COVID-19

[slsdly]

@sky, I'm not sure what the government will actually do, but I've seen the argument in Ontario that we don't test enough to trust confirmed cases, so we can only look at the death rate. Comparing to China, the argument claims they ended lockdown when they reached zero or near zero number of deaths per day for 3 weeks. From that, they argued mid June was a potential (early) target to begin lifting the first set of restrictions. Supposedly Austria started lifting lockdown well into the double digits, so I guess they will be a useful barometer for whether it could begin earlier.

[slsdly]

Perhaps an interesting question to ask is, when lockdown is lifted, will you act differently immediately or will you wait? Given it appears to take a few weeks to really know if lifting the lockdown was a good idea, I intend to remain under personal lockdown with all the same rules for an extra month (given my job allows that flexibility).

[sky]

My lifestyle has not changed much from before Stay at Home to after. But the weather is warming up, so I will want to go outside more. I had a flu in March that could have been Covid-19, but I won't know until I am tested. If I have not already had the virus, I expect to be exposed to it at some point. As long as the hospitals are not overloaded, I plan to take cautious steps out into the real world, once the Stay at Home order is lifted.

[Bankai]

when lockdown is lifted, will you act differently immediately or will you wait?

I think lifting lockdown will be done in phases, I can't imagine it being done all at once. So low-risk places will be allowed to re-open first (schools, small shops, manufacturers, etc.) followed by bigger businesses, restaurants, and bars with some restrictions on the number of customers, and the likes of sports stadiums, cinemas and night clubs at the end of the queue, depending on how the situation evolves. Shielding vulnerable groups and the least severe restrictions will likely be in place for many months to come, possibly until herd immunity is achieved. This means that I'll be probably working from home for the remainder of the year at least. I can't say I'm sad about it. As for businesses reopening, I don't think I'll be first in the queue - we rarely eat out anyway and only go to the cinema maybe once a year so not a big loss. So overall I don't expect us to change much of anything from the current routine. The only thing I might miss is going on holiday abroad - this will need to wait until next year. I can live with that and the flipside is that savings will go up quite a bit with most of the discretionary spending cut.

[Fish]

When lockdown is lifted, will you act differently immediately or will you wait?

When lockdown is lifted we will definitely wait and observe before changing our current practices. A month or two would be preferable but 2 months already seems like an eternity given we haven’t yet isolated for that long.

For a while we would need to get even more strict about distancing from other people around the neighborhood as human networks become increasingly interconnected relative to present.

If this pandemic goes to 2021, are forumites planning to self isolate for an entire year or more?

Since this would entail homeschooling kids while both adults in the house perform FT remote work, there would be an element of difficulty to this. I would also not want to limit friends and family interaction to video meetings for another year+. Though if we wear masks and physically separate while in person then it’s little better than video in my opinion. I consider this a much greater loss than the restrictions on movement or use of public areas.

The reason for our relatively early isolation was predicated on avoiding unknown-unknowns. The world is rapidly gaining knowledge about the transmissibility and severity of C-19 and the situation is more of a known-unknown at this point.

Our present plan for unwinding the isolation is to send the kids back to school in the fall while continuing to WFH into 2021 if our employers allow it. Not yet decided when we’ll resume normal social interaction for higher-value relationships or in-person shopping of groceries.

[Ego]

The White House released their "Opening Up America" plan.

https://www.whitehouse.gov/openingamerica/#criteria

[Ego]

I think maybe some here are not realizing just how much that isolation has isolated them from what is actually happening out there. The true consequences cannot be seen at the grocery store.

Are you stating we should not practice any form of social distancing ?

No. I am saying that those who are doing a good job isolating may not realize just how badly small businesses (44% of the economy / 48% of employees) are being crushed by the shutdown.

[George the original one]

No. I am saying that those who are doing a good job isolating may not realize just how badly small businesses (44% of the economy / 48% of employees) are being crushed by the shutdown.

My closest 3 towns need tourists for financial survival, but the small businesses also know we only have 25 regular hospital beds and only 4 ICU beds for the 10,000 residents. We have to share the 4 ICU beds with the rest of the county, another 30,000 residents. Nobody here is particularly in a hurry to re-open before we're ready to re-open. They're, generally speaking, more willing to adapt and think of new plans.

[George the original one]

There is a secondary argument in relation to modelling these scenarios and how they overstate the downside significantly. This to me is simply the scientific modus operandi that operates today where political implications are at the heart of the issue that is being studied. If you want a reaction exaggerate the extent of the downside and the probability of what is to occur.

