Let’s Flatten the Curve and Weaken the Wave

Early containment and delay in the US has failed. That doesn’t mean it’s the end of the world. What it does mean, is it’s time to accept we are standing on an exponential curve. It’s not insane to set reasonable goals and implement logical measures right now. But the costs of stronger measures that we may need to take because we were late is going up. #covid19

It also means that individuals, communities, and private sector leaders shouldn’t just wait on key public officials and governmental decision-makers to start having epiphanies about the benefits of science and coherent thinking. We are all decision-makers. So let’s make some good decisions.

We still can push-out and/or bend the sudden upward shape of the exponential curve downward upon which we are standing. And we are standing on one. We’ve been in the zone of complacency. This is a numbers game – even small reductions today can push-out and bend the curve down.

We need better visuals and messages of the different but interrelated impacts of large outbreaks. It’s not only just a matter of people getting sick. That’s obviously a huge part, but there are other connected chains-of-events in play to keep in mind.

There are other ‘non-health’ considerations that need to be taken into account that might not be getting attention. Whatever course the current outbreak takes, I think it makes sense to try to paint a high-level picture of how different moving parts work with, or against, each other.

I’m just some dude on the internet. I’m not a virologist, epidemiologist, or other expert in this field. I am a registered nurse, but I haven’t been bedside in a long time. So these are just some thoughts. There are way smarter ideas than these on the subject. Keep that in mind. Anyway, here goes:

Viruses like SARS-COV-2 force us to realize how inter-related seemingly independent systems and components in the world can be. A contagious illness in China might have something to do with a local economy in America.

When thinking about whether or not we should pay attention to an outbreak, we need to think about more than just its effects on an individual person. There’s a much bigger picture to a system of cogs we wrongly think don’t work with each other.

If the worst of an outbreak is to be avoided or mitigated, it’s a good exercise to identify over-arching goals to guide the best steps to take, not just how bad a pathogen might make us feel (or even if it kills us). There’s much more.

In short, outbreaks require thinking in terms of cycles, systems, and feedback loops. So, let’s see what’s needed to shift the Covid curve as far to the right and downward as much as possible.

Here are 3 broad interrelated goals:

A) Contain/delay spread (and ultimately reduce more dangerous mutations that might make a recurrence later down the road)
B) Avoid healthcare facility overload (especially critical care units)
C) Avoid/minimize economic disruption
This triad needs nimble balancing. The ABCs:

A: If early containment measures are too ‘expensive’ (draconian), economic impacts can lead to an even longer problem list, like:

  • Decreased production/distribution (food, pharmaceuticals, equipment)
  • Lower employment
  • Slower capital flows
  • Social disorder
  • Intensified spread

A: If early containment measures are too ‘cheap’ or delayed or confusing or non-existent, our travel along the exponential curve can lead to continued spread. Which, in turn, eventually hits the economy. Nasty feedback loop.

A: That’s why timing is so critical. Early, reasonable, low-cost measures can save both lives and economies. There’s a practical mental place to live in between complacency and unjustified fear, which makes early interventions sane things to implement.

B: Healthcare system overload. While most infected people may experience mild/moderate symptoms, there is a varying rate of those who require critical care (mechanical ventilation, vasopressors, 1:1 or 2:1 nursing:patient care). ICUs are relatively few in number.

B: This is why the magnitude (mass) of total infection matters, not only its (variable) rate. It’s the rate – and ultimately size – of critical care cases that significantly matter. Even a low rate of infections requiring critical care can easily overload hospitals.

B. For example, assume critical care case rates  of 1-3% among a community of 1,000 infected individuals. That’s 10-30 beds. A region with a total of 30 ICUs can be easily overrun, depending on census. Keep in mind: that’s just at *that* moment of time. But time keeps truckin’.

B. Facility overload isn’t limited to treatment of infected patients needing critical care. Also impacted: Pre/peri/postnatal care (safe delivery of new little humans) and all other important heatlh_care (e.g. chemotherapy, critical diagnostics, traumatic injury admissions, and on and on).

B: Once a critical mass of hospital overloads and reshuffling of overall censuses is reached, exhaustion of healthcare workers and depletion of resources (O2 tanks, mech vents, medications, gloves, masks, linens, antibiotics/virals, sanitation support, etc.) set in.

B: Hospital overload does not require an apocalypse, where tires are burning in the streets, bodies splayed all over the ground, and zombies finally getting their chance to jump out of the movies and into our homes.

B: It is crucial to avoid Healthcare facility and system overload. If critical care units are unable to absorb critical cases, the risk of further community spread increases. These patients need to be somewhere – at home, makeshift spots, or who knows where.

B: The risk of Healthcare worker infection also rises, further reducing absorption capacity, in turn ramping up spread. Who replaces sick healthcare workers? Where do they get treatment?

