Thursday, April 23, 2020

Despite All The Information Flung Around About The Covid Crisis, The Big Story Is Mostly About What We Don’t Yet Know

I feel like I am being pummeled with information right and left about Covid-19, most of it scary and about deaths and mounting tabulations of people confirmed as infected.

I find that I have withdrawn even more from the 24/7 news cycle, which more and more seems to be all Covid all the time.  It’s not that I am not taking the time to check in periodically to catch up on the news, but its continuing sameness is leaving me with a starved feeling.  I am still feeling uniformed.  That “sameness” left me confused and uncertain whether, the other day, I had done my daily check of Democracy Now’s headlines— Every day is so much like the other.   (Democracy Now, which for decades called itself “The War and Peace Report,” is now calling itself “The Quarantine Report”– At least it rhymes.)

The New York Times especially seems to love publishing a zillion attention-grabbing charts these days.

What I find remarkable is that, with all the information that is being directed at us about covid-19, how much we still don’t know in terms of getting an overview.

Here, listed below, are things we still don’t know.  Almost all of these things have been written or reported about somewhere.  I am going to dispense with my usual habit about carefully providing documenting links about where these things might have been covered, because, when all is said and done, it is more about what nobody seems to really know.  It all comes from what is a mish-mosh of confusion.

We don’t know:
    •    How Many People, What Percentage of the Population, Have Been Infected with Covid-19?  This is a question that can be asked country by country, region by region.  We don’t know because, especially in the United States, there is no testing to find out.  If you are in New York City and think you have a Covid-19 virus infection the first thing you will be told when you try to figure out what to do is that you probably should not try to get tested.  New York City is deemed to have perhaps the highest infection rate in the United States.  The other day I heard that less than 1% of the United States population had been tested.  When I tried to look that up I found a figure that was actually far below that.  And the virus has been spreading for a long time, which means that, in terms of knowing things, the situation hasn’t necessarily remained the same for those who tested negative for the virus when they were tested.  The numbers we get frequently and relentlessly about the latest calculation of “confirmed cases” in different places throughout the world are mostly measures of how many tests were done provoked because people were recently showing a certain (not even consistent) level of virus infection symptoms.

    •    What Percentage of Our Populations Can Be Expected To Ultimately Get Covid19?  The effect of Covid-19 will depend on how many people get it.  There are estimations that the 1918 “Spanish” flu infected about one-third of the world’s population.  Some people have put out information that Covid-19 will infect about twice that percentage.

    •    What Percentage of People Who Get Infected Will Be Asymptomatic?  The numbers people are offering on this question are wildly all over the place.  It seems that, even with a given population trending toward the elderly, at least about 20% will be asymptomatic, but it appears from other reports that in the general population about 50% or more will be asymptomatic.  The Washington Post recently reported that 88% of pregnant women in New York who turned out to have the virus were asymptomatic.  That particular figure could have something to do with likely ages and general health for women getting pregnant or for differences in the immune system when women are pregnant.  Further, in figuring out the percentage for the overall population, what does “asymptomatic” mean?; at what point is a case of infection so mild that the person who gets it pays so little or no attention to it mean that it crosses over the line to what is deemed “asymptomatic”?  This question of how many people are asymptomatic also has a lot to do with guessing how many people are possibly out and about passing the virus on to other people.

    •    What Percentage of People Who Get Infected Will Have Mild Cases And of What General Character?   This question is much like the question about who is asymptomatic, but, without virus testing or after-the-fact antibody testing, who knows?  And if we don’t know who has been sick with the virus, who can, with authority, pass on a description of what their personal experience with the virus was like, how harrowing or not it was?

    •    What Is the Mortality Rate From The Virus?  We are being given lots of figures about people dying from the virus, but without knowing how many people have been infected overall we have no idea of what the mortality rate from the virus is.  The New York Times ran a front page story to tell us that it is so hard to know what the mortality rate is that nobody knows.  Although the story managed to place some very high possible mortality rates near the beginning of the story, it had covered a very wide range of possible figures, basically covering all bases, by the time it concluded.  We don’t even know yet  exactly how many deaths to attribute to covid-19; some deaths are not being noted, while other deaths might have happened anyway from co-morbidities.  Complicating determination of the percentage is that, even if we know the infection rate, information about mortality necessarily lags information that could someday be collected about rates of infection.  Possible mortality rates include rates below 1%.  People often seek to compare mortality rates for covid-19 to annual influenza mortality rates, but this can be deceptive because mortality rates for flu can vary; for some annual influenzas it can be very high compared to other years.  Also, flu, for which people also frequently get vaccinated, probably affects a much smaller percentage of the population annually.

