Believe it or not there are things going on in the world other than COVID-19. For example, NPR reports that the U. S. Department of Justice has filed charge against Venezuelan President Nicolás Maduro for drug trafficking.

That raises a big red flag for me. Does it mean we’re going to invade?

Every morning after I rise (actually after I have my first meeting at 6:30am) I turn to the opinion pages of the New York Times, Washington Post, and the Wall Street Journal. This morning was much like other mornings. I was treated to a torrent of opinion pieces in the NYT and WaPo focusing on how everything was Trump’s fault.

Guys, it isn’t working. This morning President Trump’s approval rating is the highest of his presidency (47%) and his disapproval rating the lowest of his presidency (49.5%). You read that right. His disapproval rating is below 50%. Let me offer a prediction. If President Trump’s approval rating as reported by the RealClearPolitics Average is over 50% on election day, he will be re-elected.

I have a suggestion to offer to the editors and columnists of the NYT and WaPo and, indeed, to Democrats more generally. Declare a hudna. A ceasefire. It doesn’t make any difference if you’re right. Searching for the anti-Trump angle on every story isn’t working.

In his WSJ column Walter Russel Mead is on much the same page:

This is not what his critics expected. At 49% overall job approval in the latest Gallup poll, and with 60% approval of the way he is handling the coronavirus epidemic, President Trump’s standing with voters has improved even as the country closed down and the stock market underwent a historic meltdown. That may change as this unpredictable crisis develops, but bitter and often justified criticism of Mr. Trump’s decision making in the early months of the pandemic has so far failed to break the bond between the 45th president and his political base.

One reason Mr. Trump’s opponents have had such a hard time damaging his connection with voters is that they still don’t understand why so many Americans want a wrecking-ball presidency. Beyond attributing Mr. Trump’s support to a mix of racism, religious fundamentalism and profound ignorance, the president’s establishment opponents in both parties have yet to grasp the depth and intensity of the populist energy that animates his base and the Bernie Sanders movement.

The sheer number of voters in open political rebellion against centrist politics is remarkable. Adding the Sanders base (36% of the Democratic vote in the latest Real Clear Politics poll average, or roughly 13% of the national vote considering that about 45% of voters lean Democratic) to the core Trump base of roughly 42%, and around 55% of U.S. voters now support politicians who openly despise the central assumptions of the political establishment.

That a majority of the electorate is this deeply alienated from the establishment can’t be dismissed as bigotry and ignorance. There are solid and serious grounds for doubting the competence and wisdom of America’s self-proclaimed expert class. What is so intelligent and enlightened, populists ask, about a foreign-policy establishment that failed to perceive that U.S. trade policies were promoting the rise of a hostile Communist superpower with the ability to disrupt supplies of essential goods in a national emergency? What competence have the military and political establishments shown in almost two decades of tactical success and strategic impotence in Afghanistan? What came of that intervention in Libya? What was the net result of all the fine talk in the Bush and Obama administrations about building democracy in the Middle East?

On domestic policy, the criticism is equally trenchant and deeply felt. Many voters believe that the U.S. establishment has produced a health-care system that is neither affordable nor universal. Higher education saddles students with increasing debt while leaving many graduates woefully unprepared for good jobs in the real world. The centrist establishment has amassed unprecedented deficits without keeping roads, bridges and pipes in good repair. It has weighed down cities and states with unmanageable levels of pension debt.

While I agree both with Trump supporters and with Sanders supporters that we have deep, systemic problems, my preferred solutions aren’t the same as either. I think we need reform not revolution and we should start with boring, non-sexy stuff like civil service reform. State socialism, the preference of the Sanders supporters, is a losing proposition, particularly in a country with low social cohesion like the United States. It will inevitably lead to more government corruption.

Anarcho-capitalism is no solution, either. Too many people would be left behind. IMO what we really need is a return to the fundamentals of the American creed which include subsidiarity.

Right now the best thing the editors of the NYT and WaPo could do is to start celebrating the good. Identify what’s working and praise it. Don’t make every story a Trump hit piece. Or a puff piece on Nancy Pelosi.

You may recall that yesterday we were discussing the reasons that we don’t have as many hospital beds as might otherwise be the case. Reasons proposed included that they weren’t necessary, the increasing move to outpatient procedures, certificates of need, and other factors. This morning the editors of the Wall Street Journal have another culprit in mind affecting New York State in particular—low Medicaid reimbursement rates:

Twenty some hospitals have closed in New York City alone over the last two decades, most located in low-income communities. Statewide the number of hospital beds per-capita has fallen by 13% since 2010, according to the Kaiser Family Foundation. The number of beds across the U.S has also decreased due to declining demand as care has shifted to lower-cost outpatient centers. But New York hospitals have been closing due to financial duress amid increasing demand by low-income patients.

