Expected Daily Covid Deaths in Minnesota (May)

Version 3 of the Minnesota Model was released a few days ago. The model immediately drew skeptical reactions for its prediction that Minnesota would have roughly 1,440 deaths by the end of May:

[S]ome say the numbers just aren’t plausible… To hit the estimated deaths by the end of the month would require, on average, between 41 and 44 deaths per day for the rest of the month. Minnesota has averaged 22 deaths per day in the last week. (Source)

I grabbed the model source code from GitHub and played around with it. Here is how Version 3 of the Minnesota Model projects the next couple weeks will play out:

DateProjected DeathsActual Deaths
(Daily updates in green)
Before 13 May557614
13 May29.024
14 May30.325
15 May 31.720
16 May 33.117
17 May 34.622
18 May 36.19
19 May 37.717
20 May 39.329
21 May 41.132
22 May 4333
23 May 45.210
24 May 47.617
25 May 50.512
26 May 53.718
27 May 57.433
28 May 61.435
29 May 65.929
30 May 70.730
31 May 75.914
TOTAL1441.11040

Feel free to grab the model yourself and play around with it. (Technical notes: my numbers are from a reconstructed Scenario 5, with parms$end_time_social_distancing <- 1 + 5 + 51 + 21. [UPDATE: repo here, branch “Scenarios5and6.”])

The uncertainty on this seems to be in the neighborhood of +/- 300, based on Slide 12 here. That means anything from 1100 to 1700 deaths should be considered a success for this model.

Back in March, I wrote a very simplistic projection of how quickly covid would spread through the state if we did nothing. I did this to build a case for immediate cancellation of all large gatherings and the imposition of a temporary lockdown.

Today, I’m not writing to advocate anything in particular. These deaths can no longer be stopped. The people who will die of covid-19 over the next couple weeks have, mostly, already been infected, and will die regardless.

…Well, okay, not quite. According to the model, ending the stay-at-home order on May 18th (instead of continuing it into June) does mean an additional 53 deaths, with the first “extra” death most likely occurring on May 24th. But 53 extra deaths on a model with a margin of error of +/- 300 is invisible statistical noise. Besides, even if Gov. Walz reversed course today by extending the stay-at-home order, expectations of re-opening are now so high that it seems unlikely we could actually get back to a strong enough stay-at-home order to save those lives. (I’ll write about Minnesota’s declaration of surrender as soon as I can.)

So why make this post at all?

After I did the March post, I found it useful to have a daily “mile marker” around to check whether covid was beating my expectations or falling short. I checked back regularly to help confirm whether I was overreacting or underreacting. (In retrospect, I appear to have been just-right-reacting.) By the same token, having these “mile markers” for May will help tell us how much stock we should place in the Minnesota model.

If we end up with a death toll significantly above these numbers (above 1700), then it means the model is missing something. Perhaps it underestimated the lethality of the virus, or perhaps it overestimated the extent to which people will continue to socially distance after Sunday’s official end to stay-at-home orders.

On the other hand, if we end up significantly below this death toll (under 1100), then it means the model is missing something in the other direction. Perhaps the new treatments we’ve started receiving are really effective, or perhaps summer weather is having a substantial effect on slowing the virus’s spread. (The Minnesota model does not include weather in any way.) Or, more cynically, perhaps it means people are dying at home and not getting discovered. I’ve become a lot more pessimistic about these things since Minnesota gave up on test/trace/isolate and Virginia got caught cooking its books.

To be frank, I’m optimistic that the reality will indeed end up on the low end of this model. Looking at places like Florida and Singapore, I can’t help thinking that there may be something to this idea that the summer offers a respite from covid — a respite we can use to get on top of this thing after all. It doesn’t hurt my mood that, while I’ve been working out the details of the model, the weather has warmed up and the daily deaths in our state have started going down for the first time in weeks.

But I’ll be watching. And now you can watch with me.

See this blog’s previous analysis of the covid epidemic in Minnesota here.