    •    How Long Will The Virus Crisis Last?  Nobody knows how long the virus crisis will last, but how long the crisis will last ties in with the idea of “flattening the curve.”  The idea of social distancing to “flatten the curve” does not precisely mean that fewer people will get sick from the virus; it mostly means that the same number of people will get sick over a more extended period of time, reducing stress on the capacity of the healthcare system.  Pretty much by definition, the more the curve is flattened, the longer it will take for the curve to reduce all the way.

    •    When Did Covid-19 Infections Begin, Particularly, In Particular Places Like The United States?   To know more about how fast Covid-19 infection is spreading and predict better how it may play out (including the shape of its possible curves), it would be good to know how long it has been around.  Did it really start in the United States in mid-January?  There is some very credible discussion about whether it was actually being spread in the United States in November and December.  Some theories pushing the far end of what is speculated suggest it goes back as far as September.

    •    How Much Can We Expand The Healthcare System’s Capacity To Deal With Needs To The Extent That The “Curve” Isn’t “Flattened”?   As I heard John Kane pointing out on WBAI radio the other day, the “flatten the curve” graph, which all of us must have seen by this time, has three lines on it: A high bell curve line if social distancing doesn’t slow the rate of infection, a flatter bell curve over a much more extended period of time, and the third line is the line representing the capacity of the healthcare system.  The first two lines are the lines generally presented as malleable, subject to change and adjustment, but the third line could also be moved.  The question is how much could that third line be moved by responsive investment.  At the moment, the covid-19 crisis is serving as justification for spending trillions of dollars in subsidy money to address the economic effects of the crisis.  What amount of money would need to be spent to move the line representing healthcare system capacity upward?

    •    How Many Lives Will Be Saved By “Flattening The Curve”?   “Flattening the curve” can save lives and is expected to, but how will “flattening the curve” save lives and how many will it save?  (We are frequently admonishing younger people to socially distance and wear masks to save, not their own lives, but the lives of older, statistically more vulnerable people.) The most important way that “flattening the curve” can save lives is that it might mean, that to the extent that there are medical treatments that will be life saving for infected individuals,  flattening the curve will help to avoid any need to triage and withhold such treatment from anyone whose life could be saved.  It means, in more basic terms, that someone won’t die just because the healthcare system gets overwhelmed.  Postponing when people get the virus could also make a difference if a vaccine is developed (something that may not happen) or if time otherwise allows for the development of superior treatments. Postponing virus deaths also allows people who may ultimately soon die from another cause to live as long as they were otherwise likely to.

    •    When The Reported New Infection Or Death Rates Level Off or When They Go Down In Certain Areas, Do We Know Why?  In some areas, New York may now be one of them, the increase in new infections and the reported number of daily deaths appear to leveling off, maybe peaking before starting to go down.  This will probably also eventually happen in other areas where those numbers are still going up.  When these numbers go down, do we know why?  I have noticed a certain routineness when it the numbers are reported as going down for those reports to ascribe it to the success of the “social distancing” we are all being encouraged to be engaging in.  But the “flattening the curve” model also predicts that, at some point, these numbers will reduce because there are fewer people left, a smaller percentage of the population, to still catch the virus.  When do we know that is happening and that lowering numbers in these areas is in part due to where we are on the curve?

    •    What Is The Recovery Rate From The Virus?  Like calculating mortality, even if we know the infection rate, information about recovery, which can take time, necessarily lags information that could be collected about rates of infection.

    •    How Long Does It Take To Recover From The Virus?  While some people may seem to recover relatively quickly, how long can it take for others to recover?

    •    How Many People Will Suffer Permanent Disabilities Because Of A Bout With The Virus Rather Than Fully Recover?  In some cases, death is not the only permanent outcome of a serious virus infection. If permanent lung, organ or brain damage is, in certain instances, the result of infections, that is another thing to be taken into account in terms of the seriousness of what’s being suffered, plus, long-term, the effects of these things may need to be added in to calculate the morbidity rate.

    •    When Is Someone Recovered From The Virus?  Stories have been written about people who thought they were recovering or had recovered from the virus and then “relapsed,” so they may have not been fully recovered or recovering when they thought.  What do we need to know to have our bearings in this respect?

