Covid (Coronavirus) in Minnesota: An FAQ

by James J Heaney Posted on 30 March 2020

UPDATE 14 April 2020: I am no longer updating this post regularly, but I will try to continue posting links to my other Covid-in-Minnesota coverage for those who use this FAQ as a landing page:

Before we get into the details, how is Minnesota doing in the battle against coronavirus so far?

We’ve done okay.

We took significant state action to reduce the virus’s spread at a relatively early point in our epidemic. When we closed our schools, there were under 100 known cases in Minnesota and no deaths. (Italy had over 3,000 cases and over 100 deaths when they closed.) When our stay-at-home order went into effect, there were nearly 400 diagnosed cases and 4 deaths. 4 dead meant the real case count was likely over 4,000, far too many to easily control… but we were still in far better shape than Italy or New York City or even Louisiana. (Louisiana had 837 diagnosed cases and 20 deaths when it finally imposed a stay-at-home order yesterday.)

There are some indications that we have started to bend the curve of viral growth downward. My projections from a couple weeks ago were underestimates for a while (indicating disease growth over 33%/day), but, on Wednesday, they became overestimates. That could indicate slower disease growth thanks to social distancing measures, which generally take about two weeks to have an impact. It could also indicate that it is growing so fast that our testing can’t keep up. We should know in a little while, once the current week’s diagnosed cases start turning into deaths.

Gov. Walz and the state deserve credit for acting early and decisively to slow the growth of the disease.

What are our options from here?

There are three general strategies we can choose from. Different governments differ on many of the details, but the three broad strategies are very distinct:

  1. DO NOTHING: We could stop all (or nearly all) our efforts to prevent the spread of covid, allowing it to run its course until we acquire herd immunity. Nearly everyone would catch covid, and many of us would die. But it’s worse than that: our hospitals would run out of beds, equipment, and staff. That means some people would die due to lack of medical treatment.

    According to modeling by the University of Minnesota, 74,000 Minnesotans would die if we followed this strategy. According to modeling by Imperial College London (which makes slightly different assumptions), 2.2 million Americans would die.

    However, many believe this would be the least economically damaging path.

  2. MITIGATION: We could implement limited social-distancing and stay-at-home orders for a moderate period of time. Our goal would not be to prevent the infection from running its course, but merely to slow it down, so that our hospitals are not overwhelmed. Nearly everyone would catch covid, and many of us would die — but not as many, because we would all have hospital beds to be treated in.

    According to modeling by the University of Minnesota, 55,000 Minnesotans would die under this strategy. According to modeling by Imperial College London (which makes slightly different assumptions), 1.1 million Americans would die.

  3. SUPPRESSION: We could implement strong social-distancing measures and periodic lockdown (“shelter-in-place”) orders for a longer period of time. These would have to be strong enough not just to slow the virus’s advance, but stop it and force it into retreat by depriving it of new hosts.

    Once the number of patients has been reduced to nearly zero, you change gears: suppression methods end, but, in their place, you implement robust and universal testing and temperature checks, followed up by mandatory quarantines for anyone found infected. This way, you prevent the disease from growing out of control again. The government must be vigilant until a treatment or vaccine is found, but life can mostly go back to normal for most citizens. For this reason, you might also refer to the suppression strategy as the “suppress/test/contain” strategy.

    Wuhan implemented a very strong version of this during their epidemic, and, with the caveat that statistics from the Chinese Communist Party are often dishonest, it seems to have worked. After eight weeks, coronavirus cases have fallen enough that the CCP is beginning to end quarantine. Other countries have implemented suppression, including the U.K., but we haven’t seen the full results yet.

    The University of Minnesota did not model a suppression strategy. However, according to modeling by the University of Washington, only 1,420 Minnesotans would die under a suppression strategy. According to modeling by Imperial College London, only about 100,000 Americans overall would die under a suppression strategy (if implemented nationally). Since Minnesota has about 1.7% of the U.S. population, that very roughly works out to 1,700 dead Minnesotans.

    However, because suppression involves the greatest amount of social distancing for the longest period of time, it is believed to be the most economically damaging approach.

What strategy is Governor Walz adopting for Minnesota?

To his credit, Gov. Walz sat down for a twenty-five minute discussion with the state where he laid out his plan. If you live here, you should watch it.

Walz has picked MITIGATION as Minnesota’s strategy. That means his plan allows almost everyone to catch covid, but we’ll all have hospital beds, giving us a considerably better chance at surviving covid than we would without hospital beds.

Walz’s office, according to its own projections, expects that, if this plan is successful, 50,000-55,000 Minnesotans will die of covid by the end of this year. (And that’s if it’s successful.) That’s approximately 1% of Minnesota’s total population.

To Gov. Walz’s discredit, he did not divulge this number to the People he serves. The Minneapolis Star Tribune was able to obtain the number several days later.

If we remain on track for 50,000 deaths, won’t Governor Walz extend the stay-at-home order? Didn’t he say that was a possibility?

Governor Walz says he will extend the stay-at-home order if we are not hitting our goals for production of ventilators and ICU equipment, because the goal of his strategy is to make sure that everyone who needs a ventilator and ICU equipment gets it. So if we remain on track for 74,000 or 64,000 deaths, Gov. Walz is likely to extend the order.

However, Governor Walz will not extend the stay-at-home order simply because we remain on track for 50,000 deaths. In his strategy, 50,000 deaths is the goal.

I repeat: since reducing Minnesota’s death toll to 50,000 is the intent, Gov. Walz will interpret evidence that we are on track for 50,000 deaths as a success, not a red flag.

Some of my friends have had a hard time wrapping their heads around this. They cannot believe that Governor Walz would choose a strategy where 50,000 Minnesotans die (mitigation) when he could choose a different strategy which, according to available models, would save more than 90% of those lives (suppression).

Why is Governor Walz choosing mitigation over suppression?

I’m going to start by quoting the Governor directly, so you know I’m not messing with his words.

Just to be clear: shelter-in-place simply moves the date out. It doesn’t do a thing in terms of reducing infection rates unless we have either a vaccine or therapeutics or increased ICU capacity, you’re still going to get the same results, just at a later time.

…If I put on shelter-in-place indefinitely, what that would do, would buy more time, but it would not reduce the infection rates that would eventually be coming. It would not. The minute that we came off of that, barring a vaccine, numbers would shoot back up and ICU usage would be overrun.

So the attempt here is to strike a proper balance of making sure our economy can function, protect the most vulnerable, we slow the rate to buy us time and build our capacity to deal with this…

…The only thing we’re able to flatten a little bit — and this is what we’re trying to do at this point in time, our medical experts believe it, and our private sector partners believe it — the only thing we’re able to flatten is the ICU usage and its capacity…

…if we chose to shelter-in-place for five months, I think all of us understand what the implications would be, and all that would happen is, if we didn’t do this surge of capacity, is we would move these lines to the right and still be in the same position. I don’t believe it’s prudent to try to shelter in place until a vaccine is there. I don’t believe that, in the long run, the damage that’s done to the economy allows us to have those resources necessary as we get smarter and get more information about who can be quarantined and how we can build up the production lines.

It appears that Governor Walz believes that suppress/test/contain is either

(a) impossible,
(b) too expensive, or
(c) both.

Whether it’s too expensive is, of course, a judgment call. Think of the 100 Minnesotans you love most. Now imagine one of them is going to die under Gov. Walz’s mitigation plan. Imagine that same person would be saved under suppress/test/contain. (This shouldn’t be too hard to imagine, because it’s going to be our reality in a few months.)

Are you willing to lose your job to save that person’s life? Are you willing to sacrifice your kid’s education for a few months? Are you willing to see your retirement account plunge this year? Are you willing to shelter-in-place for weeks on end?

I am. You may not be. That is up to you, based on your circumstances.

But Gov. Walz also seems to think that, aside from being very expensive, suppress/test/contain is impossible. He keeps saying things like, “We can’t flatten this,” and that suppression “would move these lines but we’d still be in the same position;” that coronavirus cases “would shoot back up” as soon as we lifted a stay-at-home order.

This does not appear to be in line with the consensus among America’s epidemic experts.

Which experts think suppression is a viable strategy?

Gov. Walz says that the experts he’s talking to don’t think it’s possible to bend the curve of the epidemic downward far enough to suppress it. I don’t know what experts he’s talking to, and I don’t know whether he’s seeing the news from South Korea or Wuhan.

But here are a few experts who think suppression is a viable strategy, despite what Gov. Walz claims:

Didn’t those Imperial College guys say that suppression would need to last for 18 months? Gov. Walz mentioned sheltering-in-place until there’s a vaccine. Is that really what we’d have to do to save all those Minnesotans?

“Those Imperial College guys” — led by Professor Neil Ferguson, an epidemiologist who is director of the MRC Centre for Global Infectious Disease Analysis (@neil_ferguson) — did indeed release a horrifying paper a couple weeks ago. It suggested that the only way to avoid huge death tolls would be to follow very strict suppression measures for 18 months. I grappled with this paper at some length last week. I concluded that the only reasonable thing to do, given the impossible choice, was to attempt a full-spectrum suppress/test/contain approach.

