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 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.

Responses to “On testing.”

Responses to “On testing.”

My spouse posted my previous essay on social media, and I’d like to address some of people’s comments.  There were some excellent points! 

My apologies if I failed to address everything that people said, but I tried my best.

Scroll to find my responses to:

  1. A shutdown could have prevented the Covid-19 epidemic.
  2. We know that the current shutdown is either delaying or preventing deaths due to Covid-19. 
  3. Ending this epidemic with a vaccine would be ideal. 
  4. Ending the shutdown while requesting that at-risk people continue to self-isolate would save lives.
  5. Why is it urgent to end the shutdown soon?
  6. Why might more people die of Covid-19 just because we are slowing the spread of the virus?
  7. How is the shutdown causing harm?
  8. What about the rate at which people get sick?  Isn’t the shutdown worthwhile, despite the risks described above, if it keeps our hospitals from being overwhelmed?
  9. Don’t the antibody tests have a lot of false positives?
  10. What about the political ramifications of ending the shutdown?

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1: “A shutdown could have prevented the Covid-19 epidemic.”

If we’d acted early enough, we could have isolated all cases of Covid-19 and prevented this whole debacle.

But we didn’t.

Covid-19 is highly infectious, and we made no effort toward containment or quarantine until the virus was already widespread.  We took action in March, but we already had community transmission of Covid-19 by January.  Given where we are now, current models predict that the epidemic will continue until the level of immunity reaches somewhere near 70%.

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2: “We know that the current shutdown is either delaying or preventing deaths due to Covid-19.”

To date, the data suggests that the virus has only reached saturation inside a few closed environments, such as prisons.  In Italy, both the timecourse of mortality and the results of antibody studies suggest that infections were still rising at the time of their lockdown. 

Among the passengers of the Diamond Princess cruise ship, deaths peaked 21 days after infections peaked – if the virus had already reached saturation in Italy, we’d expect to see deaths peak sooner than 21 days after the lockdown began.  They did not.

So, again, this much is clear: worldwide, there was a significant new cause of death.  When we look at mortality data, we see the curves suddenly rise in many locations.  Some researchers, such as John Ioannidis, have speculated that Covid-19 causes death primarily in people with low life expectancy, in which case we would expect to see these mortality curves drop to lower-than-average levels after the epidemic ends.  But even then, it’s unprecedented to see a number of deaths that would usually occur over the course of a year all within a matter of weeks.

Covid-19 is killing people, and the shutdown is either delaying or preventing people’s death from Covid-19.

For the shutdown to actually prevent death, one of the following needs to happen:

1.) We create a vaccine, allowing our population to reach 70% immunity without as many people contracting the illness.

2.) We take action to change which segment of the population is exposed to the virus, allowing us to reach 70% immunity without as many at-risk people being exposed.

See #3 and #4, below.

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3: “Ending this epidemic with a vaccine would be ideal.”

Vaccination is great science.  Both my spouse and I love teaching about vaccines, in part because teaching the history of vaccine use is a good component of anti-racist science class.

Developing vaccines often takes a long time.  I’ve read predictions of a year or two; my father, an infectious disease doctor, epidemiologist, research physician who runs vaccine trials, and co-developer of Merck’s HPV vaccine, guesses that it will take about five years.

And then, for the vaccine to end this epidemic, enough people will need to choose to be vaccinated that we reach approximately 70% immunity.

The reason it’s worthwhile to compare Covid-19 to seasonal influenza is that a vaccine will only end the epidemic if enough people choose to get it.  Many people’s personal risk from Covid-19 is lower than their risk from seasonal influenza.  Will those people choose to be vaccinated?

Obviously, I would be thrilled if the answer were “yes.”  I’d love to live in a nation where people’s sense of altruism and civic duty compelled them to get vaccinated.  My family is up-to-date on all of ours.

But many privileged families in the United States have elected to be freeloaders, declining the (well tested, quite safe) measles vaccine with the expectation that other people’s immunity will keep them safe.  And, despite the well-documented dangers of influenza, only 40% of our population gets each year’s influenza vaccine.

Yes, the influenza vaccine tends to be less effective than many others – some years it gives as little as ten percent protection, other years about sixty percent protection.  By way of comparison, the HPV vaccine has over 90% efficacy.

A vaccine with low efficacy will still offer better protection when more people get it.  If a higher percentage of our population were vaccinated against influenza, then influenza transmission would drop, and so each person’s immunity, whether high or low, would be less likely to be challenged.

Also, the efficacy of influenza vaccines is measured in terms of the likelihood that vaccination prevents infection.  The influenza vaccine is not great at keeping people from getting sick.  But vaccination also tends to reduce the severity of your illness, even if you do catch influenza.  Because you got sick, it seems as though the vaccine “failed,” but your case might have been far more severe if you hadn’t been vaccinated.

The influenza vaccine saves lives.  In Italy, where fewer people choose to get vaccinated against influenza (about 15% compared to our 40% of the population), the death rate from influenza is higher.  Although it’s worth noting that this comparison is complicated by the fact that our health care system is so bad, with poor people especially having limited access to health care.  In the United States, people between the ages of 18 and 49 comprise a higher proportion of influenza deaths than anywhere in Europe.  Either our obesity epidemic or limited access to health care is probably to blame; possibly a combination of both.