Blame New York’s miserly Medicaid program, which reimburses providers far below the cost of care. Physicians are on average compensated at 56% of what Medicare pays—the fourth lowest in the country after Rhode Island, New Jersey and California—and Medicare also pays below cost. Hospitals typically make up for paltry government payments by charging privately insured patients more, but hospitals that treat mostly Medicaid and Medicare patients don’t have this option.

Many doctors in New York also don’t accept Medicaid patients because of low payment rates, so low-income folks stream to emergency rooms when they’re sick. This has caused a financial contagion among hospitals. When one closes, patients flock to others nearby and increase their financial strain.

Recall how Democrats claimed that expanding Medicaid under the Affordable Care Act to individuals up to 133% of the poverty line would reduce emergency-room visits. This hasn’t happened. Emergency-room visits per capita in New York have ticked up 3% since the ACA expansion took effect in 2014 and 7% since 2010.

While expanding Medicaid enrollment, Mr. Cuomo in 2014 sought to rationalize costs with an $8 billion federal grant for putative payment reforms aimed at reducing ER visits. “Will it mean some hospital beds are reduced?” Mr. Cuomo said at the time. “Yes, because that is the point of the exercise. You will have a decrease in beds.”

I cannot testify as to the veracity of this claim. I also have some problems with how they’re framing the issue in particular because most of the costs in health care are wages and I don’t believe you can have a market in health care services as long as 60% of the freight is borne by Medicare, Medicaid, and other federal, state, or local government programs.

I’m just passing this along as more fuel for the fire.

You might find this report from a Swiss physician about the situation in Italy interesting. I cannot confirm its veracity. Here’s a snippet:

According to the latest data of the Italian National Health Institute ISS, the average age of the positively-tested deceased in Italy is currently about 81 years. 10% of the deceased are over 90 years old. 90% of the deceased are over 70 years old.

80% of the deceased had suffered from two or more chronic diseases. 50% of the deceased had suffered from three or more chronic diseases. The chronic diseases include in particular cardiovascular problems, diabetes, respiratory problems and cancer.

Less than 1% of the deceased were healthy persons, i.e. persons without pre-existing chronic diseases. Only about 30% of the deceased are women.

The Italian Institute of Health moreover distinguishes between those who died from the coronavirus and those who died with the coronavirus. In many cases it is not yet clear whether the persons died from the virus or from their pre-existing chronic diseases or from a combination of both.

The two Italians deceased under 40 years of age (both 39 years old) were a cancer patient and a diabetes patient with additional complications. In these cases, too, the exact cause of death was not yet clear (i.e. if from the virus or from their pre-existing diseases).

You might also find these snippets from the most recent update interesting:

German immunologist and toxicologist, Professor Stefan Hockertz, explains in a radio interview that Covid19 is no more dangerous than influenza (the flu), but that it is simply observed much more closely. More dangerous than the virus is the fear and panic created by the media and the „authoritarian reaction“ of many governments. Professor Hockertz also notes that most so-called „corona deaths“ have in fact died of other causes while also testing positive for coronaviruses. Hockertz believes that up to ten times more people than reported already had Covid19 but noticed nothing or very little.

and

Using data from the cruise ship Diamond Princess, Stanford Professor John Ioannidis showed that the age-corrected lethality of Covid19 is between 0.025% and 0.625%, i.e. in the range of a strong cold or the flu. Moreover, a Japanese study showed that of all the test-positive passengers, and despite the high average age, 48% remained completely symptom-free; even among the 80-89 year olds 48% remained symptom-free, while among the 70 to 79 year olds it was an astounding 60% that developed no symptoms at all. This again raises the question whether the pre-existing diseases are not perhaps a more important factor than the virus itself. The Italian example has shown that 99% of test-positive deaths had one or more pre-existing conditions, and even among these, only 12% of the death certificates mentioned Covid19 as a causal factor.

Keep calm and carry on.

At the Wall Street Journal Eran Bendavid and Jay Bhattacharya explain why COVID-19 may be a lot less deadly than the present reaction would seem to indicate:

Fear of Covid-19 is based on its high estimated case fatality rate—2% to 4% of people with confirmed Covid-19 have died, according to the World Health Organization and others. So if 100 million Americans ultimately get the disease, two million to four million could die. We believe that estimate is deeply flawed. The true fatality rate is the portion of those infected who die, not the deaths from identified positive cases.

The latter rate is misleading because of selection bias in testing. The degree of bias is uncertain because available data are limited. But it could make the difference between an epidemic that kills 20,000 and one that kills two million. If the number of actual infections is much larger than the number of cases—orders of magnitude larger—then the true fatality rate is much lower as well. That’s not only plausible but likely based on what we know so far.

