Category Archives: Health

What Victory looks like

As I have said before, it is good to have alternative views to consider. And this is one.  mrossol

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WSJ  3/20/2020

A telling moment came on CNBC Thursday. A host gently shushed the learned Jim Grant, editor of Grant’s Interest Rate Observer, saying discussion of tradeoffs was not encouraged. On TV, delivering up unpleasant choices is bad for the brand. Unfortunately policy discussion is about trade-offs, especially in the hardest of circumstances. Fortunately, the dam would break on CNBC a day later, thanks in part to an editorial in this paper.

In our coronavirus quandary, the cure may not only be worse than the disease. The cure is likely no cure at all. We might hold off an expected surge in coronavirus cases for two or three weeks with the kind of extraordinarily destructive economic lockdowns seen in California, New York and elsewhere. But unless warmer weather is coming to our rescue, Americans probably won’t accept the social devastation that would be inflicted by a five-month or 18-month campaign of virus suppression of the sort promoted, variously, by the U.K.’s Imperial College London, Germany’s Robert Koch Institute and other public-health think tanks.

Mandatory social distancing might well break down. (Look for speakeasies to re-emerge in New York and other shut-in cities.) The government might well face a choice of coercion or seeing its authority collapse. I’m not being alarmist.

This is a lesson the World Health Organization’s Bruce Aylward brought back from Wuhan. People with flulike symptoms had to be isolated in dormitories, hospitals and stadiums. Asking them to self-isolate voluntarily didn’t work. “After a couple of days people get bored, go out for a walk and go shopping and get other people infected.”

And he was talking about people who knew they were sick. We would be asking apparently healthy Americans to surrender much of what makes life interesting and meaningful for an indefinite period.

Bad decision making, as shown in research, often begins with reducing a complex problem to the single variable with the biggest emotional wallop. That’s what’s happening here. All of us sense the opprobrium and disgrace that would descend on our elites if Italy-like scenes of a health-care system meltdown played out on our TVs. But we may get the bad result anyway and worse if we overtax the willingness of Americans to isolate themselves indefinitely.

We also may be underestimating their ability to adopt effective voluntary distancing even as they proceed with their economic lives. Each of us knows our own situation in a way no top-down directive can. This is a virtue to leverage. I respect those experts who say we should suppress the virus until a vaccine arrives in 18 months or two years even at the cost of a global depression. Their job is to save lives, while the larger trade-offs are the province of voters and elected officials.

When experts predict that 70% of people will get the virus, they are estimating at what point the virus no longer finds enough uninfected people to sustain its transmission in a world where behavioral change is not restricting its access to fresh hosts.

The epidemic stops. People who aren’t yet infected but susceptible are spared (at least this time). We can make this work for us. We want three curves: a flattened curve for the elderly, a steeper one for the young, and a third curve showing the virus’s infectivity being reduced by isolating those who test positive and by encouraging everybody else to take care with their sneezes, hand-washing, etc.

Inconveniently for my argument, the U.K., a pioneer of such thinking, is now shifting to an accept-a-depression- and-wait-for-a-vaccine approach. The medical experts and their priorities are hard to resist. Resisting their wisdom doesn’t come naturally in such a situation.

Happily, I have confidence in the American people to let their leaders know when the mandatory shutdowns no longer are doing it for them. Strange to say, I have confidence in our political class to sense where the social fulcrum lies. A reader emails that Donald Trump could declare victory at the end of 15 days, say the blow on the healthcare system has been cushioned, and urge Americans, super-cautiously, to resume normal life. This idea sounds better than waiting for spontaneous mass defections from the ambitions of the epidemiologists to undermine the authority of the government.

Because—make no mistake— there are things worse than the coronavirus. You think our politics are irrational now? You haven’t seen anything. The 1918 flu was far worse medically than what we’re about to experience, slaughtering even young people with strong immune systems. Yet we can end up a far more damaged society as a result of the 2020 coronavirus. The America of 1918 won a world war and launched technological and commercial revolutions that created the modern world. We may not be saying anything as flattering about the America of 2020 if we handle this badly.

