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.

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 panic.

On panic.

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

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

Don’t panic.

#

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

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

HIV is really, really scary.

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

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

That sounds scary, too.

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

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

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

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

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

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

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

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

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

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

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

#

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

ABC News reported that:

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

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

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

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

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

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

#

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

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

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

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

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

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

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

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

#

Ioannidis ends his analysis with a warning:

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

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

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

#

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

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

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

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

On sacrifice.

On sacrifice.

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

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

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

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

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

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

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

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

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

#

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

Why not?

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

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

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

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

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

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

Image from Wikipedia.

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

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

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

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

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

What about now, during the Covid-19 pandemic?

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

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

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

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

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

And the risk of death is even more skewed.

Image from Wikipedia.

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

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

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

#

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

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

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

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

#

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

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

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

On social norms.

On social norms.

I assume that you, personally, have never clear-cut and burned a patch of the Amazon rain forest.  Neither have I.  The number of people who have done the actual cutting is vanishingly small compared to the world’s population.

I also assume that you enjoy living in a world where the Amazon rain forest exists — certainly more than you’d enjoy living in a world where it had all been slashed and burned.  If we lose the Amazon rain forest, climate change might spiral out of control, flooding coastal cities worldwide and causing desertification in much of the interior United States.  If we lose the Amazon rain forest, huge numbers of species will go extinct, including a wide variety of medicinal plants that we’ve only begun to investigate.

And the rain forest is beautiful.  Future generations would feel an ache of want – likely compounded with a mix of jealousy and anger – if they saw photographs of the Amazon rain forest after it were gone.

When I was in elementary school, my third grade class sponsored a patch of the Amazon rain forest.  In retrospect, I’m not sure what this entailed.  We raised money and sent it off in an envelope.  I don’t remember whether we ever saw photographs of “our” forest, whether the arrangement was supposedly akin to a rental or purchase of those trees. 

I have no idea who received our sponsorship money, but the general idea that money should be sent from the U.S. to Brazil is actually correct.  Many of the world’s problems would be easier to address if we used a global wealth tax to fund a guaranteed basic income for everyone.  At the very least, if there are natural resources that benefit all of humanity, then countries that are currently wealthy because they ravaged their environments should pay to encourage other nations not to accrue wealth through extractive industries.

Some people in Brazil would be wealthier if the Amazon rain forest were destroyed.  Everyone in the world would suffer as a result.  If we – everyone outside Brazil – would prefer that the rain forest not be destroyed, we should compensate Brazilians for the foregone short-term economic benefits.

Unless you are fantastically wealthy, you personally will be unable to enact this policy on your own.  If I decided to split my family’s entire annual income among the people of Brazil, each would get 2% of a penny … and my family would be left with nothing.

A guaranteed basic income is the right policy, but it’s not something that I can accomplish as an individual.

In We Are the Weather, Jonathan Safran Foer discusses how each one of us can help preserve the Amazon rain forest today.  We as a people should strive for political solutions to the world’s problems, but we as individuals shouldn’t make choices that exacerbate those very problems.  It would seem hypocritical to lobby for fines against littering if we continued to blithely toss candy bar wrappers onto the ground.

Foer describes how painful it feels to recognize this hypocrisy in himself.  This sensation grows more intense as he watches his children grow in a world that is becoming increasingly dangerous.

But what kind of father prioritizes feeling good over doing good?

Foer knows that he could choose to help.  Each day, he could act in a way that makes his children’s world safer.

He often doesn’t.

There is a far more pernicious form of science denial than Trump’s: the form that parades as acceptance.  Those of us who know what is happening but do far too little about it are more deserving of the anger.  We should be terrified of ourselves.  We are the ones we have to defy.  I am the person endangering my children.

As you read this, the Amazon rain forest is being destroyed.  Why?  To clear space for cows to graze.

Photo by Joelle Hernandez on Flickr, whose caption from this 2007 photograph reads, “On a few occasions Brazilians told me that ‘People thousands of miles away are contributing to our deforestation.'”

Even if the meat or cheese you eat was not imported from Brazil, by choosing to eat it, you are reinforcing the social norm that is causing the Amazon rain forest to be destroyed. 

Eating meat is pleasurable.  A good cheese pizza can be divine.  Humans evolved as omnivores, and the tastes of meat and cheese are particularly delicious.  Choosing not to eat these foods would be a sacrifice.

