Monday assorted links

1. Deaths are still falling.  Including in some key states.  Don’t take this for granted (at all), but be accordingly suspicious of those who are not dealing with this fact in some manner.

2. Dick Cavett interviews James Baldwin.

3. China is now starting to use a vaccine on its military.

4. Miami fact of the day (NYT): “One-third of all patients admitted to the city’s main public hospital over the past two weeks after going to the emergency room for car-crash injuries and other urgent problems have tested positive for the coronavirus.”

5. Five-day course of Remdesivir will be priced at $2,340.  One-third more for insurers, cheaper in other countries.

6. Will higher ed just snap back?

7. Claims about virus mutation, and increased infectiousness (speculative, but at the very least an important caution about all the premature moralizing you are seeing.  I at least know I don’t know enough to judge this one, do the other commentators you are reading?).

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1. That is an odd framing. Or at least it leaves vague what lessons should be drawn.

Presumably it shows that flattening the curve was good, because it did indeed provide time to produce better treatments?

And any further slowing, if we could commit to it, would be good for the same reason?

the fatalities don't seem to be lagging cases counts as much as previously thought?

Of course the deaths still lag and by about the same time as ever. One thing has been consistent throughout: people draw 'solid' conclusions prematurely... especially people who don't have any particular knowledge of medicine, epidemics, biology or, apparently, history.

if you aren't adjusting for age you aren't even trying

why not just say it again? almost all deaths are in nursing homes and among those being treated for chronic or acute illnesses, i.e., they're nosocomial infections.

those two categories probably account for 60-90% of the deaths, but because there are inferences to be drawn from those facts, and much blame that would flow from those inferences, you'll never hear it stated so simply outside of a comment section or tweet.

years of lost life to covid will be substantial, and it certainly isn't a nothingburger, but the policy response was poorly conceived and executed. for example, reducing reducing nosocomial infections should have been a much higher priority, but take a look at the pics of the line-up outside the ER in Houston this weekend: many in charge of such matters are grossly incompetent.

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wally not so good at reading comprehension. "don't seem to be" and a question mark are modifiers that do not indicate a solid conclusion.
the graph suggests deaths are declining as cases are rising near exponentially.

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Didn't seem odd. I'd agree about better treatments, but also the drastic drop in the age of those infected. As long as deaths aren't increasing, isn't this good, getting closer to herd immunity, if that exists?

In part, it may also be a statistical artifact. We were counting a bunch of flu deaths as COVID deaths.

Yes, this may well be part of the answer to the discrepancy. COVID-19 doesn't kill alone a lot of the time (you can go visit the CDC site for the details), and there is, every single year, a cycle to to total mortality that is, in part, driven by influenza and pneumonia. That normal cycle is reaching its usual bottom in July.

All in all, I think there are several factors in play- better treating of those most ill (probably less resort to ventilators which seemed to a death sentence of a kind, plus better treating of the auto-immune reactions), the fact that the disease has already killed those most vulnerable to dying from all causes this year (we see this in the nursing home data), and the fact that those in the higher age brackets are taking much better precautions than they were just 3 months ago.

I will say this- at the same point New York had the same numbers of cases as Texas, for example, 2.6 times as many people had died, and New York hadn't yet experienced 25% of the deaths that would occur. If Texas and Florida don't reach New York's peak in daily deaths by the second week of July, they never will- full stop. If daily deaths in those two states don't start rising by the end of this week, it is likely they never will. The lag can't be more than 3 weeks, and we are already past that where daily deaths should have responded.

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This describes a Penn State study that estimated that infections in March were 8.7 million, compared to roughly 100,000 positive tests.

https://news.psu.edu/story/623797/2020/06/22/research/initial-covid-19-infection-rate-may-be-80-times-greater-originally

There is a link to the study in the article. Their estimates were based on CDC surveillance. If you have interest, it’s an eye opening analysis

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It could also presumably mean that since HALF of the deaths are from nursing homes, the death rates were so high originally because we didn't protect those folks. So now, presumably, we've learned to protect them, therefore sending the death rate wayyy down.

We'll see in one to two weeks!

+1 we are hoping and halfway betting you are right.
the unreported story so far is -outside of newwoke city
we have been able to better control nursing home spread (so far)

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We don't need to wait 2 weeks. The deaths have been falling since mid to late April, the new cases were only falling modestly and have started increasing since June 10. The number in serious/ critical condition is fairly stable at below 16 K.

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They are not counting deaths due to delayed life saving procedures because hospitals were seen as a likely place to be exposed to the virus

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It could also presumably mean that since HALF of the deaths are from nursing homes, the death rates were so high originally because we didn't protect those folks. So now, presumably, we've learned to protect them, therefore sending the death rate wayyy down.

It also could mean that most people in nursing homes who were most susceptible have already died. And most of the workers who were doing the most transmitting are no longer infectious.

For what it's worth, I think this argument that "the weak have already died" is just too pat.

It is also completely non-intuitive, given uneven propagation of COVID-19 across the country.

How could a county that has not been hit hard yet, already have "given up its weak?"

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A factoid I saw today says that a 40 year old entering the hospital with covid-19 today has an equal chance of dying as a seventy-year-old entering with heart attack did before.

That still seems high.

A 40 year old with covid-19 is very unlikely to need hospitalization, while a 70 year old with a heart attack 100% needs hospitalization. So the chances of death from the onset of the original problem are still vastly different.

40YOs are hospitalized in the low single digit percentages, but has *that* number improved over time?

To cut back to reality, hospitals are full in Arizona and Texas. Perhaps because 4% of a very large number is still a large number.

(4% was the early hospitalization rate for this age group in Utah)

>To cut back to reality, hospitals are full in Arizona and Texas. Perhaps because 4% of a very large number is still a large number.

Cutting to reality, no they are not. Can you show any data that they are full of COVID? Last I saw it was backed-up surgeries/procedures put on hold.

Cue media panic, because we can't let Republicans look good.

^ Seriously self-indicting argument.

How so? I've seen similar claims. My wife works for a hospital that has restarted elective procedures that have been turning into more urgent procedures. Also have seen reports that hospital admissions haven't been increasing, but stays have. Also reports that would confirm your point of view.

