It amazes me that the entire strategy of the U.S. government is "Everybody stay inside and wait until this goes away". Two months into this, that still seems to be all there is.
"And what if it doesn't go away by itself?"
"Then we stay inside for another month!"
We're not waiting for it to go away by itself. We're keeping the rate of spread below the threshold where we overwhelm our hospital capacity. This buys us time to scale testing and develop things like contact tracing, drugs, and vaccines that will be our weapons in the next stage of this fight.
Not sure. My other comment in the thread got hit with a downvote at basically the same time. If there's a constructive discussion to be had, I'd like to have it. If I got something wrong, I'd like to be corrected. But I'm getting the sense that I somehow hit a nerve with the comment above about the strategy not being to just sit and wait, which is interesting. If theres a way to improve the tone of my communication to not generate some reflexive downvotes I'd also like to know that.
On busy HN topics, you can assume downvotes are just part of the noise and not worry about it. The arrows in the UI are so close together, it’s easy to hit the wrong one by mistake.
(Less charitably, for a busy topic the odds are there’s someone around for whom it happens to be their conspiratorial hobby horse and this manifests as downvotes on anything “mainstream”.)
I think to some of us "flatten the curve" is starting to feel like a March strategy to a May problem. A month ago everyone was concerned about ventilators and hospital beds and as far as I know the USA never hit capacity outside of, possibly, New York City. It's fantastic that we never got there, but now we need to focus on the new problems, which are vastly more complicated. We flattened the curve, but now we're staring down the barrel double digit unemployment, food shortages, businesses and jobs which will never come back, and probably many things we can't even imagine at this point.
The problem with preventative measures is that if they work, people always thing we overreacted. The curve is staying flat because we are staying in lockdown. If we opened the curve, the infection rate would start going up again on its S curve to herd immunity. It'll be worse if we open up and then have to go right back and shut down again. That'll probably hurt the credibility of future efforts to open up if anything, since if someone you know in your community was one of the fatalities after the governemnt said it was safe to open up and the pandemic roared back, why would you trust the government when they say that this time you can actually open up for real?
It seems to be the strategy in the sense smashing a window with a hammer is a strategy to kill a fly. Hospitals are so empty that workers are being furloughed, say nothing about the unused field hospitals and naval ships. The Lombardy scenario does not appear to be on the table.
Many positions at a hospital aren't related to treating someone with coronavirus. For example, elective and non-time-sensitive surgical departments should have nothing to do right now.
There are only about 7,300 ICU beds in California [1]. If we're at 20%, that's only about two doublings before people start being rejected for care. In March, we were seeing a doubling every few days, with ICU requirements following [2].
I'm not disagreeing that we need to let people be infected if we want to achieve herd immunity, but I think it's a tough choice in deciding which portion of the population you put out to partially die, since letting everyone out at once will result in some high R0 value again, and a vaccine may be on the way. These politicians are in a lose-lose situation here. Anything they do will result in someone being harmed.
The scale is kind of the entire point. The logic behind Flatten The Curve is preventing excess deaths that result from a collapsed health care system. Even NY, which was literally sending covid-positive patients back into nursing homes, didn’t get there.
We didnt overwhelm hospitals, we have contact teaching apps developed, we have a drug that's likely to be approved tonight or tommorow, and we have multiple vaccines in trials. We should have done a far better job early on, especially with testing, but the biopharma sector has risen to the challenge to move faster than basically every before.
So, you are right that the "correct" and reasonable thing to do would be to use the social distancing to buy time to set up things to control the virus when you relax social distancing.
Not so much a vaccine -- "18 months" is actually already very optimistic for a vaccine, it could be years.
BUT. To increase your medical capacity, so that when cases go up you can handle them. From making sure there's enough PPE to making sure there's enough staff-- to setting up things like daily checks on people isolating at home to see if their risk level has gone up and they should be hospitalized (people can go from okay to dead very quickly with this disease).
