The backside of the peak

5,905 Views | 47 Replies | Last: 4 yr ago by HotardAg07
HotardAg07
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AG
[Disclaimer: I want to have a thoughtful discussion here on the policies/economics/disease and I realize that this is the appropriate forum for it. This post is not intended to flame or troll, so please give me the same respect. I want to do my best to show my work, so I apologize in advance for the long post.]

Hypothesis: The "shape" of the backside of the coronavirus curve will determine how robust the economic recovery is in the US/World, due to it's implication on buyer confidence in resuming activities that do not require social distancing.

My prior assumptions and understanding:
I believe that the virus has mostly acted the way that experts told us it would act in late February, early March.
  • The spread of the virus is exponential when unchecked on a level we have not seen in recent years in the US in major epidemics.



  • The virus is deadlier than the flu by some magnitude. While the "case fatality rate" was calculated to be 3.4% back in March and is 6.9% now, it was understood that there was a large amount of mild/asymptomatic cases that would lead to an eventual "infection fatality rate" of somewhere between 0.5% - 1.0%
  • The shelter-in-place orders did work by halting the exponential spread of the virus and exponential growths of the deaths. New York City is a very robust example -- they have the hardest situation in the country to prevent spread due to their population density, reliance on public transportation, high level of immigration and international travel/tourism. I think that, as expected, places that were farther along in their outbreak than others experienced higher peaks than those who sheltered early in the outbreak.



  • The hospitalization rate was initially way overestimated. This is being attributed to the data in Italy/China early in the outbreak showing much higher hospitalization rates than what we are currently seeing. In NYC, there is 3.5 hospitalizations for every death. Early estimates were 2-3 times that amount and had to be adjusted down after new data came out of the US. If you go back to nawlinsag post from March 25, you will see he states a 14% hospitalization rate and a 5% critical care rate. If you assume 80% of patients who receive critical care die, you get 14% hospitalization / 4% death = 3.5 hospitalizations per death. Texags knows stuff. I would hope part of the reason our rates are lower is that we have better doctors and better treatments. As a esult of overestimating our hospitalization early, many localities predicted doomsday scenarios that never came to pass. Lombardy was strained to the limit, but not many other places to the same degree.
  • There is no proven vaccine, cure or treatment. We do have some treatments (HCQ, Remd., IL-6 Inhibitors, etc) that are now proving to be somewhat effective at reducing the severity or duration of the virus, but still nothing yet that resembles a knock-out punch. However, it does seem like some time in the next year we could have a vaccine available.
  • Age and comorbidities have a large effect on outcomes with CV infections.
  • The most effective way to break the curve is testing, tracing, and isolation, which requires a volume of resources beyond what we currently need at our daily infection levels.

What now? The three scenarios for the backside of the peak:
Now that we are at/beyond the peak natoinally/locally, I think views have begun to diverge dramatically on where do we go from here, even amongst people who can agree on the above priors:

1. Curve "Flatteners" believe that the only intent of sheltering in place was to flatten the curve to reduce demand on hospitals and give us time to prepare. That has been done, so life must go on.
2. Curve "Destroyers" want to pursue policies that can lead to the eradication of the virus in the US, similar to what has been done in South Korea, via test/trace/isolate. They would support sheltering at home until the spread of the virus is low enough that the testing/tracing capabilities (which grow monthly) are large enough to be effective.



In weeding my way through the various positions, I have considered the following 3 scenarios and what the various outcomes would likely be.

Scenario 1: We resume activity to some level that allows R0 > 1, which allows the virus to regain exponential spread. This feels unlikely for a sustained period due to the heightened awareness of the virus, but if it did happen it would be disasterous:
  • There would be renewed calls for resuming restrictions, which would destroy the theoretical V curve of recovery and add uncertainty to the next year.
  • Consumer confidence would be shattered. Many (not all) people would avoid crowds even if the government had no guidance
  • Certain localities would go under healthcare strain with the same issues regarding testing, ppe, etc.
  • ~250,000 deaths by Aug 1
Scenario 2: We resume activity to some level that settles in at R0 = 1, which means there is a steady level of infections/deaths happening over time nationally, with some localized outbreaks. Given the extent of the country's outbreak and it's current mood, this feels like the most likely trajectory.
  • We wouldn't be overloading our health system
  • Even if the government gave no guidance, the awareness of the situation will modify behavior for many.
  • As a population, consumer confidence and spending would still be lower overall than the baseline. Vunerable people and people in regular contact with vulnerable people would still avoid crowded situations.There would be a dark cloud of fear for many. ~1,000 deaths per day would be like a 9/11 event happening every 3 days or Pearl Harbor happening every 2.5. Conferences, major sporting events, etc. would have to be adapted or eliminated entirely.
  • ~160,000 deaths by Aug 1