BUSINESS WORLD

By Holman W. Jenkins, Jr.

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Rethinking The Coronavirus Shutdown

Always good to have alternate perspectives.This “crisis” needs to be keep in perspective. mrossol
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By The Editorial Board WSJ
Updated March 19, 2020 7:40 pm ET

Financial markets paused their slide Thursday, but no one should think this rolling economic calamity is over. If this government-ordered shutdown continues for much more than another week or two, the human cost of job losses and bankruptcies will exceed what most Americans imagine. This won’t be popular to read in some quarters, but federal and state officials need to start adjusting their anti-virus strategy now to avoid an economic recession that will dwarf the harm from 2008-2009.

The vast social-distancing project of the last 10 days or so has been necessary and has done much good. Warnings about large gatherings of more than 10 people and limiting access to nursing homes will save lives. The public has received a crucial education in hygiene and disease prevention, and even young people may get the message. With any luck, this behavior change will reduce the coronavirus spread enough that our hospitals won’t be overwhelmed with patients. Anthony Fauci, Scott Gottlieb and other disease experts are buying crucial time for government and private industry to marshal resources against the virus.

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Yet the costs of this national shutdown are growing by the hour, and we don’t mean federal spending. We mean a tsunami of economic destruction that will cause tens of millions to lose their jobs as commerce and production simply cease. Many large companies can withstand a few weeks without revenue but that isn’t true of millions of small and mid-sized firms.

Even cash-rich businesses operate on a thin margin and can bleed through reserves in a month. First they will lay off employees and then out of necessity they will shut down. Another month like this week and the layoffs will be measured in millions of people.

The deadweight loss in production will be profound and take years to rebuild. In a normal recession the U.S. loses about 5% of national output over the course of a year or so. In this case we may lose that much, or twice as much, in a month.

Our friend Ed Hyman, the Wall Street economist, on Thursday adjusted his estimate for the second quarter to an annual rate loss in GDP of minus-20%. Treasury Secretary Steven Mnuchin’s assertion on Fox Business Thursday that the economy will power through all this is happy talk if this continues for much longer.

If GDP seems abstract, consider the human cost. Think about the entrepreneur who has invested his life in his Memphis ribs joint only to see his customers vanish in a week. Or the retail chain of 30 stores that employs hundreds but sees no sales and must shut its doors.

Or the recent graduate with $20,000 in student-loan debt—taken on with the encouragement of politicians—who finds herself laid off from her first job. Perhaps she can return home and live with her parents, but what if they’re laid off too? How do you measure the human cost of these crushed dreams, lives upended, or mental-health damage that result from the orders of federal and state governments?

Some in the media who don’t understand American business say that China managed a comparable shock to its economy and is now beginning to emerge on the other side. Why can’t the U.S. do it too? This ignores that the Chinese state owns an enormous stake in that economy and chose to absorb the losses. In the U.S. those losses will be borne by private owners and workers who rely on a functioning private economy. They have no state balance sheet to fall back on.

The politicians in Washington are telling Americans, as they always do, that they are riding to the rescue by writing checks to individuals and offering loans to business. But there is no amount of money that can make up for losses of the magnitude we are facing if this extends for several more weeks. After the first $1 trillion this month, will we have to spend another $1 trillion in April, and another in June?

By the time Treasury’s small-business lending program runs through the bureaucratic hoops—complete with ordering owners that they can’t lay off anyone as a price for getting the loan—millions of businesses will be bankrupt and tens of millions will be jobless.

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Perhaps we will be lucky, and the human and capitalist genius for innovation will produce a vaccine faster than expected—or at least treatments that reduce Covid-19 symptoms. But barring that, our leaders and our society will very soon need to shift their virus-fighting strategy to something that is sustainable.

Dr. Fauci has explained this severe lockdown policy as lasting 14 days in its initial term. The national guidance would then be reconsidered depending on the spread of the disease. That should be the moment, if not sooner, to offer new guidance on what might be called phase two of the coronavirus pandemic campaign.

