Morning Assortment

     I've got to get to the grocery this morning and see about assembling a week's worth of groceries, so today's post is a little hasty.  Along with that, Holden the cat is still learning that cats are not allowed on my desk at breakfast time, a rule about which he expresses great doubt.

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     But let's talk about a few things, data and ways to present it among them.

    One of the best books I can't remember the title of, a book ostensibly about commercial art, had a very good section on how to avoid telling lies with charts and graphs.  It is staggeringly easy to do so, intentionally or not, because of a few factors.

     The first is that we love a pretty picture.  If scales and hues need to be adjusted to get an eye-catching presentation (or just to fit the  page or screen), we will do so.  You end up doing things like over-emphasizing small variations between very large numbers (commonly done by rescaling or trimming bar charts or graphs to remove "all that wasted space.)

     Another is that while most of the growth (and decay) processes in the world tend to proceed logarithmically, our perceptions and expectations are linear.  Even our senses scale exponentially rather than linearly.  In the very short term, the straight line and the swooping curve track closely enough to get by -- but in the long term, they diverge rapidly.  Once a processes gets started, it ends up going like a rocket!  That's why, outside of a few hard-hit and early-onset areas, you're probably looking around and thinking, "Hunh.  Not much of a pandemic."  In NYC, ERs are packed, gurneys in the hallways, and they're nearly out of ICU beds.  Even here in Indianapolis, the biggest hospitals are starting to feel the pinch -- and we've got a couple weeks to go before the peak, if present predictions hold.

     A third is confirmation bias: we're good at cherry-picking what we see or read to conform what we already expect.  This is the bane of experimental work, and why in things like drug trials, there has to be a "control" group, who do everything your test group does -- except use the drug under test.

     A fourth is "granularity."  For the United States, the Johns Hopkins coronavirus map only goes to the county level; for Canada, case data is per Province or Territory, and for most of Europe, it's per country.  These are not sections of equal population; they're just handy chunks that probably reflect how the data comes in to JHU.  The IHME data and predictions, on the other hand, are state-by-state at their narrowest; you're not going to find anything about measures taken by cities and counties on their pages, though it may affect their predictive models.  You can't read this data any deeper than it goes.

     Fifth and last, our good old friend, Dunning-Kruger Syndrome: we don't know what we don't know.  Heck, I can do math, I can read a study written in plain English -- why shouldn't I make my own predictions?  One reason would be that I don't know how good a model a locked-down cruise ship full of the kinds of people who can afford to go on a cruise might be for a large American city, full of a wide assortment of people doing a wide assortment of things; YMMV, but remember, there are folks who make a living doing this sort of thing and the reputable ones are extremely cautious about inferring too much.

     Please, let's just do what we can to get through this.

Predictions

     There's a very good site with national and state-by-state predictions for the course of COVID-19.  It's run by the Institute for Health Metrics and Evaluation (IHME), a think tank that describes themselves as having "the goal of providing an impartial, evidence-based picture of global health trends to inform the work of policymakers, researchers, and funders."  They've got a nice, fat $279 million grant from the Bill and Melinda Gates Foundation to do it with, free and clear.*

     When it comes to COVID-19, they, like the rest of us, want to know what's going to happen next.  To that end, they are collecting and collating data as it becomes available, refining their models and updating it daily.  Unlike a lot of such sites, they include not just the median prediction, but error bands as well: they're willing to show the limits of their knowledge and their models.

     The state-level predictions I have looked at (many) are a good fit to what I know (not much) and have extrapolated.  New York and many of the surrounding states are in serious trouble; a lot of the Midwest is in better (but still worrying) shape.

     Have a look.
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* Paranoid rants incoming to comments in five, four, three....  You know, writing that in all caps isn't going to improve the odds of my letting it through the filters.  I have been patient with people's irrational suspicion for years, in large part because I figure all our institution need watching and it's a great way to keep the 'noids usefully busy; but there's a limit and I reached it some time last week.  Not every comment I sideline fits that category, and I am sorry to have had to hold up quite a few good ones because they included assertions I could not verify, or digressed into political partisanship that serves no useful purpose against this pandemic.

"Flattening The Curve" vs. "Business As Usual"

      If you're a member of the "Oh, it's no worse than a bad flu season" set, you might as well leave now, and take a look at the video coming out of Italy and NYC on your way: this thing hits hard and fast, compressing a flu season's worth of deaths and cases requiring hospital support into a few weeks.  Too many, too quickly for hospitals to cope.  Health-care workers are falling ill at a much higher rate than the population at large: they have to get universal precautions right every time, while the virus only needs to get a solid toehold once.

