Category: Medicine

A report from the hospital front, from a reliable source

I visited *** Health Center in ***.  They are not a hospital, more like an urgent care clinic funded by the city and state. They act as triage for three area hospitals, take vital signs, can write prescriptions and send serious cases to Hospital ERs.  They have been overwhelmed with people worried about COVID-19…They had been testing people for the virus; they have run out of re-agent so they have stopped that….If they were provided with isolation beds and ventilators, could they take 20 patients?  No, it is not in their license and an application to change their license takes two years. When NYC reaches maximum hospital capacity, this clinic will not be part of the solution.

I visited [underfunded public health consortium] in ***, which was at the forefront of the response to H1N1 in 2009 and Sandy in 2012.  They typically see 150 ER patients a day; during H1N1 they averaged 350 at the peak; they think they will be over 1000 during COVID-19….There is no such thing as a “test kit” which tests for the virus; when people talk about those kits, such as those dropped onto that cruise ship, they are talking about a nasal swab packaged with some reagent, which is then mailed to a facility with a Polymerase Chain Reaction Machine that can look for the RNA from the virus.

You can find PCR machines on eBay for $25,000; such a machine is labor intensive and can do maybe 10 tests a day.  The hospital complex I visited, which has been designated a testing center, has been swabbing about 200 people a day and receiving multiples of that number from other hospitals. The vast majority they are sending off to a federal lab.  Two weeks ago the turnaround time was three days; now it is five to six.

There are much faster machines.  The Roche Cobas 6800 can do 3000 tests a day with very little human interaction; it costs $500k a year to rent, which is way outside a poor hospitals’s budget (while still not providing sufficient testing for the receiving area in the coming months.) Outside their budget until today, when we gave that money (I specified first year only, though they should be sure to ask in a year) as part of a larger check.  We also gave money for 10 transport ventilators with two ports, 20 isolation beds, the money to hire 14 nurses for round the clock coverage of those beds for 6 weeks, and other things that they need.  Overall it was a $1 million check, with a promise to talk to them in a week to cover anything we might have missed and to talk to them whenever they ask during the crisis.  Overall, I was pretty happy with the visit.  They were stunned, they work in a bureaucracy where everything takes 3 years.

One thing that they can’t get enough of is N-95s [face masks]. The first thing that almost every doctor I talked to mentioned was the frustration at having to re-use N-95’s, not for multiple patients, but for multiple days.

Again, here are the Emergent Ventures prizes to encourage work to support work to fight the coronavirus, and please support them if you can.

Robert Browning and Ingmar Bergman in a Bloomberg column

With all those fools going to bars and concerts, or running marathons, it is evident we still need to solve the problem of entertainment, as I argue in my new Bloomberg column.

It is instructive to look back to the days of World War II. The U.S. government played a critical role in encouraging Hollywood to make cheery movies, and it helped by not trying to force every actor into the armed services. Major league baseball, the national pastime of the era, continued to hold a regular season and a World Series, again to distract people from wartime worries. Many top players, such as Ted Williams, were away fighting, but there were adequate replacements. The government knew that wartime drama could not be the only drama on tap.

With Covid-19, the goal is to keep people at home, at least if they are not essential workers. But if staying at home is too boring, cabin fever will take over and people will run out to social gatherings when they ought to be staying put. So solving the entertainment problem is one very real piece of the puzzle for minimizing the effects of the coronavirus and keeping Americans not just in good spirits but healthy.

The very worst scenario is that the coronavirus itself — how it is playing out, how officials and celebrities and neighbors are reacting — becomes our main entertainment. It could become an ongoing horror show that drives us crazy and makes people even more cynical about politics.

To avoid such a mix of frustration and terror, I have a modest proposal: We should restructure a few of our traditional entertainments to be safe from the coronavirus.

As suggested on Twitter, how about inducing a few of the cable providers to offer free streaming for a few months?  The Met has announced a big increase in opera streaming.  And:

Or how about proceeding with some version of the NBA Finals? Take a subset of the best qualifying teams, test every player for coronavirus, isolate them in a remote area with a college gymnasium, and have them proceed with a shortened version of the real thing in front of only a TV crew. With so many other public events closed down, television viewership would probably reach an all-time high, and the sense of drama would be incredible. It would be one NBA Finals we would never forget, and the quality of play would respond to the very high psychological stakes.

Ben Golliver serves up a concrete NBA proposal.  You’ll have to click through to get to the Browning and Bergman parts, the latter being Easter egg.  At least the Candidate’s Tournament still seems to be on in chess, you can all watch that for the next few weeks, starts Tuesday I believe, try www.chessbomb.com.