In summary, for this plan to help us save lives, we will need to develop an effective vaccine, and then people will have to get it. 

I am quite confident that we can eventually develop a vaccine against Covid-19.  The virus includes a proofreading enzyme, so it should mutate more slowly than most RNA viruses.  We don’t know how long it will take, but we can do it.

I am unfortunately pessimistic that people will choose to get the vaccine.  And, unfortunately, when a low-risk person chooses to forgo vaccination, they’re not just putting themselves in harm’s way, they are endangering others.  Most vaccines elicit a weaker immune response in elderly or immunocompromised recipients – exactly the group most at risk from Covid-19 – which is why we spend so much time harping about herd immunity.

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4: “Ending the shutdown while requesting that at-risk people continue to self-isolate would save lives.

This plan has major downsides, too.  Because we didn’t take action soon enough, every plan we have now is bad.

Low-risk people can still die of Covid-19.  Even if they don’t die, Covid-19 can cause permanent health effects.  Covid-19 reduces your ability to get oxygen to your body and brain.  Even a “mild” case can leave your breathing labored for weeks – you’re not getting enough oxygen.  Your muscles will ache.  Your thoughts will be sluggish.

With a more severe case, people can be looking at heart damage.  Renal failure.  It would be cruel to look at all these long-term consequences and blithely call them “recovery.”

If our health care system were better, we’d treat people sooner.  The earlier you intervene, helping to boost people’s oxygen levels, the better outcome you’ll have.  There’s a great editorial from medical doctor Richard Levitan recommending that people monitor their health with a pulse oximeter during this epidemic.

If you notice your oxygen levels declining, get help right away.  Early intervention can prevent organ damage.  And you’ll be helping everyone else, too – the sooner you intervene, the less medical care you will need.

Because medical debt can derail lives, many people in this country delay treatment as long as possible, hoping that their problems will go away naturally.  That’s why people are often so sick when they show up at the ER.  I imagine that this is yet another reason – alongside air pollution, food deserts, sleep loss, and persistent stress exacerbated by racism – that poor communities have had such a high proportion of people with severe cases of Covid-19.

And I imagine – although we don’t yet have enough data to know – that financial insecurity caused by the shutdown is making this worse.  It’s a rotten situation: you have a segment of population that has to continue working during the shutdown, which means they now have the highest likelihood to be exposed to the virus, and they’re now under more financial strain, which might increase the chance that they’ll delay treatment.

We know that early treatment saves lives, and not everyone is sufficiently privileged to access that.

All this sounds awful.  And it is.  But, if we took action to shift exposure away from high risk groups, the likelihood that any individual suffers severe consequences is lower.

And there is another caveat with this plan – some people may be at high risk of complications for Covid-19 and not even realize it.  In the United States, a lot of people either have type 2 diabetes or are pre-diabetic and don’t yet realize.  These people have elevated risk.  Both smoking and air pollution elevate risk, but people don’t always know which airborn pollutants they’ve been exposed to.  (Which, again, is why it’s particularly awful that our administration is weakening air quality standards during this epidemic.)

Even if we recommended continued self-isolation for only those people who know themselves to have high risk from Covid-19, though, we would be saving lives.  The more we can protect people in this group from being exposed to the virus – not just now, but ever – the more lives we will save.

We won’t be able to do this perfectly.  It’ll be a logistical nightmare trying to do it at all.  People at high risk from Covid-19 needs goods and services just like everybody else.  We might have to give daily Covid-19 PCR tests to anyone visiting their homes, like doctors, dentists, and even delivery workers. 

At that point, the false negative rate from Covid-19 PCR tests becomes a much bigger problem – currently, these false negatives reduce the quality of our data (but who cares?) and delay treatment (which can be deadly).  A false negative that causes inadvertent exposure could cost lives.

Stores will need to set aside morning hours for at-risk shoppers, and undertake rigorous cleaning at night.  We know that infectious viral particles can persist for days on a variety of surfaces.

Some people will be unable to work, either because they or a close relative has high risk of Covid-19.  Some children will be unable to go to school.  We will need a plan to help these people.

We will have to work very hard to keep people safe even after the shutdown ends for some. 

But, again, if everyone does the same thing, then the demographics of people infected with Covid-19 will reflect our population demographics.  We can save lives by skewing the demographics of the subset of our population that is exposed to Covid-19 to include more low-risk individuals, which will require that we stratify our recommendations by risk (at least as well as we can assess it).

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5: “Why is it urgent to end the shutdown soon?

1.) By delaying Covid-19 deaths, we run to risk of causing more total people to die of Covid-19.

2.) The shutdown itself is causing harm.

See #6 and #7, below.

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6: “Why might more people die of Covid-19 just because we are slowing the spread of the virus?

[EDIT: I wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!]

This is due to the interplay between duration of immunity and duration of the epidemic.  At one point in time, seasonal influenza was a novel zoogenic disease.  Human behavior allowed the influenza virus to become a perpetual burden on our species.  No one wants for humans to still be dying of Covid-19 in ten or twenty years.  (Luckily, because the virus that causes Covid-19 seems to mutate more slowly than influenza, it should be easier to design a single vaccine that protects people.)

In the Harvard model, we can see that there are many scenarios in which a single, finite shutdown leads to more deaths from Covid-19 than if we’d done nothing. Note the scenarios for which the colored cumulative incidence curves (shown on the right) exceed the black line representing how many critical cases we’d have if we had done nothing.