Well for one it starts with "no they're not" full, when they are.

https://www.houstonpublicmedia.org/articles/news/harris-county/2020/06/26/376985/harris-county-increases-covid-19-threat-level-as-hospitals-reach-full-base-capacity/

https://www.kold.com/2020/06/16/southern-arizona-hospitals-approaching-icu-bed-capacity-covid-/

https://www.click2houston.com/news/local/2020/06/16/this-dashboard-tracks-the-daily-hospital-capacity-for-general-icu-beds-in-the-houston-area/

Yes, up.
surgecap normalcap in use covid
2644 2202 2043 800

Went from 1866 used in May to 2043 now, or up 9.5%

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Last report I saw was thay 20-25% of admits were covid 19 related. So those patients being a brand new hospital problem this year have taken up the usual bed slack.

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I will say this, if it turns out that it is hospitalization rate, rather than hospital survival rate, that is falling across age groups ..

I would regard that as significant and unexpected.

s/falling/improving/

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Maybe there goes that hope,

"Georgia COVID hospitalizations jump 10% in one day, from 1,236 to 1,359"

https://twitter.com/lookner/status/1277710886329823233?s=19

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There's no real way to be sure the intake sample of hospitalized patients:tested is much the same and that there aren't heterogenities in sampled patients, so you can't really very easily evaluate growing effectiveness of treatments by looking at case fatality rate.

There's also the confound that having high numbers of initial cases probably helped UK develop what I believe is still the most effective drug treatment we know about so far - Dexamethasone.

So as with vaccines trials, having low case counts has a mixed benefit if your goal is to "get" to effective treatments (rather than simply eliminate the disease). Having high case counts at once probably helps to run large drug trials and tests, so most extreme curve flattening may not be most optimal for drug / treatment development.

Finally, it of course doesn't necessarily vindicate specific NPIs intended to "flatten the curve". Belarus curve apparently pretty flat without many measures, etc.

Anyway, I would guess, if it were real, I would guess more plausible reasons for improving survival would be:

1) Early cases had more harvesting of vulnerable individuals (close to death, specific combinations of co-morbidities), and more resilient to Covid19 syndrome individuals survive.
2) Early cases were refused more medical case due to freakout panics about "overwhelmed healthcare systems", "soldiers dragging out the dead in Italy" and so on, which led providers to ration care for young and healthy.
3) More spread of cases over wider geographical area means much more feasible attention for treatment - even if healthcare systems were never "overwhelmed" or in danger of it, it is plausible that some degree of greater medical attention helps at least a bit.
4) Because of less concentration of infection in any region, viral dose is decreased and immune systems fight off infection more easily.
5) Seasonally stronger immune / respiratory systems in the summer / seasonally weaker coronavirus in the summer.
6) Younger infection pool.
7) Decline in spread within hospitals and care homes and rather a greater community infection rate.

Is there some reason for often mentioning what happened in Bergamo as if it didn't? From an article detailing Italian antibody testing in the region (using a non-random sample) - "Antibodies were found in just over 30% of the 10,404 health operators tested although they are generally considered more at risk than other people.

In a report released in early May, national statistics institute ISTAT said the number of deaths in Bergamo was up 568% in March compared with the 2015-2019 average, making it Italy’s worst-hit city in terms of deaths.

Its hospitals were overwhelmed by infected people and, with morgues unable to keep up, convoys of army trucks carrying away the dead became a chilling symbol of the global pandemic.

Bergamo province has reported 13,609 coronavirus cases, official data showed on Monday." www.reuters.com/article/us-health-coronavirus-italy-antibodies/over-half-of-people-tested-in-italian-city-of-bergamo-have-covid-19-antibodies-idUSKBN23F2JV

That Stockholm has avoided Bergamo's fate is apparent, but the Swedish death rate is only around 10% less than Italy's, and higher than France, where the health system did collapse in several cities. We continue to learn how to effectively, and collectively, deal with a new disease.

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I have seen data on the percentage of deaths coming from nursing homes, and it was shocking. If the virus is now moving through the general population, you'd expect more infections, but fewer deaths per infection. Fewer deaths overall would be pretty surprising though.

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1. If you watch “Air Disasters,” you learn how much airplane safety improved due to better procedures. COVID outcomes are improving for the same reason. Ventilators actually killed a lot of people in March,

"ventilators actually killed a lot of people in March" is a bold claim.
what is your proof?

Here's one source:
"As the pandemic has flooded hospitals with a disease that physicians had never before seen, health care workers have had to figure out treatment protocols on the fly. Starting this month, a few physicians have voiced concern that some hospitals have been too quick to put Covid-19 patients on mechanical ventilators, that elderly patients in particular may have been harmed more than helped, and that less invasive breathing support, including simple oxygen-delivering nose prongs, might be safer and more effective."
https://www.statnews.com/2020/04/21/coronavirus-analysis-recommends-less-reliance-on-ventilators/
I've read this elsewhere.

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They didn't " kill" a lot of people , but the survival rate of people on ventilators was not good , especially at the beginning in China ( 20%). It's better now ( 50 to 70%) . They're very invasive and require sedation and patients can deteriorate after a few days, develop blood clots etc.. they require experienced care teams. They were often used too early. Gentler less invasive breathing support, including simple oxygen-delivering nose prongs, with pronation might be safer and more effective in many cases.
That's part of the learning process

All true. Strange the med professionals/experts/front line didn't know this though. Or maybe they did but the hospt. admins didn't listen to them.

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#1

Been watching this closely at the individual state level for a few weeks... particularly states like California, because they've had rising case counts for three months, but steady death counts for two months.

The amount that deaths increase over the next one to two weeks across America should be very telling. I'm optimistic: hoping death counts don't increase to the extent that cases increase because we've learned how to better protect the vulnerable.

California deaths per week:

Mar 29 to Apr 4.......185
Apr 5 to Apr 11........310
Apr 12 to Apr 18......480 <peak
Apr 19 to Apr 25......500 <peak
Apr 26 to May 2.......460 <peak
May 3 to May 9........490 <peak
May 10 to May 16....490 <peak
May 17 to May 23....470 <peak
May 24 to May 30....420
May 31 to Jun 6........375
Jun 7 to Jun 13..........410
Jun 14 to Jun 20........405
Jun 21 to Jun 27........390

I wouldn't call that steady and follows the quick rise, long peak, slow decline in most other states.