Lecturing alone won’t work: we really do need to make it more fun for people to stay at home!

Pay people to quarantine

Once a pool of money has been allocated to a city or region, the people who are paid to quarantine would be determined by auction. There are many options around how to design pricing mechanisms to incentivize consecutive days of quarantine and other types of health improving behaviors. Based on the committed payments for a city, the price of remaining quarantined would be set on a daily basis.

Consider what the cost might be to pay to place 10% of a city’s population into quarantine. I believe that it costs significantly less than minimum wage for those people. The population that would be quarantining would be the young, elderly, the sick, and those for whom working at home is possible. Quarantining a sizable portion of a population dramatically slows the progression of a virus. Even at 30% of the population, I expect the price would remain well below minimum wage. This would have a dramatic impact on the pace of spreading.

That is from Nate Baker, enforcement would be by cyber-surveillance.

How can you best volunteer?

David Brooks writes:

If you know someone who lives alone ask them to join NextDoor, which is Facebook for neighborhoods. It helps them stay in touch with those right around them. Vital in a crisis.

I am not familiar with that project, but I would trust David’s judgment in such matters.  How else can people volunteer usefully, especially if they do not wish to leave their homes?  Keep in mind that useful volunteering is also a good way to keep people occupied and at home!

Please do leave your suggestions in the comments.  if nothing else, even “placebo volunteering” could be highly worthwhile.  I will put up some of the best ideas in a later post.

What US Government should do regarding Covid-19

This is (by far) the best document I have seen on what to do on the medical side.  It is about 3 pp. long and I believe it will be updated periodically.  Excerpt:

  • Consider guaranteeing top tier treatment and ICU beds for people directly working on treatments or vaccines. We need to keep relevant science labs open. (They’re likely to be closed as things stand.)
    • No doubt logistically challenging but may be necessary. Can you get scientists to keep going without this?
  • Announce $10B prizes for first vaccine and for first cure.
    • Think about mechanics. Should there be awards for second place, too? How should collaboration be factored in?
  • Issue $1B of research grants to all competent labs and organizations that could plausibly use them. They just have to report on progress every 30 days and require that they actively share all progress with other labs.
    • Proposed structure: $100M to each of 5 companies.
    • $10M to each of 40 labs.
      • Remainder based on discretion.
    • Take what’s required for treatment cases and make an “open source” version whose bill of materials costs less than $1,000. Commit to purchasing at least 100k. Even if US turns out not to need them, donate to other countries.

The author is anonymous, but I know that he/she has followed the issue very closely from the beginning, and his/her predictions have been largely on the mark.  If you are in USG I am happy to put you in touch, just write me.

Again, here is the document, highly recommended.

*The Seventh Seal*, directed by Ingmar Bergman

We watched this movie the night before, and it struck me as very different this time around, perhaps because it is set during the time of the Crusades with the plague as a major theme. I no longer think the death character is real, and I now view the film as about how much we flirt with the idea of death, and apparitions of death, in order to make life tolerable and to feel in control. Don’t take the opening scene “as is,” but rather contrast it with all the other ways humans use the death theme for their own theatrical purposes (theatrical, both literally and figuratively) over the next 30-40 minutes of the movie, and then later throughout. Perhaps the key line is “All the damn ranting about death. Is that sustenance for modern people?”

Recommended, especially the new Blu-Ray edition of Bergman’s complete works.

Should we ration coronavirus testing by price?

This is making the rounds on Twitter:

Just went to Seattle’s UW Medical Center to ask how much patients are being charged for a coronavirus test. $100-$500 if they have insurance. $1,600 if they don’t.

Put your emotions aside and ask the logical question: since the number of tests falls short of current demand, how should we ration those tests?  I would think we most wish to test potential super-spreaders, so they can self-quarantine or otherwise be isolated or avoided.  A priori, I would expect potential super-spreaders to be those who work in service jobs connected to many other people.  Individuals who suspect they already have the disease are also more likely to be super-spreaders, if only because there is a decent chance they actually do carry the disease.

Now at a price say of $500, you will rule out some of the poor, some of the “frivolous testers” (there are people who will try anything that is new), but you don’t rule out many of the middle class people — or wealthier people — who think they might have the coronavirus.

You end up targeting potential superspreaders by “those who think they have it,” but not by “those who work in service jobs where they come in contact with a lot of people.”

An imperfect solution, but not an entirely bad one either.  It is probably better than random allocation.  And still all of the available tests get used.

