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Risk and Sensibility

The Denver Post ran an opinion piece posing a useful question: how did we do in evaluating risk of COVID-19? Answers are all over the map, but so many are so breathtakingly stupid as to make the value of the piece pretty minimal (“Hey, the mortality rate was only 1.4%, so not so bad!” “My restaurant didn’t have a case, so restaurants were safe!”). The tone of the op-ed leans towards “hey, we panicked, this wasn’t such a big threat after all.” Having the cojones to put that in print after over half a million Americans perished in under a year–easily the number three cause of death in 2020, and when you toss in the excess mortality since the start of the pandemic, you are up to ~650,000 deaths either directly or indirectly caused by the pandemic. The age-adjusted death rate increased by nearly 16% in 2020. COVID-19 was the number three killer in the U.S. Sure, your odds of dying if you were between 25 and 34 only increased by about 4%, making COVID about the #6 killer in that age range, but for 44-55 year olds, the odds of dying went up by 11% or so, making COVID the number 4 killer and close enough to “unintentional injury” that it could well be #3. And then none of this considers the long term impacts of having had COVID-19–of the more than two million Americans who have spent time in the hospital, something like a half million or more are seeing long-term effects from COVID-19, effects that are often pretty debilitating.

A way of looking at this is years of life lost to the disease–in essence, if you die at 25 and were expected to live to 85, that is 60 years lost, but if you die at 80 it is only 5 years lost. A paper in Nature tackles this and makes comparisons with traffic deaths, seasonal influenza, and heart disease. In the U.S., COVID-19 has been seven times the losses from influenza, about 2.3 times the loss due to transport (mainly auto accidents) and maybe about 0.4 times the loss due to heart disease. This is with a pretty conservative estimate of COVID’s impacts, and it is worth keeping in mind that we tried very hard to limit COVID-19 but not so much many of these other causes of death. Additionally, this study found that about 20% of the loss of years of life in the U.S. was suffered by those under 55.

So were we overreacting to a disease that did cause more loss of life that auto accidents (by more than a factor of two)? Certainly had we done nothing the toll would have been far, far worse (millions dead), so the question maybe should be, what were the really effective steps, and what was theater that did little? in other words, a better question is, how well did we do in balancing the risks posed by different activities for dying of COVID-19?

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Herd Racing

So how does the pandemic end? While we’ve discussed possible and likely overall mortality, the details of the end of the pandemic were so far away that it wasn’t worth much thought. But with vaccinations underway, we can start to see the end with herd immunity in the offing. But it probably isn’t what you are thinking. Let’s play with a straightforward scenario: Vaccinations proceed roughly as has already been outlined. Does this mean that COVID cases gradually die out? GG isn’t so sure.

Here in Colorado the governor’s main worry has been overwhelming hospitals, and he has been eager to remove restrictions on businesses. So by the end of February all those 70 and over who want a vaccination will get it. By the state’s calculation, this will reduce pressure on hospitals overall by a third, deaths by nearly four-fifths, and ICUs somewhere in between. So sometime in March the reports on deaths will plummet and the numbers hospitalized will drop. Two things are likely at this point: the state will probably reduce restrictions on businesses, and the public’s perception of the hazards of personal interaction will decrease.

So what seems highly plausible is that we’ll see the pent-up demand for movie theaters and restaurants and weddings and all the rest start to go upward. With vaccinations reaching the 60-70 year old crowd, the fraction of those infected that go to the hospital will drop by more than a factor of two. For instance, in Boulder County, a quarter of those 75 and older who test positive end up in the hospital or morgue. 65-74 year olds only end up in the hospital 7.5% of the time. 55-64 6%, 25-54 less than 2%. And the fraction of 25-54 year olds who are infected but never tested is probably higher than the older population, so it is quite possible that the actual hospitalization rate is well under 1%. So by the time the 60-year-olds and up are immunized, personal acquaintanceship with dire stories of saying goodbye to grandma via the phone will be fading fast, to be replaced with more folks saying “it was like a bad cold, not so awful, really.”

