> This was rebuilding the engine on a car going 100 miles per hour.
It isn't ideal, but this environment may make it much easier to rejig care standards.
The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally.
It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
If this is what u mean U saw, "Log in or create a free New York Times account to continue reading in private mode.", then u could be in a private browsing-mode, and hence u could not go further than first para.
Edit: spelling
I believe that technically all domain names start with (we enter them backwards into the browser) a dot and that dot represents the DNS root. So it works in the browser if you add that root explicitly. No idea for sure why this works but my guess is because the paywall is somehow programmed based on window.location or some backend equivalent that works against the domain without the explicit root.
I can see that several peoples have downvoted your comment. Only reason I can imagine is some people's here work for nytimes??
Anyone can provide a better explanation for the downvotes?
Why is paywall tolerated for nytimes but not for smaller websites? Why is it acceptable here to have this dual speed system?
A paywall is always tolerated per the site rules if there is a workaround. This paywall has a workaround, which already had been posted when the complaint was made. Complaining about paywalls on the other hand is strictly off-topic.
> Are paywalls ok?
It's ok to post stories from sites with paywalls that have workarounds.
In comments, it's ok to ask how to read an article and to help other users do so. But please don't post complaints about paywalls. Those are off topic.
Unfortunately, the answer seems "no" so far. Based on for example [1], the infection fatality ratio appears to be 10 times worse than the seasonal flu for people aged 30-39. Also, hospitalisation rate is higher (e.g. in age group 30-39, the study estimates that 3.4% of the infected people were hospitalised), which is higher (even for younger people) than the hospitalisation rate of the flu.
Without disputing that (and thx for link), it's worth noting that the "flu" has been killing a large number of people year in and year out for as long as we can remember.
The long-term death rate of COVID-19 remains to be seen. The final verdict on how bad it was will depend on whether or not lengthy immunity is attained (including to mutations).
Yeah, but I don't understand what is significance of that claim. We have flu vaccine and general push to make people vaccinate every year. Up to mandating it for hospital workers at some places. Some employers are organizing them for free for employees.
We do close schools here and there for a week or so when flu is getting large to get it under control. We do close hospitals for visits at this times.
One implication is that COVID-19 might not be "just the flu". It might actually end up being far less damaging than the flu, as viewed over decades. And we don't trash our economy and the lives of the working class that depend on it due to flu deaths, even though they are still quite dramatic.
Personally, I'm conservative on this, and have barely left my place in the last eight weeks. I can work from home and will suffer little even if the lockdown is quite lengthy. But not everyone is in such a fortunate position, and I think we need to consider what's happening very carefully.
By "viewed over decades" we count in period when vaccine is supposed to exist, when we have cheaper tests and know to put on masks when something happens and when majority of population has antibodies. Even the most pessimistic estimates expect the issue to be dealt with in decades.
Also, the thing to consider is that working class is whonis most at risk from this. Rich people have less comorbidities, can afford healthcare and are much more easily to work from home and buy via deliveries.
This is basically reason why African Americans die the most - working class can't isolate themselves so easily. They are the group to die more then same age non working class.
Honestly, I see the worry that we are overreacting. But you are way more likely to end up in the hospital with covid with rates of around 10-15%. Super broad strokes, if you get the flu every year and are at least 20 years old, what is the probability you would have be hospitalized if covid=flu?
I think we are considering things carefully. I can’t remember the last time you saw both dem and rep governors agree on anything, yet they are all agreeing on stay at home orders and testing.
New York state has had 1 person in 1,200 [0] die from COVID-19, and is on track for 1 in 1,000. Do you know 1,000 people? If you lived in NYC, how many of your acquaintances would have died? How many people you know die from the flu every year?
Not even the most extreme estimates I've seen suggest that NY has anything approaching 50% immunity. Reopening NY and letting people catch CV19 would double, triple, ? the death rate.
There is no suggestion that NY is special as regards total numbers. (Velocity, due to population density, assume yes.) This is not the flu.
NYC is absolutely not representative of the rest of the country. In fact, they appear to be the hardest hit locale in the world in no small part due to their poor and delayed response.
I agree, reopening NYC would be a mistake, but large portions of the US (especially rural areas) remain largely unaffected by this.
The average age of death in my state (MN) is 88 with preexisting conditions. Our death rate is 0.0019% (!) with a flattened curve for some time now. Most of the US is not NYC.
The point being, an unusually large percentage of the people who contract CV19 die. Lower density == longer time to hit X% infected and Y% dead, but you'll still get there. (With caveats that X is a bit lower with lockdown, and Y gets higher when medical system is overloaded.)
Minnesota death rate is, as you say, currently at 19/million, but is growing at about 10%/day. The curve fits WA state's; continuing along that curve, WA currently has 79/million and is growing by 3%/day.
The question is not "How many will die?". Sadly, many will.
The question is "How much net difference will different reopening schedules make?". The answer to that is unclear, but remaining in lockdown for six months could easily kill more people (net).
FWIW, I don't know 1,000 people. Of the people I know about, one person has (probably) had COVID-19 (mild), and it's possible that I had it early (also mild).
Aside from "old age", the leading causes of death (and certainly years lost) among people I knew are AIDS and traffic collisions. This virus is going to have to try a lot harder to get on that scoreboard.
It's also worth noting that "reopening" doesn't mean people will just revert to prior behavior. Most will be very careful, and some will never revert. Wuhan reopened, and their restaurants are not springing back (yet?).
> it's worth noting that the "flu" has been killing a large number of people year in and year out for as long as we can remember.
> The long-term death rate of COVID-19 remains to be seen.
At the moment we count flu deaths differently to covid-19 deaths.
Counting deaths due to flu is hard. We've only just started this work for Covid-19 by putting in standards for death certification. These stats lag the real time counts by some time, and they're always higher than the real time counts.
So, we're taking a method for counting flu than over-counts, and a method for covid-19 that undercounts, and then saying "covid-19 isn't that bad".
And that's just looking at deaths. We also need to look at hospitalisation (because we want to look at all the harm caused by different illness to assess whether our measures are reasonable or not; and because iatrogenic harm is a thing) and we see that covid-19 does put a lot more people in hospital than flu normally does. And this difference is only partly explained by rates of immunisation against flu.
Well in England&Wales the National Statistics Office figures show <500 deaths (I think that excludes specific flus, H1N1 and such, which would add 4 more; ) for the most recent figures (2017 IIRC), for a ~60M population. Papers I've seen suggest a adults get flu every 5 years, children ~every 3 years. So we're looking roughly at rates of 500 per 15M. 1:30000.
Now there's some controversy that UK government have been reporting other deaths as flu, basically hiding Winter deaths due, eg to poor elderly care, in flu figures. So other sources suggest far far higher flu rates; but this is going off death registrations.
Covid19 death rates for under 50s are something of the order 1:1000, 30x the flu rate in data I've seen most recent (Worldometer) but reported rates vary considerably.
That's after flu shots, in the year where flu shots were a misfire (they guessed the wrong strains) there were 2000 additional deaths (according to another source I'm not confident in that claims to have ONS figures but which I've not been able to confirm); for comparison the reported deaths (ie hospital only) for UK [which includes Scotland] has passed 15000 for Covid19 according to https://www.worldometers.info/coronavirus/#countries [fwiw I wrote 10,000 as that was the figure last time I looked ... but then checked the current number ...].
Arguably we should. For that matter, we should really do more about traffic fatalities. Bringing that down would be far easier per person than fixing flu or coronavirus.
We're not going to, though, and it's becoming less clear why COVID-19 is an exception. It reminds me some of 9/11--it's flashy and freaking everyone out, which leads to irrationally conservative behavior.
It's also hard to say what individual behavior would look like absent government orders to close businesses. Retail business could well be way down without any orders.
I think the original US lockdowns should have happened far sooner and been far more stringent. In my ultra-liberal state, the governor decided just within the last week or two that schools should definitely be closed until July. Idiot.
But, as we pass the initial peak and have better experience and surveillance, we should very carefully consider what to do next. Just locking down for a year or two is not the "safe" option.
Besides what others have pointed out, there is no benefit of having the flu and we do not really know about long term damage just yet. There has been a report (I have only found it in German so far) of 6 divers in Hamburg with irreparable lung damage post corona. While under normal conditions these patients are just fine now, doing any type of sports may become a problem for them and that's only now, they may develop scar tissue in their lungs and what not. Only anecdotal for now but again, there is no benefit from having corona or the flu, so try not to get sick.
