At Politico John F. Harris muses over a “backlash” that may emerge over the “stay at home” directives. Much of the piece consists of chortling about supposed discomfiture of Rand Paul in contracting the virus but he then turns to more substantive observations:
Now that Paul has recovered—he says he felt fine and symptom-free the whole time—it is a good time to ask: Are we sure that the pandemic joke will ultimately be on him?
What if the opposite is true? Far from rendering Paul’s brand of politics irrelevant, it seems possible, even probable, that the wake of the coronavirus will be a powerful boost to the animating spirt of libertarianism: Leave me alone.
Among the questions looming over American politics is about the nature of what promise to be multiple backlashes over different dimensions of the coronavirus crisis. Most obvious is what price Trump pays for his administration’s tardiness in responding to the contagion in its early stages. Less obvious is what price supporters of activist government pay for the most astounding and disruptive intervention in the everyday life of the nation since World War II.
The imminent libertarian surge is not a sure thing but it more than a hunch. In informal conversations, one hears the sentiment even from people I know to be fundamentally progressive and inclined to defer to whatever health officials say is responsible and necessary to mitigate the worst effects of coronavirus. It is possible both to support the shutdown and powerfully resent it — the draconian nature of the response, and the widespread perception that to voice skepticism of any aspect of its necessity is outside respectable bounds.
The absolutist nature of the country’s shutdown and the economic rescue package have democratic consent—enacted by a bipartisan roster of governors and overwhelming votes in Congress—but it was the kind of consent achieved by warning would-be dissenters, Are you serious? There is no choice!
Many people concluded that for now there is nothing to do but suck it up. It won’t be surprising if some of those people eventually have an intense desire to spit out.
If so, this would be entirely consistent with the history of crises, both recent ones and more distant. Very often, after some cataclysmic external event, politics responds in ways that scramble normal divisions and create the impression—as in that recent 96-0 vote—that familiar ideological dynamics have been suspended.
Almost always, this is an illusion. Ideology hasn’t been suspended. It has been forcibly suppressed—in ways that inevitably will come roaring back, sometimes in highly toxic ways.
He then turns to a comparison I think is completely specious:
The most vivid example in American history likely was around World War II. As the world was aflame, but the United States not yet engaged in hostilities, the country was bitterly and intensely divided over the all-consuming question of that era: intervention or isolation. Then came Pearl Harbor, and the debate ended in an instant. Isolationism looked to be a defunct ideological force. Except it wasn’t really. The movement’s essential spirit—fear of corrupt and scheming interests beyond American borders—found new and malicious expression in McCarthyism in the late 1940s and early 1950s.
That’s basically nonsense or else he’s using an eccentric definition of “isolationism” to mean, presumably, “beliefs held by people I don’t like”. The attack on Pearl Harbor killed isolationism as a political force in the U. S. There was more than one kind of isolationism (basically Jacksonian and Jeffersonian) and all varieties have largely been silenced as a consequence of the attack. The U. S. could no longer shut itself off from the rest of the world and there was a fear that the Atlantic and Pacific could no longer protect the U. S. mainland. That and the American Civil War are the sources of our present trigger-happiness. We do not want to fight a war within our borders and have decided that the best way to prevent that is to ensure that wars that start elsewhere end elsewhere as well.
It is not isolationist to think that when a foreign power has infiltrated not just your government but many other of your institutions as well that something should be done about it. But Joe McCarthy was no libertarian and conflating him with libertarians as this article does is not constructive.
IMO the longer, the stricter, and the more hypocritical “shelter in place” directives are, the greater the chafing against them will become. The scene yesterday in Lansing, Michigan was a mild preview of what is to come.
What do I mean by “hypocritical”? Chicago Mayor Lori Lightfoot was called out, embarrassingly, on having her hair done. She blurted out a feeble explanation of being the “face of Chicago” which I guess was better than “Suck it up, peasants” but everybody knew that’s what she meant. Police officers not following “social distancing” guidelines or facemask directives are other examples. You can’t make one set of rules for politicians and public employees and another for everybody else.
Arbitrary determinations of what are or are not essential businesses are problematic as well. Here lawn services are on the list of “essential businesses”. ‘Splain me, Lucy. Are clothing stores that sell candy bars at their sales counters essential while those that do not aren’t?
I continue to hear claims about “bending the curve” but still see that as mostly wishful thinking. Consider this graph from the Illinois Department of Public Health:
Each succeeding bar of that columnar bar chart is taller by a few than the preceding. That is not “bending the curve” and the state has had a “stay at home” directive in place for nearly a month now.
