Who Am I?

Is Anybody There? Does Anybody Care?

Posted: April 30th, 2020 | Author: | Filed under: Personal | Comments Off on Is Anybody There? Does Anybody Care?
Is anybody there?
Does anybody care?
Can anybody see what I see?

I remember the first time I saw the musical, 1776. It was when we were living in Shreveport. I remember the street and the theater where Mom took us to see the stage performance sometime after the particularly … eventful period in West Virginia. Shreveport wasn’t any less challenging for me than the other places we had lived, but it was a change. I date and order my memories by their location and setting. And that place and those events mean I was either 9 or 10 years old then. So it was the spring or early summer of 1975.

I loved many of the lines and songs in the musical, and as was often true for me, I repeated many of them over and over for years. No, that makes it sound like I stopped repeating them at some point. I never have. It’s a combination of verbal stimming and delayed echolalia, but of course I didn’t know that the things I did and my experiences had descriptive names until the last few years.

One song in particular, though, haunted me. It was one of those songs that seemed to speak directly to my pain. Is anybody there? Does anybody care? Can anybody see? I remember crying in the theater that day in the final part of the song. When the words echo in my head today they still bring tears to my eyes. Yes, I understood then and understand now the meaning of the song in the context of the musical, but those words when the performance level meets their emotional weight transcend that context. Those are the words I’m certain every child in pain has screamed silently to the world.

I searched and there’s a recording of Brent Spiner performing the song. It’s wonderful and if you’re not familiar with the musical, take a minute to listen to it.

The song’s three questions have been on loop in my brain the past couple of days. The loop is triggered again and again each time I hear and read statements even from those trying to do the right thing in the Austin/Round Rock metropolitan area during this pandemic in the face of immoral and malign actions by the Texas governor. I can’t tell if they can’t see the outcomes that are so clear to me or if they are simply willing to accept outcomes that should never be considered, much less tolerated.

While my meaning and intent were clear in my mind, I realized in retrospect my comments linking certain actions to eugenics in my post on “herd immunity” may not have been obvious to the reader. Herd immunity in human populations is often a goal specifically because it protects the vulnerable members of the population from serious illness or death. That’s a laudable and moral goal. When we act to protect each other, especially our most vulnerable members, to the best of our ability, we are living as moral, loving human beings. We are highly social creatures and we are in many ways wired for goodness. Evolutionary biology, anthropology, evolutionary psychology, social science, and every other measure we have points toward that truth. And yet we are also the most violent and destructive species on this planet. We are capable of great evil. And both tendencies are on full display during this crisis.

Far too many people across the political and ideological spectrum discuss this pandemic in terms of managing the rate at which the vulnerable members of our society die off so it doesn’t overwhelm our medical system and cause suffering for everyone else. The pandemic becomes something to manage to spread severe illness and death over an extended period of time so those most vulnerable to it don’t disrupt society by all dying at once. In this scenario, they hope that those who survive the illness develop this perverse version of “herd immunity” (when there is nobody left alive to protect) so the virus will stop inconveniencing their lives.

That perspective is based entirely on eugenics and the theory that we’ll improve the species by weeding out the weak and vulnerable. It is evil. Trading human lives for money or convenience should be a taboo trade-off. And those even willing to consider that trade have demonstrated by not immediately rejecting it out of hand that they are at best morally suspect human beings and cannot be trusted with the lives of others. If you did not read Dr. Richard Beck’s essay linked in my previous post, read it now.

Our Moral Fragility

The University of Texas in Austin has been doing modeling and projections for the state and the nation, but they began with studies focused on the local area and they continue to produce those as well. Every study involving SARS-CoV-2 and COVID-19 is preliminary and still undergoing review. That’s the nature of the world dealing with a highly infectious and deadly virus that simply did not exist half a year ago. The world is seeing how science works at full speed in real time. And it’s never one breakthrough building systematically on another. It’s an erratic convergence on the facts over time. But UT is a Tier 1 research institution. Their preliminary studies are at least as credible as anyone else’s and more so than those from many sources.

UT has published two recent studies on relaxing social distancing mitigations in the Austin/Round Rock area. The first was on April 23 and the second was on April 28. I’m focusing on the latter in this post, but the former is here for those interested.

COVID-19 in Austin, Texas: Relaxing Social Distancing Measures

After the state governor’s late and detrimental interference in local metropolitan area management of the pandemic, UT released the following study.

COVID-19 in Austin, Texas: Averting healthcare surges while relaxing social distancing

I appreciate the way they framed in the study what should be the only moral consideration, protecting those at highest risk, as a practical consideration. When your political leadership lacks moral character and a significant portion of the population appears to share that lack, moral guidance has to be framed in practical terms and compared to outcomes that would negatively impact those who lack such basic moral character. It’s sad that we live in a world in which that approach is required, but I understand why they used it. Since there is no evidence we will have any sort of effective test, trace, and isolate containment infrastructure and we will not be allowed to suppress the outbreak to levels where TTI is feasible, it’s not considered in the study. (I could be mistaken, but I tried to parse the details to the extent I was able and that didn’t seem to be part of the assumptions.)