It is more deadly still, but lets pretend it is the same as the flu. Have you noticed that due to the efforts to prevent the spread of the Chinese virus, we've also lowered the number of people dying from the flu dramatically? We've designed our societies so that we needlessly kill tens of thousands of people every year from common communicable diseases. Maybe going "back to normal" isn't the right idea.
Also, comparing this to anything long-standing is flawed because it misses the point that we have an opportunity to solve this that we don't have with other situations.
Smoking habits and seatbelt habits and just about everything else is in a steady state. Nothing we can do can change those situations dramatically, we can only nudge them to a small degree slowly because those situations and habits are entrenched.
The point isn't that N people die from this so we should be cool with it because N is in the same ballpark as stuff we've accepted. The point is that we have a short window to solve the new situation before acceptance sets in.
Anecdata: I distinctly remember spending a lot of time lying on my stomach in hospital beds during several stints of double pneumonia I experienced as a child, some 30 years ago. It's hard to imagine that front line doctors didn't know about proning a month ago.
Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators?
Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs
> Is this a technique that went out of vogue since my childhood
I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it.
Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
proning was recommend quite a while ago... i first heard about proning during the italian outbreak... the new change is to delay putting people on the ventilator... and when you do put them on the ventilator, you max oxygen and keep pressure low. this is not the typical way to treat ards.
> “You put a tube into somebody,” Dr. Levitan said, “and the amount of work required not to kill that person goes up by a factor of 100,” creating a cascade that slows down laboratory results, X-rays and other care.
I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal.
But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
”I'd hope this could be a generally applicable lesson after the pandemic.”
It may be news to (some) doctors, but that is not a lesson this pandemic taught us. In cost-utility analysis (https://en.wikipedia.org/wiki/Cost–utility_analysis), different interventions are compared against each other and against the “do nothing” approach.
If the WHO is right in that having contracted Covid doesn’t make you immune, then the strategy of going for herd-immunity is not only losing more people, it’s losing them for no reason.
Using extreme scenarios to plan for normal life has long been the recipe for bad policy.
This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning.
The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff.
Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses.
I’d be wary to practically apply this beyond the next viral epidemic.
If you read through the Red Dawn email chain NYT pieced together through FOIA requests [1], which gives an overview of initial professional thinking (January / February), there's a great insight in the first few emails.
No other emergency grows exponentially.
Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At worst they grow linearly at a high rate.
Consequently, highly contagious pandemic response must be fundamentally unlike any other response.
There are references to this bearing out in their prior wargaming of scenarios. All players (mistakenly) escalated linearly based on intuition.
When in reality you're talking about needing 10x resources every week, ceteris paribus.
I don't want Patriot act thinking—we agree there—but the US is so used to assuming it's rich/powerful beyond belief and then getting poor outcomes. We have general efficiency and cost disease issues that emergency planning can absolutely teach us how to address.
A patient coming to a doctor, in the similar condition, is 4 times more likely to come out with a prescription in the United States when in Europe. Why? Because it is profitable. What is the result? Well, life expectancy in the United States had been going down. Ref. https://www.nature.com/articles/d41586-019-02686-2
This epidemic might be an opening to shift the current equilibrium of over-medication and over-use of expensive treatments with questionable efficacy.
The proper solution could be changing the incentives structure in the medical system. From profit and executive compensation aligned structures that over-sell services and drugs into something that is connected with long-term public health.
That has significant risks of infection. I think a negative pressure ventilator like the iron lung are probably the lowest risk of adverse effects. But, it’s going to hamper other treatment options, and works on a relatively narrow range of issues. https://en.wikipedia.org/wiki/Negative_pressure_ventilator
Positive pressure ventilators however cover a wider range of medical issues though at increased risks.
External oxygenators are really a last resort which should be avoided whenever possible.
Check out the “Side Effects” section of that page. ECMO is brutal, and requires a very tight balance of anticoagulation to prevent clotting on one side and bleeding on the other.
There are only a few hundred ECMO machines in the US. I suspect that’s less due to cost, and more due to the limited number of patients per year for whom ECMO has a good chance of being a net benefit.
My company has been working with a hospital in the Bronx for several years. We’ve been working on a system that is designed to tell when intubation is actually needed and when it is not. They already knew, a long time ago, that intubation increased mortality, but no one expected the mortality rate they are seeing with COVID-19.
>> In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower.
And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.
FWIW not all ventilation is intubation, you can have non-invasive ventilation. Just in case you weren't aware, this makes stats hard to ascertain as some sources seemingly are interpreting orginal sources as if they were synonymous.
Confounding factor: obesity rates and comorbidities
From a glance, the US averages 3x the incidence rate of obesity as Sweden. Obese patients with existing health problems will result in substantially worse outcomes from Covid-19.
>The trajectory of cases and deaths in Sweden does not seem special to me
Certainly doesn't seem to be well outside of the range of outcomes in other countries at any rate. From what I've read--no first hand knowledge--it's also a bit hard to interpret the effect of Sweden not locking down. Apparently, at least around Stockholm, many people were staying home and not traveling. On the other hand, in at least some places, people were still going to bars and the like so it's a bit of a mixed bag. Almost certainly not business as usual but also likely a fair bit looser than a lot of places with more formal lockdowns. (And there's even quite a bit of variance there.)
> To date, ICNARC have been notified of 6664 admissions with confirmed COVID-19, either at or after admission to critical care, by critical care units in England, Wales and Northern Ireland. Of these, early data covering the first 24 hours in the critical care unit have been submitted to ICNARC for 6313 admissions of 5578 patients (Figure 1 and Figure 2). Of the 5578 patients, 2936 have outcomes reported and 2642 patients were last reported as still receiving critical care (Figure 3). The largest number of patients (1924) are being managed by the three London Operational Delivery Networks (Figure 4). Please note that Figure 2 and Figure 3 are affected by a variable lag time for submission of data of about 1-3 days (shaded grey)
[...big snip...]
> Critical care unit outcomes have been received for only 2936 (of 5578) patients, of whom 1499 patients have died and 1437 have been discharged alive from critical care (Figure 8 and Figure 9).
"The obesity rate has steadily increased since the initial 1962 recording of 23%. By 2019, figures from the CDC found that more than one-third (36.5%) of U.S. adults[5] and 17% of children were obese.[6] A second study from the National Center for Health Statistics at the CDC showed that 39.6% of U.S. adults were obese as of 2015-2016 (37.9% for men and 41.1% for women).[7]"
Sweden has reported 1,511 deaths and 13,822 cases. Does that mean 7,555 of the 13,822 cases have passed through the ICU or a significant number of people have died without entering the ICU?
Can be lots of things, there's lots of evidence that data quality is extremely poor right now, but not enough to be able to say accurately what all the data should be.
For example, in the Netherlands, in a blood test about 3% of the population was found to have antibodies, while the number of people confirmed to have corona via tests is at 0.15% of the population. We're looking at a 1:20 confirmed/actual rate.
That tells you testing is way off, about 20x so. The total tests performed is roughly similar to the US by the way, about 1 in 100.
Then there's death rates. The Netherlands currently saw 2 in 10.000 confirmed deaths from corona. This is about double the rate in the US. However if we look at excess deaths compared to a 3-year average for the same period (2017-2019) we see about triple the amount. Apparently 2 in 3 die of corona without it being tested or confirmed. (likely in nursing homes where mortality rates are often around 30% per year, and it's not uncommon for staff to find a patient died in their sleep for example).
And the Netherlands is a small country with high-quality public infrastructure. It's quite likely that it is among the countries with the best record-keeping system, and is among the countries with the highest tests per population, and even here we see massive undercounting of infections and deaths.
It's good to keep looking at the numbers, but only with a huge caveat. I'm actually completely flabbergasted that the media report on infection numbers without ANY mention of a confidence interval, standard deviation or some kind of uncertainty measurement, as well as some basic stats around testing methodologies, in particular when reporting cross-country comparisons. This should be the norm, but instead we just get country comparisons, world maps and graphs displaying wildly inaccurate and limited data (which is absolutely useful, but criminal to report without caveats). Apart from a mention about 'Chinese data isn't reliable' or 'India isn't testing much, so the problem may be far greater', there's really no consistent discussion about this. There's lots of standard statistical tools to express uncertainty which have been used in science for decades, but they're completely absent in our reporting or discussions at the moment.