Furthermore, their model does not account for people’s immunity potentially waning over time.  Currently, we do not know how long people’s immunity to Covid-19 will last.  We won’t know whether people’s immunity will last at least a year until a year from now.  There’s no way to test this preemptively.

We’ve seen that immunity to other coronaviruses fades within a year.  If immunity to Covid-19 is similar, we really don’t want to prolong the epidemic past a year.

If we could all go into stasis and simply not move for about a month, there’d be no new cases of Covid-19, and this virus would be gone forever.  But people still need to eat during the shutdown.  Many people are still working.  So the virus is still spreading, and we have simply slowed the rate of transmission.

This seems good, because we’re slowing the rate at which people enter the hospital, but it’s actually bad if we’re increasing the number of people who will eventually enter the hospital.

Based on our research with other coronaviruses, we expect that re-infection will cause a person to experience symptoms less severe than their first case of Covid-19.  But a re-infected person can still spread the disease to others.  And we don’t know what will happen if a person’s risk factors – such as age, smoking status, diabetes status, etc. – have increased in the time since their last infection.

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7: “How is the shutdown causing harm?

If you turn on Fox News, I imagine you’d hear people talking about the damage we’re doing to our economy.  They might discuss stock market numbers.

Who gives a shit?  In my opinion, you’d have to be pretty callous to think that maintaining the Nasdaq bubble is more important than saving lives.

At the same time, I think you’d have to be pretty callous to not feel extremely concerned by the United Nations’ policy brief, “The impact of Covid-19 on children.”

In this report, they estimate that the shutdown we’ve had so far will cause hundreds of thousands of children to die, many from malnutrition and the other health impacts of poverty.  The longer the shutdown continues, the more children will die.

That’s a worldwide number, and most of those children live outside the United States.  But I’d like to think that their lives matter, too.

The report also discusses the lifelong harm that will be inflicted on children from five months (or more!) of school closure.  Drop-outs, teen pregnancy, drug abuse, recruitment of child soldiers, and the myriad health consequences of low educational attainment.

I live in a wealthy college town, but even here there is a significant population of students who don’t have internet access.  Students with special needs aren’t getting the services they deserve.  Food insecurity is worse.

You’re lucky that privacy protections prevent me from sharing a story about what can happen to poor kids when all the dentists’ offices are closed.  I felt ashamed that this was the best my country had to offer.

As the shutdown continues, domestic violence is rising.  We can assume that child abuse is rising, also, but we won’t know until later, when we finally have a chance to save children from it.  In the past, levels of child abuse have been correlated with the amount of time that children spend in the presence of their abusers (usually close family), and reporting tends to happen during tense in-person conversations at school.

We know that online sex work has increased during the shutdown.  There is an increased supply of sex workers who are experiencing increasing financial insecurity.  We don’t yet have data on this, but I’d be shocked if the shutdown hasn’t led many to feel pressured into riskier acts for lower amounts of money, including meeting clients in isolated (and therefore unsafe) spaces.

The shutdown has probably made our drug epidemic worse (and this was already killing about 70,000 people per year in the U.S.).  When people are in recovery, one of the best strategies to stay sober is to spend a lot of time working, out of the house, and meeting with a supportive group in communal space.  Luckily, many of the people I know who are in recovery have been categorized as essential workers.

But any slip can kill someone recovering from addiction.  One of my friends froze to death last year.

A neighbor recently sent me a cartoon suggesting that the biggest harm caused by the shutdown is boredom.  (I’m going to include it, below, but don’t worry: I won’t spend too much time rattling sabers with a straw man.) And, for privileged families like mine, it is.  We’re safe, we’re healthy, we get to eat.  My kids are still learning – we live in a house full of computers and books.

But many of the 75 million children in the United States don’t live in homes like mine, with the privilege we have.  Many of our 50 million primary and secondary school students are not still learning academically during the shutdown.

Whether the shutdown is preventing or merely delaying the deaths of people at risk of serious complications from Covid-19, we have to remember that the benefit comes at a cost.  What we’ve done already will negatively impact children for the rest of their lives.  And the longer this goes on, the more we’re hurting them.

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8: “What about the rate at which people get sick?  Isn’t the shutdown worthwhile, despite the risks described above, if it keeps our hospitals from being overwhelmed?

In writing this, I struggled with how best to organize the various responses.  I hope it doesn’t seem too ingenuous to address this near the end, because slowing the rate of infection so that our hospitals don’t get overwhelmed is the BEST motivation for the shutdown.  More than the hope that a delay will yield a new vaccine, or new therapies to treat severe cases, or even new diagnostics to catch people before they develop severe symptoms, we don’t want to overwhelm our hospitals.

If our physicians have to triage care, more people will die.

And I care a lot about what this epidemic will be like for our physicians.  My father is a 67-year-old infectious disease doctor who just finished another week of clinical service treating Covid-19 patients at the low-income hospital in Indianapolis.  My brother-in-law is an ER surgeon in Minneapolis.  These cities have not yet had anything like the influx of severe cases in New York City – for demographic and environmental reasons, it’s possible they never will.  But they might. 

Based on the case fatality rate measured elsewhere, I’d estimate that only 10% of the population in Minneapolis has already been infected with Covid-19, so the epidemic may have a long way yet to go.