Ok fine, we won’t call it a steady death rate.

That’s even more interesting, because the California cases have definitely been increasing over that same time frame.

Confirmed cases have been increasing over that time frame. Because testing was slow to take off in California, you can't say anything about the number of actual infected. It skews the analysis.

Fair point.

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In California the positivity rate has also increased from about 2% 12 days ago to 6% now, indicating that actual infected were indeed rising. The number of cases is actually declining again the last few days.
More telling are the demographics (you can download the data at covid19.ca.gov)
The older group representation ( 50 and over ) has declined by 28 % in the positives since April,the younger group: ( 49 and younger) has increased commensurately.
The newly infected are younger

Good info

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The age of the newly infected has been steadily declining in CA since April from ~ 49 years to now 37.8

*the median age

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1. That doesn't surprise me. From what we can tell, the big surge in cases is primarily hitting people <65 years old, so there's much fewer deaths - and we've had a couple months to figure out better hospital regimes for treatment.

Granted, that won't be much comfort if you still end up overwhelming ICUs and end up with an unnecessarily high death rate in the week or two after that happens, but as long as we don't reach that point it's not shocking to see the death rate low.

3. I guess if they've determined it's probably not dangerous, then the worst that could happen is that it's ineffective and they've wasted some money.

A worry is a vaccine that does not protect might as a side effect trigger an immune response that prevents certain future effective vaccines from working.

A not completely theoretical worry, but little studied so far, but maybe explaining varying effectiveness of other vaccines. So much is unknown, but paying more researchers to work costs too much, which kills jobs, so it's impossible to know without causing 10-25% unemployment.

This is a concern for viral vectors where the vector virus is modified so it produces target proteins intended to create an immune response. This is a new method that hasn't been used for human vaccines yet. At this point with over 100 vaccine development projects a lack of researchers is not a problem.

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Cheaper alternative?

"Five studies, including two controlled clinical trials, have demonstrated significant major outpatient treatment efficacy. Hydroxychloroquine+azithromycin has been used as standard-of-care in more than 300,000 older adults with multicomorbidities, with estimated proportion diagnosed with cardiac arrhythmias attributable to the medications 47/100,000 users, of which estimated mortality is <20%, 9/100,000 users, compared to the 10,000 Americans now dying each week. These medications need to be widely available and promoted immediately for physicians to prescribe."

https://academic.oup.com/aje/article/doi/10.1093/aje/kwaa093/5847586

Maybe the reason Red states are doing better: Trump is using Hydroxychloroquine, so are Republicans (early - when it can work).

But every Blue outlet has made it a mission to find any reason it doesn't work.

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7 was interesting, but I don't see how it connects to moralizing.

#7 - is especially interesting if you consider that lab RNA viruses are less robust, and possibly mutate faster, than natural RNA viruses. I'm not qualified to answer this but my hunch is that it's true. The Covid-19 virus already is temperature sensitive, a trait of a non-robust lab virus. As CatInTheHat would not agree, SARS-CoV-2 is Made In China.

To me it just confirms that viruses mutate fast, and then, if you have a lot out there, a lot of mutations from them are possible.

A lot of D led to G? Probably not surprising.

@anon - of course that's the conventional wisdom, and RNA viruses like the C-19 virus do mutate fast. BTW this story is 3 months old, in that a similar story appeared in March.

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The D614G mutation was flagged by the los Alamos team in late April ( B Korber et al). They claim 614G overtook 614D pretty much everywhere in the world ( except Iceland strangely where the reverse is true).
This would seem to take care of the founder issue where a strain just expands faster just because by happenstance it found easier conditions enabling it to spread.
Their main claim : 614G required fewer PCR cycles to be detected indicating a higher viral load. This could mean higher infectiousness.
But they also found in a study in the Sheffield geographical area in the UK where the strains over time shifted from 614D to 614G
“no significant correlation found between D614G status and hospitalization status; although the G614 mutation was slightly enriched among the ICU subjects, this was not statistically significant”
At any rate, this is the main strain, we’re dealing with now.” I don’t think we should especially have a serious concern about it, but we should keep an eye on it.

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RNA viruses mutate faster than DNA viruses which limits their genome size to ~ 30k . RNA polymerase doesn’t have the proof reading mechanisms of DNA polymerase.
Viral RNA polymerase incorporates the wrong base approximately ~ 1 in 10K times vs DNA polymerase ~ 1 in 10 million times
At the extreme, for example, the picornavirus RdRp mis incorporates the wrong base approximately once for every 2,000 RNA template bases copied and so its genome has to be small ( 7kbp), otherwise the high number of mutations makes the virus incapable of replicating in the next generation
Covid-19 has pretty much the largest genome of + strand RNA viruses ( ~ 30 kbp vs the more common 10kbp). It doesn’t mutate as fast because its nonstructural protein, nsp14 (ExoNuclease) performs a basic proofreading function.
For comparison the Influenza A virus is a negative strand RNA virus, and probably mutates at 10 x the rate of Covid-19. It has a small genome ( 13.5 kbp), no proof reading and comes in 8 segments which facilitates inter segment reassortment

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"I at least know I don’t know enough to judge this one". Neither you nor I even knows enough to judge who might be equipped to judge this one. That's the trouble with a novel virus. It's also the trouble with predicting the future.

I saw a blog post today attributing the success of the Aussie government to its ignoring the advice of its medical men.
https://quadrant.org.au/opinion/qed/2020/06/the-dizzy-doctors-of-the-covid-crusade/

Badly argued article at Quadrant. The premise is that closing off Australia from the rest of the world would work to magically keep Australia safe forever. But it would not work for long unless every country followed the same advice and did the same thing and China was successful in defeating Covid-19. Unless Australia wants to become like the Hermit Kingdom (btw closed borders in North Korea did not work to isolated North Korea from C-19 either, proving my point). One person with Covid-19 introduced into a population where nobody has immunity is enough to create a chain reaction, unless precautions like I list below are made (kind of like smallpox in the post-1492 Americas

The reality is that a lockdown, social distancing, mandatory masks in public, test-and-trace, bans on public gatherings and so on, indefinitely, are in order until such time (if ever) a vaccine is found for the chimeric SARS-CoV-2 virus that causes Covid-19.

