Diamond Princess, which is at least 10/712 or ~1.4% and may go up a bit from unresolved 15 serious/critical cases and 100 more active cases. The population there is older, but also have good care.

If the Diamond Princess age group represents just 20% of a population (they are not all elderly), population IFR must be >= 1.4%/5 = 0.28% and likely higher. 0.28% is above the IFR upper range from the paper in your comment.

“Estimated fatality ratio for infections 1%

Estimated CFR for travellers outside mainland China (mix severe & milder cases) 1%-5%

Estimated CFR for detected cases in Hubei (severe cases) 18%”

By the MRC center at Imperial College: https://twitter.com/MRC_Outbreak/status/1226765905306234881?...

For what it's worth, South Korea has 9k confirmed cases after performing 349k tests.

Super interesting. So, 2.5% of the tests are positive. I heard (it think somewhere else here) that in Germany it is 3%.

Has Germany performed one million tests already?

> it takes 3-4+ weeks from exposure to death

Up to 8 weeks though I haven't found typical distribution/median. The increase in deaths might exponentially grow for a while after new patient load stabilizes.

If you have the raw data you can easily estimate CFR even though the number of infected are increasing by doing a culminate graph over "death share vs time since symptom onset or diagnosis" for the cases.

John's analysis is cherry picking in many ways. Death rate in Diamond Princess is 1.1% today and 2% is listed as severe. Assuming 50% of severe make it, final fatality rate for the ship may end up closer to 2%. John then adds a 50% discount factor but it is not clear how he picked that number. Also, the 1% of population infected seems to be another number pulled out of a hat. If we are basing our figures based only on the ship with no other assumptions, we have to go with 20% infection rate. Thus, one reasonable estimate of risk from the ship data is 20%x2%x330M = 1.3M deaths if we wait for "evidence" and did nothing. Clearly, this argues for doing something!

Edit: Also, Germany does not test dead folks for coronavirus while Italy does. Further, SK death rate has gone up to 1.3% (0.9% is an old number) and many more are in severe category. Thus, the sub 1% numbers seem more like the outliers than the above 1% numbers.

The Dimond Princess was evacuated. It’s passengers where unusually healthy for their age range, and while older than the general population had few people over 85 which is the most at risk population. Further, these people got world class care from experts and whatever minimal care an overworked heath system could provide.

Given all that they still had 9 deaths out of 712 infected with many still in critical condition.

> It’s passengers where unusually healthy for their age range

based on what?

Based on going on cruise. People who are bedridden or who can barely walk don't usually do that.

You don't have to be bedridden to have lungs that are one cold away from death.

People with advanced COPD etc are everywhere but can walk short distances etc and prefer cruises to schlepping through airports and whatnot.

Knowing people who go on large long cruises they tell me they've never been on one where they didn't have at least one death. Indeed I know people with serious health issues who go on these knowing there is good on site medical care at hand.

Large ships have a lot of passengers. In the US Men hit a 2% chance of death at 68, which jumps to 3.6% at 75. At 85 that jumps to 9.6%, and by 95 your at 26% and the numbers keep increasing.

This means you can’t simply look at the average age to estimate risk factors. Still a 2% risk of death per year x 3000 people = 1.15 deaths per week ignoring crew. In other words what you’re describing is still a fairly heathy population.

I don't know what your are trying to achieve here but the demographics of the cruise ships in absolutely no way represents society

I am pointing out curse ship populations are actually at lower risk than society for this specific disease. The crew is all young and it’s mostly irrelevant if someone is 4 or 40 relative to people being a heathy 80 or sick 90.

That's just not true. It's pretty much impossible to be 80 years old and not be more susceptible to infection generally. Statistically the people dying have an average of 2.7 comorbiditities.

the average age on the ship was 62. In what world is the average 62 year old bedridden or too sick to go on a cruise?

Average is meaningless in this context. US Men hit a 2% chance of death at 68, which jumps to 3.6% at 75. At 85 that jumps to 9.6%, and by 95 your at 26% and the numbers keep increasing. A 50:50 mix of 85 year old men and 38 year old men have vastly higher risk of death than a group of just 62 year olds.

Except those higher odds of death are strongly associated with major heath issues. So, simply excluding the sickest 5% of the population makes a huge difference in survival rates.

Why 20%?

That also seems wildly optimistic. 80% seems like a more reasonable assumption than 20%.

Also - 99.9% of those patients (pulled out of a hat) wouldn't have access to health care because the capacity was already overwhelmed, so the death rate will jump markedly.

Because 712 out of the 3711 passengers and crew were infected, and 713÷3713 ≈ 19.2%. So that gives us some sort of vague idea how much of the population from which the ship was drawn will become infected if exposed.

Diamond Princess was largely elderly people.

The Diamond Princess is also likely not a random sample of the population - they are healthy enough to be fit for travel.

You don't need to be particularly fit or healthy to go on a cruise. Yes, sure, you can't be on life support, but generally 'healthy enough' to travel on a cruise is exactly what I'd expect from any random sample of the overall population.

The problem is the disease is mostly killing off the least heathy. Exclude only 5% of the population and deaths might easily drop by 1+%. Further the Dimond Princess was evacuated specifically because they could not contain the spread. Suggesting their rate of infection is indicative of anything would mean we had somewhere to be evacuated to.

You may not understand what "random sample of the overall population" means if you would expect every single person in the sample to be healthy enough to travel on a cruise. Almost 1% of the population in the US has Alzheimer disease or other dementias, for example.

I noted exactly that in my comment. Yes, not all the population can go on a cruise. No, it's not like it's only the healthiest 20% of the population that can. If I randomly sampled the population I'd expect the majority to be capable of a cruise. What do you think cruises are like?

It's been hitting those in assisted living facilities rather hard, and those people would likely not be able to take a cruise.

If you agree that they are not a random sample of the population - they are healthy enough to be fit for travel (like the majority of the population) you are not trying to contradict ant6n's comment as I thought. I misunderstood, my apologies.

and it's not a small travel (e.g. the British tourists that went on board the Diamond Princess).

If you are not in good health at the beginning, you don't adventure yourself 10 hours+ from your home. So this group is likely in better shape than average population.

Isn't the average age on a cruise ship far older than in the general population? I would've thought the people on board would on average be far more vulnerable.

It’s a narrow band excluding the young and oldest so, the average is older but the maximum is younger. With a very sharp decline in their 80’s, which is when things really get bad.

Considering how quickly the numbers get worse with age and ill heath many countries are at higher risk.

~0.3 and ~0.9% are also not optimistic guesses but the current numbers for Germany and SK.

Fine numbers in the presence of a health system that is not overloaded, or a country that has managed to make effective changes to prevent transmission (how did they do that without science huh?)

By John’s numbers (0.3% die and 1% of population) Italy should get a total of 1800 deaths. Yet Italy is at 6000 and rapidly rising - using real numbers his assumptions are already wrong for a first world country that is a few weeks ahead of the rest of the world.

And why the fuck does he assume 1%? Because some actions have been taken? What actions can be taken since by his own words we lack evidence to make decisions...

Edit: by my calculations the US has 800000 cases at the moment (compared to ~40000 tested positive). 500 deaths with a 0.5% death rate, so three weeks ago there were 100000 cases, but it will have doubled 4 times in 21 days so there is now 800000 cases (already 0.2% of population). Three more doublings (easily realistic) beats John’s 1% within weeks. Ironically, going with his low mortality rate (0.025%) would mean US has 2% infected already...

> By John’s numbers (0.3% die and 1% of population) Italy should get a total of 1800 deaths. Yet Italy is at 6000 and rapidly rising - using real numbers his assumptions are already wrong for a first world country that is a few weeks ahead of the rest of the world.

Just highlighting this bit of the parent’s post. If you want hard evidence that COVID-19 is quantitatively and qualitatively different from other coronaviruses that, as John puts it in his article, “actually infect millions of people every year”… Italy is it.

It's also possible that Italy is vastly unlucky for some generic reason, considering most of the deaths are in a particular region of the country and among an age bracket that is less cosmopolitan and more likely to reflect limited geographic genetic dispersion.