EDIT: Now that I’m exploring the released version of the Minnesota model for myself, let me know in the comments if there’s anything specific you’d like me to take a look at, and I’ll see whether I can make the time during the next few days.

Minnesota released Scenarios 1, 2, 3, and 4 (described here). I was able to exactly reconstruct Scenarios 5 and 6. I think I can build out the rules to reconstruct Scenario 7. Scenarios 5a, 6b, and 8 are beyond my capabilities right now, because the Minnesota modeling team did not include sufficient (any?) documentation about them.

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Where Are Minnesota’s Tests?

Some very odd (but potentially relieving?) information in Friday’s Minnesota covid presser.

The thing that worries me most about Minnesota right now, the thing that keeps me up at night, the thing that makes me confused and frustrated and worried that our stay-at-home order will have to last longer than in most U.S. states, is our testing positivity rate.

It’s generally agreed, based on the countries where they’ve got covid under control (South Korea, New Zealand, Australia, Taiwan), that you are doing enough testing to accurately track the epidemic if your positivity rate (the number of positives divided by the total number of tests given) is 2% or lower.

As of Thursday, the median U.S. state or territory’s average positivity rate over the past seven days was 11%. This high number indicates that, as a country, we are still flying mostly blind and have zero ability to get ahead of covid-19 with testing, tracing, and isolation. However, the number has been falling steadily for days, as national testing rises.

Also as of Thursday, Minnesota’s average positivity rate over the past seven days was 17% — and steadily rising. Our daily testing was supposed to hit 5,000/day a week ago (on a steep path towards 30,000), but it has yet to do so, and has instead spent nearly two weeks fluctuating between 3,000 and 4,000. This indicates that we are not only doing far worse than we need to be, but that our control over the epidemic is actually slipping… this despite a set of stay-at-home orders that are buying us limited time to get things under control. We’re also one of the few states right now where, given our official case count, the virus still seems to be growing.

Let’s be clear: once the stay-at-home orders end (and they will have to end within a couple months, if not weeks), we either have the ability to test, trace, isolate, and suppress the virus… or we don’t. If we do, we can get through this without it being too much worse than a real bad flu. If not, brace for impact, because thousands of Minnesotans are gonna die. We don’t get a do-over. We need our positivity rate at 2% or lower YESTERDAY. And we need to start seeing daily case counts and death counts fall very soon if we plan to get it to a controllable point by May 30th (I don’t see how May 18th is viable at this point).

So that’s context for two tidbits from this hourlong Friday briefing that really caught my attention:

(1) Commissioner Jan Malcolm reports early in the call that Minnesota just found out this week that some testing sites are only reporting positive tests, not total tests. This means that the positivity rates for those sites is being recorded as 100% — but that’s not actually accurate. Minnesota is now trying to correct that data. We don’t know how widespread this is, and whether it will have a meaningful impact on the size or direction of our positivity rate, and it’s… surprising… that this reporting error was allowed to persist up until now. But HOPEFULLY, once the data is corrected (SOON PLEASE), we will see that we’ve actually been conducting more tests than we realized.

[UPDATE: Commissioner Malcolm clarified later in the day that this only happens occasionally, and that, on May 7th, only one lab did this. That’s good news for the competence of Minnesota’s data scientists; bad news for all of us who were hoping it could explain away our high positivity rate.]

(2) Even more interestingly, Commissioner Malcolm and Governor Walz answer a question by stating that Minnesota, right now, today, has capacity to test 10,000 people per day. That capacity is not being used. According to Commissioner Malcolm, people are literally not showing up at testing sites to get tested, possibly because of communications months ago that we don’t have enough tests and that mild cases shouldn’t get tested.

This has changed! MILD CASES SHOULD GET TESTED NOW. If you show symptoms of covid-19, get thee to a testing site!