If “stay at home” directives remain in place long enough, they will inevitably disrupt the food supply chain and elected officials will have much, much more to worry about than not overloading the health care system.
Positive tests arent the best metric. How are admissions? We are still having trouble finding test supplies so if Illinois has the same issue and then they intermittently have enough, you may be looking at test supply metrics not actually increasing numbers of patients.
Steve
I thought the curve in bending the curve is number of new cases per day — not the total cumulative number of cases.
Anyway, the strategy is not “bending the curve†— where you have the same number of cases but stretched out over a period of time. The strategy is suppression, as in shrink the area under the curve.
That’s right. The number of new cases per day has actually increased every day. Here’s the link to the actual page.
Unfortunately, granular data on admissions is not available. I’m not sure what that would tell us anyway. Changes in policy from day to day could have as much to do with admissions as “bending the curve”.
“Changes in policy from day to day”
What would those be? Maybe medicine is practiced differently there. Admission is a clinical decision. I follow those plus ICU admissions. Much more objective and not so dependent upon testing. No blood pressure, low O2Sats you go to ICU regardless of test status (unless you are DNR, refuse, etc).
Steve
The devil is in the reporting. What is proportion of positive tests versus hospital admissions? Is the graph showing positive tests rather than actual cases? The only hard numbers I even halfway trust are actual admissions and deaths, and the way New York seems to be going (recategorizing cases retroactively) makes me not trust even them.
Steve, you seem to be doing it right, taking care of the patients first and worrying about the reporting afterwards. Others might not be so scrupulous, especially since there seems to be a financial interest in inflating Kung Flu admissions as much as possible.
If you feel I’m being too critical and cynical about your profession, I don’t think its the actual doctors who would be adjusting the numbers, I would point my fingers at administration instead. I hope you get your PPE and medicinal shortages soon.
“Much more objective and not so dependent upon testing. No blood pressure, low O2Sats you go to ICU regardless of test status…”
Heh. A point I made in a gentile (snicker) fashion a couple weeks ago. (but was ignored, because testing was the darling issue of the day) I think my phrasing was “test your asses off, but doctors are going to make decisions based upon patient presentation and clinical judgment.” Since I have no doubt steve is a competent physician I also have no doubt he would, for example, dictate off to the ICU with O2 numbers in the (mid?) 80’s. Worry about tests later.
We need tests to get the mortality rate statistic right, not make hospitalization decisions. Further, perhaps (perhaps) testing could identify “hot spots” and cause quarantine measures to be taken, or identify people in workplaces who need to be quarantined. But I think that’s dubious. Unless the test is fast and accurate I doubt you are accomplishing much.
“…the strategy is not “bending the curve†— where you have the same number of cases but stretched out over a period of time. The strategy is suppression, as in shrink the area under the curve.”
I’m not sure that’s true. Throttling down the curve is really a strategy to not overwhelm health care resources. And perhaps draw out total infections until vaccines and treatments can be developed. We haven’t been good at that strategy See: NYC or other major metro areas or sites where vulnerables exist, like nursing homes. And vaccines and treatments are an open issue. The total area under the curve may not be materially different at the end of the day whether you lock down early and completely, or draw it out. The costs are vastly different.
Hard to say since it would vary from institution to institution. Let me just suggest a few realities.
Every individual in an organization makes policy. How much varies from organization to organization. Medicine is a combination of art and science. If it were not, doctors would be unnecessary. And the first patient seriously ill with COVID-`19 will look different to a treating physician than the nth. Combine those three and there will, in fact, be changes in policy from day to day. When you’re trying to measure very small changes, that’s all it takes.
Maybe it is my eyes, but each bar in the graph is showing the cumulative # of positive tests up to that day.
From the graph, it looks like the # of positive results per day is ~1-1.5k, which is stable. If it is not an artifact of not running enough tests — the stability is an indication the curve is flattened, albeit at a very high level.
Sort of my point. Stability is not nearly enough. If the number of cases remains stable for a month, the “stay at home” directives might not be lifted until August.
Here’s the change in the number of cases by day over the last week:
Is there a trend? Or is there variability in reporting?
If the accumulated number of cases is logistic, then IL might have passed the inflection point, which suggests the grand total will peak out at about 50,000 to 60,000. The end might be in six weeks or so.
For some reason, Ohio is only experiencing one-third the cases that IL has, today’s total being about 8,400. We also might have passed the inflection point.
That’s the number of tests performed (5-8K / day). Positive tests were 1-1.5K / day.