So there is an excellent chance that rather than seeing numbers gradually decline, there will be one final wave of COVID-19, one tearing through young adult communities more than likely (communities that have already demonstrated the impatience of youth). Given that we are seeing rates of infection in LA County where 1% of the population is testing positive each week–and probably 2-3 times as many are actually infected–it might be a race to see if more people become immunized by having had COVID-19 or by having gotten a shot. While hospitals and morgues will be far less likely to be overwhelmed, case numbers could skyrocket in this final wave. This might end quite abruptly as we rapidly approach herd immunity levels of exposure+vaccination.

In a way this sounds hopeful: we’d actually reach herd immunity sooner in such an environment. But that is not an unmitigated good. While less than 1 in 50 of these victims of the disease will be hospitalized, that is still a huge number of people. And given the high rates of long-term effects of COVID-19 among those hospitalized, ending the pandemic by a final wave among younger people would carry some real costs in terms of disabilities and collateral illnesses.

What might prevent this? Keeping high-risk businesses closed longer might well help; this realistically requires these businesses to get financial support from the government (here in Colorado, Gov. Polis has noted that the absence of such support figures into his decisions on COVID interventions). Having a known date to get the vaccine might help, too. If your calendar reminds you how many more days until you get the vaccine, you might be more willing to tough it out than to break with your good behavior to go out with friends. Certainly the faster vaccines are distributed, the fewer cases of COVID we will see. And finally, there is the weather factor. Going into spring we might see cases decline simply because we have fresh air in houses and spend more time outdoors; maybe this is enough to counterbalance these other impulses.

So while the end is in sight, how the end comes remains in question.

The ICU Christmas

Pictures from around the country, but especially California, are giving GG déjà vu. Two years ago I had the misfortune to spend Christmas (and New Years) in an ICU room. Seeing the images of drawings of Santa or snowmen taped to walls or plastic tents brought back memories of the decorations my family brought in to the hospital. Not really warm, wonderful memories.

I discovered that ICUs are usually pretty quiet over the holidays (this year an obvious exception); this largely because elective surgeries are on hiatus for the most part. Other than that, I can’t imagine it is all that different from the rest of the year in terms of routine and inconvenience; it is of course quite different emotionally. One day you are stringing up lights, and then you’re the one strung up on tubes.

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COVID killed which learning?

Last spring the word was that because of the coronavirus, remote teaching would finally be the killer app that would make good on the promise of MOOCs and other efforts to liberate colleges from the hidebound methods of teaching that date back to the Middle Ages. College presidents looking at budgets heavy on old professors’ salaries were rubbing their hands with some glee; this could finally make colleges more financially secure. Then students weighed in with “ick.” Over the summer the institutional response was, well of course the old farts couldn’t teach online that well, you had to do it right with preparation and tools and workshops. Universities spent money on IT resources and the various teaching improvement groups held workshops and faculty played with Zoom breakout rooms and such not. So here in the fall, we were to see the conquering of education by remote teaching after the slap-dash failure in the spring.

What did we get? Um, lawsuits demanding refunds for lower than expected teaching quality. Schools cutting programs because students were not flocking to get an education through a somewhat small TV screen. So where are we going?

Right now, of course, there will be more of the same for the spring. But let’s skip past that. What will things look like in the fall of 2021?

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Tenure, the coming COVID fatality

Universities and colleges have been under tremendous financial pressure due to the coronavirus pandemic. This is particularly true of state schools that have seen general fund moneys decline markedly since the Great Recession. While students and families yell, scream, lobby or file lawsuits to try to get money back from an educational environment that they find to be substandard, the response from most colleges and universities is, we hear you, but our pockets are bare.

What does this mean for the future? Well, administrators are now saying things like “our budget is quite brittle”–which kind of means that if stressed, it doesn’t bend, it breaks. If you get beyond a certain level of cuts that can be managed with furloughs and temporary salary reductions, the next step is outright dissolution of departments and programs. Part of the reason is presented to be tenure, though the reality is that tenure protections do not extend to financial hardship of the university. Of course it can be hard to show that a tenured faculty member had to be let go while colleagues in the same department continue forward; it is for this reason that most schools view the easier solution as ending programs.

So what is the solution?

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Climate v COVID: Personal Choice?