But apparently our own Minnesotan politeness — the same dumb obsequiousness that makes us a joy to grocery-shop with and a nightmare to zipper-merge with — is keeping us from using our full testing capacity, getting a true handle on the disease, and getting out ahead of the rest of the country as we should. (That, or the Governor is not telling us the full story. Always a possibility with government officials.)

Walz and Malcolm vowed to communicate this better. They’d better be quick, because this has been turning into a farrago for Minnesota even as North Dakota whups our butts on testing and cases and deaths.

In Other News: Minnesota has received its first batch of remedisivir, which I still can’t spell after two months. If this thing is capable of cutting covid’s fatality rate by even half, I’ll feel very comfortable about our position, tests or no tests. One of the reasons we locked everything down was to buy time to develop treatments, and now those treatments are finally starting to arrive.

Q&A: Collected from readers over the past few days.

I heard that Minnesota will peak late because we did a good job slowing the spread. Is that true?

I don’t see why this should be true. Peaks happen in one of two ways: (a) achievement of herd immunity forces the disease into decline, or (b) human interventions like vaccination or decisions to stay at home (legally mandated or not) force the disease into decline.

No state has reached herd immunity, not even New York City (where it seems about 20% have been infected; herd immunity is expected after around 75% have been infected).

So all states that have passed their peaks (their first peaks, that is) have done so by staying at home and other measures, like washing their hands and wearing masks. (They will immediately start toward their second peaks when they lift those orders, unless they have some suppression in place OR people continue voluntarily staying home.)

It is very frustrating (and confusing!) that our very similar measures have not had this same effect so far. Hopefully it’s just a bizarre fluke in our relatively weak testing… but, every day that our positivity rate stays high, that becomes less likely.

Are we seeing Minnesota’s positivity rate go up because we have more tests now and are detecting more cases we weren’t detecting before?

We are doing more tests, so we should be detecting more cases — and we are. That, in itself, is not alarming. It should actually be reassuring. The absolute case numbers were bound to go up once we got our act together with testing.

But, if our testing is actually catching up to the virus, our positivity rate should be going down. We should be detecting more cases overall, yes, but we should also be detecting far more negative results as we test more and more marginal and questionable cases. (That’s how you discover all the real cases — by testing everyone who might have it.) We’re not seeing that. The ratio of positive results to negative results has been rising, which indicates that even our increased testing hasn’t kept pace with the spread of the disease.

Are we really doing worse than most other states in terms of testing?

We’re not abysmal. There are other states with much lower per-capita averages, and (if you pull out a spreadsheet and do the math) lots of states with higher positivity rates over the past 7 days.

We in Minnesota are significantly worse than average, both on per capita testing and on positivity rate. To everyone who shares my serene confidence in the competence of Minnesota’s bipartisan government and in the character of its hardy people — confidence that has been consistently rewarded for decades — this is inexplicable.

Remember how everyone took a few days to bash Florida a few weeks ago? I did a bit of this on Facebook, too. Well, they seem to be kicking our butts on both measures.

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Covid and My Inner Skeptic

I have taken a pretty strong position on covid-19: it will kill a ludicrous number of Minnesotans/Americans unless we shut things down pretty hard until we have the ability to suppress it (either through treatments or through testing and contact tracing). I don’t think it’s possible to remain shut down until we have a vaccine, because we simply don’t have the resources (financial, mental, logistical) for an 18-month lockdown. But I think we will reap the rewards, in both lives and dollars, if we continue lockdown until we have some means of suppressing or defanging this virus.

For once, I seem to be on the side of The Experts about something! Disease experts, from Dr. Gottlieb and Dr. Christakis on the (relative) right to Dr. Lipsitch and Dr. Rasmussen on the (relative) left, have formed something resembling a consensus in favor of this approach.

There’s a Bloomberg article going around lately about what we should learn from coronavirus “skeptics,” who oppose this consensus. A couple of them are experts themselves. I’m not going to link the Bloomberg article, because, even though it’s an earnest, well-intentioned article, it makes some dumb rookie mistakes. Nevertheless, it makes a good core point — there ARE things to be skeptical about in the current experts’ consensus. Some of what we’re doing is based on best guesses that we know could be off.