A few days ago, before Parliament, Prof. Ferguson endorsed exactly that approach. The initial Imperial College paper, he explained, was based on the assumption that there would not be enough tests to go around. Rapid scaling-up of British testing capacity has convinced him that the South Korean suppress/test/contain strategy is the most likely approach going forward.

So who are the experts who might be telling Gov. Walz that suppression is impossible?

Although some experts believe suppress/test/contain will be extremely hard (and I strongly suspect they’re correct), the only prominent public-health authority I can think of who (like Gov. Walz) considers the strategy impossible is:

  • Dr. Michael Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy.

Mind you, Dr. Osterholm does not appear to believe that suppression is impossible in principle. As he wrote in this week’s New York Times, Osterholm is just very pessimistic about American supply chains. Suppress/test/contain depends on tests, and Dr. Osterholm doesn’t think we’ll be able to manufacture enough tests in time. Thus, he contends, the strategy is doomed to failure.

It is unclear to me whether Dr. Osterholm’s medical expertise includes American supply chain analysis.

However, it so happens that Dr. Osterholm is, by far, the most prominent epidemiologist within the state of Minnesota. Dr. Osterholm is widely and deservedly respected by Minnesotans, and the Center he directs is at the University of Minnesota, just a few miles from Gov. Walz’s house. I have routinely shared Dr. Osterholm’s interviews about the virus with friends and family, encouraging them to take it seriously before everyone was taking it seriously–and they didn’t necessarily listen to me, but they listened to Dr. Osterholm.

So it is perhaps not surprising that the governor’s plan mirrors the opinion of the state’s most prominent expert.

Nevertheless, Gov. Walz does Minnesotans a grave disservice by failing to present the broad spectrum of views among American epidemiologists; by failing to even model the possible impacts of suppress/test/contain in Minnesota; and by consigning some 50,000 Minnesotans to the morgue without even attempting a strategy that could quite possibly save nearly all of them.

[Editor’s Note: I will add to this FAQ as necessary. Basically, if I see enough of you asking a question, I’ll try and answer it here.]

UPDATES:

Well, what do YOU think we should do, James?

I’ve tried to limit this post to factual reporting, but you can probably tell that I am alarmed by Governor Walz’s current strategy. If you agree, then I suggest signing my petition to Governor Walz (and the heads of both houses of the state legislature) requesting and demanding a shift in strategy to suppression, in line with the increasingly detailed plans articulated by many experts in the field.

Hang on. I heard Dr. Fauci predicted 100,000-200,000 deaths nationally, and Dr. Birx confirmed that this morning. You’re telling me to expect 50,000 in Minnesota alone — a quarter or half of all deaths nationally? How can that be? Are the models really that different?

Very reasonable question! Minnesota has only 1.7% of the national population, so, however many people are going to die nationally, we should only have about 1/50th of that, tops!

Dr. Fauci’s comment in his interview was very short and off-the-cuff, so it’s hard to know what was in his head. Dr. Birx’s comments were more detailed but still did not include detailed modeling assumptions.

However, from context, I believe that the estimate of 100,000-200,000 dead is based on the assumption that the country will adopt a nationwide suppress/test/contain strategy, instead of the mitigation strategy Gov. Walz supports.

If a mitigation strategy were adopted nationwide instead, we would expect to see over a million deaths nationwide. (This is more or less what the Imperial College model showed.) In that scenario, 50,000 dead in Minnesota would be a lot less egregiously out-of-line. (1.7% of a million is 17,000.)

There are differences in all models, of course, but not vast ones. The conflicting comments appear to mainly reflect differences in Dr. Fauci’s and Gov. Walz’s strategies, not their models. 

I just saw a model that said Minnesota will only have a little more than 1,000 coronavirus deaths!

Ah, yes, the University of Washington model. I’ve mentioned this elsewhere in the FAQ, but I’ve received enough questions about it to justify giving it its own q&a.

Something very important about this model that you don’t necessarily find unless you read the fine print: it’s a model of the suppression strategy. I’ll let them explain:

For states that have not yet implemented all of the closure measures, we
assumed that the remaining measures will be put in place within 1 week.

This study has generated the first set of estimates of predicted health service utilization and deaths due to COVID-19 by day for the next 4 months for all US states, assuming that social distancing efforts will continue throughout the epidemic.

Our estimate of 81 thousand deaths in the US over the next 4 months is an alarming number, but this number could be substantially higher if excess demand for health system resources is not addressed and if social distancing policies are not vigorously implemented and enforced across all states.

So this is a model that assumes that any states that haven’t gone to full shelter-in-place mode yet will do so within seven days, and that all states will remain fully shut down until the epidemic is over, either because a cure or treatment has been found or because covid has been suppressed enough for us to move to the test-and-contain phase. Either way, the University of Washington model assumes full shutdown of the economy until, at the very least, mid-May.

If we do that, we could indeed achieve some very low death counts. I suspect we can’t actually get down quite as far as this model says, because of the reasons Carl T. Bergstrom noted here, but it seems not unreasonable to believe that strong suppression measures could reduce Minnesota’s fatality rate below 3,000… rather than the 50,000 currently projected.

What other states are adopting a suppression strategy?

You have to give Gov. Walz credit: he has been much more clear about Minnesota’s long-term strategy than have the executives of other states. Wisconsin’s government has consistently been somewhat more aggressive than Minnesota’s on COVID-19, and it seems poised to extend its stay-at-home order… but I could not find any clarity from Gov. Evers’ office about what Wisconsin’s long-term plan is. It looks like suppression? Or maybe it’s just panicked mitigation. I don’t know, and nobody else seems to, either.

That’s true across many different states. At least Gov. Walz had the decency to tell us the plan, even if he concealed the full horror of it.

(If Gov. Evers has announced his long-term strategy somewhere, please drop me a link.)

That being said, there are several states that have adopted very long-lasting shelter-in-place or stay-at-home orders. These orders are not consistent with a mitigation strategy, and strongly indicate that the state intends to hunker down until COVID-19 is either contained or defeated. The states I have in mind are:

  • Virginia (stay-at-home until June 10th)
  • Delaware (stay-at-home until May 15th)
  • California (Gov. Newsom’s initial order lasts into May, but he has said he expects it to be extended for “many months”)

There may well be others that have already indicated their shutdowns are going to last well into May… but the rapidly evolving situation, combined with fairly weak reporting of expiration dates, combined again with governors who may find it less politically painful to issue a series of “extendable” three-week orders instead of a single three-month order, all adds up to a situation where it’s very hard to see exactly what each state’s long-term strategy is.

Unless they get up in front of the state and explain their plan, as Gov. Walz did. The fact that I think it’s a bad plan does not erase the fact that it’s very, very good that he told us what it is.

Is this decision a straightforward trade-off between lives and GDP? More lives saved = more GDP lost (and thus people dying for other reasons)?

No, it’s not. I noted at the top that many believe that a no-mitigation strategy would be the least economically damaging. However, personally, I am dubious. As a friend of mine wrote to me:

I haven’t seen serious economic modelers try to estimate the cost of an unmitigated outbreak. But I am very dubious of the claim. In the first place, I don’t think you could actually get everyone to just stride into the oven. I think that without socially coordinated mediation efforts, you’d nevertheless see quite significant individual mitigation efforts, which would be quite economically disruptive.

However, it’s unlikely that that kind of individual mitigation effort would contain the virus. It might protect some individuals from infection (at least in the short term), but would be too piecemeal to contain the virus. So you would still have hospital systems overloaded. The medical sector is a very large segment of the economy. How would private medical insurers be affected? How many medical professionals would die? Would this be a bonanza for hospitals and other medical megacorporations? Or would it push some into bankruptcy?

If the medical system is overwhelmed, and the disease goes unmitigated through the population, the death rate at younger ages will go up substantially. Let’s focus on 50-65, the senior managers, project engineers, administrators, fund managers. What would it do to the economy to lose 2% of CEOs? What about 5%? What happens when the one engineer who understands the whole project dies? How much of a delay will occur as others try to figure how to get things back on track, with a few % of workers at all levels gone? What about younger workers with asthma or other comorbidities?

No matter what strategy we adopt, we are in for a rapid and drastic economic recession. That’s just a fact of life in a pandemic like this one. So when we choose suppression, we are not choosing between continued prosperity and economic catastrophe; we are only choosing between two different flavors of economic catastrophe. And it is not immediately obvious which approach is least catastrophic. Cass Sunstein reports on some very early efforts by economists in this space, and they aren’t terribly friendly to the “reduce mitigation” crowd.

Economic modeling is a lot harder than disease modeling, though, so I would imagine that there are a whole lot of economists working long nights this month, and that we’ll start to see better answers soon.

Maybe if Stefan Gildemeister reads this, he can point me in the direction of some more resources on the economic trade-offs. Otherwise, I’ll keep you posted.

Is it Gov. Walz’s fault that Minnesota isn’t testing enough?

No. It’s complicated, but the main party at fault is the CDC. Gov. Walz is not the reason we aren’t testing enough.

Right now, everyone wants to be testing more, including Gov. Walz. Testing is key to suppress/test/contain, obviously, but it would also be very useful in Gov. Walz’s mitigation strategy.

We can’t test more because we don’t have the test kits, and we don’t have the capability to manufacture more quickly.