How about a government price of zero, combined with rationing?  Of course it depends what the principle of rationing would be.  From other countries, “I came into contact with a traced person” seems to be one standard, noting that the United States has nothing close to Singapore’s surveillance mechanism in this regard.  So you would get a very loose version of that standard, with many flu-laden nervous nellies taking the test, claiming they came in contact with a sick person.

That could perform either better or worse than the market solution.  In Singapore it is probably better than the market solution, but I am not sure for the United States.  My intuition would opt for the market prices, but I admit that is not verified by either model or data.

A separate issue, hard to judge from current information, is whether there is any positive supply elasticity at the higher price.  Of course if there is, that will make the higher price look better, but perhaps other regulatory and pipeline restrictions on testing will mean the higher price won’t matter.

And note that as the supply of tests becomes much greater, as is happening right now, the case for those high market prices becomes much, much weaker.  Zero price and no rationing is where we would like to end up, and I think we will.

I find that this problem, and how you tackle it, is a good test for whether or not you think like an economist consistently.

The Danes wish to know more about the coronavirus

From Martin Permin, for formatting reasons I have imposed no further indentation:

“Thanks for the excellent coverage on MR.

I lead a small team of tech workers in Copenhagen, who are donating our time and money towards building a covid-19 self-reporting tool for those citizens not (yet) in contact with health care services.

As countries shift from containment to “flatten the curve” strategies, authorities lose track of the number of non-critical cases, and to which degree people adhere to social distancing dictums. This makes it hard to predict the number if ICU beds needed a few days into the future. We’re aiming to solve this by asking all Danes for daily status updates.

Denmark is a good testing ground, but we’ll open source everything, and are building with developing countries in mind. We’re aiming to launch Monday — currently working on a green light from local health authorities.

We’re determining which data to collect. We’d love it if you’d help by asking your audience: “What daily self reported measures would you most like to see from the complete population Denmark?” (or some variation thereof).

There is of course a tradeoff between data fidelity and engagement.

What we’re considering:

  • Symptoms
    • Binary
    • Type
    • Severity
  • Whereabouts
    • Degree of social distancing
    • Hygienic measures
  • Moral
    • How concerned are you
    • Do you know anyone who’s been sick”

Are there comparable efforts to do this elsewhere?

Which are the safest restaurants to eat in?

This is my subjective impression, not based on scientific sampling.  Nonetheless, I think you should prefer cooked, hot food from a cuisine whose associated country already has had a traumatic experience with coronavirus.  They will take the risk more seriously.  You should avoid uncooked salads from lackadaisical countries that have been slow to respond.

In other words, I believe Chinese food is safest.  Furthermore, entry restrictions have been on Chinese people for some time, so the chance that your cook or waiter picked up the coronavirus from China and is still carrying it is very small, whereas Italians have been free to come and go with no real questioning at the airport.

Chinese restaurants also tend to be in the suburbs, and they pack in the tables less closely.

The British approach to coronavirus

Not sure how aware you are of what’s happening here but the British government is taking a decidedly different approach to most other nations. They are not shutting schools or cancelling large gatherings or recommending self-isolation. They’re taking a longer view and saying if that happens it will be a way off yet. The policy is led by the scientists.

It’s a very bold approach, the govt is coming under a lot of pressure to do what other nations are doing, there’s a lot of shouting to DO MORE, but so far they’re ignoring it. It’s kind of fascinating to see it play out. If you have time, today’s press conference is really worth a watch, the chief scientific and health advisers give a pretty detailed explanation of what they’re doing (Johnson introduces and then the scientists start talking at 31.50). They don’t say this explicitly but their bet is that what China and South Korea are doing is not economically or psychologically sustainable and will just lead to another peak. (My friend has drawn a cute visual explanation of the thinking here).

In this press conference they also make a pretty persuasive case that cancelling large gatherings is pointless and may be counter-productive.

…One more thing – good summary of the arguments the govt scientists made in that press conference, in this Guardian report. eg “closures would have to be at least 13 weeks long to reduce the peak of Covid-19 by 10-15%. Measures such as self-isolation for seven days for those with symptoms … have been modelled and are shown to be much more effective”

That is from an Ian Leslie email.  I am skeptical about this approach (is it politically sustainable?), but we will know more soon.  Here is another good explanation, by another guy named Ian:

3. A UK starting assumption is that a high number of the population will inevitably get infected whatever is done – up to 80%. As you can’t stop it, so it is best to manage it. There are limited health resources so the aim is to manage the flow of the seriously ill to these.

