On hydroxychloroquine, expertise, and the power of persuasion.

On hydroxychloroquine, expertise, and the power of persuasion.

Recently, a friend who works in the ER wrote to ask me about hydroxychloroquine.

Yes, I know. I was shocked, too. But my friend was sincere. Although most reputable news outlets have publicized that hydroxychloroquine doesn’t work against Covid-19, my friend read an article from Harvey Risch in Newsweek that seemed really compelling.

Risch has impeccable credentials – he’s an M.D. Ph.D. and a professor of epidemiology at Yale’s School of Public Health. And a lot of what he wrote for his July 23rd article is quite sensible:

Why has hydroxychloroquine been disregarded?

First, as all know, the medication has become highly politicized. For many, it is viewed as a marker of political identity, on both sides of the political spectrum. Nobody needs me to remind them that this is not how medicine should proceed.

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Medical data isn’t perfect, and confirmation bias is very real. So there’s a chance that medical doctors really could hoodwink themselves into discounting a helpful medication, the same way that so many medical doctors get suckered into overprescribing drugs after pharmaceutical companies bribe them with gifts. Yup, medical doctors are human, too.

I know that I’m so dismayed by our current president that I’m inclined to distrust hydroxychloroquine just because he says the drug is great.

So it was a shock for me to read Risch’s article. He wrote that there was data showing that hydroxychloroquine, when used in a combination therapy early during a high-risk person’s Covid-19 infection, could dramatically reduce the risk of serious complications. If more people took hydroxychloroquine, he wrote, fewer would die.

Risch acknowledges that hydroxychloroquine is dangerous – it might kill 1 out of each 10,000 people who take it – but Covid-19 is obviously dangerous, too – it kills 3 out of each 1,000 people who contract it:

In the future, I believe this misbegotten episode regarding hydroxychloroquine will be studied by sociologists of medicine as a classic example of how extra-scientific factors overrode clear-cut medical evidence.

But for now, reality demands a clear, scientific eye of the evidence and where it points. For the sake of high-risk patients, for the same of our parents and grandparents, for the sake of the unemployed, for our economy and for our polity, especially those disproportionately affected, we must start treating immediately.

Those are strong words. And, really, the Newsweek article felt persuasive to me. And so I looked up Risch’s research in the American Journal of Epidemiology, hoping to see the actual data in support of his claims.

I’m lucky, that way. I’m a scientist, so I don’t have to trust the words of a supposed expert. I’m an expert. I get to look at the data.

The data are much less compelling than Risch’s words.

Risch discusses the results of an uncontrolled study by Vladimir Zelenko, a medical doctor in Monroe, New York: “For example, among Connecticut cases 60 years of age or older, at present the mortality is 20%. Thus it would be ballpark to estimate that some 20% of the 1466 treated high-risk patients in the Zelenko cohort would have died without outpatient hydroxychloroquine plus antibiotic.

This is an egregiously inaccurate statement. The high death rate cited – 20 – is for older patients who test positive for Covid-19 and have such severe symptoms that they need to be hospitalized.

As described in the short statement released by Zelenko, he treated 405 people who visited his office complaining of mild cough, fever, headache, sore throat, or diarrhea. His patients were not given a Covid-19 test. Presumably, many were never infected with Covid-19.

It is not a surprise to see that a 60-year-old patient who takes hydroxychloroquine after developing a sore throat from seasonal allergies is less likely to die than a 60-year-old patient who is diagnosed with Covid-19 in the hospital.

Of Zelenko’s 405 patients, at least two 2 died. This is lower than the expected 1% mortality rate of high-risk patients who contract Covid-19. But this set of 405 patients included low-risk patients experiencing shortness of breath and high-risk patients experiencing mild headache, many of whom never had Covid-19.

Zelenko’s report is two pages long and written in extremely lucid prose. Risch either totally misread it, which is galling, or intentionally mis-described it, which is worse.

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So, why was Zelenko giving people hydroxychloroquine in the first place?

Well, I’d heard that an in vitro study – which means “inside a test tube or petri dish, not a person” – showed that hydroxychloroquine reduced Covid-19 viral replication. But I hadn’t read the original paper. So I looked it up.

It should have taken me less than a minute to find this paper. Unfortunately, people have been pretty sloppy with their references. I get it. Covid-19 is scary, and it’s urgent, so people are publishing faster than usual.

I assumed that I could pull up almost any paper on hydroxychloroquine and Covid-19 and quickly find the citation for the original study. Indeed, most purport to be citing it. But in this, the citation that ought to have pointed to that study instead sent me to a paper on the differentiation of lung stem cells, and in this, the relevant citation incorrectly points to a paper on the drug lopinavir.

Ugh. I mean, these bungled citations aren’t that big a deal for me, personally – just means I had to give up on piggybacking and instead search Pubmed. But it undermines trust when you can’t get the little things right.

Anyway, the earliest reference that I found was from Liu et al., their study “Hydroxychloroquine, a less toxic derivative of chloroquine, is effective at inhibiting SARS-CoV-2 infection in vitro.” And, yes, I’ll admit – I thought about putting in the wrong link just to mess with you. But, if I did that, would you still trust me about the rest of this?

Liu et al. used Vero cells – a cell line derived from a kidney cancer in African green monkeys – and for Figure 1, they measured both how much hydroxychloroquine it takes to kill cells (about 200 micromolar is a cytotoxic dose) and how much hydroxychloroquine it takes to inhibit viral infection (about a 10 micromolar dose).

Okay. To me, that’s already sounding a little spooky. The bigger the difference between an effective dose and a lethal dose, the safer you are.

That’s why a bunch of hippies died after The Teachings of Don Juan was published. That book touted jimsomweed as a psychedelic. Indeed, the plant contains a high concentration of scopolamine, which can give people nightmarish visions of flying. It’s a powerful hallucinogen. But the effective dose is quite close to the lethal dose – when curious kids try to get high off it, they’re flirting with death.

Everyone’s body is a little different from everyone else’s. Maybe a dose that’s safe for you would kill me. The odds of disaster are worse when the effective dose and lethal dose are similar.

So, Liu et al. saw cytotoxicity kick in at around 100 micromolar hydroxychloroquine, getting pretty high by 200 micromolar. And for their visual assay of viral infection, they bathed their Vero cells in 50 micromolar hydroxychloroquine.

To block viral entry, they were coming pretty close to just killing these cells with the drug.

And the problem is even worse inside a human body. You take a drug and it gets into your bloodstream. It’ll reach some concentration there. This is the concentration that matters most for toxicity.

But the drug will only be effective against Covid-19 when it reaches your lungs. When Marzolini et al. used mass spectrometry to measure how much of hydroxychloroquine was actually getting from a patient’s blood to their lungs, they found that it wasn’t at a high enough concentration to reproduce any effects seen in vitro.

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Indeed, a randomized clinical study showed that hydroxychloroquine fails as a post-exposure prophylaxis. The drug was given to people who were worried about exposure because they’d spent time with someone who tested positive for Covid-19. The drug didn’t help – these people contracted the infection at the same rate as people who were given a placebo.

A randomized clinical study also showed that hydroxychloroquine fails as a cure. People who visited a hospital and tested positive for Covid-19 but had mild symptoms were given the drug. Their disease was just as likely to progress as people who received a placebo.

Hydroxychloroquine doesn’t work, and it’s toxic.

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I was left wondering: why would Risch write these things? Why would he write that article for Newsweek? He’s clearly intelligent, and, from the tone of his writing, I feel confident that he wants to help people.

He might even believe wholeheartedly in the conclusion he’s presenting.

That’s generally true among scientists. Confirmation bias is insidious.

That paper from the team at Harvard? They did some modeling and argued that, if Covid-19 is seasonal, we will save most lives by periodically shutting down. But their model left out the waning immunity that would cause Covid-19 to be seasonal! Whoops. That’s why they reached the wrong conclusion.

Or the recent New York Times editorial from Iwasaki and Medzhitov, both professors of immunobiology at Yale, reassuring readers that they won’t get Covid-19 twice. Well, that’s not correct.

Some antigens confer immunity that lasts about as long as our lives. Most don’t. Influenza immunity lasts months, not years. The paper that Iwasaki and Medzhitov cited in their article, a study in which people were intentionally infected with a less dangerous coronavirus, found that immunity to that virus lasted months, not years.

Covid-19 immunity will not last forever. The relevant question isn’t whether you can be infected again, it’s how soon you can be re-infected. With the data we have so far, it’s reasonable to expect that the answer will be measured in months, not years.

There’s some good news – the second time you contract Covid-19, it’ll probably be less severe than the first. In addition to antibodies, your immune system has “T cell memory” to help you fight off subsequent infections. But, as is also described in the paper cited by Iwasaki and Medzhitov, even people who felt fine were shedding virus again the second time they were infected.

During the second infection, the research subjects were shedding viral particles for a shorter period of time. But, especially with Covid-19 – a virus that can be transmitted simply by talking – a person who sheds virus for a short time while feeling fine is probably more likely to transmit the disease than somebody who sheds virus for a whole week while feeling like garbage.

The person who feels like garbage will stay home. The person who feels fine won’t.

Still, though, I was left wondering – what underlying beliefs would sway Risch enough that he’d make these blunders?

Eventually, I decided to lump his motivation in with mine. Maybe that’s fair, maybe it’s not. Really, I have no idea what he was thinking, so this is just my best guess.

But I imagine that many of these people – Risch, Iwasaki, Medzhitov, John Ioannidis, David Katz, all of whom are very smart, and all of whom mean well – understand that the strategies we’re using against Covid-19 are both ineffectual and are causing harm.

No shutdown will eliminate Covid-19 – the best we can do is to delay it. And we can delay it only as long as we maintain the shutdown. Maybe that seems fine if you’re an older, wealthy person brimming with optimism about vaccine development, like Anthony Fauci who thinks we’ll have a working vaccine early next year, but it’s unconscionable if you think a working vaccine might be five or more years away.

I don’t think we should try to pause children’s development for five years.

Still, there’s no mathematical or logical way to prove what we should do. School closures definitely slow the spread of Covid-19. How do you balance the good of delaying an elderly person’s infection by three months (which is equivalent to a drug that extends a patient’s life by three months) with the harms we’re causing?

I know what I’d do, but other people have different priorities than me. And that’s okay!

I’d like to think, though, that I’m not trying to hoodwink anybody about the science in order to deceptively get them to do the thing I think is right.

Like, yes, I think schools should be open. I think we owe it to children. Right now, children are suffering, but this is our fault, the fault of grown-ups.

We have known for over a decade that we ought to make coronavirus vaccines – we didn’t devote enough resources to it, and now we don’t have one. We’ve known for decades that eating animals – both those sold in meat markets like in Wuhan and the ones raised in “concentrated animal feeding operations” throughout the U.S. – will create more zoogenic diseases, and we kept doing it. We know that a guaranteed basic income would’ve given people the resources they needed to self-isolate during an epidemic – we don’t have one. We know that guaranteed access to health care would keep our death rate down.

Climate change will make pandemics more frequent, in addition to making our world unliveable for future generations. And we haven’t taken action to stop it.

None of these failings are children’s fault. We, older people, have failed. We fucked up. And now we’re asking children to make sacrifices to dampen the impact of our mistake (although, again, it won’t work – it’ll just delay the eventual repercussions).

I think today’s children deserve a fair shot at a good life, and I think that school is an essential part of that.

But don’t let anybody try to convince you that it’s safe to re-open schools because hydroxychloroquine will stop Covid-19.

On money, nursing home care, and Covid-19.

In April, I wrote several essays and articles about our collective response to Covid-19.

I was worried – and am still worried, honestly – that we weren’t making the best choices.

It’s hard not to feel cynical about the reasons why we’ve failed. For instance, our president seems more concerned about minimizing the visibility of disaster than addressing the disaster itself. We didn’t respond until this virus had spread for months, and even now our response has become politicized.

Also, the best plans now would include a stratified response based on risk factor. Much more than seasonal influenza, the risk of serious complications from Covid-19 increases with age. Because we didn’t act until the virus was widespread, eighty-year-olds should be receiving very different recommendations from forty- and fifty-year-olds.

Our national response is being led by an eighty-year-old physician, though, and he might be biased against imposing exceptional burdens on members of his own generation (even when their lives are at stake) and may be less sensitive to the harms that his recommendations have caused younger people.

I’m aware that this sounds prejudiced against older folks. That’s not my intent.

I care about saving lives.

Indeed, throughout April, I was arguing that our limited Covid-19 PCR testing capacity shouldn’t be used at hospitals. These tests were providing useful epidemiological data, but in most cases the results weren’t relevant for treatment. The best therapies for Covid-19 are supportive care – anti-inflammatories, inhalers, rest – delivered as early as possible, before a patient has begun to struggle for breath and further damage their lungs. Medical doctors provided this same care whether a Covid-19 test came back positive or negative.

(Or, they should have. Many patients were simply sent home and told to come back if they felt short of breath. Because they didn’t receive treatment early enough, some of these patients then died.)

Instead, our limited testing capacity should have been used at nursing homes. We should have been testing everyone before they went through the doors of a nursing home, because people in nursing homes are the most vulnerable to this virus.

I realize that it’s an imposition to make people get tested before going in, either for care or to work – even with real-time reverse-transcription PCR, you have to wait about two hours to see the results. But the inconvenience seems worthwhile, because it would save lives.

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From March 25 until May 10 – at the same time that I was arguing that our limited Covid-19 tests be used at nursing homes instead of hospitals – the state of New York had a policy stating that nursing homes were prohibited from testing people for Covid-19.

