Covid + 7

 It's now been seven months since Mr Covid joined us.  Here are my past pieces and you can read where I was right and wrong.  Current reflections:

1.  I never thought the storm would go on for this long.  Back in February I anticipated it would be bad but over by summer or latest early fall.  To me the lead indicator of how bad it was going to be was that China, which does not place individual health as its highest priority, was willing to take a substantial hit to its top priority, the economy, in order to control Covid.  Now, who knows?

2.  As older folks (though in good health) we are in the more vulnerable category.  It's to our benefit that a lot of younger people get this to develop immunity and break transmission chains, and it is also to our benefit to take reasonable precautions to make we don't get infected but it may be to others benefit that we do. 

3.  Let's be thankful that unlike many other similar pandemics, this is not disproportionately impacting the young.  Better us old folks than them.

4.  Would any other strategy have made for a significant difference for the United States?  As I look at what's happened globally I am more doubtful about this than I was earlier in the year.  And I am speaking of practical measures, not those invented in the public health dreamworld.

5.  People need to stop making premature declarations about winner and losers, particularly claims driven by politics.  As we've seen from the ups and downs and various waves it ain't over until it's over.  We simply don't know what will happen in the next few months and you cannot extrapolate from current conditions.

When the Northeast was hit early in the this, many in the rest of America thought they were handling it better than the Northeast.

When later the Southeast was hit, many blamed state leadership, even though the results (as of now) weren't as bad as the Northeast. 

Maybe now that most states have experienced at least one wave we can get beyond that.

After the Western Europe initial wave crashed and cases were very low in the summer, some people claimed it proved they were handing it better than the U.S., where deaths had declined but were at a relatively high level.  Now Western Europe faces a massive second wave.

Worldometer data for Today:

U.S. (pop. 331 million), 73,000 cases, 959 deaths

Spain, UK, France, Italy, Germany, Belgium, Netherlands (pop. 371 million), 135,000 cases, 783 deaths

 ADDED: Next day data:

U.S.: 79,000 cases, 894 deaths

S,UK, F, I, G, B, N: 141,000 cases, 978 deaths

6.  What is a Covid death?  I've learned there is great variation in how deaths are classified by various countries which makes direct comparisons difficult.  It is also very difficult to get definitive, as opposed to anecdotal, information on this.  From my research, Belgium may have the most expansive definition while the U.S. is relatively liberal in attribution along with a number of other countries.  For some other countries, like Italy and Spain, there have been credible allegations of under counting.  And some countries, like Russia and Iran appear to have pretty restrictive definitions.

Mortality differences between countries are also influenced by demographic and health conditions.  Countries with younger populations will have lower rates (for instance, the states of the Arabian Peninsula have high infection but relatively low mortality) as will healthier populations with less high blood pressure, diabetes and obesity, all conditions that are more prevalent in the U.S. than in many other countries.

This is the current list of countries with death rates in excess of 400 per million.  I picked this because it provides a broad bracket with the U.S. in the middle.  About all I feel comfortable saying right now is all of these countries are in the same ballpark.

U.S.  688

Brazil  732

Spain  738

Argentina  607

France  524

Colombia  581

Peru  1,026

Mexico  676

UK  652

Chile  720

Italy  612

Netherlands  404

Belgium  908

Ecuador  705

Bolivia  730

Panama  599

Sweden  586

Moldova  407

North Macedonia  420

Montenegro  403

There are several other countries currently on track to exceed 400, including Armenia, Iran, Ireland, Romania and South Africa.  Given the extent of the current outbreak in eastern Europe I anticipate several more countries from that region joining the list.  And with the unknowable future course of the pandemic the list could look entirely different in early 2021.

7.  Per capita versus absolute numbers.  I see a lot of this, again often for political purposes when people argue whichever one suits their purpose.  Please stop it.  

Example - India is not on the list above but it has the third highest number of deaths (117,000) and second highest number of cases (8.7 million).  The U.S. has the highest death total but, as you saw above, it is not the highest per capita.

8.  What is happening now?  The entire Western Hemisphere has been hard hit, even Canada which had done fairly well and is seeing a surge.   Western Europe is seeing a huge second wave, and Eastern Europe, which had been relatively insulated earlier is now seeing a major wave.  In contrast the Scandanavian countries have been stable so far.  Things are getting worse more slowly in Russia and the former Soviet Republics.  The Middle East has been seeing many cases for a while with Israel, Iran, Jordan, Lebanon and Iraq having recent surges.

Sub-Saharan Africa has, so far, seen minimal impact with the exception of South Africa.  In South Asia, India faces a full scale pandemic.