Here are some of the arguments my inner skeptic has with me:

1. Outdoor transmission doesn’t seem to be a big thing based on the evidence so far. Playgrounds/beaches/mayyyyyyyybe swimming pools could potentially reopen at, say, half capacity.

Why my inner skeptic still loses this argument: I’m waiting for a little more confirmatory evidence before embracing it. My state is starting to see a few playgrounds reopen, and it will be interesting to see how that goes.

***

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Two Cheers for Governor Walz

I haven’t been able to find very much time to blog this week. I keep meaning to spend a night on it, and then something comes up in real life.

However, after how hard I have been on Gov. Walz, I really do need to say something about this, even if it’s shorter and less well-researched than I would have hoped:

Gov. Walz is talking sense.

On Monday, the governor said this: “The plan to re-open is very, very clear: Test, trace, isolate and then open back up, and continue this until we get a vaccine.”

He went on to say this: “We need to be testing 40,000 a week, or more. We need to be making sure that the testing and the PPE are there. To do so, we need to be testing 5,000 people a day and that needs to happen as soon as possible.”

There’s also some hot stuff about the need for major contact tracing and isolation of positive cases.

None of this has ever been clear in any of his official plans until now, at least not in the hours and hours of briefings I’ve watched. But I’m not going to prosecute him for inconsistency.

The important thing is, on the most important single question facing a Minnesota lawmaker in the last twenty years, Gov. Walz is now answering the question correctly. Walz has embraced a suppress/test/contain strategy, which is what I’ve been saying he needs to do — and, indeed, I demanded it in a petition a couple weeks ago. Apparently Gov. Walz thinks we’re calling it test/trace/isolate now (Trevor Bedford is doing the same), and I’m fine with that.

This is tremendously hopeful. The way our state’s institutions have responded to Gov. Walz’s “moon shot” has been even more hopeful.

5,000 tests per day might not sound like much, and, truthfully, it may not be enough in the long run. But we’ve only done 44,000 tests total in the state of Minnesota in over a month, and our daily capacity (which needs to keep increasing) has stalled out.

South Korea, often held up as a shining exemplar of test/trace/isolate, has a population of 51 million and the capacity to test 15,000 people per day. (They’re not even using this full capacity right now, as their epidemic is largely under control.) Their positivity rate is about 2%, indicating that they are testing everyone with even mild symptoms and identifying more or less all cases of covid-19.

In Minnesota, we have only 5.6 million people, so we need fewer tests to match South Korea’s testing rates. In fact, on our best days, we are already matching or exceeding South Korea in tests per thousand residents. But our positivity rate for the past week has been hovering around 9 or 10% (source: MDH statistics loaded into a spreadsheet on my computer), indicating that our epidemic is starting to get beyond our capacity to test for it. We need more tests because we didn’t arrest the epidemic as well as South Korea did. (Relative to many U.S. states, however, we’ve done a very good job.) But 5,000 tests per day, if we started running them before the stay-at-home order lifts, when cases should (we pray) be at their nadir… that, combined with the aggressive contact tracing the governor is talking about, would give me a lot of confidence in our ability to keep the virus contained while beginning to ease many of the most economically destructive parts of our lockdown.

Two cheers for Governor Walz. He gets a third cheer when he follows through.

Meanwhile, a great many Republican politicians, I am ashamed to say, are opposing the Governor — not by pressing the Governor to take these sorts of actions, as I have, but by insisting that the Governor end the stay-at-home order prematurely, without testing and other firebreaks in place to prevent a devastating epidemic. Many of these Republicans insist that covid-19 is not as dangerous as we’ve been told, but they are unwilling to wait for data that would prove their claims. They want the economy open now, heedless (indeed, willfully ignorant) of the steep human toll. They are egged on in this by President Trump himself, whose tweets continue to encourage people to act in a manner harmful to themselves and others. (Fortunately, the official policies of the White House have been much better, and actually largely make sense.)