Foer has tried to be a vegetarian for decades.  He has previously written about the animal welfare arguments against eating meat; now he’s written about the environmental arguments.  He knows that eating meat is immoral – the cow suffered to produce it, and Foer’s own children will suffer a worse climate as a consequence.

But this knowledge isn’t enough.  He still surreptitiously buys cheeseburgers.

So why hasn’t vegetarianism become any easier after thirty years?  Why has it become harder?  I crave meat more now than I have at any point since I became a vegetarian.

Foer wishes that there were a social norm to eat only foods made from plants. 

Eating meat is pleasurable.  Eating cheese is pleasurable. 

Injecting heroin is pleasurable too.  Driving a car while drunk is pleasurable.  Heck, even cruising down the road while everybody else pulls aside for the ambulance behind you would be pleasurable.

In our culture, there’s a social norm to pull aside for ambulances.  Even though it would be more pleasurable to keep driving, most people don’t.

Meats and cheeses are responsible for somewhere between 20% and 50% of all climate-change-causing emissions. 

(There’s a wide range in that estimate because, although it’s incontestable that it takes more land to produce meats and cheeses than it does to make equivalent foods from plants, it’s debatable what would be done with all that extra land if people changed their diets.  If the extra space would be used to restore forests, then animal agriculture is responsible for 50% of climate change.  If the extra space would be kept as grass – setting aside the curious question of why – then animal agriculture causes only 20% of climate change.  Only 20%.  By way of comparison, all the world’s cars, trucks, and airplanes together cause less than 15% of climate change.  You can look at the appendix to We Are the Weather for an explanation of these numbers, or even glance at Donald Trump’s EPA website for some pie charts with identical information.)

The current administration has gutted the EPA, and compelled their staff scientists to restate their findings in the weakest ways possible … and these are the numbers still posted on their website.

If every gasoline-powered car was replaced with a hybrid vehicle – instantly, world-wide – greenhouse gas emissions would be about 96% of what they are currently.  If that was the only change we made, our planet would be toast.

If we all followed a social norm to eat food made from plants, greenhouse gas emissions could be 50% of what they are currently.  With no other changes, humanity would survive.  Our planet would remain habitable for our children, and our grandchildren.

Pleasure matters.  I’m an atheist, and I’m well aware that the eventual heat death of the universe means humanity will go extinct eventually.  I don’t believe you can make a viable philosophical argument for existence based on helpfulness or social connections alone – your life needs to be pleasurable, too.

Your life can be pleasurable without meat or cheese.  I support responsible hedonism.  Good food is a joy, but you can eat well while making only choices that protect our planet.  Most people think that sex is great fun, but we have a social norm that you should enjoy your sexuality only with other consenting adults.  Groping a beautiful stranger might be more fun than eating cheese – in our culture, a social norm restrains us. 

Well, most of us.

Foer wishes that we, as a people, could choose better.  He’s been struggling to eat food made from plants.  But he doesn’t struggle to restrain himself from murder, or theft, or groping his students.  In those instances, our social norms make it easy to do the right thing.

And you can still be a hedonist while eating plants!  If you’re ever in Chicago, you should stop by my dear friend Auntie Ferret’s vegan deep-dish pizza restaurant, or use Happy Cow to find a decadent plant-based restaurant near you.

Deep dish pizza, mac and cheese, nachos and more — all vegan at Kitchen 17.

Feature image by Neil Palmer / CIFOR on Flickr.

On white supremacist vegetables and watchful eyes.

On white supremacist vegetables and watchful eyes.

Recently, my hometown of Bloomington’s farmers market has been covered Fox News and The New York Times.  Not because the vegetables sold here are particularly deserving of national attention.  The market was deemed newsworthy because one of the farm stands is run by outspoken white supremacists.

Although Bloomington is a fairly liberal college town, this region has a sordid history of hate.  The national Klan headquarters is less than 30 minutes away – when I was in college, the campus diversity coordinators warned students not to stop in that town, not even to buy gas.  Even right here in Bloomington, there was a fracas at the local high school recently because some students decided to honor a friend who’d died by using cremation ashes to print bumper stickers – but they printed stickers of the Confederate flag.

Teaching poetry in the local jail has made me much better at recognizing supremacist imagery.  Most people know that the Confederate flag is bad news, but I’ve gotten to see a wider range of hateful symbols tattooed onto people’s flesh. 