Just a note on the "3% prevalence of antibodies": we need to consider the false positive rate and selection bias for general population antibody tests as well. A biologist I follow was skeptical about a study showing that 1.5% of Santa Clara had antibodies for SARS-CoV-2. I don't know anything about the study in the Netherlands, but the 20x or 100x undercount ratio is going to be very sensitive to the antibody test specificity.
> In the supplement they say 2 out of 371 + 35 known negative samples tested positive. This means that the 95% confidence interval for the false positive rate is [0.06%, 1.77%]. In their samples from Santa Clara County they had 50 / 3,349 = 1.5% test positive.
I'd love to know where you got those statistics. I couldn't find anything on country mortality rates for COVID-19 ICU patients. However, since the US obesity rate is way higher than Sweden, it is surprising that the COVID-19 death rate in the US is around five percent, while it is around ten percent for Sweden. Of course, Sweden has decided not to impose a lockdown, so I have no idea how much that might be overwhelming their hosipitals.
Since January leaks from Chinese health care warned about all of this. Was there internet ban in US I was unaware of? Or a widespread belief in exceptionalism?
edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment
(3) Prone Position Ventilation
Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position.
Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance.
MGH is proning a bunch of awake patients (who have the physical strength to do so) and about ~30% of our ventilated patients.
There is no "shocking degree of arrogance from the West" but there may be a failure of adequate reporting, in this article and others, of what we are doing in hospitals.
Except it's applied to literally every part of the Asian pandemic response from masks to contact tracing. Asian countries have been saying for months that there's not some magical technological solution to contact tracing, the tech helps maybe 10%. The rest of it is just plain on the ground shoe leather pounding, public communication and talking to people.
Watch as Western countries start discovering as they roll out their automated contact tracing apps how little the tech plays a role in an effective contact tracing system.
Regarding the contact tracing, etc, that you are describing (which is a bit beyond the article's scope, since it is talking about medical therapies): the West's failure is a political one. The experts in the West know and agree with everything you're saying.
Just so we're clear, can you explain succinctly the key details of how contact tracing has been implemented in the various countries that have rolled it out and which parts you object to?
There's a lot of parameters in the "design space" of contact tracing. If you're objecting to simply the most extreme version of it, then duh, anyone would, including the Chinese.
That is hard to answer can you anser what kind of contact tracing are you missing in "the West", and what level of privacy invasion are you comparing it against.
In the first stages of Corona we did a lot of old school contact tracing.
But this is what I mean when I say "shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this."
There's many different ways of doing contact tracing that involve myriad tradeoffs. Every Asian country that has rolled it out has had negotiations between the citizens and the government over the various dimensions and how to balance between competing concerns (yes, even China). Every country has landed in a slightly different form of contact tracing based on existing resources, societal norms and degree of urgency.
It's shockingly arrogant to assume that Asian citizens haven't grappled seriously with these issues and, even if they have landed in a different position than you would prefer, that the conversations they're having don't have any value.
I've yet to read a single English language piece on Asian contact tracing that has accurately described how contact tracing works on the ground in a nuts and bolts way across multiple countries. Instead, all I read are exoticised, fetishized pieces that focus on technological bells and whistles or highlights a bunch of theoretical privacy violations that either aren't a big deal in practice or easily gotten around with some simple design tweaks.
Then, you get people who go off half cocked and make sweeping statements about an entire category of methods while having done literally no research on how it actually works in a real world context.
FWIW that is not my picture, but you are too unspecfic, you do not give any accurate description either, and if there is no such info in "the west" how can I be arrogant, ignorant maybe? The people who care about privacy do not care about how things seem to work for the masses, what is important is the edge cases of privacy.
That does not mean there are other voices in the West. But I do not know what you are looking for, and what you think is bad information.
Just as a simple example, how do you enforce home quarantine? In Hong Kong, they use a bluetooth bracelet, in Taiwan, they're using a combo of a cell phone tower gate + requiring you to answer the phone and police checking on you if you don't. In China, they have a hardware door sensor that will alert authorities if it's opened. In South Korea, I think they're also using cell phone tower gates.
Each approach has different pros & cons when it comes to privacy and effectiveness. Which one specifically do people think is acceptable and unacceptable?
> There's simply a shocking degree of arrogance from the West
Not sure it is Western arrogance rather than standard medical arrogance.
The video accompanying the NYT piece (5m:37sec) one doctor says:
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
The problem is that Covid-19 is caused by a NOVEL virus which has no evidence base. There should be at least some skepticism regarding the applicability of previous studies.
Coworker of mine who happens to be Chinese bought portable oxygen for use in this situation. She bought it in February, after looking at videos about what was going on in Wuhan. We all thought she was kind of crazy. Doesn’t look so crazy now.
This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well.
We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
conceptually, flattening the curve is meant to turn an exponential infection curve into something more manageable.
We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission.
If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you know, an O(2^n) algorithm is extraordinarily hard to keep up with once n approaches any large number.
That's the curve we're trying to flatten - by changing the approach, changing the "algorithm" so to speak, by not allowing people to interact so they have less chance of infection.
If you are able to build a new hospital in a week, and then continue building a new hospital every day after that and then one every hour after that, and then a new hospital every few seconds after that, then you have a chance to keep up with an exponential curve (well, until the virus runs out of people to infect, so until it reaches 100% of the global population).
I was writing that we should both create hospital capacity and have some moderate flattening of the curve. Of course we shouldn't let the virus run free.
But unless you are hoping for a vaccine to be invented soon, which would of course be wonderful, you have to face the other scenario and that is that we have to slowly build up herd immunity. Herd immunity means that people have to get infected and a percentage of that will have to go to the hospital. No matter how you manage it, bigger hospital capacity simply means that you are able to reach herd immunity more quickly.
What does her immunity actually mean though? What other diseases do we try to tackle using herd immunity? How many deaths would make herd immunity acceptable or not acceptable?
There are 350m people in the US. We need to get about 60% of them to have had covid-19. That's 210m people. We don't know how fatal covid-19 is yet, so here are some lower numbers:
And once we've killed off all these people what have we achieved? Covid-19 would be in the population and will come back every year as a seasonal respiratory illness, killing off more people every year until we get a vaccine.
There are ways to limit the number of deaths and still reach herd immunity. For instance by keeping elderly and sick people isolated but the healthier part not, until herd immunity is reached.
This disease has to be handled with intelligence and common sense, not with rethorics and dogma's.
> Covid-19 would be in the population and will come back every year as a seasonal respiratory illness, killing off more people every year until we get a vaccine.
Do you have any evidence to support that it would keep coming back? As far as I know there's only very small anecdotal evidence of people getting reinfected and we simply have no way of knowing yet whether the average person's immunity will last weeks, months or years.
For context, about 3 million people die each year in the US.
IF (and that's a big if), the infection fatality rate really were just 0.1% (i.e., regular flu), then yeah I think letting this thing run its course is the reasonable thing to do.
In my mind, the reason for the lockdowns is because we don't know the morality rate yet, and so we should be cautious in case it's 1-3% how it was looking at first.
I could turn the question around on you, and ask what fatality rate makes the "run its course" strategy reasonable to you? No deaths?
We have to smash the curve so that we don't need the hospital capacity.
It turns out that getting the number of infected down close to zero would also be good for the economy.
I don't understand why so many people think that the best possible plan is for everyone to get infected. The best possibilities involve a few percentage points of the global population getting infected, no where near everyone.
This simply isn’t possible, and it’s a maddeningly irresponsible shifting of the goalposts. The public was sold these extreme tactics on the basis of preventing excess deaths, not locking down society for years on end until the virus (hopefully) goes away.
Respiratory viruses, once endemic, have never been completely suppressed. Even China is seeing a resurgence in cases. What we’re doing now isn’t sustainable or ethical, and we have to move on to smarter tactics soon.
The lockdowns are a necessary step to smarter tactics working.
My point is that if we move forward as if letting lots of people get infected is a 'smarter tactic', it's going to be worse in all ways. More death, more economic damage.
No, not “lots of people”, I don’t see anyone saying that. Given that it’s factually impossible to lock down the economy for a very long time we need conditions where the hospital system retains enough capacity to handle the really sick people.
Since it looks like we’re close to this (even in places like NYC that are sitting on a vent stockpile) we can start loosening the economy back.
The point of “flattening the curve” is not — and was never — to reduce the area under the curve. This is a contagious respiratory virus, and it’s going to spread until there is herd immunity. Maybe there will be a vaccine in 12-18 months. Maybe not. But regardless, we can’t go on for that long with over 30% of society out of work.