I, for one, am a committed right-wing voter who is writing down the names of state representatives, state senators, and gubernatorial candidates for whom I will never cast another vote. I simply can’t let Jason Lewis near the levers of power again. (Of course, I can’t let Tina Smith near them, either, so that’s going to be a rough election for me.)

On this issue, Gov. Walz appears to be taking the state in the best direction possible under impossible circumstances. Two cheers for him.

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Covid Bombshells at the Minnesota Modeling Presser

On Friday, Minnesota unveiled a lot of details about its disease model for covid to the world. That press conference featured a number of bombshells, most of which seem to have received little or no follow-up from the media. (Are they distracted? Overworked? Are these revelations not interesting to the general public? Unclear.) I figured I should therefore blog about them, but I’m having a hard time figuring out how to do so efficiently.

Today, I’m giving up. I’m just going to list the revelations with no particular rhyme or reason.

(Here’s the briefing, well worth watching: https://www.youtube.com/watch?v=iDqUjeIib-Q)

ITEM!

The “rule of thumb” for the past few months — a pretty wild guess, frankly, and everyone knew it — was that, for every 1 confirmed case of covid, there were 9 more going undetected. In other words, our covid detection rate was, at a guess, about 10%.

On Friday, Minnesota announced that it believes this rule of thumb is wrong. In fact, Minnesota believes that, for every 1 confirmed case of covid, there are closer to *99* cases going undetected — a detection rate of 1%.

What this means:

We currently have 1,621 confirmed cases in a population of 5.64 million. (0.03% of the state confirmed infected)

Until recently, we believed that 1621 confirmed cases meant 16,210 actual cases. (0.3% of the state presumed infected)

But we now believe that 1621 confirmed cases means some much larger number — something like 162,100 actual cases.

In their technical paper, the Minnesota team explained that they estimate a detection rate of 1%, with a possible range from 0.5% to 5%.

That’s actually (mostly) really really good news. If lots and lots and lots of people have already been infected, that means two things:

  1. The disease is less lethal than we thought. If 20,000 Minnesotans caught covid and 1000 died of it, that’s a fatality rate of 5%. We could expect covid to kill hundreds of thousands of Minnesotans. But if there’s actually 200,000 Minnesotans who’ve caught covid, and still only 1000 died of it, that’s a fatality rate of only 0.5%, and we could expect deaths in the low tens of thousands. (These are numbers I pulled out of a hat to illustrate the point. You can’t actually take current case/death counts and do napkin math with them very easily, because deaths lag cases by several weeks. But there’s no other way to slice it: this is good news, and means fewer people will die.)
  2. Meanwhile, if more people have had it, we’re closer to developing herd immunity than we think. As I have argued strenuously elsewhere, herd immunity is not something we should aspire to, because it means consigning a lot of people to die. But it’s reasonable to expect that we would acquire herd immunity if 75% of Minnesotans caught covid. That’s about 4.1 million people. If 20,000 Minnesotans have had it already, we’re still just a tiny fraction of the way to herd immunity. If 200,000 Minnesotans have had it, then we’re already 5% of the way there. That means that the large peak Gov. Walz is expecting and planning for in summer will come a little faster and be a little lower. Not much lower, but it’s something.

The bad part about the low detection rate is that it implies covid is more transmissible than previously believed. Let’s talk about that.

ITEM!

Until the past week, most estimates of the basic reproduction number (or “r0”) for covid have fallen in the low 2’s. The famous (or infamous, depending who you talk to) Imperial College London report assumed that the r0 for covid was between 2.0 and 2.6, with a median assumption of 2.4. That means that, without intervention, the average person who catches covid will spread it to 2.4 people.