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What is the *standard* lag time (if there is a standard) - or the average time - between confirmation of covid positive test and death for those individuals that ultimately succumb to the disease? I've read 10 days in places, but looking at the historical data, it seems more like 2-3 weeks for the death curve to track along a spike in the case curve. Anyone have a good source for this?

Here is the timeline . Median numbers , there is significant variation ( in days)
• Day 0 : infection
• Day 3- 4: test positive ( lots of variation on this one)
• Day 5: symptom onset
• Day 6: fever
• Day 12 : Dyspnea ( difficulty breathing)
• Day 15: sepsis
• Days 17 : ARDS (Acute respiratory distress syndrome)
• Day 17 : ICU admission
• Day 23: death

See https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext#tbl2
And
https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

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This is a somewhat tricky thing to ask, particularly if your intent is to review public data of cases and deaths looking for trends in their relationship. Early on, when tests were extremely rare, people were presenting at hospitals already very sick. So the date from positive test to death could be artificially low ( indeed, we had many cases of post mortem covid confirmation). There is also a great deal of non-conformity in how covid case data is presented. For example, Houston/Harris county in Texas has a convoluted algorithm for reporting case date based on 1) symptom onset 2) diagnosis date 3) date of test result 4) date of report of test result. This means that if you look at the Harris county covid site, you'll see something like 20 or 30 cases for the most recent date despite public reports of 1000+ daily cases. Indeed, at the TX state level, cases appear to be posted on the date for which a test result was reported, which may lag from a day or two to weeks after the onset of symptoms. This disconnect is increasingly problematic when date from symptoms to date to test and finally test results has increased as test demand had increased through June in the states experiencing a surge in illness. Mass targeted testing case data (ie prison/meatpacking/nursing facility data) are also often reported en mass, which can look like warning signs of exponential disease spread in a broader community. Some states/counties are also better and worse about promptly reporting deaths, with report time lag between days and weeks. For some counties, I see deaths reported only on one or a few days a week. This is part of the reason so much data is presented as a 7 day moving average, but the proper period for averaging is still something of a crap shoot given all the variation in how the data on cases, hospitalization and deaths are reported.

A great deal of data is publicly available for covid and I strongly encourage everyone to download the datasets for their state/county/city. It's extremely helpful to get a feel for the biases and deficiencies in these datasets to better understand and identify reasonable, uninformed or outright disingenuous takes on the data.

I was really interested at where to place the outer bounds. Seems like, given the variation, it would be sensible to wait at least 3 weeks before passing judgment on whether a jump in confirmed cases has been followed on by an uptick in deaths. I know many will say this is inevitable, but if the new cases are heavily concentrated in people in their 20s, then the resultant deaths may be far fewer than we have seen in, say, the northeast in April.

I was playing around with the Dallas/Ft Worth numbers earlier. While this area has certainly seen an increase in both the absolute number and percentage of cases amongst those age 40 and under, the absolute number of high risk age 65+ cases has held relatively steady, despite shrinking as a percentage of overall cases. Whether this is true in other region experiencing growing case burden will have an impact on absolute mortality levels (though we may expect the case fatality rate to diminish).

Granularity is increasingly necessary, without losing sight of the facts - that absolute number of 65+ is clearly a serious concern, and changes in percentages are meaningless against that background.

I'm still trying to figure out how many of these 65+ are in nursing or long term care facilities, but the Texas data is aggregated in a way that makes it hard to determine change over time. There is a large fatality risk difference between 65+ year olds healthy enough for independent living and those requiring regular nursing care.

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5: I see we are on to Tyler Phase Two!

As long predicted, he has seamlessly transitioned from (1) THERE IS NO TREATMENT to (2) THE TREATMENT IS TOO EXPENSIVE.

Next up is (3) THE TREATMENT IS NOT 100% EFFECTIVE.

Followed by (4) IT IS TOO HARD TO GET THE TREATMENT.

Should be fun! Keep score at home, folks. Four more months of this!

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#1. Further to my earlier question, I went to the link and the tweet highlights overall US death rate. This seems like a red herring. The case spikes have only been in certain states. I would reason one has to look there to see whether new cases are leading to new increased deaths. I queried the lag. In places like Arizona, Texas, and CA, the confirmed case spike is less than 10 days old. I don't know what is going to happen, but I'm certain of one thing, the scolds who are saying I told ya so don't know either.

Scolds: it is too early to reopen, cases will rise

(We reopen, cases rise)

You: this doesn't prove anything!

They literally said deaths will rise:
https://www.theatlantic.com/health/archive/2020/04/why-georgia-reopening-coronavirus-pandemic/610882/

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You'll need to fill me in on how any reopening, anywhere, ever, would result in fewer cases, not more, and who it was that said that it might.

Scolds: Cases will rise if we reopen. We must therefore never reopen.

Plenty of nations beat the virus *and then* reopened.

How can anyone possibly argue that is a bad plan?

Just what level of suppression did states like FL, TX, and CA need to see before reopening? It seemed like they had it every bit as much under control as those unnamed *successful* states did when they reopened. It took quite some time for them to see the case spikes we're seeing today. Complete suppression a la Iceland, NZ or Taiwan is a fantasy world solution for the US.

Austria seems to have done quite well. Masks, and effective suppression before the first steps of reopening.

But you are sadly correct, the U.S. is not going to reach Austrian levels of suppression in the foreseeable future, even as it until very recently reopened even more vigorously.

Interesting example. Cases in Texas have been rising fast very recently. However, as of today, Austria registers 78 deaths/mil pop from Covid, whereas Texas records 83 deaths/mil. When Texas did reopen, their case count was comparable. That leaves masks. I'm not sure there's conclusive evidence that that would have made all the difference.

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This. Scolds don't realize the cost part of the lockdown. How many lives have been lost because people are afraid to go to the ER when needed, or even the shutdown of normal testing for 4 months? The only suicide number I could find was a claim by a suicide hotline that they are up 2x since the start of covid. The financial impact is also enormous.