COs bring twelve people to each week’s class – often two to four will be Black (in a town where the total population is approximately 4% Black or African-American), and the rest are usually white guys.  It’s pretty common for one or two of the white guys to have visible supremacist tattoos.  Which doesn’t even include questionable stuff like the dude who got an poke and stick of the words “White Trash” in elaborate two-in-tall cursive letters during his time there.  Tattooing runs afoul of the jail’s “no self mutilation” policy, but most COs studiously overlook the guys’ rashy red skin and burgeoning designs.

When I’m there, we often read poetry that directly addresses racial injustice.  I’ve brought stuff by Reginald Dwayne Betts, Ross Gay, Terrance Hayes, Adrian Matejka, and Tracy Smith.  Sometimes these lead to good discussions.  Sometimes our class gets totally derailed.

In one of the poems titled “American Sonnet for My Past and Future Assassin,” Hayes pulls off a stunning trick.  The same line is included twice, but the word “haunted” changes from a verb into an adjective after the language slides into a less formal diction.  It’s a beautiful moment.  The first time I brought this poem, we talked about the clinginess of the past, the way not only our own histories but also the histories of our forebears can stalk us through time.

The next time I brought this poem, several guys reacted by saying that Black people don’t talk right.  Then they went off about sagging pants.  All this from southern-accented white guys whose missing-toothed, meth-mouthed mumbles and guffaws I could barely comprehend.

We had to quickly move on.

Or there was the time when we read Betts’ “Elegy with a City in It,” a fantastic poem that uses a spare, stark set of words and sounds to simultaneously evoke both the deprivations of the inner city and the epic grandeur of The Iliad, which uses a similarly constrained lexicon.

Many gone to the grave: men awed

by blood, lost in the black

of all that is awful:

think crack and aluminum.  Odd

what time steals,

or steals time: black robes, awful

nights when men offed in the streets awed

us.

If you read the poem aloud, you’re chanting the same phonemes over and over, but their meanings twist and turn as they spill from your tongue.  That’s what I wanted to discuss.

Instead, a few guys latched onto lines like

                                                Black,

Mario, Charles, they all blackened

the inside of a coffin

and this offended them because “white people have it bad, too!”  As though Betts could not describe Black pain without trivializing their own.  Soon somebody was saying “All lives matter” and that he’d voted for our current president.  This guy was in jail because he’d been caught selling heroin to support his own habit.  The president he’d voted for had recently recommended executing drug dealers.

Somebody else shook his head and muttered, “y’all are fucking [stupid].”

We moved on.

In my classes, I work with a wide range of ages – sometimes guys as young as seventeen, sometimes men in their sixties.  My spouse, as a high school teacher, works with younger people – anywhere from fourteen to eighteen years old.  But ideology can set in early.  My spouse has had students whose families were prominent in the Klan.

At the beginning of the year, she asks each student to fill in the paper silhouette of a head with words and pictures of what inspires them to succeed.  She then posts these along the ceiling of her classroom.  Several times, she’s had to ask kids to erase supremacist imagery.

So it isn’t terribly surprising that some farmers at our local market have hateful beliefs.  Right-wing supremacist movements are major terrorist organizations in this country, and they do a lot of recruiting.  As our nation has become slightly less horrible, though, many of these people learned to be circumspect.  They maintain a divide between their private and public language.

People who rely upon public, liberal venues like our farmers market can’t be too outspoken with their hate.

Indeed, the white supremacist farmers who were recently outed tried to be circumspect.  But they must have felt lonely, and they grew too careless.  Under a pseudonym, they posted on the Identity Evropa message board.  This is a website devoted to the ideologies that have inspired the vast majority of terrorism in the United States.  Theoretically, this is a venue where people get to cultivate their hatred anonymously.  But one of their compatriots was caught painting swastikas on a synagogue (see image below) and blew their cover.  Sort of.  The vandal was interrogated by the FBI, and his remark unveiling the farmers’ pseudonym was buried deep in a 200-page sentencing document. 

Through assiduous work, a team of activists was able to prove that these farmers were white supremacists.

The activists who had worked so hard to gather evidence were obviously against hate.  They wanted to take action.  But the plan they favored wasn’t very flashy.  They would organize a boycott of that farm stand.  They also proposed that the city use the sellers’ farmers market fees to fund grants for people of color, with the understanding that our nation’s long history of racism has inequitably skewed the demographics of agricultural land holdings.