Previously GG pointed out how it seems that the closer coronavirus gets to a community, the more they are willing to double down on dangerous behavior. And this behavior suggests that fighting climate change may well run into the same mindset, where a shifting perception of “normal” combined with partisan messaging would lead the U.S. to stall out on any climate mitigation. While GG feels there is some merit to this pessimistic view, there is another side to this that might just make a fight against climate change easier.

There are two parts: economics and the role of personal behavior. Let’s take the second first. In a pandemic, if you decide you are going to go out, get sick, and spread the disease, you yourself might not pay much of a price, but your actions extend the pandemic farther forward. At this point in the U.S., slowing the virus is entirely on the backs of individual Americans.

In contrast, personal choice has far less of an impact on climate change mitigation. You really have very little choice in where your electricity comes from; if a state has mandated that some fraction will be from renewables, you can’t exactly opt out. If auto fuel efficiency standards are tightened, your new car might get better mileage even if you’d rather it didn’t. Sure, you can find some old beater car or refuse to put solar panels on your roof, but derailing the entire country isn’t really possible. This is, ironically, the flip side of how powerless individuals are in stopping climate change.

The second side is economics. There is little doubt that a lot of the avoidance of complying with public health rules is driven by fear of economic disaster. Even as many economists argue that we really need to shut down the pandemic to have a healthy economy, the immediate threat to a personal business has created political pressure that results is ridiculous rules contrary to evidence-based regulations. For instance, the most dangerous place in this pandemic is indoors in a restaurant. The very first thing that should be shut down are restaurants and bars, yet they are often staying open even as less dangerous targets like schools shut down. Politically driven demands to reopen the economy reached receptive ears of those being hurt financially.

But for climate change, at least at this point in the battle, economics is increasingly on the side of shedding carbon-based businesses. This is most obvious in the electrical power industry, where renewables are now as cheap or cheaper than fossil fuel power sources. Utilities are finding that becoming more nimble in storing power and using distributed power sources makes their bottom line look better. And when the government puts in place incentives for electric cars or carbon-storing farming practices, lots of folks will change their behavior; the laggards won’t prevent progress.

The top-down nature of the energy economy makes it more likely to overcome minority resistance to change; this is different than the pandemic, where the bottom-up nature of transmission empowers individuals to scuttle progress made by a majority. Of course, if a majority decides to prevent progress, then indeed progress will be difficult–but we’ve already seen an attempt to bring back coal as a source for electrical power, and it failed to gain any traction.

If the coronavirus pandemic does, in the end, increase trust in scientific evaluation of risks, and this in turn strengthens the majority that favors addressing climate change, then failures in keeping people alive and free of infection won’t necessarily doom us to an ice-free and drowned coastal future.

Familiarity Breeds Contempt

11/17 update. Seems either Paul Krugman reads this blog, or GG is clairvoyant or this is just really obvious…

Many (including GG) have pointed out the parallels between coronavirus and global warming, suggesting that being forced to see science as useful in confronting a previously marginalized hazard will pave the way for the public to embrace fighting an even less immediate threat. And, well, could happen. But it is worth considering what is going on right now with the coronavirus in large parts of the U.S. As documented in a New York Times article, plenty of people encountering the virus at fairly close range are shrugging it off. God’s will, or “most people recover” seem the most common refrains. Of course others lean the other way, becoming more careful and protective. What does this bode for fighting climate change?

In general, the public is in favor of doing something about climate change. But the thing about human beings is that we kind of adopt as “normal” the climate from some point in our personal past. Since we all have finite lifetimes, the cultural “normal” will slide forward in time. This has the effect of reducing the emotional impact of a changing climate. So when we see folks shrugging off a fatal disease kicking around the neighborhood, it seems even more plausible that folks might start to accept drowned cities, frequent hurricanes, floods and droughts as just part of “normal.”

We have already crossed many red lines. We’ve been partially rescued from the very worst that could have happened by the fruition of seed money planted years ago in wind and solar power but also by the technological advancement that brought forth sufficient natural gas that coal plants are quickly vanishing. If the public pushes to lighten our impact on the planet–or even if they are just willing to go along with it–there is hope for preventing more dire outcomes. But get complacent, say “eh, no big deal” as some are to the coronavirus, and we’ll enter a world we aren’t really prepared for, and one likely to be far less diverse in fauna and flora than today. Being jaded and stoic in the face of these crises is perhaps as much an obstacle as industries being shunted to the side.