I really dislike the phrase “asymptomatic transmission” – it’s both confusing and inaccurate, because viral shedding is itself a symptom – but we knew early on that Covid-19 could be spread by people who felt fine. That’s why we should have been using PCR tests before letting people into nursing homes.

But in New York, nursing homes were “prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.

This policy caused huge numbers of deaths.

Not only do nursing homes have the highest concentration of vulnerable people, they also have far fewer resources than hospitals with which to keep people safe. Nursing home budgets are smaller. Hallways are narrower. Air circulation is worse. The workers lack protective gear and training in sterile procedure. Nursing home workers are horrendously underpaid.

The low wages of nursing home workers aren’t just unethical, they’re dangerous. A recent study found that higher pay for nursing home workers led to significantly better health outcomes for residents.

This study’s result as described in the New York Times – “if every county increased its minimum wage by 10 percent, there could be 15,000 fewer deaths in nursing homes each year” – is obviously false. But even though the math doesn’t work out, raising the minimum wage is the right thing to do.

If we raised the minimum wage, we probably would have a few years in which fewer people died in nursing homes. But then we’d see just as many deaths.

Humans can’t live forever. With our current quality of care, maybe nursing home residents die at an average age of 85. If we raise the minimum wage, we’ll get better care, and then nursing home residents might die at an average age of 87. After two years, we’d reach a new equilibrium and the death rate would be unchanged from before.

But the raw number here – how many people die each year – isn’t our biggest concern. We want people to be happy, and an increase in the minimum wage would improve lives: both nursing home residents and workers. Which I’m sure that study’s lead author, economist Kristina Ruffini, also believes. The only problem is that things like “happiness” or “quality of life” are hard to quantify.

Especially when you’re dealing with an opposition party that argues that collective action can never improve the world, you have to focus on quantifiable data. Happiness is squishy. A death is unassailable.

Indeed, that’s partly why we’ve gotten our response to Covid-19 wrong. Some things are harder to measure than others. It’s easy to track the number of deaths caused by Covid-19. (Or at least, it should be – our president is still understating the numbers.)

It’s much harder to track the lives lost to fear, to domestic violence, and to despair (no link for this one – suddenly Fox News cares about “deaths of despair,” only because they dislike the shutdown even more than they dislike poor people).  It’s hard to put a number on the value of 60 million young people’s education.

But we can’t discount the parts of our lives that are hard to measure – often, they’re the most important.

On money: Health care, police officers, and social services.

On money: Health care, police officers, and social services.

Last week, my kids and I visited my father in Indianapolis. We went to a playground near his apartment.

Playgrounds had re-opened the day before, so my kids were super excited. They’d gone almost three months without climbing much. And the playground near my father’s apartment is excellent, with a variety of nets and terraces suspended from platforms near the canal.

When we arrived – at about eleven a.m. on an eighty-five degree day – we noticed a child sprawled face down in the shade at the other end of the playground, apparently asleep.

My own eldest child promptly started climbing toward the highest slide, which was going to be quite difficult for her. I followed her up, ready to provide encouragement whenever she felt too nervous, and to catch her if she slipped.

My four-year-old hopped onto a swing.

My father, temporarily free of supervisory duties, crossed the playground. In addition to us and the sleeping child, one other family was playing – a woman my age with a baby strapped to her chest and a four-year-old careening in front of her.

My father asked if the sleeping child had come with them. The woman shook her head. So my father asked a few more people, calling down to folks who were sitting on benches near the water.

Nobody knew who this child was.

My father knelt down and gently woke him, to ask if he was okay. My father is a medical doctor. Helping people is what he likes to do.

When roused, the child had a seizure. His body shook. His eyes went stark white, having rolled all the way to the side.

My father called 911.

But then, after about thirty seconds, the child’s seizure ended. And, unlike the fallout from a typical epileptic seizure, the child sat up immediately, alert and unconfused.

My father told the dispatcher that maybe things were fine – no need to send an ambulance – then hung up to talk to the child.

“Are you okay?” my father asked.

“Oh, that’s my sugar high,” the child said. “Some people get a sugar high from eating sugar, but I get that when I sleep. It happens a lot, just when I sleep.”

“I think you had a seizure.”

“Well, I just call that my sugar high.”

“Do you take any medications?” my father asked.

“Only a little, sometimes, for my ADHD.” And then the child started to climb up toward the high slide of the playground, near me.

A few moments later, a drone began to hover near us. I’m not fond of drones, mechanically whirring through the air. And I’ve never even had reason to feel traumatized! They must be so terrifying for people who’ve survived contemporary war zones, or who’ve been subject to drone-enhanced policing.

“What’s that noise?” my six-year-old asked.

“It’s a robot,” I said. “A flying robot. See, over there. Sometimes they put cameras in them.”

“It’s called a drone,” the formerly sleeping child clarified. “I used to work with drones. I’m an inventor. But that person should be careful. That drone is over the water, and when drones crash into the water they can short circuit and catch fire.”

“You like drones?” I asked.

“I like to build stuff. Some drones you can control with your mind, like telekinesis, with a strap …”

“Oh, like an electroencephalogram?” I asked. “We played a game at a museum once, you wear a headband and try to think a ping-pong ball across the table.”

“You can make a drone fly that way, too. But those are tricky because if you laugh they crash.”

“You wouldn’t want to laugh while it was over the water!” my six-year-old exclaimed, giggling.

“You wouldn’t,” the child agreed, sagely. And then he turned to me to ask, “Say, do you know where the nearest McDonalds is? My dad wants me to get him something.”

I shook my head, apologizing. “We’re visiting my father, I don’t know where anything is around here. But you could try asking him.”

When asked, my father shook his head, too. His apartment is in a rather fancy part of of Indianapolis, it seems. “I don’t know of one … I don’t think I’ve seen a McDonalds around here.”

“Well, that’s okay, I’ll get something at a gas station instead. Thanks!”

And with that, the child jogged away. I never even learned his name.

My father walked over to me. “I’m worried about him,” he said. “That was a tonic-clonic seizure! I don’t know how he came out of that feeling lucid. I mean, he’s obviously a bright kid, but …”

“It didn’t look like he had a phone with him,” I said. “I don’t know, suddenly needing food … I’d guess schizophrenia, but that’d be really strange for an eight-year-old.”

“I know,” my father said. “But something’s wrong.”

On that, we definitely agreed. A lot of somethings might be wrong if a third grader is napping at a city playground on his own.

And I didn’t help him.

In retrospect, I’m still not sure what I should have done.

When my father thought the child was experiencing an acute medical emergency, he called 911. But then he canceled the request when the problem seemed chronic, not urgent. The arrival of an ambulance probably would’ve caused more harm than good, because a trip to the ER is often followed by egregious bills.

A few weeks ago, my spouse woke up with blurry vision. This might be nothing serious, or it might be the sign of a detached retina, so we drove her to the ER. After two hours of waiting, a doctor spent three minutes with her, visually examining my spouse’s eye while shining a light on it.

Thankfully, nothing was wrong.

We received a bill for $1,600. After requesting an itemized bill, they split the charges into a $200 ER fee and $1,400 for “ED LEVEL 3 REGIONAL.”

To diagnose a child who’d just emerged from an atypical seizure, they might levy poverty-inducing charges, which is why my father canceled with the dispatcher. He volunteers at the free clinic because he knows how many people are priced out of access to health care in our country.

But, if not a hospital, who could we call for help?

Currently, there’s a big push to defund the police. In many cities, the budget for policing is so large, and the budget for other public services so small, that police officers are de facto social workers. Which doesn’t make anybody happy.

In a recent New York Times conversation, Vanita Gupta said, “When I did investigations for the Justice Department, I would hear police officers say: ‘I didn’t sign up to the police force to be a social worker. I don’t have that training.’

Police officers are tasked with responding to mental health crises, despite receiving little training in psychology, counseling, or even de-escalation. Police officers use their budget to combat the downstream effects of poverty – which often includes theft, vandalism, and domestic violence – without a commensurate amount being spent on addressing the poverty itself. Police budgets dwarf the amounts spent on jobs programs and public work projects.

Many police officers join the force because they want to help people. They’re motivated by the same altruism that inspired my father to practice medicine. But just as hospital billing, as a system, undermines the altruism of individual doctors (“In this seminar, we’re going to train you to optimize billing. If you perform diagnostics on a third organ system, we elevate patient care to the preferred reimbursement tier.”), American policing, as a system, exacerbates racial injustice and inequality.

Even a charming, well-spoken, eight-year-old Black child has good reason to fear the police. I don’t think any good would have come from us calling the cops.

And so I’m left wondering – what would it be like if we did have an agency to call? What if, instead of police officers with guns, we had social workers, counselors, and therapists patrolling our streets?

Maybe then it would have been easy to help this child.

As is, I did nothing.

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Feature image: photograph of sidewalk chalk by Ted Eytan, Washington D.C.

On moral outrage.

On moral outrage.

My family had spring break travel plans for before the shutdown.

We canceled them.

At the time, we feared for our safety. My spouse said to me, “You caught the flu twice this year, even after you were vaccinated, and the second time was the sickest I’ve ever seen you. I’m really worried about what will happen if you catch this new thing, too.”

She wanted me to cancel my poetry classes in the local jail. My father, an infectious diseases doctor and professor of immunology, recommended that I still go in to teach. “If somebody’s in there coughing up a lung, you should recommend he skip class next week,” my father told me.

But I was spooked. I felt glad when the jail put out a press release saying they’d no longer allow volunteers to come in – I didn’t want to choose between helping the incarcerated men and protecting my family.

My spouse is a high school science teacher. She felt glad that her biology classroom has over a dozen sinks. During the final week of school, she asked all her students to wash their hands for 20 seconds as soon as they walked into the room.

My spouse and I are both scientists, but it wasn’t until a week into the shutdown that I began to read research papers about Covid-19. Until then, we had gotten all our information from the newspaper. And the news was terrifying. Huge numbers of people were dying in Italy. Our imbecilic president claimed that Covid-19 was no big deal, making me speculate that this disease was even more dangerous than I’d thought.

Later, I finally went through the data from Italy and from the Diamond Princess cruise ship. These data – alongside the assumption that viral exposure should be roughly similar across age groups, if not higher for school children and young people who are out and about in the world – showed my family that our personal risk was probably quite low.

Still, we stayed inside. We were worried about harming others.

When I saw photographs of beaches packed with revelers, I felt furious. Did those selfish young people not realize that their choices could cause more people to die?

So it was shocking for me to learn that those selfish young people were actually doing the thing that would save most lives.

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We now know that Covid-19 can be transmitted by people who feel no symptoms, and that it was widespread in this country by March.

If we, as a people, had acted earlier, we could have prevented all these deaths. In January, it would have been enough to impose a brief quarantine after all international travel. In February, it would have been enough to use our current strategy of business closures, PCR testing, and contact tracing. In March, we were too late. The best we could do then – the best we can do now – was to slow the spread of infections.

Unfortunately, slowing the spread of infections will cause more people to die.

There’s an obvious short-term benefit to slowing the spread of infections – if too many people became critically ill at the same time, our hospitals would be overwhelmed, and we’d be unable to offer treatment to everyone who wanted it. We’d run out of ventilators.

This problem is exacerbated by the fact that we, as a people, are terrible about talking about death. There’s no consensus about what constitutes a good life – what more would have to happen for you to feel ready to die?

Personally, I don’t want to die. As my mind stopped, I’d feel regret that I wouldn’t get to see my children become self-sufficient adults. But I’d like to think that I could feel proud that I’ve done so much to set them on the right path. Since my twenties, I’ve put forth a constant effort to live ethically, and I’d like to imagine that my work – my writing, teaching, and research – has improved other people’s lives.

I’ve also gotten to see and do a lot of wonderful things. I’ve been privileged to visit four countries. I visited St. Louis’s City Museum when one of my kids was old enough to gleefully play. I have a bundle of some two dozen love letters that several wonderful people sent me.

I’ve had a good life. I’d like for it to continue, but I’ve already had a good life.

Many medical doctors, who have seen how awful it can be for patients when everything is done to try to save a life, have “do not resuscitate” orders. My spouse and I keep our living wills in an accessible space in our home. But a majority of laypeople want dramatic, painful measures to be taken in the attempt to save their lives.

People are making this choice even during the pandemic, when the choice to experience an excruciating death puts medical professionals at risk and reduces the quality of care available for everyone else.

Still. Even without our reluctance to discuss death, there would be a short-term benefit to slowing the spread of infections. The American healthcare system is terrible, and was already strained to the breaking point. We weren’t – and aren’t – ready to handle a huge influx of sick patients.

But the short-term benefit of slowing the spread of Covid-19 comes at a major cost.

The shutdown itself hurts people. The deaths caused by increased joblessness, food insecurity, educational disruption, domestic violence, and loneliness (“loneliness and social isolation can be as damaging to health as smoking 15 cigarettes a day”) are more difficult to measure than the deaths caused by Covid-19. We won’t have a PCR test to diagnose which people were killed by the shutdown.

Those deaths won’t all come at once. But those deaths are no less real, and no less tragic, than the immediate horror of a person drowning from viral-induced fluid buildup in their lungs.

And, perhaps more damning, if the shutdown ends before there’s a vaccine, the shutdown will cause more people to die of Covid-19.

Without a vaccine, slowing the spread of Covid-19 has a short-term benefit of reducing the rate of hospital admissions, at the long-term cost of increasing the total number of Covid-19 cases.