And then also -- setting up an enormous testing regime. If you don't know what the infection rate is, you are "flying blind" -- you need to know when you relax 'lockdown' in some ways, how much of an effect this has on infection, so you can adjust accordingly, figure out the ways you can optimize for maximizing social and economic activity while minimizing infection. You have to know the infection rate to do this!
And then, based on testing, you need contact tracing (and more testing) to try to catch infected people before they infect others, to keep slowing down the infection rate even while relaxing "lockdown". And you need comfortable (voluntary) isolation facilities so people can be isolated away from their households so their households don't get infected -- and can be closer to medical care should they need it.
And you need all kinds of education and social support to make people comfortable and secure enough to increase compliance with all of this.
So okay, yes, that is the point of the waiting. Or... it's supposed to be.
The problem is we're doing really bad at setting this stuff up. So that's the point... but it's not clear that's what we're doing. This stuff should have been ramped up, with a seriously "apollo moon shot" level of focus and investment -- starting in january. But at the end of April, we haven't made too much progress at much of it.
So it can appear that all we're doing is waiting... for, like, some kind of miracle, or for it to go away. Which will not work.
So the arguments over the "lockdown" in terms of "have we waited long enough or should we wait longer" are totally missing the point. The "lockdown" sucks, it is TERRIBLE. But to end it, we have to as a society be doing things that we are somehow really failing at doing. It is somewhat baffling, and highly alarming -- how is one of the richest countries on the planet, a huge locus of medical and public health expertise -- doing so poorly at this. And instead of expressing alarm about this and collective resolve to make it better... people are fighting about "the lockdown" as if it is an independent "wait it out", have we waited it out long enough? As if it is unrelated to the things we gotta be doing to make 'long enough' happen. It is a mess. It's gonna get worse before it gets better, at this point.
I think there are serious issues which we need to start addressing in this lockdown discussion;
1) Hospitalization rates have been shown to be about an order of magnitude lower than estimates.
2) The most effective treatment is no longer limited by availability of invasive ventilation but rather widely available non-invasive ventilation and frequent repositioning.
3) Hospitals across the country are mostly empty and furloughing workers because their “elective” (e.g. chemo and surgical) wards were all shut down and now everyone is afraid to go to the hospital even when they’re having a cardiac event or a stoke
4) A steady drumbeat of serological studies are showing IFR is lower than estimated, and asymptomatic or mild spread much more prevalent. NYC hospitalization rate is < 2% based on serology.
5) Now that the scale of the economic devastation is becoming clearer and the scale of non-COVID deaths caused by lockdown are coming into focus, a clearer headed calculation can be made about the true immediate trade-offs of a lockdown, to say nothing of long term effects.
I’m personally concerned that we’re going to blow our chance to gain significant widespread immunity during summer months where IFI prevalence is low and vitamin D levels are high. A surge next winter concurrent with a flu spike is the worst case scenario.
We’re also starting to see stress on the food supply chain, or if it wasn’t going to be an issue it probably is now with the latest media coverage enough to provoke some major hoarding of meats / protein in the coming weeks. It’s almost comedic when you can’t buy toilet paper, it’s a different kind of problem when major grocery staples go missing.
These are all important points which weigh on the side of lightening up on restrictions. It’s a spectrum, and right now we are pressing full tilt to lockdown when the actual purported and scientific purpose of lockdown is no longer being served.
I'm from Australia where our government is slowly easing restrictions because our daily case count has been in the single digits for multiple consecutive days now, and even then it is very gradual. Reopening resturants and bars is still very far on the horizon.
In the US, even with full lockdown restrictions for several weeks now, the daily death count has hovered at 2,000 for almost two infection cycles (first >2k death day was Apr 7th).
If 'full' lockdown only achieves stabilisation of the death rate, how is easing restrictions, which as far as I can see only rationally relies on the still-shaky evidence from serology studies, what exactly is the plan?
I genuinely ask this in a state of disbelief at the current "end lockdown" narrative circulating in the US. Here in AUS/NZ the Gov didn't fuck around; we locked down, had brutally strict measures for 6 weeks now, and at this point nobody is rushing to re-open (except for a few regional cities that haven't even had cases), while the US has been at 2,000 deaths a day.
