Hey, I'm in broad agreement with you, but, a nit ...

> Here’s how you can tell people’s philosophical positions: if they talk about fear of a “second wave” they are Containers, since that implies the initial “wave” will not infect the majority; ie the virus is successfully contained.

Here in the SF Bay Area we pretty effectively blunted the first wave with public health controls, which meant health care was not stressed much. Despite the Stanford serosurvey saying that we have 3% with a history of infection, the real number is probably more like 1%. Daily case counts are decreasing, so the initial "wave' did not infect the majority.

It's not enough to decrease Rt noticeably at all. We need to figure out how to loosen up controls in a way that provides economic benefits, keeps a nice constantish burn towards herd immunity, but with enough safety margin to prevent catastrophe that New York got too close to.

Instead, our public health seems to be further tightening instead of experimenting with small measures to relax the controls. There's a loud contingent advocating what would effectively be permanent controls.

So, that's definitely a good point to raise. I agree and should have been more clear. I think there should not be a second wave because I think we need to resume more or less normal society and let people naturally get exposed (since voluntary self exposure will not ever be tenable in the US I fear).

But given the way that California aggressively locked down early into this, I agree that we have been sloping down and thus there is guaranteed to be subsequent waves.

Basically, the waves are real but are arbitrary and are caused by our own misguided interventions.

> We need to figure out how to loosen up controls in a way that provides economic benefits, keeps a nice constantish burn towards herd immunity, but with enough safety margin to prevent catastrophe that New York got too close to.

100% agreed. Now the argument I do somewhat agree with is that it's very hard to get that balance right when dealing with exponential transmission. Which is why on balance I'm leaning much more towards "we'll cross that bridge when we get there" (because the alternative is that we have to stay permanently locked down).

Also the portion of the population I am advocating should be allowed to return to work is precisely the portion of the population that produces very low hospitalization rates.

I strongly believe that anyone who has been reading CNN the last few weeks would be _shocked_ to learn that we get 1 hospitalization for every 500 20-29 year olds infected (and again, these numbers are not fully settled but they're at least in the right order of magnitude IMO)

> There's a loud contingent advocating what would effectively be permanent controls.

Yup, this is what has me really scared. The widespread belief being that it is actually plausible to avoid ever getting infected and therefore any infections that follow a softening of lockdown introduce deaths that never would have occurred in the hypothetical alternate universe.

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So, thanks for raising that point, I fully agree. The TL;DR is that implicit in "we need to watch out for the second wave" is the notion that "we need to fight these waves and halt their spread" which I strongly disagree with.

EDIT: And just to be clear, if we "re-open" we'll still all be wearing masks and keeping arbitrary distance between each other so it's not like we're all running around exchanging bodily fluids willy nilly. But I really do think that the shutdown has been, in some part, effective in curtailing spread, and thus naturally I would expect a higher infection rate following a re-opening.

EDIT 2: Removed the part about the political leanings of those advocating for long-term lockdown because it's going to set off people's defense mechanisms and potentially cause them to draw the wrong impression of what I'm saying

In San Diego people under 30 are close to 20% of total confirmed and over 5% of hospitalized cases. About 7% of confirmed are hospitalized for this age group. Our positive test ratio is under 7%. Tests are constrained by policy but not dramatically so. https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs...

Another data point is the US military. I believe they test much more widely due to their living conditions. So far the cfr is about 0.4%.

Young people interact with more individuals, and engage in more behavior that exchanges microbes such as unprotected sex, protected sex, sharing pipes/vapes, sharing utensils, etc.

We should expect that the proportion of people with Covid should be heavily biased towards the young for that reason, as it is for any disease that does not have a biased transmission.

Most indications I've seen is that the young are not harmed much by covid, but can still get infected just as easily, thus why we see:

"X% of hospitalizations are young people" as opposed to the statement that people actually interpret it as: "X% of young people infected with covid are hospitalized".

Does that make sense?

For any test that is not given randomly or universally, there is a selection bias. A test given based on severity of symptoms bias heavily against patients with light symptoms, presumably younger people. But to get from 7% (hospitalized to confirmed) to 1 in 500 is a factor of 35. BTW the city of Canton (Guangzhou) just tested all their high school seniors in preparation for school reopenning and found zero positive case so far. And they did find cases among other groups.

I don't think anyone enjoys lockdown. At a minimum we need sufficient testing, sufficient ppes, sufficient surge capacity and training for standard supportive care. We are still quite a ways from that. Even if death is unavoidable people deserve to have reasonably good care.

> But to get from 7% (hospitalized to confirmed) to 1 in 500 is a factor of 35.

This is broadly in the range implied by a number of measures across the entire population. 20x for randomized population sampling (Iceland), 20-80x from serology studies, etc.