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All immunity fades – sometimes after decades, sometimes after months. Doesn’t matter whether you have immunity from recovery or from vaccination – eventually, your immunity will disappear. And, for a new disease, we have no way of predicting when. Nobody knows why some antigens, like the tetanus vaccine, trigger such long-lasting immunity, while other antigens, such as the flu vaccine or the influenza virus itself, trigger such brief protection.

We don’t know how long immunity to Covid-19 will last. For some coronaviruses, immunity fades within a year. For others, like SARS, immunity lasts longer.

The World Health Organization has warned, repeatedly, that immunity to Covid-19 might be brief. But the WHO seems unaware of the implications of this warning.

The shorter the duration of a person’s immunity, the more dangerous the shutdown. If our shutdown causes the Covid-19 epidemic to last longer than the duration of individual immunity, there will be more total infections – and thus more deaths – before we reach herd immunity.

This is, after all, exactly how a one-time “novel zoogenic disease” like influenza became a permanent parasite on our species, killing tens of thousands of people in the United States each year. Long ago, transmission was slowed to the point that the virus could circulate indefinitely. Influenza has been with us ever since.

That’s the glaring flaw in the recent Harvard Science paper recommending social distancing until 2022 – in their key figure, they do not incorporate a loss of immunity. Depending on the interplay between the rate of spread and the duration of immunity, their recommendation can cause this epidemic to never end.

And, if the shutdown ends before we have a vaccine, the lost immunity represents an increased death toll to Covid-19. Even neglecting all the other harms, we’ll have killed more people than if we’d done nothing.

This sounds terrifying. And it is. But the small glimmer of good news is that people’s second infections will probably be less severe. If you survive Covid-19 the first time you contract it, you have a good chance of surviving subsequent infections. But prolonging the epidemic will still cause more deaths, because herd immunity works by disrupting transmission. Even though an individual is less likely to die during a second infection, that person can still spread the virus. Indeed, people are more likely to spread the virus during subsequent infections, because they’re more likely to feel healthy while shedding infectious particles.

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This calculation would be very different if people could be vaccinated.

Obviously, vaccination would be the best way to end this epidemic. In order to reach herd immunity by a sufficient number of people recovering, there would have to be a huge percentage of our population infected. Nobody knows how many infections it would take, but many researchers guess a number around 60% to 70% of our population.

Even if Covid-19 were no more dangerous than seasonal influenza (and our data so far suggest that it’s actually about four-fold more dangerous than most years’ seasonal influenza), that would mean 200,000 deaths. A horrifying number.

But there’s no vaccine. Lots of people are working on making a vaccine. We have Covid-19 vaccines that work well in monkeys. But that doesn’t necessarily mean anything in terms of human protection. We’ve made many HIV vaccines that work well in monkeys – some of these increase the chance that humans will contract HIV.

It should be easier to make a vaccine against this coronavirus than against HIV. When making a vaccine, you want your target to mutate as little as possible. You want it to maintain a set structure, because antibodies need to recognize the shape of external features of the virus in order to protect you. HIV mutates so fast that its shape changes, like a villain constantly donning a new disguise. But the virus that causes Covid-19 includes a proofreading enzyme, so it’ll switch disguises less.

Still, “easier to make a vaccine against than HIV” is not the most encouraging news. Certain pharmaceutical companies have issued optimistic press briefings suggesting that they’ll be able to develop a vaccine in 18 months, but we should feel dubious. These press briefings are probably intended to bolster the companies’ stock prices, not give the general public an accurate understanding of vaccine development.

Realistically, a Covid-19 vaccine is probably at least four years away. And it’s possible – unlikely, but possible – that we’ll never develop a safe, effective vaccine for this.

If we end the shutdown at any time before there is a vaccine, the shutdown will increase the number of people who die of Covid-19. The longer the shutdown, the higher the toll. And a vaccine is probably years away.

The combination of those two ideas should give you pause.

If we’re going to end the shutdown before we have a vaccine, we should end it now.

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To be absolutely clear, vaccination would be the best way to resolve this crisis. Vaccination saves lives. The basic principle of inoculation was used for hundreds of years in Africa, India, and China, before it was adapted by Edward Jenner to create the first smallpox vaccine.

For a vaccine to end the Covid-19 epidemic, enough people will need to choose to be vaccinated for us to reach herd immunity.

Unfortunately, many people in the United States distrust the well-established efficacy and safety of vaccines. It’s worth comparing Covid-19 to seasonal influenza. On a population level, Covid-19 seems to be about four-fold more dangerous than seasonal influenza. But this average risk obscures some important data – the risk of Covid-19 is distributed less evenly than the risk of influenza.

With influenza, healthy young people have a smaller risk of death than elderly people or people with pre-existing medical conditions. But some healthy young people die from seasonal influenza. In the United States, several thousand people between the ages of 18 and 45 die of influenza every year.

And yet, many people choose not to be vaccinated against influenza. The population-wide vaccination rate in the United States is only 40%, too low to provide herd immunity.

Compared to influenza, Covid-19 seems to have less risk for healthy young people. Yes, healthy young people die of Covid-19. With influenza, about 10% of deaths are people between the ages of 18 and 45. With Covid-19, about 2% of deaths are people in this age group.

I’m not arguing that Covid-19 isn’t dangerous. When I compare Covid-19 to seasonal influenza, I’m simply comparing two diseases that are both deadly.

I get vaccinated against influenza every year.

Yes, you might have heard news reports about the influenza vaccine having low efficacy, but that’s simply measuring how likely you are to get sick after being vaccinated. We also know that the vaccine makes your illness less severe.

The influenza vaccine saves lives. The data are indisputable.

But people don’t choose to get it! That’s why I think it’s unfortunately very likely that people whose personal risk from Covid-19 is lower than their risk from influenza will forgo vaccination. Even if we had access to 300 million doses of a safe, effective vaccine today, I doubt that enough people would get vaccinated to reach herd immunity.

Obviously, I’d love to be wrong about this. Vaccination saves lives.

Please, dear reader, get a flu vaccine each year. And, if we develop a safe, effective Covid-19 vaccine, you should get that too.

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We don’t have a vaccine. The shutdown is causing harm – the shutdown is even increasing the total number of people who will eventually die of Covid-19.

Is there anything we can do?

Luckily, yes. We do have another way to save lives. We can change the demographics of exposure.

Our understanding of Covid-19 still has major gaps. We need to do more research into the role of interleukin 6 in our bodies’ response to this disease – a lot of the healthy young people who’ve become critically ill with Covid-19 experienced excessive inflammation that further damaged their lungs.

But we already know that advanced age, smoking status, obesity and Type 2 diabetes are major risk factors for complications from Covid-19. Based on the data we have so far, it seems like a low-risk person might have somewhere between a hundredth or a thousandth the chance of becoming critically ill with Covid-19 as compared to an at-risk person. With influenza, a low-risk person might have between a tenth and a hundredth the chance of becoming critically ill.

The risk of Covid-19 is more concentrated on a small segment of the population than the risk of influenza.

To save lives, and to keep our hospitals from being overwhelmed, we want to do everything possible to avoid exposing at-risk people to this virus.

But when healthy young people take extraordinary measures to avoid getting sick with Covid-19 – like the shutdown, social distancing, and wearing masks – they increase the relative burden of disease that falls on at-risk people. We should be prioritizing the protection of at-risk people, and we aren’t.

Because this epidemic will not end until we reach the population-wide threshold for herd immunity, someone has to get sick. We’d rather it be someone who is likely to recover.

Tragically, we already have data suggesting that a partial shutdown can transfer the burden of infection from one group to another. In the United States, our shutdown was partial from the beginning. People with white-collar jobs switched to working remotely, but cashiers, bus drivers, janitors, people in food prep, and nurses have kept working. In part because Black and brown people are over-represented in these forms of employment, they’ve been over-represented among Covid-19 deaths.

There is absolutely no reason to think that poor people would be more likely to safely recover from Covid-19 – indeed, due to air pollution, stress, sleep deprivation, limited access to good nutrition, and limited access to health care, we should suspect that poor people will be less likely to recover – but, during the shutdown, we’ve shifted the burden of disease onto their shoulders.

This is horrible. Both unethical and ineffective. And, really, an unsurprising outcome, given the way our country often operates.

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If we want to save lives, we need for healthy younger people to use their immune systems to protect us. The data we have so far indicates that the shutdown should end now — for them.

It will feel unfair if healthy younger people get to return to work and to their regular lives before others.

And the logistics won’t be easy. We’ll still need to make accommodations for people to work from home. Stores will have to maintain morning hours for at-risk shoppers, and be thoroughly cleaned each night.

If school buildings were open, some teachers couldn’t be there – they might need substitutes for months – and neither could some students, who might switch to e-learning to protect at-risk family.

We’ll need to provide enough monetary and other resources that at-risk people can endure a few more months of self-isolation. Which is horrible. We all know, now that we’ve all been doing this for a while, that what we’re asking at-risk people to endure is horrible. But the payoff is that we’ll be saving lives.

Indeed, the people who self-isolate will have lowest risk. We’ll be saving their lives.

And no one should feel forced, for financial reasons or otherwise, to take on more risk than they feel comfortable with. That’s why accommodations will be so important. I personally would feel shabby if I took extreme measures to protect myself, knowing that my risk is so much lower than other people’s, but you can’t look at someone in a mask and know their medical history, much less whom they might be protecting at home.

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All told, this plan isn’t good. I’m not trying to convince you that this is good. I’m just saying that, because we bungled things in January, this is the best we have.

If we could go back in time, we’d obviously do things differently. It’s only based on where we are now that physicians like David Katz argue we need to end the shutdown based on the principle of “harm minimization.”

Based on the data we have, I agree.

Ending the shutdown now, but only for some, will save lives.

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So, those selfish young people crowding on beaches? I looked at the photos and hated them.

But it turns out that their selfish actions were actually the exact plan that will save most lives.

I’ve had to swallow my moral indignation. I hope you can too.

On testing.

On testing.

UPDATE: Wow, this got a lot of readers! Honestly, though, I wrote a response to common questions and comments about this essay and it is probably a better read.

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My spouse recently sent me a link to the article “Concerns with that Stanford study of coronavirus prevalence” by Andrew Gelman, a statistician at Columbia University.  From reading this article, I got the impression that Gelman is a good mathematician.  And he raises some legitimate concerns. 

But I’ve noticed that many of the people criticizing the work coming out of the Ioannidis group – such as the study of how many people in Santa Clara county might have antibodies to Covid-19 – don’t seem to understand the biology underlying the numbers.

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First, some background: in case you haven’t noticed, most of the United States is operating under a half-assed lockdown.  In theory, there are stay-at-home orders, but many people, such as grocery store clerks, janitors, health care workers, construction workers, restaurant chefs, delivery drivers, etc., are still going to work as normal.  However, schools have been closed, and most people are trying to stand at least six feet away from strangers.

We’re doing this out of fear that Covid-19 is an extremely dangerous new viral disease.  Our initial data suggested that as many as 10% of people infected with Covid-19 would die.

That’s terrifying!  We would be looking at tens of millions of deaths in the United States alone!  A virus like this will spread until a majority of people have immunity to it – a ballpark estimate is that 70% of the population needs immunity before the epidemic stops.  And our early data suggested that one in ten would die.

My family was scared.  We washed our hands compulsively.  We changed into clean clothes as soon as we came into the house.  The kids didn’t leave our home for a week.  My spouse went to the grocery store and bought hundreds of dollars of canned beans and cleaning supplies.

And, to make matters worse, our president was on the news saying that Covid-19 was no big deal.  His nonchalance made me freak out more.  Our ass-hat-in-chief has been wrong about basically everything, in my opinion.  His environmental policies are basically designed to make more people die.  If he claimed we had nothing to worry about, then Covid-19 was probably more deadly than I expected.

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Five weeks have passed, and we now have much more data.  It seems that Covid-19 is much less dangerous than we initially feared.  For someone my age (37), Covid-19 is less dangerous than seasonal influenza.

Last year, seasonal influenza killed several thousand people between the ages of 18 and 49 in the United States – most likely 2,500 people, but perhaps as many as 5,800.  People in this age demographic account for about 10% of total flu deaths in the United States, year after year.

Seasonal influenza also killed several hundred children last year – perhaps over a thousand.

There’s a vaccine against influenza, but most people don’t bother. 

That’s shocking. 

Seasonal influenza is more dangerous than Covid-19 for people between the ages of 18 and 49, but only 35% of them chose to be vaccinated in the most recently reported year (2018).  And because the vaccination rate is so low, our society doesn’t have herd immunity.  By choosing not to get the influenza vaccine, these people are endangering themselves and others.

Some people hope that the Covid-19 epidemic will end once a vaccine is released.  I am extremely skeptical.  The biggest problem, to my mind, isn’t that years might pass before there’s a vaccine.  I just can’t imagine that a sufficient percentage of our population would choose to get a Covid-19 vaccine when most people’s personal risk is lower than their risk from influenza.

When I teach classes in jail, dudes often tell me about which vaccines they think are too dangerous for their kids to get.  I launch into a tirade about how safe most vaccines are, and how deadly the diseases they prevent. 

Seriously, get your kids vaccinated.  You don’t want to watch your child die of measles.

And, seriously, dear reader – get a flu vaccine each year.  Even if you’re too selfish to worry about the other people whom your mild case of influenza might kill, do it for yourself. 

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We already know how dangerous seasonal influenza is.  But what about Covid-19?

To answer that, we need data.  And one set of data is unmistakable – many people have died.  Hospitals around the world have experienced an influx of patients with a common set of symptoms.  They struggle to breathe; their bodies weaken from oxygen deprivation; their lungs accumulate liquid; they die.

