How Would I Feel if a Loved One Died of COVID-19 after Re-Opening?

Some online commenters, rather a lot, say that re-opening the economy and ending enforced social distancing is wrong if it causes any increase in the mortality rate, and by the way, how would you feel if it were your loved one dying of the Great Contagion of 2020?

First, let us grant that we continue to get a pantload of conflicting information about every aspect of this disease and its management.  It is very difficult to know whether re-opening is the right thing to do.  Federal state and local officials say some smart and empathetic and cool-headed things, and some stupid and thoughtless and nonsensical things.  Our formerly ethical press has not helped matters with its poor and sensationalist reportage.  When the story of The Contagion is written, there will be the usual heroes and villains around the world.  We'll have to wait for that.

Second, let us grant that it is very appealing to think that human life is more important than money.  How much more important?  That we can think about.

We think about it every day, whether we're aware of it or not.

In fact, we do not live our lives in a way that reduces the risk of death at any cost.  We balance risk with commerce every day.

--  We don't social distance for ordinary seasonal flu. 

--  We don't drive 35 on the highways instead of 65.

--  We don't forbid the sale and use of alcohol. 

We don't do these things, and many others, because the common sense of the populace is that the risk of death and illness is outweighed by the benefits of allowing seasonal flu to take its course, driving 65 on highways, and drinking alcohol, even though the death toll from those choices is huge and could be hugely reduced with the suggested restrictions.  The risks of ordinary life are already baked into the health care system, the tax system, government spending, all infrastructure, commercial activity, and laws governing all manner of conduct, not to mention the common sense that guides us in our daily lives.

It is obvious that there is a point where as a society we must be willing to trade normal human activity (that is, the avoidance of economic collapse)  for the risk of increased mortality -- remember we're not talking about all CV deaths, only the ones that have been avoided so far by the shutdown -- that would result from the easing social distancing rules and allowing businesses to open and people to gather. 

So how would I feel if a loved one died of CV after re-opening?  Real damned bad.  But I would feel the same way I would feel if one died in a car accident going 65 when she wouldn't have died if the speed limit were 35.   We can't sacrifice a world economy for the sake of any single individual (or some number greater than a single individual), and whether any are related to you is of no moment.

Of course, there is a fulcrum at which marginal deaths -- that is the increased deaths from reopening -- are so numerous that you are willing to kill a lot of the economy for a long period of time.   What is that number?  It isn't one, and it isn't a dozen, and it isn't several hundred.  How about 10,000? 

Is it OK to have a years-long depression for to avoid 10,000 additional deaths?   Maybe, maybe.  But what about the deaths caused by the shutdown?  Caused by widespread economic depression?  Caused by civil unrest when people have had their fill of house arrest?   Today's news brings articles about hospitals suffering enormous COVID-19-related losses that threaten their continued operation.  

I admit, it's a tough call.  And it sounds awful to say it, but it is not -- marginal deaths are an acceptable price for the resumption of ordinary life. 

There comes a point at which sentiment needs to be suppressed for the good of civil society, and we have reached that point.   Re-opening should be undertaken in a sensible fashion with the full knowledge that some will be infected who otherwise would have avoided it.

And if you disagree -- you can stay home or be unemployed if it suits you. 

That's part of civil society, too.

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Anyone Else Out There Notice This Weird Thing in the Knopf/Pevear/Volokhonsky Version of War and Peace?

I'm reading Tolstoy's War and Peace.  You call yourself a reader, you call yourself a lover of fiction, you have to have tackled it at sometime in your reading career.

This is not a review, but here's a quick hit:  Too many princes, too many princesses, too many counts, too many people with the same name, too many different names for the same individuals, and families difficult to account for as the scenes shift.  But after an initial struggle, I was drawn in, and I'm enjoying it very much.  Classic Russian literature is so astonishingly different from modern English literature.  The characters feel everything very deeply, express their feelings exuberantly, and the author explains everything in detail.  (Same experience with Dostoevsky's Crime and Punishment.)  A far cry from Hemingway and the moderns' denatured heroes and heroines and an insistence on "showing, not telling."

This particular report is peculiar to the 2007 Alfred A. Knopf publication of the Pevear/Volokhonsky translation in hardcover, which I believe is now considered the standard modern translation.  It looks like this. 