I suppose central China, northern Italy, Iran, Spain, the rest of Italy, and soon enough France, Germany, New York City, Israel, followed by plenty of other places just happen to be vastly unlucky for “some generic reason”.

It turns out the generic reason was being human

No, the generic reason is age. This is presumably the oldest we've been on average as a species, let alone in certain countries.

While age is probably a factor in Italy, it's less of a factor in China, Iran and Spain, which also have high death rates (though the Chinese high death rate was mostly in the early stages). What these cases have in common is a very large surge which overwhelmed local health services.

If it was entirely based on age, you'd expect higher rates of death in Japan and Germany (both very elderly populations), lower in China (less elderly population) and much lower in Iran (young population).

The cfr in those areas is not even close. It seems NYC has one of the lowest cfrs in the us.

It typically takes 2.5–3 weeks after the start of symptoms for hospitalized patients to die. It only takes a few days to a week for a positive test result to come back.

Up until recently people hospitalized in NYC has had access to doctors and equipment, but NYC hospitals are already on the verge of being overwhelmed, and the crisis is just starting there. 2–3 weeks ago the “CFR” (i.e. deaths to date divided by known positive cases) was also very low in Lombardy.

The mass social distancing interventions they have undertaken in NYC should hopefully start kicking in, and we can all hope that the situation doesn’t get as bad as Lombardy, but in the mean time there are going to be thousands if not tens of thousands of deaths there, and it looks like doctors may soon end up facing choices about who to put on ventilators.

Italian here. The most probable cause for that is that these areas started being affected earlier, so the virus had more time to spread before the lockdown.

That doesn't affect cfr, which was higher even before the hospitals got overwhelmed. I suppose it's possible that Italian doctors are just generally bad, but I doubt that.

CFR is affected by the methodology with which you count the positive cases. Italy is badly underestimating the number of affected people (the head of the Civil Protection service says that we could have 10 times more cases than those accounted for).

In Italian:



I've seen the claim that northern Italy's manufacturing industry is more integrated with China, so there was more cross traffic. I don't know how true this is.

For sure it’s more integrated than southern Italy, but I don’t know and can’t speak about other EU countries. It’s entirely possible the higher traffic brought in the first asymptomatic cases earlier than in other regions.

Many cases in SK and Germany have not resolved yet. I don’t think you can use those numbers so definitively.

I think SK's numbers are becoming more reliable by the day though. The new case rate has stabilised to a small number in the range of 50 to 150 per day and the active case count is dropping at a rate of over 200 per day. The daily death rate has been below 10 the whole time I believe. If that trend continues then SK's CFR will be well known soon and I would guess not dissimilar to current estimates. Though it's always possible a false sense of security will set in and people will relax their habits and send it higher again.

Compare to Germany: weeks behind SK but already more than three times as many cases, new case rate in the last few days of 2500-4500 (SK's max: 851), daily deaths in the last few days 10-29 and heading north. Actually the death rate must reflect an amazing health care system given 30k cases, but it's early days for Germany. Their pipeline is very full, agreed I wouldn't want to make a prediction there.

EDIT: sensitivity.

OK, SK's new case rate is stabilizing, but they still have 5400 active cases. If even 1% of those active cases die (which is possible, since these longer-lasting cases are likely more severe), that's a total CFR of 2%. And this is for a country that everybody claims has been doing contact-tracing and testing asymptomatic people.

I find it interesting that SK is always brought up in these discussion about CFR and how now action is required. Actually SK is the prime example of a country acting quickly and early (also showing that general lockdown is not necessary in that case). They would have been even better off had it not been for patient 31.

One of the main effect of that action (apart from slowing down spread) was that they managed to keep the virus away from the most vulnerable parts of the population. Look at the age distribution in SK: https://www.statista.com/statistics/1102730/south-korea-coro... and compare that to Italy: https://www.statista.com/statistics/1103023/coronavirus-case...

Significant evidence that 50%+ of cases are asymptomatic or very mild and those people are not being tested at all. In the Uk even quite bad cases don't get a test

> Their pipeline is very full, agreed I wouldn't want to make a prediction there.

German here. I assume the recent hard lockdowns will work out pretty much for us... I'm more worried about the US, this is gonna be a mass die-off, and the Trump government's handling of the issue is... let's say abysmal.

German resident here. Why do you assume the recent hard lockdowns will work out? I have discovered in my time here that the German reputation for orderliness and rule following is exaggerated.

South Korea coped with the outbreak by having a test early, test often strategy, but the German strategy seems to be test eventually, test perfectly. That means that there isn't any process to flag essential workers and others as needing a good proper test. Korea's showed it's better to do a test with a high false positive and even a significant false negative many times a day and get the person out of circulation awaiting an accurate test, than to wait for them to find the symptoms concerning and ask for a proper test.

China coped with the outbreak by having actual curfews. Major lockdowns. The sort we couldn't reasonably expect. When I went to do my weekly/fortnightly shopping yesterday, I saw several police officers looking around into restaurants and on the local town square. Not hard to hide from. No-one cared what my business was.

Italy still hasn't really peaked. They did this test-free lock down strategy that Germany is doing. Apparently the amount of intercourse required for viral transmission is ridiculously low.

There's already tens of thousands of sick people here, and the government was very lethargic in their response. The peak will be huge. As I mentioned before, they gave up after Gangelt and seemed to act as if the whole thing would be minor. It took weeks after discovering a major problem existed that needed hard work before German authorities actually agreed to do hard work.

Learning lessons seems to be really hard for authorities at the moment, and I'm genuinely worried. It's like even ideas are subject to the European protectionism - better import a bad idea from Italy than an effective one from South Korea. My goal is to not get ill before there's space in the hospitals again, because any other goal seems unrealistic.

Actually South Korea is a perfect place to look for a nation which kept it under control.

Germany just lost control last week, so I expect a lot more death starting next week.

Hopefully Germany's plan of isolation will reduce the spread enough, but we will see...

Germany didn't lose control last week. A few days after they realised what happened at the Gangelt carnival, they gave up - that's when they lost control. The spread of cases took a couple weeks to be shockingly high, but this was locked in already in the first week of March.

We must stop confusing the outbreak of diagnoses with the outbreak of cases. That's the mistake every government agency in the West has made, and it's why it spreads faster and better in the west than in South Korea or Taiwan.

German here. Could you elaborate how we lost control last week? At least in Bavaria everything seems to be ok - considering the circumstances...

Isn't it the circumstances that are being considered, that are the problem? Germany "lost control" of the pandemic. (Germany didn't actually lose control last week, it's just the numbers stopped growing fast in the "ho hum" range and started growing fast in the "I'm scared" range. This is how exponential growth works. Germany lost control when they decided to do nothing for two weeks after noticing community spread.)

Germany does not report resolved cases IIRC.

It takes ~2 weeks for a person to die after they get infected. So when you are looking at numbers from Germany, you should look at current death count / number of infected somewhere around 10-14 days ago.

While virus is actively spreading, taking "current death count / current total infected", can easily underestimate mortality rate by 5-10x because it takes quite a while from infection -> death.

Go check South Korea's numbers again. As their cases have resolved, death rate has steadily increased, and it's now at 1.33%. It will continue to rise. Same with Germany, it just takes time to die. South Korea had already found majority of their current cases 2-3 weeks ago, but deaths are only now picking up.

Edit: now 1.37%, up again since I checked a couple hours ago.

The same rise in death rate was observed way back when SARS happened. At first people estimated death rate at 2-3%, and it was continually revised upwards as cases resolved.

The opposite happened with H1N1 (swine flu) in 2009, though. The CFR was estimated to be significantly higher during the pandemic but afterwards was estimated at 0.02% with 60M American cases. [0]

Policymakers should use conservative estimates to be careful, but we still just don't know how deadly COVID-19 is.

[0] https://www.eurosurveillance.org/content/10.2807/ese.14.33.1...

That's a difference between IFR and CFR.

Unless they have a test that determines whether fully recovered people had it at some point, they are never going to get an accurate CFR.

The unanswered question of the GP is why you'd expect only 1% of the US population to be infect?

