It is very difficult to apply it to his specifics; his specifics are more questions that have to do with end of life expenditures in general, and while as a society we do a not too inconsistent job of applying QALY and the statistical value of a life to population wide interventions, we throw it all out the window when faced with, well, a face.
None of the systems used explicitly value populations differently based on what the op seems to consider moral failings or poor choices made. We spend on smokers and drinkers, for example.
My only contribution here is that it is VERY ethical, really necessary, to consider the full range of near to longer term costs/benefits, inclusive of indirect but predictable impacts, to each element of ongoing interventions, and to use QALYs as part of that analysis, with full recognition of what is being assumed and what the evidence to support each option is. There are people with whole toolboxes to apply to those questions and they do not seem to be involved in the process very much.
The importance of being as sure as possible that our response to the disease is thoughtful, maximizing the benefits of controlling its spread and harmful impacts over the harms that the disruptions of the interventions cause are illustrated in this article.
[QUOTE=HoneyBadgerDC;22302304Once we became aware of who was primarily at risk …[/QUOTE]
When did this happen?
We’re still learning what the main risk factors are; we are having to make decisions on the fly because we simply don’t have all of the information needed to make truly well-informed decisions.
For example, early on, it was thought that asthma was a major risk factor; now, not so much, with hypertension and obesity being apparently greater issues. Early on, we thought that kids weren’t really at risk; the recent investigations of Kawasaki-like illness in kids is a warning that we don’t know that for sure. Is this a really rare complication, or even something only obliquely associated, or is it just that the virus goes into stealth mode in kids, and six months or a year or five years down the road we’re going to have a huge outbreak of COVID sequelae sickening and killing children? We can make some guesses, even educated guesses, but at this point, we are NOT “aware” of exactly what the risks are, and pretending we know for sure what’s going on is not somehow an improvement on the current situation.
I would also point out, again, that dying isn’t the only risk. For example, right now about a quarter of COVID-19 hospitalizations are in adults aged 18-49 (cite) and another 30% are adults 50-64 (i.e., still working age); that’s not counting the people who are sick at home. With COVID-19, illnesses tend to be protracted, with recovery times typically ranging from two to six weeks. The people most likely to have been laid off in the recent shutdowns, such as retail clerks and restaurant workers, are also the people most likely to lack employer-paid health insurance and paid sick leave, which means that if they get sick, they’re not getting a paycheck, they’re not “available to work” so can’t collect unemployment, AND they risk getting slammed with medical bills, so a trifecta of financial hurt.
I will be apparently saying this over and over again: we know as much as we have known for a while now that serious outcomes in kids occur … very rarely. There is absolutely NOTHING that suggests other than that. It is clearly NOT “stealth mode” … fear mongering about kids is NOT useful.
I’m not so sure you understand how the shutdowns work if you’re saying that.
Basically there’s no such thing as “too soon”. Hypothetically, had the President possessed the power and the desire to mandate that ALL states lock down in the last week of February, there’s every chance that we’d have come out of the lockdown earlier AND have had less in the way of extreme situations like that of NYC.
Similarly, by unlocking early, it’s entirely likely that those states are going to suffer larger, more intense outbreaks than had they just stayed locked down another few weeks.
Think of it like a fire; is there ever a point when you can put it out “too soon”? Or if it’s still burning, to quit spraying water on it? This is very similar in concept.
I’m not so sure you understand how the shutdowns work if you’re saying that.
Basically there’s no such thing as “too soon”. Hypothetically, had the President possessed the power and the desire to mandate that ALL states lock down in the last week of February, there’s every chance that we’d have come out of the lockdown earlier AND have had less in the way of extreme situations like that of NYC.
Similarly, by unlocking early, it’s entirely likely that those states are going to suffer larger, more intense outbreaks than had they just stayed locked down another few weeks.
Think of it like a fire; is there ever a point when you can put it out “too soon”? Or if it’s still burning, to quit spraying water on it? This is very similar in concept.
The recent reporting on the kids with Kawasaki-like illness suggests that it typically presents some weeks after the primary infection; Dr. Sunil Sood at Northwell Health in NYC (a pediatric infectious disease specialist) is quoted as saying about four weeks later. Most of the kids test positive to antibodies but not to the actual virus, indicating a post-infectious complication rather than something concurrent. Post-infectious inflammatory responses weeks or months (rarely, years) after the primary infection are known from other diseases; what about this disease says it cannot happen, or even happen commonly, with COVID-19?
At this point, nobody can say for sure even that the Kawasaki-like illnesses are related (except temporally) to COVID-19; perhaps it is mere coincidence that the illness has been reported so far only in kids testing positive to either the virus or the antibodies. Why is it “fear-mongering” to say that it might not be a coincidence? If some kids are getting sick four weeks after the illness, what stops others from getting sick six or eight or twelve weeks later? We know so little about how this virus actually attacks humans that I’m not sure it is accurate to say serious outcomes in children must and will always remain very rare. Making promises about the long-term consequences, good OR bad, of a disease identified less than six months ago is a bold step.
YES. The presumptive understanding is a post infectious response … that is NOT the virus being in some weird stealth mode. It is occurring, it seems, in kids who have had great response to beating off the infection … but in these very few the reaction goes too far.
It is fear mongering to portray this rare event as something that is anything other than rare. There is NOTHING about this that raises fear of more showing up in a more delayed manner to any of those who understand the pathophysiology. I for one am unaware of other established post infectious (not latent or prolonged) conditions that show up with onset much later than a month after the infection has been beat off.
Be afraid! This could be the one! Who knows?!! Sorry no.