The purpose of interventions like social distancing and stay-at-home orders is to lower the effective reproduction number, or “rE”, from that “natural” rate of r0 to something more manageable. As long as rE stays above 1, that means the average person who catches it spreads to more than 1 person, and the epidemic may be slowed, but will continue to grow. So we’ve been hoping, basically, that social distancing was lowering covid’s reproduction number from something like 2.4 to something like 0.8.

The Minnesota modeling team no longer believes an r0 of 2.4 is plausible. Based on the latest data, which has pointed toward more infections and lower lethality than previously believed, they now believe r0 is at least 2.5, and possibly as high as 4.7 (!), with a median assumption of 3.9. That means the infectiousness of covid is less like the 2009 pandemic influenza (r0 = 1.4-1.6) and more like smallpox (whose r0 has been estimated in the range of 3.5-6).

That means covid may be much, much harder to suppress, test, and contain than previously hoped. Lowering r0 from 2.4 to 0.9 seems plausible, especially with half the state staying home all the time and going out only for groceries. But lowering r0 all the way from 3.9 (or 4.7!) down to 0.9 may be futile. I still think the alternative is so bad that it’s worth devoting extraordinary resources to the attempt — with huge disruption and damage to employees and businesses — but seeing these numbers gives me more sympathy for Gov. Walz’s decision to write off tens of thousands of Minnesotans as doomed to die and focus instead on keeping our hospitals from getting overwhelmed.

There’s bad news here for mitigation, too. If the virus is more transmissible, it’ll take us longer to reach herd immunity. The most naive formula for herd immunity is [(r0 – 1) / r0]. So, if r0 were 2.4, like we thought last week, then we wouldn’t have herd immunity until (1.4/2.4=) ~58% of the population caught covid. If r0 is 3.9, then we don’t acquire herd immunity until 74% of the population has had it — which adds up to another 900,000 Minnesotans getting sick. This isn’t bad enough to outweigh the very good news that the virus is less lethal than feared, but it still means — unless we switch to a suppress, test, and contain strategy — a lot more Minnesotans have to get sick before this goes away.

Just to put in perspective how big a deal this higher transmissibility is: back in January, on Facebook, I shared a Twitter thread by Dr. Eric Feigl-Ding where he cited a Chinese paper that suggested an r0 as high as 3.8. After he was roundly criticized by the entire mainstream media and much of the scientific establishment for way-over-the-top alarmism, I retracted my Facebook post and Dr. Feigl-Ding issued a correction to the thread. And now the State of Minnesota officially considers the r0 to be around 3.9.

To some extent, this is a measure of how much America wanted to stick its head in the sand about covid: at the time, the media wanted us focused on impeachment, which was reaching its climax at the time, and they accused all the marginal right-wing voices who were worried about the “Chinese coronavirus” as alarmists and xenophobes. And, to some extent, it was fair deuce: Dr. Ding’s thread was way over-the-top in several other ways. But it also shows how much we have learned about this disease in just the last 90 days — and how much those of us who aren’t epidemiologists but wanted to keep tabs on the “Wuhan virus” (as it was called back then) were depending on the sketchiest of information mere weeks ago.

SIDEBAR!

There are still some people out there saying things like, “Half of us already had the coronavirus, so we’re actually very close to herd immunity,” or, “Lots of you had coronavirus in December and didn’t realize it.” They will often cite the so-called “Oxford model,” which implied that herd immunity in the U.K. was imminent because only 1 in every 10,000 cases was being detected. Then they’ll tell you about how they (or their godparents’ roommates or whatever) had a really bad cough that just wouldn’t go away a couple weeks before Christmas and wasn’t the CDC saying the December flu season was worse than expected? Surely that was the first wave of the ‘rona!

These people are fools.

We now know, with absolute certainty, that the so-called “Oxford model” is false. We know this because the U.K. has 88,621 confirmed covid cases. If the Oxford model were true, then there would currently be 886 million undetected cases of covid in the U.K., with another 500,000 being infected every day — which represents a problem, because the total population of the U.K. is only 67 million. We are juuuuuust starting to get decent serology tests, and even the sunniest findings suggest that we’re light-years away from the optimism of the “Oxford model.”