 

One of the major characters of the novel, Pierre Bolknosky, had become a Mason, as in Freemasonry, as in Masonic Lodges, with all of the mysteries and secrets and alleged conspiracies.  (Not flatteringly portrayed in the novel.)  In a passage that occupies one page in Volume III, Part One, Chapter XIX, Pierre considers the Masons' assignment of numbers to letters of the alphabet - 1 through 10 to letters a through l, and 20 through 160 (multiples of 10) to the remainder of the alphabet. When applied to "l'emperuer Napoleon," the corresponding numbers add up to 666, the Number of the Beast in the Revelation of St. John.  (Napoleon = villain, as he was in the process of invading Russia.)  Pierre then manipulates his own name with various honorifics and misspellings to reach the same sum.  The page looks like this (my copy, my fingers) -- you can see the chart of letters corresponding to numbers at the top  (it is not necessary to read this page to get the punch line here):

At the bottom you see the three dots, indicating that this passage has concluded.

I turned the page.

This is the first thing I see.

I thought sure the internet would yield up some commentary on this somewhere, but I haven't been able to find any, perhaps because surely this coincidence -- that is how I regard it -- is limited to the original 2007 Knopf publication of the Pevear/Volokhonsky translation (this one happens to be from the fourth printing).  

I'll check the Knopf paperback next time I'm at Barnes & Noble.  If you have noticed this, leave me a note or email per below.

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Some Early Thoughts on the Reopening

I'm trying to work through the implications of easing of the shutdown, which easing appears to be coming, whether through government edict or growing civil disobedience. I need the more epidemiologically inclined among us to help me out here, but I keep coming back to this train of thought:

(1)  The Contagion is still active among us.  Still out there infecting people as it always has.  (I learned of my first "positive" acquaintance yesterday; he's fine and over it after self-quarantining.  He reported it was like "a bad flu.")

(2)  The shutdown and enforced social distancing have been effective in keeping the mortality rate lower than it would have been without those rules.

(3)  With restrictions loosened, the death rate will increase, if not "spike."

(4)  In fact, depending on how much reopening takes place, we will be returning to a civil order in which the death rate will approach what it would have been had there been no loosening to begin with. That is, since we are assuming The Contagion is still active, people will be exposed to the same degree as they would have been had there been no shutdown.

(5)  Which means that leaders and citizens are willing to tolerate the increased number of deaths and the risk to themselves in order to get their lives, and society's general health, back to something approaching what they were before the shutdown.

(6)  Which in turn suggests that the shutdown accomplished little or nothing and was almost solely destructive.  Put another way:  If The Contagion returns with anything like its initial ferocity, then the only difference between not shutting down early and reopening now is that in the meantime we severely damaged the economy and suffered the many other ills identified with social isolation.

What would make this analysis wrong is if the prophylactics of the past couple of months make it far less likely that deaths will increase to the level they would have reached without them. I haven't seen a suggestion of this anywhere, but one can envision a way that this could be the case. Perhaps, for example, it has forestalled deaths while progress has been made toward a vaccine/cure and that "flattening the curve" for this period of time (if that has in fact been its benefit) will result in fewer deaths in the long run. Again, I have not seen this as a justification for the shutdown, but it's possible; if the shutdown will have materially decreased total deaths by the time this has passed, then the foregoing chain of reasoning is weakened.

This train of thought also may wrongly assume that the loosening will return us all the way to pre-loosening freedom. If loosening is not total, deaths may not return to the "worst-case" non-loosening levels, but will increase to some material degree. So even if the analysis  overstates the danger for this second reason, it still suggests that the shutdown was too severe because it did not sensibly balance the economy/social order and the mortality rate; we're willing to tolerate some trade-off.

I concede there is some unfairness in this line of thinking.  We were uncertain of the lethality of The Contagion, so it is difficult to blame policymakers for acting decisively to be on the safe side. But at least based on what we know about decisionmaking in this case (which, of course, may be quite incomplete), this kind of balancing wasn't even considered by policymakers. Radical prevention entirely supplanted intensive fact gathering that might have permitted the kind balancing we are apparently now willing to undertake.

*     *     *

A final toss-off thought:  If the majority of the population accepts the new freedom/death rate trade-offs that loosening represents, whom does it help in November? There seems to be a right/left divide emerging on the issue of economy rescue versus every-life-worth-every-sacrifice. Depending on how it's handled by both federal and state officials, and assuming the spike in deaths is not too horrifying, I think it helps Trump and Republicans.