4. The Italian model the aims to stop infection. The UKs wants infection BUT of particular categories of people. The aim of the UK is to have as many lower risk people infected as possible. Immune people cannot infect others; the more there are the lower the risk of infection

And here is a polemic critique of the British strategy.  Continuing…

A new proposal for coronavirus rebound

The $8 billion emergency spending bill to deal with coronavirus includes $3 billion that can be used for the research and development of a coronavirus vaccine or treatment. There’s a better way: The U.S. government should take advantage of the recent stock market plunge to incentivize firms to develop a coronavirus cure, vaccine, or other approaches.

We call this proposal the Epidemic Market Solution or EMS. The government should offer each of 10 firms stock options worth ten billion dollars if the Dow Jones increases by 15 percent over the next six months, and maintains that average increase over a month.

A coronavirus cure or vaccine would generate such an increase. For example, if a firm has $10 billion in options based on index funds, and a new cure or progress towards a cure causes the stock market to rise by 15 percent, the firm would make a profit of $1.5 billion. An even better response might be an increase in the market by 20 percent; in this case, the firm would make a profit of $2 billion.

That is from my old colleagues Linda Cohen and Ami Glazer at UC Irvine, and yes that is the Ami Glazer of Glazer’s Law.  Here is the full proposal.

$1 million plus in Emergent Ventures Prizes for coronavirus work

I believe that we should be using prizes to help innovate and combat the coronavirus. When are prizes better than grants? The case for prizes is stronger when you don’t know who is likely to make the breakthrough, you value the final output more than the process, there is an urgency to solutions (talent development is too slow), success is relatively easy to define, and efforts and investments are likely to be undercompensated. All of these apply to the threat from the coronavirus.

\We do not know who are the most likely candidates to come up with the best tests, the best remedies and cures, the best innovations in social distancing, and the best policy proposals. Anyone in the world could make a contribution to the anti-virus effort and it won’t work to just give a chunk of money to say Harvard or MIT.

Progress is urgent. I am still keen on talent development for this and other problems, but the situation is worse every week, every day. It is important to incentivize those who are working on these problems now.

The innovators, medical professionals and policy people at work on this issue are unlikely to receive anything close to the full social value of their efforts.

I therefore am grateful that I have been able to raise a new chunk of money for Emergent Ventures — a project of the Mercatus Center — for ex post prizes (not grants) for those who make progress in coronavirus problems.

Here are the newly established prizes on offer:

1. Best investigative journalism on coronavirus — 50k

2. Best blog or social media tracking/analysis of the virus — 100k

3. Best (justified) coronavirus policy writing — 50k

4. Best effort to find a good treatment rapidly — 500k, second prize 200k

5. Best innovation in social distancing — 100k

6. Most important innovation or improvement for India — 100k

What might be an example of a winning project?  What if this attempt to build scalable respirators succeeded?  That would be a natural winner.  Or a social distancing innovation might be the roll out of more meals on wheels, little libraries, online worship, easier ways to work from home, and so on.  The vision is to give to people whose work actually will be encouraged, not to give to Amazon (sorry Jeff!), no matter how many wonderful things they do.

These are not prizes you apply for, they will be awarded by Emergent Ventures when a significant success is spotted.  (That said, you still can propose a coronavirus-related project through normal channels, with discretionary amounts to be awarded as grants per usual procedures.)  And typically the awards will apply to actions taken after the release of this announcement.

I would love to be able to offer more second and third prizes for these efforts, and also to increase the amounts on offer, and perhaps cover more countries too. Or perhaps you have an idea for an additional category of prize. So if you are a person of means and able to consider making a significant (tax-deductible) contribution, please email me and we can discuss.

In the meantime, the rest of you all need to get to work.

Massive US Government Failure

NPR: Ashish Jha, who runs the Harvard Global Health Institute, says the response to the coronavirus has varied dramatically around the world.

…So how has the United States’ response been?

“Our response is much, much worse than almost any other country that’s been affected,” Jha says.

He uses the words “stunning,” “fiasco” and “mind-blowing” to describe how bad it is.

“And I don’t understand it,” he says incredulously. “I still don’t understand why we don’t have extensive testing. Vietnam! Vietnam has tested more people than America has.” (He’s citing data from earlier this week. The U.S. has since started testing more widely, although exact figures still aren’t available at a national level.)

…Jha believes that the weekslong delay in deploying tests — at a time when numerous other tests were available around the world — has completely hampered the U.S. response to this crisis.

“Without testing, you have no idea how extensive the infection is. You can’t isolate people. You can’t do anything,” he says. “And so then we’re left with a completely different set of choices. We have to shut schools, events and everything down, because that’s the only tool available to us until we get testing back up. It’s been stunning to me how bad the federal response has been.”

I too am stunned .