I can't see the slightest basis for such an assumption. This an extremely infectious, quickly spreading disease. 30% of the US population seem like a more likely estimate.

SK has a 1.3% fatality rate at the end but that was with a functioning health case system. If even 1% of the US population get infect, the health system won't be function and you'll have a higher fatality rate.

Infected != Ill != death

Once the hospitals run out of ventilators and supplies and once the doctors are all sick themselves. Then sick-with-serious-viral-pneumonia = dead, for a large portion of the sick. Infected != sick, no doubt but we know the ratio of infected to sick over time, despite Ioannidis' disgraceful efforts to cast doubt here.

that's not what the WHO says

>The unanswered question of the GP is why you'd expect only 1% of the US population to be infect?

Ioannidis addresses this in the article. Extensive community spread is actually unlikely to be the case for this virus, epidemic development is hard to discern from simply increasing rates in testing and sensitive populations seeking testing, and maybe most importantly there is little evidence that lockdowns and other extreme measures have significant impact on reducing this sort of respiratory infection, he cites this paper. [1]

" The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children.[...]Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure."


His own numbers predict fewer deaths in Italy than it's already reported.

The lockdown in Italy has, thankfully, seemed to limit the virus to sublinear growth, using the very small sample of the past three days.

But talk about lack of data. This is looking at the spread of a different virus - a virus that certainly does not have the infectiousness of the Covid virus. So the this pure speculation.

It's a meta-study looking at over 67 papers that address the question of the spread of respiratory viruses. Obviously, every virus is a new virus, that is always a problem.

The question remains however why we ought to treat concerns about data about the virus different than concerns about data about the response to the virus. Why do we treat the virus like a black swan event, but not the unprecedented response of shutting economic and civil liberty down to a degree maybe not seen in 100 years?

It seems ironic that people critize Ioannidis for a sort of first-order error in thinking by not considering uncertainty. Yet causing damage and applying first-order thinking to disruption of global supply chains that likely will drive entire nations into deep recession and instability is apparently adequate.

It's a meta-study looking at over 67 papers that address the question of the spread of respiratory viruses. Obviously, every virus is a new virus, that is always a problem.

Yeah, and if any of those other viruses caused a world wide pandemic, I missed it. The article is a specious disaster.

Why do we treat the virus like a black swan event, but not the unprecedented response of shutting economic and civil liberty down to a degree maybe not seen in 100 years?

An extreme provokes an extreme response? Of course?

Human lives are more important than economies. And economies can't function with massive loss of life anyway. Even more, this is a massive exogenous shock. Once it's done, the various players can pick up the pieces. Until then, it should be treated like a war. Society trumps economics (hopefully, otherwise both are headed for disaster, 1 million deaths+ was the Imperial College Report estimate for what happens if the US does nothing).

>Yeah, and if any of those other viruses caused a world wide pandemic, I missed it.

They do actually. Several of the outbreaks studied among the papers were influenza pandemics, coronavirus pandemics, and SARS. (page ~110-120)

This rhetoric you're starting here about bringing out the war drums to fight invisible enemies is exactly what Ioannidis is afraid of. It is not scientific, it is not based on evidence, and it does not, weigh the tail risk of a global economic breakdown. Which may, in fact, be literal war in some places.

There is a trade-off between the economic effects and response to the virus. It is not a binary question.

This rhetoric you're starting here about bringing out the war drums to fight invisible enemies is exactly what Ioannidis is afraid of. It is not scientific, it is not based on evidence, and it does not, weigh the tail risk of a global economic breakdown.

Science is a means of discovering the most likely state of things and an always uncertain one. Other human institutions have to come into play when it is necessary to act. Those institutions make the trade-off rather simply calculating them. In the current context, the institution of a war is appropriate (more appropriate than all the semi-wars we've had over the last 50 years in fact, better than "war on drugs" or "war on terror"). We confronted by tiny semi-living creature that happens to be very good at killing us. We should band together and engage in unified, determined action to protect ourselves.

As far the economy goes - the economy is a phenomena of society. The productive machinery should kept going as much as practical and the entire process managed by the government, essentially a machinery akin to WWII needs to be in place for the duration of this. Such war measures kept things running at that time and there's little reason to think they wouldn't work today. Now, as far as lots of people losing their investment. Well, sorry, investments aren't life. This, in a sense, very quick trip from 1929 to 1948 for y'all.

But the government isn't aiming to keep the productive machinery going as much as possible. They're doing precisely the opposite, shutting down productive machinery as much as possible.

Bogus wars against viruses would've been totally unnecessary if leaders had prepared for this eventuality and not shutting down long-term preparedness. Look at this as payback with interest to that debt. Waiting for evidence would lead to worse handling, and shut everything down during panic time instead. Ensuring even worse outcomes.

Doesn’t influenzas cause a pandemic every year?

I’ve read from various sources influenza cause multiple hundred-thousand deaths every year.

That's broadly correct, although most definitions of "pandemic" jump through some hoop or another to make seasonal flu not count.

Yes, influenza causes over 250,000 deaths worldwide each year.


> Italy sits at 9%. So the situation is either that Italy is vastly underestimating cases, or Germany and South Korea have lost a magnitude of corpses somewhere. I find the latter less likely than the former.

Both could be true. For example, Germany doesn't systematically test dead old and/or hospitalized people for Coronavirus infections while Italy apparently does. Germany has more resources to test potentially infected people than Italy, where all resources are needed for treatment of the hospitalized cases.

In reality, both Italy and Germany will have infections in the 100.000s, most of them with mild or no symptoms.

That's a false dichotomy. The situation could also be that access to treatment is a huge factor in mortality, and that Italy and Wuhan faced a large enough caseload that people were unable to get healthcare, which drove up mortality significantly.

This is a much more likely factor than the idea that Germany and South Korea are somehow 10x-30x more effective in testing their population than Italy.

I'm not sure about Germany, but South Korea was and is extremely effective at testing their population. They also did and are doing a fantastic job tracing infections (although part of this is due to being able to mostly focus on a single super-spreader rather than many simultaneous outbreaks. I think that South Korea probably confirmed 70-80% of their actual number of cases, while Italy probably has at least 2-3 actual cases for each confirmed case. Testing and tracing en masse is really, really hard, and is basically impossible if you don't catch it soon enough. I think that hospital overloading is definitely able to double or triple the death rate, though.

Bruce Aylward's visit to China made it sound like they were testing everyone too.

Germany is at 0.42 and South Korea is at 1.24 now that more diagnosed people have had time to die.

China outside of Hubei has a CFR under 1%, actually. And they sure as hell didn't test everyone or even 10% of those infected in Hubei.

They tested every single person in the country who showed up to a doctor with a fever.

No, they absolutely have not anywhere closed to the peak in Hubei. People with grave respiratory difficulties were given Kelatra and sent home.

Outside of Hubei and after the peak, sure.

I am speculating, but it might be because Italy tested some (many) people after they died. That would skew the fatality statistics.

Or Italy’s hospital system got overrun and people with survivable cases died for lack of treatment.

Deaths are not instantaneous, add exponential growth and it taking up to 9 weeks from infection to death and it’s really deceptive. All deaths tell you is how many people where infected weeks ago.

Just look at the lag in China’s rate of infections vs deaths. They had 22 deaths on March 8th and 40 new infections. Further, new cases drops off vastly faster than infections with the sickest talking longer to get better and staying at risk of death for weeks.

Italy is a very elderly population. If, as seems to be the case, death rate ramps up dramatically over 70 and especially over 80, then this may explain part of it (though clearly testing in Germany and SK has been more effective than in Italy, too).

> So the situation is either that Italy is vastly underestimating cases, or Germany and South Korea have lost a magnitude of corpses somewhere.

There is a third possibility. False positive tests: Germany and South Korea may have less cases than they think they do.

Prof. Drosten who developed the test says that cannot happen in practice. One would get a false positive result with SARS-1 (de facto extinct) and related coronavirus strains in Asian bats (that have not crossed into humans).

Source: https://www.ndr.de/nachrichten/info/coronaskript132.pdf#3

> Prof. Drosten who developed the test says that cannot happen in practice.