In response to the catastrophic shortage in working test kits, the FDA has removed nearly all regulatory hurdles for would-be testers, but no amount of deregulation can create manufacturing capacity out of thin air (and, as an experienced lab tech I know explains, the deregulation creates problems of its own).

Until this is rectified, a suppress/test/contain strategy can’t leave the “suppress” stage. It is likely that pessimism about America’s ability to rectify this played some role in Gov. Walz’s decision to go with a mitigation strategy instead, although he has made no public comment about this to my knowledge.

Since April 1st, Gov. Walz has given several major public presentations on Minnesota’s coronavirus response. Has he changed course at all?

No.

Gov. Walz did announce flexibility and opennness to evidence, which is very hopeful. He also announced specific goals for testing, which were missing before. But he announced no actual change in policy from the current “re-open the state sooner and accept that 1% of Minnesotans will die” policy.

The dashboards he announced are very slick, though: https://mn.gov/covid19/.

Here, for the record, are his speeches: the April 3rd update and the State of the State address. Both are reasonably good speeches that grasp the unthinkable magnitude of this catastrophe.

Those of you who have followed this blog for a long time know that I am a conservative, and it grieves me to report that the Minnesota GOP leadership’s response to this disaster has, to put it mildly, lacked seriousness. Too many Republicans deny stay-at-home orders are necessary at all. But Gov. Walz does not need to meet them in the middle. He needs to save Minnesotan lives.

Posted in Mere Opinion | Tagged , , , , | 4 Comments

The Hard Road Ahead

by James J Heaney Posted on 21 March 2020
A rocket scientist does math on a chalkboard.
“This is the Apollo program of our times. Let’s get to it.” -Trevor Bedford

Fighting the Chinese coronavirus is important. That’s been my message for the past couple weeks: This is not the flu. We need social distancing or we’ll end up digging mass graves. I’ve been very focused (as have most of the experts I trust) on getting people to take the appropriate precautions now, leaving other questions to be answered later, when we had more data on the virus.

And, guys, we’ve been doing a okay job of it, altogether. There are always morons, but the schools are closed, parents are working from home, Domino’s Pizza won’t let you in the store unless there’s enough room for you to stand six feet apart… yes, we still need to tighten the cordon. We still need individuals to take it more seriously. But I’m proud of our nation’s decision to treat this disease like a serious threat before our hospital wards look like this… or this.

I want you to think about this for just a moment: since the dawn of civilization, plagues have killed staggering numbers of human beings. Individual communities have had some very basic self-defense tools, but, until recently, nobody knew enough about disease and how it spreads to do more than cancel the parade once the plague arrives. In the covid plague, for the first time in human history, we have a choice. We can choose to save lives, albeit at great cost to ourselves. I’ve written that COVID-19 could easily kill 3 million Americans, maybe 100 million people worldwide. That’s more people than died in World War II (including the Holocaust). But I’ve also written that, through collective action to slow and stop the disease, we could save most of those people.

And that is what we have collectively decided to do. We didn’t have to. We could have let those people die (mostly old people, after all) and kept the economy intact. But we opted to plunge ourselves into recession instead.

If your business is shut down, it’s for the sake of those hundred million people. If you had to cancel your wedding, you’re saving those lives. If you’re stuck in a hospital, unable to receive visitors in your hour of suffering, it’s because you’re trying to save more people than died in World War II. And, of course, if you’re a front-line health care worker, you are not only physically saving lives, but are putting yourself at risk, too. Personally, it’s been pretty easy for me so far, but the sacrifices some of you have made are stunning. You are Big Damn Heroes, and I am very proud to be able to share this planet with you. Thank you for everything you’re doing.

After 9/11, we (correctly) lionized the New York City Fire Department, which charged heedlessly into a burning building to save life and paid the price. The millions of you who are suffering in this crisis, for the sake of saving those lives, are this generation’s FDNY. And you have already saved literally tens of thousands of lives, with more saved every day through your social distancing. (And, who knows? The life you save may be your own.)

When we started social distancing, one key question we hadn’t answered yet was, “How long will this need to last before we go back to our normal lives? 2 weeks? 6 weeks? 12 weeks?”

Another, related question was, “What’s our strategy to get through this?” Lots of people talked about “flattening the curve,” spreading out the coronavirus patients so our health care system doesn’t get overwhelmed. This strategy is called “mitigation.” But others spoke of crushing the curve, where we ended the infection totally, as quickly as possible, no matter the cost, so we could go back to living regular lives sooner. This strategy is called “suppression.”

At the time, the answers to those questions didn’t really matter. Whether our long-term strategy was going to be mitigation or suppression, any response to covid (besides “let millions die”) had to start with a lockdown like the one we’re living through now. Transmission had to slow down enough for us to get our footing. We would figure out plans for the next month and the next year only after we were sure our hospitals weren’t going to collapse in the next week.

Well, we did that. Although it will take weeks to see the results, because of the coronavirus’s long incubation period and our country’s very bad testing, we should soon start seeing the pace of new infections slow, then fall. So what’s the next step?

By now, you’re probably aware that Imperial College London has a terrifying answer to that question. In a blockbuster paper published early this week, their blue-ribbon COVID-19 Response Team explained that a mitigation strategy was doomed to failure. The hospital system would still exceed its maximum capacity by a factor of eight. Over a million people would die in America alone. Many others would die of non-covid treatable illnesses because we would no longer have a medical system to care for them. Not as bad as doing nothing, but still unacceptable. Mitigation and “flattening the curve” don’t work.

The Imperial College thought that a suppression strategy would work, though. Heavy lockdown would keep Wuhan coronavirus infections at a very manageable level, and we could even relax suppression measures from time to time and go back to normal life for a week or two. We would only need to maintain a suppression strategy until worldwide deployment of a working vaccine…

…in 18 to 24 months.

According to the Imperial College model, if we drop suppression measures before the vaccine, the disease surges back. Our hospitals are overwhelmed, and tens of millions of people die, including millions of Americans. (The Imperial College paper predicts shockingly large death tolls, but these are actually lowball estimates, because the Imperial College did not take into account how the collapse of our hospital system would increase fatality rates.) That means 18 months of this global paralysis, of lockdown. Some wrote about what that could mean.

I didn’t. When I read the Imperial College report, my stomach dropped, and I stopped writing about covid for a few days.

Why? Because it’s impossible. We can’t do it. Two weeks of partial lockdown have plunged us into a severe recession. Essential services, like the supply chains that keep my grocery store stocked, are visibly faltering. Less essential services, like haircuts, are totally inaccessible. Months of this will spell depression. Years? That’s a civilization-ending event.

Reader, if the Imperial College is right, if our choice is between 18 months of lockdown and 100 million deaths, it doesn’t matter how much we want to make the heroic choice: those people are going to die. Some of them could be people I love. One of them could be me. It doesn’t matter: I do not believe our economy has the werewithal to do this for a year and a half without civil unrest, famine, and starvation.

I stopped writing because I didn’t want to share my despair with you.

But I’ve had a couple days to think about it now, and I think despair is unjustified. The stark choice presented by the Imperial College paper does not represent all the possibilities. It only represents all the possibilities available to us today.

Right now, we’re in varying levels of lockdown. The Chinese coronavirus has been slowed. We are all doing our parts to #BendTheCurve. That doesn’t end the crisis. We’re not all going back to work in two weeks with this all behind us. The worst is, in fact, still ahead.

But all our efforts right now are buying us time. If citizens and state governments take the lockdowns seriously, we probably aren’t going to see the entire U.S. medical system collapse in the next couple weeks, which is the path we were on just days ago. We can hold the virus in stasis (more or less) for a while… which means we can now focus our resources on finding an acceptable solution. We don’t have one yet, but we have many promising leads.

Like what, James?

Well…

We could develop a treatment! A vaccine is still at least a year away, but there are lots of treatments out there for different viruses. One of them might work on covid. If that happened, it could bring the fatality rate down to an acceptable number — maybe a couple hundred thousand Americans, rather than a few million. That would still be nightmarish, but it would be tolerable — and it would keep our hospitals functional.

There are lots of potential covid treatments to explore. Some scientists are looking into treatment with antiretrovirals normally used against HIV. Some are still working on corticosteroids, although early data was disappointing. You’ve probably heard about the promising outlook for anti-malaria drugs, still in trial. There’s an anti-MERS drug that we’re trying called remdesivir (and, if it works, we’ll all have to learn to spell that). MERS, remember, was also a coronavirus, so I’m pretty hopeful about remdesivir.

There are a dozen other treatments being explored right now, with brand-new, tailor-made antivirals in development across the world. Thank free markets for that: there is a lot of money to be made by whoever makes the cheapest anti-covid drug, and every drug company in the world wants a piece of it.

Disease science is a grim place. The vast majority of these trials will either fail or show disappointing results. (That’s why the drugs that do work are so often so expensive.) While we could have some results by late April, others are months away.

But we only need one treatment for covid. If we get one, and it’s effective enough to bring covid’s fatality rate down to “flu pandemic” levels, then we can end the lockdown and go back to something like normal life.

We could get lucky! There is still so, so much we don’t know about China’s coronavirus. Does it die off in summer? We don’t know. That could buy us a few months lockdown-free while we fortify ourselves for the coming battle in winter.