I'm going to say BS on this one. For instance, the US federal government certainly understood the complexity of modeling this and if you read through the government plan published when President Trump began the fight against COVID-19 on March 13, you'd have seen it spelled out in the assumptions on page 4:

"3. The spread and severity of COVID -19 will be difficult to forecast and characterize."

https://int.nyt.com/data/documenthelper ... d/full.pdf

Going into the US response, you also could compare how wide the range of outcomes could be by looking at South Korea vs. Italy. On March 16, the Surgeon General had this to say:

"We are at a critical inflection point in this country, people. We are where Italy was two weeks ago in terms of our numbers," U.S. Surgeon General Dr. Jerome Adams told Fox News. "When you look at the projections, there's every chance that we could be Italy."

[Ego]

Nobody here is particularly in a hurry to re-open before we're ready to re-open. They're, generally speaking, more willing to adapt and think of new plans.

Well, you and I are speaking with people who have very different outlooks. Fixed costs and zero income can only be endured for so long.

[thrifty++]

@c40 - if you are looking at this thread im wondering if you have any more recent updates on the covid19 situation in Vietnam? It looks barely touched if the online worldometer figures are anything to go by.

[steveo73]

I am saying that those who are doing a good job isolating may not realize just how badly small businesses (44% of the economy / 48% of employees) are being crushed by the shutdown.

I know that they are getting devastated. It's having a massive impact. I'm hopeful businesses will get back up and running but I feel for anyone whose livelihood is significantly impacted by this event.

There are a tonne of side-effects of taking these actions. Still I don't see any alternative for the moment. Maybe everything will return to normal relatively quickly and the impact will be lessened. Are we going to get second and third or whatever phases ? Will they develop a way to minimize the effect of the virus quickly ?

[thrifty++]

I think the economics of the do nothing or do less approach is overplayed. Dealing with thousands of deaths and hundreds of thousands of others sick as a dog in a community is hardly good for the economy either. The death, the stress, the sickness the trauma and the grieving. Doesn't sound like a good mix for the economy to me. It really seems like an economic hit takes place either way.

[steveo73]

For instance, the US federal government certainly understood the complexity of modeling this and if you read through the government plan published when President Trump began the fight against COVID-19 on March 13, you'd have seen it spelled out in the assumptions on page 4:

That study you presented was pretty good from what I read. I actually didn't notice any projections or outright modelling of exponential growth so I don't think we are talking about the same thing here. There is a massive amount there in the appendix that I didn't read so if I missed something let me know.

The figures that I've seen modelling results have been much higher than what has actually occurred. I believe that the models use the same approach that Jacob mentioned at the start of the thread. Typically these models suggest that the impact is worse than what plays out.

https://www.nytimes.com/2020/03/20/opin ... comes.html

[C40]

@c40 - if you are looking at this thread im wondering if you have any more recent updates on the covid19 situation in Vietnam? It looks barely touched if the online worldometer figures are anything to go by.

They've had a continual and only linear influx of virus cases. Most of them were initially foreigners entering on flights from Europe (because they stopped them from China and Korea early on)... They stopped letting foreigners in.. maybe in late February or early march. They still allowed Vietnamese to come home, and many did in March, some coming back with the virus. The government has put increasing restrictions in place over time. Things like

- Stopped all entry from China and Korea
- Put restrictions on giving visas to foreigners entering
- Stopped letting any foreigners enter
- Requiring all people entering Vietnam (at that point pretty much only vietnamese people) to go into 14 day quarantine upon arrival and be tested. I think about half of those were quarantined at government sites, and the rest at home.
- Continuing contact tracing when someone gets the virus.
- Some specific shutdowns of businesses that get the virus.. They also closed off some districts in Hanoi. and I think closed in a fairly small city on the outskirts of Hanoi that has had a lot of cases. A hospital got significant spread of the virus (maybe 20-30 people) and I think they totally closed that hospital down and made everyone who had been there at the time stay in the hospital for 2-3 weeks.

That was basically what happened up until April 1. The total number of cases had grown to maybe 200, with maybe 150 current cases. They were getting community spread in Hanoi from that hospital, and also had a bunch (10) of cases from when some European pilot flew into Hanoi and then went to a popular tourist bar two nights in a row. So... up through this point, most of the restrictions were travel related or applied only to certain at risk individuals or areas. Most of the country could carry on as usual. Of course, many expats went home, tourism stopped, business slowed down. But generally life carried on as normal

- On April 1 they started a bunch of restrictions for the entire country. Shut down all businesses like restaurants, bars, coffee shops, stores (aside form food), and so on. People are supposed to stay home and only go out for necessities, and you have to wear a mask. These are followed fairly well. Plenty of people go outside, but there aren't large gatherings or people partying in bars. Those restrictions just got extended until April 22, and may likely go to the end of the month. They are starting to loosen restrictions in low-risk areas like small cities.