Obviously not true

False positives are always possible in practice even if they aren't possible in theory

Get a bunch of tired lab techs running tests 24/7 and one of them will accidentally write down the wrong result at some point

I would not consider that a false positive in the test, maybe in the procedure, but that's quite different.

Moreover it is statistically irrelevant, that would maybe account for 1%, but only if they would only note false positives.

And the fourth: there were claims that only 12% Italy's COVID-19 deaths can be directly attributed to COVID-19.

How many HIV deaths can be directly attributed to the virus? Italy’s way of counting may be preferable to the method in other countries (which I assume will be revised at some point when the full history of covid-19 is studied). And even Italy is undercounting!

interesting. this sounds reasonable given its "deaths of people who tested +ve for cv19" and not "deaths of people from complications caused by cv19"

Have you got a source?


I know this may sound ridiculous, but Kimchi and Sauerkraut? Are any other countries with a high consumption of low pH fermented foods also showing a lower CFR?

> Furthermore, death isn't the only negative outcome - what do we know about permanent organ damage (lungs, heart, liver, kidneys) in survivors?

Exactly: why all this focus on deaths, when sickness rates are massive and are sure to have horrific long terms outcomes for more people than those that die. Intensive care strongly implies bad things are happening.

John Ioannidis has been a fabulous force for good fighting scientific fraud and misinformation. But clearly he doesn’t know what effective decision making looks like. It usually doesn’t look very academic in my experience! edit: I mean decision making in an emergency (we did have two months to be proactive, but now we have a reactive emergency).

There is nothing "sure" about "horrific long terms outcomes".

From the CDC As of 24-Mar there have been 589 deaths of 46292 tested which is 1.27% Mortality Rate. Not 3% or 4% as was initially reported. The more we test, as the days go on, we see this is not nearly as deadly as we thought. This will continue to decline as we test more and probably be around Germany and Korea's < 0.5%

I heard that in US if somebody dies and had pre-existing conditions the pre-existing condition is usually the official cause of death. So the person is not count.

This has to be even more true with flu. If somebody had lung problems and the flu season makes things worse and she ends up dying, the doctors are not normally going to test for flu. And the cause of death is not going to be "flu".

What I am trying to convey is that both numerator and denominator of the death ratio are very noisy since they depend on who and when is tested.

I have been trying to understand for a few days how the numbers are really counted for COVID-19. And again, it pretty clear that we do not have the real data for a "normal" flu either.

So for now my understanding of how bad COVID-19 is compared to "standard" flu has been largely inconclusive.

One thing though started getting clearer. COVID-19 is a virus with no vaccine. I have largely underestimate the importance of immunizations and being in a good health. Now I started to picture more and more that without a way to keep our immune system alert against the viruses, we will be greatly screwed almost every year because the demographic at risk would inondate the health care system in a way that they cannot cope.

> What I am trying to convey is that both numerator and denominator of the death ratio are very noisy since they depend on who and when is tested.

In this case now, you don't need that: the hospitals in Italy know for years how many new cases they get. Now it's like 50 times more cases that need hospital, and 50 times more dead.

It can't be anything but something completely new. If it's not a new virus X it must be a new virus Y as dangerous as X. But we know there is a new virus X. Old viruses simply had totally different need for hospitals:


In Italy there were 55 times more deaths per week (two weeks already) than the peek during the flu season. The same with a need for the beds in the intensive care units.

One possible outcome for survivors is losing up to 30% of their lung capacity.

Keep in mind this number is just as certain as saying 5% at this time.

Also, if 1% of the population becomes infected, and you continue economic activity, then 67% will be infected in a matter of months... This is a virus with R0 around 3 people. Suppression is the only strategy.

For those who want some indicative data of what happens in a few weeks if you don't act early, together with Italy, take a look at Spain. The health system in Madrid is already overwhelmed because the growth was incredibly fast.

Ioannidis even questions if ventilators are helping. He basically says without evidence to the contrary, they may be a placebo (the part about ICU beds).

And all the low CFRs he cherry picked have now increased dramatically.

"As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute."


That's not exactly a ridiculous hypothesis. A ventilator is life support; you're put on it when you're in the process of dying in hopes that something will happen before you finish.

Your lungs are filling up with fluid and your blood oxygen level is going below livable. Drain it and and ventilate which usually works much better than not doing so with pneumonia in general, or just who knows, no good empirical studies in ventilating with pneumonia related to this specific respiratory virus?

> a total of 10k (by say the end of the year)

Two weeks ago Italy had 463 deaths, and it now has 6000. I'm not convinced the US containment measures have been quick enough or effective enough to be significantly better than Italy, so I'd expect 10k deaths in under 3 weeks.

Not having great data to go by is part of the definition of a crisis. If we had perfect data then its unlikely we'd be in a crisis.

> but sometimes you have to make decisions without enough data and change your game

How orgs mess up handling complex problems, which they are not prepared for, or have the capacities, or time to handle has been studied ever since the second world war scientifically.

And science comes up with the concept of Bounded Rationality.

Which says if an org doesnt have the mental capacities, time, resources or the problem falls in a certain class of complex problems then whatever solution the org comes up with will be half baked.

And half baked solutions create their own issues and the cycle repeats creating a cascade.

Secondly when orgs Choose or are Forced to do something about problems above their capacities and naturally fail, they get blamed, they get defensive and react causing counter reactions which again produce a cascade of issues.

What gets lost in that blame game trap is everyone forgets that no one can solve the problem.

Bounded Rationality and more modern iterations of such theories suggest a simple solution - Pick simpler problems.

> Bounded Rationality and more modern iterations of such theories suggest a simple solution - Pick simpler problems.

Reality and emergent behaviour throws us complex problemS (like a novel virus), so how does that advice help?

With more data and info flowing its getting more and more obvious how bad we are at handling complexity. That evidence is going to keep accumulating.

How people deal with that fact (or dont) is important.

The current response/reaction to that, is to blame/replace leaders/find false messiahs/feel good narratives/distractions etc but all that doesn't reduce complexity.

It doesn't require everyone to agree on what our collective and individual limitations are but just to focus on limitations of those we don't like.

Its a trap and what the theory says is it wont matter what people do in response to crisis when they are stuck in that trap.

Orgs do a bunch of things to create conditions where groups/factions don't get carried away by blindness to their own limitations. If you are interested in the subject start with Herbert Simon's books.

> Ioannidis says: “If we assume that case fatality rate among individuals infected by SARS-CoV-2 is 0.3% in the general population — a mid-range guess from my Diamond Princess analysis — and that 1% of the U.S. population gets infected (about 3.3 million people), this would translate to about 10,000 deaths.”

For anyone wondering, this quote is from [1] and doesn't appear in the linked article. I think the linked article is better worded and more nuanced.

> I think John has good reason to desire evidence based decisions, but sometimes you have to make decisions without enough data and change your game as it develops e.g. look at what effective entrepreneurs do in uncertain times?

I think comparing the measures that governments take with what effective entrepreneurs do is misleading for two reasons. First, for a country there is no single bottom line: a good balance has to be found between low mortality, good quality of life for those that do not die, and economy (which can be tied into the latter, or it can be independent if the government prioritises the wealth of a minority). Success of a company is mostly measured financially, or perhaps by visibility.

And second, the stakes are a lot higher for governments. They cannot fail and disappear if the measures are not a success. If they fail, human consequences are massive, but the country still exists. If entrepreneurs fail, the company might go into bankruptcy and disappear, but the impact is mostly financial. On the one hand this means that the risks can be acceptable if the consequences are only financial, and on the other hand this leads to a certain selection bias -- the successful entrepreneurs you see are ones that take risks and act decisively, and were lucky enough that their risks paid off.

1. https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-a...

In the article Ioannidis says: "The most valuable piece of information for answering those questions would be to know the current prevalence of the infection in a random sample of a population and to repeat this exercise at regular time intervals to estimate the incidence of new infections. Sadly, that’s information we don’t have."