We know covid doesn’t cause many children to experience severe symptoms, but do children transmit it as efficiently as adults? Believe it or not, we still don’t know. If it turns out that children aren’t very good disease vectors for this coronavirus, we could potentially reopen the schools, easing many problems.

We are still having a very hard time nailing down exactly what covid’s “natural” fatality rate is (in a non-overwhelmed hospital system), and there is still a surprising amount of uncertainty about how viral it is (its “basic reproductive number”). Some even question basic assumptions about how long the coronavirus’s exponential growth will continue. If covid turned out to be less fatal or less transmissible than currently believed–a faint hope, but a plausible one!–we may find that the lockdown was an unnecessary overreaction all along.

Wouldn’t that be fantastic?

We could test the hell out of everyone! This seems to me like the most plausible way out. It’s based on existing technology, and it seems to be what most of the experts I respect most are thinking about. That’s not surprising, because it’s what South Korea and Singapore both seem to be doing… and it seems to be working.

Here’s the idea in a nutshell: we start out with a standard suppression strategy. We lock everything down for a while, long enough to slow the virus’s spread to a trickle. Then, we lift the lockdown. However, this time, instead of letting the coronavirus spread freely until our hospitals are again overwhelmed, we test everyone, constantly.

When you go to work, you’re not allowed in the door until you’ve had a temperature check to verify no fever. When you show the slightest symptoms of anything, you are immediately tested and sent to quarantine until the results come back. Drive-up testing is universal and free.

We catch infected people the instant they start showing symptoms, and we quarantine them. Then we aggressively track down everyone they’ve had recent contact with (this is known as “contact tracing”), and we quarantine them, too. Quarantines are not voluntary and self-monitored, as they usually are in the United States today. Quarantines are mandatory, administered by the local constabulary, and violations are punishable by fines and jail.

With these tools, we can shift back from “mitigation” and “suppression” to the original strategy from February: “containment.” In containment, we know there’s a few people who have the disease, but we know exactly who they are, we keep them from spreading it, we aggressively seek out any cases that may have gotten past us, and the result is we avoid another round of exponential spread.

We can’t do this right now, because there are 20,000 known infections, almost certainly more than 100,000 actual infections, and millions of people who’ve been in close contact with the infected. There are no resources to track down all these people and quarantine them, even if we had tested them, which we haven’t.

Speaking of which, we also can’t do this right now because we don’t have the tests. America fell massively behind in February due to severe technical and bureaucratic errors at the CDC, and we will never catch up as long as the epidemic is growing exponentially. (That’s a big reason why containment failed the first time.) The PCR tests we have are slow, we can’t run them fast enough to keep ahead of demand, and we’re now running out of supplies. Minnesota is rationing tests, openly telling people who think they have it but aren’t dying to just stay home and try to get better. That approach is absolutely incompatible with the “test everyone” regime. But it’s the only approach possible right now, given our low testing capacity.

But in, say, three to five months? (Imperial College said five months.)

By then, our suppression strategy should be a clear success. The hospitals should be through the worst of this first wave. Thanks to all the social distancing we’re doing now, that wave should be less dire than I predicted last week. Our hospitals should get through it more or less intact. Cases should be back down to a manageable level.

And, if we start now, we should be able to fix our testing problems by then. We should be able to ramp up production on test supplies. We should be able to build out more capacity for testing. We should be able to augment our current PCR tests with fast, cheap, very useful serology tests. There are hundreds of labs working to make a test you can take at home for a dollar–and some are hopeful of a breakthrough within three months. There are now, quite suddenly, millions of unemployed Americans, many of whom could be hired as contact tracers.

If we can get the United States’ testing capacity up to around 100,000 tests per day (the same as South Korea’s, adjusted for population), push our case count down to maybe 400 new cases per day (again, that’s where South Korea is today, adjusted for population), and get everyone on board with aggressive monitoring strategies, then we could (presumably) lift the lockdown and switch to this “containment” strategy.

Life would not go back to normal–this really is going to last until we have a vaccine, which is almost certainly a year or more away–but life would go back to something pretty close to normal for the vast majority of us.

So we can’t do a South Korea containment strategy yet, but, even if all the potential treatments fall short, we should be able to do one after a few more months of social distancing.

If you want to hear this plan from a real epidemiologist, read Trevor Bedford’s thread about the way forward, or Adam Kuharski’s little infographic about the same thing. If you want to read a more formal treatment of this plan, using math and stuff, take a look at Chen Shen et. al.’s review of the Imperial College paper.

This is doable. However we get out of this trap, it’s not going to be easy. We’re still going to have a lot of heroes at the end of this, and I fervently wish we didn’t need them. I really don’t know when baseball or public worship is coming back, nor do I think international borders will start opening up again any time soon. But we’ll be able to go to work. We’ll be able to see our friends. We’ll be able to shop in the stores. We’ll be able to go to confession.

The bottom line is, we can get through this. There are many approaches we are taking to try to get COVID-19 under control, and lots of them are promising. Keep the faith, do what you can, and we’ll get through this.

Time to put your money where your mouth is, James. What does all this actually mean, on a practical level? WHEN will life go back to normal? WHAT are the next few months going to look like?

Okay, with the very big caveat that I am not an epidemiologist or even a real scientist, here’s my personal read of the situation. I make no guarantees. Last week, when I was simply describing exponential growth and applying simple math formulas, I was on firm ground. Here, I’m beyond my expertise. I know there are some actual medical professionals who read this blog; I invite their corrections and their doubts, and I will update this post with them if I get any. But here’s where I think we’re headed.

One way or another, it seems to me that we will be able to get out of full “social isolation mode” this summer. Maybe as early as June, maybe as late as August, but we are going to get this infection under control, we are going to get our testing capacity up, and we may even find a treatment. If we’re lucky or clever, we might get out of this even earlier. I would not be shocked to see life returning to normal-ish by mid-May… but I’m not counting on it, either.

Over the next month or two, there are going to be quite a few deaths. If the United States doen’t pass 200,000 diagnosed cases nationwide by April 1st, we will be very, very, very lucky. Worse, since our testing is so poor, 200,000 diagnosed cases is likely closer to 2 million cases nationwide, with nearly 1% of Americans infected. If that’s true, then, by May 1st, we can reasonably expect 10,000-20,000 people to be dead of the coronavirus. That’s bad, but keep it in perspective: a bad flu season infects 50 million and kills 50,000. The Chinese coronavirus will push our medical system to its limit, but it won’t collapse. And, if our social distancing measures to date have been enough (and I pray they have been), then early April should be our peak.

For the time being, it is imperative that our social isolation continues. Otherwise, we will never get to the point where we can safely lift it. Since the U.S. is a big country, with several different epidemics in progress in different places right now, there may be some local variability in what controls are necessary. But these basic rules should hold for everyone for at least the next couple of months: Don’t gather in groups larger than 10 people. Work from home if you possibly can. Schools need to remain shuttered for now, likely for the rest of the school year. Don’t fly. Be paranoid about your fevers and coughs–and equally paranoid about the fevers and coughs of those around you. Be a little scared: it’s healthy, and it might keep you alive.

Support the economy however you can, if you’re in a position to do so. Order delivery, take-out, or drive-through, even more often than you ordinarily eat out. So many stores are closed to foot traffic right now, but try to order goods from them anyway–and I mean the Red Balloon Bookstore down the road from your house, not Amazon.com. They might be able to limp through to summer that way.

There’s no disguising the fact that three or four months of this will be hell for our economy. But we’re saving millions of our countrymen, and tens of millions of people around the world. That seems worth a deep recession to me. It looks like the United States Mint stands ready to print its way out of economic trouble. If there has ever been a time to cut every American a nice fat check — quite possibly several checks, over several months — this is it. We can deal with the fiscal fallout later. (Coming 2021: tax hikes!)

Meanwhile, what you want to be looking for is testing breakthroughs (and, if you’re feeling a little optimistic, clinical drug trials). Some people on Twitter are saying that testing doesn’t matter anymore, because containment has failed. They’re right, in a way: containment has failed. The first wave of deaths is coming, and there is no longer a single thing we can do to stop it.

But South Korea and other Asian nations show that we can get back to a containment posture once our case loads are down and we have extensive testing. That should be our aim now.

Our decision to take the novel coronavirus on directly like this is without precedent in human history. Every other generation since the rise of civilization would simply have lost 100 million people, because they wouldn’t have had a choice. The choice itself is terrible, but I’m glad that we have it, and I’m proud of us–of you–for choosing to shoulder the costs of saving those lives. You may not hear this enough in the coming days, so let me say it now: thank you. You’re my hero.

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Coronavirus and the Flu: A Q&A

by James J Heaney Posted on 15 March 2020

Is coronavirus worse than the flu?

Image of SARS-CoV-2, the virus causing covid-19.
The cutie causing all the trouble.

Much worse.

That’s ridiculous.

And that’s not a question.

Well, why should I trust you — or the media hysterics you’re parroting?

Don’t trust me, and certainly don’t trust the media. Trust the evidence.

You’re right about the media, by the way: just a few weeks ago, the media was actively pooh-poohing experts it now considers authorities, condemned President’s Trump’s excellent, prescient China travel ban (which bought us weeks of needed time) as a racist stunt, and kept telling us that we should worry about the flu more than we should worry about coronavirus. Michael Brendan Dougherty got pilloried as a sexist on Twitter for pointing out what is now a commonplace: our society lacks the flexibility to close schools because so many families have both parents in the workforce.