     The thing that social isolation and stay-home orders sets out to accomplish is not quite like a classic quarantine order used to contain something like measles, where quarantine and contact tracing can stop an outbreak in its tracks.  COVID-19 appears to be infectious for a couple of weeks before symptoms appear.  By the time you know you're sick, you've already been spreading it.  The best we can hope for is to slow it down.

     Slowing it down will save lives.  It will save many more lives indirectly than directly: The goal is to keep from smashing our healthcare system so flat that it takes years to recover, and does a much worse job coping with the surge and its aftermath.

     Nobody seems to understand that facilities and personnel are not going to bounce right back from an Italy-type caseload. Few people grasp that every patient in a hospital suffers when it is overloaded by a surge of COVID-19 patients.  A lot of people will die of a lot of things while we learn this lesson.

     In Marion County, Indiana, my county, we've got 676 known cases as of midnight.  That's about fifteen to twenty times as many as a week ago.  We're two or three weeks away from the peak if present projections hold.

How Do I know It's A Pandemic?

     Because the COVID-19 heat map at Johns Hopkins has nearly one-to-one correspondence with population density, at least for the United States.

     Like most of my generation and subsequent ones, I grew up in a world of cureable (or at least treatable) disease.  Throughout my adult life, the planet has kept issuing little reminders that it's not a simple battle; we just got a big one.

     The models for coping with this look like the more-successful responses to the 1918 - 20 influenza pandemic, or London when they best coped with Plague.   We cannot stop it by sheer force of will.  There's no bluffing a blind, biological robot.

     And no matter what we do, this is going to hurt.

     We had good years, good generations.  My Dad and Mom grew up fearing polio but my sibs and I didn't; my nieces and nephews didn't.  We've all got the scar from our measles vaccination.  Antibiotics have been truly miraculous -- I would have succumbed to childhood rheumatic fever were it not for penicillin and later drugs.  It was a halcyon time and now it's over.

     We're back to the 1930s at best in dealing with this virus.   There's no magic bullet, not yet.

If You Like Crunching Numbers

     Here's a decent set of charts and graphs, presented with straightforward, factual description and discussion.

     Remember, having a helmet fire is never helpful.  Knowing the facts is usually helpful, if there's anything you can do; and if there's nothing you can do, it's at least entertaining.

     I'm still home with what I hope is kidney stones.

Worried?

     CDC has an online coronavirus symptom checker.

Oh, Darn It

     I am experiencing what feels like a kidney stone.  The pain is....  Well, it's not as bad as the worst of one of these.  But it's not good.

Stay-Home Morning

     There's a remarkably beautiful and dangerously thick fog over Indianapolis this morning.

     It's a good morning for it.  Indiana is under a formal "Stay at home" order as of twelve this morning.  My industry is deemed essential, so I'll still be going in to work.

     I have yet to find a scaled-to-population graph of the progress of the infection per country.  There are so many of us in the U.S. that it's not as easy as it first appears to compare growth rates from country to county.  It appears the rate of increase in the U.S., the slope of the curve, is at par with that of Europe as a whole; we do not appear to be as bad off as Italy, we're not doing as well as the best; but it's not a huge difference and we're a week or more behind Europe.  The slope could change.  The data is so minimal that it's only a guide to making informed guesses.

     The world will get through this.  It is not going to be easy.  This is comparable to WW II; not as intense but breaking out all over, in the space of a few months.  It's going to take the same pluck and determination to get through it -- and there will be casualties.

Hard Lessons: Triage

     You've seen the headline or tagline: in Italy, patients above a certain age aren't getting respiratory support.

     I'd like to tell you it's a huge lie, but while the details may be a little askew or oversimplified, the gist of it is true.

     There are a lot of people sick with coronavirus in Italy.  The number of them who need respirators exceeds the number of respirators available.  There's no way to save everyone.

     Let that sink in: There is no way to save everyone.

     Pretty horrible, isn't it?  That's the position doctors found themselves in World War One, the biggest if not the first collision of 20th-Century military technology with 19th-Century tactics.  Men were falling in vast numbers and many of them were not quite dead.  There were only a limited number of doctors and medics; field hospitals were minimal, medical supplies were inadequate.  Men were dying of easily-treated injuries while doctors labored to save those who were unlikely to live.  Something had to be done!

     There is no morally-satisfying answer to such a dilemma.  All that can be done is to mitigate harm; all that can be done is to try to do the greatest good with the resources available.  It's called triage: doctors began sorting patients into three groups:

• Those who are likely to live, regardless of what care they receive;
• Those who are unlikely to live, regardless of what care they receive;
• Those for whom immediate care might make a positive difference in outcome.