Most people are going to get this virus. If you don’t understand that, you are scientifically illiterate. You are pushing on the ocean to prevent the tide.
Trying to forestall the inevitable by keeping us all locked in our homes will inflict such massive economic and social collateral damage that it’s simply unthinkable. We won’t stop the virus, and we’ll burn down our society trying.
I am well aware of the numbers in South Korea. The virus is still spreading. There are still new cases, every day.
We have managed to eliminate one human virus in history: smallpox. And we only did that through mass vaccination.
We have never eliminated a respiratory virus, nor have we ever developed a successful vaccine against a coronavirus, despite huge financial incentives to do it.
The inevitable outcome here is herd immunity. Maybe we’ll get there by vaccine, but not for a long time.
I never conceded that flattening the curve was not about reducing the area, so I have not moved any goalposts.
I was going to make a comment on this article about the meme being too effective, in that it convinced people that the only point was to reduce the load on the medical system. Of course the goal is to reduce the load on the medical system, but that's step one, to get though the first wave of infections and to a situation where the spread is potentially controllable.
Well, Americans are going to be forced into multi-year lockdowns when they realize that reinfection is a real possibility and even if not that the infectivity of this is so high that lifting of stay at home orders will cause numbers to begin overwhelming hospitals again within weeks. Herd immunity is unlikely to save us in the short or even medium term.
There's talk of multiple strains or of it mutating in ways which aren't necessarily more deadly but make reinfection possible independently of the currently found 2% who seem to be testing positive again after "recovering" from covid
Then the powers that be will realize just how deep of a shit situation we are in. The people who are protesting now are likely infecting themselves or will soon know a loved one with this and soon they will personally realize how stupid they were to protest this. It's only a matter of time...
> think that the best possible plan is for everyone to get infected
That's like asking why does everyone think the best plan is for the sun to rise tomorrow morning.
It's not a "plan", it is fact. Everyone (to some level of precision) will be either have anti-bodies from infection or have been vaccinated (or the unrealistic enough to ignore; remain in isolation their entire life).
We don't have a choice in that. We can try to alter the parameters (rate, timing, etc.) of that. But, that is the limit of our control.
We don't run massive test and trace programs against cold viruses because they are relatively less harmful. We easily have the resources to run a massive test, trace, isolate and support program against COVID-19, and we can eradicate it using those methods.
And if a vaccine comes out before suppression is complete, so much the better.
The fact that we have only ever eradicated a pandemic by using vaccines is no reason to not try doing it without one. It's very hard to understand why people aren't screaming to spend a few hundred billion dollars to start doing this right now, as the payoff is essentially incalculable.
But our hospitals do have enough capacity. So far we have not seen widespread hospital overruns as predicted. Army field hospitals were set up and then taken down with no one treated. New York wanted 40000 ventilators but only needed 5000. Surely we should increase availability, but the original predictions that inspired this level of lockdown have not come to pass and with the information we have now, we know they are just delaying the inevitable.
At any given moment, the appropriate way to look at a fast spreading infectious disease is to consider the more likely range of potential outcomes, work for the best one and plan for the worst one.
When the work pays off with a better outcome, it's foolish to look back and criticize the planning for worse outcomes, especially when the tools to manage the infection are pretty limited (social distance works well, but it's a brutal tool, so you want to use it only as necessary).
> the original predictions that inspired this level of lockdown have not come to pass
The predictions of what would have happened had no lockdown been introduced then haven't materialized precisely because the lockdown have been executed.
That is no argument that the lockdown haven't been needed.
No, my claim is that the models that were used with the lockdown were wrong. Cuomo claimed to need 40k ventilators after the lockdown was put in place. He ended up needing only a fraction of that. Obviously, without the lockdown, there would likely be more needed. Of course, modeling has errors, but this is an extremely large error, and one that has direct policy implications.
Had the model's predictions been more accurate we could have found a better middle ground when it comes to lockdown. Every job saved and individual financially secure is one more person who can contribute to the community's well-being. I think it's pretty safe to say in retrospect that the lockdowns need not have been as draconian as they were. We had the hospital capacity to have less severe lockdowns and we should have done that. While we can't change the past, we can certainly look at how our models failed and rework our approach in the future. Anything else is irresponsible.
> No, my claim is that the models that were used with the lockdown were wrong. Cuomo claimed to need 40k ventilators after the lockdown was put in place. He ended up needing only a fraction of that.
What you state now reflects exactly how many casual observers have problems to understand the exponential nature of the epidemics: if one observes the doubling time of three days, and that is what has been observed, this means only that the difference between needing 10k ventilators and needing 40k ventilators is only 6 days -- less than a week! Nobody can wait to actually need them to order them and get them delivered in so short time frames!
It was surely not possible to predict reliably how would have people reactd to which kinds of measures requested of the people, and the exact impact to the slowing down the spread (when exactly would doubling time get to be how much longer as a response).
Having an error of just 6 days in the middle of the exponential growth is not so negative if you are attempting to allocate resources to avoid tens of thousands of unnecessary deaths. And that statement of needing 40k ventilators is not what prevented some "better middle ground".
The "better middle ground" was surely possible to achieve by simply treating the epidemics much earlier as a serious issue and not acting as it is "just like flu" or would "disappear" overnight before anything has to be done.
Hospital capacity is one motivation for flattening the curve. The other is to move infections later in time, when there will be more effective treatments and therefore lower rates of fatality and permanent disability.
This is a perplexing article. Prone ventilation has been known to reduce mortality in severe ARDS from randomized, controlled trials for almost a decade[1].
Proning is great! It keeps people alive. We are doing a lot of it. It's not new.
I agree it was a weird focus of the article based on the title.
There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week.
I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
That's why I'm perplexed. It comes across as trying to make something more dramatic than it already is. (And, I mean, hospitals being full of patients with a novel disease is already sufficiently dramatic.)
Sorry, I misread you, we're in agreement there. I think it's partly an issue of journalists wanting to make their stuff more clickbaity than it deserves to be.
This was the single scariest piece I've read in a while. The video is even worse. Especially Dr. Hardin from Massachusetts General Hospital at 5m:37sec in the video:
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
After watching this video [i] it seems like there's an opportunity here to completely rethink/redesign of the related equipment. I.e. instead of a normal bed, one that allows for a device to temporarily enclose the patient (like a tanning bed) inflate like a blood pressure cuff, rotate/turn the patient, then deflate and be removed for use on the next bed (i.e. the bed and rotating machines are co-operative, but separate).
Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation.
Example [i]. The issue is that the cost to equip care facilities with these beds. My suggestion is to separate the rotating function such that a much less expensive general purpose bed can be used.
If patients are in shape to be on the phone why do they feel the need to put in a breathing tube?? I have measured my O2 saturation being in the 80s and my reaction was "so that's the effect of being this high up"--and I continued to head up the mountain. I had been there before, I knew I wasn't getting into too much. (I forgot to check on the summit itself. I don't expect to be there this year but I'm going to check again next year.)
why in the fuck was this voted down?? I want a fucking answer. I am sick of this site... Mark my fucking words... I am good at discerning fake news from stuff that shows promise. This is not a 5G tower theory of the disease... this is promising insight that points toward the truth. I am going to link back to this comment and this downvote as the problem with social media. there are too many ignorant stupid self righteous people that think they're doing the right thing.. and they are fools. fuck you hacker news
Yeah the HN userbase can be extremely frustrating to deal with. Your comments will be flagged and you'll likely get some admin telling you to read the HN guidelines as though it means anything or matters.
But I want you to know that someone else on this site sees the bullshit within the community that exasperated you so much. The HN crowd will upvoted BS posts and downvote substantial discussion on basically a random whim. The admins are known to very insulting label good posts as things such as "tedious ideological boilerplate" or "political flame bait" when they personally don't like what was posted. The userbase treats upvotes and downvotes exactly the way they're used on Reddit. This place is basically just nerd Reddit.
Unfortunately your claim about the virginity of the userbase is both unnecessary (and guaranteed to find the wrath of the powers here) and most likely wrong because the folks here really do make money.
You gotta play the game by their rules or they grey you out. Use those coding skills we all supposedly have to make a new platform and make it better so you can steal away the part of HNs userbase whose worth a damn. That's likely the only way to "fight da powah" since you're obviously very unhappy about this whole ordeal...
I have always bit my tongue on here.. I went to Startup School 2012. So I have tried to keep my cool because I thought it might lead to some opportunity.