B: Hospital overloading may not be foremost on the minds of the general population and key decision-makers, but it’s an endpoint to avoid as much as possible. It’s another reason to implement sensible containment/delay measures *early*.

C: Economic consequences and considerations. Economies have everything to do with individual and public health. Production and distribution of (vital) goods and services, stable employment of labor, and adequate capital flows ultimately support physical, mental, and social health.

C: Containment/delay measures have varying economic costs and consequences. Early measures are substantially less expensive than late measures. (This is where policy deciders often miscalculate.)

C: What are the high costs of *late* containment measures?

  • Large-scale quarantines
  • Slowdowns, disruptions, or shutdowns of (in worsening cases):
    • Factories
    • Power plants
    • Sewage treatment facilities
    • Garbage collection
    • Capital markets

C: Low-cost early containment/delay measures include:
Work-from-home. If employees can do all their work (or critical work) remotely, it makes sense to keep employee working from home. Employers should shift as much work from in-office to remote as quickly as possible. Kind of a no-brainer. Although…

C: …work-from-home isn’t always a functional option for all workers and employers. Living paycheck to paycheck limits employees’ capacity to stay home without being able to perform duties. Indeed: economies have everything to do with health.

C: Some more low-cost early containment measures.

  • Hand-washing: proper technique, routine, and protocols.
  • Avoiding face-contact (specifically: mouth, nose, eyes)
  • Social activity: reduce travel/meetings
  • Wiping of contaminated surfaces
  • Hydration (a dry mouth can invite infiltration into airways)
  • Masks – properly worn masks can reduce exposure (care must be taken use proper handling technique – they shouldn’t be considered panaceas, especially if they aren’t high grade)

C: Low/medium-cost containment/delay measures include cancelation/delay of mass gatherings and in person meetings. But the cost of these cancelations can have big payoffs for the economy and public health, and go a long way to smoothing and pushing out the curve.

C: Serious, intelligent consideration of air travel (domestic and international). Keeping in mind the nimble balancing act of the triad, this is a tough one! Staggering closings, criterion-setting, boosting airport monitoring/triaging could be intermediary steps before full shutdown.

C: School systems should already have had backup procedures in place (tele-education). Again, there are economic consequences to school closures, but we’re up against the high costs of uncontrolled viral spread. There’s a smart way to do this.

C: There are other strategies and measures and you can read more here: https://www.cdc.gov/flu/pandemic-resources/pdf/community_mitigation-sm.pdf

Healthcare Communication. Public messages from healthcare leaders, public health officials, and private sectors need to be straightforward, easily digestible, and free of fallacies (e.g. equating *absence of evidence* with *evidence of absence*).

Appallingly, even some authoritative sources have made fallacious (and weird) pronouncements. Healthcare communicators should triple-check their messages (and consult with critical thinkers with relevant knowledge/experience). Words like “never”, “always”, “should”, “shouldn’t”, “can’t”, and other unfounded absolutisms, are yellow/red flags.

Officials and pundits who say “research has shown X to be useless” should be held to account to cite specific research and explain exactly what context they have in their minds. If they’re winging it, call them out, or throw them off the set.

Information requires proper context and framing. Yes, bad information is…bad. But even accurate information can still be misinformation if it isn’t issued within proper contexts or framing. Generalizations from particulars can be false, even when the particulars are true.

The P-word. Very often, the first response of even capable interviewees on TV shows to the question “What should we do” is “First, don’t panic!”. But that’s a useless response. In fact it isn’t even an answer to the question. The question wasn’t “What shouldn’t people do?”

There’s an ingrained myth that people can’t handle good information. The goal of dealing with threats of an outbreak isn’t to avoid panic – it’s to prevent or reduce the outbreak’s effects. Keep that the focus of mass communications.

People will not panic if you provide them with empowering, useful, and relevant information. When asked about what people might be able to do, eliminate “don’t panic” from your talking points. It’s a terrible habit, much like saying “uh” and “um” when fumbling for words.

Social media are engines and amplifiers of unhealthy behavior and poorly-produced information. But so too are established, major new organizations across other media (TV, radio, newspapers). RSS may be old school, but it’s still one of the best tools for managing info-flow.

As stated earlier, we are all decision-makers now. None of us will have the absolutely ‘true’ information. We aren’t g-ds, we’re all just humans. But it’s a numbers game. Small reasonable steps can make big differences.

If this current outbreak turns out to be a much smaller event than can be reasonably foreseen today, that’s great. It means when we have confirmation that we’re sufficiently past the curve, we will need a major re-assessment of how we *prepare to prepare so we are actually prepared* to successfully take measures.

It is near Spring. Hopefully we can shift out and bend the viral curve downward. But viruses mutate. We still don’t know what the Fall may bring. We might get lucky now, but dangerous mutations might evolve by the Fall. Let’s get early containment right.