The media position swung, immediately and completely, minutes after reporters started to realize that the Centers for Disease Control had bungled the rollout of covid tests. (This has indeed proved to be an extremely damaging error.) The media recognized it now had an anti-Trump hook for this story, and that was the moment the media decided that coronavirus was actually worse than the flu after all.

So, yeah, forget the media.

And me, too. I’m just some guy, and, full disclosure, I’m not exactly the President’s biggest fan, either.

But trust the evidence.

There’s a ton of data about this pandemic now. I didn’t trust the numbers coming out of China, but the WHO sent in a team of skeptics, and they came away mostly convinced that China was on the level about their case and fatality counts. Besides, China’s basic data on infectiousness and fatality has been replicated in half a dozen countries by now. And I don’t believe Italy or Taiwan is cooking their books — certainly not in the same way, and certainly not in a way calculated to influence U.S. politics. Italy did not destroy its own economy to hurt President Trump.

Also trust first-person accounts — ones that reach past the media narrative (whatever it happens to be today) and just report what people in the heart of the epidemic are seeing. Back when American media was insisting that covid was no big deal, I was watching first-person videos from Wuhan residents that had been ported to YouTube and subtitled. The picture they painted was dire indeed. Today, it’s easier to find people in the heart of the Seattle and NYC and Italy outbreaks who can give you the straight dope from their streets and their hospitals.

And trust the experts. Not the media “experts” who get trotted out to reinforce whatever the narrative is right now, but the experts who have been on this since day one and who have consistently been on the ball about what covid could mean for us. I suggest Eric Feigl-Ding, Trevor Bedford, Scott Gottlieb, and Tom Frieden as a starter pack. These guys have been way ahead of the news cycle… and, thanks to them, so have I.

Okay, whatever. People who’ve survived coronavirus say it’s a lot like the flu. So what’s the big deal?

Well, first up, the flu is a very big deal. Every single year, billions of dollars are spent developing vaccines and deploying them to as many people on Earth as possible. Even though those vaccines are only moderately effective, the entire global medical establishment spends three months, every single year, doing nothing but shouting, “PLEASE GET YOUR FLU SHOTS” at the top of their lungs.

They do this because thousands of hospital beds are filled, every single winter, by flu patients. And plenty of them die. Influenza and pneumonia are the 8th leading cause of death in the United States — the only infectious disease currently in the Top 10.

COVID-19, the Wuhan coronavirus, is much worse.

Okay, smart guy. Swine flu killed 12,000 Americans. Coronavirus has killed 60. So how is it so much “worse”? What am I missing?

What you’re missing is the fatality rate (as opposed to the fatality count).

Not very many people have died of covid (yet), because not very many people have been infected by covid (yet). Why not? Because almost every government in the world is fighting really really hard to protect people from being infected.

We could stop all those measures and just allow covid to spread like swine flu. Let’s see how that would work out.

The CDC estimates that swine flu infected one out of every five Americans over the course of one year. And it killed 0.02% of the people it infected, for a total of 12,000 dead.

Under ideal circumstances, the covid virus appears to kill about 0.6% of the people it infects. That’s how many people it is killing in South Korea, which has done extensive and widespread testing to make sure that they are not underestimating the number of mild cases. South Korea has also imposed strict controls to prevent covid from overwhelming its top-notch health care system, and has more hospital beds per capita than just about anyone (including the U.S.).

There are 327 million Americans. Let’s say covid infects one in five Americans, just like swine flu. And then let’s say it kills 0.6% of the infected, just like in South Korea.

That’s 392,400 deaths. 32 times as bad as swine flu.

Under ideal circumstances.

Why do you keep saying “under ideal circumstances”?

Because our conditions are not likely to be ideal.

First, coronavirus appears to be somewhat more infectious than swine flu. Swine flu reached one in five Americans. It’s possible covid, left unchecked, would do the same… but that’s on the lower end of plausible estimates. The Spanish Flu of 1918 infected nearly one in three Americans. The Hong Kong Flu of 1968 infected nearly four in ten Americans.

Epidemiologists believe that covid, left to its own devices, could plausibly infect as few as 20% Americans… or as many as 60% of us.

We simply don’t know yet how infectious covid really is, but “swine flu” would be on the optimistic end. If it infects 60% of Americans instead… well, that’s 327 million Americans times 60% infection rate times 0.6% fatality rate = 1.2 million dead Americans.

This number is roughly in line with worst-case scenarios from the CDC and other public health experts.

But that’s not the thing that really scares me. It could get so much worse than that.

Wait, how can it get worse than a WORST-CASE SCENARIO?!

Neither of the worst-case models I just mentioned appears to account for the possibility that America’s hospital system will be overwhelmed. They assume that there are going to be hospital beds and ventilators for all the covid patients who need them.

Unfortunately, that’s almost certainly not the case. Without strict containment measures, covid sweeps through the population so quickly, and requires such dramatic and sustained medical intervention to keep people alive, that the hospitals literally run out of beds, ventilators, and basic equipment like face masks (which means they start running out of doctors and nurses a few days later).

We saw this in Wuhan, then Iran, then in Italy. Patients literally die of covid in the waiting rooms or on the floors, waiting for access to a ventilator, or even basic treatment. Doctors are forced to decide who lives and who dies. There are no doctors or beds left to treat people who come in for non-covid reasons, like car accidents or cancer. A lot of people die who could have been saved, simply because there aren’t resources to help them.

Under these less-than-ideal circumstances, covid’s fatality rate jumps from <1% to something like 4.5%.

If covid infects 20% of Americans, but kills 4.5% of them, you end up with 3 million dead.

That’s about 250 times worse than swine flu — and far worse than America’s leading causes of death, heart disease and cancer, combined.

But that is where the U.S. is headed, even though the models don’t appear to account for it. (Yet.)

Aren’t they working on a vaccine?

Yep. And I’m confident we’ll have it… in about a year. Some effective antiviral therapies could emerge before then. Pray that they do.

But right now? For all our vast technological expertise, we’ve got nothing.

Not a single person on Earth ever caught covid before October 2019, so there is absolutely zero natural immunity in the population. No vaccine means zero artificial immunity, either. This thing is poised to rip through us, and there is nothing we can do except lock the doors and wait for the Angel of Death to pass over us.

What can we do, then?

I just told you: lock the doors and wait for the Angel of Death to pass over you. Did you think I was kidding?

The CDC’s euphemism for this is “social distancing.”

This helps! Nations that have implemented harsh containment measures have seen immediate reductions in the rate at which the covid pestilence grows. Some countries that got hit early and implemented tough measures right away are seeing few or no new cases.

But it’s all pointless if you morons go out and “partay hartay” anyway. You stupid, f–

Excuse me?

Sorry. I lost my temper.

But, really, once there are cases in your community, you really should not be gathering in public or with large groups. Malls, zoos, sports, are all verboten. As much as possible, you should be at home–and you shouldn’t be hosting more than the smallest gatherings of friends and family (nor attending them). Work from home if at all possible. Get delivery or take-out instead of visiting restaurants, if you must order out at all. Give serious consideration to pulling your kids out of school — by the time covid is detected in your school, it’s too late to protect your children (and therefore you) from exposure.

Don’t mess with this. Even if you don’t kill yourself, you could easily kill someone you love.

That’s a tiny bit true of flu, too, yeah, and, yeah, you should get your flu shot. But the Wuhan coronavirus is not the flu. It’s going to kill an unthinkably large number of people worldwide. Make sure you and — more to the point — your elderly parents aren’t among them.

UPDATE:

Something isn’t adding up. China has 1.5 billion people, but only 3,000 dead of coronavirus. You’re projecting that the USA, a country of 300 million, could lose 500,000 to 1 million people (or more). I have my doubts.

Two days after China passed 100 diagnosed cases, they completely locked down Hubei province — an area with the population of California. People weren’t allowed to leave their houses more than once per week. Private cars were banned. Quarantine was forcibly — and brutally — enforced. Drones were (allegedly) launched with temperature sensors to monitor whether locked-in residents had developed fevers. Apartment building doors were soldered shut.

Within a week, China did the same thing in hundreds of other cities and provinces, placing over 300 million people (roughly the population of the entire United States) under significant movement restrictions.

It was by far the largest and most dramatic quarantine in human history.

…and it appears to have worked.

We can expect to see similar results if and when we start arresting people for being on the streets without a good reason. Until then, brace for impact.

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When Should We Cancel for Covid-19? A Family Email

by James J Heaney Posted on 13 March 2020

My parents, siblings, and kids normally get together every Sunday night for family dinner. Due to the covid (coronavirus) outbreak, which recently arrived in Minnesota, some of us have asked whether it’s time to suspend the meal and switch to a weekly Skype call instead. It’s a sensible question! It’s not at all obvious how to actually quantify and weigh the risk of family dinner. On Wednesday night (March 11th), I thought about it and wrote this in response. And then I thought that readers of this blog might find it useful, too, as you try to shape your own thinking about this.

Hey, all,

I don’t think we’re to the point where the risk is high enough to cancel Sunday dinner. Work — a gathering of hundreds or thousands of fellow employees and/or students — yeah, it’s probably time to empty work if we can. 