How does he know that this is not happening? It's been published for Sweden that they now moved to use "Sentinel tests" to track the spread of the virus (https://www.thelocal.se/20200320/fact-check-has-sweden-stopp...). This might explain the reason why the Swedish government is still quite relaxed. However, I would be very surprised if other governments would not be doing the same. Maybe this is the reason why governments really increased the response, because they are acting on this data.

[edit typo]

What makes it very likely that the US will not see a situation similar to the one in Italy is the following:

  * Lower amount of population with High blood pressure.
  * Lower median age.
  * Not having the same one big family model as in Italy.
  * Seeing how bad it can get in Italy and having a better response as a result.
It will still get quite bad in the US, but not like in Italy due to the above factors.

The title is funny, since Ioannidis is actually the one proposing measures ("do nothing") based on no evidence and exaggeration. Basically every number in the paper is tainted by him cherry-picking the most optimistic number possible, and then trying to twist it further into something even better.

Like his argument for the R0 being near 1.3 is just that it's "probably" the case.

At some point we need to be able to call the data we have good enough for making decisions.

R0 is at the initial onset, without any immunity and any preventive measures. If the virus had R0 of 1.3 it would be easily containable. The reality is that it has an R0 of 2-6 and an effective R > 1 in most except Asian countries.

A R0 of 1.3 with an incubation time of 1 week would not lead to the doubling of cases in 4 days. The whole thing is a crime against math.

Weirdly enough, just yesterday I took all available sequence data currently on GISAID, used it to estimate R0, and got ... 1.3.

The imperial college had it estimated 2.1 - 3.3 before "stay at home" measures. Obligatory influenza is 1.5.

If that were true then how can you possibly explain how rapidly the pandemic is spreading?

It's curiously spreading at the exact same rate that tests are being administered. Curious indeed..

Long time to spread.

Maybe you got the terminology mixed up like I had? `* 1.3` is just about the growth rate per day, which isn't R0.

Intersting. Can you post what you did maybe on a Jupyter notebook?

Um. He doesn't advocate do nothing. He specifically says the opposite. Read the paper. WTF?

Sure he recommends researching vaccines faster, giving people flu vaccines since the flu is more serious than Covid, admitting fewer Covid patients into hospital care, and doing more research so that we're better prepared next time when something actually serious happens. Or if this is serious, doing more research so that the data is the most accurate possible.

I think calling that doing nothing is pretty generous. Since you disagree, what measure that he's proposing did you have in mind?

He seems to recommend the protection of the high-risk slices of populations and campaigns to increase awareness regarding the importance of hygiene. Also figuring out the real incubation period since, he claims, the original patient that was found contagious was already symptomatic, but researchers did not ask.

he seems to advocate individual hygiene and avoiding the public when sick, which also btw seems to be the response that countries like Japan, Taiwan and Singapore have taken, where complete lockdowns or closures have largely been avoided. Together with tracing they seem to have handled the situation just fine.

> together with tracing

This is key — these countries were able to avoid lockdown by testing and tracing early, before the case load became unmanageable. In the US, we’ve missed that opportunity

But US still needs to develop that capacity as quickly as it can, because once quarantine brings the virus under approximate control, testing and contact-tracing are what can eliminate it.

Completely agreed!

South Korea, with one-sixth the population of the US, peaked at 10,000 cases. We haven't passed that per capita case load - and even if we do, lower population density should make it easier to get the virus under control in the US (except in NYC).

We're still a long way from Korea's testing capability. Mass use of surgical masks in public probably also helps.

On Friday, March 20, The Atlantic said over 100,000 people in the US have been tested.[1] More recently, Mike Pence said 250,000 people have been tested.

We're a few days away from Korea's testing capability, if we haven't already matched it.

I think southeast Asia in general handles pandemics better. The people know how to respond and do so more quickly than Americans. Wearing masks, not going on spring break, etc.

1: https://www.theatlantic.com/health/archive/2020/03/how-many-...

300 tests per million people is much, much better than we were a week before that.. But South Korea is at 6,000.


Those are old numbers. Roche alone is sending out 400k test kits per week (over 1000 per million people).[1]

According to [2], more than 290,000 Americans have been tested for the coronavirus (close to 1000 per million people) and in Washington and New York, over 3000 people per million have been tested.

What is South Korea's testing capability (tests per week)? They've had several weeks to get a lead in absolute number of tests performed, but if they've only done 6000 per million people in all that time, we've probably matched them in testing capability.

1: https://diagnostics.roche.com/us/en/news-listing/2020/roche-...

2: https://www.msn.com/en-us/news/us/one-map-shows-how-many-cor...

Taiwan is doing more than public service announcements. Singapore too. Japan closed all schools in Feb. Tracing won’t work without first getting the number manageable.

I saw the videos from Wuhan hospitals 2 months ago and it was clear that the severity of this was off the charts. You can pretty much scale up the situation from a single hospital, because it tells you that it's impacting locally more than the hospital can respond.

You don't need "evidence" of how many are actually infected or what is the correct R or CFR or which way it spreads. Just look how it's impacting the local health care system. If it exceeds the capacity by X % that's how big a problem it is.

Spot on. Too many comments are see-sawing on details of parameters and trade offs but just talk to a doctor in NYC, they are out of room in ICUs and terrified about triaging that will start taking place.

Mt. Sinai in NYC is not currently reporting shortages of any kind. They are preparing for shortages, but are not currently experiencing them:


Perhaps you want to reconsider your news sources.

Hospitals in Italy are currently reporting dramatic shortages of many kinds.

CFR can give you an indication of how long its going to last. If its low and you're getting smashed, that tells you that significant portions of the population are getting infected and it will run out of steam sooner. Higher CFR tells you that the exceeded capacity will last for longer. That will impact the strategies you use.

> Just look how it's impacting the local health care system. If it exceeds the capacity by X % that's how big a problem it is.

Ok, let's look. There are 1175 serious/critical cases in the US [0]. I assume all of them are hospitalized, and mild cases are asked to stay home. There are 900k plus total hospital beds in the US, and 132K ICU beds [1], resulting in the current COVID demand from hospitals to be between 0.1% to 1% depending on how many of them need ICU beds. What am I missing? Before I am accused of not understanding exponentiation, I am all for prepping, but much alarm is about how we are already running out of capacity.

[0] https://www.worldometers.info/coronavirus/country/us/ [1] https://www.aha.org/statistics/fast-facts-us-hospitals

Say it's 1% and doubles every 3 days, that's 7 doublings away from over capacity or 21 days or 3 weeks time. Keep in mind bed to patient distribution is non uniform so we'll see shortage before then. Lockdowns take 12 days or so to see effect (from what Italy is seeing). So really, we have about 9 days to do a national lockdown.

It’s much easier to quantify the harms of allowing business as usual and letting the infection spread (namely # of deaths) than it is quantifying the cascading repercussions of a massive global economic meltdown.

Accordingly, world leaders are being judged based on their ability to contain the spread rather than prevent economic devastation.

As a society we are faced with navigating the delicate balance between how many lives we put to risk vs how much economic turmoil we can tolerate.

With so little data on the latter (economic crashes absolutely can lead to deaths as well), it feels like we aren’t equipped to make educated policy decisions on how far we should go to limit the spread.

I hope after all this we can create a more cohesive playbook for navigating these tradeoffs in the future. Many of these public health orders feel like knee jerk reactions lacking evidence.

Better to err on the side of caution I suppose.

An economy is not something that one should have to shovels lives into to keep going. And in any case, if we sacrifice all the lives this virus could take to the economy, it won't help the economy at all - the massive dislocation involved in the deaths will certainly be far worse than the shutdown, if you really want to think that way.

All that said, part of the collapse of things like the stock market comes through the financial system having been built up into finely tuned but extremely fragile edifice - end QE created an environment of limitless leverage and short-term thinking. This environment created the situation of not having future resources, of jury rigging everything to work in a super-efficient but fragile fashion (the 737Max being a perfect product of this paradigm).

Covid shock is logical result - in another, a more far seeing society might have made preparations beforehand, had an epidemic team in place, etc.

So a lot of things are collapsing because they weren't built to last to begin with, not because of the virus.

> An economy is not something that one should have to shovels lives into to keep going.