Many people have been put on ventilators, but that’s often the beginning of the end.  Most people put on ventilators will die.  Among patients over 70 years old, three quarters who are put on ventilators will die

For each of these patients saved, three others are consigned to an agonizing death in the hospital, intubated among the flashing lights, the ceaseless blips and bleeps.  At home, they’d die in a day; in the hospital, their deaths will take three weeks.

And the sheer quantity of deaths sounds scary – especially for people who don’t realize how many tens of thousands die from influenza in the United States each year.

Or, consider: cigarette smoking causes 480,000 deaths per year in the United States, including 41,000 people who die from second-hand smoke exposure.  Those 41,000 aren’t even choosing to smoke!  But cigarettes kill them anyway.

Indeed, when people die of Covid-19, it’s often because their lungs fail.  Smoking is obviously a major risk factor for dying of Covid-19 – a significant portion of reported Covid-19 deaths could be considered cigarette deaths instead.  Or as air pollution deaths – and yet, our current president is using this crisis as an opportunity to weaken EPA air quality regulations.

Air pollution is a huge problem for a lot of Black communities in the United States.  Our racist housing policies have placed a lot of minority neighborhoods near heavily polluting factories.  Now Covid-19 is turning what is already a lifelong struggle for breath into a death sentence.

I would enthusiastically support a shutdown motivated by the battle for clean air.

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So, Covid-19.  We know how many people have died – already (CORRECTION AS OF APRIL 21) forty-two thousand in the United States

But if we want to know how scary this virus is, we need to know how many people were infected.  If that many people died after everyone in the country had it, then Covid-19 would be less dangerous than influenza.  If that many people died after only a hundred thousand had been infected, then this would be terrifying, and far more dangerous than influenza.

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Initially, our data came from PCR testing.

These are good tests.  Polymerase chain reaction is highly specific.  If you want to amplify a certain genetic sequence, you can design short DNA primers that will bind only to that sequence.  Put the whole mess in a thermocycler and you get a bunch of your target, as long as the gene is present in the test tube in the first place.  If the gene isn’t there, you’ll get nothing.

PCR works great.  Even our lovely but amnesiac lab tech never once screwed it up.

So, do the PCR test and you’ll know whether a certain gene is present in your test tube.  Target a viral gene and you’ll know whether the virus is present in your test tube.  Scoop out some nose glop from somebody to put into the test tube and you’ll know whether the virus is present in that nose glop.

The PCR test is a great test that measures whether someone is actively shedding virus.  It answers, is there virus present in the nose glop?

This is not the same question as, has this person ever been infected with Covid-19? 

It’s a similar question – most people infected with a coronavirus will have at least a brief period of viral shedding – but it’s a much more specific question.  When a healthy person is infected with a coronavirus, the period of viral shedding can be as short as a single day.

A person can get infected with a coronavirus, and if you do the PCR test either before or after that single day, the PCR test will give a negative result.  Nope, no viral RNA is in this nose glop!

And so we know that the PCR test will undercount the true number of infections.

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When we look at the age demographics for Covid-19 infections as measured by PCR test, the undercount becomes glaringly obvious.

Consider the PCR test data from the Diamond Princess cruise ship.  To date, this is our most complete set of PCR data – everyone on board was tested multiple times.  And from this data, it appears that very few children were exposed to the virus.

Friends, it is exceedingly unlikely that such a low percentage of children were exposed to this virus.  Children are disgusting.  I believe this is common knowledge.  Parents of small children are pretty much always sick because children are so disgusting. 

Seriously, my family has been doing the whole “social distancing” thing for over a month, and yet my nose is dripping while I type this.

Children are always touching everything, and then they rub their eyeballs or chew on their fingers.  If you take them someplace, they grubble around on the floor.  They pick up discarded tissues and ask, “What’s this?”

“That’s somebody’s gross kleenex, is what it is!  Just, just drop it.  I know it’s trash, I know we’re not supposed to leave trash on the ground, but just, just drop it, okay?  Somebody will come throw it away later.”

The next day: “Dad, you said somebody would throw that kleenex away, but it’s still there!”

Bloody hell.  Children are little monsters.

It seems fairly obvious that at least as high a percentage of children would be infected as any other age demographic.

But they’re not showing up from the PCR data.  On the Diamond Princess cruise ship, the lockdown began on February 5th, but PCR testing didn’t begin until February 11th.  Anyone who was infected but quickly recovered will be invisible to that PCR test.  And even people who are actively shedding viral particles can feel totally well.  People can get infected and recover without noticing a thing.

We see the same thing when we look at the PCR data from Italy.  If we mistakenly assumed that the PCR data was measuring the number of infections, and not measuring the number of people who were given a PCR test while shedding viral particles, we’d conclude that elderly people went out and socialized widely, getting each other sick, and only occasionally infected their great-grandchildren at home.

Here in the United States, children are disgusting little monsters.  I bet kids are disgusting in Italy, too.  They’re disgusting all over the world.

A much more likely scenario is that children spread this virus at school.  Many probably felt totally fine; some might’ve had a bad fever or the sniffles for a few days.  But then they recovered.

When they got their great-grandparents sick – which can happen easily since so many Italian families live in multigenerational homes – elderly people began to die.

So we know that the PCR test is undercounting the true number of infections.  Unless you’re testing every person, every day, regardless of whether or not they have symptoms, you’re going to undercount the number of infections.

In a moment, we can work through a way to get a more accurate count.  But perhaps it’s worth mentioning that, for someone my age, Covid-19 would seem to be about as dangerous as influenza even if we assumed that the PCR data matched the true number of infections.

If you’re a healthy middle-aged or young person, you should not feel personally afraid. 

That alone would not be an excuse to go out and start dancing in the street, though.  Your actions might cause other people to die. 

(NOTE & CORRECTION: After this post went up, my father recommended that I add something more about personal risk. No one has collected enough data on this yet, but he suspects that the next most important risk factor, after smoking and age, will be type 2 diabetes. And he reminded me that many people in their 30s & 40s in this country are diabetic or prediabetic and don’t even realize it yet. Everyone in this category probably has elevated risk of complications from Covid-19.)

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After you’ve been infected with a virus, your body will start making antibodies.  These protect you from being infected again.

Have you read Shel Silverstein’s Missing Piece book?  Antibodies work kind of like that.  They have a particular shape, and so they’ll glom onto a virus only if that virus has outcroppings that match the antibody’s shape.  Then your body sees the antibodies hanging out on a virus like a GPS tracker and proceeds to destroy the virus.

So to make an antibody test, you take some stuff that looks like the outcroppings on the virus and you put it on a chip.  Wash somebody’s blood over it, and if that blood contains antibodies that have the right shape to glom onto the virus, they’ll stick to the chip.  All your other antibodies, the ones that recognize different viruses, will float away.

An antibody test is going to be worse than a PCR test.  It’s easier to get a false positive result – antibodies are made of proteins, and they can unfold if you treat them roughly, and then they’ll stick to anything.  Then you’ll think that somebody has the right antibodies, but they don’t.  That’s bad.

You have to be much more careful when you’re doing an antibody test. I wouldn’t have asked our lab tech to do them for me.

An antibody test is also going to have false negatives.  A viral particle is a big honking thing, and there are lots of places on its surface where an antibody might bind.  If your antibodies recognize some aspect of the virus that’s different from what the test manufacturers included on their chip, your antibodies will float away.  Even though they’d protect you from the actual virus if you happened to be exposed to it.

If you’re a cautious person, though – and I consider myself to be pretty cautious – you’d much rather have an antibody test with a bunch of false negatives than false positives.  If you’re actually immune to Covid-19 but keep being cautious, well, so what?  You’re safe either way.  But if you think you’re immune when you’re not, then you might get sick.  That’s bad.

Because antibody tests are designed to give more false negatives than false positives, you should know that it’d be really foolish to use them to track an infection.  Like, if you’re testing people to see who is safe to work as a delivery person today, use the PCR test!  The antibody test has a bunch of false negatives, and there’s a time lag between the onset of infection and when your body will start making antibodies.

It can be dangerous to use antibody tests to address the wrong questions.

If you use the antibody test on a bunch of people, though, you can tell how many were infected.  And that’s useful information, too.

In the town of Robbio in Italy (pop. 6,000), the PCR test showed that only 23 people had been infected with Covid-19.  But then the mayor implored everyone to get an antibody test, and 10% of people had actually been infected with – and had recovered from – Covid-19.  Most of them couldn’t even recall having been sick.

The PCR test measured 23 cases.  The antibody test suggested there’d been at least 600.  And antibody tests, by design, will generally have a bunch of false negatives.  When a team at Stanford assessed the antibody tests manufactured by Premier Biotech in Minneapolis, they found that for every 3 people who’d been infected with Covid-19, the tests registered only 2 positives.

I don’t know who made the tests used in Robbio – maybe they were a little better, maybe they were a little worse.  Based on my experience, I wouldn’t be so surprised if the true infection rate with Covid-19 in that town was really just 10% – nor would I be surprised to hear that the chips had a high false-negative rate and that the infection rate was 20% or more.

If you calculate the fatality rate of Covid-19 in Italy by assuming that the PCR tests caught every infection, you’d get a terrifying 10%.

If you instead assume that many other towns had a similar infection rate to Robbio, you’ll instead calculate that the fatality rate was well under one percent. 

Italy has higher risk than the United States due to age demographics, smoking rates, and multigenerational households – and even in Italy, the fatality rate was probably well under one percent.

When researchers in Germany randomly chose people to take a Covid-19 PCR test (many of whom had no symptoms), they found that 2% of the population was actively shedding virus – a much higher number of cases than they would have found if they tested only sick people.  And when they randomly chose people to take an antibody test, they found that 15% had already recovered from the infection (again, many of whom had never felt sick).  According to these numbers – which are expected to be an undercount, due to false negatives and the time lag before antibody production – they calculated a case fatality rate of 0.37%

That would be about three-fold more dangerous than seasonal influenza.

In the United States, our bungling president gutted the CDC, leaving us without the expertise needed to address Covid-19 (or myriad other problems that might arise).  During the first few months of this epidemic, very few people managed to get a PCR test.  That’s why our data from the PCR tests is likely to be a dramatic undercount – indeed, when we finally started producing accurate tests, the apparent growth in Covid-19 caseload superimposed with the growth in test availability.

In the absence of good PCR data, we have to rely on antibody data to track infections after the fact.  Which is why a town in Colorado with zero reported infections, as measured by PCR, had sufficiently widespread exposure that 2% of the population had already recovered from Covid-19.

And it’s why the data from the Stanford Santa Clara county study is so unsurprising. 

Yes, there were problems with the Stanford study’s data collection – they displayed advertisements to a random selection of people, but then a self-selected subset responded.  The pool of respondents were enriched for white women, but Santa Clara’s outbreak probably began among Asian-Americans.  And we all know that random sampling doesn’t always give you an accurate depiction of the population at large – after all, random polling predicted that a competent president would be elected in 2016.

Now look at us.

It’s also likely that people with a poor understanding of the biology could misinterpret the result of the Stanford study.  They found that PCR tests had undercounted the infection rate in Santa Clara county, at the time of this study, by 85-fold.

It would be absurd to assume that you could simply multiply all PCR results by 85 to determine the true infection rate, but some people did.  And then pointed out the absurdity of their own bad math.

In places where more people are being tested by PCR, and they’re being tested more often, the PCR results will be closer to the true infection rate.  If you gave everyone in the United States a PCR test, and did it every day, then the PCR data would be exactly equal to the true infection rate.

If we had data like that from the beginning, we wouldn’t have been scared.  We would’ve known the true case fatality rate early on, and, also, at-risk people could’ve been treated as soon as they got infected.  We’d be able to save many more lives.

If access to health care were considered a basic right in the United States, we might’ve done something like this. 

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In Italy, it seems like Covid-19 is three- or four-fold more dangerous than seasonal influenza.  My guess is that Italy might have had about 50,000 deaths if they hadn’t enacted the lockdown.

In the United States, on a population level, Covid-19 is probably also more dangerous than seasonal influenza.  But there’s a big difference in terms of the distribution of risk.

The New York Times is running a series with short biographies of people who’ve died of Covid-19.  As of noon on April 17, about 10% of the people profiled were younger than 35.

10% is roughly the proportion of young people who die of seasonal influenza.  But only 1% of Covid-19 deaths are people younger than 35.  The news reports don’t always make clear how much the risk of Covid-19 is clustered in a small segment of the population.

This has serious implications for what we should do next.  If we were dealing with a virus that was about three-fold more dangerous than seasonal influenza for everyone, we might just return to life as normal.  (Indeed, we carried on as normal during the bad years when seasonal influenza killed 90,000 people instead of last year’s 30,000.)

Because the risk from Covid-19 is so concentrated, though, we can come up with a plan that will save a lot of lives. 

Healthy people under retirement age should resume most parts of their lives as normal.  Schools should re-open: for students, Covid-19 is much less dangerous than seasonal influenza.  I think that people should still try to work from home when possible, because it’s the right thing to do to fight climate change.

At-risk people should continue to isolate themselves as much as possible.

This sounds crummy, but at-risk people would just continue to do the thing that everyone is doing currently.  And the plan would save many lives because the epidemic would end in about 3 months, after the virus had spread to saturation among our nation’s low-risk cohort. 

Indeed, when a team of researchers from Harvard’s School of Public Health modeled the Covid-19 epidemic, they found that social distancing was generally unhelpful.  That’s what their data show, at least – but in their abstract, they instead recommend that we continue social distancing for the better part of two years.