     The last group was the only one that received full-on medical care.  Any leftover time or materials was spent on the first group.

     It is cold, harsh and heartbreaking.  The only worse things are all the other available options.  You're hearing stories of doctors breaking down in tears in Italian hospitals?  This is why.  They're not military doctors.  They learned about triage but they have never had to practice so harsh a version; even landslides and floods rarely put so much stress on medical resources.

     And this is why you're social distancing.  This is why you're being asked to stay home.  Overload the health system and you get a sorting-out that leaves the weakest dying, that leaves the strongest gasping for breath to get through the worst of the illness, and focuses resources where they will do the greatest good.

     It can happen here.

     Let's do everything we can to keep things from getting that bad.
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     Further reading?  Tom Godwin's The Cold Equations.

Will You Please...?

     Another reminder: I will not publish rumor or hearsay in comments.  If your paragraph starts with "We're now hearing about..." and does not include a link to an actual Official Person In The Know saying this thing you have heard, it's not going to get published on my blog.

     Come on, this isn't that hard.  Distinguish between rumor and facts.  I encourage you to dig for facts -- and verification of them.  Don't speculate, guess, or repeat something some guy you know heard from his brother-in-law's cousin.  It doesn't help.

Week Two Of Taking It Seriously

     And, of course, since I set ground rules for comments, commenters are testing the limits.

     They're pretty strict.  If you have ideas, feelings, thoughts that you simply must get off your chest, and they are not supportive of your fellow humans trying to get through this thing, please get your own blog (they're often free!).  I'm not going to publish them.  I will try to answer them.

*  *  *      For the RN, irked at the government's response and the limited supplies, I don't have much comfort.  I'm slightly less qualified to explain supply-chain logistics than a non-surgical nurse is to explain the subtler details of brain surgery: I sometimes see it happening and occasionally I help it along, but....

     Still, I'll give it a try.  In normal times, the usage of PPE is essentially constant. The factories know their market and produce about what they need; this probably doesn't get warehoused in any great quantity (the miracle of just-in-time manufacturing processes!).  Instead, it goes on train cars to a wholesaler, and on trucks from from the wholesaler to retailers and bulk purchasers.  Figure the whole process takes somewhere between one and six weeks.

     Ramping that up -- first, you need raw materials.  Assume them, and if the factory was running one shift, it can run three, if it can find the workers.  Congratulations, you have tripled the supply; a week to train them, and a week, minimum to get to get the PPE to the end users, if they have ordered them; better add another week to sort that out.  Meanwhile, hospitals and testing in the hardest-hit areas is burning through these supplies five or six times as quickly as normal.  And changing from a supply-and-demand model to a command model won;t make it any faster or ensure the supplies get to where they are most needed.

     Federalism plays into this as well.  Public health in this country is a good example of federalism; it's bottom-up, as FEMA and CDC keep trying to explain: locally run, state managed, Federally supported.  FEMA does not have any super-deep infinite stockpiles; they have some supplies, suitable to support a state's response to an ordinary disaster, to get them through the first few weeks while the supply chain reacts.  The scale of this problem is ten to a hundred times as great.  FEMA's stockpiles, your state's stockpiles -- they're like spitting on a bonfire. 

     I'm sorry the Feds and state-level agencies lack the power of precognition, but that's the case.  Complaining about it now won't help.  Chewing them out just wastes time better spent on doing what we can, while we can.  Take notes and write a searing analysis after we're through this.   Do what FEMA appears to have done after Katrina: take a good hard took at the mission and how to manage it, and try to figure out how we can avoid this kind of problem in our next response.

     Testing is a PPE problem.  I will keep explaining this: the only way to keep the testers from risking passing the virus from the infected to the merely worried is for them to discard their PPE -- gloves, at the very least -- every time they take a sample.  If you're low on PPE, you restrict testing.  You need that PPE for the caregivers treating the people who are already ill.

*  *  *      Another commenter asked if I really believed that flattening the curve won't reduce the death rate.

     The answer is that it's probably not going to make a huge difference in the direct death rate.  Probably the overall deaths will be lower, though by how much is impossible to say.  People are saved by having equipment available to save them,m and the flatter we make the curve, the better that looks.  The virus puts the same proportion of the people it makes ill in mortal danger. 

     It is very likely someone you know is going to die of this, especially if you live in a large city.  And I'm damned sorry about that.

Speed Of Response; Five Stages Of Grief

     One of the complaints that I keep encountering almost everywhere, from fairly reasonable people and conspiritards alike is, "Why didn't The Government do more, sooner?"