That will surely include strict measures to isolate and protect the most vulnerable—our elderly and those with underlying medical problems. This should not become a debate over how many lives to sacrifice against how many lost jobs we can tolerate. Substantial social distancing and other measures will have to continue for some time in some form, depending on how our knowledge of the virus and its effects evolves.

But no society can safeguard public health for long at the cost of its overall economic health. Even America’s resources to fight a viral plague aren’t limitless—and they will become more limited by the day as individuals lose jobs, businesses close, and American prosperity gives way to poverty. America urgently needs a pandemic strategy that is more economically and socially sustainable than the current national lockdown.

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What We Can Learn From the 20th Century’s Deadliest Pandemic – WSJ

A good perspective:  Containment, isolation, quarantine. Truth. Leadership. mrossol

In 1918, the Spanish flu killed more than 50 million people around the world. The lessons of that outbreak could save countless lives in the fight against the coronavirus.

By  Jonathan D. Quick    –   

The “Spanish” flu of 1918 was one of the deadliest pandemics in human history. Seeming to come from nowhere in the waning days of World War I, it spread through a war-ravaged world like wildfire. In a matter of months, a third of the world’s population was infected, 50 to 100 million people died, and the global economy shrank by 5%.

The world of 1918 was very different from today’s, where the new coronavirus is emerging as another potential pandemic. A century ago, antibiotics, modern hospitals, intensive care units and instant communication did not exist; most people lived in rural communities; intercontinental travel took weeks rather than hours. Now the world’s population is four times larger, with more than half living in urban areas. National economies are heavily intertwined because of globalization. Health services are highly sophisticated in wealthy countries, though their quality varies greatly in the rest of the world.

From a public health perspective, however, there are important similarities between the 1918 flu and the 2019 coronavirus. Both were previously unknown viral strains for which there was no existing vaccine or proven medical treatment. Both spread through respiratory droplets and killed primarily by means of pneumonia and other complications. Both caused severe economic disruptions. With the growing risk of a full-blown pandemic, applying the lessons of the 1918 flu could save countless lives in 2020.

In 1918, a sign warns naval workers in Philadelphia about the danger of spreading the flu through spitting.

PHOTO: ALAMY

Provide effective leadership. In 1918, Philadelphia was one of the hardest-hit American cities, partly because it was, as the muckraker Lincoln Steffens put it, “the worst-governed city in America.” In his book “The Great Influenza,” the historian John M. Barry describes the efforts of Dr. Wilmer Krusen, director of Philadelphia’s Public Health and Charities department, a well-intentioned man who lacked public health experience and was prone to inaction. On Sep. 28, 1918, he allowed the city to proceed with a Liberty Loan parade to sell millions of dollars in war bonds, despite warnings that the event would spread illness. The parade drew 200,000 people; within 72 hours, every bed in the city’s 31 hospitals was filled.

By contrast, Mr. Barry shows, St. Louis had the most success of any large American city in fighting the pandemic. Dr. Max Starkloff, the city’s health commissioner, said that his goal was to “keep the epidemic out of the city, if possible, and if that fails, to use every means to keep it down to the lowest possible number of cases.” He created an advisory body that included representatives of the city’s chamber of commerce, schools, medical society, university, Red Cross and local public health services. He pursued what he called “intelligent citizen cooperation” through active outreach to the community. And he engaged health department staff, policy makers and teachers to implement individual quarantines and bans on public gatherings. Thanks to Starkloff’s rapid, inclusive and systematic efforts, St. Louis’s mortality rate from the flu was half of Philadelphia’s.

Leadership mattered even more at the national level. President Woodrow Wilson was so focused on winning World War I that he would not listen to repeated warnings about the pandemic from the chiefs of the Army and Navy, or even from his own personal physician. The U.S. ended up losing 675,000 lives to influenza, compared with 53,000 killed in combat in World War I.

The cities that fared best in 1918 were the ones that started isolating patients early and continued until the epidemic was unquestionably under control.