But reopening was not an economic cure-all. You actually need to beat the virus for that.

https://www.npr.org/sections/money/2020/06/23/881662948/why-reopening-isnt-enough-to-save-the-economy

Who said cure-all? There's no such thing in the real world. A cost benefit analysis, which I alluded to when I said to consider the costs as well, will tell us what'll do the least harm.

Is this cost benefit analysis wrong?

https://www.nytimes.com/2020/06/29/opinion/republicans-coronavirus.html

The NYT is a political activist organization, not exactly credible on politics...

Would you trust Russia Today or Sputnik on the US? If not, then the NYT is not credible on Republicans.

We should remember who Will Wilkinson is, his libertarian roots, and how he evolved to support his form of public/private state capacity.

From there, he has an argument for the optimum path, with trade-offs implied, but hardly hidden.

If you open without beating the virus you don't win, because all that missing economic activity won't come back.

The two links above, data from Raj Chetty, and plan from Wilkinson, obviously connect in that way.

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I didn't see any cost benefit analysis in the article. It was kind of a muddle on what maybe we could do. Compares us to other countries when in reality we have no idea why other countries have done worse or better than us, and puts a lot of faith in Contact tracing, which most consider useful only at the beginning of the infection. And what have republicans got to do with any of it? Everything in the article had nothing to do with part affiliation. This was just a rehash of things that have been out there for a long time. Pretty useless.

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Hey, aren't you at least glad that Hydroxychloroquine might be working out? See my link above.

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It’s not an analysis, let alone a cost benefit one.

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1. "In these two fundamentally similar undertakings—managing the skies, containing disease outbreaks—the United States has set a global example of success in one and of failure in the other. It has among the fewest aviation-related fatalities in the world, despite having the largest number of flights. But with respect to the coronavirus pandemic, it has suffered by far the largest number of fatalities, about one-quarter of the global total, despite having less than one-20th of the world’s population." Sometimes Cowen pretends that everything government does is a fail, but it's not. The failure of response to the coronavirus crisis belongs with an unqualified pilot: https://www.theatlantic.com/politics/archive/2020/06/how-white-house-coronavirus-response-went-wrong/613591/

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#5. That's cheap.

Depending on the hospital, that cost might be a single day of admission. If the data hold, we may be looking at the drug companies capturing less than 20% of the cost savings to the system (before putting a value on the patients' time and the like).

Indeed. We should start quoting costs for drugs like this in units of Ivy League tuition, i.e. here about 40% of one semester of Introduction to Sociology.

Greedy drug companies profiting off of the sick and the suffering is one of the worst evils of neoliberalism.

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# Under General Secreatry Xi's guidance, the Chinese people has been able to develop a great vaccine, showing again the might of the Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era. China and Brazil's agreement for technology exchange will go down history as a great example of what can be achieved when principled, brave leaders take a stand and act on their convictions instead on short-term interests and demagoguery. Now, imagine if the world had to depend on Mad King George III, the Second, who inhabits the White House. That is why, as an American, I thank Brazil's President Captain Bolsonaro and China's General Secretary Xi for their correct leadership. It is said that the East is Red. Well, now it has become clear the West is Green and Yellow (Brazil's national colors).

https://www.bangkokpost.com/world/1942868/chinese-coronavirus-vaccine-approved-for-military-use

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A day less in the hospital has other large potential positive values. Including less risks of other other inadvertent side effects, errors and potential misadventures while hospitalized. A day less in the hospital, and families are reunited sooner with those substantial emotional and physical benefits. A particularly valuable event if there can be no hospital visitors. A particularly valuable event if the patient had to be shipped out some distance to due to a lack of local HC resources.

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#1. Didn't read. Here to share a death story of interest:

My friend's mother just died (sad). Friends' mother had been in a nursing home for a year. Friends' mother had successfully battled pneumonia before. Despite not catching Covid, friend's mother became recently sick with pneumonia again. She refused treatment, because life was so miserable, because she can't have visitors, because of Covid. So, in a sense, Covid killed her, even though she never contracted the virus. 

The number of people in her tragic situation, is shrinking. So we'll see less deaths of that type as the months go on.

I don't know anyone who has died from Covid. I know three people for whom the shutdown was a contributing factor in their deaths.

I think about them when reading about "extra deaths".

Can you explain how the shut down contributed to anyone's death, outside of purely accidental things like "unemployed person is out biking when they would have been at work and gets run over"? I can see that in the really long term a person could get depressed and start doing drugs (or drinking heavily) and die from that, but would expect that to be a lengthy process of months or even years not just a few weeks.

I have heard a number of anecdotes of people who put off medical treatment due to fear of catching COVID at an ER. My wife told me about one patient that showed up in the ICU who had had some chest pain, did not want to go to the ER for fear of covid so waited until they could get in the GP. Turned out they had multiple heart attacks and extensive heart damage.

Violent crime is up.

Depression can kick in fairly quickly and it is easy to OD on hard drugs.

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From my view things I have been seeing:

1. An increase in non-accidental trauma. Historically children and spouses often deal with violent family members by getting out of the house to visit parks, movie theaters, etc. My best guess is that being locked down means all of that is harder so when they blow up, it is harder to get out of the line of fire.

2. The heart attacks and strokes that are showing up are doing so later in the course. People are scared to come to the hospital out of infection fears so their thresholds for calling 911 and the like are higher. Time is brain and time is heart so inevitably this means that you have higher mortality when people are scared by a virus deadly enough to shut down 20% of the economy. Also making matters worse is the loss of contact, many people get told "you look terrible" at work, go see the doc, and then find something scary. That does not happen. Likewise, extended families not being present means they may miss cues that Grandma is not acting the same. Having another human who knows you well look things over is extremely valuable and catches a lot of unstable angina, TIAs, and other precursor illness. Losing that means when they get here, it is later and their death risks are higher.

3. Increased alcohol related mortality. Total booze consumption is significantly up and has been for months. Worse a lot of AUD patients are out of work but getting very good cash to stay at home. This combination removes one of the primary checks on binging (having to make it to work tomorrow) as the number of binges increase the risks of pancreatitis or other acute events goes up. Arguably a lot of these are just pull-forwards (if each binge has a 1/20 risk of mortality given their current portal circulation having 20 binges in May/June does them in rather than having 20 binges in 2020) but certainly some are not.