If we ended the shutdown today for everyone, with no recommendation that at-risk groups continue to isolate and no new measures to protect them, we would see a spike in severe cases.

If we ended the shutdown for low-risk groups, and did a better job of monitoring people’s health to catch Covid-19 at early, more-easily-treatable stages (through either PCR testing or oxygen levels), we can avoid overwhelming hospitals.

And the shutdown itself is contributing toward chaos at hospitals.  Despite being on the front lines of this epidemic, ER doctors in Minneapolis have received a 30% pay cut.  I imagine my brother-in-law is not the only physician who could no longer afford day care for his children after the pay cut.  (Because so many people are delaying care out of fear of Covid-19, hospitals are running out of money.)  Precisely when we should be doing everything in our power to make physicians’ lives easier, we’re making things more stressful.

We could end the shutdown without even needing to evoke the horrible trolley-problem-esque calculations of triage.  Arguments could be made that even if it led to triage it might be worthwhile to end the shutdown – the increase in mortality would be the percentage of triaged cases that could have survived if they’d been treated, and we as a nation might decide that this number was acceptable to prevent the harms described above – but with a careful plan, we need not come to that.

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9: “Don’t the antibody tests have a lot of false positives?

False positives are a big problem when a signal is small.  I happen to like a lot of John Ioannidis’s work – I think his paper “Why Most Published Research Findings Are False” is an important contribution to the literature – but I agree that the Santa Clara study isn’t particularly convincing. 

When I read the Santa Clara paper, I nodded and thought “That sounds about right,” but I knew my reaction was most likely confirmation bias at work.

Which is why, in the essay, I mostly discussed antibody studies that found high percentages of the population had been infected with Covid-19, like the study in Germany and the study in the Italian town of Robbio.  In these studies, the signal was sufficiently high that false positives aren’t as worrisome. 

In Santa Clara, when they reported a 2% infection rate, the real number might’ve been as low as zero.  When researchers in Germany reported a 15% infection rate, the real number might’ve been anywhere in the range of 13% to 17% – or perhaps double that, if the particular chips they used had a false negative rate similar to the chips manufactured by Premier Biotech in Minneapolis.

I’m aware that German response to Covid-19 has been far superior to our bungled effort in the United States, but an antibody tests is just a basic ELISA.  We’ve been doing these for years.

Luckily for us, we should soon have data from good antibody studies here in the United States.  And I think it’s perfectly reasonable to want to see the results of those.  I’m not a sociopath – I haven’t gone out and joined the gun-toting protesters.

But we’ll have this data in a matter of weeks, so that’s the time frame we should be talking about here.  Not months.  Not years.  And I’ll be shocked if these antibody studies don’t show widespread past infection and recovery from Covid-19.

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10: “What about the political ramifications of ending the shutdown?

I am, by nature, an extremely cautious person.  And I have a really dire fear.

I’m inclined to believe that ending the shutdown is the right thing to do.  I’ve tried to explain why.  I’ve tried to explain what I think would be the best way to do it.

But also, I’m a scientist.  You’re not allowed to be a scientist unless you’re willing to be proven wrong.

So, yes.  I might be wrong.  New data might indicate that writing this essay was a horrible mistake.

Still, please bear with me for a moment.  If ending the shutdown soon turns out to be the correct thing to do, and if only horrible right-wing fanatics have been saying that we should end the shutdown soon, won’t that help our current president get re-elected?

There is a very high probability that his re-election would cause even more deaths than Covid-19.

Failing to address climate change could kill billions.  Immigration controls against migrants fleeing war zones could kill millions.  Weakened EPA protections could kill hundreds of thousands.  Reduced access to health care could kill tens of thousands.

And, yes, there are horrible developments that neither major political party in the United States has talked about, like the risk that our antibiotics stop working, but I think it’s difficult to argue that one political party isn’t more dangerous than the other, here.

I feel pretty confident about all the scientific data I’ve discussed above.  Not as confident as I’d like, which would require more data, but pretty confident.

I feel extremely confident that we need to avoid a situation in which the far right takes ownership of an idea that turns out to have been correct.  And it’ll be dumb luck, just a bad coincidence.  The only “data” they’re looking at are stock market numbers, or maybe the revenue at Trump-owned hotels.

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EDIT: I also wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!

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Header image by Goran Paunovic.

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 reading poems from Donika Kelly’s ‘Bestiary’ in jail.

On reading poems from Donika Kelly’s ‘Bestiary’ in jail.

This post briefly touches on sexual assault and child abuse.

Many of the men in jail have struggled with interpersonal relationships.

After reading Bruce Weigl’s “The Impossible,” a poem about being sexually assaulted as a child, somebody stayed after class to ask if there were resources to help somebody recover from that sort of experience.  The next week, he brought a two-page account of his own abuse.

After reading Ai’s “Child Beater,” many men proffered their own horror stories.  Sometimes they offered excuses for their parents: “My mom, she had me when she was thirteen, I guess what you’d call it now would be ‘statutory rape.’  So she didn’t know what to do with us.  But there were plenty of times, I’d be mouthing off, she’d tie my arms to rafters in the basement with an extension cord, and … “

Seriously, you don’t need to hear the rest of that story.  Nor the conversation (we’ve read “Child Beater” about once a year) when the men discussed which objects they’d been hit with.  They appraised concussions and trauma with the nuance of oenophiles.