Perhaps not much, and perhaps not enough to preserve Trump's incumbency.  But that's a topic for an upcoming column.


*     *     *


I welcome correction on any of the medical or epidemiological errors in the foregoing.  I would love to publicize anything that points to a less gloomy conclusion on (1) what will happen to the death rate on reopening and (2) whether the shutdown will have accomplished anything if reopening results in a material increase in deaths.

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I'm More Confused Than Usual

The Contagion death rate is underreported because of inconsistent and incomplete reportage and lack of resources.

*     *     *

The Contagion death rate is overreported because bureaucrats are requiring coroners to list COVID-19 as the cause of death for almost any pneumonia-related fatality.

*     *     *

We should be able to start loosening some of the restrictions on social activities by the end of the month, at least in certain areas.

*     *     *

The lockdown could and should last for months.  Loosening it now would spark a renewed outbreak.

*     *     *

The enormous burden of The Contagion is wrecking the healthcare system, overworking healthcare workers and exposing our lack of hospital beds and respirators.

*     *     *

With the exception of a few hotspots, the healthcare system is managing pretty well, and, as has been the case for awhile, the biggest problem hospitals are having is too many empty beds.

*     *     *

Politicians' responses in ordering shutdowns and requiring self-isolation have, in general, been altruistic and effective in keeping the death rate far lower than initial estimates.

*     *     *

Politicians are using The Contagion opportunistically to impose coercive restrictions on economic activity and personal freedom in order to advance their own leftist collectivist agenda and their personal power.

*     *     *

We don't have enough respirators.

*     *     *

With the exception of the very, very sickest patients, a respirator is one of the worst things you can do for a Contagion victim.  What they really need is oxygenated blood.

*     *     *

Boris Johnson is "at death's door."

*     *     *

Boris Johnson has been sent home, testing negative.

*     *     *

Chloroquine and hydroxychloroquine antimalarial drugs  are proving very effective against The Contagion.

*     *     *

It is dangerous to begin widespread use of these drugs for both safety and efficacy reasons, and because the proper testing has not been done.

*      *     *

Companies are making remarkable progress in identifying promising vaccines. 

*     *     *

Not nearly remarkable enough to keep us from killing civil society while we wait.

*     *     *

Flattening the curve was worth the enormous damage to the economy.  You can't put a dollar value on human life.  The market doesn't work in situations like this.

*     *     *

No, it wasn't, and yes, you can.  We do it all the time in allocating resources and engaging in unpredictably risky social interactions.

*     *     * 

If you've had it, you're immune.

*     *     *

If you've had it, you're not immune.

*     *     *

In an interview email, the Pope stated that The Contagion is "nature's response" to humans ignoring the ecological crisis.

*     *     *

No word on God's response.

*     *     *

The Contagion will permanently alter our way of living.  People will become accustomed to solitude, doing without, working away from traditional offices, spending less, saving more, home schooling.

*     *     *

Lifestyle changes will vanish when restrictions are lifted.  The economy will boom with pent-up demand and people's normal appetites.  The longing for personal contact will return after a short period of readjustment.

 *     *     *

Masks are highly effective in preventive the spread of The Contagion.

*     *     *

Masks are all but useless.  Just keep washing your hands and stop picking your nose.

 *     *     *

The Chinese Communist Party is largely to blame for the worldwide pandemic.

*     *     *

Bats and pangolins.  Pure coincidence they were in China at the time.

*     *     *

People are stupid to hoard toilet paper.

*     *     *

What do you expect when you make people defecate solely at home for months at a time?

*     *     * 

The Contagion will be a boon to the Green and Climate Change movements because it demonstrates the world's susceptibility to catastrophic natural events and vindicates the value of expert analysis and powerful central governments.

*     *     *

The Contagion will make the Green and Climate Change movements look ridiculous because expert forecasts were so wildly wrong and the economy-killing cure imposed by bureaucrats and politicians was worse than the disease of increased, but not limitless, deaths.

  *     *     * 

Trump's approval rating has increased since the onset of The Contagion.  His response was timely enough under the facts as we knew them at the time, and appropriate since the seriousness of the situation became apparent.  He has shown leadership with his initiatives and especially his outreach to other world leaders.

*     *     *

Trump's approval rating has declined since the onset of the coronavirus.  His press conferences have been foolishly optimistic and at odds with his own experts.   Having portrayed himself as a boorish bully for three-and-a-half years, his attempts at empathy ring hollow.

