31 March 2020 – Tuesday – #16

Will the US Covid-19 response be worse than Italy’s? There are new data points since I estimated US Covid-19 mortality a few days ago. It’s not good news.

The Chinese Covid-19 death toll may be ten times higher than officially reported based on cremation activity in the area. Reports that Wuhan residence were paid for their silence suggest the government is covering up actual Covid-19 mortality there. I want to point out that even though the mortality rate may be much higher than reported, the test-and-quarantine method the Chinese used to quell the epidemic worked.

Based on overall death rates in several northern municipalities, the Italian Covid-19 death toll may be four to ten times higher in that region than officials report, apparently because people who died at home weren’t counted as having Covid-19.

It is extremely reasonable to think that these excess deaths are largely elderly or frail people who died at home or in residential facilities, without being hospitalized and without being swabbed to verify that they have actually become infected with Covid-19.

Corriere del Sera

As a result of this, I’m revisiting a chart I made two days ago. Here’s the original chart:

Estimated Total
Deaths per
Implied US

Spain13,000 – 19,0000.3 – 0.4 per 1k96,000 – 128,000
Italy20,000 – 30,0000.3 – 0.5 per 1k96,000 – 160,000
Original Chart from 29 March 2020

I was a little surprised when I made the original chart that the overall Italian mortality was so close to Spain’s because, while the cities of Madrid and Igualada were Covid-19 hot spots, Spain hasn’t experienced an entire region turning into a hot spot the way Lombardia and its surrounds did.

There are two assumptions I’ll make in revising the chart. One is that Italian under-reporting was only in the hardest hit cities. In areas that weren’t hit hard, I’ll assume there were not scores of people who died at home and went unreported. The second assumption is that 1/3 of the deaths happened in hot spot cities that under-reported. Based on the 4x – 10x under-reporting from the article, that means that countrywide Italian mortality is something like 1.3x – 3.3x higher than reported. Putting all that together, here’s the revision.

Estimated Total
Deaths per
Implied US
Spain13,000 – 19,0000.3 – 0.4 per 1k96,000 – 128, 000
Italy26,000 – 99,0000.4 – 1.7 per 1k128,000 – 544,000
Estimate US Covid-19 mortality based on Spanish and Italian Covid-19 mortality rates

This makes more sense to me. Higher mortality reflects the larger healthcare system overload Italy experienced. It says healthcare overload probably increases countrywide mortality by something like 2x – 3x.

Using Spanish and Italian Covid-19 mortality to estimate US mortality is a stretch because of differences in culture, healthcare systems, politics, etc. But I’ll go with my chart as a reasonable first-order estimate. I acknowledge that Dr. Fauci’s current estimate of 100,000 – 200,000 US casualties is a tighter estimate than mine. I also think Fauci may be low for a number of reasons I’ll discuss below. Retrospective studies will be able to determine what factors most influenced each country’s final outcome.

[1 APRIL 2020 UPDATE: I realized the shape of the prediction curves are not symmetric. The tails are always longer than the head. That suggests that I use the higher end of my estimates, which assume we’re 1/3 of the way through Covid-19 mortality curve when we reach peak, rather than the low end, which assumes we’re 1/2 of the way through mortality. Yesterday’s revised White House estimate is 100,000 – 240,000 US deaths. My estimate is the higher end of my range, so 350,000 – 500,000.]

There are many reasons I think the US response will turn out worse than Italy’s. Before Covid-19 hits peak, we’re seeing overwhelmed healthcare systems in New York City, Atlanta, and New Orleans. So there’s evidence that the US already is experiencing the kind of healthcare system overload Italy experienced.

One key issue is the US federal government’s inability to prioritize its efforts effectively. Let’s use the administration’s current focus on the malaria drug hydroxychloroquine to treat Covid-19 as an example.

The French have given provisional permission to doctors to use hydroxychloroquine as a Covid-19 treatment after Dr. Didier Raoult issued a pre-print of his second “observational” study with 80 patients. His second study is larger and more flawed than his first. The problems with Dr. Raoult’s new study include the lack of a control group and of a presentation of per-patient data. The UK has banned the use of hydroxychloroquine for treatment of Covid-19 and a few other countries like Iran are testing it. No country has adopted it as a cure. On the other hand, the US FDA, has accelerated the acquisition of hydroxychloroquine, presumably at the behest of the president who has stated it is the magic bullet.

It’s unclear why the Trump administration seems to be putting all its Covid-19 eggs in its hydroxychloroquine Easter basket. There is one New York doctor claiming to have cured hundreds of patients with hydroxychloroquine. He has produced many videos claiming he has a cure, often providing his phone number, but not a study. Other American doctors are trying it, but none have declared it a cure.

The reality is that, like all the other candidate Covid-19 treatments, and there are many of them, hydroxychloroquine needs to go through a human testing process much more rigorous than Dr. Raoult’s. Luckily, the Gates Foundation is funding the Therapeutics Accelerator to assess and prioritize candidate treatments, something I would have expected the FDA or CDC to manage. So there is at least one organization coordinating and prioritizing Covid-19 treatment analysis. Six months is an optimistic time frame for any candidate, including hydroxychloroquine, to pass the human trials needed to show efficacy.

I’m going to harp on testing. Again. Testing is the real short-term answer, and short-term is what we’re talking about. Most of Europe is hitting peak Covid-19 infection now and US will hit peak Covid-19 infection in April or early May. Investing time and money into hydroxychloroquine is a huge gamble, especially without a study that shows it works. The administration is shifting resources from testing, which is known to work, and ventilators, which are know to save lives, to an unproven treatment.