But this site is so bad at this point. I really don't care anymore. I might lose my karma or get kicked off but I frankly do not care...
I have read the guidelines. and I defy someone on here to give me a good reason to downvote the original comment.
My guess, though I have not downvoted, is because it’s off topic. This isn’t a general coronavirus thread. The discussion is about the article posted. Why not submit that link independently?
@dcow
I agree off topic is a possible explanation... however... The link is to one of the sources for the video and the article.
I did submit it as a separate link and it's got no traction.
My concern is this... there is a lot of fake news... like the 5G tower theory which is absurd. But there are also legit people out there trying to figure out this problem. They are being dumped into the same bucket... by well meaning social media moderators.
I suspected it was downvoted because people think they're doing the right thing... stopping the spread of wild theories or disinformation.
Respectfully, I think you’ve described your exact problem. I watched 30 seconds of the video. I wouldn’t call it a wild theory or disinformation. But I also don't find it particularly relevant or insightful. So I don’t think your assumption that this site is full of idiots who are downvoting you to try and stop the spread of _fake_ fake news (god I hate that term) is accurate. You’re simply using a popular thread to try and get visibility which, I’m sure, you believe is warranted because you find the video compelling. However this is not a strategy that’s generally acceptable on HN. You posted the link. People haven't found it interesting enough to upvote on its own merit. HN is not a virus fighting machine. Don’t pretend that posing some under-informed (based on the discussion here) doctor on vimeo talking about his hypothesis would have had any impact on anything had it _just_ been more favorably received... In other words, don't fret it. HN comment threads (social media as you put it) are not going to cure a pandemic.
Obviously you can't post like this here. Note that your original comment has since been upvoted.
I'm going to put this down to your going on tilt (it happens to almost everyone), but please don't do it again. We all get downvoted. It stings, and it sucks not to necessarily know why, but it happens to everyone and it's the way HN works.
Over time, if your comments are consistently getting downvoted, you should reflect on what might be wrong with them. I looked through your recent account history and it doesn't seem so hard to figure out. In one case, you posted a comment which got a lot of upvotes, but then you pasted it in two other places in the thread and got downvoted for that. Another case was https://news.ycombinator.com/item?id=21983017 which is obviously a bad comment for HN. If one is to judge by these examples, it looks like downvoting is functioning ok.
Incidentally, the user who downvoted your comment upthread is a working doctor. (I hope it's ok for me to say that as long as I don't leak the name.) They are also a fine, scrupulous HN user, so they probably did that for a good reason. You may be disappointed that they didn't give you a substantive reply, but there's no obligation to do that on HN. Sometimes people don't want to get into an argument; sometimes they have their hands full with other things; sometimes they just don't have the energy. It takes a lot of time and energy to think through and type out a substantive comment, especially on a divisive topic where the chance of being misunderstood or attacked is quite high.
Well... that is my complaint about hacker news is that people frequently downvoted stories and comments that "gratifies one's intellectual curiosity" and don't violate any other guidelines. And they are never held accountable.
I am not referring to my own history. I often read downvoted comments and sometimes upvote them.
If people could indicate a reason for the downvote, it would probably help the whole situation.
The fact that this guy is a doctor... does not help your case. It makes it worse... if this were another lay person that downvoted cuz they thought it was off-topic, I would be ok with that.... But it sounds like this is another doctor, that disagrees with the doctor I linked to.
You might have a mistaken idea of how HN works, which is maybe why you've been finding it frustrating. On HN, it has always been ok to downvote a comment because one disagrees with it: https://news.ycombinator.com/item?id=16131314
Sure that's controversial, but the controversy is perennial. People have been making exactly the same arguments about it for a dozen years now, and that's just on HN—the debate goes back well before that. Different takes are possible. HN has its take. It's stable, we're not going to change it, and in my opinion it works relatively well. Moreover, the problems with it are not the problems that the users who post complaints about it are complaining about.
Are these comments from pg in 2008 the main source that downvoting signals disagreement? If so, I would suggest you document it somewhere more prominent. Perhaps you could add guidelines on downvoting.
When more is known about covid-19 I plan to come back to this thread and see who was right. If Dr Cameron Kyle-Sidell was wrong, totally off-base, on the wrong track... then maybe you're right... maybe this system does work "relatively well"
Even if there was a more prominently stated, formal policy about when downvotes are appropriate, it would make no material difference; the overwhelming majority of downvote-inclined people will downvote any comment that gives them a negative feeling.
That said, some of the best comments are ones that carry an argument that most people would disagree with, but are worded persuasively and/or informatively enough that they attract upvotes. It's difficult to achieve but well worth aiming for.
Outside of encouraging that, I'm not sure what else dang is meant to do. Discussion platforms that try to enforce policies like requiring explanations for any downvotes don't seem to have substantially better quality discussions.
Hi, I downvoted your post. I think `dang hit the nail on the head in re: why I didn't reply (don't really want to argue since arguing on this topic has occupied more of my recent HN activity than I really like; and I'm busy doing other things).
I certainly don't think your original post violated HN policy by any means, but that isn't the threshold for downvoting on HN as far as I understand.
I downvoted because the material in question isn't inline with how the majority of us are thinking about this disease. It creates a false controversy. To be fair, much of what he's describing is the pathophysiology of diffuse alveolar damage (the correlate of ARDS), but simultaneously he's saying it's not ARDS. Even in this video he seemingly felt compelled to walk back his high altitude pulmonary edema comments from a prior video.
I am not going to be replying further in this thread, but since things got off the rails a bit and my downvote was a part of that, I did want to try to explain my views of the content.
> the material in question isn't inline with how the majority of us are thinking about this disease.
That may be true. But that is what makes this important. The current protocols aren't working. This guy is a doctor on the front lines. Gattinoni, whom he references, is an expert in ventilation. This is not a crackpot conspiracy like 5G towers and I'm sick of seeing it dismissed like it is.
I have watched all his videos and I have never seem him say it is HAPE. My recollection is he said it was similar to HAPE.
He... nor Dr. Gattanoni are asserting that it doesn't meet the criteria for ARDS, but rather that it's not typical ARDS.
Gattanoni states:
However, the patients with Covid-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing (confirmed by colleagues in other hospitals), is the dissociation between their relatively well preserved lung mechanics and the severity of hypoxemia.
The New York Times video features Dr Corey C. Hardin at Mass General. The user carbocation is a "a cardiology fellow at the Massachusetts General Hospital" He is a colleague of the guy featured....
My link is to the twitter account of the doctor that disagrees with the doctor at Mass General.
This is a clear case... as I suspected... of the people in the article trying to manipulate the discussion about how they are perceived.
One dead giveaway of people getting their friends and colleagues to manipulate the way they are perceived on social media... is when your comment is quickly downvoted... before any casual user would have had time to absorb it.
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[ 3.9 ms ] story [ 249 ms ] threadIt isn't ideal, but this environment may make it much easier to rejig care standards.
The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally.
It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
> Are paywalls ok?
It's ok to post stories from sites with paywalls that have workarounds.
In comments, it's ok to ask how to read an article and to help other users do so. But please don't post complaints about paywalls. Those are off topic.
https://news.ycombinator.com/newsfaq.html
I think assuming it is from people who work for the nytimes is a stretch.
Really - it seems like most people aren't having issues reading the article. I was able to without logging in.
(“Fora” is the plural of “Forums” the Times’ Stylebook makes us use)
What stats are you basing that on please? Because I can't find any stats that support this claim.
[1] https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820...
The long-term death rate of COVID-19 remains to be seen. The final verdict on how bad it was will depend on whether or not lengthy immunity is attained (including to mutations).
We do close schools here and there for a week or so when flu is getting large to get it under control. We do close hospitals for visits at this times.
Personally, I'm conservative on this, and have barely left my place in the last eight weeks. I can work from home and will suffer little even if the lockdown is quite lengthy. But not everyone is in such a fortunate position, and I think we need to consider what's happening very carefully.
Also, the thing to consider is that working class is whonis most at risk from this. Rich people have less comorbidities, can afford healthcare and are much more easily to work from home and buy via deliveries.
This is basically reason why African Americans die the most - working class can't isolate themselves so easily. They are the group to die more then same age non working class.
I think we are considering things carefully. I can’t remember the last time you saw both dem and rep governors agree on anything, yet they are all agreeing on stay at home orders and testing.
Not even the most extreme estimates I've seen suggest that NY has anything approaching 50% immunity. Reopening NY and letting people catch CV19 would double, triple, ? the death rate.