All we can say is that serious disease resultant of SARS-CoV-2 including the KD -like syndrome is MUCH less common than serious disease from influenza among children. It is weird but true.
I hesitate to go over this ground again but for anyone who is actually interested in understanding the issue, “herd immunity” is not a strategy but the (hopefully) end result of driving the contagion down to sub-epidemic levels. This can be achieved by vaccination (if we had a vaccine), variolation (measured exposure to the active virus), or unmeasured exposure by letting the contagion spread in either a controlled fashion (gradually loosening isolation measures) or uncontrolled (let the contagion run its course. If we do the last by “maximizing infections going for herd immunity” then what will happen is that we will achieve the maximum mortality as health systems are overwhelmed and people who could be saved with interventions instead die because of the lack of facilities, drugs, and medical personnel to care for them. Not a good plan.
As for “Once we get about 50% infected things should start slowing down,” this is incorrect. The R[SUB]0[/SUB] of the virus has been found by more recent and accurate test data to be between 3.8 to 8.9 with a mean of 5.7 (“High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2”, CDC Emerging Infectious Diseases, Volume 26, Number 7—July 2020 (early release)). This means the threshold infection level for herd immunity is between 74% and 89%. That means in the best case assuming an infection fatality rate of 0.5% we would be looking at 1.125M dead; however because so many people would be seriously ill at once, the fatality rate would climb as hospitals are unable to treat the seriously ill but potentially savable. Again, not a good plan.
Using your analogy, the fire kills very few people so to the effort should focus on the vulnerable in order to save the financial houses of everyone else.
No, that isn’t correct, either. Aiming to maximize infections that fall under the threshold of what the health care system can deal with (even if we had that kind of ability to fine-tune the extent of contagion, which we don’t) will just result in other casualties are people with chronic, traumatic, or unexpected serious medical needs fail to seek aid or are denied access because the care system is dealing with COVID-19 patients and people are fearful of going to hospitals because they may become infected. What the goal should be is to drive new infections down to a level where the effective replication number is below 1, develop and use antigen testing to track and trace new infections, develop antibody tests and determine the degree of immunity conveyed by previous exposure, and work on therapeutics and vaccine candidates. We also need to restructure industries and the economy to cope with long term isolation, distancing, hygiene, and epidemic surveillance measures not only to deal with SARS-CoV-2 but also future infectious pandemic pathogens so we aren’t caught flat-footed by the next and potentially more virulent contagion.
That isn’t the silver bullet that “rushing to herd immunity” might seem to be, but then, nobody uses actually uses silver bullets because it is a dumb idea. We don’t even know if we can achieve herd immunity with this virus without a vaccine (it was never achieved naturally with chickenpox despite nearly every person on the planet acquiring immune response in childhood, and waves of smallpox and other infectious plagues swept through Eurasia repeatedly despite nearly total levels of infection) and this idea of somehow controlling the spread of contagion just below the threshold of what the health system can cope with is, aside from the trauma that puts medical personnel and first responders through, is just not practicable given how little we still know about the spread and pathogenesis of the virus. The point of the ‘lockdown’ measures is to reduce the rate of spread such that we could relax isolation measures incrementally and measure the effects before proceeding with further relaxation. Just opening things up and hoping for the best—which is not even a fraction of a plan—essentially assures the worst case scenario, and we already have evidence of how that will go.
I’m not defending HoneyBadgerDC’s position here but your analogy in this case if anything makes his point … yes you do sometimes want smaller natural fires to occur, they tend to be of lower intensity, clearing out shrubs, and reduce the risk of huge conflagrations later. Too much suppression of them is a bad thing. There are also controlled burns that manage a forest by controlling the not only the where and the when of fires but the intensity of the events. Tricky business that.
And certainly there is a time to stop spraying water, when the water is causing more damage than benefit, even before a fire is completely out.
If forest fires are managed they don’t need to be fought so hard and so often.
No one would advocate for letting a forest burn out of control, in a rush, just get it done. That position is even more untenable.
Does the analogy hold? Maybe.
There are cautions out there by experts against thinking that a vaccine is just around the corner bound to put this fire out. Mike Ryan of the WHO for example -
Keeping the brakes fully applied until and if there is a vaccine is not a good plan. Depending on a vaccine as the only path is not a good plan. It is a great hope, but not a plan.
Rushing to herd immunity is not a good plan.
Cautiously finding the moving point that maximally reduces the damages of the interventions while controlling the intensity of disease within the population within some, to be determined, acceptable parameters, hoping for a vaccine but meanwhile trying to advance to a path forward that lives with the disease if that is what the future requires … is not a good plan. It is however the least poor one. And that parameter won’t be zero any more than it will be just below healthcare system capacity.
The controlled burn fire analogy may in fact be apt.
If we could determine why some people are susceptible to the blood clot development, severe vasculitis, and other multi-organ failures from SARS-CoV-2 AND demonstrate that exposure produces long lasting immunity, variolation of non-sensitive people might be an option, especially if we can determine that certain infection titers or routes produce minimal impacts; essentially, vaccination with the unattenuated vaccine in a controlled measure. But those are big ifs which still require effective tracking and tracing to protect vulnerable populations. Until we have better data, keeping the contagion under control by limiting public gatherings and contact is the only practicable way of assuring that inevitable outbreaks do not grow to epidemic proportions.
I think we are dealing with a virus that will be around for a long time. Most of the outbreaks once past a base level for herd immunity will likely take place in children whop show little ill effects from it. No matter what we would like to think we have limited resources, we have been operating in a deficit and cannot continue very long at all like this. The economy will have to certainly open up and soon or face financial suicide. I see no benefits to anything besides just slowing it down to manageable levels.