Population samples from China, Italy, Iceland and the U.S. provide relevant evidence. On or around Jan. 31, countries sent planes to evacuate citizens from Wuhan, China. When those planes landed, the passengers were tested for Covid-19 and quarantined. After 14 days, the percentage who tested positive was 0.9%. If this was the prevalence in the greater Wuhan area on Jan. 31, then, with a population of about 20 million, greater Wuhan had 178,000 infections, about 30-fold more than the number of reported cases. The fatality rate, then, would be at least 10-fold lower than estimates based on reported cases.

Next, the northeastern Italian town of Vò, near the provincial capital of Padua. On March 6, all 3,300 people of Vò were tested, and 90 were positive, a prevalence of 2.7%. Applying that prevalence to the whole province (population 955,000), which had 198 reported cases, suggests there were actually 26,000 infections at that time. That’s more than 130-fold the number of actual reported cases. Since Italy’s case fatality rate of 8% is estimated using the confirmed cases, the real fatality rate could in fact be closer to 0.06%.

In Iceland, deCode Genetics is working with the government to perform widespread testing. In a sample of nearly 2,000 entirely asymptomatic people, researchers estimated disease prevalence of just over 1%. Iceland’s first case was reported on Feb. 28, weeks behind the U.S. It’s plausible that the proportion of the U.S. population that has been infected is double, triple or even 10 times as high as the estimates from Iceland. That also implies a dramatically lower fatality rate.

What all of this tells us is that we just don’t know. Ignore the Chinese statistics. We should treat them a PR rather than a guide for policy. But the findings from Italy and Iceland, in particular, are interesting. A mortality rate of 2% with a prevalence of 1% is more analogous to another seasonal flu than it is to the Black Death.

I want to emphasize three things. First, the purpose of the lockdowns, bans on large gatherings, and so on is not to reduce the number of people who will become infected by COVID-19. It is to pace the number of those who become seriously ill so that they do not overwhelm our health care system. It would be tragically irresponsible if we do not, simultaneous with that attempt, exert at least as much effort to increasing the size of the available resource with all due speed.

We have no reason to believe that COVID-19 won’t be with us forever. It should be obvious that the lockdowns can’t persist forever. What is needed is a modus vivendi with the persistent presence of COVID-19. As I have been pointing out we have lived with diseases that can kill before and we will need to learn to do so again.

Finally, we simply do not know and just “more testing” will not provide us with the knowledge we need. We need well-designed epidemiological testing before we really can understand the scope of what we’re dealing with. Diagnostic testing of individuals who present themselves at the hospital or putative testing centers won’t do that. Such testing would be a good job for the federal government but, if Washington won’t do it, we may be forced to do it ourselves. Maybe some trusted health care organization needs to start a “Go Fund Me”. As G. K. Chesterton observed, there are some things that are too important to be trusted to the state.

As I suggested in the previous post, in this post I’m going to remark on why we don’t have more reserve capacity in hospital beds. I’m open to other suggestions but I suspect one of the causes is the growth of hospital chains. It’s a pretty common story. A hospital chain acquires local hospitals, consolidates facilities, and reduces the total number of beds to reduce cost and increase occupancy. The number of hospital beds relative to the population has been declining for 40 years or more. That does not seem to have had the effect of reducing costs.

You probably won’t be surprised to learn that three of the states with the lowest number of hospital beds per 1,000 population are California, Oregon, and Washington. New York and Illinois are about in the middle of the pack. More here. I haven’t been able to determine the number of beds per 1,000 population in major cities yet. I’ll keep trying. I suspect we’ll learn that New York City and Los Angeles are in worse shape than Chicago but that’s just an instinct.

Another possible factor is the transition from in-patient to out-patient care. That’s a complicated subject, far beyond the scope of a blog post. Sometimes the distinction isn’t that great. I once went to a hospital for outpatient surgery which unbeknownst to me or my wife was revised to inpatient surgery while I was on the table. When I came to I got out of the bed in which I was recovering and went home, to my surgeon’s horror as I later learned.

As with strategic manufacturing I don’t think that the public at large should be underwriting the risks being taken by large companies. A hospital chain with 15 hospitals, cf. here, whether for profit or nonprofit is a big business—revenues of $1 billion or more. Community capacity requirements should be determined and, while one of these big companies should be free to close or consolidate operations, when the capacity falls below the predetermined requirements, they should be taxed for the privilege, the proceeds to be used to maintain capacity outside those systems. We’re presently learning what some of those capacity requirements are.