Consider this gorgeous poem by Mouse:

 

THAT CAT

– Mouse

 

We had this cat

Small gray and frantic

Always knocking over my mother’s lamps

 

Me and my sister can’t sit on my mother’s furniture

But that cat can

My mother would whoop my ass for her lamps

Knocked over and broken

 

One day my mom bought me a dollar sign belt

Made of leather and metal

I put that belt to use every time I

Got my own ass whooped

 

We humans evolved to hunt.  By nature, we are a rather violent species.  But these cycles – people’s crummy childhoods; institutional violence during schooling and incarceration – amplify aggression.  Our world “nurtures” many into malice.

If you ask people in jail why they’re in, almost everybody will say that they were busted for drugs or alcohol.  But if you look at bookings, or hear from somebody what sort of case he’s fighting, about half the time it’s domestic violence.

So we’ve been reading poems from Donika Kelly’s Bestiary, a charming volume that uses abundant animal imagery to elucidate human relationships.  The men need a safe space to discuss love and romance.  Obviously, a dingy classroom inside a jail is not the ideal place, but this is what we’ve got.

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Kelly’s “Bower” opens with:

 

Consider the bowerbird and his obsession

of blue,

 

… then catalogs some of the strange objects that a male bowerbird might use to construct his pleasure dome.  They are artists, meticulously arraying flowers, berries, beetles, even colorful bits of plastic, striving to create an arch sufficiently beautiful that a visiting female will feel inclined to mate.

Among tropical birds with female mate choice, most males will remain celibate.  They try to woo each visitor, but fail.  Usually one single male – he of the most impressive aerial gymnastics (among manakins) or he of the most impressive bower – will be chosen by every female in an area.  Because the males don’t actually raise their young (their contribution ends after the ten or twenty seconds needed to copulate), any given male will have more than enough time for everyone who wants him.

Every male bowerbird devotes his life to the craft, but most of their creations will be deemed insufficiently beautiful.

 

And

how the female finds him,

lacking.  All that blue for nothing.

best

I love the irony of this ending.  This bird’s bower has failed.  The bits of blue that he collected were not sufficient to rouse anyone’s interest in him as a mate.

But life will generally seem pointless if we focus only on goals.  Most bowerbirds won’t mate; Sisyphus will never get that boulder up; you and I will die.    This poem is heartbreaking unless we imagine that the bowerbird takes some pleasure in the very act of creation.

(The natural world is not known for its kindness, but in this case it probably is – because every male bowerbird feels compelled to build these structures, it’s likely that their artistic endeavors feed their brains with dopamine.)

Indeed, most poems that we humans write will go unread.  Even for published poets, it’s probably rare that their words woo a future mate.  But even if Kelly’s own creation did not bring her love (and, based on what little I know about the publishing industry, it almost certainly did not bring her great fortune), it’s clear that all that effort was not for naught.

She made something beautiful.  Sometimes, that alone has to be enough.

At another class, we read Kelly’s “What Gay Porn Has Done for Me.”

Thanks to the internet, many people learn about sexuality from pornography.  One flaw with this “education” is that even when the female actors mime pleasure, they do so while gazing outward.

 

Kelly writes:

 

Call it comfort, or truth, how they look,

not at the camera, as women do,

but at one another.

 

In generic heterosexual pornography, there is a distance.  There is no “relationship” shown between the actors – they’re not even looking at one another.  Instead, the female actor is expected to gaze at a camera, and the (likely male) consumer is gazing at a computer or telephone screen to make some simulacrum of eye contact.

 

Each body is a body on display,

and one I am meant to see and desire.

 

Generic heterosexual pornography seems to objectify the actors much more than gay pornography because the focus is on a performer’s body more than the romantic acts depicted.  Because so much of this pornography is consumed by a homophobic audience, male bodies are depicted minimally – usually only a single organ within the frame – which prevents couples from being shown.

The pleasure offered isn’t quite voyeurism, pretending to watch another pair make love.  It’s fantasy, the chance to imagine being the bearer of the male genitalia.  But this fantasy, independent a fantasy of conversation and mutual seduction, makes others’ bodies seem a thing to be used, not a carriage for the partner’s personality.

 

I am learning

 

what to do with my face,

and I come on anything I like.

 

To desire, and to be desired, need not be degrading for anyone involved.  This is a hard lesson to square with the sort of “sex education” that I received in school, which was sufficiently Christian that sex was presented as both desirable and bad.  If a person thinks that he or she is wicked for wanting, it’ll be hard to discuss what each person wants.

There’s no way to pretend “I’m a good person who just got carried away!” if you make a sober, premeditated, consensual decision to do something bad.

Of course, sexuality isn’t bad.  But many people still posture as thought it is.  When these people feel (totally natural!) desire, they’re forced to create dangerous situations that might excuse their subsequent behavior.

Which, because of those excuse-enabling contortions, often winds up being bad.

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On nature.

On nature.

The modern world is a stressful place – some medical doctors advocate “therapeutic” nature walks.  Surround yourself with trees, wildlife, a babbling stream or waterfall, and your body will remember what it means to be alive.

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Image by Steven Depolo on Flickr.

For millions of years, our ancestors needed specific environments in order to survive.  Almost every animal species experiences instinctual urges toward healthful habitats – it would be surprising if our own minds didn’t have a residual response toward landscapes that provide what our forebears needed.  Running water, trees for shelter, grassy meadows to hunt, fecund animal life suggesting a thriving ecosystem.