9.  I'd like to have more and better information on what the countries that have escaped the worst have been doing.  I am not including isolated islands nations (Australia, New Zealand) or small city states (Hong Kong, Singapore) with conditions difficult to replicate here.  What interests me are places like Uruguay, surrounded by hard hit Brazil and Argentina.  Or Germany which, until recently, had also done much better than its neighbors.  Why has Vietnam, which does not have the most robust public health system, done so well?  

On a related matter, I'd like to know if there are genetic, health, or demographic factors that are playing into the relatively good performance of East Asian nations in addition to their control measures.

10.  Related to #9 is trying to make sense of the Sweden response.  My reading indicates that the measures it took (and didn't take) are is less dramatically different from most countries than either its supporters or detractors claim.  The other thing to note is that, as of today, Sweden's death rate (586) is substantially higher than its neighbors Denmark (120), Norway (51), and Finland (64).  The only thing I know for certain is that we can only draw conclusions when this is over.  It would be premature now.

11.  U.S. pandemic planning was built around an influenza, not coronavirus, outbreak and predicated on an infection with a fatality rate of 10-20%!  We still don't know the ultimate fatality rate for covid-19 but it is substantially less.  As of today the fatality rate per confirmed cases is 2.6%.  However, we know the actual cases are a multiple of that figure so the actual fatality rate is less than 1% and might be as low as 0.15%.  Looking at how we (and the world) have reacted to this I do not think we could, under any circumstances, handle an influenza pandemic of the scope in our planning documents and that is a very, very sobering thought.

12.  This is definitely not the flu (or at least like any flu we've experienced in the U.S. in the past half century).  Before covid I'd never paid any attention to how the CDC developed its estimates for flu cases and death each year.  Now that I have it is clear to me that the deaths are very likely overestimates, so covid is actually worse than it appears from a comparison with the CDC flu estimates.

Covid is also very different in its impact on age groups.  The groups hit hardest by flu are the youngest and the oldest, but as we've seen, covid has much less impact on those under 20 than the flu and may have a slightly less impact on those under 40.  But for populations older than 65 it is much worse.

ADDED: I've also realized the need to be cautious when comparing covid with prior pandemics.  With prior pandemics death and cases are rough estimates while we've never counted any disease in real-time with the specificity with which covid is tracked globally.  Comparisons can be very misleading if not properly caveated.

13.  Treatments are better which is contributing to the lower death rates since April but there is still a lot we don't know about covid transmission, how it acts on the body and any longer term impacts on those infected.

14.  There's been a lot written about herd immunity with some suggesting it may kick it at lower population infection rates than previously postulated.  The verdict it out but it looks to me that the Western Europe resurgence is not a good sign.

15.  The original idea about lockdowns was to implement them for a few weeks to avoid surges and collapse of health care systems.  They have evolved to some extent to be in place until there is a cure for covid-19.  I think this unsustainable the longer the pandemic goes on and the economic, societal, physical, and psychological costs are substantial.

16.  Though I think outcomes would not have been substantially different (the one exception that does come to mind is sending infected patients to nursing homes) most of our leaders and institutions have not come out of this looking good.

- Public health officials told us for the first two months that public wearing of masks was stupid and ineffective and then started calling us stupid if we didn't mask.  In February, I looked online at mask studies (most in East Asia) and concluded they had at least some marginal benefit in crowded or indoor locales and we've been using them since then.

- They completely screwed up the development of a reliable covid test which set us back at the beginning.

- The published government plans developed since 2007 (which I reviewed online) were so general as to be not usable as practical implementation and response guides. 

-  In May and June we were suddenly told by public health officials and some politicians that participating in mass gatherings somehow magically gave you covid immunity if it was for purposes the public health and politicians approved of.

- And as for Dr Fauci he's been on every side of every issue since January.  I know he has some big fans, but I don't get it.  He also has detractors who think he's been wrong on everything but he hasn't.  He's been wrong and right about everything because of his shifting statements.

- State politicians in some cases downplayed covid early on, in others sent infected patients back to nursing homes, in others delayed urging the use of masks, and in other completely overreacted in their dictates which have been kept in place well beyond reason.  And not enough bad can be said about the ghoulish Governor Andrew Cuomo.

- The President did what he often does.  The actual actions taken at his direction were often good or at least not bad, but they were accompanied by terrible rhetoric, bad tone, conflicting messages, goofy ramblings and stream of consciousness which is not what the public wants to hear at a time like this.  He sounded (and sounds) like a man not in control of himself.