In this analysis, https://www.medrxiv.org/content/10.1101/2020.04.18.20070821v... 35x is actually the exact factor that cases are estimated to be under-reported by in California. :P

> I don't think anyone enjoys lockdown. At a minimum we need sufficient testing, sufficient ppes, sufficient surge capacity and training for standard supportive care.

Here in the SF Bay Area, ICU usage peaked 3 weeks ago, and controls have been tightening. We're well below seasonal norms for ICU usage at this point. Surely the original controls that caused the original trend down in disease would be good enough now, and could even be loosened slightly further to have more parity with other jurisdictions that are successful.

> In San Diego people under 30 are close to 20% of total confirmed and over 5% of hospitalized cases.

People under 30 are over half the population in San Diego, so you've just said there's 1/10th as many of them in the hospital as we'd expect if the total risk were equal.

The serology data tells us that an even greater portion of cases in the young are missed-- they are probably actually half the number of infections in San Diego, but a much smaller proportion of hospitalized cases.

The current data implies something close to what he said: about a 1 in 500 to 1 in 1000 chance of hospitalization for people under age 35.

It's not like business was going to go on as normal when people started filling up hospitals.

The lock down was a choice between what we are going through now and a much worse disaster if the spread continued through a couple more doublings. Of course the extreme stay at home orders should be continued for as short a time as possible, but what we do next also doesn't have to be exactly what we were doing before (and realistically won't be).

My impression at the moment is that containment isn't going to happen, but mostly because people don't want to bother, not because it is the more costly alternative or impractical. Given the lack of appetite to test and isolate, we had better all start doing things like wearing masks.

Note that ~80% of American's favor the stay at home orders right now. It's not a partisan issue, it's an issue where a loud minority is getting some attention from the media.

> As others have said, for those around age 45 or less, Covid is equally or less dangerous than Influenza. And particular for those under 30 the flu is an order of magnitude more deadly at least.

Can you share the specific numbers you used to reach this conclusions? The reason I ask is because I'm seeing a lot of people in this thread comparing:

1) Overall influenza fatality rates to age stratified Covid fatality rates, and

2) Symptomatic influenza fatality rates to symptomatic + asymptomatic Covid fatality rates.

Both of which are highly flawed comparisons for reasons that should be obvious.

Following up here:

I came across https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-.... It's not clear if it's referring to CFR or IFR but I imagine it must be CFR given how high some of the numbers are (500 deaths per 1000 in some cases).

I agree that finding properly stratified data that is comparing IFR and not just symptomatic CFR is quite tricky.

At a minimum though, if we assume the chart I linked is CFR and compare to the Covid 5-20% CFRs we've seen, we still get that order of magnitude difference for the very, very young. But like I said in my previous comment here, I don't think the statement for all under 30's holds. It'd have to be <18 years old (and to be clear while https://bmcmedicine.biomedcentral.com/track/pdf/10.1186/1741... is helpful, I still haven't proven anything)

I’ll try to dig up some sources later today. But briefly, on second thought “under 30” was sloppy of me to say and so that statement is probably false. I would expect for those 25-30 years old they should fall outside the range where Influenza kills a lot. So I think the order of magnitude is almost certainly true for those under 18, but I am now doubting it holds all the way up to age 30.

> when you do the math on mortality due to suicide and overdose it’s not clear that containment would even save more lives in the long run.

I'm waiting for people to do the analysis of mass unemployment from lockdown leading to people losing their healthcare, just in time for the pandemic to widen or return this summer or fall.

You're exactly right to consider all of the externalities of our current approach.

I hadn't thought of it specifically in terms of our broken employer-based healthcare system. That's a really good point.

I quit my job Feb 7, before all this unfolded. And COBRA costs me $612.54 per month.

For the same reason I was able to quit my job, I will be totally fine. I have over 5 years of living expenses in liquid assets, so I will be fine.

But for someone who was living paycheck to paycheck and lost their job because it's not the type of job that can work from home, how the hell could they possible afford healthcare?

Along those lines, I do really think that part of the reason so many people don't see the harm in locking down for the next several months is because, like me, they work in the tech industry and really have not been affected by this as far as employment goes.

Thanks for this comment, puts into words what I have been casually thinking. Also, this is the strategy in Sweden, seems to be working out fine for them.

Thanks, I've been trying to find the words as well, which is really difficult when expressing a position that runs counter to "we need to lock down for the next 18 months" is basically characterized as wanting to kill granny.

I generally have to spend more time prefacing the ideas with "I'm not a trump supporter and I think covid is real and I think it's more deadly than the flu and..." than talking about the actual ideas themselves. Especially on Reddit...

I agree with some of what you said here, but there is one specific point I want to disagree with. All the projections for unemployment related deaths are based on society functioning as it previously did. I think many of the people who are suggesting we are in for long term isolation are also suggesting a much bigger increase in the social safety net to help people through these difficult times.