But people who need to heal are cut off from these environs.

When somebody doesn’t fit in our world, they wind up in jail.  Maybe this person has trouble holding down a job and so forged checks, or counterfeited money, or robbed a store.  Maybe somebody is plagued by nightmares and takes methamphetamine to forgo sleep.  Or shoots opiates to stave off the pain of withdrawal.  Maybe somebody has so much tension and anger that he threw a television at his girlfriend.

These are people who’d probably benefit from a de-stressing stroll through the woods.

Instead, they’re surrounded by concrete, in a clanging, reverberating room with 25-foot-high ceilings, locked doors stacked atop each other, steel tables, boaters crowding the floor (with two tiers of 8 double-occupancy cells, the jail could hold 32 per block … but most have wobbled between 35 and 40 people all year, with the excess sleeping on plastic “boats” on the common area floor.  Things were worst in July, when they were so many inmates that the jail ran out of boats – then people slept on a blanket spread directly over the concrete), toilets overflowing with the excreta of many men shitting their way through withdrawal.

grow posterIn the classroom where I teach poetry, there’s a picture of a redwood forest.  It’s shot from the ground, the trunks soaring up to the canopy overhead, and at the bottom of the poster there’s the word “GROW” above a corny quote from Ronald Reagan.

Stephen “Greazy” Sapp wrote the following poem at the end of class one day; he’d spent almost the whole hour staring at the picture of those trees:

 

GROW

Greazy

 

I want to live to see things grow –

From the fury of a great storm, started from

A single drop –

To the ten foot tree from one tiny seed, one sheet

Of paper as from any other tree

Knocked down by a great storm –

The child who grew from a seed in the spouse

Of the man who held paper from the tree –

Maybe the seed buried in his mind could become

Greater in life than the tree that withstood

The storm, now given opportunity to transform

Into stories – of future, generations who dwell

In the single rain drop in

The forest of days to come –

 

Greazy told me that he loves plants.

(My inclination is to use people’s first names as a sign of respect, but he told me not to – “nobody calls me ‘Stephen’ unless they’re mad about something.  You know, like, my grandma, if she was pissed, I might hear her yell, like, Stephen!  Even the cops.  They pulled up one day, they were like, ‘Greazy, come here, we want to talk to you,’ I knew everything was fine.  They were like, ‘look, man, we know you’re selling pot … but stay up near 17th street or something.  We don’t want you downtown, selling it to college kids.’  But then, another day, they came down, spotted me, said ‘Stephen, get over here!’ I was like, ‘man, I know they’re gonna haul me in.’ ”)

Greazy was in the jail all through autumn, waiting on his trial, and he told me that one day he was sitting in his cell on the fourth floor, watching a leaf blowing around on the sidewalk down below, and he found himself thinking, “Man, I’d sign whatever, I’d take whatever plea they wanted, if they’d just let me out there, get to look up close at that little leaf.”

Another man told me that he felt so starved for the world that he started gardening inside the jail.  He didn’t want for me to include his name but graciously allowed me to share his story.  Here’s a poem I wrote:

 

OUR MAN GROWS AN ORANGE TREE

 

by sprouting seeds in a paper towel,

planting one in dust & dirt

he collected scraping his fingers along

each corner of the concrete walls,

& using an Irish Spring soap box as a shelf

to lift his sapling to the light.

 

Our man only wanted to

oxygenate his air

but soon the whole block shuffles by

checking on the tree each day.

They’re surprised that it survived,

but proud to see it grow

until the warden declares it contraband.

 

Young_orange_tree

On Tao Lin’s ‘Trip,’ targeted advertising, and finding scraps of life in books.

On Tao Lin’s ‘Trip,’ targeted advertising, and finding scraps of life in books.

Featured image: artwork by Tao Lin on Flickr.

trip

I recently borrowed my local library’s copy of Tao Lin’s Trip.  I read ten pages before a business card fell out.  I didn’t find the other until about a hundred pages later.  The cards were really crammed in there – I often read at nap- and bedtime, lying on my back, with little feet kicking my books, belly, neck, etc.  I’m surprised the second card wasn’t ejected earlier.

In Trip, Lin writes about drugs and some of the people who frequently ingest them.  For instance, Lin spent several months reading the oeuvre of Terrance McKenna, a passionate advocate for the legalization of psychedelic drugs (which I support) who argued that his chemical-induced visions (language elves, fractal time) represent tangible features of our universe (which I think is asinine).  At other times, McKenna self-described as a “psychonaut,” which I think is a better term – compounds that perturb the workings of a mind do reveal truths about that mind.

That’s the essence of the scientific method, after all.  First, formulate a predictive model about how something works.  Then, perturb your system.  If your prediction holds up, try to think of a different test you could make to try to prove yourself wrong.  If your prediction is off, try to think of a new model.  Repeat ad infinitum (physicus usque ad mortem).

In an undergrad-designed psychology experiment, the perturbation might be to compel a study subject to think about death by mixing a lot of photographs of car wrecks into a slide show.  Does a person exposed to these images seem more inclined to spend time with close family members (based on the results of a 30-question survey) than equivalent study subjects who were instead shown photographs of puppies?