Let’s quantify this! Yes, let’s do my favorite thing: solve all problems with 9th-grade math!

TLDR: I think dinner should be on for this week. Next week probably, too. After that, pretty dicey.

Sunday dinner is at most nine people, usually just five, and the risk there is pretty low… especially if everybody at that dinner starts working from home. We can use this chart (especially the equation at the bottom!) to estimate risk.

In Minnesota, we right now have 5 diagnosed cases out of a population of (5.3 x 10^6). It’s safe to say that assume that are some undiagnosed cases circulating right now. Let’s say, somewhat pessimistically, that there are 10 such cases — covid carriers who are spreading the virus right now, but whom we haven’t found yet.* [SEE NOTE] Assume 6 people come to Sunday dinner (which is about average). If that dinner were held tonight, the risk that an infected person will attend the dinner is (1-(1-(10/5300000))^6) = 0.0011%. 

This estimate is likely high, because the 9 of us do not represent anything like a diverse cross-section of Minnesotans, and several of us are socially isolating. And note that this is an estimate of exposure, not transmission, much less death. But we’ll go with it, because better safe than sorry.

Bear in mind that any given American has a 0.01% chance of dying in a car crash in any given year, and a 0.04% chance of dying of accidental causes in general. So the odds that family dinner this Sunday will kill one of us are not quite “odds of getting struck by lightning” low (0.0002%, in case you were wondering), but they are pretty darn low.

I think we should suspend dinner when the chance of exposure goes above 0.05% — a 5-in-10,000 chance, which is about when I think most people start worrying about risks. Do some algebra and continue with the same assumption about circulation, and that implies we should stop having dinner when Minnesota passes 221 diagnosed cases.

Assuming the number of diagnosed cases continues to grow in Minnesota at the rate of about 33% per day — which is a consistent global pattern at this stage in the infection — then we will still be able to have Sunday dinner this coming Sunday (the 15th, when there will be ~15.6 diagnosed cases in Minnesota), and again on Sunday the 22nd (~115.2 cases). [Editor’s Note: See our post yesterday on how Minnesota’s coronavirus infections will grow in the next few weeks.]

By Sunday the 29th, we can expect to have ~850 diagnosed cases, and that is when we can expect to suspend Sunday dinner.

Reporting to work is quite a bit more dangerous. Assume ~6000 people on campus (be it [father’s workplace] or [siblings’ workplace]). Tomorrow, on these assumptions, there will be a 1.1% chance that someone on campus is already infected, aka 20 times the danger threshold I am proposing for family dinner. By Monday, that becomes 4.4%. 

By Monday the 30th (two weeks from now), the odds of someone on campus being infected would be about 72%. However, I expect all our campuses to be closed by then — except [family medical professional]’s, of course, which will be dealing with (on a per-capita basis) a Lombardy-scale crisis by then. Hopefully the Minnesotan health care system proves more up to the task than the wealthiest part of Italy’s.

We should obviously keep our eyes on the case count, since Minnesota could still take strident action to “flatten the curve,” and (happily) that would ruin all my dire predictions.

Love, Jamie

*NOTE: Out of everything in this letter, this is the part that makes me most nervous. How many cases are really circulating in Minnesota? I have no idea. “Double the diagnosed count” seemed like a comfortable number on Wednesday night, but tonight? I just don’t know.

It will be hard to speculate on the true case count until there’s a death; we have good estimates for the disease’s fatality rate (~1%) and doubling time (6 days), so we can work backwards from there. It appears to take roughly 16-24 days to die of COVID-19 after initial infection. Since the fatality rate is 1%, if 1 person dies, then you can reasonably guess that 99 other people had it at the same time, but recovered. Which means 100 people had it… 16 to 24 days ago. In the meantime, the virus, doubling every 6 days, has doubled in size 3-4 times. Which means there are actually now 800-1600 cases today… and 8-16 of them will be dying over the next several weeks.

In short, 1 death today = approximately 1200 cases today, probably, roughly, ish. More deaths can make that estimate more precise.

But Minnesota has no deaths yet, so we’re just guessing wildly. There could be 10 unidentified cases in circulation, like I speculated; there could be 100. With so little testing, it’s very hard to know!

(P.S. Thanks, Cate.)

UPDATE: Epidemiologist Trevor Bedford, who was the first to notice sustained community spread in Washington, suggests a “very rough” rate of 10 undetected infections for every 1 diagnosed case in the U.S. currently. That’s a good deal more pessimistic than I was in this email, and implies that there were, very roughly, 50 cases circulating in Minnesota on Wednesday, not 10. (And it’s up to 140 by now.)

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Expected Spread of Covid (Coronavirus) in Minnesota

by James J Heaney Posted on 13 March 2020

People keep asking me how bad this thing could get.

I don’t think it’s helpful to look at the national level, because there is no single national outbreak. There are a series of local outbreaks, each of which is currently in a different stage. Washington State, right now, is under serious strain right now, desperately trying to mitigate what has already become an out-of-control epidemic. Minnesota has several cases, but (supposedly) it is not yet spreading person-to-person here, so Minnesota is still trying to work on containment, delaying the start of a real outbreak. Alabama has no cases at all, so it’s simply in monitoring-and-preparation mode, hoping to recognize covid (and contain it, for a while) when it does finally show its face in Dixie. Unfortunately, Alabama cannot lend its hospital beds and nursing staff to Washington State; those resources are fixed in place.

So when I want to know how risky it is for me to go to church on Sunday, it’s not that helpful for me to look at the number of cases nationwide. Most of them are thousands of miles away from me. I want to know how many cases there are around here — and, more importantly, how many there will be a few days from now.

Something interesting: so far in the epidemic, diagnosed case counts have grown by approximately 33% daily, unless there is dramatic government intervention. Even more interesting, this has been fairly consistent at both the local and national levels.

For example: in the morning on March 2nd, the U.S. had 102 diagnosed coronavirus cases. Suppose you wanted to predict how many cases the U.S. would have in the morning today, March 12th. Assuming a 33% average daily growth rate, you would have pulled out your calculator and typed:

102 * ((1.33) ^ 10) = 1,766 cases expected by March 12th.

How many diagnosed cases did the U.S. actually have this morning? 1,697, off by 4%. Not bad, for an estimate made 10 days ago about a virus whose case count doubled four times.

Similarly, in the morning on March 4th, Seattle had 39 diagnosed cases. Assuming a daily 33% average growth rate, how many would Seattle have eight days later, on March 12th?

39 * ((1.33) ^ 8) = 381

How many did they actually have? 366, again off by 4%.

I played around with this looking at recent historical data for Italy, and Colorado as well, and it did pretty well. 33% growth per day has been a pretty decent average. Sometimes the estimate went a bit high, sometimes a bit low, but it was always fairly close to the truth.

I’m not really sure why this works so well. These are only diagnosed cases, and our testing regime is very bad right now, so we are certainly lagging the actual progress of the disease. At times, diagnosed cases may only be a fraction of real cases. (We saw that in Wuhan, although they eventually caught up.) So I wouldn’t expect to see the diagnosed case count grow so smoothly. But, hey, it does, and I’ll take it.

What I want to know is how bad it’s going to get in Minnesota.

This is only an estimate, and not a very smart one. It doesn’t account for any specific factors on the ground, community spread vs. imported infections, etc. And it only predicts diagnosed cases; there are likely many more undiagnosed cases, and we won’t really know how many until we start having people die of it. Yet I’m going to stick with this formula, since it has proven fairly good at predicting the future, and I don’t have anything more sophisticated at hand.

As of dawn on Friday, March 13th (oof, Friday the 13th, I just noticed that), we will have 9 diagnosed cases in Minnesota. (That’s not an estimate, that’s a news report.)

By dawn the following day, March 14th, assuming a 33% growth rate on average, we can estimate that Minnesota will have approximately 12 diagnosed cases.

By Sunday, March 15th, we can estimate 16 diagnosed cases.

By Wednesday, March 18th: 37 diagnosed cases.

By Sunday, March 22nd: 117 cases.

By Wednesday, March 25th: 276 cases.

By Sunday, March 29th: 863 cases.

By Wednesday, April 1st: 2,030 diagnosed cases.

By Sunday, April 5th (Happy First Contact Day):, 6,351 cases.

By Wednesday, April 8th: 14,941 cases.

By Sunday, April 12th: 46,751 cases… approximately 1,589 of whom will die.

By Monday, April 20th, we arrive at 450,000 diagnosed cases.

The day after that, the total number of cases exceeds 10% of the state’s population. At that point, the virus will naturally begin to slow down, because enough of the population will have developed immunity (or died) to start to grant herd immunity. Covid won’t actually stop, of course, but it will no longer grow on a 33% daily curve. A statistically significant chunk of Minnesota’s over-60 population will already be dead or dying, but the deaths won’t stop for some time after.

That’s where we are headed right now, on our current trajectory. 9 (known) cases today turns into tens of thousands in a matter of weeks. That’s exactly what happened in Italy.