I think this is almost the literal definition of the economy. I've been shoveling my entire life and eventually I will die.

>> An economy is not something that one should have to shovels lives into to keep going.

I mean I want to agree in principle, but this is just an incorrect statement. It's a matter of what is a good-enough tradeoff of risk and reward. If you make people drive to work, some will die. If you want to mine lithium, some people will die in industrial accidents that wouldn't have died if you never built a lithium mine. If you are only willing to accept 0.000% risk, then we have to respond with a full economic shutdown whenever there is a flu outbreak, or even a common cold outbreak, because people will die if we don't stop the spread. All economic activity leads to deaths, most of the time the deaths are less obviously linked, and at a much lower rate, so we don't connect the fact that people commute to work in trains, and so the economic activity they are commuting into work to engage in directly causes their death in the form of the flu, train crashes, pedestrian accidents, and so on.

There is also a question of net lives lost, or harm minimization. Economic activity also leads to resources which can be used to tend for the sick and elderly, or better nutrition, or education, and to sum up everything that isn't eating acorns you can find on the ground (except even that is a form of economic activity). I would assume that just letting covid run free would be dramatically worse than shutting down the economy for a few weeks, but then what the endgame is I'm not sure, it really does depend on the death rate in an ICU vs with limited medical support, and the amount of economic harm this causes.

However, I think we can learn a lot from this outbreak. I was very, very embarrassed to wear my filter mask when I went to the store, so I only wore work gloves up until yesterday. Now I'm sitting in bed with a fever wondering whether I'm about to start coughing up blood (probably not, it's still more likely to be the flu). Next flu season (or, sadly, next covid season) I think I will wear my mask, though.

If people start wearing fashionable masks and gloves in the winter, we can virtually eliminate lots of communicable diseases.

> It's a matter of what is a good-enough tradeoff of risk and reward.

This also sounds very short-sighted. Yes, people die in a lithium mine, but in most countries, I'm the one taking the risk to become a miner or not. Understandably, the situation isn't that easy: in some countries, you may indirectly or directly be forced to risk your life for the economy. Yet often, I don't see the physical risk-takers being particularly rewarded for their risk-taking either, with few exceptions. Miners are definitely not one of them. Its a difference between who is taking the risk and who's life is on the line: I don't mind risking my own life. I do mind the government toying with it while a prime minister is sipping tea in his comfy seat.

Reality is, the current economy is maintained through exploitation in one way or another, and its fragile balance is now attacked by a force that doesn't care about our economy. Every time people bring up the economy as an argument, its abundantly clear the people in trouble either can't make a buffer, or don't have the discipline to make a buffer. It wasn't that long ago we were forced to go through harsh winters using the harvest of a possibly failed summer and autumn. Yet today, the economy is in jeopardy if a quarter of all activity is told to shut down temporarily. Why can't make people a buffer? Why aren't people making a buffer? Why aren't governments prepared for this?

Something unexpected can always happen, we're not gods nor do we have crystal balls. In a competent software industry, you'd be summoned for making a fragile software system where traffic stops coming through. Yet now we tolerate the same in regards to our economy. It really is time we take a step back and go on the defense rather than looking no further than 3 months.

> It wasn't that long ago we were forced to go through harsh winters using the harvest of a possibly failed summer and autumn.

Well, not really. Lots of people would fail to prepare and rely on their community, and during times the community couldn't afford to help them, they would starve to death. Lots and lots and lots of people just starved to death. They didn't prepare enough, and then they slowly and painfully died from not eating anything. Lots of rich people said "they should have prepared", but it's hard to imagine what it's like to have to decide whether your children will have to be barefoot all winter, or just not go to school at all this year if you don't decide to sell a few extra potatoes instead of saving them.

There is no trade-off. Exponential functions are pretty binary. We contain this (R0<1) or we let this kill 3.6% of the population, and likely permanently harm the lungs of many more.

A core problem is that we're not looking at how to mitigate damage to the economy. We can handle a month or two of the economy shutting down, no problem. You'll get your new car 2 months later.

Most of the damage is auxiliary: businesses going bankrupt, people defaulting on mortgages, etc. All of that can be mitigated with the right measures.


The economic harm of losing 2 months of production -- or even a year of production -- is much smaller than the economic harm of supporting people disabled by coronavirus for the rest of their lives. That is assuming we mitigate the economic fall.

>> The economic harm of losing 2 months of production -- or even a year of production -- is much smaller than the economic harm of supporting people disabled by coronavirus for the rest of their lives.

That is a tradeoff? I don't understand how you are disagreeing with what I said. You are literally spelling out what we are trading off, the fact that its a very good trade (in your opinion, which is based on expert advise and almost certainly correct, but there are no guarantees) doesn't make it stop being a trade. In fact, that is how all tradeoffs work, one option is better than the other so you pick it.

The economy is someways equivalent to poverty which is highly correlated with mortality rates. Some caution with your reasoning should be warranted.

I definitely agree with you, but I want to see more data. Without broad testing it’s difficult to ascertain the true death rate of the virus (many infected are asymptomatic).

But my hope is we can come up with similarly effective measures (e.g. require n95 masks in public, keeping the elderly at home, offer voluntary isolated infection to low-risk individuals to increase herd immunity, etc) that can achieve both.

South Korea did extensive testing when they successfully eradicated the virus. As user rramach points out, Ioannidis cherry picks the data in many ways, including ignoring the extensive data of South Korea. Not did was Koreans' testing program extensively documented (by Korean scientific institutions, The Western press, and etc), we know they found most or the larger portion of cases because they were able to bring new infections and deaths down to zero.

(e.g. require n95 masks in public, keeping the elderly at home, offer voluntary isolated infection to low-risk individuals to increase herd immunity, etc)

These "get the economy going" measures are totally nuts. You know 10-20% of even fairly healthy people get pneumonia and require hospitalization for virus. Most young people survive but many of those surviving suffer permanent lung damage.

Further, people between 50 and 65 make a huge contribution to the economy and taking them out for an extended period would be highly costly like all this is highly costly (but quarantine should eliminate the virus so could be even quick). Just much, quarantining just some people would require moving a vast number of people from place. IE, what happen with young people living with old people (as happens a lot). The movement of people from place to place would naturally ... spread the virus extensively. More over, where do you get the extra places for either the young living or the old leaving? The UK talked about plans, true but abandoned quickly when infection began because they are obviously impractical fantasies.

Quarantining everyone is extremely simple and just requires doing what South Korea did but on a large scale.

But see, this is the kind of exaggerated information Ioannidis is concerned about. South Korea has not brought new infections and deaths down to zero.

”Most young people survive but many of those surviving suffer permanent lung damage.”

This is not true. You are repeating misinformation.

For the record, in March 2018, 58 000 people died in Italy. We will see how many died this March 2020 :

http://demo.istat.it/index_e.html (see green section on the right, By Month)

Also the following study from August 2019 (before covid19) shows that Italy has more deaths due to influenza every year than any other EU country :


> shows that Italy has more deaths due to influenza every year than any other EU country

I’ve read that if an elderly person dies in Italy while they have the flu or coronavirus, then that is recorded as the cause of death.

Some other countries put down other reasons like diabetes complications, or heart failure. Possibly due to pressure from insurance, or avoiding liability for iatrogenic diseases, or avoiding KPIs targeting lower death rates for infections in hospitals.

You are jumping to conclusions based on a few numbers, without understanding the background of where those numbers come from or how to validly compare them between countries.

What proves me that you understand them better than I do?

Nothing. But you are the one making conclusions based on some data series. If Italy is an outlier, are there papers about it?

> Accordingly, world leaders are being judged based on their ability to contain the spread rather than prevent economic devastation.

Actually I am judging countries by their ability to face facts, act proactively Over the last few months, act responsibly by making sensible decisions that are effective in controlling their outbreaks, while keeping their economy functioning.

A++ for Taiwan (they started acting on Dec 31st, and they had preplanned what to do if faced with a virus outbreak). Very few infections, under control, economy working at 100%.

A+ for South Korea, Vietnam, Singapore, Japan and South Korea. Fast actions, effective tracing, economies running.