There is no suggestion that NY is special as regards total numbers. (Velocity, due to population density, assume yes.) This is not the flu.
[0] A of 2020-04-17 880 deaths per 1M population. http://91-divoc.com/pages/covid-visualization/
I agree, reopening NYC would be a mistake, but large portions of the US (especially rural areas) remain largely unaffected by this.
The average age of death in my state (MN) is 88 with preexisting conditions. Our death rate is 0.0019% (!) with a flattened curve for some time now. Most of the US is not NYC.
Minnesota death rate is, as you say, currently at 19/million, but is growing at about 10%/day. The curve fits WA state's; continuing along that curve, WA currently has 79/million and is growing by 3%/day.
The question is "How much net difference will different reopening schedules make?". The answer to that is unclear, but remaining in lockdown for six months could easily kill more people (net).
Aside from "old age", the leading causes of death (and certainly years lost) among people I knew are AIDS and traffic collisions. This virus is going to have to try a lot harder to get on that scoreboard.
It's also worth noting that "reopening" doesn't mean people will just revert to prior behavior. Most will be very careful, and some will never revert. Wuhan reopened, and their restaurants are not springing back (yet?).
> The long-term death rate of COVID-19 remains to be seen.
At the moment we count flu deaths differently to covid-19 deaths.
Counting deaths due to flu is hard. We've only just started this work for Covid-19 by putting in standards for death certification. These stats lag the real time counts by some time, and they're always higher than the real time counts.
So, we're taking a method for counting flu than over-counts, and a method for covid-19 that undercounts, and then saying "covid-19 isn't that bad".
And that's just looking at deaths. We also need to look at hospitalisation (because we want to look at all the harm caused by different illness to assess whether our measures are reasonable or not; and because iatrogenic harm is a thing) and we see that covid-19 does put a lot more people in hospital than flu normally does. And this difference is only partly explained by rates of immunisation against flu.
Now there's some controversy that UK government have been reporting other deaths as flu, basically hiding Winter deaths due, eg to poor elderly care, in flu figures. So other sources suggest far far higher flu rates; but this is going off death registrations.
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsde...
Covid19 death rates for under 50s are something of the order 1:1000, 30x the flu rate in data I've seen most recent (Worldometer) but reported rates vary considerably.
Happy for you to show it if this is wrong.
We're not going to, though, and it's becoming less clear why COVID-19 is an exception. It reminds me some of 9/11--it's flashy and freaking everyone out, which leads to irrationally conservative behavior.
That's with lock downs.
It's also hard to say what individual behavior would look like absent government orders to close businesses. Retail business could well be way down without any orders.
But, as we pass the initial peak and have better experience and surveillance, we should very carefully consider what to do next. Just locking down for a year or two is not the "safe" option.
So best to err on the side of caution until this disease is more fully understood.
Smoking habits and seatbelt habits and just about everything else is in a steady state. Nothing we can do can change those situations dramatically, we can only nudge them to a small degree slowly because those situations and habits are entrenched.
The point isn't that N people die from this so we should be cool with it because N is in the same ballpark as stuff we've accepted. The point is that we have a short window to solve the new situation before acceptance sets in.
Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators?
Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs
I think in this situation, it’s letting these patients be managed without sedation or intubation.
Where do you get the idea they didn’t?
https://edition.cnn.com/2020/04/14/health/coronavirus-prone-...
I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it.
Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal.
But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
It may be news to (some) doctors, but that is not a lesson this pandemic taught us. In cost-utility analysis (https://en.wikipedia.org/wiki/Cost–utility_analysis), different interventions are compared against each other and against the “do nothing” approach.
This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning.
The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff.
Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses.
I’d be wary to practically apply this beyond the next viral epidemic.
No other emergency grows exponentially.
Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At worst they grow linearly at a high rate.
Consequently, highly contagious pandemic response must be fundamentally unlike any other response.
There are references to this bearing out in their prior wargaming of scenarios. All players (mistakenly) escalated linearly based on intuition.
When in reality you're talking about needing 10x resources every week, ceteris paribus.
[1] https://int.nyt.com/data/documenthelper/6879-2020-covid-19-r...
This epidemic might be an opening to shift the current equilibrium of over-medication and over-use of expensive treatments with questionable efficacy.
The proper solution could be changing the incentives structure in the medical system. From profit and executive compensation aligned structures that over-sell services and drugs into something that is connected with long-term public health.
https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...
Positive pressure ventilators however cover a wider range of medical issues though at increased risks.
External oxygenators are really a last resort which should be avoided whenever possible.
There are only a few hundred ECMO machines in the US. I suspect that’s less due to cost, and more due to the limited number of patients per year for whom ECMO has a good chance of being a net benefit.
And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.
Are we perhaps using less mechanical breathing devices here i Sweden?
Edit: this didn’t come out right... couldn’t find total icu death rate but have read stories about high mortality in NY.
Couldn’t find this data for us/ny.
It seems like there’s been a high focus on ventilator supply so I was just guessing a lot of severe icu cases would be put on one.
I have no idea, but would like to know.
If there was dishonest statistical comparison, this is the one.
In the UK it seems to be 50%.
Ventilators seem to exacerbate the condition for covid patients.
Sweden seem to have better success with intensive care than average.
Are we perhaps intubating less.
Train of thought ^.
I was assuming the 80% death rate was intubated ventilation.
From a glance, the US averages 3x the incidence rate of obesity as Sweden. Obese patients with existing health problems will result in substantially worse outcomes from Covid-19.
Also the swedish study is from 2012, so it's probably slightly higher now.
https://www.sciencedaily.com/releases/2016/06/160604050632.h...
The trajectory of cases and deaths in Sweden does not seem special to me, generally they seem to follow similar curve as other countries so far.
Certainly doesn't seem to be well outside of the range of outcomes in other countries at any rate. From what I've read--no first hand knowledge--it's also a bit hard to interpret the effect of Sweden not locking down. Apparently, at least around Stockholm, many people were staying home and not traveling. On the other hand, in at least some places, people were still going to bars and the like so it's a bit of a mixed bag. Almost certainly not business as usual but also likely a fair bit looser than a lot of places with more formal lockdowns. (And there's even quite a bit of variance there.)
https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports
This link opens a PDF download: https://www.icnarc.org/DataServices/Attachments/Download/c9b...
(17th April 2020)
> To date, ICNARC have been notified of 6664 admissions with confirmed COVID-19, either at or after admission to critical care, by critical care units in England, Wales and Northern Ireland. Of these, early data covering the first 24 hours in the critical care unit have been submitted to ICNARC for 6313 admissions of 5578 patients (Figure 1 and Figure 2). Of the 5578 patients, 2936 have outcomes reported and 2642 patients were last reported as still receiving critical care (Figure 3). The largest number of patients (1924) are being managed by the three London Operational Delivery Networks (Figure 4). Please note that Figure 2 and Figure 3 are affected by a variable lag time for submission of data of about 1-3 days (shaded grey)
[...big snip...]
> Critical care unit outcomes have been received for only 2936 (of 5578) patients, of whom 1499 patients have died and 1437 have been discharged alive from critical care (Figure 8 and Figure 9).
There's probably some more stats about critical care capacity here: https://www.england.nhs.uk/statistics/statistical-work-areas...
https://en.wikipedia.org/wiki/Obesity_in_the_United_States
"The obesity rate has steadily increased since the initial 1962 recording of 23%. By 2019, figures from the CDC found that more than one-third (36.5%) of U.S. adults[5] and 17% of children were obese.[6] A second study from the National Center for Health Statistics at the CDC showed that 39.6% of U.S. adults were obese as of 2015-2016 (37.9% for men and 41.1% for women).[7]"
A lot (100s) of deaths where old people have died of flu-like symptoms is counted as covid deaths. Teating has not been possible until just recently.
Likely an ICU patient in Sweden is in really bad condition seeing we have something like 90 ICU spots on 2,4 million people in Stockholm.
For example, in the Netherlands, in a blood test about 3% of the population was found to have antibodies, while the number of people confirmed to have corona via tests is at 0.15% of the population. We're looking at a 1:20 confirmed/actual rate.
That tells you testing is way off, about 20x so. The total tests performed is roughly similar to the US by the way, about 1 in 100.