An illustration. Assume 100 cases today, with cases doubling every week (R0=2.0), and a critical case rate of 1%. Without any measures, in 13 weeks we’d have over 800,000 total cases, over 8,000 critical cases.  That’s over 8,000 needed units.

If in the above scenario, if we even implemented reasonable measures and reduced R0 by 0.3% to 1.7%, in 13 weeks we’d have just under 100,000 total cases and just under 1,000 critical cases.

Depending on the varying capacities and capabilities of healthcare facilities across the United States, that 0.3% decrease in R0 could convert into an 8-fold reduction in cases. We could still be a war, but we’d be fighting with better chances.

We haven’t covered case fatality rates here. That’s because a primary purpose of this appeal is to redirect attention away from ‘doom-and-gloom’ in order to articulate the triad of ABCs in a realistic and rounded conception of what outbreaks can do to the world.

As of today, we don’t have an established R0 for covid-19, nor do we yet have a firm handle on R0 or critical care and case fatality rates. They aren’t inherent, immutable numbers because they depend on different factors that vary across countries, regions, and local areas, such as:

  • Individual and community behaviors
  • Government and private sector decisions and actions (or lack thereof)
  • Mutations
  • Demographic variances
  • Quality and capacity of healthcare facilities in different countries, regions, and local areas.

In other words, reasonable goals and logical measures matter, especially when these metrics can vary. They can also change as descendant mutations evolve novel properties, further complicating late efforts and media coverage.

The United States should have started working on the ABC’s several weeks ago. It could have pushed-out the curve. Complaining (without specific and useful calls-to-action) at this point, however, probably won’t help right now. Put it this way: viruses don’t have ears.

Very smart people have already worked out the proper goals and measures for greatly reducing the spread and impacts of outbreaks. What to do isn’t as mysterious as why we don’t do what we know we can do.

There’s still room for further research and knowledge, but the onus is us to exert pressure on governments, NGOs, private sector leaders, and others in power and ensure that what they do works for us, not them. The power we once gave them should never have been about them.

We also need to not only fund and support researchers in this field, we also need to *empower* them to play much bigger roles in prevention initiatives – not just in planning, but in active, ongoing participation to keep decision-makers from making bad decisions and missing key targets.

We need to pay attention to slowing down the replication of these tiny but *evolving* machines that don’t at all care about our happiness. We can’t expect them to care about our politics or economies or children. That’s our job.

What’s outlined in here can still be implemented starting now. It’s been said that evolution via natural selection is ‘smarter’ than us. We might not be able to outsmart them, but we can do our best to contain their spread, curtail their mutations, and avoid/minimize their impacts.

Let’s hope this Spring’s Covid curve is relatively gentle on us. Regardless of what it becomes, the next curve might be even bigger.

Let’s prepare for the next curve with the resources to support pre-pandemic plans when it’s *early*. Vital resources (such as testing kits, equipment, infrastructure, food and fluid stores, and so on) should be produced, available and accessible BEFORE it’s past the early stages of pathogen proliferation.

I tried my best to avoid errors in my thinking here, but I’ve also tried my best to put what I hope are useful ideas into the ether. Anyway, be kind, be thoughtful, be alert. #covid19

The Malls Are A Changin’

Perhaps the ‘middle class’ was a fluke, but it was nonetheless a crucial layer in the flowering of America so-to-speak. Families could afford the leisure of fishing, vacation homes, guilty pleasures, and, more importantly, reading. Books were cheap and they augmented leisure time with ‘cerebral’ time. The middle class also served as intermediary between the ‘lower’ and ‘upper’ classes. They could, through voting and political expression, give voice to both classes’ interests and moderate extreme liberal and conservative impulses.

George Carlin jokes aside, we still need this layer as we transition to fast-shifting patterns in social and economic structures and dynamics driven by technologies largely beyond our control.

But we now see a bifurcation of classes into the disenfranchised and the empowered. It’s not a matter of “the poor are lazy” nor the “rich are parasites” – rather that political powers are imbalanced and distorted, undermining crucial elements of a civilization’s survival and maturation.

This new structure won’t be healthy for either side – even the empowered class will suffer: a human can only sustain so much power until figurative and literal boredom, mania, depression, and addictions set in. Eventually, the house of cards burns down and everybody loses. A flattened society of broken adults is left. A national state-of-affairs like that always leads to mass child abuse.

Much of this bifurcation is unseen. Perhaps malls are giving us a visual taste of what’s to come.

Another place to witness the bifurcation? Bars. There was a time when a blue collar worker driving a beat up Oldsmobile and a CEO driving a brand new midlife crisis chick-magnet could pull up to a hole in the wall, order rounds, trade war stories, and leave shaking hands. It was American equality in its most practical sense, even if momentary. Those times are going away. They were nice. America had wonderful moments. I hope it’s not too late.

Link: https://www.bloomberg.com/news/features/2018-02-08/this-mall-is-only-for-the-rich-and-it-s-doing-fine