There appear to be three ways to prevent this exponential growth in case counts from happening:

  1. Stop testing. Can’t have diagnosed cases if you don’t try to diagnose! This won’t reduce the case load or the fatality rate, and actually will make things much worse and kill lots of people needlessly… but it will make your numbers look good, so there’s that.
  2. Wait until the virus burns itself out (basically, until so many people have been infected that it can’t infect enough new patients to remain an epidemic) and hope that it burns out much faster than other flu-like diseases. Maybe you’ll get lucky, and Minnesota’s wet, warming climate means that the infection rate will start to fall long before late April! There seems to be no reason to believe this will happen, but it COULD!
  3. Impose and support major restrictions on the movement and gathering of human beings in Minnesota. Ban parades, ban sports, close schools (perhaps leaving them partially open, on a skeleton-crew basis, solely for the children of health care workers who have nowhere else to put them), cancel concerts, require businesses to support telecommuting and/or provide paid time off. Shut. Down. Everything.

Iran has tried option (1), and it’s working out pretty well for them. Although a number of senior officials have died and they’re currently digging mass graves, their official numbers aren’t growing quite as fast as you’d expect them to grow if they were doing honest testing and reporting. And that’s the goal of option (1), so it’s working as intended.

Italy tried option (2), but chickened out completely after their medical system collapsed under the strain of patients flooding every bed and corridor in their hospitals, with doctors forced to use scarce resources to treat the young while leaving the elderly to die. They are now trying option (3), locking down the entire country, like a bunch of boring mcboringstans… but it’s probably too late for option (3) to stop the mass casualties for at least a couple more weeks.

Who knows? Maybe we could try option (2) ourselves, and we’ll have better luck than Italy. We have absolutely no reason to believe we’ll do any better, but it’s a chaotic world! Who knows?

There are four countries on Earth that have successfully beaten back the exponential growth of covid. They are all still seeing cases on a daily basis, but they are not having huge numbers of cases coming in all at once and crushing their medical systems. Those countries are: South Korea, Japan, China (after the initial calamity in Hubei province), and Singapore. At the moment, it looks like they are all going to get through this relatively okay.

By a truly bizarre coincidence, all four of these countries adopted the same strategy to fight covid. That’s right! They all chose option (3)! They shut down their cities, ordered widespread testing, closed the schools, and cancelled everything. And, after each country did this, cases started to fall almost immediately!

Thomas Pueyo goes into a lot of depth about how this worked in his article from earlier this week, “Why You Must Act Now.” I wouldn’t trust every number in his post — some of his speculation about the “true” number of cases in any given community is a little wild, and the “model” he offers at the end is a bit high-strung as a result, but his basic point is sound: the sooner these countries imposed social distancing, the more lives were saved, and the difference was drastic.

They might be on to something!

So consider this post a prediction. If Minnesota takes no real action to combat covid, expect over a hundred thousand cases in a little over a month.

If Minnesota does take real action, then you can look at this post instead as a kind of alternate universe. Every time you miss out on something you were looking forward to doing, you can look at this post, compare my predicted case count with whatever the actual case count is that day, and thank God and your fellow Minnesotans for moving Heaven and Earth to spare us from that.

Happily, there are signs that Minnesota will indeed take appropriate measures. Several local colleges are going online-only, the Archdiocese has dispensed everyone from the requirement to attend Sunday Mass, and locals seem to be stocking up for impending social isolation appropriately.

Don’t panic. This isn’t the end of the world. It’s not like that movie Contagion, where most of the infected died. Covid likely kills a little less than 1% of its victims, most of them elderly. Many more than that are left with permanent scars of one form or another. But we will get through this, just as humans have got through every other epidemic in history. And our forefathers didn’t have Hulu. Or indoor plumbing.

Don’t pretend. This isn’t a run-of-the-mill flu pandemic. Stop imagining it is. It’s likely the most serious health threat the human race has faced since the Spanish flu almost exactly a century ago. The fact that bodies aren’t stacked like cordwood outside hospitals doesn’t mean covid is a hoax; it simply means that covid hasn’t taken root in your community yet. Again, look at those mass graves in Iran. (I’ll be writing more about this tomorrow / later today.)

Do prepare. If you’re in Minnesota, it’s time to start working from home if you can. I hope you did the sensible thing and stocked up on essentials over the past few weeks; if not, there’s still time. (However, please DO NOT buy masks — health care workers need them much much much much much more than you do.) Stop going out for non-essential activities. Don’t gather with large numbers of people. Take care of yourself and those around you, especially the elderly. Do your part, and we’re that much closer to “bending the curve” and preventing the awful predictions in this post from coming true.

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Political Disruption Due to Novel Coronavirus

by James J Heaney Posted on 5 March 2020

Assume that these “consensus” projections for covid (aka “novel coronavirus”) are correct:

  • This report’s fatality rates by age (Table 1) end up being more or less accurate — particularly the high fatality rates for people age 70+.

These are both large assumptions. Covid might not be this bad. Or it might be worse. The first assumption arguably conflicts with the second. There’s still so much we don’t know or aren’t sure of.

If these assumptions are true, though, and all else is held equal (another huge assumption), a little back-of-the-envelope math shows:

  • There is a 1-in-5 chance that one of the five main candidates currently running for President of the United States will die of covid by the end of the year.
  • There is just about a 1-in-4 chance that one of the current justices on the U.S. Supreme Court will die of covid by the end of the year.
  • A little over a 1-in-3 chance that at least one of these things happens.
  • About a 1-in-20 chance that both will happen.

70-to-90 year olds dominate our key political institutions, and are also (according to that particular paper) roughly 50 times more vulnerable to coronavirus than 20-50 year olds. This has consequences.

(I don’t even want to think about running this math for all of Congress, which is chock full of old people. Mitch McConnell is 78. Nancy Pelosi is 79.)

This math is very naive, and ignores things like co-morbidity and celebrity-level health care… but (assuming the assumptions about covid are true) it’s in the ballpark. It stands to reason that folks should start pricing in at least some possibility of significant political disruption caused by the novel coronavirus.

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A Viewer’s Guide to Outcomes in June Medical Services v. Gee

by James J Heaney Posted on 4 March 2020

Tomorrow, the Supreme Court will hear the first significant abortion case since Justices Kavanaugh and Gorsuch joined the Court. You can read a lot of great analysis about it at SCOTUSBlog, including a symposium article by my friend and brilliant lawyer Teresa Collett.

This blog will simply attempt to describe the range of plausible outcomes in June Medical Services v. Russo (known until quite recently as June Medical Services v. Gee). After tomorrow’s oral arguments, we will have a much clearer idea of where the Court is heading. The pro-choice mainstream media will scream in horror at the top of its lungs under all plausible outcomes. The headline “The End of Roe is Nigh” will appear regardless of whether the end of Roe is, in fact, nigh. I want to post a few insights about the case now to help you set expectations and put the media’s forthcoming tantrum in perspective.

June v. Gee revolves around a series of medical regulations the state of Louisiana has imposed on abortion clinics. (Interestingly, the regulations were imposed in large part by Louisiana’s strong contingent of pro-life Democrats, God bless ’em.) These regulations are in many ways similar to regulations imposed by Texas several years ago. The Supreme Court struck down the Texas regulations in the 2016 case Whole Women’s Health v. Hellerstedt.

Hellerstedt was a 5-3 decision, with Justice Scalia absent (due to being dead). Leftist justices voted to strike down the regulations; right-wing justices voted to uphold them. Justice Kennedy cast the deciding vote and sided with the left-wingers.

But Scalia and Kennedy have both been replaced with conservative justices. Meanwhile, the 5th Circuit Court of Appeals has ruled that the Louisiana regulations are actually not that close to the Texas regulations and shouldn’t be affected by Hellerstedt.

What will the new Supreme Court do? Will they accept Hellerstedt as settled precedent? If they do, will they hold the new regulations should also be struck down, or are they different enough to be upheld? Will they finally act to minimize (or eliminate) the demented precedents of Roe v. Wade and Planned Parenthood v. Casey? Will they try and wriggle out of the whole question on a technicality, and both sides live to fight another day? Have pro-lifers finally succeeded in restoring the Supreme Court to correct constitutional rulings on abortion… or were all those votes for pro-life presidents and senators over the past twenty-five years ultimately in vain?

There are a few plausible possibilities:

REGULATIONS STRUCK DOWN (DEFEAT): In this outcome, the pro-lifers lose. This would be pretty bad. First, it would foreclose a huge area of legislation that pro-lifers have used to protect human life (unborn and born). Second, it would be a strong indication that the Court will be unwilling to consider more aggressively pro-life laws, like the heartbeat laws passed in several states, and even fairly routine medical regulations will be subject to years-long judicial review by partisan judges before coming into effect. Third, for the Louisiana regulations to be struck down, the Court would have to reaffirm Hellerstedt, a narrowly decided precedent from just a few years ago — a far weaker precedent than Roe itself. That would mean that, fundamentally, nothing has changed on the Supreme Court with Justice Kennedy’s departure. Abortion would still be an unlimited constitutional right trampling over state laws and regulations of all kinds, and there’d be not a damn thing we can do about it short of revolution. The past twenty-five years of pro-life campaigning to rescue the judiciary would have all been for nought.