Then there's death rates. The Netherlands currently saw 2 in 10.000 confirmed deaths from corona. This is about double the rate in the US. However if we look at excess deaths compared to a 3-year average for the same period (2017-2019) we see about triple the amount. Apparently 2 in 3 die of corona without it being tested or confirmed. (likely in nursing homes where mortality rates are often around 30% per year, and it's not uncommon for staff to find a patient died in their sleep for example).
And the Netherlands is a small country with high-quality public infrastructure. It's quite likely that it is among the countries with the best record-keeping system, and is among the countries with the highest tests per population, and even here we see massive undercounting of infections and deaths.
It's good to keep looking at the numbers, but only with a huge caveat. I'm actually completely flabbergasted that the media report on infection numbers without ANY mention of a confidence interval, standard deviation or some kind of uncertainty measurement, as well as some basic stats around testing methodologies, in particular when reporting cross-country comparisons. This should be the norm, but instead we just get country comparisons, world maps and graphs displaying wildly inaccurate and limited data (which is absolutely useful, but criminal to report without caveats). Apart from a mention about 'Chinese data isn't reliable' or 'India isn't testing much, so the problem may be far greater', there's really no consistent discussion about this. There's lots of standard statistical tools to express uncertainty which have been used in science for decades, but they're completely absent in our reporting or discussions at the moment.
https://twitter.com/CT_Bergstrom/status/1251344851984986118
https://twitter.com/CT_Bergstrom/status/1251346572656304128
> In the supplement they say 2 out of 371 + 35 known negative samples tested positive. This means that the 95% confidence interval for the false positive rate is [0.06%, 1.77%]. In their samples from Santa Clara County they had 50 / 3,349 = 1.5% test positive.
https://bnonews.com/index.php/2020/04/the-latest-coronavirus...
https://www.svt.se/nyheter/inrikes/over-80-procent-overlever...
"(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended.
When human resources allow, prone ventilation should be carried out for 12 hours or more every day. "
https://www.chinalawtranslate.com/coronavirus-treatment-plan...
There's simply a shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this.
For example, people are finally grudgingly admitting that CT scans could play a useful role in diagnostics after months of CDC & ACR denialism: https://www.statnews.com/2020/04/16/ct-scans-alternative-to-...
edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment
(3) Prone Position Ventilation Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position.
Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance.
https://www.alibabacloud.com/universal-service/pdf_reader?cd...
There is no "shocking degree of arrogance from the West" but there may be a failure of adequate reporting, in this article and others, of what we are doing in hospitals.
Watch as Western countries start discovering as they roll out their automated contact tracing apps how little the tech plays a role in an effective contact tracing system.
There's a lot of parameters in the "design space" of contact tracing. If you're objecting to simply the most extreme version of it, then duh, anyone would, including the Chinese.
In the first stages of Corona we did a lot of old school contact tracing.
There's many different ways of doing contact tracing that involve myriad tradeoffs. Every Asian country that has rolled it out has had negotiations between the citizens and the government over the various dimensions and how to balance between competing concerns (yes, even China). Every country has landed in a slightly different form of contact tracing based on existing resources, societal norms and degree of urgency.
It's shockingly arrogant to assume that Asian citizens haven't grappled seriously with these issues and, even if they have landed in a different position than you would prefer, that the conversations they're having don't have any value.
I've yet to read a single English language piece on Asian contact tracing that has accurately described how contact tracing works on the ground in a nuts and bolts way across multiple countries. Instead, all I read are exoticised, fetishized pieces that focus on technological bells and whistles or highlights a bunch of theoretical privacy violations that either aren't a big deal in practice or easily gotten around with some simple design tweaks.
Then, you get people who go off half cocked and make sweeping statements about an entire category of methods while having done literally no research on how it actually works in a real world context.
That does not mean there are other voices in the West. But I do not know what you are looking for, and what you think is bad information.
Each approach has different pros & cons when it comes to privacy and effectiveness. Which one specifically do people think is acceptable and unacceptable?
Not sure it is Western arrogance rather than standard medical arrogance.
The video accompanying the NYT piece (5m:37sec) one doctor says:
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is insane for a new disease.
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
The problem is that Covid-19 is caused by a NOVEL virus which has no evidence base. There should be at least some skepticism regarding the applicability of previous studies.
Starting at 1min https://youtu.be/rfkbv_WQtn0
I thought it was just official health care, public institutions talking thru public media?
Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve.
(Waiting for a my job to begin, waiting for my son to get his surgery)
We should aim to do better than that.
This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well.
We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission.
If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you know, an O(2^n) algorithm is extraordinarily hard to keep up with once n approaches any large number.
That's the curve we're trying to flatten - by changing the approach, changing the "algorithm" so to speak, by not allowing people to interact so they have less chance of infection.
If you are able to build a new hospital in a week, and then continue building a new hospital every day after that and then one every hour after that, and then a new hospital every few seconds after that, then you have a chance to keep up with an exponential curve (well, until the virus runs out of people to infect, so until it reaches 100% of the global population).
But unless you are hoping for a vaccine to be invented soon, which would of course be wonderful, you have to face the other scenario and that is that we have to slowly build up herd immunity. Herd immunity means that people have to get infected and a percentage of that will have to go to the hospital. No matter how you manage it, bigger hospital capacity simply means that you are able to reach herd immunity more quickly.
What does her immunity actually mean though? What other diseases do we try to tackle using herd immunity? How many deaths would make herd immunity acceptable or not acceptable?
There are 350m people in the US. We need to get about 60% of them to have had covid-19. That's 210m people. We don't know how fatal covid-19 is yet, so here are some lower numbers:
And once we've killed off all these people what have we achieved? Covid-19 would be in the population and will come back every year as a seasonal respiratory illness, killing off more people every year until we get a vaccine.This disease has to be handled with intelligence and common sense, not with rethorics and dogma's.
Do you have any evidence to support that it would keep coming back? As far as I know there's only very small anecdotal evidence of people getting reinfected and we simply have no way of knowing yet whether the average person's immunity will last weeks, months or years.
IF (and that's a big if), the infection fatality rate really were just 0.1% (i.e., regular flu), then yeah I think letting this thing run its course is the reasonable thing to do.
In my mind, the reason for the lockdowns is because we don't know the morality rate yet, and so we should be cautious in case it's 1-3% how it was looking at first.
I could turn the question around on you, and ask what fatality rate makes the "run its course" strategy reasonable to you? No deaths?
It turns out that getting the number of infected down close to zero would also be good for the economy.
I don't understand why so many people think that the best possible plan is for everyone to get infected. The best possibilities involve a few percentage points of the global population getting infected, no where near everyone.
Respiratory viruses, once endemic, have never been completely suppressed. Even China is seeing a resurgence in cases. What we’re doing now isn’t sustainable or ethical, and we have to move on to smarter tactics soon.
My point is that if we move forward as if letting lots of people get infected is a 'smarter tactic', it's going to be worse in all ways. More death, more economic damage.
Since it looks like we’re close to this (even in places like NYC that are sitting on a vent stockpile) we can start loosening the economy back.
The point of “flattening the curve” is not — and was never — to reduce the area under the curve. This is a contagious respiratory virus, and it’s going to spread until there is herd immunity. Maybe there will be a vaccine in 12-18 months. Maybe not. But regardless, we can’t go on for that long with over 30% of society out of work.
Most people are going to get this virus. If you don’t understand that, you are scientifically illiterate. You are pushing on the ocean to prevent the tide.
Trying to forestall the inevitable by keeping us all locked in our homes will inflict such massive economic and social collateral damage that it’s simply unthinkable. We won’t stop the virus, and we’ll burn down our society trying.
Umm, no.
The number of people who pretend South Korea does not exist is too damn high these days...
We have managed to eliminate one human virus in history: smallpox. And we only did that through mass vaccination.
We have never eliminated a respiratory virus, nor have we ever developed a successful vaccine against a coronavirus, despite huge financial incentives to do it.
The inevitable outcome here is herd immunity. Maybe we’ll get there by vaccine, but not for a long time.
We had 18 new patients yesterday.
(I'd normally write a snarky comment here, but the numbers speak for themselves.)
I was going to make a comment on this article about the meme being too effective, in that it convinced people that the only point was to reduce the load on the medical system. Of course the goal is to reduce the load on the medical system, but that's step one, to get though the first wave of infections and to a situation where the spread is potentially controllable.
There's talk of multiple strains or of it mutating in ways which aren't necessarily more deadly but make reinfection possible independently of the currently found 2% who seem to be testing positive again after "recovering" from covid
Then the powers that be will realize just how deep of a shit situation we are in. The people who are protesting now are likely infecting themselves or will soon know a loved one with this and soon they will personally realize how stupid they were to protest this. It's only a matter of time...