Their data are easy enough to understand.  In each of these graphs, they show a blue box for how long social distancing would last, and then four colored lines to represent how many infections we’d see if we did no social distancing (black), medium quality social distancing (red), good social distancing (blue), or excellent social distancing (green).

So, from top to bottom, you’re looking at the graphs of what happens if we do a month of social distancing … or two months … or three, or four … or forever.

And you can see the outcomes in the panels on the right-hand side.  The black line shows what would happen if we did nothing.  Infections rise fast, then level off after the virus has reached saturation.  There are two important features of this graph – the final height that it reaches, which is the total number of severe cases (and so a good proxy for the number of deaths), and the slope of the line, which is how fast the severe cases appear.  A steeper hill means many people getting sick at the same time, which means hospitals might be overwhelmed.

So, okay.  Looking at their graphs, we see that social distancing saves lives … if we do it forever.  If you never leave your house again, you won’t die of Covid-19.

But if social distancing ends, it doesn’t help.  The slopes are nearly as steep as if we’d done nothing, and the final height – the total number of people who die – is higher.

(Often, one of their curves will have a gentler slope than the others — usually the good-but-not-excellent social distancing seems best. So you’d have to pray that you were doing a precisely mediocre job of not infecting strangers. Do it a little better or a little worse and you cause people to die. This isn’t an artifact — it’s based on the density of uninfected people when social distancing ends — but let’s just say “mathematical models are wonky” and leave it at that.)

In a subsequent figure, the Harvard team tried to model what might happen if we occasionally resumed our lives for a month or so at a time, but then had another shutdown.  This is the only scenario in which their model predicts that social distancing would be helpful.

But, unfortunately, there’s a problem.  Research done with other coronaviruses shows that immunity fades within a year.  Because the Harvard model would cause the epidemic to last longer than a year, people would have time to lose their immunity and get infected again.

Even in the extreme case that we mostly stayed in our homes for the better part of two years, social distancing would case more deaths from Covid-19 than if we had done nothing.

That’s not even accounting for all the people who would die from a greater risk of domestic violence, hunger, drug addiction, suicide, and sedentary behavior during the shutdown.  

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When our data was limited, the shutdown seemed reasonable.  We wouldn’t be able to undo the damage we’d done by waiting.

Except, whoops, we waited anyway.  We didn’t quarantine travelers in January.  The shutdown didn’t begin March, when the epidemic was well underway in many places. 

Now that we have more data, we should re-open schools, though.  For most people, Covid-19 is no more dangerous than seasonal influenza.  We already have enough data from antibody testing to be pretty confident about this, and even if we want to be extremely cautious, we should continue the shutdown for a matter of weeks while we conduct a few more antibody studies.  Not months, and certainly not years.

At the same time, we need to do a better job of protecting at-risk people.  This means providing health care for everyone.  This means cleaning our air, staunching the pollution that plagues low-income neighborhoods.  This might mean daily medical checkups and PCR tests for people who work closely with at-risk populations.

Our country will have to be different in the future, but mostly because we, as a people, have done such a shitty job of creating justice and liberty for all.  We need to focus on addressing the inequities that we’ve let fester for generations.  That’ll help far more than using a bandanna to cover up your smile.

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UPDATE: Wow, this got a lot of readers! Thanks if you made it this far. I’ve also written a response to common questions and comments about this essay.

On inequality and disease.

On inequality and disease.

I should preface these remarks by stating that my political views qualify as “extremely liberal” in the United States.

I’m a well-trained economist – I completed all but the residency requirement for a masters at Northwestern – but I don’t give two shits about the “damage we’re doing to our economy,” except insofar as financial insecurity causes psychological harm to people in poverty.  Our economy should be slower, to combat climate change and inequality.

One of my big fears during this epidemic is that our current president will accidentally do something correctly and bolster his chances of reelection.  The damage that his first term has already caused to our environment and our judiciary will take generations to undo – imagine the harm he could cause with two.

And yet, in arguing that our response to the Covid-19 epidemic is misguided, I seem to be in agreement with our nation’s far right. 

As far as I can tell, the far right opposes the shutdown because they’re motivated by philosophies that increase inequality.  Many of them adore Ayn Rand’s “Who will stop me?” breed of capitalism, as though they should be free to go outside and cough on whomever they want.  They dislike the shutdown because they think our lives are less important than the stock market.

By way of contrast, I care about fairness.  I care about the well-being of children.  I care about our species’ future on this planet.  It’s fine by me if the stock market tanks!  But I’ve written previously about the lack of scientific justification for this shutdown, and I’m worried that this shutdown is, in and of itself, an unfair response.

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Quarantine could have prevented this epidemic from spreading.  If we had acted in December, this coronavirus could have been contained.  But we did nothing until several months after the Covid-19 epidemic began in the United States. 

Then schools were closed: first for two weeks, then a month, then the entire year.

Stay-at-home orders were issued: first for two weeks, then extended to a month.  No data supports the efficacy of these orders – haphazard, partial attempts at social distancing, from which certain people, like my buddy doing construction for a new Amazon facility, have been exempted.  And no metrics were announced that might trigger an end to the shutdown.

Currently, the stay-at-home orders last until the end of April.  But, as we approach that date, what do people expect will be different?  In the United States, we still can’t conduct enough PCR tests – and even these tests yield sketchy data, because they might have false negative rates as high as 30%, and they’re only effective during the brief window of time — perhaps as short as one week — before a healthy patient clears the virus and becomes invisible to testing.

Based on research with other coronaviruses, we expect that people will be immune to reinfection for about a year, but we don’t know how many will have detectable levels of antibody in their blood.  As of this writing, there’s still no serum test.

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In the United States, New York City has the largest concentration of risk – densely populated elderly people with constant exposure to unclean air. But even the New York Times has begun to print articles describing the folly of our response to Covid-19.

The Italian government is considering the dystopian policy of drawing people’s blood to determine if they’ll be eligible for a permit to leave their homes.  If you were worried about the injustice that the virus itself imposed on people who are elderly or immunocompromised, this is worse!

We can’t evaluate our response without tests.  Missteps by the CDC (which was gutted by the Trump administration) have left us blind to the progression of the epidemic.  And we can’t evaluate our response if we have nothing to compare it to – we will have to end the shutdown to see what happens next (with the option of resuming these safety measures if our test shows they were necessary).

We know, clearly, that the shutdown has been causing grievous harm.  Domestic violence is on the rise.  This is particularly horrible for women and children in poverty, trapped in close quarters with abusers.  The shutdown is creating conditions that increase the risk of drug addiction, suicide, and the murder of intimate partners.

We don’t know whether the shutdown is even helping us stop the Covid-19 epidemic.  And we still don’t know whether Covid-19 is scary enough to merit this response.  As of this writing, our data suggest that it isn’t.

Covid-19 is a rare breed, though: a communicable disease where increased wealth correlates with increased risk.

And so we’re taking extreme measures to produce a small benefit for the most privileged generation to ever walk the face of this Earth, at the cost of great harm to vulnerable populations.  This is why I feel dismayed.

Hopefully I can present some numbers simply enough to explain.

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Many diseases are more likely to kill you if you’re poor.

Malaria kills between 400,000 and one million people every year.  The vast majority are extremely poor, and many are children – the World Health Organization estimates that a child dies of malaria every thirty seconds.

Wealth protects against malaria in two ways.  Wealthy people are less likely to live in parts of the world with a high prevalence of malaria (most of the deaths each year occur in Africa and India), and wealthy people can buy effective anti-malarial medications. 

I took prophylactic Malarone when I visited Ecuador and India.  Lo and behold, I did not get sick. 

I believe Malarone costs about a dollar per day.  I am very privileged.

HIV kills between 700,000 and one million people every year.  Again, the vast majority are poor.  HIV is primarily transmitted through intimate contact – exposure to blood, needle sharing, or sex – so this virus rarely spreads across social boundaries in stratified communities. 

In the United States, HIV risk is concentrated among people living in our dying small towns, people without homes in inner cities, and people trapped inside the criminal justice system. 

It seems that these people are all easy to ignore.

Wealth will protect you even if you do contract HIV.  We’ve developed effective antiretroviral therapies.  If you (or your government) can pay for these pills, you can still have a long, full life while HIV positive.  About 60% of the people dying of HIV happen to have been born in Africa, though, and cannot afford antiretrovirals.

Even the myriad respiratory infections that plague our species – of which Covid-19 is but one example – are more likely to kill you if you’re poor.  The World Health Organization lists the top causes of death for people living in low-income versus high-income countries.  The death rate from respiratory infections is twice as high for people living in low income countries.

The second-highest cause of death among people in low-income countries is diarrhea.  Diarrhea kills between one million and two million people each year, including about 500,000 children under five years old.

These deaths would be easy to treat and even easier to prevent. 

Seriously, you can save these people’s lives with Gatorade!  (Among medical doctors, this is known as “oral rehydration therapy.”)  Or you could prevent them from getting sick in the first place by providing clean water to drink.

We could provide clean water to everyone – worldwide, every single person – for somewhere between ten billion and one hundred billion dollars.  Which might sound like a lot of money, but that is only one percent of the amount we’re spending on the Covid-19 stimulus bill in the United States.

We could do it.  We could save those millions of lives.  But we’re choosing to let those people die.

Because, you see, wealthy people rarely die of diarrhea.  Clean water is piped straight into our homes.  And if we do get sick – I have, when I’ve traveled – we can afford a few bottles of Gatorade.

Instead, wealthy people die of heart disease.  Stroke.  Alzheimer’s.  Cancer.

If you’re lucky enough to live past retirement age, your body will undergo immunosenescence.  This is unfortunate but unavoidable.  In old age, our immune systems stop protecting us from disease.

Age-related immunosenescence explains the high prevalence of cancer among elderly people.  All of our bodies develop cancerous cells all the time.  Usually, our immune systems kill these mutants before they have the chance to grow into tumors.

Age-related immunosenescence also explains why elderly people die from the adenoviruses and coronaviruses that cause common colds in children and pre-retirement-age adults.  Somebody with a functional immune system will get the sniffles, but if these viruses are set loose in a nursing home, they can cause systemic organ failure and death.

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I haven’t seen this data presented yet – due to HIPAA protections, it can’t easily be collected – but Covid-19, on average, seems to kill wealthier people than influenza.

On a personal level, wealth will protect you from Covid-19.  We know that early treatment saves lives, which is a reason why Germany’s death rate is so low, and wealthy people are less likely to postpone going to the hospital.  Wealthy people can afford the Albuterol inhaler that might keep you out of the ICU. Wealthy people are less likely to experience the stresses, sleep loss, and discrimination that have caused disproportionate numbers of Black people in the United States to succumb to Covid-19.

But on a population level, wealth is correlated with increased risk.

Part of this wealth gap is due to age.  I’ve made a rough sketch of the risk of death versus age for both Covid-19 and seasonal influenza.  Currently we don’t have enough data to know exactly where these risk curves intersect, but it seems to be around retirement age.  If you’re younger than retirement age, seasonal influenza is more deadly.  If you’re older than retirement age, Covid-19 is more deadly.

In the United States, if you’re older than retirement age, you’re more likely to be wealthy.

Covid-19 is also more dangerous if you’re already sick.  A study of Covid-19 deaths found that 97% of the people killed were already sick with at least one serious medical condition.  The average person killed by Covid-19 had 2.7 other serious diseases.

Because these people were receiving expensive medical care, they were able to survive despite their other diseases.  Imagine what would have happened if these people had chanced to be born in low-income countries: they would already be dead. 

This is a tragedy: all over the world, millions of people die from preventable causes, just because they had the bad luck of being born in a low-income country rather than a rich one.

We don’t have data on this yet, but it’s likely that Covid-19 will have a much smaller impact in Africa than in Europe or the United States.

When my father was doing rounds in a hospital in Malawi, his students would sometimes say, “We admitted an elderly patient with …”  And then my father would go into the room.  The patient would be 50 years old.

Covid-19 is particularly dangerous for people in their 80s and 90s.  Great privilege has allowed so many people in Europe and the United States to live until they reached these high-risk ages.

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Our efforts to “flatten the curve,” in addition to increasing many people’s risk of death (from domestic violence, suicide, and the lifelong health repercussions of even a few months of sedentary living), will save relatively few lives, even among our country’s at-risk population.

The hope is that we won’t exceed the capacity of our hospitals.  If someone’s condition deteriorates after a Covid-19 infection, they need invasive ventilation.

Please note that we can often prevent people’s condition from deteriorating by giving them Albuterol inhalers.  And these used to be so cheap!  In the early 2000s, you could buy an inhaler for about five dollars.  But pharmaceutical companies were allowed to re-patent these and the price has soared to nearly four hundred dollars.

Many news reports have included sensational numbers about how many people in their 30s and 40s have gone to the hospital for Covid-19.  These reports rarely mention that many of these hospitalizations could be prevented with a five dollar inhaler.

But we’re allowing drug companies to charge people four hundred dollars a pop for these now, which puts them out of reach for many people.

When I caught what I assume to be Covid-19, I took an inhaler.  I am very privileged.

Some young people can’t afford an inhaler, and many elderly people develop symptoms too severe to be treated with Albuterol, so they need care in an ICU.

But the benefit of this shutdown is simply the difference between how many people would die if we did nothing, compared to how many people will die now. 