We now know, with absolute certainty, that there were no cases of covid-19 in the United States before, at the extreme earliest possible date, 5 January 2020. We know this because we’ve decoded the genome of many different covid viruses from all over the world. Since viruses are constantly mutating very slightly, we’ve compared their mutations in order to create a kind of viral “family tree.” Thanks to this “tree,” we know, with a surprising degree of precision, where each strains of the virus came from and when.

The American infections came from many different sources, some in Asia, some in Europe. But our early infections all came from China, and we know that this particular strain of the disease did not leave China until at least 5 January 2020. There’s simply no way anyone in the United States had the coronavirus before then. Even once it arrived here, it started in only a handful of people, mostly on the coasts, and then started to build. So the odds that you, some random suburban Minnesotan who hasn’t been overseas in a decade, had the ‘rona at any time in January, are not quite zero, but let’s just say it’s more likely that you were struck by lightning.

(This is another body blow to the “Oxford model,” which implies that not only are we missing a lot of cases, but that covid arrived on our shores weeks earlier than could possibly be true.)

Minnesota is saying that it now believes that covid has been spreading more widely than previously expected, that it is less lethal than previously believed, and that we are closer to herd immunity than we thought. This is all excellent news. But don’t confuse this with vindication for those who believe this will turn out no worse than a severe flu.

Minnesota usually has fewer than 100 flu deaths in a year, although we can lose as many as 500 in especially bad years.

Thanks to its higher lethality, higher threshold for herd immunity, and our complete lack of ability to create artificial herd immunity with vaccines (which keeps influenza contained to about 15% of the population every year), Minnesota expects to see not fewer than 9,000 deaths if the stay-at-home order is cancelled, expects 22,000 deaths, and fears 36,000. That’s even with “commonsense” social distancing (keep high-risk people at home, don’t have large gatherings) kept in place after stay-at-home ends.

That’s a lot better than the 50,000 Minnseotan deaths we were talking about a week ago. The State has cut its projection in half. But it would have to cut its projection in half six more times to achieve the hundredfold reduction it would take for us to get down to the “just a flu” threshold. (Bear in mind, also, that Gov. Walz reports that the Mayo Clinic and other hospitals have their own models, and they are not as sunny as the state’s.)

Feel free to hope for further downward adjustments, but don’t count on them.

ITEM!

The State of Minnesota officially believes it will not have enough ICU beds to take care of all patients at peak, which it expects to arrive in June, July, or August. I can’t believe this conference was so full of bombshells that this one only gets mentioned 1500 words in the article, because this, too, is a very big deal. Gov. Walz’s strenuous planning effort (which deserves considerable praise) looks like it’s going to be close to meeting our needs, but close is no cigar. We expect to need somewhere between 2,700 and 4,800 ICU beds. We expect to have only about 3,000 ICU beds available.

We could get lucky, and even our worst-case scenario doesn’t look quite as bad as Italy — but we’re still operating on the expectation that our medical system will be overwhelmed, and that some people who need critical care are going to be left to die, as has happened elsewhere.

The good news for us epidemic hawks is that, unless this supply situation resolves itself in the next couple weeks, Gov. Walz will likely either extend the stay-at-home order further into May. Walz’s whole strategy has been to acquire herd immunity while ensuring that every infected Minnesotan has a hospital bed to die in. Since he doesn’t have the beds, yet, he may not have a choice but to buy more time for his supply chain. That also buys more time for our preferred solution (massive testing, contact tracing, surveillance, and targeted quarantines) to come online as an alternative to waiting for herd immunity.

ITEM!

Gov. Walz and the Minnesota modeling team are still refusing to model what would happen if covid were suppressed with an indefinite stay-at-home order until a vaccine, treatment, or test-and-contain strategy became available. The Minnesota team modeled five different scenarios, but the most aggressive of them merely extended the stay-at-home order to May 17th.