*     *     *

Joseph Biden is unelectable because he is obviously unwell with age-related issues and The Contagion has effectively halted his campaign.  His appearances have been pathetic and his Contagion response insipid.   The Democrats are desperate to replace him with someone electable.

*     *     *

President Biden. 

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Some Further Fatuities on the Response to The Contagion

(For previous fatuities, see https://cool-hot-center.blogspot.com/2020/03/a-few-fatuous-notes-from-congation.html)

I will here describe a way of thinking about the response to CV-19 that much smarter and more knowledgeable scientists, doctors, actuaries, economists, statisticians, and politicians – and, I suggest, philosophers – might at least be thinking about thinking.  (Not to distance myself too obviously from what follows.)

Assumption #1:  It is tragic when people die and more tragic when they die before they should actuarially be expected to – for example, from a novel virus for which there is no vaccine or cure.  The strain on the healthcare system itself risks deaths from other causes for which treatment is unavailable owing to the crush of CV-19 cases.

Assumption #2:  It is also tragic, and can lead to fatalities of its own, when the leading economic power in the world is thrown into an artificial depression with misery for millions and no real strategy in sight to lift it.  The deprivation and unrest are themselves horrors, and just as unjust.

Assignment:  What level of death can we tolerate to avoid economic catastrophe?*

*  I will assume for the time being that an illness not resulting in death in the usual case would not have produced the current lockdown, although given the media’s panicked reporting, I’m not entirely sure about that.  So I will focus on deaths while understanding that non-fatal infections also cause pain to victims and the healthcare system.

To ask the question may seem cold-blooded.  Assumption #2 contains the subassumption that the damage to the economy and the population at large from a near-full shutdown of indefinite duration, which is where we seem to be heading at this writing, would be catastrophic:  At a minimum a classic deep depression, this time around possibly accompanied by social unrest and even violence in a population unaccustomed to privation and full of confidence about its "rights."  Is this assumption correct?  If it is not, you may stop reading now.   There is at least the strong possibility that the currently contemplated measures would yield a national condition that is itself very bad, so bad that it is at least worth thinking about how it balances with the deaths to be expected from the contagion.  So let’s think about it.

As of today, the numbers provided by reputable websites (Johns Hopkins among them) yield about the same U.S. death rate:  2.7% (8,098/297,575).  For seasonal flu, it is much less than 1%.  Worldwide, the CV-19 death rate is about 5.4%, depending on what you think about the accuracy of foreign (e.g., Chinese) reporting.

The R0 (number of persons estimated to be infected by an infected person) is unknown with precision, but since it is certainly greater than 1, the disease can be expected to spread – it won’t die out naturally.  The number most recently seen is about 2.5, which is higher than regular flu.  The thing is highly infectious; it isn’t going to go away on its own, and it is more lethal than regular flu.

Current forecasts of deaths in the United States under these circumstances vary.  In February, the Centers for Disease Control ran a series of scenarios and came up with an unhelpful estimate of from 200,000 to 1.7 million deaths.*  The same article quotes another expert as estimating 480,000 deaths. 

*  https://www.nytimes.com/2020/03/13/us/coronavirus-deaths-estimate.html; March 13, 2020.

It is hard to know what to make of these estimates.  “At the outset of the H1N1 swine flu outbreak in 2009, President Obama’s Council of Advisors on Science and Technology predicted that the virus would result in 900,000 to 1.8 million hospitalizations and 30,000 to 90,000 deaths. Actual figures a year later were to be 274,000 hospitalizations and 12,000 deaths.”

*  https://thehill.com/opinion/healthcare/488494-estimating-coronaviruss-us-toll; March 19, 2020.  This article estimates far fewer deaths.  

Which is what makes essays like this fatuous.  I have no idea how many U.S. deaths to expect.  A lot.  And a crushing burden to the healthcare system.

It is no comfort to compare The Contagion to seasonal flu.  The sites I have visited estimate this year’s influenza A and B death toll to be anywhere from the low- to mid-five figures.  And the health system is already equipped to handle those.

At first blush, one might conclude:  Based on current estimates and our current understanding of the disease, CV-19 is much more deadly than seasonal flu and justifies the economy-depressing measures being taken.