In a recent essay, I gave an estimate for how many people would die if we’d done nothing.  New data suggests that my estimate was too low – the numbers out of Italy (where they did nothing until it was probably too late) suggest that around 80,000 people might have died in the United States.  Hospitals would have been overwhelmed, and some people whose condition required invasive ventilation would have been denied that treatment.

Even with the shutdown, though, we’re doing a crappy job.  Our numbers are pretty much guaranteed to be worse than Germany’s, which has a more equitable health care system overall and is testing enough people to track the spread of the disease and treat people early.  With this shutdown, all we’re hoping for is that the severe cases will be spread enough in time that everyone whose condition deteriorates to the point of needing invasive ventilation can have it.

Maybe.  The shutdown is so slapdash that hospitals in certain high-risk areas, like New York City, will still be overwhelmed.

Assuming that our efforts to flatten the curve succeed – and neglecting all the other risks of this strategy – we’ll be able to provide ventilation to everyone.  But there will still be a lot of deaths.  The shutdown will not have helped those people.  The shutdown is only beneficial for the small number who would be treated in one scenario, would not be treated in another, and who actually benefit from the treatment.

The Lancet reported that in the initial wave of the Covid-19 epidemic, 97% of patients receiving invasive ventilation died.  Later on, the death rate among people receiving ventilation was still over 80%

So we’d actually be saving only a fifth of the people who would have to be triaged if we’d exceeded our hospitals’ capacity to provide care.  This could be as few as 10,000 at-risk people.

Their lives matter, too.  Many of us have a friend or relative whose life was cut short by this. But something that we have to accept is that we all die.  Our world would be horrible if people could live forever.  Due to immunosenescence, it becomes increasingly difficult to keep people alive after they reach their 70s or 80s.

And the priorities of elderly people are different from mine.  I care deeply about the well-being of children and our planet’s future.  That’s why I write a column for our local newspaper discussing ways to ameliorate our personal contribution to climate change.  That’s why my family lives the way we do.

These priorities may be quite different from what’s in the short-term best interests of an 80-year-old.

Schools are closed.  Children are suffering.  Domestic violence is on the rise.  All to protect a few thousand people who have experienced such exceptional privilege that they are now at high risk of dying from Covid-19.

Our national response to Covid-19 is being directed by a 79-year-old doctor.  I haven’t gotten to vote in the presidential primary yet, but if I get to vote at all, I’ll be allowed to choose whomever I prefer from a selection of a 77-year-old white man or a 78-year-old white man.  Then comes the presidential election, where there’ll be an additional 73-year-old white man to choose from.

It makes me wonder, what would our national response be like if we were facing a crisis as risky as Covid-19, but where elderly people were safe and children were most at risk?

And then I stop wondering.  Because we are facing a crisis like that. 

It’s climate change.

And we have done nothing.

On immunity.

On immunity.

Our efforts to “flatten the curve” of the Covid-19 epidemic are onerous. 

Children aren’t allowed to go to school.  We’re forcing small retailers out of business.  People aren’t hugging when they greet.

Some people think these sacrifices are worthwhile, though, if they reduce the number of people who die from Covid-19.

Unfortunately, the effort to “flatten the curve” can cause more people to die of Covid-19 — including more of our elders — than if we’d carried on with life as usual.

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Antibodies are like the memory of your immune system.  After you’ve been infected with a particular virus, your body can destroy further copies of that virus.

This memory doesn’t last forever.  Your body will “forget” how to fight off the coronavirus that causes the common cold within a year.

If we carried on with life as usual, the coronavirus that causes Covid-19 would probably make its rounds through the population of the United States within a few months.  After that, there would be no new people to infect, and so the virus would disappear.

If, however, we practice social distancing and slow the rate of transmission – the same number of infections spaced over eighteen months instead of eighteen weeks – your immune system has a chance “forget” how to fight off the virus while this virus is still circulating in the population.  By slowing the rate of transmission, you give yourself the opportunity to contract the infection twice

If we slow the rate of transmission enough, this coronavirus will survive indefinitely.  Then people will continue to die of Covid-19 forever.

Even if you are currently at risk — elderly or immunocompromised — you should still fear this possibility. Will you be less at risk when this virus hits your hometown again in another year?

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When a virus infects a cell, it uses that cell’s replicative machinery to make more copies of itself.  A virus can’t reproduce on its own – it can only co-opt its host’s cells into making more copies for it.

Each time the host makes a new copy, it must replicate the entire genome of the virus.  Our cells are pretty good at copying genomes – every time the cells of our own bodies divide, they produce a new copy of our 3-billion-base-pair genome, and the copies usually have only a handful of mistakes.

Of course, a handful of mistakes compounded over time can be deadly.  That’s what cancer is – your cells didn’t copy your DNA perfectly, and so you wound up with slightly mutated DNA, and this mutated DNA instructs cells to form a tumor that kills you.

The same accumulation of errors can change a virus.  In the 1918 influenza epidemic, huge numbers of people died because the virus mutated to become more deadly.

The longer we allow the Covid-19 outbreak to go on – the more we strive to “flatten the curve” – the more mutations will accrue in its genome. 

Consider a city in which ten people live, one of whom has the virus.  If they throw a party, the other nine will be infected all at once – they will all come down with the Nth generation of the virus, whatever the current sick person is shedding.  If, however, they practice social distancing and get sick one at a time, each passing the infection to the next, the last person in the chain will be infected with viral generation N+9.  It could be very different, and more dangerous, than the initial virus.

Mutation doesn’t always make a virus more dangerous.  It’s entirely random.  It was bad luck that a mutation in 1918 made that strain of influenza more deadly.

But the risk is real.  It’s a risk we aggravate if we “flatten the curve.”  Right now, very few young healthy people will be hurt by Covid-19, but no one can know what monstrosity we’ll produce if we allow this virus to cycle through enough generations.

Inconveniently for us, Covid-19 is caused by an RNA virus.  Our cellular machinary is pretty good at making copies of DNA – every round of cell division makes a few mistakes, but not so many.  Our cellular machinary is worse at making accurate copies of RNA.  A virus with an RNA genome will mutate faster.

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People are worried that, without drastic efforts to slow the rate of transmission of Covid-19, the influx of new cases would overwhelm our hospitals.  We might run out of ventilators and be forced to triage, providing heroic medical interventions only to those people most likely to survive.  Some number of elderly patients with a low chance of survival would not receive care.

Is this bad?

Most medical doctors have signed “do not resuscitate” orders.  I have, too.  Most medical doctors, who have seen over and over again what it’s like when elderly patients with a low chance of survival receive heroic medical interventions, don’t want it for themselves.  They would rather die in peace.

The New York Times – which, alongside the New York Review of Books, is my favorite news outlet, even though it’s been full of fear-mongering about Covid-19 – printed a quote from Giacomo Grasselli, who coordinates intensive care units throughout Lombardy, Italy.  Grasselli is working at the front-lines of the Italian Covid-19 outbreak.

“My father is 84 and I love him very much,” but it would be irresponsible, he said, to make him go through the invasive procedures of an I.C.U.

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In the United States, we spent over three trillion dollars on medical care in 2016.  A huge fraction of this spending is used for minuscule extensions of life.  A third of all Americans have surgery during their last month of life.  We often spend more on interventions that extend the life of wealthy patients by a month than we do on all the pre-natal, preventative, and acute care that other people receive, ever.

What’s been missing, in the United States, is a conversation about what constitutes a good life.  What needs to happen for people to be able to face death with the thought that their lives have been enough? 

Covid-19 has killed thousands of people who were privileged to live to extremely old age.  In the United States, the worst outbreak will be in New York City – a city that is so expensive to live in that it harbors huge concentrations of wealthy elderly people.

In the United States, the life expectancy is 78 years.  Of course, there are major inequalities.  If you are wealthy, you might live longer than that.  If you are poor, you’ll probably die younger.  My spouse’s parents both died in their 60s.

Covid-19 has a high mortality rate for people who have already exceeded this life expectancy.  For people under retirement age, Covid-19 is less dangerous than seasonal flu.

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In the United States, life expectancy has been falling.  This decline is primarily due to an epidemic of “deaths of despair”: Drug addiction.  Suicide. 

In the United States, around 40,000 to 50,000 people die of suicide each year.  Around 60,000 people die of drug overdose.  Around 70,000 people die from alcohol abuse.

Each year, the epidemic of “deaths of despair” kill somewhere between 100,000 and 200,000 people.

Our efforts to “flatten the curve” will probably increase the number of people who die from deaths of despair.

Small towns across the United states have been gutted by the internet.  People used to visit local retailers, which could employ local salespeople.  Then we switched to buying things on Amazon, giving Jeff Bezos our money instead.

Now, local retailers are being forced to close due to fears about Covid-19.  People have to buy things online.  But local retailers still have expenses.  They still have to pay rent.  The owners still have to eat.  Many small retailers will run out of money and never open again after the Covid-19 epidemic is over.

As if our small towns needed yet more punishment.

In general, people will experience more financial woes because of our response to Covid-19.  Businesses are closed.  Work has slowed.  The stock market has tanked. 

And financial instability increases the risk of deaths of despair.  That’s a major reason why there’s been such a dramatic rise in deaths of despair among young people.

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Thankfully, our efforts to “flatten the curve” aren’t guaranteed to make this coronavirus mutate.  Our efforts aren’t guaranteed to make this virus a permanent parasite on the human race. 

We might cause these calamities, but we don’t know for sure.

Indeed, we know very little about this illness.  We do know that tens of thousands of elderly people have died.  But we don’t know whether ten thousand died out of a hundred thousand who were infected, or a million, or tens of millions.

Our perception of the disease would be very different in each of those scenarios.  But we do not, and can not, know.  We have no retrospective testing, and we have never tested a random sample of the population to investigate viral prevalence.

The best we can do is estimate from small data sets, the way Stanford epidemiologist John Ioannidis has done.  Ioannidis is very clear about his methodology, so if you happen to disagree with any of his assumptions, you can re-work the math yourself.

He concludes that our response is a horrific over-reaction.

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The people recommending these policies – social distancing, school closure, stay-at-home orders, or total lockdown – aren’t doing so out of malice.  They’re making the decisions they feel to be best.  But no policy is neutral, obviously. 

These policies prioritize the short-term needs of wealthy people who have exceeded their expected lifespans, at the expense of everyone under retirement age.  In particular, these policies do not value the needs of children.

Many of our country’s policies prioritize the desires of wealthy older people over the needs of children, though  “Flatten the curve” is just another example.

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In many places, we are probably attempting to “flatten the curve” after the epidemic has already run its course.

More likely than not, I already had Covid-19.  In early January, a co-worker of my children’s best friends’ parent left China, stayed briefly with her daughter in Seattle, then returned to Bloomington. 

A few days later, she came down with a high fever and a bad cough.  She went in for a flu test, but tested negative.  The doctors sent her home.

A week later, my children’s best friends’ parent – the sick woman’s co-worker – came down with a high fever and a bad cough.  His children were sick enough that they stayed home from school for a day.  He was sick enough that he missed a week of work.

A week later, on February 10th, my children and I got sick.  We had a high fever and a bad cough.  The kids felt better the next day.  I felt wretched for an entire week.  I am an endurance runner with strong lungs – still, I needed puffs of my spouse’s Albuterol inhaler four times a day.  I took naproxen but still had a hallucinatory fever.  I wouldn’t wish that illness on anyone.  For the next two weeks, I was vigilant about washing my hands and tried to minimize my contact with other people.

Over the next month, many other people in town came down with a cough and fever.  It would typically last a week, then they’d feel better.

But it was pretty scary for some people. I’d felt wrecked. Another friend of mine — 55 years old, cigarette smoker, & former methamphetamine addict — felt like he could barely breathe. The doctor said that if his oxygen flow had been any lower, she would’ve kept him at the hospital.

He wasn’t tested for Covid-19. There were still no tests available. And after a horrible week, he felt better.

And then, on March 12thafter the epidemic had probably run its course in our town – our schools closed.  The university students left for spring break, and the remaining populace of our small town began to practice social distancing.

And yet, in mid-March, the first case of Covid-19 was diagnosed here.  This patient could not trace the social connections that would have led back to a known Covid-19 outbreak.  As should be expected by that late stage of an epidemic.

All around the country, reported Covid-19 cases are exponentially rising.  But that doesn’t mean that Covid-19 infections are exponentially rising.  It only means that access to Covid-19 testing has risen.

When the epidemic likely spread through my town, it went undetected – no Covid-19 tests were available in the United States, and there’s no way to test whether someone was infected in the past.  The reported numbers of Covid-19 cases are guaranteed to be lower than the true number of people infected, because you can only be counted as a Covid-19 if you feel sick enough to visit a doctor, and then somehow manage to get access to the test.

The test will only register positive during the acute phase of the illness.  There is no possible way to test whether someone who isn’t currently shedding virus has been infected.

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A useful way to consider this epidemic is to imagine what would happen if the Covid-19 PCR test wasn’t invented. 

People would still get Covid-19.  We would take no extraordinary protective measures, because we wouldn’t realize what they were sick with.

This is like what happened at the beginning of the HIV crisis in the United States.  Medical doctors called the disease GRD, or “gay-related disease,” and it was terrifying.  Healthy young people suddenly wasted away.

If we lacked a PCR test to accurately diagnose Covid-19, though, we wouldn’t call it “age-related disease.”  We would call it “seasonal flu.”  This year, about 30,000 people will die of seasonal flu, including many healthy young people.  This year, my nephew almost died of the flu.  He couldn’t breathe.  He needed invasive ventilation to survive.