As long as you can keep your borders effectively shut for the next year or so I think you’ll be in great shape. That ship has sailed in the case of the US.
As I understand it, there is a bimodal approach to managing an epidemic. You’re on a totally different pathway of successful suppression, where you’ve never actually seen exponential community spread. Your endpoint is not herd immunity.
The US probably was seeing uncontrolled exponential community spread in ~January. There are major metro areas which have 20%+ prevalence. The only endpoint left for the US is herd immunity.
So you would not expect the same measures to be taken, as long as AU is striving to maintain suppression I think that means your local measures will have to remain quite a bit stricter than a country trying to obtain herd immunity as quickly as possible.
EDIT: (Since HN won’t let me reply) You’ve had a total of 6,700 detected cases and 63% of those were imported.
Your total community spread over this entire time was what we see in two days in Massachusetts.
You’ve done 500k tests total, the US is presently running 160k tests a day. Harvard just came out with a study saying they thought we would need to get to 5 million tests a day. This is what I mean by bimodal.
Show me evidence that there is 20% prevalence please. What I have seen so far has been very limited study with very shaky evidence (the RKI in Germany back pedalled pretty quickly on the results of the antibody test for example)
NYC's initial antibody study tested 3,000 people and came back with 21.2% positive.
NYC expanded their antibody testing to 7,500 people last week and as of Monday it had come back with a 24.7% positive rate.
> Building on an initial testing run of 3,000, another 4,500 random New Yorkers have been screened since last week for antibodies, which would indicate that their immune system battled the bug, the governor said in his daily Albany press briefing.... Some 24.7-percent of those tested in the city were found to have antibodies, up from 21.2-percent in the first round.
We had an R0 greater than 1 for a long enough period that if the response wasn't on point, we'd be in a similar position to the US.
One aspect that's missed is our testing rate - 500,000+ tests performed so far with a 1.2% positive rate. That's half of South Korea's.
None of this is to blow my Aussie horn. Whilst I'm proud to live in a country that handled this crisis well, I can't help but feel frustration at many of the remarks that Trump has said, particulary comments such as "can you really believe the numbers coming out of these countries?" it's just baffling considering that the AU-US alliance is unshakeable and there is no reason to mistrust our figures.
It's difficult for us to believe any country's officially reported test numbers because ours (and most European ones) are known to be at least order of magnitude below the actual number of infections.
That was the strategy. If that was still the strategy we'd be opening up much faster, as was observed in sibling comments, hospitals are laying people off now and other such things.
Since we are not opening up, that does not seem to be the strategy any more, regardless of what is stated. What is done matters a lot more than what is said.
What is the strategy now? That's a good question. Based on the actions I see, I find it hard to construct an answer to that question. But there sure does seem to be an unhealthy large dollop of deciding that Lockdowns are Rightthink and Opening Up is Wrongthink. I've noticed how few people advocating for continuing the lockdowns for months more provide concrete metrics for when we should stop.
Because most of the sensible concrete metrics you would have based on the whole "flattening the curve" plan have been met.... yet... here we are.
The nicest and happiest interpretation is just lag time, since of course you can't turn on a dime and change policy on a metaphorical Tuesday at 3:14:34 pm just because you finally hit a milestone. I'd put more stock in that interpretation if there wasn't such substantial attacks being put forth on what seems to be the very idea that some places may be able to open up now. But if in the next couple of weeks we do start substantially opening up (NY may not be able to, maybe a couple of other areas) then perhaps it was just latency in the end.
Hospital layoffs aren't necessarily because they have overcapacity. Elective procedures were canceled, and all non-covid departments were basically shut down in NYC at the peak. In NY, the plan is to start reopening on May 15, with frequent testing, with the metric being the replication rate (trying to keep R0 below 1.1). There are plans. The US did not approach this crisis in a centralized way which we probably should have, so opening up is going to be a collection of 50 plans as well, but that's not no plan.