    •    How Long After Apparent Recovery Will Somebody No Longer Be Infectious So They Are Safe To Rejoin The Company of Others?  The New York Times has published information saying that people who have recovered after a bout with the virus are no longer infectious to others after a very short period of time. Meanwhile studies have come out saying that the advent of the safe period may take weeks longer than the Times published. 

    •    Does It Matter And Are There Different Ways of Getting Infected?  I have seen nothing talked about respecting whether it matters how a person’s body is introduced to the virus when it gets infected.  If a healthcare worker tending to a very sick patient gets a faceful of coughed-out virus just as they are deeply inhaling, is that going to have the same probable effects as someone who picks up a pen previously used by an infected person, then puts their fingers to their lips and swallows virus to be taken in by their digestive system?

    •    Are Some People Going To Be Immune To Covid-19?  This may seem to be a strange question to ask, but do we know all the reasons that an estimated two-thirds of the world’s population did not get the 1918 flu?  A friend of mine is one of the individuals who presented himself for study when he was surprised that he had never gotten AIDs.  It turned out that he is one of the people in the world with a double set of genes that means he can’t get AIDs.

    •    What Makes Some People Particularly Susceptible To The Worst Expressions Of The Virus When They get Infected?  While we were initially told that older people and people with a long list of health problems would be those worst affected if they got the virus, it has not turned out that predictions are guaranteed to follow such simple dividing lines.  People in their 90s and even over 100 are getting expressed, symptomatic cases of the virus and recovering just fine.  Young adults are sometimes dying, succumbing surprisingly quickly.  An explanation offered for why some individuals have more problematic responses to being infected with covid-19 than others is that they suffer “cytokine storms,” an over-response of the immune system where the response itself becomes the problem because it isn’t balanced.  It is thought that the provocation of “cytokine storms” was the reason that the 1918 flu seemed unusually lethal for young, healthy and strong people. There may be other ways we don’t know that some responses to being infected may be idiosyncratically worse for some individuals.

    •    Do We Know All The Reasons That Certain Sub-populations Of Some Communities Are Being Hurt By Covid-19 At Far Higher Rates?  The death rate from Covid-19 for blacks and Latinos is far outpacing the rate for other cohorts of the population.  To an extent, that would be expected as the result of health and wealth disparities previously in place that create inequities and differences in baseline health, and living conditions.  Also, the economic situation facing such populations may prevent people from engaging in the same amount of social distancing, thus pushing them to the front of a less “flattened” curve.  While those are things that likely contribute to explanations, have we identified all the reasons for the difference in the effects from the virus?  Are these the only ones?

    •    Are There Different Strains of The Virus Circulating; To What Extent Are People Getting Sick To Different Degrees Because They Are Not Getting Precisely The Same Version Of The Virus?  Are there two strains of the virus?  Are there three strains of the virus?  Are there eight strains of the virus?  I have read assertions that each of those things is true.  Is the new coronavirus steadily evolving?  Covid-19 is a coronavirus, which puts it in the larger family of viruses that includes the common cold viruses.  The common cold viruses constantly evolve and mutate. My understanding is that most coronaviruses do.  So do flu viruses.  So it is likely that not everyone is getting exactly the same version of the Covid-19 virus now and, in the future, people may get still other versions.  One question is to what extent getting a different virus may produce illness more or less likely to be severe.  Another question is whether getting one version of the virus can confer immunity or protection against getting another.  There could be good news in this if a more benign edition of the virus could confer immunity against the ravages of a more malign version. There could also be bad news in this if different strains of the virus, and a constantly evolving virus, mean it is possible to get infected and suffer effects more than once, particularly if the subsequent infections could be as severe as the first or worse.  The difficulty of creating a vaccine for constantly evolving coronaviruses is one explanation for why there has never been a vaccine created to immunize people against the common cold.  On the other hand, one theory offered to explain the demise of the 1918 flu is that the flu defeated itself, by evolving itself out of existence by evolving less and less lethal strains that, in essence, served to vaccinate the population.  That 1918 flu theory supposes that healthier people were transmitting strains of the viris that were progressively less lethal.