Mr. “never let a good crisis go to waste” himself, Rahm Emanuel takes to the pages of the Washington Post with an op-ed proposing ways in which we should respond to the crisis presented by COVID-19. I don’t agree completely with his first two ideas (increased public health spending and creating a “surge capacity” in hospital beds) but I do agree with this one:

Third, despite all the double talk coming from the White House, it is clear our strategic supply chain is inadequate. As demonstrated by the frustrating struggle to produce the ventilators, masks and other equipment that health-care workers need in this crisis, we must continue to make investments in re-industrializing the United States. For years, plants and industries have migrated offshore in search of cheaper labor. While diminished trade barriers have played some role in that shift, the search for lower production costs eroded our industrial capacity. We now have technology that allows Americans to compete on price with more distant economies.

I completely agree that companies have a right to seek lower costs for their products, the components they use to assemble their products, or labor anywhere they care to including offshore. I also believe that we should not be dragooned into underwriting the risks they assume by doing it. I also think that companies involved in the production of strategic goods (the list is long—everything from semiconductors to N95 masks) should be taxed for offshoring that production and the money earmarked for domestic production. It is unconscionable for the U. S. to be dependent on China or any other country for memories, for example, but we are.

I’ll dive into the hospital beds issue in a later post.

Every morning I take about a 3 mile walk around the neighborhood with our seven year old female Samoyed, Kara. Over the last week or so we have seen both the auto and foot traffic dwindle. This morning, for example, I only saw three cars and no joggers on our walk. There were very few pedestrians walking, just a few people walking their dogs.

The one thing I did see was a city work crew doing non-emergency work on some of the trees in the neighborhood. They were not observing “social distancing” and, indeed, blocked both the street and the sidewalk so we needed to walk across nearby lawns to maintain the appropriate distance ourselves.

As you can see Gov. Pritkzer continues to give daily press conferences, not not observing “social distancing”. Note, too, that the sign language interpreter repeatedly touched his face. Can he stop short of touching his face without changing the meaning? I don’t know. My point here is not a “gotcha” or claiming hypocrisy but more to point out that what is being advised is difficult.

If city and state employees including the governor himself won’t take the directives the governor has issued seriously, why should Illinoisans more generally?

I agree with Allison Schrager’s assessment from her op-ed in the Wall Street Journal:

Almost everything about the novel coronavirus is uncertain. It was unexpected, though perhaps more of a surprise than it should have been. Public-health experts have been warning for years that a pandemic could happen. But every few years come warnings of potential catastrophes that never seem to materialize.

Among the unknowns about the virus: the true hospitalization and death rates; how infectious it is; how many asymptomatic patients are walking around; how it affects young people; how risk factors vary among different countries with different populations, pollution levels and urban densities. It seems certain the virus will overwhelm hospitals in some places, as it has in China and Italy. We also don’t know how long these extreme economic and social disruptions will last. Without reliable information, predictions are based on incomplete data and heroic assumptions.

This uncertainty makes it much harder to manage the virus, or to strike a balance between public health and the economy. What happened in 1918 or 1957 isn’t particularly instructive. The virus is different. The world is different. So is our health-care system.

The goal should be to move from uncertainty to risk, which will take time and data. The way forward is testing as many people as possible—not only people with symptoms. Some carriers are asymptomatic. California is starting to test asymptomatic young people to learn more about transmission and infection rates. Testing everyone may not be feasible, but regularly testing a random sample of the population would be informative.

This helped in South Korea, which tested thousands of people a day. South Korea has managed to slow the rate of new cases and gather data about how the disease has spread, its effects on different populations, and the mortality rate in that country. More testing would also help spare the world from future shutdowns if the virus reappears before there is a safe, effective vaccine.

Every medical test has some rate of false positives and negatives. The error rate for Covid-19 tests may be especially high. Scientists are still learning about how long the virus lives in the body. Administering tests takes skill and is prone to human error. We don’t know how reliable tests were in China; studies suggest the false-negative rate there is between 3% and 50%—an enormous range. If tests aren’t reliable, the supposed source of certainty can create even more uncertainty. The Food and Drug Administration must balance the urgency for more testing with caution to ensure new tests meet its standards for accuracy.

Policy makers should throw as much energy as possible into getting accurate data. That would allow the world to assess the real risk of the coronavirus. This may lead us to continue to take drastic action to limit its spread, or it may allow us to temper our response, managing the risk at a much lower cost to both society and the economy. Whatever the response, it will be appropriate, based on an assessment of risk—not uncertainty and fear.

What is needed is not just diagnostic testing but epidemiological testing. Right now I believe that most elected officials are acting from political calculus or just plain panic rather than responding to COVID-19. I’m not sure how else you can explain that Illinois is “locked down” (population 12 million/1,200 COVID-19 cases) while Washington State (population 7 million/2,200 COVID-19 cases) is not.