4. Vaccination rates are down as is most all preventative care. Many people are avoiding the doc and when the numbers get into the millions you can quickly generate a few hundred or thousand folks who will miss the window to surgically cure their cancer or to prevent their child from getting rotavirus, etc.

5. We delayed all the "elective" surgeries. Everybody thinks boob jobs and maybe tonsils, but actually this included a large number of mastectomies and even brain tumors. For a lot of elective stuff delaying a month increases the mortality rate from something like 0.2% to 0.3%, but when you did this on a global scale that is a lot of dead people.

6. Suicides are significantly up. This is a mess to untangle, but things we know that correlate well include job loss, business failure, and isolation. Alcohol and drug use are also highly correlated.

Homicides are also significantly up. This is basically 1(a), but deserves to be mentioned separately.

Is there any solid documentation for this? Is there a break down of the sorts of homicides that have increased? I'd expect random street crime to decrease since there's been less street traffic for criminals to prey on. Is it domestic violence? Drug gang violence due to declining profits?

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https://www.wfp.org/news/wfp-chief-warns-hunger-pandemic-covid-19-spreads-statement-un-security-council

"But now the World Food Programme analysis shows that, due to the Coronavirus, an additional 130 million people could be pushed to the brink of starvation by the end of 2020. "

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+1.

I read somewhere (maybe here) that COVID killed off a whopping 12% of New Jerseys nursing home population. At rates like that there are going to be a lot of nursing homes going out of business in the next few years. We still have a long way to go.

Not really. The average stay in a full care nursing home (NOT an assisted living facility) is 7 months. That means 170% of the nursing home population dies every year. My mom lasted less than 6 months when here advanced dementia forced us to move her from assisted living to nursing homes. It's where people go to die. Death is not a surprise.

Nursing home stays do not always end in death. In some cases they are temporary and the patient improves after a really bad rough spell and resumes a degree of assisted life outside the facility. There are also "respite stays" where a seriously ill person is being cared for at home, but the family needs a "time out". This was the case with a cousin's husband who was declining with ALS and was mainly cared for at home but a couple of times went into a nursing home for a two week spell to give the family some much needed rest.

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Yes, there are the collateral deaths; for example patients with dementia or Alzheimer who don't understand what's happening and don't have visitors anymore. The lack of visitors make them lose their already tenuous grip on reality. They get agitated , they're more prone to falls and it goes downhill from there.

Since no one is disputing that nursing home patients are truly at risk from dying due to a novel contagious disease, and that one case will rapidly spread in such a setting, this would seem to be more in the category of what the American military might refer to as theater non-hostile deaths. That is, people whose deaths are connected to the fact there was a conflict, without their death being the result of hostile action.

Considering the problems with classification having been relentlessly politicized in the U.S. at this point, it seems very unlikely such deaths will be categorized in any meaningful way.

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For the average citizen, death rates and infection rates are not the metric; rather, we want to have a firm sense of "is there a significant risk of hospitalization?" Many weeks of supermarket visits, or pick ups, deliveries, out and about, with precautions, seeing many others out and about, with precautions, watching some groups and congregators ignoring risk. Time and the absence of sensational local outcomes lead to: I have control over risk, the risk of hospitalization is negligible, the risk of death non existent.

Non-existent? No. But of the same order of magnitude as the risk of death in auto accident from commuting to work by car. Something that can happen and you may take some precautions (wear your seat belt) but not a big enough risk to force any major change in your behavior.

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Re: Chinese testing

It's Phase 2 results were very good. Note - all testing phases involved testing on humans, but for different purposes. The size of the group increases in each phase. Without more details it could be that China is going to use soldiers as its Phase 3 group. We do not know if the testing participation will be voluntary or not. The US has a checkered history in this regard, both with civilians, prisoners, the military, and the homeless. I believe the lawsuits involving testing without consent on US soldiers are still around. As for using the homeless, this article is 6 years old - I don't know what is happening today. https://medium.com/matter/did-big-pharma-test-your-meds-on-homeless-people-a6d8d3fc7dfe One of the worst things the VA does is load up veterans with mind altering drugs to treat PTSD, depression etc. Some feel this is a reason for the increasing suicide problem. Real mental health treatment can be drawn out and expensive. I have citations to these things but I'm not at my personal computer.

So I hope the Chinese are observing consent protocols. It has been observed that consent is an iffy issue. Can prisoners, for example, ever truly consent? I also hope the creation of a safe vaccine is not viewed through the lenses of politics or nationalism.

You ought be sure America's clumsy imperalist leaders will do their best (which means their worst) to make the creation of a Chinese vaccine be seen through the lenses of petty politics and rabid, jingoistic, unthinking, Fox News-like nationalism. It is the only chance of political survival they have after having dropped the ball so badly and having killed myriads of their own citizens. This plot, however, will fail and their treachey will be laid bare to be seen and repudiated by all peace-loving nations of the world.

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I can understand the concern. On the other hand, it does seem that ethical concerns (I include the protests here) have drowned out a realistic response to the coronavirus. I am not just talking about the epidemiologists who think that the real health issues are things like racism and guns, and that the initial problem was more xenophobia than pandemic, but also the people (usually considered the "other side") that finds masks and other reasonable strictures an imposition on freedom. China has done very well since it finally admitted that the virus was transmitted by humans. It may have the first vaccines. It appears that there is a balance to be achieved here, and the US is far from optimum.

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#5. "One-third more for insurers, cheaper in other countries."

Interesting that insurers are being charge more than out-of-pocket customers. It's usually the reverse. Or is the medical market discovering rationality? You can always screw the insurer ... the out of pocket customer is more price sensitive.

That might be vs Medicare or Medicaid. Insurers typically subsidize these.

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Insurers aren't going to pay the sticker price—they'll probably pay somewhere between 30 and 70% of it. Same ballpark as the discount you would get from the hospital if you paid out of pocket, possibly a higher sticker price depending on the contract.