Scenario 3: We socially distance long enough and effectively enough, while simultaneously investing heavily in testing/tracing capabilities to go on South Korea-like test/trace/isolate programs which can destroy the curve to near-0 levels.
  • Even vunerable people would not have be afraid of normal interactions
  • Large gatherings could resume, as 1-10 new cases per day is infinitesimally small risk, especially when any new cases' contacts can be traced back two weeks and tested.
  • Consumer confidence could go back to normal.
  • ~100,000 deaths by Aug 1

My conclusion: As painful as it may be in the short term, there is a larger long term payoff for stretching to Scenario 3 than the alternatives.
  • The economic rebound will be more robust and long lasting
  • Some tens of thousands of lives will be saved
  • If you believe in our ability to make a vaccine in the next 12 months, >100,000 lives would be saved over the course of the virus.
  • We have spent trillions of dollars in economic recovery, but not nearly enough in testing and tracing resources. We should be unlocking every bottleneck nationally and enlisting and training as many people as possible to destroy the curve. It would be better for the economy to spend $500B on a testing/tracing national program than it would be to shelter at home one more month.
  • Small measures like mask-wearing, which may have only incremental value to R0, can have huge economic impacts.

In closing: I think that the model for the best response for the virus has already been established, and it's not Sweden. It is and always has been South Korea, Taiwan, etc. Veterans of previous Chinese-borne outbreaks, they managed to destroy the curve and resume something much closer to normalcy than their peer countries/states such as Italy. It's hard to recall how South Korea and Italy had similar rises in cases/deaths early in the global outbreak, given how dramatically they diverged. I do believe in American exceptionalism, which is why I believe we should be able to do it better than all of them.
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HotardAg07
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AG
Sorry. It came out longer than expected.
Shooter McGavin
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AG
Damn you must be bored.
texagbeliever
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Your post seems to assume the number of deaths reported in the united states is accurate and not an overstatement. What if the number of deaths is really only 60-70% due to covid? How would that change your model? Would it substantially reduce the wave 2 risk?
aggie appraiser
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Here's my simplistic take.

"We need 15 days to flatten the curve so we don't overwhelm the medical community".

Ok. You got it.

60 days later, the medical community is nothing resembling overwhelmed. People and businesses are going broke. Lock up the ones who are susceptible and let the rest of us get back to work.
BQ_90
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AG
so then, one more week
beerad12man
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AG
Scenario 2, without a doubt.
The Fife
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Quote:

If you believe in our ability to make a vaccine in the next 12 months, >100,000 lives would be saved over the course of the virus.


I don't believe there will be one in the next 12 months. People have been trying to cure AIDS and the common cold for decades with no vaccine to show for it. No reason to believe this one will be different IMO.

Where I work we're looking at a 20% RIF between now and July. That's more than disastrous enough, especially for those who get caught up in it.
YouBet
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AG
I'm voting for Scenario 1.5 - open everything up and let the minority of us who want to leave the home do whatever the hell we want because most people are going to self-regulate at home anyway and we end up with S2 numbers. I say this as a Scenario 1 guy who joyfully showed up at my local Mexican restaurant sans wife on Friday and ate and drank the afternoon away. I was also largely alone in the restaurant.

Most people are conditioned to be scared of this thing at this point and don't want to get back out there despite we S1 peoples insistence to open up. So, let's do that and let us brash S1 folks live life. Rest of y'all can catch up to us later.
Rapier108
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HIV is a very unique virus in the way it operates which is why a vaccine has remained elusive.

The common cold is not worth creating a vaccine for, and since it is caused by more than one type of virus, and numerous strains among each type, there is really no point in even trying.

Whether we can create one for the Kung Flu remains to be seen.
"If you will not fight for right when you can easily win without blood shed; if you will not fight when your victory is sure and not too costly; you may come to the moment when you will have to fight with all the odds against you and only a precarious chance of survival. There may even be a worse case. You may have to fight when there is no hope of victory, because it is better to perish than to live as slaves." - Sir Winston Churchill
aggiebq03+
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From a practical standpoint, I think we missed out on the test/trace/isolate ship back in late January, if not earlier. Once it's actually spread to multiple locations it's too late.

From a policy standpoint, I'll take my personal liberty over an authoritarian government with enough power to do the kind of lockdown really required for that type of method to be truly effective.