To stay at the farmers market, the supremacists would have had to support a cause they loathed … and they were making less and less money here.  I was told that, during the boycott, the farmers had begun padding their bins, bringing fewer vegetables each week so that they could still appear to be selling out their stock.

Unfortunately, the tropes of social media have changed public discourse in our country.  I assume it’s relatively uncontroversial to claim that social media prizes style over substance.  Quiet, careful plans are at a disadvantage in the attention economy.

As word spread that these farmers were white supremacists, patrons demanded that they be banned from our market.  People of color now felt unsafe in that space, for obvious reasons.  There’s a difference between the perceived threat level felt by a pale-skinned activist and by somebody who is recognizably a member of a racial minority.

The mayor, whose spouse is a constitutional law professor, rightly argued that the farmers would be able to sue the city on a First Amendment case. 

Still, people felt that we had to do something more visible.  Passively allowing outspoken white supremacists to hawk their tomatoes at our market would seem to be tacitly endorsing their political stance.

Everybody has a right to believe whatever garbage they want.  Do you sincerely believe that people of northern European descent have a genetic inclination toward greater intelligence?  You’re wrong, and you’re a jerk, but you’re allowed to believe that.

The problem is that white supremacist organizations like Identity Evropa use terrorism to back their asinine beliefs.  Implicit threats of violence, delivered by people known to stockpile military-grade weaponry, are different from “mere” hate.

If these farmers couldn’t be banned, then we’d hold signs in front of their booth.  Eventually, a protester was arrested – the police had asked her to stand in a designated “announcements” area instead of in the middle of the market – and, as always happens following an arrest, her home address was published online. 

She was soon inundated with death threats.

As coverage of the dispute increased, right-wing militia types were also drawn to our town.  Three percenters, unaffiliated gun nuts, other supremacists – they began to support that farm, undermining the boycott.  And these radical Protestant faux-constitutional terrorists made sufficiently credible threats of mass violence that our mayor had to shut down the entire market for two weeks at the height of the growing season.  Other farmers were suffering.

Image from the Richmond Times-Dispatch.

Calm, careful behavior from the original activists – assiduously combing through those lengthy, dull documents, not to mention their efforts to infiltrate local supremacists’ in-person social circles – had undoubtably helped.  Hateful ideologies were exposed, and efforts were made to impose consequences.

But then our visible protests made matters worse.  We’ve helped the proponents of hate to make more money.

And, now that we’ve drawn attention to them, we’ve inadvertently connected these white supremacists with their allies.  They will no longer need to post on public forums, which was the only reason that activists were able to prove that they supported these ideologies in the first place. Now these supremacist farmers are invited speakers at right-wing events.

As this whole struggle was unfolding, my spouse and I participated in a poetry reading.  We shared poems written by people in our local jail.  We were joined by one of the authors, a man who had just been released after five months inside.  He described what it was like to write while he was there – breathing fresh air in the outdoor rec courtyard only nine times in five months, having access to a pencil sharpener only once each week, and feeling forced to confess to a crime that he swears he hadn’t committed because they promised to release him for time served.

Our audience clapped for the poems and stared aghast during our banter, which is probably as it should be.

We closed our set with a piece from M.G.  This poem was written in February, before the public turmoil regarding our farmers market began.  At a moment when so many of us were warily watching that space, it seemed important to remind people that there have always been watchful eyes gazing at the market.

The farmers market is just down the street from our five-story county jail.

MARKET

M.G.

As I look out this window of bars

There’s a farmer’s market.

People coming and going.

I wonder if I have any friends over there.

The sun is warm and bright.

One day soon I will be at

That farmer’s market.

I hope to see my friends again.

On the moon landing, and who benefits if you believe it was faked.

On the moon landing, and who benefits if you believe it was faked.

If you’re worried that you don’t feel enough stress and anxiety, there’s an easy chemical fix for that.  Habitual methamphetamine use will instill intense paranoia. 

In our poetry classes in jail, I’ve talked with a lot of guys who stayed up for days watching UFO shows on TV.  A few were also stockpiling military grade weaponry. One man used strings and pulleys to link his shotgun’s trigger to a doorknob, ensuring that anyone who tried to enter the house would be rudely greeted. 