It is not unexpected. Seattle has averaged 100-200 positive tests / day since 3/20 with perhaps a slight downward trend in the last week. Italy / Spain cases per day are also going down slowly.
I take it as evidence the “lockdown” can reduce the virus’s “R” to slightly below 1. But to really get the outbreak under control you need to move “R” far below 1, ideally below 0.5.
A Harvard professor actually wrote a paper explaining why a lockdown only brings R down to 1.
https://www.hsph.harvard.edu/biostatistics/2020/03/watch-xihong-lins-webinar-on-covid-19-research/ –> view updated slides (esp slides 32-49)
I know Ms. Lin relies a lot of data from China, and there are reasons to be skeptical — but South Korea / Hong Kong also utilize “centralized quarantine” (Hong Kong used it for SARS as well). The Aussie’s are also utilizing it now; they call it out of home quarantine.
PS. If the lockdowns last until August, then many businesses will close permanently, and their jobs will be lost. Then the Second Depression will really set in, and it will be long-lasting. Some people are suggesting a relaxation of the lockdowns in early May. We had better hope and pray that is possible.
“Medicine is a combination of art and science. If it were not, doctors would be unnecessary.”
I’ve always thought that medicine was functionally very similar to intelligence analysis – I could change the titles around and make your paragraph apply just as well to my former profession.
@Bob Sykes, 80% of the confirmed cases in Illinois are in the Illinois portion of the Chicago MSA, which has 63% of the state’s population. I don’t think Ohio has anything comparable to Chicago’s density, but on the other hand, the rest of Illinois doesn’t have anything comparable to Cincinnati, Columbus or Cleveland, or even Dayton, Akron or Toledo. The Illinois portion of the St. Louis metro has 5% of the state’s population and 2% of the confirmed cases.
” I also have no doubt he would, for example, dictate off to the ICU with O2 numbers in the (mid?) 80’s.”
Depends upon the patient. A lot of pts with bad COPD live in the low to mid 80s. Their oxyhemoglobin dissociation curve shifts so that deliver more O2 to the tissues with that lower O2Sat so they do OK. This is what we see with chronic changes and the body has time to adapt. These people live at home like that and dont need an ICU.
These patients are different. Younger pts, occasionally an older one also, tolerate pretty acute drops in O2Sats without immediately crumping. They act more like chronic lungers. So, we have been tolerating lower O2Sats for longer in these people than we would normally, trying to keep them off vents. We were prepared for this because we had talked with the Italian ICU guys. I will say it is a bit odd to talk with someone whose sats are in the 60s and doesn’t have chronic lung disease. Usually someone with a sat that low isn’t talking with you. They can be pretty lucid. However they are also usually pretty tachypneic, or at least the ones I know about. Folks in NYC who took care of a lot more than we did might have seen something else. Anyway, no one can sustain a really high respiratory late for very long so unless we can get the sat up we do end up intubating them.
“We need tests to get the mortality rate statistic right, not make hospitalization decisions.”
We also need them for treatment decisions. Not every pt with a cough and fever has Covid. People can have other pneumonias. Chest CT is not reliable. It also helps to be sure since we can potentially use less PPE.
BTW, we are still short on testing materials in our area.
Steve
LOL Thanks for the tutorial, steve. You understand my point. If you, as the physician, look at, for example, blood O2 numbers and given the patient specific variables you cite, make the decision to go ICU, you ain’t waiting for corona tests. You know that patient has a problem……now.
Shorter: there is no substitute in acute care for experience and judgment. Tests can become a nice to have.
Sorry for that. They took away the med students so I don’t have anyone to pontificate in front of anymore, plus I do like what I do for a living most of the time. Once a geek always a geek.
Steve
Steve,
Is there an association here with Pneumonia?
Just anecdotal, but since this epidemic started my brother and closest friend developed bacterial pneumonia. Both tested negative for Covid and neither has been this sick in decades. Probably just a coincidence, but the congruence just seems odd.
Andy- Not that I am aware of, but dont think anyone has looked at it if I am understanding what you mean. We have seen people with another pneumonia who also had Covid but I haven’t seen anyone report a series on this yet. (They could have. I dont read everything but at least it isn’t being talked about much if there is one.) Did see a claim somewhere that Pneumovax does not lessen risk of Covid. Sorry that does help much.
Steve
Thanks Steve, that’s kind of what I figured. It just seemed weird that two very healthy people I know suddenly got a bad pneumonia right in the middle of the Covid pandemic.