If we did nothing to staunch the Covid-19 outbreak, somewhere between 15,000 and 30,000 people probably would die from it.  Combined with the 30,000 deaths actually caused by influenza, we would think that between 45,000 and 60,000 people had died from seasonal flu.  No more than a dozen or so of the additional deaths would have been healthy young people.

That’s many more deaths!  But nothing exceptional.  In 2017, 60,000 people died of seasonal flu.

In 2017, we still let children go to school.  I’m not sure I read any news articles about seasonal flu in 2017.  And in the following years – after huge numbers of people died! –  about half our population didn’t bother to get a flu vaccine.

Influenza is a more dangerous illness, and it’s preventable.  But our country’s vaccination rate is too low to confer herd immunity.  Even if you are young and healthy, a bad case of the flu can kill you.  Even if you are young and healthy, your vaccination protects others.

Social distancing would protect people from the flu, also.  Every flu season, we could stay six feet away from each other for a few weeks, and then we’d vanquish the flu.  But social distancing comes at a tremendous cost, as we’re now learning.

Or we could get the vaccine.  But we, as a people, don’t.

On panic.

On panic.

Note: As we’ve gathered more data, it’s become clear that, on a population level, Covid-19 causes approximately five-fold more deaths than seasonal influenza. Because it is more infectious, an unaddressed outbreak of Covid-19 in the United States probably would have caused between 750,000 and 1,000,000 deaths. My original estimates were incorrect.

The front cover of The Hitchhiker’s Guide to the Galaxy is emblazoned with the words “DON’T PANIC.”  The authors knew that you might forget some of their advice during an emergency.  If you can keep those two words in mind, though, you’ll often be all right.

Don’t panic.

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Right now, the world is experiencing a viral pandemic.  Last year alone, 770,00 people – almost a million! – died from this viral infection.  There are treatments, but no cure.  And the known treatments are out of reach for many people who contract the disease.

In a recent outbreak in my home state of Indiana, an additional 235 people were infected with this fatal virus.

HIV is really, really scary.

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Right now, the world is also experiencing an outbreak of oppressive government control.  In many European countries, the citizens are on lockdown.  In France, people must apply for authorization in order to visit the grocery store.

In the United States, “non-essential” businesses have been forced to close.   Children have lost access to their schools.  University students were locked out of their dormitories.  People are suffering psychological damage from the effects of social isolation and fear.

That sounds scary, too.

But also strange.  Because schools didn’t close in response to the HIV pandemic, or the outbreak of gun violence, or lead-tainted drinking water.  Schools closed in order to combat the spread of a new zoogenic coronavirus – a virus that appears to be less dangerous than seasonal influenza.

And yet, even though data suggests that Covid-19 is less dangerous than seasonal influenza, lives are being up-ended. 

The New York Times has been full of sensational scaremongering.  But the subtitle for today’s article about Seattle tells the story of the real calamity:

In a state that has seen more deaths from the coronavirus than any other, the stress has started to multiply.  Jobs lost.  Kids underfoot.  Parents at risk.  “It’s exhausting,” one woman said.

Jobs lost, children barred from continuing their education – that’s a problem!

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Schools were not closed in response to the seasonal influenza.  Why would they be?  That happens every single year – the seasonal flu isn’t news.  Although the deaths are sometimes noticed.  In early January, The Seattle Times reported that:

Of the people who have died so far this season, one was younger than 5 years old and another was between the ages of 5 and 17, state health officials report.  Two adults between the ages of 30 and 49 have died, and the remaining 17 were people 50 or older.

The seasonal flu is scary!  It can kill you even if you are young and healthy.  Already, this year’s seasonal influenza has killed something like 30,000 people in the United States alone. 

Compared to influenza, Covid-19 is less likely to kill you if you are young and healthy.  From Nell Greenfieldboyce’s article, “Who Faces the Greatest Risk of Severe Illness from Coronavirus?

The person who died in Placer County, California was described by officials as “an elderly adult with underlying health conditions.”  Most of the people who died in Washington were residents of Life Care Center, a nursing facility.  All but three of the victims in Washington were over age 70.

The younger people who died include one man in his 40s and two men in their 50s.  Officials said these individuals had underlying medical problems.

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Worldwide, only one (1) person younger than 21 has died of Covid-19.  By way of comparison, this year’s not-particularly-deadly seasonal flu, as of March 14, had already killed 6 children in Washington State alone.  Washington state, the epicenter of the United States’ Covid-19 outbreak.

ABC News reported that:

The data in the U.S. is similar to Italy, which has been particularly hard-hit by coronavirus […] found the average age among the 105 patients who died from the virus as of March 4 was 81 years old.

And yet, even though the data suggest that Covid-19 is not exceptionally dangerous – less dangerous than seasonal flu for people under 50 – many news organizations have published sensational numbers about the high chance of death.  Even the World Health Organization claimed that Covid-19 had a 3.4% fatality rate.

These numbers are obviously false.  This is the percentage fatality rate of people who tested positive for Covid-19 … but the only way to receive a test was to have a high fever, cough, and difficulty breathing, and feel sick enough that it seemed prudent to go to a hospital to be tested.

Many other people also had the virus.  Those people didn’t get very sick, though, so they didn’t go to the hospital to be tested.

When Stanford epidemiologist John Ioannidis analyzed the available data in detail, he estimated that the actual fatality rate might be as low as 0.05%, and that the upper bound was probably 1%.  Ioannidis writes:

That huge range markedly affects how severe the pandemic is and what should be done.  A population-wide case fatality rate of 0.05% is lower than seasonal influenza.  If that is the the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational.  It’s like an elephant being attacked by a house cat.  Frustrated and trying to avoid the cat, the elephant accidentally jumps of a cliff and dies.

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Even if Covid-19 is as dangerous as the upper bound suggests, however, the advice to “flatten the curve” seems misguided.  In the United States, people repeated the phrase “it would be better to have the same number of infections spread out over 18 months instead of 18 weeks,” and proposed the (initial) cure of a 3-week school closure.

A 3-week closure would not magically cause infections to be spaced over 18 months.  It would simply delay the exponential growth phase of the epidemic by 3-weeks.  To actually space infections over 18 months, you would need at least a year of social isolation.

Spacing infections over 18 months also makes them more dangerous.  In the 1918 flu epidemic, the virus mutated midway through the season and became much more lethal.  Right now, Covid-19 poses very low risk to people who are under 50 years old and in good health.  But there’s a chance that it could mutate and become more dangerous.

The probability of mutation increases with the number of viral generations.  Let’s say we start with a sick person and nine people who have not yet been exposed.  If these people all go to a party together and get infected, the nine new cases will all wind up with the same viral generation.  Then they’ll clear it, and there’ll be nobody new to infect.

If they instead practice “social isolation,” then the virus will hop from one person to the next.  The tenth person receives a virus that has undergone many additional replications, potentially mutating to become more dangerous.

Our society would be better off if every young healthy person were exposed as quickly as possible – this would get the epidemic over with as quickly as possible, and reduce the pool of potential carriers.

It’s reasonable for people who feel like they are at high risk of death from the virus to practice social isolation until the epidemic is over.  But it’s not reasonable for everyone else to do it.

Out of misguided fear, though, we are causing real harm.  We have disrupted children’s schooling.  We’re destroying businesses.  Local retailers have struggled for years – now many cities are forcing them to close, shifting even more business to Amazon.  Out of misguided fear, we’re accelerating the forces that are destroying our country.

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Ioannidis ends his analysis with a warning:

In the most pessimistic scenario, which I do not espouse, if the new coronavirus infects 60% of the global population and 1% of the infected people die, that will translate into more than 40 million deaths globally, matching the 1918 influenza pandemic.

The vast majority of this hecatomb would be people with limited life expectancies.  That’s in contrast to 1918, when many young people died.

One can only hope that, much like in 1918, life will continue.  Conversely, with lockdowns of months, if not years, life largely stops, short-term and long-term consequences are entirely unknown, and billions, not just millions, of lives may be eventually at stake.

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To be perfectly honest, I was spooked, too.  It’s hard to stay calm when so many news organizations are publishing sensational stories.  When I went out to the climbing gym with friends, my spouse asked me to change out of my potentially-infected clothes as soon as I got home.

Then we looked up the data, and realized we’d been hoodwinked.  We had panicked over nothing. 

Except, wait, no – there is reason to panic.  Because this lockdown is scary!  Needless social isolation for the masses is scary! 

And the chance that our proto-fascist president uses this faux-crisis to commandeer even more control?  That is really scary.

On sacrifice.

On sacrifice.

Worldwide, people are making huge sacrifices to quell the Covid-19 outbreak.  The burden of these sacrifices falls disproportionately on young people.

Across the United States, universities have closed for the year.  My governor has announced that all elementary and high schools will be closed at least until May 1st.  Bars, restaurants, and malls have been forced to shut down – their employees have been laid off.

Graduating during a recession greatly reduces people’s lifelong earnings.  Young people who have the bad luck of entering the workforce in the next few years will suffer the consequences of this shutdown for their entire lives.

Childhood development has an urgency unmatched by other stages of life.  When children don’t learn to socialize at the appropriate age, they will always struggle to catch up with their peers.  Across the country, huge numbers of children were first learning to read in kindergarten and the early grades.  Now they’re watching television. (My kids, too.) With schools closed until May, and summer break coming soon after, they might be watching TV for months.  They’ll have to work harder to match other people’s educational achievements, for their entire lives.

Many students depend on school meals to stave off hunger.  Kids on free & reduced-price lunch often dread holiday weekends – now, not only have their educations been yanked away, but they’re also suffering through worse food insecurity. Schools and communities are scrambling to provide resources. 

Everyone is being asked to stay at home, to keep at least six feet away from other people. 

The cost of social isolation is lower if you’re established in a white-collar or professional career.  Many office workers can work from home.  The people who were cleaning those offices, or selling coffee and bagels to people on their way to work, get laid off.

The cost of social isolation is lower if you have enough money to stock up on supplies.  The cost of social isolation is much lower if you’re retired.

Everyone is being asked to make sacrifices, but young people are sacrificing more.

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This pandemic wouldn’t be as bad if people could be tested for the virus. We could quarantine the sick and staunch the spread.  But U.S. citizens don’t have access to a test.

Why not?

In their article for the New York Times, Matt Apuzzo and Selam Gebrekidan write that:

As the virus reached into the United States in late January, President Trump and his administration spent weeks downplaying the potential for an outbreak.  The Centers for Disease Control [a government agency gutted by our current president] opted to develop its own test rather than rely on private laboratories or the World Health Organization.

The outbreak quickly outpaced Mr. Trump’s predictions, and the C.D.C.’s test kits turned out to be flawed, leaving the United States far behind other parts of the world – both technically and politically.

Indeed, the Republican party consistently argued against preparing for the virus, downplaying its significance, even as Republican senators used information from confidential briefings for illegal insider trading, selling most stocks and buying shares of companies that make teleconferencing software.

This risk of pandemic was exacerbated by voters who put the Republican party in power.

This is a problem that was created by older Americans.  By age, these were the results of the 2016 presidential election

Image from Wikipedia.

Anyone who is currently younger than 22 – the people who are being made to sacrifice most during this crisis – was not allowed to vote in the 2016 election.

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I was too young to understand the 1980s HIV crisis, but I imagine that it was at least as scary as the Covid-19 pandemic for the people at risk. 

That virus was inevitably fatal.  The deaths were agonizing.  Rampant homophobia and cultural stigmatization – even in the medical community – meant there were few places to seek help. 

The only way to keep safe was to make sacrifices.  Fooling around is fun, but it seemed like it might kill you.  To stay alive, you’d have to tamp down your desire.

But if you made that sacrifice, you’d be safe.  The people making sacrifices were the people who’d benefit.

What about now, during the Covid-19 pandemic?

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My whole family probably contracted Covid-19.  There’s no way to know for sure, because at that time the U.S. didn’t even have tests for people experiencing the acute phase of the illness, and there’s still no antibody test to check whether someone was exposed to the virus in the past. 

I fell sick on February 10th.  I had a pretty bad case, it seems. I had to take high doses of naproxen, but the week-long fever still left me dizzy at times.  The only way I could breathe well enough to sleep soundly was by taking puffs of my spouse’s albuterol inhaler.  My joints ached so much that it hurt whenever I went running even three weeks later.

My children were sick on February 11th and February 13th.  Each napped for half the morning and then felt better.  They’d spiked a high fever, but these lasted less than a day.

In China, 87% of the people who got sick enough to be tested for Covid-19 were at least 30 years old

Only 2% of the people who got sick enough to be tested were 20 years old or younger.

And the risk of death is even more skewed.

Image from Wikipedia.

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Young people are being forced to make tremendous sacrifices.  They will suffer the consequences of this disruption to their education for their entire lives.  But they aren’t the people who benefit. 

Young people have very little risk from Covid-19.  It’s no fun to be sick, but when my children contracted what I assume to be Covid-19, it was no worse than any of dozens of other coughs or colds they come down with each year. 

Most teenagers – whose lives are being up-ended by school closings – could contract Covid-19 and be totally fine.

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My spouse asked, “What would you do about it?  Not months ago, but if you were handed this crisis today?”

My answer was the same as always.  We should enact a wealth tax – preferably a global wealth tax to undermine the tax havens – and use it to fund a guaranteed basic income. 

Using a global wealth tax to fund a guaranteed basic income would help address the persistent inequities caused by historical injustice – it would be a sensible form of reparations.  It would provide a buffer against the economic insecurity caused by automation and the gig economy.  It would transfer money away from the people who drew salaries during the years when we really ravaged our environment, and give it to the people who must now settle for a lower standard of living due to climate change.