"Hospital layoffs aren't necessarily because they have overcapacity. Elective procedures were canceled, and all non-covid departments were basically shut down in NYC at the peak."
There is this peculiar internet pattern I've seen many times now, where people seem to believe if they can explain why X happened, they can therefore prove X didn't happen. It is one of those things I just can't wrap my head around. You say in one sentence that hospitals don't have overcapacity right now, then explain exactly why they do.
That's overcapacity. They shut down everything to make capacity for the incoming crush of Covid cases, and those have almost entirely not materialized. So we are grossly overcapacity for Covid cases, in the vast majority of the country.
"In NY"
New York is the outlier. It is not what the entire country should be basing its plans on. It isn't even what the entire State of New York should be basing its plans on.
"so opening up is going to be a collection of 50 plans as well, but that's not no plan."
I didn't say there was no plan. I'm observing that the stated plan is deviating from the actions. Almost everywhere, we have nominally hit the benchmarks that were the initial trigger for re-opening things, but for the most part, anyone reopening things is doing it against massive political pressure and criticism, while people, yea verily even people in power like governors, are pushing for it to continue for more weeks or months with no end criterion given.
I'll reiterate that one possibility is just lag, but if in another month there's still a lot of lockdowns going on in non-outlier areas, that's clearly not going to be what's going on.
(I know there's a lot of grumbling online, but my personal position is, my job is nearly unaffected, our schools are already closed for the rest of the year regardless and I'm planning on staying home no matter what the state does, and I live close enough to one of the outlier areas that I would be perfectly fine with me personally still being in significant lockdown in another month. But what's good for me isn't what's good for everybody in the country.)
Testing and tracing is still very much the strategy, just that we still don't have the capacity for it.
The head of the federal government has utilized the defense production act to force people to work in meat processing plants where the virus is rampant - but has done much less to get testing, tracing, and PPE unblocked. States appear to be struggling as well. Hard to tell about a lot of the details; there's definitely a 'fog of war'.
Yeah, at this point how likely is COVID-19 going to be eradicated? Even with a vaccine?
As far as I know we have vaccines for many viruses which aren't eradicated, but maybe that's just because we haven't vaccinated enough? Then again, if herd immunity works then why isn't chicken pox eradicated?
At this point it just seems like it's here to stay like the seasonal flu and we're mostly just doing economic harm to ourselves...
Chicken pox goes dormant in nerve cells then it reactivates after immunity fades (shingles). That's how new generations keep getting it. Now there's a vaccine given to children but the world is still full of us carriers for a long time.
There is a huge number of flu strains out there so that's a different kind of problem. Along with the fact that the immunity provided by a vaccine is not 100% anyway, and often much lower for influenza viruses.
Of course coronaviruses have been around a long time too (many as common colds) without much (any?) success in combating them.
> Now there's a vaccine given to children but the world is still full of us carriers for a long time.
Strictly speaking, the chickenpox vaccine is a live (attenuated) virus, so even the vaccinated will continue carrying it. I was born in the mid 90s, so I am part of the first generation who got the chickenpox vaccine. About 10 years ago I had a small outbreak of shingles, just on part of one hand.
It’s weird to think about all the viruses that live inside us without us realizing 99% of the time, until we do.
Even if we can't eradicate it, an effective vaccine should be able to get it to the same state as tuberculosis, where the average person in a country with a good health system doesn't have to worry about it.
The day that my work group decided to start working from home, there were roughly a couple thousand reported C19 cases in the US. The conventional wisdom among the people around me was that we stay inside until the game changes, which could happen for a variety of reasons:
* We gain a definitive understanding of how the virus works: Its prevalance, severity, etc., and can adapt our plan based on that information.
* Effective vaccine, treatment, etc.
* Massively scale up testing, tracking, etc., so the spread can be controlled effectively.
Sure. What bugs me is that testing is still minimal, and there doesn't seem to be any attempt at setting up a tracking system.
Vaccine/treatment is still at least a year away, and a year of lockdown doesn't seem feasible
"And what if it doesn't go away by itself?" "Then we stay inside for another month!"