The past century has reinforced the importance of thoughtful, principled, decisive leadership in combating epidemics. Smallpox was officially eradicated in 1980, in what might be the greatest achievement in the history of public health. Dr. D.A. Henderson of the U.S. Centers for Disease Control and Prevention was the tenacious advocate who convinced the World Health Organization to take up the challenge of eliminating smallpox everywhere in the world; he then led the campaign to victory.

In 2003, President George W. Bush launched his Emergency Plan for AIDS Relief, which was crucial in helping the people of Africa to confront the AIDS epidemic. He announced the program with words of grace and compassion, without blame or judgment: “I propose … a work of mercy beyond all current international efforts to help the people of Africa…. This nation can lead the world in sparing innocent people from a plague of nature.”

Rely on classic public health measures. In 1918, the lack of national leadership meant that every city and state pursued its own approach to dealing with the epidemic. This created a series of natural experiments that allowed later researchers to assess the effectiveness of different approaches. They found that cities which implemented isolation policies (such as quarantining houses where influenza was present) and “social distancing” measures (such as closing down schools, theaters and churches) saw death rates 50% lower than those that did not. The cities that fared best were the ones that started isolating patients early and continued until the epidemic was unquestionably under control.

In the century since the 1918 outbreak, studies of seasonal flu infections and occasional pandemics have underscored the benefits of hygiene instruction and regular handwashing, which can reduce influenza cases by more than 40%. During the 2009 “swine flu,” school closures in Texas reduced acute respiratory illness by 45% to 72%. Such classic public health measures are sometimes as effective as the seasonal flu vaccine, which reduced infections by less than 40% in four of the last 12 U.S. flu seasons.

Give accurate information and build community trust. In every pandemic, people fall prey to stigmatization, distrust and rumor-mongering. The “Spanish” flu, as the 1918 pandemic is still widely known, did not originate in Spain. Rather, because the country was neutral in World War I, its uncensored press was the first to report on the disease. As a result, many around the world blamed the Spanish for the epidemic, and the nickname persists to this day.

As the flu spread in 1918, many communities found scapegoats. Chileans blamed the poor, Senegalese blamed Brazilians, Brazilians blamed the Germans, Iranians blamed the British, and so on. In the U.S., the country’s millions of new immigrants had often been stigmatized as disease carriers during previous epidemics, but the 1918 flu struck every social class and every part of the country, so no single ethnic group was blamed for it.

Some populations, though, were more vulnerable to the disease than others. A study of data from 438 U.S. cities, published last year in the journal Economics and Human Biology, found a wide variation in pandemic-related mortality rates in 1918, ranging from 211 deaths per 100,000 people in Grand Rapids, Mich., to 807 in Pittsburgh. Half of this difference was attributable to three factors—poverty, prior health status and urban air pollution. The same will likely be true with the coronavirus, which means that ensuring prevention and care for the most vulnerable is vital for saving lives.

The Red Cross Motor Corps on duty in St. Louis in October 1918.

PHOTO: THE GRANGER COLLECTION

Remarkably, despite the ubiquitous daily horror of the 1918 flu, there were few instances of flu-related attacks or riots. On the contrary, in her book “Pale Rider,” the science journalist Laura Spinney finds many examples of good Samaritans. In Alaska, 70-year-old Dr. Valentine McGillycuddy came out of retirement to fight the flu; in Tokyo, doctors went out at night to give free vaccinations to the poor; in Germany, the Catholic Church helped to train young women as nurses.

During pandemics, the reflex to help one another is more common than we might think. At the deadliest moments in 1918, when city governments in the U.S. were overwhelmed, volunteer groups—from Phoenix’s citizens’ committees to Philadelphia’s bluebloods—stepped in to distribute resources to those in need. When communities did lose trust in their leaders, it was often because, in Mr. Barry’s words, they had lied about the severity of the pandemic “for the war effort, for the propaganda machine that Wilson had created.”

In the face of highly variable responses from public officials, the media served as an essential ally of the public health community in fighting the pandemic.

What the public needed was accurate answers to the questions raised by the appearance of an unfamiliar, deadly disease. Where did it come from? How could I get infected? Can I pass it on to others? How can I protect myself and my loved ones?