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Not many patients in the ICU will be asked if they want life saving medication at some added cost. Not many OOP patients will be able afford a hospitalization of that magnitude requiring that added cost.
Insurers will bargain and use Medicare and Medicaid rates as a focus point. Obamacare plans which are private pay 25-30% of overall hospital billings. Which is about typical for overall hospital collections.
Private payers do not directly subsidize public plans or payers. All the hospital can do is try and negotiate higher rates the following year.

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2.) Was a really good interview. Baldwin's discussions about the true meanings behind the lyrics in black music, both contemporary to him and traditional, makes me think a Straussian review would yield a lot.

I'm trying and failing to think of a recent major TV star as decent as Cavett.

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Cavett doesn’t try and baby Baldwin. He stays firm and tries to honestly get to the heart of Baldwin’s message. As a result, we get to really HEAR Baldwin and the power of his argument.

Skip ahead to today and your average TV personality would be so far up Baldwin’s ass it would make the interview basically worthless.

Powerful segment all around and it’s a real show of how much we have lost as a civilization.

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Knowing nothing about James Baldwin I started the video and within a minute of his starting to talk I asked myself, Is he gay?

Wikipedia says yes, my gaydar is working fine.

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1. "...but be accordingly suspicious of those who are not dealing with this fact in some manner."

Is Tyler subtweeting Krugman?

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1. As everyone knows now, the problem with deaths is that it's a trailing indicator and, although the average is though to be 14 days from detection to death, there's a large spread. A sharp peak in cases can be smoothed out a lot by that spread.

Tracking new Covid admissions would give much more useful information. Though for consistency it has to clear that these are people hospitalized for Covid, not just people who have a covid infection but are hospitalized for something else.

Hospitalizations have no lag with cases. That seems strange, people seem to think that they do lag. In practice, the reason is that cases are detected at hospitalization. People could be sick for a few days before they go to the hospital. In principle, they could get a test when they first notice they are sick, and then go to the hospital later. But that's not what happens. Compare hospitalization and cases versus time plots, and you can see the lag time is essentially zero.

I saw something today where a hospital exec describes people showing up for other things, getting automatically tested and found positive.

Throughout this thing different jurisdictions and regions have had very different results. Lots of reasons:
Culture.
Virus strain.
Public health infrastructure. This isn't hospitals, but infection tracking, dissemination of information, care home protocol standards, etc.
Living density.
Job person density.
Housing type.
Weather.

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Well, not all cases are just detected at hospitalisation, or the numbers wouldn't differ. But if you are right it seems like there's relatively little "OK, go home and self isolate... Then come back and get hospitalised when sick" effect.

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6. One thing he does not factor in that admissions officers are worried about. . . a fairly significant drop in 18 year olds graduating from high school beginning in 2024-2025.

All too true. That’s the existential crisis coming.

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#1 This has been well recognized and commented on. Who are we supposed to be "suspicious" of for not "dealing" with this?

Thiago

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1. COVID cases cause a lot of problems short of death. Hospitalization, pain and suffering from illness, potential long-term health consequences that we don’t know about yet, and fear in general. The spike in cases in my area in the last week hasn’t resulted in any deaths, but it has resulted in people canceling their plans and businesses emptying out.

Sorry, but I’m not going to avoid bars and hanging out with friends to keep you from being scared.

Snowflake

My bad, sometimes I forget there are people who live in the shadows. Must be nice to have an excuse for once.

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#6 Re Higher Education. a) Surely there will be some permanent shift from face to face to online (as with medicine). b) Some snap-back may be hampered by 1) incomplete unraveling of recent anti-immigration policies as they affect the education-foreign-born skilled labor nexus 2) permanent damage to the US "brand" stemming from the perceived outlying failure to control the pandemic.

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1. There is a fair amount of evidence that Texas and Florida are classifying Covid deaths as Pneumonia, or at least were back in March-May as those states had 4x-5x the usual pneumonia deaths for that period. I suspect we will see the same when June numbers come out. Whether this is intentional as many on the left claim or just due to lack of testing leading to unknown deaths being classified as non-Covid as most of the statisticans/epidemiologists I have seen believe remains to be seen. But from what I heard from a couple of friends in the Houston area, they still have a shortage of tests down there.

Haven't you heard? At this blog, the commenters are sure COVID deaths are being mightily increased. In fact, only 30,000 will die of it in a year's time. No doubt.

The only one ranting about 30,000 was prior.

Not even sure where he grabbed that number from.

Some Econ pundit said it in Feb / early March. Not even an important of influential guy (can't even easily find his name when searching it out).

PA seems to keep waving it around like a totem of how he's gotcha'd everyone or something, mostly baffling most people, who never endorsed or even heard about that prediction.

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george floyd was killed one month ago. dying from covid from infection to death takes maybe 4 weeks. but first we need infected people. covid deaths should be beginning to rise right now.

So far, they aren't. Those protesters have been wearing masks. Most of the newer deaths have been from bars, beaches and family get togethers.

Where did people get this idea that the protesters were wearing masks?Some were, but many were not. I've seen crowds of protesters, and mask-wearing appeared to be about 50%, mostly older people.

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We've all heard about the other negative effects of COVID-19 such as permanently damaged lungs, loss of testosterone production, etc... I assume (hope) that death rate is a proxy for all of these other effects as well.

The fact is, we are incrementally improving outcomes through multiple methods. A ten percent reduction here, a five percent there - after enough of these, you reduce the death rate by 90 percent and herd immunity is a real option.

Can you provide links because I have seen at least two post on here speculating about these long term effects but it isn’t in the news, it isn’t on MR, and isn’t tracked by any gov’t or gov’t agency I’ve seen. With as many people as have had it by now it seems like someone would have looked into it and if they had found anything I’m sure it would have been used all over the liberal media to slam Trump. Everyone I know whose had it has gotten over in less than a week and is back to normal FWIF.

Of course, since we haven't tracked any covid patients long term, there are no true long-term studies, but here's a couple of studies about secondary damage:

https://jamanetwork.com/journals/jamacardiology/fullarticle/2763524?resultClick=1
https://pubs.rsna.org/doi/full/10.1148/radiol.2020200843

And here's a couple of 'lay public' articles:
https://www.advisory.com/daily-briefing/2020/06/02/covid-health-effects
https://www.adventhealth.com/blog/covid-19-what-are-long-term-risks-your-health

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In Sweden, 38% of all people with COVID-19 have been sick for 10 weeks or more.