Right now, there’s another rationale.  Young people are making huge sacrifices during this pandemic; older people receive the benefit.  A wealth tax used to fund guaranteed basic income would provide some recompense for the sacrifices of young people.

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My family is practicing “social isolation,” although it hasn’t been mandated yet.  My children are willingly making sacrifices for the benefit of others, insofar as a four- and six-year-old understand what’s happening.  And yet I’ve seen little acknowledgement in the news of the enormous, selfless sacrifice that children are making – that young people across the country are being forced to make.

They will endure the consequences of this sacrifice for their entire lives.  This sacrifice almost exclusively benefits others.  And yet there’s been no talk of recompense.  No gesture of gratitude from the people who benefit toward the people who are paying the costs.

Which, unfortunately, is how our country has often worked.

On meditation.

On meditation.

More is different.

In the beginning, subatomic particles careened too quickly to connect.  The universe was “hot.”  (Temperature is a measure of average speed as objects jiggle.  When physics people say that our universe was “hot,” they mean that everything was moving just shy of the speed of light.)

In the beginning, our universe wasn’t very interesting.  But then the homogeneous cloud of fast-moving particles cooled as it expanded.  Speeds slowed.  Soon, particles dawdled long enough in each others’ vicinity that they could interact.  Hydrogen atoms formed, then hydrogen gas, then stars. 

Stars are interesting – when a cloud of gas is big enough, its net gravity can pull everything inward until the density becomes so high that nuclear fusion begins.  This raging cascade of explosions counteracts the force of gravity and the star reaches an unsteady equilibrium until, eventually, it runs out of fuel and collapses or explodes.

An exploding star scatters heavier atoms across the sky.  When these are incorporated into a new star, they can participate in nuclear fusion events in turn, producing even heavier atoms. 

Then that star might explode, too.

Eventually, there were enough heavy atoms floating about the universe that a condensing cloud could form both a star and a set of orbiting satellites.  On these satellites – planets – atoms combine in more interesting ways than inside the bellies of stars. 

After all, the infernal core of a star is pretty hot, too.  Inside that blazing oven, particles can form atoms, and atoms can combine to form heavier atoms, but these are too frantic to form molecules – long strings of atoms bonded together.

The chemical bonds that hold a molecule together are much weaker than the electrostatic and nuclear forces that maintain an atom.  But planets – even broiling, meteor-bombarded ones – are peaceful places compared to stars.  On the primordial earth, lightning strikes or UV radiation probably catalyzed the formation of complex molecules like amino acids and nucleic acids.

These molecules are just big amalgams of subatomic particles.  The underlying stuff is the same … but there’s more of it.

More is different.

Consider the behaviors of a single amino acid.  An amino acid is complex compared to a quark or electron.  It can do acid-base chemistry!  Its mix of charged and neutral surfaces lets it interact in neat ways with various solvents. 

But if you compare that single amino acid to a protein – and a protein is just more amino acids joined together – you’ll realize that the single amino acid is total snoresville.

Proteins, though … wow!  They can fold into fantastical shapes.  They can function as molecular machines, their parts churning and twisting and flipping as they shuttle other molecules from place to place, or even create whole new molecules.

When you glom more and more and more subatomic particles together, eventually you create things that are complex enough to imprint patterns on the world.  They create more things like themselves.  Proteins and RNA make new proteins and RNA.

And then, a cell!  A cell is an amalgam of molecules all dissolved inside a bubble of fat.  If you thought proteins were cool, check this out!  Cells can swim, they can eat, they can live and die.

Or, what if there were more cells?  Then you can make us!  With many cells, you can make brains, which makes consciousness, which can give all those subatomic particles the ability to work together and realize that they are subatomic particles.

Well, no. One single human animal, in isolation, probably wouldn’t figure that out.  Each human, as an individual, can be pretty great – but to form a culture complex enough to study particle physics, you’ll need more people.  Contemporary physics papers list hundreds of authors, and that doesn’t even credit everybody who worked to build the equipment, and or worked to grow the food, and took care for the children, or taught the physicists, when they were young, allowing them to one day become physicists …

And each of those physicists, and engineers, and farmers, and caregivers, and teachers … each is a collection of cells, which are collections of molecules, which are collections of atoms, which are collections of subatomic particles.  As we transition between scales, we see qualitative differences in behavior from adding more.

This essay is made from a set of just 26 letters, but these can be combined to form a few hundred thousand different words, and those can be combined to convey an infinite number of different ideas.

We blink many thousands of times each day.  Our eyes close, pause, and then open again.  We need to blink.  Staring at screens – as I’m doing now, typing this essay, and as are you, reading it – causes us to blink less frequently, and that can lead to headaches.  But the quality of each blink doesn’t affect us much.  Most blinks pass by without our even noticing.

Meditation is just a long blink.  Close your eyes and let more time elapse before you open them again.

But more is different.  A blink doesn’t disrupt your thoughts.  Meditation, however, can be a psychedelic experience.

Many religions praise the value of meditation, especially in their origin stories.  Before he began his ministry, Jesus meditated in the Judaean Desert – he saw all the world’s kingdoms before him, but rejected that vision of power in order to spread a philosophy of love and charity.  Before he began his ministry, Buddha meditated beneath the Bodhi tree – he saw a path unfurl, a journey that would let travelers escape our world’s cycle of suffering.  Buddha decided to share that vision with others.

Before teaching his fellows to reshape the world with words, Odin meditated from a tree branch – he felt that he had died, transcended life, and could see the secret language of the universe shimmering before him.

I’ve been preparing anti-racist material about paganism and spirituality so that we have more things to send to people who contact Pages to Prisoners.  As part of this project, I’d like to include information about meditation.  After all, neo-paganism is invented – typically quite recently – and, as above, many religions have preserved stories suggesting that their founders’ meditation inspired their faith.  These religions don’t always prioritize meditation as a contemporary practice, but many do: Christian monks repeat prayers in a way that’s strikingly similar to mantra meditation, Hindu adherents are advised to sit and experience a simulacrum of Shiva’s asceticism, and even warrior cultures have prized pre-battle stillness as a way to focus attention and more fully inhabit the present.

The scientific literature is also replete with papers about meditation — but most of these are junk. It’s fairly easy to find published studies claiming that mindfulness training can confer disease resistance, immunity to aging, or even paranormal abilities like extra-sensory perception.  Scientific papers aren’t inherently more trustworthy than the internet.

But it’s true that your mind is plastic, and your moods can dramatically alter the way you perceive the world.  Conditions that affect our nervous system – like depression, insomnia, and even chronic paincan be treated through meditation.  The experiments that scientists use to assess things like “creativity” or “attentiveness” are often open to interpretation, but it’s not unreasonable to imagine that meditation would help.

All people are creative.  Our problem, often, is that our ideas can flit away before we fully grasp them.  Like dreams, they fade, and we’re left with the irksome sensation that “I feel like I just had a good idea, but …”

Meditation can clear the turbid waters of your mind.  Like gazing into a pellucid lake, it could become easier to spot your good ideas when they come.

I’ve never been inside a prison, so I’ll have to collaborate with friends who have spent time there as I make the pamphlets.  But everything I’ve read suggests that most prisons are loud, chaotic, stressful, and dangerous.  Which has obvious implications for how easily people can meditate.  If you live near a beautiful glen, you could probably do well by your brain by simply taking some time each day to sit peacefully beside some flowing water.

Instead, I’ve been learning about mantra meditation.  By silently intoning the same phrase over and over – even if it’s just a nonsense word – you can overcome a fair bit of external distraction.  To test, I’ve tried meditating at the YMCA.  This place is very calm compared to our county jail, which I’ve heard is itself calmer than a prison, but where I sit, people are usually conversing, and there are a variety of rattling exercise machines.

Several of the guide books I’ve read recommend that you pay somebody a bunch of money to teach you transcendental meditation.  During your training, you’ll be given a secret Sanskrit word or phrase.  People who’ve taken these training courses have posted a bunch of the words online, and apparently a mantra is selected based upon your age and gender. 

That seems silly to me – although it’s possible that different people’s minds would respond best to different mantras, my gender isn’t a big component of my identity, nor is my age. 

I did pick out a Sanskrit phrase, which is perhaps a silly choice in and of itself.  After all, I can’t speak Sanskrit.  But I thought it might be nice to have a set of sounds that didn’t carry a lot of semantic meaning in the rest of my daily life.  Although Sanskrit mantras would have held meaning to the original practitioners of this style of meditation, Sanskrit is generally considered a formal, ritual language, not something that people speak at home with their families.  Even for native speakers, the chance of crossed wires, in which people were inadvertently saying their special mantras at other times of day, was probably pretty low.

While meditating, there are times when I’m pretty oblivious to my environs, even though I’m sitting in a crowded, noisy place.  I assume that I should recommend, for people meditating in prison, that they use a buddy system.  Unless somebody you trust immensely was sitting nearby, I assume it would feel too unsafe to allow yourself to completely let go in the way that deep meditation requires.

In case you’re interested in trying, I can tell you what’s worked so far for me.  I’ve been thinking the phrase “sat nam.”  I liked the translation when I looked it up online, and it’s felt convenient to have two discrete sounds – I think the “sat” while breathing in, and “nam” while breathing out.  I’ve read that people aim to spend about six seconds each on inhalation and exhalation, but I breath much more rapidly than that. 

If nothing too distracting is going on nearby – maybe just some clanking from the ellipticals, treadmills, and stairmasters – I breath in and out once every four to eight seconds.  But when people are having a conversation right next to me, I take a breath every one or two seconds, which means I’m intoning my little mantra more often and can do a better job of isolating myself from what’s going on around me.

As far as I can tell, that isolation is the goal of meditation.  Our minds evolved to expect constant stimulus during our waking lives.  If you reduce the degree of outside stimulation, like with a sensory deprivation chamber, you invite your mind to conjure strange thoughts, visions, and sounds to replace the inputs that it expects.  But you have to keep at it long enough.

When particle physicist Richard Feynman described his experience with sensory deprivation tanks, he wrote:

Ordinarily it would take me about fifteen minutes to get a hallucination going, but on a few occasions, when I smoked some marijuana beforehand, it came very quickly.  But fifteen minutes was fast enough for me.

Mr. Lilly had a number of different tanks, and we tried a number of different experiments.  It didn’t seem to make much difference as far as hallucinations were concerned, and I became convinced that the tank was unnecessary.  Now that I saw what to do, I realized that all you have to do is sit quietly.

I would like to have done it at home, and I don’t doubt that you could meditate and do it if you practice, but I didn’t practice.

I’ve only had a bit of practice, but when I sit still with my eyes closed and block out the outside world with a repeated phrase, my mind will sometimes drift.  I’ve been trying to sit for twenty minutes, although I often inadvertently rouse myself after about fifteen – which hasn’t seemed to be quite enough, for either me or Dr. Feynman.  But I get the feeling that it has to be continuous.  Once I’ve opened my eyes and glanced at the clock, I stop for the day.  Even if nothing much has happened.

On these days, I console myself with a quote from Maharishi Mahesh Yogi that I learned from Bob Roth’s Strength in Stillness:Even in a shallow dive, you still get wet.

I begin by stretching – although I’m practicing in a relatively distracting environment, it seems reasonable to minimize the distractions of my own body.  I try not to move while meditating, and it’d be harder to maintain a single posture if I could feel my body ache.

After I close my eyes, the first few minutes typically feel like a waste of time.  I’m sitting there repeating a nonsense phrase and I can’t help but think of the myriad other things that I ought to be doing.

As long as I can force myself to keep at it, though, the experience changes.  More becomes different.  Undulating phosphenes blossom in the umber field of my closed eyes.  Sometimes I slip into reverie; if I catch myself daydreaming, I’ll resume intoning my bit of Sanskrit, which helps me set aside whatever vein of thought led me astray.

Nobody is totally sure why we need sleep, but recent results have suggested that nitrogenous waste and other metabolic toxins can only be cleared from brain cells while we’re snoozing.  If you stay awake too long, trash piles up along the roadways of your mind, and all that junk prevents learning, memory formation, and attentiveness. 

During my classes in jail, I often work with men who have stayed awake for weeks at a time by taking methamphetamine – they’ve experienced a wide variety of hallucinations, paranoia, and mental turmoil.  Amphetamines aren’t very toxic, but loss of sleep can seriously damage a person’s brain.

One day without sleep won’t kill you.  Luckily so – since having kids, there have been many nights when a little one wakes up screaming and I never get to rest.  But more is different.  After three days without sleep, the shadow people start talking.  After eight days, my students have started talking back: “I knew they weren’t real … but I still didn’t want to be rude.  But we got into all these arguments.

Sleep washes away the argumentative shadow people.

When meditation goes well, I sometimes imagine my mind being cleansed – I’ll sit there thinking sat nam, sat nam and envision a cascade of water flowing over me like Heracles used to clean King Augeas’s stables.  But meditation might not help with keeping a brain tidy – those experiments on the waste-clearing function of sleep were done with mice, and (to the best of my knowledge) nobody has taught mice to meditate.

If you trust my spouse’s subjective evaluation, though, meditation seems to help.  I’ve apparently been more pleasant to live with since I started practicing. 

If you’re going to try, aim for at least twenty minutes, maybe once or twice a day for a few weeks.  My apologies if it seems pointless at first.  I’d recommend you keep at it – just like a single minute won’t give you the same benefit as twenty, it seems reasonable to expect that a single day wouldn’t have the same benefit as a month’s daily practice.

After all, more is different.

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Featured image by Mitchell Joyce on Flickr.