I don’t think it’s especially likely the regulations will be struck down like this, but pro-lifers have been burned before: nobody expected Planned Parenthood v. Casey to loudly reaffirm abortion rights, either, but that’s exactly what happened. Justice Kavanaugh’s judicial philosophy remains unclear to me, and everyone should be nervous about Justice Robert’s deep desire to preserve so-called “respect for the Court” among a left-wing press that holds him in complete contempt regardless. I’m nervous about this outcome.

This is the only outcome where the media won’t completely freak out, although they will still write Very Very Angry pieces about how horrible it is the the Court, in upholding Hellerstedt, failed to actually affirm the so-called constitutional right to an abortion.

REGULATIONS UPHELD BUT HELLERSTEDT PRESERVED (MINOR VICTORY): The Court could do what the Fifth Circuit did: obey the Hellerstedt precedent (keeping it on the books) but in a really narrow way (making it much less of an obstacle to pro-life regulations). This would give states considerable flexibility to regulate abortion clinics while allowing the Court to say that they respect precedent. Personally, I think this is the one of the most likely outcomes, because it’s one of Justice Roberts’ very favorite moves, especially if he can bring over a vote from the other side to support him.

And, you know what? It’s an okay outcome. Not great, because it signals they are still too concerned about political considerations to actually uphold the Constitution. Also not great, because the Hellerstedt precedent involves a laborious and highly subjective legal test, which will be applied by ideological judges on both sides every single time a clinic regulation is passed… but, still, upholding the Louisiana regulations should give states a free hand to regulate abortion clinics (many of which cannot survive adequate medical regulation), and suggests at least the possibility that the judiciary will allow cautious, well-considered moves toward other abortion restrictions.

The media will completely freak out if this happens, but it will be mostly hype. A small victory for pro-lifers that enables us to sometimes enact broadly popular measures like the Louisiana regulations will continue things on their current trend (clinic closures are up, abortions are down), but won’t fundamentally alter the trajectory of the American abortion debate. The media is just used to the Left controlling the Court, as it did for the entire period between 1938 and 2018, and is taking the transition very badly.

DISMISSED FOR LACK OF STANDING (BACKDOOR VICTORY): Pro-lifers have advanced the very interesting argument that the plaintiffs in this case (abortion clinics who are suing on behalf of the women they serve) do not have legal standing to sue over this regulation, because the interests of the clinics and the interests of the women they’re supposedly representing are too divergent. (And women who oppose the regulations could just file lawsuits themselves.) If the Supreme Court agrees, the case would be dismissed without ruling on the underlying question of whether Hellerstedt was correct. The Louisiana laws would be upheld by default… although some individual Louisiana woman (or women) could file a future lawsuit, sending the case through the entire court system all over again. (This case was originally filed in August 2014, so… see you in six years!)

It would not be a bad outcome for pro-lifers, though, because abortion clinics have used the “we are suing on behalf of women” excuse to challenge every abortion law we’ve passed in every state for thirty years, bringing their massive reserves of cash and organization to bear on our ragtag movement. Forcing them to at least recruit actual clients who are actually able to claim some kind of legally cognizable injury from abortion regulations could make suing against every pro-life law a bit less legally feasible. And it is sort of weird that abortion clinics seem to be an exception to regular court rules about standing. Still… while many pro-lifers are cheering for this outcome, it doesn’t seem worth it to me, when, really, Hellerstedt needs to go.

I think there’s a very good chance of this outcome. It’s probably the most likely outcome. Roberts will be looking for an out on this case (as discussed above). He may be able to win somebody on the other side over to this opinion, maybe Kagan, therefore showing a bipartisan consensus, which he loves. And pro-lifers are actively campaigning for this in recent legal briefs, so it won’t be interpreted as a betrayal the way either of the lesser outcomes would be.

The media will moderately freak out if this happens, but it will be mostly hype, and they’ll be mostly too confused about the implications to really let loose about it.

(UPDATE: A lawyer friend of mine, whom I greatly respect, and who is routinely involved in national abortion litigation (including before the Supreme Court), thinks I am underselling the effect of this outcome. If clinics don’t have standing, certain kinds of regulations, including these regulations, could become very difficult or even impossible to sue against, because few/no individual mothers would have standing. The Obama Administration used this “nobody has standing” trick a few times to violate the Constitution, as in the suspension of the employer mandate, so it would be nice to see this used to prevent constitutional shenanigans in the judiciary for once. She spoke of other benefits to the pro-life legal movement as well. I’m still getting a handle on what exactly this outcome would mean, but I trust this friend implicitly. A backdoor win on standing might be terrific.)

HELLERSTEDT OVERTURNED (MAJOR VICTORY): As I’ve mentioned, the Court ruled 5-4 in Hellerstedt (technically 5-3 because Scalia died) to strike down clinic regulations. The 5th vote was Kennedy. Roberts strongly opposed the decision at the time, and he joined a scathing dissent.

Kennedy is gone now. If Kavanaugh is the man we think he is based on his lower-court opinions, and Roberts isn’t a coward who abandons his own published opinions, they really should overturn Hellerstedt. Under any reasonable analysis of stare decisis, Hellerstedt just doesn’t have many of the elements that make it a strong precedent, so even fear of overturning precedent shouldn’t hold Roberts and Kavanaugh back.

Practically speaking, overturning Hellerstedt would not just deliver a victory to women and children in Louisiana; it would also make it much easier for other states to pass these medical regulations on abortion clinics, without fear of a court striking them down. It would signal to pro-life activists that the Court is willing to reconsider and overturn various non-Roe abortion precedents. That would encourage states across the country to pass new legislation finding new ways to push the envelope, eventually undermining Roe and Casey to the point where it becomes “unworkable” and they’re overturned, maybe ten or fifteen years from now. So this wouldn’t be the perfect outcome, but it would be very good.

It had better be! It’s why our side put President Trump in office, and God knows the cost of doing that has been terribly high. Based on Kavanaugh’s testimony about precedent in his hearings (before the rape allegation consumed everyone’s attention), I think this is how he would like to approach it. I don’t think Kavanaugh is opposed to overturning Roe, but he wants to build a lengthy judicial line of contrary precedents before finally acknowledging Roe‘s incompatibility with the Constitution. So I consider this the last of the three most likely outcomes, and the only one I would be really, really happy with.

If this happens, the media will completely freak out, with some justification. They’ll call it the imminent end of Roe, when really it’s more like pro-lifers have finally found the first chink in Roe‘s judicial armor plating since we won Gonzales v. Carhart 13 years ago. (The media had a nice solid freak out about that, too… but here we are, it’s 2020, and Roe is still on the books.) It will adjust the trajectory in the abortion wars in favor of life, but only modestly… at least for now.

CASEY OVERTURNED (DECISIVE VICTORY): The Court could go further than overturning Hellerstedt. Hellerstedt is built on Casey, the 1992 precedent that made “undue burden” the standard by which all abortion regulations are judged. It would not be shocking for the Court to revisit Casey, 27 years later, and modify its central holdings. The “undue burden” standard has repeatedly proven vague and unworkable for an entire generation now, with courts swinging back and forth on its meaning based on their partisan makeup, and that’s the kind of thing that ordinarily invites Supreme Court re-review (at least outside the bizarro world of abortion law).

Casey is the worst Supreme Court decision of all time (as Michael Stokes Paulsen has correctly argued elsewhere), so it’d be great to see it gone. Killing off Casey and imposing some new set of rules on abortion would be incredible, and, depending on what the new rules are, it might be effectively the same thing as killing off Roe without the Court actually admitting that’s what they’re doing. This is probably the best we can reasonably hope for from Roberts and Kavanaugh… but, again, depending on how they write the opinion, they could use this to kill Roe in all but name, so we wouldn’t really have anything to complain about.

ROE OVERTURNED (TOTAL VICTORY): Obviously, the Holy Grail. In this outcome, the Supreme Court just comes out and admits what we’ve all known, on all sides, since 1973: there is no constitutional right to abortion. Harry Blackmun made the whole thing up. Abortion would be thrown entirely back to the states, and all of a sudden the pro-life movement, having won a great victory, is thrown into battle on 50 different state fronts, in a huge variety of ways. (After all, those states with heartbeat bills and trigger bans on the books suddenly have no abortion — do they have enough crisis pregnancy centers to take care of the sudden surge in mothers with crisis pregnancies?)

For either of these last two outcomes, the media freakout would be justified. The media in this country is deeply committed to the constitutional right to a dead child, and overturning either Roe or (depending on how it’s done) Casey would effectively end that supposed right. (States could still protect it, and many would.)

This honestly could happen. It’s certainly not likely, I don’t even think it’s wise to get your hopes up… but it could. Indeed, I guarantee you that Justice Thomas will write an opinion calling for the end of Roe regardless of the outcome. I will bet you five dollars that that opinion is joined by both Alito and Gorsuch. That’s 3 votes to kill Roe in your pocket. But you need 5 for a majority.

Roberts is a sane man who knows that Roe is bad law, but he’s also intensely anti-confrontational and intensely worried about the Court’s prestige. And Kavanaugh is still something of an unknown quantity. So I am not holding my breath in hopes that June Medical Services v. Gee will herald the end of Roe. I’m hoping for — and expecting — a modest victory that helps us push the battle for unborn rights another step forward. But you shouldn’t be caught entirely flat-footed if, next June, Roe v. Wade suddenly falls on the ash heap of history where it belongs.

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