The historian Nancy Tomes has shown that in 1918, since radio broadcasts and newsreels were focused on war news, people turned to the print media for information on the flu. From trade magazines like Variety to scientific journals such as Survey, journalists asked difficult questions about how the epidemic was being handled and presented the best available answers to their readers. In the face of highly variable responses from public officials, the media served as an essential ally of the public health community in fighting the pandemic.

As we now face the specter of a coronavirus pandemic, it is reasonable to ask: Are we more or less vulnerable today than we were a century ago? In some ways we are clearly better off. We have modern vaccines and medical care, dramatically improved communication tools and healthier, better nourished populations. Modern governments plan in advance for how to respond swiftly to outbreaks, and there are mechanisms in place for international cooperation.

Yet according to the 2019 Global Health Security Index, less than one in five countries is fully prepared for a global pandemic. More than a billion people don’t have access to essential prevention services, vaccines and medicines, and most of the world lacks intensive care services capable of handling severe cases of the coronavirus.

And we are vulnerable in other distinctively modern ways. Growing resistance to many antibiotics makes it hard to treat pneumonia and other bacterial complications. Large numbers of people suffer from heart disease, diabetes, cancer and other diseases that weaken the immune system. Rapid international travel has spread the virus at lightning speed. And as we are already seeing with the new coronavirus, globalized supply chains, dependent on just-in-time delivery of medicines, food and other essentials, are vulnerable to disruption in a global pandemic.

This face-off between the factors that reduce our vulnerability and those that increase it leaves humanity at considerable risk. Thousands, possibly millions, of lives depend on our ability to apply the lessons of 1918 and other pandemics. Only by taking full advantage of scientific and public health advances, investing in strong health systems and developing new technologies to prevent and respond to disease will we be able to meet the challenge of the new coronavirus—and the other outbreaks that will inevitably follow.

Dr. Quick, an adjunct professor at the Duke Global Health Institute, is the former president of Management Sciences for Health, a global public health organization, and served as Director of Essential Drugs and Medicines Policies at the World Health Organization. His books include “The End of Epidemics: The Looming Threat to Humanity and How to Stop It.”

https://www.wsj.com/articles/what-we-can-learn-from-the-20th-centurys-deadliest-pandemic-11583510468?mod=hp_featst_pos1

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The Backward March of Civilization

Disease on those who unresponsively denigrate vaccination. Nothing is risk-free. Even stupid me knows that. I don’t have the time of day for them.

 WSJ  12/7/2019

Our age likes to believe in the inevitability of human progress, but for an example of the opposite consider the Pacific island nation of Samoa. A measles outbreak there has already killed more than 60 people, and authorities declared a two-day curfew on Thursday and Friday.

Businesses were obliged to close and vehicles had to stay off the roads from 7 a.m. to 5 p.m. Mike Cherney of The Journal reports that residents were told to fly red banners from their homes if anyone inside needed vaccinations in the country of roughly 200,000 people. Officials were going door-to-door to vaccinate people. Most of the dead were children under 4 years old, and more than 4,300 have been hit with the disease.

The outbreak is especially tragic because measles can be contained with vaccinations. But misinformation from vaccine opponents has spread around the world in recent years, including in supposedly civilized America.

An outbreak hit New York last year among Orthodox Jewish neighborhoods where parents often block vaccinations. New York State banned nonmedical exemptions for school vaccinations as a result. Some 1,200 measles cases have been recorded across the U.S. so far this year, the most since 1992. Countries like Samoa are more vulnerable because they have less developed health systems and sometimes less efficient governments. Only 31% of Samoans were vaccinated against measles as of 2018.

The outbreak—and death toll—ought to chasten celebrities and others in the U.S. who have spread fears about vaccines, which are remarkably safe and prevent more deaths by far than they cause. It’s also a reminder that the march of civilization isn’t always for the better. Especially in the age of social media and lack of social trust, bad information can drive out good. Avoidable deaths like those in Samoa can be the tragic result.

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