What is next?

Greetings from the future! The progression of covid-19 in Italy is running about eight days ahead of France and Spain and about 16 days ahead of the United States. Here in Lombardy, which is about ten days ahead of NYC, we have been “sheltering at home” for 13 days already.

How is social distancing working out for me? I thought that I was well prepared for it, but it is still not easy. I have started to talk to the furniture, and apparently this is perfectly normal, at least as long as the furniture does not talk back.

As I have been telling my dining table, it has been very dismaying to read news from the US, where there seemed to be a very dangerous complacency. I am relieved to see that this is changing, especially at the state level, which makes me much more hopeful.

I have also found media coverage to be disappointing. Apparently, many highly educated people, including people whose job involves understanding policy issues, have no idea how numbers work (source). This is a problem because a lot of issues concerning this epidemic have to do with numbers, which can be misleading if they are not reported in context.

For example, before the time when Trump decided that he had retroactively been concerned about a pandemic since January, conservative media emphasized the estimate of a 2% mortality rate, in a way that made it sound, well, 98% of people survive, and 98% is approximately 100%, so what is the big deal. For context, the Space Shuttle only exploded 1.5% of the times, and this was deemed too dangerous for astronauts. This is the kind of intuitive reference that I would like to see more of.

Even now, there is a valid debate on whether measures that will cost the economy trillions of dollars are justified. After all, it would be absurd to spend trillions of dollars to save, say, 10,000 lives, it would be questionable to do so to save 100,000 lives, and it would be undoubtedly right to do so to save millions of lives and a collapse of the health care system (especially considering that a collapse of the health care system might create its own financial panic that would also cost trillions of dollars).

So which one is it? Would doing nothing cost 10,000 American lives? A million? How long will people have to “shelter at home”? And what is next? I can recommend two well-researched articles: this on plausible scenarios and this on what’s next.

Kristof’s article cites an essay by Stanford professor John Ioannidis who notes that it is within the realm of possibilities, given the available data, that the true mortality rate could be as low as 0.05%, that is, wait for it, lower than the mortality rate of the flu. Accordingly, in a plausible scenario, “If we had not known about a new virus out there, and had not checked individuals with PCR tests, the number of total deaths due to “influenza-like illness” would not seem unusual this year.”

Ioannidis’ essay was written without reference to data from Italy, which was probably not available in peer-reviewed form at the time of writing.

I would not want professor Ioannidis to tell me how to design graph algorithms, and I don’t mean to argue for the plausibility of the above scenario, but let me complement it with some data from Italy.

Lombardy is Italy’s richest and most developed region, and the second richest (in absolute and PPP GDP) administrative region in Europe after the Ile de France (source). It has a rather good health care system. In 2018, on average, 273 people died per day in Lombardy of all causes (source). Yesterday, 381 people died in Lombardy with coronavirus (source). This is spread out over a region with more than 10 million residents.

Some areas are harder-hit hotspots. Three days ago, a Bergamo newspaper reported that 330 people had died in the previous week of all causes in the city. In the same week of March in 2019, 23 people had died. That’s a 14x increase of mortality of all causes. Edited to add (3/22/2020): the mayor of Bergamo told Reuters that 164 people died in Bergamo of all causes in the first two weeks of March 2020, versus 56 in the first two weeks of March 2019, a 3x increase instead of the 14x increase reported by Bergamo News.

Bergamo’s hospital had 16 beds in its intensive care unit, in line with international standards (it is typical to have of the order of an ICU bed per 5000-10,000 people, and Bergamo has a population of 120,000). Right now there are 80 people in intensive care in Bergamo, a 5x increase in capacity that was possible by bringing in a lot of ventilators and moving other sick people to other hospitals. Nonetheless, there have been reports of shortages of ICU beds, and of people needing to intubated that could not be. There are also reports of people dying of pneumonia at home, without being tested.

Because of this surge in deaths, Bergamo’s funeral homes have not been able to keep up. It’s not that they have not been able to keep up with arranging funerals, because funerals are banned. They just do not have the capacity to perform the burials.

So coffins have been accumulating. A couple of days ago, a motorcade of army vehicles came to Bergamo to pick up 70 coffins and take them to other cities.

It should be noted that this is happening after 20 days of “social distancing” measures and after 13 days of “sheltering at home” in Lombardy.

My point being, if we had not known that a news virus was going around, the number of excess deaths in Bergamo would have not been hidden by the random noise in the number of deaths due to influenza-like illness.

10 thoughts on “What is next?

  1. Thanks for writing these posts. It is interesting to get your future perspective in a way that is not quite captured by the media.

    California instituted a statewide lockdown late yesterday. As of March 18 (2 days ago), California had 675 positive cases and 16 deaths. On February 27 Italy had 17 deaths and 655 cases. Italy went on lockdown March 9 with ~9000 cases and 463 deaths. So, roughly, California is 20 days behind Italy and is taking action 11 days faster. (I’m ignoring things like testing differences and the fact that Italy has 1.5x the population.)

  2. Thank you Luca for these posts! Please continue writing, especially if you’re bored of talking to your dining table 🙂

    Ioannidis’ post is interesting. If I understand it correctly he says “more data is needed, so let’s ignore the 250K cases world wide and focus on 700 cases on one cruise ship”.

  3. @Boaz, in fairness to Ioannidis, the Diamond Princess data used to be the only data set about a group of people all of whom were tested.

    In other places, people were tested because there was a reason to test them, and so the sample would be biased toward sicker people.

    In Italy, the whole town of Vo’ Euganeo was tested before and after a strict lockdown, but I was not able to find published data about that study

  4. Very interesting information about Vo! There are also several countries where through massive testing and tracing (aided by sharing 100% of phone location data of every resident in the country with the government) they know to trace the source for almost all COVID19 cases which means that even most asymptotic people wont stay undetected for long (e.g. if they infect someone that infects someone that becomes symptomatic). While there may be factors of 2 or 3 uncertainties in the probability of hospitalization, ICU, death conditioned on age, it’s certainly not a factor of 300

    Ioannidis talks about testing random samples of the population: if the US today has about 100K true cases out of 300M people then to get enough data (say at least 100 positives) we would need to sample 300K people. Regardless of test availability, sampling 300K random people to ask them a question would be completely infeasible. (Of course if we follow his recommendations we can simply wait a couple of months and then we’ll only need to sample 200 people to get 100 positive cases..)

  5. Today 546 deaths with coronavirus in Lombardy (twice the daily average of deaths by all causes in 2018)

  6. luca, the new ipad has augmented reality features. so perhaps it can be used to encourage your furniture to be better conversation partners.

  7. hang in there and stay safe. we are also living in the future now!
    and thanks for the wonderful suggestion of talking to a dining table, i should try that too 🙂

    hope it won’t be too long till we are all able to see each other again~~

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