They’ve dismantled dozens of computers and phones: sometimes out of suspicion, sometimes because there are valuable components. Although they were rarely organized enough to hawk the proceeds of their dissections.

Suffice it to say that, deprived of sleep and dosed with powerful stimulants, their brains became tumultuous places.

Which is why we spend so much time talking about conspiracy theories.

I’ve written several previous essays about conspiracy theories – that the Santa myth teaches people to doubt expertise (children learn that a cabal of adults really was conspiring to delude them); that oil company executives have been conspiring to destroy the world; that, for all the ways Thomas Pynchon’s Gravity’s Rainbow probes at the undercurrents of truth beneath government conspiracy, the text blithely incorporates metaphors from a Disney-promulgated nature conspiracy.

But, with the fiftieth anniversary coming up, the men in my class have been talking more about whether the moon landing was faked.

There’s only so much I can say.  After all, I, personally, have never been to the moon. 

One of my colleagues from Stanford recently conducted molecular biology experiments on the International Space Station, but that’s only zero point one percent of the way to the moon … and she and I were never close enough for me to feel absolutely certain that she wouldn’t lie to me.

Visiting the moon does seem much easier than faking it, though.  Our government has tried to keep a lot of secrets, over the years.  Eventually, they were leaked.

But that line of reasoning is never going to sway somebody. The big leak might be coming soon.

Instead, the strategy that’s worked for me is to get people worried about another layer of conspiracy.

“Let’s just say, hypothetically,” I say, “that we did send people to the moon.  Why would somebody want to convince you, now, that we didn’t?”

When NASA’s project was announced, a lot of people were upset.  Civil rights activist Whitney Young said, “It will cost $35 billion to put two men on the moon.  It would take $10 billion to lift every poor person in this country above the official poverty standard this year.  Something is wrong somewhere.”  (I learned about this and the following quote from Jill Lepore’s excellent review of several new books about the moon landing.)

During John F. Kennedy’s presidential campaign, he argued that we needed to do it anyway.  Despite the challenge, despite the costs.  “We set sail on this new sea because there is new knowledge to be gained, and new rights to be won, and they must be won and used for the progress of all people.

We did reach the moon. But, did we use that knowledge to benefit the rights and progress of all people?  Not so much.

A lot of the guys in jail went to crummy schools.  They grew up surrounded by violence and trauma.  They didn’t eat enough as kids. They’ve never had good medical care.  They’ve struggled to gain traction in their dealings with government bureaucracies … we’ve spent years underfunding post offices, schools, the IRS, the DMV, and, surprise, surprise!, find that it’s arduous interacting with these skeletal agencies.

To keep these men complacent, the people in power would rather have them believe that we didn’t visit the moon.  “Eh, our government has never accomplished much, we faked that shit to hoodwink the Russians, no wonder this is a horrible place to live.”

The fact that people in power are maliciously undermining our country’s basic infrastructure would seem way worse if you realized that, 50 years ago, with comically slapdash technologies and computers more rudimentary than we now put into children’s toys, this same government sent people to the moon. 

Ronald Reagan said, “Government is not the solution to our problem; government is the problem.”  And he was in a position to make his words true – he was the government, so all he had to do was be incompetent.  And then people would hate the government even more, and become even more distrustful of anyone who claimed that good governance could improve the world.

Needless to say, 45 has taken strategic incompetence to a whole new stratosphere.  Beyond the stories of corruption that pepper the news, there’s also the fact that many appointments were never made; there are agencies that, as of July 2019, still don’t have anybody running them.  These agencies will perform worse.

If people knew how good our government used to be, they might revolt.  Better they believe the moon landing was a sham, that the faked photographs are as good as anybody ever got.

Our one and only.

On storytelling in games.

On storytelling in games.

I recently read my friend Marco Arnaudo’s Storytelling in the Modern Board Game, a detailed history of the games that were designed to give players an interesting narrative experience.  These have ranged from Renaissance-era parlor games in which permutations of Tarot cards were used to inspire tall tales, to Dungeons & Dragons, in which a narrator ushers a group of friends through a fantasy quest that they collaboratively embellish, to the contemporary board games that, despite their meticulously-delineated rules and victory conditions, also include gorgeous art and fanciful text to evoke cinematic moments along the way.

Arnaudo’s expertise is unquestionable.  He produces a popular series of video reviews.  And I often join him for Friday night gaming, where we play surrounded by his mind-boggling collection.  I only wish that there had been space in his book to address the topic of precisely which types of narrative are better conveyed by board games than other forms of media.