D- for US: little pro-activity, rampant community transmission, head of state in the sand, focusing on not spooking economy while ignoring downside risks to same, extremely poor planning with poor medical stocks. Health system of many states likely to fail. Now headless chickening, with every state left to act for itself (except for some negative interference from GOP). Meanwhile democrats dropped ball on opportunity of a lifetime to act well and help before the shit hit the fan.

B for China: first to have to act, zero pre warning. China acted and seem to have done better than many other countries that had plenty more warning (yes, China did downplay, but that seems to have been internal and not aimed at other countries. Either way, other countries had enough information from the 31st December or at latest mid-January but didn’t act).

C- for New Zealand: some late actions, tried to protect tourism industry and now the whole economy is paying price with shutdown. Extremely poor communication with population (trying not to worry everyone?). Mostly wasted months with inactivity, lack of planning (from my POV watching what info was given to a nurse), lack of emergency medical equipment. However expect that we’ll now respond well given shock treatment of shutdown of whole country,

If South Korea deserves two A+ maybe you could award them an A++ :-)

Would you (or anyone) care to add some countries in Europe for comparison?


What do you like about their approach?

If 10% of the population needs ICU and dies because they cant get it, then there is no business as usual.

You make a valid point.

At the same time, economic problems affect everyone while it seems that covid-19 harm scales with age.

No easy solutions to be sure, but I have hope more data becomes available soon so we can implement more nuanced policies to achieve similar containment while preventing massive unemployment. Testing random samples of the general population would be a good first step.

In Italy, median age of people who have died of Corona is 83 for women and 79 for men [1]. Normal life expectancy is lower than that in the United States [2]. Lockdown measures will have severe impact on GDP, and GDP is correlated with life expectancy [3].

It can easily happen that by killing economy in order to save lives, we may actually be doing the opposite in the long term.

[1] https://www.iss.it/web/guest//comunicati-stampa/-/asset_publ...

[2] https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

[3] https://ourworldindata.org/grapher/life-expectancy-vs-gdp-pe...

Normal life expectancy is lower than that in the United States

I read on your link that average life expectancy in Italy is 83.4, about 4 years more than US (at 78.9). So I don't get your point unless you are speaking about the age structure: https://en.m.wikipedia.org/wiki/List_of_countries_by_age_str...

The US might not be the best country to benchmark other developed countries against, so.

Personnaly, I have issues with people using economic data, read money, to define the value of other peoples lives.

It's not just 83 year olds on the ventilator. What's the economy going to be like with millions 'working from hospital?'

That's an "if" though.

It's kind of a shame that he's wound-up writing an article like this. It certainly discredits him in my eyes and it seems utterly opposed to stated principles of evidence based medicine.

As others have noted here, the article calls for action based on very little data and lots of ad-hoc speculation. It also cheery picks its and falsely claims we don't have enough data.

I wonder if thinking all research is false too much lets jump to the idea you dream any opinion that's convenient.

Moreover, Ioannidιs has absolutely jumped into advocating this position from a partisan political position, with his positions picked up by partisan political sites such as the dailywire.com; Headline: "Stanford Professor: Data Indicates We’re Severely Overreacting To Coronavirus" https://www.dailywire.com/news/stanford-professor-data-indic...

What Ioannidis is advocating is to do nothing until we have scientific certainty of what the correct decision should be, and only then act. What he's not taking into account is that the situation is unfolding right now, and if "do nothing" turns out not to have been the correct decision then you can't go back and change that. If we overreact and cause 20% unemployment for the next year, then a harm has been caused, but if we underreact and 20 million people die, then another harm would have been caused. In the face of this alternative, with not enough data to know the probability of outcome #2, but with enough to know that it can happen, then I think it is rational to choose the route that most surely avoids it.

> if we under-react and 20 million people die, then another harm would have been caused

And it's worth noting if anything on the order of millions of people die, then there going to be economic impacts -- that's a hell of a demand crater and productivity shock.

Worst case. Instead of quickly developing herd immunity, the US ends up with persistent low level outbreaks over two to three years like the 1918 flu. If that happens the rest of the world will quarantine us.

What are you trying to say? If the rest of the world would develop hard immunity, they would have no need to quarantine you.

Assume they don't, assume they manage to stop community spread of the disease instead. Then they don't have herd immunity.

Imagine this. Your driving down the freeway at 60 mph, accelerating at 30%. The car in front of you puts on the breaks. Before you react, you first gather your speed gun, check the deceleration rate of the car in front, then calculate based on your speed when you should put your breaks on. I'm all for the scientific approach, but in this particular instance, our survival instincts need to take precedence. Please, we need to stop peddling evidence based approaches for an exponential situation.

Stepping on the breaks perfectly align with what we know scientifically. People think of science as something very narrow – but it's also evidence and rationality. What China and South Korea have done works. What other alternatives do we have?

What all the western countries have done. A half arsed lockdown, not like China's, without testing-and-tracing, not like South Korea's. There's still no evidence that a half arsed lockdown is unsuccessful and good reason to believe they generally aren't.

Except China and South Korea did different things.

Which is consistent with what I wrote.

Except for every time you hit the brakes, they heat up and stop working after some time.

There are significant economic impacts of the measures countries are taking, and the reality is people will only put up with quarantine so long. I think it makes sense to spend some time looking at the evidence because shutting everything down has significant negative impacts, both economically, and potentially with the spread of the virus if people give up on quarantine too soon. Given the evidence I have seen current measures make sense (at least in Ontario) but saying that we should just follow our survival instincts seems wrong, especially when everything is so distorted by the media.

It's an interesting analogy. Instinctual human response is in a way letting nature take over, and suspending analytical thinking. Govt policy making and intervention is more akin to latter, wouldn't you say?

Let's check back on this piece in...2 weeks, say, when there are 10,000+ Corona deaths in the US. Well see how it ages then.

Source: https://www.nytimes.com/interactive/2020/03/21/upshot/corona...

427× 16 =11102

Epidemiology is not putting numbers in excel and running a formula to generate a chart. Which seems like what half the world is doing now. US has already the same number of cases that Italy had one week ago when it had 4000 deaths (only 500 for US at this point). So some data is wrong and you can't model every country in the world based on data that is just plain misleading (Italy). Median age of tested people in Italy is 13.3 years higher than the general population median age, in Germany, the difference is just 0.7. Stop treating Italy as being the only point of truth and other countries (like Germany) like the anomaly.

I think people should be allowed to express a different opinion.

We should criticize and point out mistakes, but let's not demonize.

The world is complex and interdependent, overreacting can be just as bad as not doing anything, what we need to find is the right balance between the two approaches.

If we check back and he was right then what? You, like everyone else, will be elated.

Completely dismissing certain observations early on as 100% wrong is not the right approach. One has to navigate the path balancing the tradeoffs.

That rate is highly unlikely to hold. There's enough stay in place restrictions in effect to drive it down after about a week or so.

FWIW, at this point, it looks like NYC is going to take a huge hit and the other outbreaks (Seattle, California) will look mild comparitively.

Washington state doesn't have a statewide lockdown, I don't know if even Seattle has a lockdown. California is doing the best but there are still crowds defying the lockdown at beaches and parks. Just as much, grocery stores are open as usual and even with most people trying to do social distancing, I'm doubtful you're clamping that hard on the infection, unfortunately.

I think the best is that when fatalities spike here in California, we're in better shape to intensify the lockdown.

The measures that have in place in both states have drastically clamped down on infection rates - the growth in WA is barely above linear at this point (and remember you are always looking 10 days backward). CA is also sub-exponential. Look at the data (in the presence of high testing):


If you look at thermometer data (less accurate, but a good predictor), there's little problem going forward in either state. (but serious problems in the NY metro area):


To my eyes, California just looks slower exponential and Washington is ambiguous. A few days of non-growth can be randomness or reporting problems.

But I hope you're right! We all need to do our parts.

I'd also note that things are getting "hot" in other states and each has it's problems.

At least some of WA's lower numbers recently were due to fewer tests performed.

Washington does as of 5:00 pm PDT today.