I can say both of the above while still appreciating the thought you out into the OP.
Shakes the Clown
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Regardless of the numbers, analytics and the scorning of the "progressive" vs. "right to work" camps - it's hard to argue the blueprint had been set in place on how to ruin a strong and prosperous American economy.
FrontPorchAg
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Hotard Hall, we may be small but we've got posts that are bonfire tall!
All animals are equal, but some animals are more equal than others
Stinky T
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AG
I say we let the states that want to stay on lockdown until Aug 1 do just that. And the states that want to get things started back up now go that direction. In the end, we will know what was the correct response for when this happens next time.

By the way, to do this right means that no states get any form of bailout for either of their decisions.
Nitro Power
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I originally read your screen name as "shanked the clown"
When you fall to your knees and ask God for help, don’t forget to fall back on your knees and say ‘thank you’ when He answers.- Steve Torrence
Michael Cera Palin
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I think we're realistically headed for the scenario between 1 and 2 as another poster already mentioned. Even when we open things back up, enough of the population is so spooked about this that they aren't going to shift out of their quarantine routine for at least a couple more months.

The biggest unknown for me is what happens when K-12 schools reopen in the fall. Schools are already a cesspool of germs. Throw in the fact that 99% of kids are asymptomatic and you've got an issue.

Also, I will add, regardless of what scenario is chosen there's a strong enough contingent of people in the media who believe 1 new case is too many. If there's even an iota of an increase in a region, the particular politician in charge is gonna get blasted by the media. It's part of the reason things have taken this long, no governor wanted to be the first one to start easing back because they knew it could result in the end of their political career.
rocky the dog
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Elections are when people find out what politicians stand for, and politicians find out what people will fall for.
Maroon Dawn
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This thing is less deadly than the Flu for people under 60

Let the workers get back to work and build the economy and herd immunity

Keep Meemaw and Peepaw in quarantine

It's really that simple

Any desire to keep young healthy people locked up is being done to kill the economy and enable a Dem fascist police state
AG81xx
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Tell me again why Sweden isn't the answer.

I see no modeling done of isolating the susceptible and letting everyone else develop immunity. Where is that model? I'm sure someone could build a model where the fatality rate for the general population is much lower than that for the susceptible. Also different R factors for different groups.
FrontPorchAg
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There is so much here I don't even know where to start but here we go:
Quote:

Hypothesis: The "shape" of the backside of the coronavirus curve will determine how robust the economic recovery is in the US/World, due to it's implication on buyer confidence in resuming activities that do not require social distancing.
This is more or less correct though I will say social distancing isn't even required for many groups. For example, it's was probably a big mistake to shut down schools. Children are largely unaffected and there is some studies that say that child to adult transmission is limited if not improbable.

Quote:

The most effective way to break the curve is testing, tracing, and isolation, which requires a volume of resources beyond what we currently need at our daily infection levels.
I think this theory is grossly overrated. Between asymptomatic carriers, a high R0 value and a long incubation period contact tracing is little more than a placebo. By the time you see a hotspot developing it has well spread throughout the community.

Quote:

My conclusion: As painful as it may be in the short term, there is a larger long term payoff for stretching to Scenario 3 than the alternatives.


This wrong on two fronts. First, there are more than three options here. You don't address a fourth option of isolating the vulnerable and high risk patients and letting everyone else just go get on with their lives.

Second, I think beyond the problems I have already pointed out you overlook the other health costs that are being tolled. For instance, almost no one in my county has had a mammogram in 2 months, inpatient chemo-care has been halted, people who are coming into the ERs are much sicker than before because they have waited too long to see a physician. You are looking at COVID in isolation of the other health costs and waiting for contacting tracing isn't just "painful in the short term" it is literally killing people
All animals are equal, but some animals are more equal than others
NormanAg
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Very good post - your analysis was thorough and obviously the result of a lot of work. But I have a fundamental disagreement with all three of your scenarios. Unless I missed it, all three are "one size fits all" for the ENTIRE country.

I have made the argument since early in the crisis that this NOT necessary and ends up penalizing vast areas of the country that are relatively sparsely populated. I have seen this play out in OK where our Governor initially put restrictions on only 19 counties out of 77 and then SLOWLY increased the number of counties affected as new cases developed. I am convinced that was the correct approach and it has WORKED IMO. And we are one of the first states to "open it up" again, albeit in stages.

From what I have seen on texags over the past several weeks the Texas Governor did NOT take that approach and many, many citizens in sparsely populated areas have needlessly suffered. IMO you can't find a better example of that than the countless empty hospitals that have laid off staff and are close to running out of money. The ban on elective surgeries should have ended for most of the state 3 weeks into the crisis.