    •    Could A “Contact Tracing” Approach Help Deal With Covid-19 Effectively?  “Contact tracing” with isolation has been described as an alternative to the “flattening the curve” approach.  “Contact tracing” actually tries to prevent and stamp out virus infections rather than just prolonging the period over which people get infections.  “Contact tracing” is resource intensive in terms of finding and eradicating the virus.  (Not that “social distancing” isn’t having a huge effect on how other resources are being redirected during this time.)  “Contact tracing” can work if a disease is just arriving in a population.  It works less well when a disease is highly communicable, particularly if that disease is highly communicable throughout a period when it is difficult to identify that people have it.  It is not likely to work when a disease has become endemic to a population, i.e. when it is already widely spread and found throughout a population.  It starts with testing.  That’s something we have been doing very little of, particularly in the beginning when “contact tracing” would have had better odds of being effective.  Then, for every case of a disease known and identified because of such testing, you have to identify and trace the contacts of the infected person.  Then they need to be tested as well.  Then you should be tracing the contacts of those people if they are infected as well.  If your tests are not giving you immediate results you may need to start tracing and further testing sooner, based on guesses.  All the infected people need to be isolated and quarantined when found.– Finding and tacking all the contacts spreading the disease can be very difficult if, as may be the worst case, people can have spread the Covid-19 virus for up to two weeks before getting sick themselves, there is more than a 50% chance, maybe 60-70% or more chance, of being asymptomatic or having symptoms mild enough people never know they have the virus, and they may be spreading the virus for weeks after having symptoms.– Maybe there are communities in some parts of the United States that have so far been sufficiently isolated and don’t yet have the virus so that “contact tracing” can prevent the disease from gaining a foothold, but for how long will those (rural?) communities have to remain isolated and reliant on “contact tracing” before a virus endemic in the rest of the country dies out and is no longer a threat?

    •     What Tests Are Available And How Reliable Are they?  “Contact tracing” depends on tests to know who has the virus and who has had the virus. Tests can also put a lot more in perspective, which can help us plan and make decisions.  Although there is very little testing going on, there are a number of different tests available and apparently others in development.  That makes it hard for the public to know what’s what.  To what extent are these tests reliable?  Do they provide false positives or false negatives, some more than others?  Probably everyone has heard by now the exceedingly odd fact that critical time was lost when the first tests shipped out by the United States government were completely unreliable. (Those tests were the ones shipped because our federal government rejected the test available through the World Health Organization.)  There are two kinds of tests: tests for who has the virus, and antibody tests that may be able to determine who has had the virus.  It’s necessary to accurately answer both questions for a lot of things like determining mortality rates or tracing.
    •    How Communicable Is Covid-19?  In the beginning I remember the instructions about the conscientious hand washing that was prescribed to prevent communication of covid-19.  Now everyone in New York City is wearing masks.  There are signs everywhere in NYC telling people to stay six-feet apart, some of those signs with visuals demonstrating what “six-feet” is.  Distances are taped off to show people how far apart to stand while waiting your turn to be one of a limited number of shoppers in a supermarket.  But these “be afraid and careful” messages are now being supplemented by new analysis and charts that suggest that the clouds of virus infected people can breath out may go eighteen feet, may go over and under partitions, maybe doorways.  We are told that heavy-breathing joggers may send their infected breath farther than others.  And we are told that the virus, liking flat surfaces, can sit waiting on metal or shiny plastic for days.  So it seems that a jogger or a bicyclists speeding down a New York City street can exhale and spew virus on blockworths of car doors and car door handles that could remain infectious for days?  Mothers are all wearing masks as they accompany their children on trips into the breeze and sunshine, but children and babies in New York City almost never wear masks.  There are practically no instances of children or babies getting sick from the virus themselves so they don’t need the protection of masks for themselves, but they do get and transmit the virus.  Are they spreading the virus?  Not wearing masks, we can think of them as little virus spreaders?. . . Recently, someone thought to test household cats for the virus.  This was after tigers in a New York City zoo got the virus.  Yes, cats get the virus, presumably from their owners and presumably the infection can go the other way too.  What about all the dogs being walked on NYC streets that don’t wear masks?  However communicable covid-19 actually is, are we doing what would assuredly prevent it from spreading, or are we only diminishing the odds to slow up and space out incidences of transmission to “flatten the curve”?  When I go to the supermarket these days, aren't I touching items that others have touched or breathed on?  When I pay at the the supermarket or the pharmacy these days in NYC, the store worker I am dealing with is behind a shiny new plexiglass partition, but then I am asked to sign for my purchase using the same stylus as everyone who came before me used and the same payment screen and buttons they used.  That’s at the pharmacy where people go to pick up their medicines if they aren't feeling well. That’s if I use my credit card.  If I use physical cash to pay (I understand virus connected efforts are afoot want to replace cash with digital currency) I will receive physical change for my currency that has been touched by other people who came to the pharmacy, and others before that.
    •    Will There Be A Vaccine In The Near Future?  We don’t know whether there will a vaccine anytime soon.  The long-term failure to come up with a cure for the common cold, covid’s cousin, doesn’t auger well.  On the other hand, there have been some hints that a vaccine might be coming, hints even that some companies have gotten a head start. There is also the question of how long a vaccine might work well if the virus keeps evolving.  Aside from a vaccine which could prevent infection, there are other very similar questions about whether we will discover and exchange information about other drugs, treatments and approaches that enable us to deal more effectively with people who get infected.