I've dug through everything I can find. I'm feeling really stupid at the moment, but I cannot find a confirmation of that 5pm start time, though it does appear to start today and "immediately." It runs through April 6, but could be extended.

Tweet is from 6:50pm: https://twitter.com/GovInslee/status/1242267557295321090



That’s when the announcement of it was broadcast, which is why I used that time.


> There's enough stay in place restrictions in effect to drive it down after about a week or so.

Why do you think that?

I have no strong opinion but I really hope that the fact that the US is not dense, and people are not very tactile, compared to European cities will help us.

Deaths lag measures by more than that. We might see Washington’s measures kicking in strong by then but NY will probably be some time.

Yes, death lags and testing is inaccurate. We're flying blind.

I wonder. Willing to admit incorrect if parent prediction proves true? Or pivot if not to a new supposition and declare victory? (I'd say 3.5 weeks myself.)

I fear we will be well past 10,000 deaths in the US in 2 weeks.

Well deaths in the US only for flu were 50,000 last year. Still 5x less.

Corvid 19 deaths are doubling every 3 days in US and a few other countries. Do the extrapolation.

In 47 days, twice the population of the Earth will be dead.

Of humans or crows?

Even in Italy, the National Health Institute said that 88% of the declared "dead by covid19" had in fact at least 1 or 2 other pre-morbidities.

If a 80 years old dies from heart attack and is tested positive by covid19, it will count as "dead by covid19".

The numbers we see in the news of "CFR" for the covid19 are, in my opinion, inaccurate. The number only shows the spread of the infection, not its actual fatality rate.

CFR is a death rate of the population with particular medical conditions by definition. It is a correct usage.

CFR doesn't translate to the additional death rate, but it does contribute to the death rate by unspecified amount. In particular high enough CFR directly translates to the additional death rate when it exceeds the original crude death rate.

In anything Italy is undercounting covid-19 deaths:

The mayor of Bergamo, a city in northern Italy devastated by coronavirus, said on Monday that the actual death toll from the pandemic is likely several times higher than official count.

Giorgio Gori told NBC News on Monday that the total deaths in Bergamo are three to four times higher than during an average year, signaling that the virus is killing many more people than medical authorities have reported.

"We [have] evidence now in our territories that many people are unfortunately dying in their homes or in the residence for [seniors]," Gori said via Skype. "They are not officially tested because the test is only for people that go to the hospital with serious symptoms."

Doctors are also reporting that patients who seem to be improving are suddenly arresting due to the virus. So counting those victims as "dead by covid19" seems to be correct.

Trillions will die.

You can only extrapolate so far.

People seem like computers these days: they only think in logarithms, they "forget" to add some common sense.

The number of coronavirus deaths is already over 10,000:


Updated: comment was only for US since John is based at Stanford.

China quarantined 700 million of its citizens for fun and it still killed thousands. I'm sure that they regret the policies they implemented right now as they've finally gotten a hold of the outbreak.

Edit: I was being sarcastic here. China messed up the initial response but their draconian tactics worked well.

Why would they regret it? I don’t follow your reasoning. They got a hold of the outbreak precisely because they ramped up quarantining

I was being sarcastic.... it never translates well over text.

I must have have a naturally sarcastic inner monologue, because your sarcasm came through loud and clear to me.

I thought it was so outlandish that no one could actually believe it. Then I thought about my crazy uncle who still thinks this is a bioweapon released by the Chinese on its own citizens.

Yes, only thousands. The point of the quarantine was to avoid deaths of millions. China has flattened thoer curve, no one else has.

South Korea has. It's still going up but it's flatter than it was: https://coronavirus.jhu.edu/map.html

"And yet it moves" Galileo Galilei https://en.m.wikipedia.org/wiki/And_yet_it_moves?wprov=sfla1 . I agree that in many axpects the situation is exagerated, in primis by general panic. But If the Covid is not much worse than flu why in Italy we have military trucks convoy that transport death to southern regions because the wait line for crematory in North is becomed too long?

In normal times Italy has a death rate of 10 deaths/1000 people. Which translates to ~1500 daily for a population of 60 millions. What were they doing previously with the dead?

Those people haven't stopped dying. As a comparison, 700 people have been dying every day for covid-19 in Italy. Also deaths are not (yet) evenly distributed but greatly concentated in the north.

> Those people haven't stopped dying

Right... they're dying from covid-19.

You are building the world around your arguments. You have no proof but still talk, talk, talk.

What does that even mean? The world is what it is. Italy is seeing huge increases in background death rates at the moment, owing solely to COVID-19 (while at the same time seeing diminished deaths from things like traffic accidents, though not remotely enough to make up for all the extra COVID-19 deaths).

What is your argument exactly? It's a fact that Italy is running at a higher overall mortality rate owing to COVID-19.

You didn’t refute him/her.

They buried or cremated them. Unsurprisingly, the system can't handle a sudden one-of-a-kind spike.

Covid-19 deaths are not spread out over the country. There are places where people is dying at four times the usual rate.


Mortality across Europe has drastically declined in the past few months. Seems like everyone sitting at home is saving a ton of lives. Fewer accidents, fewer sicknesses, maybe even people eating a bit healthier.

Why stop locking yourselves indoors when so many lives are being saved by not leaving home?

Mortality _always_ falls at this time of year. As you can clearly see on the chart.

From your own link:

> Pooled estimates of all-cause mortality show normal expected levels of mortality in the participating countries.

The issue isn't that COVID is killing a lot of people right now on a continental level; in the scheme of things it's a statistical blip. The issue is the _potential_ deaths if it gets broadly out of control. If all Europe had rates similar to Northern Italy, this graph would look very, very different.

Europe was not sitting at home for months. Few weeks basically, including most of Itally.

The website itself says they have several weeks of delay in reporting and outbreaks are focal in nature

It kinda proves the point that covid19 alone is less deadly than many other causes

I don't see how you've come to that conclusion.

Did you look at the charts? If you didn't know there is a global epidemic, would you have been able to see it on these curves?

In France and Italy, there were between 50000 and 60000 deaths per month in 2018 and 2019. If most of those people died because of 2 or 3 accumulated factors, covid19 would be just one more factor. But maybe those people would have died one month later anyway without covid19

I don't understand people like you who can look at the current numbers and say "Oh, it's not so bad" while also conveniently ignoring that the numbers are growing exponentially. People that are raising the alarm are not talking about the numbers now, they are talking about the numbers in the future if nothing is done to address it.

The numbers are growing exponentially until they don't. You can argue that they would have, had extreme measures not been put in place, and there are reasonable arguments for that. But you have to keep track of the fact that it is an argument you're making and not an observation directly from the data. Otherwise you won't update properly on new information.

For example, one thing I've seen people worry about is that there could be huge numbers of undetected infections; one guy quoted me 1.5 million for the US's 40k known cases. This would be wonderful news if true - death rates and hospitalization rates are 37 times smaller than believed, and the theoretical peak is nearer than we'd thought? But I've universally seen people present these scenarios as bad news, because they've internalized "numbers going to grow exponentially" as an observed fact rather than a contingent conclusion.

In every country where we have seen case load sigmoid out, there have been heavy mitigation and suppression efforts put in place that preceded it by several weeks. Thus far, many European countries and the US have only just started to get serious about this. Therefore I am fairly confident that we will be in the exponential growth phase for a while longer.

This is a new virus, _no one_ knows about the future. Data we have now could be biased toward an hidden variable we didn't figure out yet.

One can predict the future with bounded error bars though. Weeks of observation yielded some numbers including R0 around 2 and CFR around one digit percent (yes, we still don't know if it's around 1% or 2%, but it is certainly not 0.1% [1] or 10%), so 0.1---5% of the total population will die somehow due to COVID-19 if absolutely nothing is done. For the reference, less than 1% of the total population dies each year in developed countries. Enough reason to be alerted.

[1] CFR is a function of age (notably among others) and more careful analysis would involve demographics. Still, the rough order of magnitude doesn't change.

Well, why don't we just wait around and sit on our hands until hundreds of thousands are dead and this hidden variable makes its presence known? Sounds like a winning strategy to me.

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