COVID Fatalism

GG took a couple of stabs at just how the pandemic was going to evolve back in the spring and with case numbers soaring just like back then, it seemed worthwhile to see how those panned out. Keep in mind that we are essentially at a quarter million deaths in the U.S. at this writing.

In March, guessing that this would burn through the population to the point of herd immunity, GG was pegging the total eventually dead at 1.2 million in the U.S. to as high at 10 million if hospitals were overwhelmed. At that time, a survey of epidemiologists estimated the 2020 toll to be 230,000 dead. Given the current 1000 deaths/day average in the U.S. looks to be increasing, the remaining days of 2020 seem nearly certain to carry the total to over 300,000 dead.

In April, GG revisited this and noted that lockdowns had bent the curve, but that governments were accepting fairly high rates of infection. From this, extrapolating from where Colorado seemed headed, GG speculated that 660,000 might well die in the U.S. before a vaccine emerges; a more hopeful number would be 140,000 if rates could drop more.

Now to be clear, none of this would pass muster in a hallway at an epidemiological conference; the point was that the scale of this is enormous and that ditching efforts to drive numbers low enough for meaningful contact tracing was going to doom many to a very uncomfortable death. GG was guessing that state strategies were going to be to loosen and then tighten rules to kind of stay at a certain level of hospitalizations and deaths. More or less that is how it played out in Colorado until recently. Elsewhere? Some of the summer swings were way more dramatic than you’d have expected (Arizona and Florida being excellent examples), but it did seem that things did level out overall.

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Memo-ing COVID

August 1, 2020
From the office of the Dean
Big State U.

Dear students, it is my pleasure to welcome you back to Big State U for the fall semester. We have spared no expense in making campus safe for everybody, and we look forward to your arrival (and a check from your parents) in the coming weeks. Go BSU!

September 2, 2020
From the office of the Chancellor
Big State U.

BSU students,
In these troubling times, we all need to work together so that BSU can continue to provide the educational experience you all have come here for. Of course, that means foregoing the social experience you were hoping for, but we all know that this is not going to be a major sacrifice while you pursue your dreams of a BSU diploma on the wall. So we expect you to obey all the COVID-19 rules, including wearing a facemask while walking on campus, indoors and outdoors, and for good measure when in your dorm room and probably too when you go swimming at the rec center–scratch that, we’ve closed the rec center. And of course stay socially distant from everybody–we suggest a 12′ diameter hula-hoop (with the BSU’s cartoon logo of a campus dean) that you can wear so as to avoid close contact.

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The heroes’ middle finger

It is no shock that cases of COVID-19 are rising rapidly across many states. Many of these states have been spared the worst of the pandemic until now, but construction of field hospitals, long ambulance rides to distant ICU beds, and the cancellation of elective medical procedures is hinting at dark days ahead. (Well, ok, darker days ahead. Pretty dark right now). And what will happen in those dark days? Once again, there will be “thank you, first responders” and “medical staff are heroes” and the like. We might be back to celebrating Instacart shoppers and grocery store stockers.

But why are health professionals bothering to take care of a bunch of people who won’t follow even the simplest public health measures? After getting a big middle finger from folks who will not stay socially distant, who confuse a mask with an attempt to deny them “freedom,” who attend large gatherings indoors without any precautions…why would any sane person go out of their way to provide aid to these nimrods? They have made the lives of doctors and nurses and first responders both more risky and more stressful. What is more, their actions lead health departments to do things like close restaurants and bars in desperation as the simpler, personal actions are not being followed.

Look, nobody likes this. Aside from bank robbers, none of us like masks. None of us are happy with restrictions on who we can meet and how. It sucks. But if you delight in flaunting the rules most of us are trying to follow, don’t expect a lot of sympathy if you or a loved one is in the hospital. Expect worse if your inaction results in another becoming infected and ends up in the hospital.

Meanwhile be grateful that, so far, admissions forms at hospitals don’t include questions like “Have you worn a mask when near non-household members?”