The White House is placing a risky bet when safer bets are available.

Testing is easy, it’s approved, it works, and it is scaling. The US is too far along to flatten its Covid-19 infection curve the way South Korea, China, and Vietnam did with their test-and-quarantine programs. But testing will mitigate healthcare overloading in US hot spots, keep currently unaffected areas, especially rural areas with inadequate healthcare infrastructure, from turning into hot spots, and save lives of healthcare providers everywhere. In other words, even though testing won’t give the US as good an outcome as South Korea at this point, it can keep the US outcome from becoming a lot worse than Italy’s.

In my opinion, either Trump isn’t smart enough to understand this or he wants a cure for political reasons, to look like a hero. Or he’s good at bad bets. He put his casinos into bankruptcy, after all, proving that the house doesn’t always win. But no one has to be a hero to reduce Covid-19 mortality. What the US needs to do in the next week is increase testing and build ventilators.

Unfortunately what I believe we’re seeing with Dr. Raoult and his two incomplete hydroxychloroquine studies is a strange repeat of the Paris AIDS treatment that Rock Hudson begged for and Nancy Reagan refused. It wouldn’t have mattered if Reagan had granted Hudson his wish, though, because the Paris AIDS treatment didn’t work as advertised. Like dozens of other AIDS “treatments” in that desperate time, the Paris AIDS treatment might have worked a couple times, but without a proper published human trial, it’s difficult to understand what “worked” means. Without solid published results, I doubt Dr. Raoult’s Covid-19 remedy works, either. If he had the goods, he’d publish them. Even if hydroxychloroquine does work, testing is still the preferred short-term approach because it can get to market in the next week or two.

I’m pretty sure Trump doesn’t understand this. I’m going to step out on a limb and predict that at the state level, the governors who want all the federal support they can get, like Florida Gov DeSantis, will shove hydroxychloroquine pills down the throats of unwitting Covid-19 patients.

Sorry, I’m blowing off some steam. Such a brain dead federal response.

Another reason the US response probably turns out worse than Italy’s is that you can’t take two steps in any directions in the US without ending up in a crowded religious service. Whether you’re in Lousiana, Florida, Washington, or Virginia, you can expose yourself to the Lord and to Covid-19 at a nearby religious institution.

Theaters have closed, concert halls have closed, sports stadiums have closed. Maybe pastors think their relationship with God will protect their flocks. Maybe Trump’s Evangelical base believes the president when he says Covid-19 is just like the flu. It’s hard to know how certain segments of the US population are rationalizing their resistance to isolation, but they are.

Actually, in the case of Jerry Falwell, Jr. and his Liberty University, it’s not hard to understand the rationalization. Falwell’s power stems from his relationship with Trump so, when Trump says Covid-19 is no more harmful than the flu, Falwell has no choice but to put his 46,000 member institution at risk. Well, actually, it’s probably money, too. Liberty U will refund just $1,000 of fees to students who opt to return home. So far, eleven students have Covid-19 symptoms.

Lockdowns work if everyone does them. If the religious right decides on its own that it gets a pass, the US response will be worse than Italy’s.

To the president’s credit, he has extended US social distancing through the end of April. Also to his credit, the president now is acknowledging that there may be as many as 100,000 Covid-19 casualties in the US. Which brings me to the main reason I think the US response turn out worse than Italy: Trump took too long to acknowledge the severity of the Covid-19 pandemic.

Worried Covid-19 would derail his reelection, Trump claimed that Covid-19 would be no worse than the flu and would go away as Spring brought warmer weather. Now we know a paper called “Coronavirus Perspective” by Richard A. Epstein of the Hoover Institute provided the Trump administration with its rationalization to continue downplaying the severity of the outbreak through the end of this month, even as the numbers climbed worldwide, as most of Europe went into lockdown, and as WHO provided clear warnings.

When Trump repeated throughout mid-March that he wanted the US to reopen for business on 12 April, he relied on Epstein’s analysis. But Epstein is as much of a quack as Raoult, it seems. In a recent New Yorker interview, Epstein is unable to distinguish between the way viruses and bacteria work and claims incorrectly that the strength a virus attenuates over the course of an epidemic. The irony is that Epstein bases his erroneous claims on his misunderstanding of Darwin, the same Darwin whose theories are an anathema to conservatives and Evangelicals.

While it may not seem like a big deal that Trump dillydallied for another week or two while he espoused Epstein’s views, consider this chart.

San Francisco issued its lockdown order on the same day as Epstein’s paper came out. New York’s isolation order came one week after San Francisco’s. This isn’t a completely fair comparison. If San Francisco waited a week, it wouldn’t necessarily have looked like New York, and vice versa.

However, that one week is a large part of the difference between looking like Vietnam’s response in San Francisco’s case and looking worse than Italy’s response in New York’s case. Why? Because Covid-19 is an exponential math problem. Every day the president ignored Covid-19 meant more dead Americans. Exponentially more dead Americans.

Time to wrap it up for today. Good luck to the state officials who are doing the real work in the American response to Covid-19. They are the ones who leading the American Covid-19 response.

In the unexpected consequences department, sales of shirts at Walmart are zooming. Not because people are buying any of the zillion t-shirts supporting Covid-19 causes, but because people are wearing the new stuff in front of the camera and the old stuff under the table while they video.

In the Spanish department, because I try to provide a little local color in each post, how about some bagpipe music. Wait, what? I’d always assumed the best use for bagpipes during isolation was to scare people back inside. However, this rendition of the Spanish anthem seems to have good intentions to keep us safe and happy inside.

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