Walz and the modelers should change course and model indefinite stay-at-home.

First, it’s just not a good thing to withhold data about a strategy that lots of Minnesotans are talking about and what to consider… even if it may not be the governor’s preferred strategy

Second, the stupid-but-popular IHME / University of Washington model is based on the assumption of more-or-less permanent stay-at-home orders. When people look at the IHME model, they almost always ask why Minnesota expects 22,000 deaths when the IHME model expects only 656 Minnesotan deaths (at this writing). A very, very big part of that discrepancy is the fact that the Minnesota model assumes the stay-at-home orders are lifted before there’s a treatment or widespread testing available — May 17th, at the very latest — while the IHME model assumes the opposite.

Another reason is that the IHME model is based on an “incredibly optimistic assumptions.” Those are the exact words Stefan Gildemeister used in this briefing. There’s a lot wrong with the IHME model, not just its poor communication. Gildemeister alludes to the unreliable data it depends on. I would point instead to the fundamentally questionable way the model operates: it doesn’t use a real simulation of the epidemic based on what we actually know about it. Instead, it takes observed death counts and tries to fit those deaths to a mathematical curve, then guess where that curve is going next if it follows a normal distribution. (EDIT: We might also point to its horrendous performance, even on its core metric of death counts, to say nothing of its often-outrageous hospitalization projections.)

But it’s still a very, very popular model, probably because it has such a slick interface. A lot of powerful Minnesotans who have absolutely no excuse are depending on IHME’s projections to make sense of what’s going on. Many of them are insisting that, because the IHME model projects so few deaths, we should immediately reopen the economy (which the IHME model says we absolutely must not do, or deaths will skyrocket).

Gov. Walz should model the same thing so that we can directly compare the models — and so he can give lawmakers a clear choice between a prolonged economic closure and relatively few deaths or a shorter economic closure and 10,000-30,000 deaths.

ITEM!

We confirmed in this conference that the State of Minnesota believes we are currently cresting the “first peak” of the epidemic, and that cases (and deaths) will start to decline over the next couple of weeks. We expect very few total deaths at this stage — well under 1,000, if I’m reading the chart right. That’s actually fairly consistent with the IHME estimate.

However, as soon as we lift the stay-at-home order, currently scheduled for May 4th, we begin building toward a much higher “second peak”, with (ultimately) somewhere between 9,000 and 36,000 Minnesotans dying.

(A friend asks: why would the second peak be higher than the first peak? Shouldn’t the second peak be less bad, because more of the population will have immunity? I gave him a long answer, but the short answer is: the first peak was made artificially tiny by our massive stay-at-home interventions — that was the whole point! — and not nearly enough people will have immunity in the second peak to make a significant difference.)

I would have emphasized this “first peak” much more than the State did, since, as soon as case counts start to decline, the fools will start to crow about how the epidemic is over, it was all a huge overreaction, and we should chill out. The fools will be wrong, but it would be smart for Minnesota to get out ahead of their criticism.

So, yeah, extraordinary press conference, lots of huge bombshells.

The next day’s headline was the “feud” between Sen. Gazelka and Gov. Walz, wherein Gazelka made an ass of himself. Because it’s always about the personalities, not the reality. That’s just the world we live in. Hopefully, your desire for more is why you’re reading my blog.

Okay, gotta run for now. Questions or comments to combox or email. G’night!

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Epilogue: A Bye-Ku for Tulsi Gabbard

Editor’s Note: At the time Tulsi Gabbard dropped out, Anne Maloney was in the hospital. This, therefore, is our series’ swan song.

A Bye-Ku for Tulsi Gabbard

A 2020 guest series by Anne Maloney, inspired by James Taranto.

Dems choose old white guy
Last girl gone. Hillary asks:
Tears shed in Russia?

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Covid (Coronavirus) in Minnesota: An FAQ

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 necessaryBasically, 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.

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The Hard Road Ahead

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 thisor 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

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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