Maybe you’d learn something from that.  But, honestly, 0.5 mgs per kg of psilocybin is a more powerful perturbation.

(A man who has been attending my poetry class for the past few months also self-describes as a Buddhist psychonaut – his favorite psychedelic is LSD, but he also struggles with a nagging impulse to shoot heroin.  He’s a vegetarian and has been writing poetry for twenty years, ever since his first friend died of overdose.  The only way for him to avoid prison time is to enroll at a court-mandated Christian-faith-based rehabilitation clinic where everyone works daily at the Perdue Meats slaughterhouse.  He’s just waiting on a bed before they ship him out there.  Personally, I think that having a recovering addict decapitate hundreds of turkeys daily would be an unhealthy perturbation of the mind.)

As Lin researched pharmacology, he realized that he’d made the same error in thinking about his body that our society has made in thinking about our environment, especially the oceans.  He’d assumed that his body was so large, and each drug molecule so small, that he’d be relatively unchanged as the pills he swallowed were metabolized away.  But he was wrong.  He’d turned his own body into a degraded environment that felt terrible to live inside.

He realized that corporations shouldn’t have free license to destroy the world that we all share.  And he realized that he needed to practice better stewardship of his body, his own personal environs.  He changed his diet and his lifestyle and no longer felt like garbage all the time.

good dayLin also provides some useful information about this country’s War on Drugs.  If someone was looking for an accessible way to learn more about this, I can see myself recommending either Trip (for the dudes in jail) or Ayelet Waldman’s A Really Good Day (for the harried parents working alongside me in the YMCA snack room).

And those business cards?  They made convenient bookmarks.  Verdant green, the front advertised a local hydroponics supply store, the back listed the store manager’s name and telephone number.

This seemed like a great advertising strategy.  Much more precise (and less evil) than Facebook’s targeted ads.

I won’t be buying any hydroponics supplies, but I’ll probably put those business cards back before I return the book.

Most of what I’ve found in books has been less directly relevant to the subject matter.  I felt dismayed to find a business card for a local artist / writer / model / actor – the front showed her in pinup-style undergarments with the cord for a video game controller entwining one stockinged leg – inside a library copy of Against Our Will by Susan Brownmiller.

When I flipped through one of Deepak Chopra’s new-age self-help books (that I pulled off the secondhand inventory shelf at Pages to Prisoners to mail to someone who’d requested stuff about UFOs, Wicca, and conspiracies), I found a Valentine’s Day note (written by a small child in crayon) and a polaroid of a tired-looking bare-breasted woman staring  at the camera from atop a camper’s bed.  MWPP totally would’ve gotten dinged if I’d mailed the book with that picture still inside.

And I’ve written previously about the time I found an acceptance letter from Best of Photojournalism inside a previous year’s edition of the book as I selected books to mail to a prisoner interested in photography.

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But I didn’t mention that I visited the university library to find the accepted photograph (of a stretch of highway closed for the emergency landing of a small plane in distress) …

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… or that I then put together a package of books to send to that photographer, because it turned out that he was also in prison after murdering his son-in-law.

The impression I got from news reports was that this man had a daughter whom he’d raised alone.  When his daughter was 13 years old, she fell in love with an abusive, oft-unemployed 19-year-old.  She soon became pregnant.  As it happens, this boyfriend took too many drugs.  I’ve met many men in jail who are totally charming while sober but (“allegedly!”) wail on women when they’re not.  Some are quite frequently not sober.

During this man’s trial, several witnesses testified to the violent physical abuse his daughter was subject to.  His daughter’s boyfriend “would grab ____, jerk her by the face, force her to go places, cuss her out if she didn’t do the right thing … “

Not that this is a reason to shoot somebody.

Still, I wondered how a book from the man’s personal library had wound up in the inventory of the Pages to Prisoners bookstore.  The murder occurred in August of 2012.  Mid-autumn, 2015, his book was on our shelves.

I like to imagine that his daughter made the donation.  That perhaps, by then, she’d forgiven her father.  That she’d realized how miserable U.S. incarceration can be and wanted to do a little something to make it better.

I certainly hope that his book helped people at the prison where I sent it.

 

On drinking.

On drinking.

In our poetry classes, we’ve had a lot of guys doing time or awaiting trial for domestic.  As you might expect, their troubles are often wrapped up with alcohol.  Nobody wants to think of himself as the kind of dude who’d hit his partner, but booze saps self-control.  Sober, we feel angry; drunk, we lash out.

Screen Shot 2018-05-24 at 7.20.19 PMWe began a recent class with Dave Johnson’s “Dave Gibson Makes His Way Down.”  Johnson teaches poetry in probation office waiting rooms, and he cares deeply about the ways so many of us struggle to be good.  His poem opens with the line,

image         Seven Sundays in a row he fell

         on his knees at the altar

         of Rocky Creek Presbyterian.

Each week, the protagonist of Johnson’s poem slips again.  He drinks then he repents.  At church, he’s “shaking his head / crying for forgiveness.”  But everyone knows that it won’t last, until one day his wife has had enough.  He staggered home drunk; she sewed him up inside a rug.

         And she beat him blue.  He swore he’d never

         drink anymore, and she beat him.

         And then he swore he’d go to church every Sunday.

         And she still beat him.

         He told her he’d love her forever.

         She kept on.

         And he said he’d repent.  She beat him harder.