Right, but I think some of that suicide rate comes from the lack of "purpose" (it's silly that we rely on our jobs for purpose but we really do), or more broadly the desynchronization of one's internal schedule that many of us have experienced (which leads to worse sleep and therefore higher mortality).

I also think that given we know about the level of competence of our government, it will be very difficult for "real" safety nets to be put into place. That's not even getting to the partisan divide inherent to our system.

So in my eyes, we had one big problem, covid, and turned it into two big problems, covid and an economy in ruin. And these two problems affect a greater set of individuals than either one alone. Since a huge number of deaths from Covid are those who weren't working because they're 70+.

Lastly, one of the most "famous" social safety nets in America is social security, which is a farce that is known to redistribute money from the poor to the rich. (It is an eternal frustration of mine that the Left in America is so heavily in favor of social security despite it being flawed from its inception) [1]

[1] See Milton Friedman's excellent take https://www.youtube.com/watch?v=rCdgv7n9xCY

You are missing the point in that if nothing was done in terms of trying to (at least temporarily) contain COVID, then the economy would be just as bad off.

We're currently at 50K deaths in the US, largely in a four week period. I think it's safe to say that the shutdown has cut the death rate in half, if not more. If 100K people die in 4 weeks in the US, the people will shut the economy down whether the government initiates it or not.

Either way we're screwed. And I think your data is far off in terms of IFR and CFR. Imagine the IFR being a magnitude higher for COVID versus influenza. I personally think this is a safe guess based on what we've seen in a wide variety of environments, complicated by different testing methodologies etc etc. So we'll use 1% for the IFR.

Now current thought is the R0 is between 2 and 5. Hopefully closer to 2 since R0 dramatically affects the percentage of infections required to reach herd immunity. But to be simple, we'll assume we need 50% to reach herd immunity. So we'll use 164M as the number of Americans needing to be infected before we can "return to normal."

With 164M cases, and an IFR of 1%, 1.6M Americans will die. An additional 9% will need hospitalization, but survive. That's 14.8M.

Say we're off by a lot and "it's just a flu" with an IFR of 0.1%. You'll have 164K fatalities, and we'll still have the 14.8m hospitalizations. Say the hospitalization rate is off by a magnitude, it's still 1.48M.

There's no way our country can operate "normally" with these types of numbers.

I will grant you the lack of purpose being a motivator for suicide, but none of us know how that would transpire during a global pandemic. I know there is debate over the specifics over Maslow's hierarchy of needs nowadays, but generally speaking I think a lot of us will focus less on these internal issues in times of external danger.

Also if we are going to use government incompetency as an argument here. I would throw it right back at you and say I have little faith in the government implementing a reopening plan that doesn't either kill people or damage the economy long term.

Lastly it is a false dichotomy to present a choice between protecting people from COVID-19 or protecting the economy. If we refuse to do the latter, we are going to ruin the economy anyway. Hundreds of thousands of people dying would certainly put a damper on demand. And while there are certainly people protesting about reopening sooner, I don't think think movie theaters would be selling out if they opened tomorrow.

>In the general population overall, Covid is undeniably more deadly than the flu, but only about 3-5x (and I think 3x personally right now).

I don't see how you get close to 3X more deadly than the flu. If 14% of New York state residents have been infected, 20M population, 15000 deaths + another 3000 that are infected now and will die (this disease takes a long time to kill people) you get an IFR of 0.64. If the IFR for flu is 0.05, that makes covid 12X more deadly than the flu.

Lots of people reporting an IFR of 0.5 based on the NY serological data; that is "right censoring" the deaths. It's got to be a bit higher than that. Either way you have covid with 10X the infection fatality rate of the flu. If worst flu years have IFR of 0.1 then covid is still 5X worse than the worse flu seasons. And as contagious as the worst flu seasons too.

So twice as contagious as the flu, 10X deadly. Much more likely to put you in the hospital, and thus overwhelm the hospital system, causing many ancillary deaths. This NYTimes article sums it up: https://www.nytimes.com/2020/04/06/well/live/coronavirus-doc...

At the peak in NY, hospitals stopped seeing heart attacks and strokes, because those people were too afraid to go to the hospital. Many of those people died at home, as supported by the overall death rates in NY.

The narrative put out there by those that look at the recent serology results and say "this proves that this disease was really just a bad flu all along; we can reopen the economy without fear" is just not supported by the data. An IFR of 0.64 and hospitalization rate of double that, like 1.2%, for a disease this contagious, shuts down the economy until we get a vaccine or effective treatment or a Korea-like testing/tracing regime in place.

And one more thing: the Great Depression was great for public health. https://www.pnas.org/content/106/41/17290

Yes suicides go up. But this is more than compensated for by other benefits. Overall, people may well be much healthier in a depressed economy. We will certainly see a decline in car accidents.

Excellent summary. Thanks for taking the time to write it up.