That seems very unlikely to be true

My wife still hasn't fully recovered from her mid March infection.

That is a lot more likely to be true

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Patients are very old and sick to begin with.

10 weeks on in a young and perfectly person. lolNope. But in an old and sick person, very feasible.

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Covid CFR in US will likely settle at around 1.4%, the Australian number. Heavy testing and tracing in Australia means most cases identified. First wave completed. Will vary a bit with age profile case mix. Health system similar quality to Australia. See https://www.medrxiv.org/content/10.1101/2020.05.14.20101378v1

If CFR is really the number of reported deaths per number of reported cases then what good is the metric? You can’t compare between illnesses because if 10000 had COVID in Seattle in Jan and there are zero COVID deaths in Seattle in Jan that just doesn’t work. Idk who would bother with a test for any illness if they’re not at least mildly sick and COVID tests are still hard to get in many places. You can’t compare between regions because the “pandemic” responses are different. Unless you assume all those biases work themselves out. Or you have a political agenda since the media could say “1-2% of Americans will die of COVID!”

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That seems very likely to me, John. To avoid confusion I'll just make it clear the 1.4% figure that's for US sufferers who are the same age spread as Australian suffers. The lower median age of the infected in the US will make their fatality rate lower.

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#7 D614G corresponds to the Nextstrain SARSCoV2 genetic classification of Clades 20A, 20B and 20C.

https://nextstrain.org/ncov/global

https://i.ibb.co/qy8vr8N/cla619.png

SARSCoV2 entry to human cells through two receptors, one promotes entry and the other resists. SARSCoV2 has mutated to deactivated the the resist receptor for some human, mostly Europeans with the SNP marker rs35074065, where the infection rate is enhanced. From real world data form JHU and Nextstrain, Clade 20s are the killer clades, the higher the % Clade 20s the higher the per capita fatality rate.

https://i.ibb.co/dBf5Zb5/covcla19a.png

https://i.ibb.co/pdkydsY/covcla19b.png

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1) I ran some numbers, basically dividing the number of deaths by the sum of the past week's total new positive test count. NY and NJ still have a very high death rate compared to elsewhere in the country. Is this the European strain versus the Chinese strain of the virus? Is it a large cohort of infected people with long term symptoms? One would expect the death rate to decline as treatment improves and more cases are discovered by increased testing.

4) Does COVID-19 cause car crashes and other ER ready health problems? Is this a problem for the DMV, no the CDC? Are 1/3 of all Floridians infected already?

5) Remdesivir seems pretty moderately priced to me.

6) Higher ed won't just snap back. A lot of schools were collapsing and closing before the epidemic. Odds are the trend will accelerate. This is what is happening with retail.

7) The coronavirus mutation paper looks credible. The European mutant has a less fragile spike so it is 10X more infectious in vitro. Odds are it is more infectious in vivo. This would explain what happened in Italy and the NYC area.

"Remdesivir seems pretty moderately priced to me."

Indeed. If it reduced ICU stays by even one day (and it seems to be around 4 on average) that would be easily worth it for any insurer to pay.

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"I am not your negro."
That's right, you dastardly complicit White People. Stop trying to make it better by doable, smaller steps. Make everything perfect instantly. Because we know that White People can make everything happen just by wanting to. (In current babble, you're complicit = horrible, fascist, racist, murderer) if you don't do what I want, immediately.) James Baldwin was a good writer (I know because I read everything every Black Writer of note wrote, back in the day when there were Real Black Writers rather than snotty-nosed poseurs and untalented Lesbian wannabe artists. But Mr. Balldwin was a very bitter, angry homosexual who blamed his personal struggles on White People in general. Not like today, of course, because BLM.

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"I am not your negro."
That's right, you dastardly complicit White People. Stop trying to make it better by doable, smaller steps. Make everything perfect instantly. Because we know that White People can make everything happen just by wanting to. (In current babble, you're complicit = horrible, fascist, racist, murderer) if you don't do what I want, immediately.) James Baldwin was a good writer (I know because I read everything every Black Writer of note wrote, back in the day when there were Real Black Writers rather than snotty-nosed poseurs and untalented Lesbian wannabe artists.) But Mr. Baldwin was a very bitter, angry homosexual who blamed his personal struggles on White People in general. Not like today, of course, because BLM.

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Remdesivir will cost $3120 in the US.

https://www.washingtonpost.com/business/2020/06/29/gilead-sciences-remdesivir-cost-coronavirus/

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Well worth it if it saves with a few days less of hospital/ICU care.

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It just occurred to me: the new COVID deaths may be lower even as the number of cases goes higher — because the cases are more heavily weighted towards younger people who are in less danger …

… the young that die had many more years ahead of them then the elderly — possibly leading to the same number of lost years of human life overall.

And because many higher risk and older patients have already been culled out.

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You have to examine COVID-19 trends by DALY (disability-adjusted life-years). Deaths are very important, but deaths are an incomplete metric. Illnesses matter, too — lost productivity and long-term chronic problems. Trend lines comparing cases vs. mortality are a side issue. I can't find any plots of COVID DALY. Are there any? And BTW, not just trend lines, but DALY relative to relevant benchmarks. Regulatory policy uses threshold levels, so irrespective of how COVID is trending on DALY, is it above key thresholds used in other domains? Anyhow, I think the cases vs. deaths debate has gotten way out of hand. Deaths is not the best metric.

Too soon to say much about the resultant chronic disabilities related to the covid 19 infections.

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If we had a trustworthy and capable President, CDC could get to the bottom of new infections vs. mortality issue and have it effectively communicated across the country. Instead we get to argue it on Twitter.

I will hazard a guess that mortality decrease is likely an issue of more infections in young folks are less in old (so far), but who knows if that data is being effectively collected and examined. I know 8 people under 60 who survived Covid-19, only 1 was briefly hospitalized on oxygen. I know 1 person 70+ who survived Covid-19 who was hospitalized on oxygen, and the only person I know personally who died of Covid-19 was 70.

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