Some cities or areas put their own extra restrictions in place. For my city (Da Nang), if someone comes here from Hanoi, or maybe almost anywhere else, they are caught at the airport or at road checkpoints outside the city, and if they want to enter, have to go to quarantine for two weeks. So, I don't think I'd be going on any little trips outside the city, and if I did, I'd make sure to carry some kind of proof that I live here (copy of lease, letter from landlord, possibly even a standard form/report you can get from the police station confirming your address and presence here)

Right now there are about 265 total positive cases, around 100 current, and no deaths. There were some people really close to dying and who were in the hospital for about a month, but they all pulled through (and when they are released, they post pictures of them, so I think it's fairly likely this is true)... I think that if the current restrictions work well, and active case numbers continue going down, Vietnam will take on a 'turtle' strategy for the coming months:
- Continue huge limitations on people entering Vietnam
- Possibly keep strict limitations on travel from one part of the country to another
- Let businesses open and life to generally go on as usual

[thrifty++]

@C40 - interesting. Thanks for the update. Sounds like a very proactive approach has been taken there.

[Lemon]

@Bankai

On the Nightingale Hospitals. Certainly in London it has taken patients. Not close to the theoretical 4000. But when you consider the stress intensive cares working well past their normal capacity in the capital are under this is very helpful. If there had been slightly less adherence to the lockdown or it had been less effective they would have been coming in to major play. There is also a concern about exit from lockdown. More provision = more time before a theoretical relockdown needed in a second wave etc.

The system isn't working as normal. All elective work cancelled. Clinics cancelled and Doctors drafted on to general medical rotes. This can be done for a crisis but the longer it carries on the more problems you build up in people with chronic ill health/cancer/everything not COVID. Even patients are changing behaviour to make things less busy to the point we are worried people are sitting at home not presenting with other serious pathology for fear of getting COVID. Yes Lombardy type hundreds in corridors scenarios have been avoided but given exponentials work this was much closer than people think.

Nightingales could then be useful for later on for longer term suffers of COVID. ITU stays result in de-conditioning particularly if very prolonged and thus lots of rehab/weaning form ventilators, we also don't know the post severe COVID patient journey yet. Using them for this is possible would allow regular hospitals to get to restart some normal activities sooner.

@Jacob
On people not wanting to move away from conventional treatment I would have to disagree. All sorts of things have been being tried and we are involved in multiple trials simultaneously just where I am working let alone globally. I don't think I have ever seen this many trials started and gone from zero to multi-centre in such a small time. Certainly no one I am around seems to be being concerned about Career risk. The reasons more radical things are not being tried everywhere in a scatter gun approach is medicine has learnt caution, lots of theoretically sounds treatments throughout history have turned out to actually be ineffective/harmful. The caution is for the patients not normally the career of the doctor.

Another more obvious anecdote is Proning. This is something that did get used before but only in intensive care in a very small subset of patients and rarely then. Before COVID I had seen it a total of once (I am not an intensivist though). In COVID people respond well to it. Really well. It is keeping lots of people out of the ICU in combination with CPAP and high flow oxygen. This is not something that was ever done outside of ventilated patients in ITU that is now going on on general wards and working. It helps we think partly because of redistribution of blood flow in the lungs (to areas less COVID affected) and with alveolar recruitment. But to be honest I don't know exactly ITU isn't my normal domain.
Other things will take longer to change because they are less blatantly obviously effective. the more marginal the treatment (so larger numbers needed to treat for a positive outcome) the longer it is going to take for it to change.

on CPAP. Roughly the increased pressures open up more of the airways/recruit them for gas exchange. Ventilation does the same but can do higher pressures (this has downsides too) and can also take over breathing when you are too exhausted to do it for yourself.

[slsdly]

@jacob, it looks like you aren't the only one asking the ventilator question:

https://www.cbc.ca/news/world/ventilato ... -1.5534097

[Ego]

@slsdly, great article. Thank you for posting it.

Reading between the lines, what they are not saying is the reason they are reluctant to stop using ventilators despite contradictory evidence. Patients on nasal cannula, mask oxygen or cpap can still cough. Often the patient will pull the mask to the side and cough partially into it allowing the oxygen to blow the aerosolized droplets all over the room. This is dangerous for healthcare workers, especially those with inadequate PPE.

[Ego]

Socially acceptable attitudes and behavior are changing by the minute...

I woke to find that @Naval has suggested reopening the economy for those at lowest risk and strict lockdown of those at high risk. Also, Scott Adams posted a "thought experiment" on variolation and linked to Robin Hanson's proposal I posted earlier. '

Neither are experts of any sort. Adams is a cartoonist and Naval a tech investor. Like ZAF, I've been amazed at how fast things go from unthinkable to possible, so we shall see.