That's like asking why does everyone think the best plan is for the sun to rise tomorrow morning.
It's not a "plan", it is fact. Everyone (to some level of precision) will be either have anti-bodies from infection or have been vaccinated (or the unrealistic enough to ignore; remain in isolation their entire life).
We don't have a choice in that. We can try to alter the parameters (rate, timing, etc.) of that. But, that is the limit of our control.
We don't run massive test and trace programs against cold viruses because they are relatively less harmful. We easily have the resources to run a massive test, trace, isolate and support program against COVID-19, and we can eradicate it using those methods.
And if a vaccine comes out before suppression is complete, so much the better.
The fact that we have only ever eradicated a pandemic by using vaccines is no reason to not try doing it without one. It's very hard to understand why people aren't screaming to spend a few hundred billion dollars to start doing this right now, as the payoff is essentially incalculable.
I think some people must consider the economy to exist in a vacuum. But economics is based on confidence in the future.
A robust, unified, can-do response would do wonders to shore up that confidence.
When the work pays off with a better outcome, it's foolish to look back and criticize the planning for worse outcomes, especially when the tools to manage the infection are pretty limited (social distance works well, but it's a brutal tool, so you want to use it only as necessary).
The predictions of what would have happened had no lockdown been introduced then haven't materialized precisely because the lockdown have been executed.
That is no argument that the lockdown haven't been needed.
Had the model's predictions been more accurate we could have found a better middle ground when it comes to lockdown. Every job saved and individual financially secure is one more person who can contribute to the community's well-being. I think it's pretty safe to say in retrospect that the lockdowns need not have been as draconian as they were. We had the hospital capacity to have less severe lockdowns and we should have done that. While we can't change the past, we can certainly look at how our models failed and rework our approach in the future. Anything else is irresponsible.
What you state now reflects exactly how many casual observers have problems to understand the exponential nature of the epidemics: if one observes the doubling time of three days, and that is what has been observed, this means only that the difference between needing 10k ventilators and needing 40k ventilators is only 6 days -- less than a week! Nobody can wait to actually need them to order them and get them delivered in so short time frames!
It was surely not possible to predict reliably how would have people reactd to which kinds of measures requested of the people, and the exact impact to the slowing down the spread (when exactly would doubling time get to be how much longer as a response).
Having an error of just 6 days in the middle of the exponential growth is not so negative if you are attempting to allocate resources to avoid tens of thousands of unnecessary deaths. And that statement of needing 40k ventilators is not what prevented some "better middle ground".
The "better middle ground" was surely possible to achieve by simply treating the epidemics much earlier as a serious issue and not acting as it is "just like flu" or would "disappear" overnight before anything has to be done.
Proning is great! It keeps people alive. We are doing a lot of it. It's not new.
1 = https://www.nejm.org/doi/full/10.1056/NEJMoa1214103
There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week.
I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
https://coinmarket01.blogspot.com/2020/04/what-is-iq-option-...
Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation.
[i] https://youtu.be/E_6jT9R7WJs?t=65
[i] www.arjo.com/en-us/products/medical-beds/critical-care/rotoprone/
https://twitter.com/cameronks/status/1251233871137574913
But I want you to know that someone else on this site sees the bullshit within the community that exasperated you so much. The HN crowd will upvoted BS posts and downvote substantial discussion on basically a random whim. The admins are known to very insulting label good posts as things such as "tedious ideological boilerplate" or "political flame bait" when they personally don't like what was posted. The userbase treats upvotes and downvotes exactly the way they're used on Reddit. This place is basically just nerd Reddit.
Unfortunately your claim about the virginity of the userbase is both unnecessary (and guaranteed to find the wrath of the powers here) and most likely wrong because the folks here really do make money.
You gotta play the game by their rules or they grey you out. Use those coding skills we all supposedly have to make a new platform and make it better so you can steal away the part of HNs userbase whose worth a damn. That's likely the only way to "fight da powah" since you're obviously very unhappy about this whole ordeal...
But this site is so bad at this point. I really don't care anymore. I might lose my karma or get kicked off but I frankly do not care...
I have read the guidelines. and I defy someone on here to give me a good reason to downvote the original comment.
I did submit it as a separate link and it's got no traction.
My concern is this... there is a lot of fake news... like the 5G tower theory which is absurd. But there are also legit people out there trying to figure out this problem. They are being dumped into the same bucket... by well meaning social media moderators.
I suspected it was downvoted because people think they're doing the right thing... stopping the spread of wild theories or disinformation.
One feature that would be useful on hacker news, would be to indicate which guideline you're violating when you downvote.
I'm going to put this down to your going on tilt (it happens to almost everyone), but please don't do it again. We all get downvoted. It stings, and it sucks not to necessarily know why, but it happens to everyone and it's the way HN works.
Over time, if your comments are consistently getting downvoted, you should reflect on what might be wrong with them. I looked through your recent account history and it doesn't seem so hard to figure out. In one case, you posted a comment which got a lot of upvotes, but then you pasted it in two other places in the thread and got downvoted for that. Another case was https://news.ycombinator.com/item?id=21983017 which is obviously a bad comment for HN. If one is to judge by these examples, it looks like downvoting is functioning ok.
Incidentally, the user who downvoted your comment upthread is a working doctor. (I hope it's ok for me to say that as long as I don't leak the name.) They are also a fine, scrupulous HN user, so they probably did that for a good reason. You may be disappointed that they didn't give you a substantive reply, but there's no obligation to do that on HN. Sometimes people don't want to get into an argument; sometimes they have their hands full with other things; sometimes they just don't have the energy. It takes a lot of time and energy to think through and type out a substantive comment, especially on a divisive topic where the chance of being misunderstood or attacked is quite high.
I am not referring to my own history. I often read downvoted comments and sometimes upvote them.
If people could indicate a reason for the downvote, it would probably help the whole situation.
The fact that this guy is a doctor... does not help your case. It makes it worse... if this were another lay person that downvoted cuz they thought it was off-topic, I would be ok with that.... But it sounds like this is another doctor, that disagrees with the doctor I linked to.
Sure that's controversial, but the controversy is perennial. People have been making exactly the same arguments about it for a dozen years now, and that's just on HN—the debate goes back well before that. Different takes are possible. HN has its take. It's stable, we're not going to change it, and in my opinion it works relatively well. Moreover, the problems with it are not the problems that the users who post complaints about it are complaining about.
When more is known about covid-19 I plan to come back to this thread and see who was right. If Dr Cameron Kyle-Sidell was wrong, totally off-base, on the wrong track... then maybe you're right... maybe this system does work "relatively well"
That said, some of the best comments are ones that carry an argument that most people would disagree with, but are worded persuasively and/or informatively enough that they attract upvotes. It's difficult to achieve but well worth aiming for.
Outside of encouraging that, I'm not sure what else dang is meant to do. Discussion platforms that try to enforce policies like requiring explanations for any downvotes don't seem to have substantially better quality discussions.
I certainly don't think your original post violated HN policy by any means, but that isn't the threshold for downvoting on HN as far as I understand.
I downvoted because the material in question isn't inline with how the majority of us are thinking about this disease. It creates a false controversy. To be fair, much of what he's describing is the pathophysiology of diffuse alveolar damage (the correlate of ARDS), but simultaneously he's saying it's not ARDS. Even in this video he seemingly felt compelled to walk back his high altitude pulmonary edema comments from a prior video.
I am not going to be replying further in this thread, but since things got off the rails a bit and my downvote was a part of that, I did want to try to explain my views of the content.
That may be true. But that is what makes this important. The current protocols aren't working. This guy is a doctor on the front lines. Gattinoni, whom he references, is an expert in ventilation. This is not a crackpot conspiracy like 5G towers and I'm sick of seeing it dismissed like it is.
I have watched all his videos and I have never seem him say it is HAPE. My recollection is he said it was similar to HAPE.
Gattanoni states:
However, the patients with Covid-19 pneumonia, fulfilling the Berlin criteria of ARDS, present an atypical form of the syndrome. Indeed, the primary characteristics we are observing (confirmed by colleagues in other hospitals), is the dissociation between their relatively well preserved lung mechanics and the severity of hypoxemia.
My link is to the twitter account of the doctor that disagrees with the doctor at Mass General.
This is a clear case... as I suspected... of the people in the article trying to manipulate the discussion about how they are perceived.