    •    Will There Be Additional Rounds To Go Through With Covid-19 In Future Seasons?  Some months from now will we, in the United States find ourselves on the subsiding side of a flattened covid-19 infection bell curve only to discover that we are facing a new wave of covid-19?  The 1918 flu came through the United States population in two waves and there are already some predictions that something like this will happen with covid, including that a new wave of covid could coincide with the cold weather that ushers in a new regular flu season with a much more crippling combined effect.  One explanation for a covid’s return in a new wave of infections is a theory that the virus might mutate sufficiently by that time to override any previously acquired immunities. If there can be a second wave of covid there is the possibility that there could be more waves after that, a third, fourth, etc.  People have therefore asked what should be expected in terms of new normals for how we deal with our health, our economy, our entire culture.
As I said, I am eschewing my usual practice of carefully providing links as I write about the above because there is so much contradictory information about what isn’t yet known.  You can Google these things yourself.  With things changing every day, you may get better, more up-to-date information, than if I provided particular links.

I have focused on the big picture unknowns in terms of trying to figure out what we need to deal with, background for deciding what may be a rational response.  I am not getting into different ideas of where the covid-19 virus first emerged or where it came from.  Nor am I getting into the most political aspects of responding to the situation, like the new “stimulus” bills or such things as the ridiculous proposals to further subsidize the health insurance industry at this time.

The fact that I am enumerating so many things here as official unknowns to which we are all subject, hasn’t prevented me from trying to get my personal bearings about where I think we may stand where I live.  I live in New York City.  Because of fatalities and infections here, New York City has been described as the center of the crisis in the United States.

Starting almost a week ago, I ran some numbers several different ways. I am not going to share my calculations, because with all the unknowns factoring in, even a small difference in filling in some of the unknown numbers different ways could swing the calculation results very much one way or another.

Based on what I looked at, I would say that it would not be an unreasonable guess that somewhere nearing one out of every four New Yorkers currently in the city, or at least one in five, either has or has already had the covid-19 virus.  That's what I have been telling people since last Saturday and Sunday. That guess is not out of sync with my knowing a lot of people who think they likely had the virus.  It is not wildly out of sync with hearing that recently 20% of the city police force was out sick, seven times the normal rate, while remembering that more people may likely be asymptomatic than not.  It is not wildly out of sync with a report that, recently, pregnant women in the city were testing positive for the virus at almost a 15% rate (and I don’t think that study was combined with an antibody test).  Thus I am looking at my fellow city residents seeing the virus essentially everywhere.  I suspect that I am one of the one who has already had it– As advertised, this is an article about how much is not known.

While there may be a leveling off of new rates of infection in New York City, I am guessing that, for a time, new infections will continue here without declining rapidly.  I am afraid, but guessing that we may ultimately have about three times the number of covid deaths in the city that we have already had.

I have tried to catalogue, as best I can, the panoply of covid-19 unknowns that plague us.  There are far too many.  I hope that if there are others ahead of us in filling in these blanks we will be informed promptly.  It would only be fair to do so.

In dealing with all these unknowns, I am reminded that the best, scariest monster movies are the movies that never show the monster– Or at least they are the ones that wait as long as possible to do so– Those films, instead, rely on hinting at the monster’s parts moving in the shadows; they show you the scared people screaming in terror in reaction. . . Maybe, like the original Jaws, they, from time to time, suggestively reveal a few chomped on body parts.  I feel a little like that now.

We are living with some other unknowns now too.  When we as New Yorkers walk down the street with our masks on, we can’t see whether our neighbors are smiling.  Will we forget what it is like to smile at somebody in the street or to smile at someone serving us at the store and get a smile back?

Living a virtual life via internet connections is not the same thing.  What’s more, our substitute existences through the internet are subject to data scraping and surveillance.  I reflected and wrote more about that, March 28th here: Reflections On What It Means To Be Retreating More Into Virtual Existence In Fear Of A Virus.

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