     In part, this is rooted in an odd corner of American Exceptionalism that wants our President, Party leaders and Congressthings to be bigger than life.  If we approve of them, they're philosopher-kings, wise, well-informed and malevolent; if we disapprove of them, they're crafty, malevolent Bond villains.

     What these two characterizations have in common is they describe people who are extremely smart and extremely competent.

     Think back to the kids who were in student government when you were in High School or college.  They're weren't nerds or geeks; they were often fairly bright.  But they were almost never the most bright, and were rarely gifted with great abilities in math or the sciences.

     Those are the people who grew up to run for office.  Other than a certain need for approval, and often a preoccupation with appearances, they're just about average.  They're not Bond villains.  They're not philosopher-kings.  If you compare the whole lot of them to an equal number of randomly-chosen citizens, they two groups will be neither more benevolent or more malevolent than one another.

     So we've got these more-or-less ordinary people, with their individual personalities, and along comes news of a new virus in China.  There are a number of reasons why this happens in China a lot -- population density, the sale of live animals for food and lower food-safety standards among them -- but the important thing is that it does.  It's one item of a hundred in the morning briefing and it's not unusual.

     Time passes and the news out of China's not looking good, but the Chinese government swears they've got a handle on it. By SHOT Show, Tam and I were speculating about the unfortunate confluence of SHOT and the Chinese New Year, which brings a huge influx of Chinese tourists to Vegas and throughout the world.  I warned her to carry hand sanitizer while attending and to not lick any strange door handles.  And we laughed.  --Politicians in the U. S. were not much more worried.

     And it is at this point that I'd like to mention a handy tool to understand how people deal with huge and tragic changes in their world.  It's really just a list of general tendencies in a certain chronological order, but it's a useful to understanding how people react to things like, oh, the Hindenberg disaster, 9/11, WW II, or the coronavirus pandemic: The Five Stages Of Grief. 

     They run like this:
     1.  Denial -- "This isn't happening."
     2.  Anger -- "We're gonna get the people who did this to us!"
     3.  Bargaining -- Can we do only a little, and make this happen less?  What about...?
     4.  Depression -- "Game over.  We're doomed!"
     5.  Acceptance -- "This is happening, and here's what we can do to deal with it."

     You can take, for the easiest possible example, President Trump's public reactions to the pandemic, and map them right into this (with a quick skip over "depression;" he's not really the depressive type).  From what I was seeing from FEMA, they went through much the same process -- as an agency, a few days or even a week ahead of the President; but worrying about disaster response is their only job, so they would be leading.

     This is why we got the official response we got, why the UK had the response they had, and so on around the world: it took time to grasp what what was going on and to accept it.  There was a sudden change in plans in the UK as news came out of Italy.  The UK had hoped to isolate the elderly and let the remainder of the population develop immunity by exposure. Italy had attempted a somewhat relaxed version of that and it failed dramatically.

     About that failure -- people keep mentioning the death rate from this virus as if that was the only effect.  Well, it is bad, worse than a typical flu season, but yeah, it's not so bad -- unless  it happens over a very short period of time.  Flu season runs all winter and a bit longer at start and end.  The other problem is for every death, figure ten or more afflicted who need ventilators to survive; figure 20 - 25 who need hospital care.  If it all comes at once, it adds up to far more patients than we have beds available.  This is the problem; this is why there is such a big effort to slow the spread, to flatten the curve.  The death rate won't change; the number of people who need hospital care and breathing support won't change -- but they won't all need it at once.

     The other complaint I see,  even from the press, is about the shortage of PPE.  Why don't we have enough masks, gloves and gowns?  And that comes right back to the scale of the pandemic; we have enough of those for normal times; State and Federal-level stockpiles have enough to deal with a "normal" disaster -- hurricane, tornado, flood, earthquake, even an outbreak of anthrax or smallpox.  A nationwide pandemic is a whole order of magnitude greater.  Maybe two.

     A related issue is the recent restriction in testing to people being admitted to hospitals (and a few exceptions).  Why would they do that?  Here's why: The supply of tests isn't the problem.  The supply of PPE is the problem: the only sure way to keep the test sites from becoming disease vectors is to discard PPEs after every sample is taken.  Line up five hundred people to get a Q-tip up the nose and you've burned through a thousand gloves and possibly five hundred masks and gowns.  Those are needed for people working with the known-infected.  There may be shortcuts; maybe the testers can slather on sanitizing gel between every sample -- but they don't dare get any on the sample!

     So here we are.  The country reacted pretty quickly, in a series of drastic-feeling steps.  Maybe it wasn't as quick as you would have preferred.  It was as quick as the ordinary people in government could manage.  Maybe it was quick enough. 

     Ask me in another week.  Ask me in another month.