But let’s come at this from a slightly different angle.  Consider the infection rates upon which the worst-case scenarios are based – the ones that have stopped us all down:  Those February CDC scenarios I cited above assume the infection of between 160 to 214 million people.  (Fatuity alert:  I don’t know if those numbers take any degree of any of the current preventive measures into account.)  The current population of the U.S. is 330 million.  The estimate assumes that half to about 65% of the citizenry will be infected.  According to an article posted a couple of days ago reporting on a late-March article from Lancet Infectious Diseases, the infection rate is about 50% (again, effects of prophylactic measures unknown).

*  https://reason.com/2020/04/03/what-percentage-of-covid-19-patients-are-likely-to-die/; April 3, 2020.

Which would lead me to ask the experts I assembled in the first paragraph of this essay the following question:  How would the infection rate differ if we (1) had no restrictions of any kind in place, or (2) allowed a substantial but not total resumption of normal economic activity?  Would it be a whole lot worse than 50-65%?  

The question is:  Would it be so much worse that the increase in deaths justifies the shutdown of the American economy with its attendant miseries, including health-related problems, possible civil unrest, and, quite probably, an increase in non-CV-19 deaths?*

*  I won’t get into the question of who is most at risk here – who is more likely to die.  I’m assuming that the lives of elderly and health-compromised persons who are at greater risk are of equal value to those of younger or healthy persons (who are at some risk themselves).

The revival of the economy would not have to be total.  Here’s a suggested half-measure program:

• Keep schools closed.
• Maintain the moratorium on organized sporting activities, including professional sports.
• Maintain a moratorium on stadium-auditorium-theater entertainment.
• Permit all other economic activity, including restaurants, and all retail, all manufacturing, supply, and service activity; that is, it is voluntary.
• Where feasible, require social distancing as many grocery stores are now doing.
• Require masking for certain activities, perhaps most activities; perhaps something close to all-mask-all-the-time when one leaves one’s residence  for any purpose (you can unmask to eat), including employment.
• Pass laws necessary to assure that all persons who do not self-quarantine, and all persons choosing to work for employers that choose to do business, assume the risk of infection; that is, all civil liability for transmitting the disease is eliminated except for intentional transmission.  I would also protect employers and merchants from civil rights suits for excluding symptomatic persons from the workplace or establishments (unless pretextual to disguise forbidden discrimination).
  

The analysis becomes, crudely: 

Projected infection rate from liberalization of economic activity minus current infection rate, times 330 million, times 2.5% = estimated number of additional deaths.  Crudely, because, among many other imponderables, that 2.5% might go up as the strain on the healthcare system increases.

But you’re not done, because you have to assume that the vast depression that would result from the full-measure shutdown would cause a certain number of deaths that will now be avoided.

But you’re still not done, because the revival of the economy (to the extent permitted with the foregoing half-measure proposal) will bring with it other benefits:  economical, psychological, governmental, hedonic, maybe even spiritual, while we all take a deep breath and gut out the higher mortality rate from CV-19 during the half-measure phase. (And don't forget that we need to check the assumption that a shutdown would be the disaster I'm assuming.)*

*  Remember:  all models are suspect.  Dr. Fauci:  "There are things called models, and when someone creates a model, they put in various assumptions. And the model is only as good and as accurate as your assumptions," he said. "And whenever the modelers come in, they give a worst-case scenario and a best-case scenario. Generally, the reality is somewhere in the middle. I've never seen a model of the diseases that I've dealt with where the worst-case scenario actually came out. They always overshoot."

So if you are thinking carefully about the full shutdown that seems to be approaching, you are comparing:

a numerically large, percentage-wise small, number of human lives

     with

certain hardship, sometimes severe, sometimes fatal, for close to 100% of millions that will likely outlast the pandemic. 

I state that prejudicially, but I acknowledge that it is a very hard choice because human life is very, very valuable.  But the choice should be considered.  As noted, people much smarter and better-informed and devoted than I sitting in my compression shorts and rash shirt for a few hours on a Saturday afternoon might usefully do the arithmetic and sound much less fatuous reporting on it.    

And, by the way, if my numbers are wrong -- what are the right ones?  If the current projections are not as dire as reported, then how less dire are they, and how does that change the lockdown analysis?  If the infection rate is more dire, doesn't that shift the analysis toward easing, rather than intensifying, the lockdown?  Whatever the numbers are, the question remains the same:  Is the death-delta from coercive-lockdown versus something-considerably-less-than-coercive-lockdown an acceptable price for the potentially huge damage to the economy and social order?

Too cold-blooded for you?   Come see me in a month.  If you can find a sitter.

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