I firmly believe that ANY approach from here on out must NOT be "one size fits all". Maybe there is some version of your Scenario Two that takes into account population density and allows low population areas to basically return to normal sooner rather than later? Or maybe there should be a range of scenarios that take population density into account?

I don't have the answer - but I'm convinced it sure as hell isn't "one size fits all". I think we tried that and some states ignored it and other states that SHOULD have ignored it didn't and failed miserably.
WestTexAg12
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HotardAg07 said:

Sorry. It came out longer than expected.


Can't believe it took this long to post this, but...


That's what she said!
"Give me an army of West Point graduates and I'll win a battle. Give me a handful of Texas Aggies, and I'll win the war.”
- General George S. Patton
Tony Franklins Other Shoe
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I still don't understand and always get riled up when people bring in comparisons to 9/11, Pearl Harbor, and Viet Nam. That shoots down any argument you have. They have no place when comparing what this virus is doing.
lb3
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lb3
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HotardAg07
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I should have clarified that my main point is not that we should continue to be locked down until August or something. I think now that we have more information we should loosen up restrictions. I have always thought that a location-based approach makes sense, what works for Harris County doesn't have to be forced on King County. I think we can sustain R0 < 1 for a few months this summer with continued social distance focus (not mandate) and mask wearing.

But, I did want to explain my support for why I think it makes sense to continue to strive for R0 < 1, rather than to just pursue herd immunity or get comfortable with a thousand deaths per day for months on end. There are many people on this board that disagree with that basic premise. I know @agnalaska was extremely angry that I believed in the idea that most people won't necessarily have to get CV, so I wanted to explain myself.
swampstander
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People get sick, people die...

Open it up.
Line Ate Member
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I just think back to the poster that linked the story of the guy that lived through and survived the Spanish flu. That thing killed everyone. Poor and rich. Young and old. It also happened as our soldiers were returning from Europe.

We can sit here and argue that those people did not know about viruses as well as we do now. However, as those around them died, it seemed that did what most of us have wanted to do since this started. Take precautions, but live your life.

As for the OP. Nice job presenting your ideas. I feel as though there are still too many unknowns as far as the numbers, especially asymptomatic people. Without that, ratios and even trend lines are still too hard to predict.

Just a question for those that have kept up with the population of sick people, how has this virus impacted the homeless in our country? I figured since they are more likely to be less hygienic then most and live in conditions worse than most, then the populations would be dropping in most urban areas. I have not heard that and am wondering if someone does know anything about them.
samurai_science
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The Fife said:

Quote:

If you believe in our ability to make a vaccine in the next 12 months, >100,000 lives would be saved over the course of the virus.


I don't believe there will be one in the next 12 months. People have been trying to cure AIDS and the common cold for decades with no vaccine to show for it. No reason to believe this one will be different IMO.

Where I work we're looking at a 20% RIF between now and July. That's more than disastrous enough, especially for those who get caught up in it.
They have been trying to create a non deadly SARS vaccine since 2004...good luck
samurai_science
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Line Ate Member said:

I just think back to the poster that linked the story of the guy that lived through and survived the Spanish flu. That thing killed everyone. Poor and rich. Young and old. It also happened as our soldiers were returning from Europe.

We can sit here and argue that those people did not know about viruses as well as we do now. However, as those around them died, it seemed that did what most of us have wanted to do since this started. Take precautions, but live your life.

As for the OP. Nice job presenting your ideas. I feel as though there are still too many unknowns as far as the numbers, especially asymptomatic people. Without that, ratios and even trend lines are still too hard to predict.

Just a question for those that have kept up with the population of sick people, how has this virus impacted the homeless in our country? I figured since they are more likely to be less hygienic then most and live in conditions worse than most, then the populations would be dropping in most urban areas. I have not heard that and am wondering if someone does know anything about them.


This is less deadly to young people than the flu. That is not an unknown.
the last of the bohemians
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Did the post calculate for heat, humidity, sunshine, mass transit usage, density?
Probably not, because no other side of the peak model has figured that all out yet.
B-1 83
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AG
"While the "case fatality rate" was calculated to be 3.4% back in March and is 6.9% now, it was understood that there was a large amount of mild/asymptomatic cases that would lead to an eventual "infection fatality rate" of somewhere between 0.5% - 1.0%".

Ok............ If this virus sets up shop in your body, you have between 0.5 and 1% chance of not making it.

What is that rate in NYC? Doesn't it all come back to that?
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