         And he said he wanted to die.

         She beat him.

         And he said he’d never repent again.

         She stopped.

A man in class – back inside after only nine days out because he drank the night before a visit with his parole officer – hung his head.  “I should send this to my wife,” he said.  “I’m always telling her, I’ll stop, I’ll stop.  But then I hit that bottle.”

Apologizing isn’t enough.  We have to make sure we won’t apologize again.  “Sorry” doesn’t mean much if you have to say it again and again.

And, yes, it’s still mind boggling to me that MDMA and psilocybin – two low-risk chemicals that can help turn somebody’s life around – are illegal whereas alcohol, one of the world’s most dangerous drugs, is openly shilled with flashy television ads.

waterThen we read two poems by Raymond Carver.  “Woolworth’s 1954” has long been a favorite of mine – a man slips into reverie while he’s out walking with a buddy and the buddy’s young kids.  The man thinks about when he “was sixteen, working / for six bits an hour” as a stockboy in a department store.  An older man was training him; Carver writes,

        Most important memory

         of that whole time: opening

         the cartons of women’s lingerie.

         Underpants, and soft, clingy things

         like that.  Taking it out

         of cartons by the handful.  Something

         sweet and mysterious about those

         things even then.  Sol called it

         “linger-ey.”  “Linger-ey?”

         What did I know?  I called it

         that for a while, too.  “Linger-ey.”

Poets play with the difference between private and public language.  Some words mean almost the same thing no matter who hears them.  When I write “of,” chances are there are few strong associations in your mind that would cause you to misinterpret my intent.

But many words feel very different from one person to the next.  When the New York Times printed poems alongside photographs they inspired last summer, I brought them in to jail.  I had no idea that a line from Ada Limon’s “What It Looks Like to Us and the Words We Use” would jolt the men out of reading.

         And how we stood there,

         low beasts among the white oaks, Spanish moss,

         and spider webs, obsidian shards stuck in our pockets

But “shard” is slang for methamphetamine, apparently, and once the idea of meth has wormed into their brains, it’s hard to shake away.  That’s the whole problem with addiction. 

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A shard of crystal (in this case, meth).

For Carver, the private meaning of “lingerie” is safer.

        Then I got older.  Quit being

         a stockboy.  Started pronouncing

         that frog word right.

         I knew what I was talking about!

         Went to taking girls out

         in hopes of touching that softness,

         slipping down those underpants.

         And sometimes it happened.  God,

         they let me.  And they were

         linger-ey, those underpants.

         They tended to linger a little

         sometimes, as they slipped down 

Raymond_CarverCarver thinks back to those bright early years, when everything felt charged with possibility.  Dangerous, but navigable.  Undergarments “kicked free / onto the floor of the car and / forgotten about.  Until you had / to look for them.

But his past is gone.  He’s grown up, made mistakes, worked crummy jobs and started drinking.  He has more freedoms now – a house to take dates to, instead of fumbling in the car – and yet fewer possibilities.  Those women he knew have grown up too; they have families and responsibilities.  Or they’ve died.  Some of us find less luck than others. 

Carver is left lamenting his mistakes, knowing that some things he’ll never fix.

Then we read Carver’s “Fear.”  One man read the first half of the poem, but when he reached the line “Fear of my children’s handwriting on envelopes”, he paused, blinked, started again, and found he had no voice.  We sat in silence for about ten seconds, then he said, “Yeah, that one got me.  Somebody else is gonna have to read the rest of this.”

He was too broke for bail and had spent almost a year inside (waiting on a case that would wind up dismissed when the witnesses didn’t show), and each week said something to me about his daughter, seven years old, living a state away, whom he hadn’t seen in years.  On his good days, he’d tell me, “When I get out, I’m gonna get myself on a bus, go up and see her.”

On his bad days, he’d say, “I don’t know if she’s gonna want to see me.  Cause it’s been years, you know?”

After reading the poem, I thought we’d use “Fear” as a writing prompt.  “Jot down five things,” I said.  “What are you afraid of?” 

This was a terrible writing prompt.

Seriously.  Only two people wrote anything (“I’m afraid of being killed by an ex / I’m afraid of dying broke / I’m afraid of dying alone”).  It can’t feel safe to write about your fears in jail. 

Mea culpa.

But some of what the guys said while telling me that they couldn’t write was heartbreaking.  Like the guy with the seven-year-old daughter he wanted to visit:

I’m afraid that when they let me out I’m not gonna want to go, cause I’ll have forgotten how to live any place but here.

Or another guy, who said that his first grandchild was born while he was stuck there.

The only thing I’m scared of is that I’m gonna drink again and my daughter won’t let me see my grandkid.  Because she says that if I get back to drinking, she won’t let me around.  I’m an alcoholic, and I’m a mean alcoholic.

And yet, the week before he left, he told me, “When I get out, first thing I’m gonna do, I’m gonna walk down to that liquor store and buy myself a beer.”

At the end of class I told him, “I don’t have anything against drugs, you know.  But some of us, some drugs, we just don’t mix well.  So I wish you’d go, maybe buy that grandkid a present, go down to see her instead of buying yourself a drink.”

“I know, I know … but it’s something I told myself, to get me through this time here.  That I’d get out, and when I got out, I’d get to have a beer.”

“I mean, if it’s just one …” I said.

“Yeah, but I’m an alcoholic.”