I’ve written previously about the narrative potential of games, but not board games specifically.

Consider a story of moral complicity.  When presented through text, as in a newspaper article or novel (perhaps Donald Antrim’s Elect Mr. Robinson for a Better World, Ford Madox Ford’s The Good Soldier, or J.M. Coetzee’s Waiting for the Barbarians), it’s easy to think that we would do better than the characters described.  Even when a tale of depravity is written in the second person, like Jay McInerney’s  Bright Lights, Big City, it’s easy to maintain a sense of moral superiority, because the actions taken by McInerney’s “you” aren’t things that I would actually do.

But there’s no excuse within a game.  The actions taken by a game’s protagonist are things that you might do, because you were in control.

In “The Soldier’s Brief Epistle,” poet Bruce Weigl writes:

You think you’re better than me,

cleaner or more good

because I did what you may have only

imagined

When we learn that the soldiers in Vietnam murdered civilians, or that military guards at Abu Ghraib tortured prisoners, it’s easy to think that we would never sink to that level. 

In “Life on Mars,” U.S. Poet Laureate Tracy K. Smith writes:

                                    The guards

Were under a tremendous amount of pleasure.

I mean pressure.  Pretty disgusting.  Not

What you’d expect from Americans.

Just kidding.  I’m only talking about people

Having a good time, blowing off steam.

Despite the fact that many Americans worship a deity who would torture prisoners, we feel that we would not sink to that level.  We can feel unmitigated disgust at our compatriots when we see horrific photographs like those presented in the (Not Safe For Work, nor emotionally safe for any other setting) Abu Ghraib article on Wikipedia.

And yet.  In Grand Theft Auto, players are asked to torture a prisoner.  And players did it.  Some people might have felt dismayed that they needed to, but they rationalized their action because there were sunk costs … after all, they’d purchased a copy of the game … and they’d spent so many hours progressing that far … and there was no possible way to move forward in the story without torturing the guy …

Screenshot from GTA 5.

You could say, “it’s just a game!,” but that should actually make it easier to walk away from.  Imagine, instead, that someone has made a career in the military.  Then it wouldn’t be about progressing to the next level – their family’s next meal might depend upon torturing someone if a superior demands it.

From Alex Hern’s report in The Guardian:

“Rockstar North has crossed a line by effectively forcing people to take on the role of a torturer and perform a series of unspeakable acts if they want to achieve success in the game,” said Freedom from Torture chief executive Keith Best.

There are some pieces of art that I personally don’t want to engage with – this game, Stanley Kubrick’s adaptation of A Clockwork Orange, etc. – but I believe that they can succeed as art.

I would argue that Grand Theft Auto, as a piece of narrative art, teaches a valuable lesson about how to prevent torture.  It succeeds precisely because it is able to lure so many people into committing immoral acts.  We learn that torturers, or the soldiers in Vietnam, or Nazi prison guards, are not monsters – or perhaps that whatever monstrosity those people called upon lurks inside nearly all of us.

The volunteers who played the twisted role-playing games known as the “Stanford Prison Experiment,” in which players were assigned to be either captives or guards, or the “Milgram experiment,” in which players were instructed to shock an actor to death for making mistakes on a memory test, already understood this truth.  But by packaging the experience into a video game, Grand Theft Auto made this lesson widely accessible.

We are monsters.  That’s why social norms that constrain our worst impulses are so valuable.

And I don’t believe this message could be conveyed as powerfully by a novel, film, or painting as it was by a game.

Similarly, board game designers Max Temkin, Mike Boxleiter, and Tommy Maranges created Secret Hitler as an interactive form of art that could teach people how easily widespread confusion and distrust can lead to horrendous political outcomes.  The role-playing experience in Secret Hitler evokes the distress of trying to root out treachery in a world of non-overlapping information sets — and does so better than any text-based historical narrative.  Even my favorite films about uncertainty and information sets pale in comparison as ontological tools.

Picture of Secret Hitler by Nicole Lee on Flickr.

When I played Secret Hitler, I learned that I wasn’t clever enough to stop my nation’s descent into fascism.  I only wish Temkin, Boxleiter, and Maranges had made their game earlier.  It’s better to learn about moral failures from a game than to glance at the news and watch the worst unfolding around us.

Header image by Padaguan.