Even so, look at the two graphs in the study marked as figure 2 on page 6. Those are the two “best case” scenarios where the projections predict we can at least keep from exceeding hospital capacity. They require that we maintain at least 40% social distancing mitigation, “cocoon” the 25% of the population that is high risk and vulnerable, and cycle in and out of lockdowns every time hospital utilization exceeds a trigger threshold.

First pay attention to the vertical y-axis of the graphs. Yes, both graphs keep the hospitalizations below the critical hospital capacity horizontal line but look at the numbers used in the scale. Thousands of people will be hospitalized on an ongoing basis. I believe something like half of the people hospitalized end up in ICU. The typical hospital stay is well over two weeks. And a large percentage of those who end up in ICU die. And it is not an easy death, if such a thing exists. People are left fighting for each breath, their organs failing. And they are alone, with no family and no friends. It’s a lengthy, brutal, terrifying, and lonely death. All of those who do recover will spend their stay desperately ill, fighting for life, with no assurance they will ever leave. And they all will have no family with them to comfort them or help them. Sure, the rest of us will still have functioning hospitals, but don’t gloss over the reality.

Now look at the horizontal x-axis of the graphs. That’s the length of time measured in months. There are lots of variables in the length of time those lines extend. I don’t pretend to know them all, but I’ve learned some of them. Variance in those numbers can easily extend the period with hundreds and thousands in the local hospitals even longer. The second figure extends longer than the first with only one change in the assumptions. But both graphs extend at high hospitalization levels for a year or more.

That’s horrifying! And I don’t see any way it can be sustainable. As awful as COVID-19 can be for each individual hospitalized victim and their family, try to place yourself in the shoes of the hospital staff providing care. It most directly impacts doctors, nurses, and nursing assistants, of course, but nobody at the hospital will be spared. The technical staff providing tests and treatment, the kitchen staff, the custodial staff, the administrators, and everyone else working in the hospital will show up every day in a hospital filled with desperately ill long-term patients fighting for life with many dying every single day. They will work in fear of being infected and infecting people they love. Some of their friends and coworkers will die from COVID-19.

And we expect them to show up and keep doing the intense and critical work they do day after day after day under those crushing conditions for a year or longer?!? My God! That’s more than any human being can bear. People break under that degree of unrelenting stress, fear, pain, and empathy for those who are suffering and dying. Everybody breaks in their own unique way at different times and at different points, but every human being has limits.

As a veteran, I mostly dislike the shallow, empty, and sometimes harmful comparisons of this pandemic to a war. A medical crisis is not a war and you don’t approach it the same way you do a war. But even though I served in relative peacetime, I was trained for divisional level staff planning in my specialty and I remember one critical planning consideration was always the human toll. We always had to allow periods of less intense operations and opportunities to recuperate from the unrelenting high stress of direct combat or operations in a high risk environment. Human beings can rise to amazing challenges and endure tremendous pressure in the short term and even for longer periods when utterly necessary. We’re highly adaptable creatures. That doesn’t mean those experiences don’t have long term consequences. They do. But the majority of people can remain mission effective as long as you ensure they have opportunities to relax and recuperate. If you push people too far, too hard, and too long under extremely high stress situations, we stop functioning effectively. We break. We can no longer fulfill the mission, whatever it might be.

That’s what I see when I look at that x-axis. I see what we are asking our medical caregivers to endure. My eldest is an ICU nurse in San Diego. I see her face and all those like her in those graphs.

Any person who can look at those graphs and the human suffering and death they entail and perceive them as any sort of acceptable or even desirable outcome has abandoned their humanity. Such a person is not moral or kind or loving. That person has made themselves into a horror and an abomination, a gross caricature of a human being, and a moral cancer on our society.

Moreover, the approach outlined in those graphs is not only immoral and inhumane, it is impractical and unrealistic. As we destroy our healthcare workers, that red horizontal line representing hospital capacity will move down. “Beds” are used as a shorthand way to describe everything required to care for a patient. Yes, appropriate physical space matters, but it’s the most trivial of the requirements. Equipment and supplies matter more. But the most critical aspect are the people providing care. They are not expendable or easily replaced. Training more is a long slow process, even assuming others are willing to enter the field under those conditions. A year or more without any meaningful break? At most of the hospitals around the country? That’s an impossible demand to meet.

We are the wealthiest nation that has ever existed on this planet. Right now, everyone around the globe is effectively begging to pay us to hold their money at interest rates that are not just extremely low but negative when inflation is considered. (Of course, most of the national debt is simply money we owe ourselves as a nation in an accounting exercise because that’s how macroeconomics works in general.) We have all the resources we require to manage this pandemic, stabilize families and businesses economically, produce and distribute the medical equipment required, provide essential medical care, build and deploy the essential testing, tracing, and isolation public health infrastructure, and save countless lives.

We lack only the moral will to do it.

COVID-19 and “Herd Immunity”

Posted: April 28th, 2020 | Author: | Filed under: Misc | Comments Off on COVID-19 and “Herd Immunity”

I’ve heard a lot of takes, even from more mainstream and even “liberal” sources in the United States that the goal is to control the spread of the virus so it doesn’t overwhelm our health care system, but let it spread through the human population in some sort of “controlled” manner until we eventually reach “herd immunity”. I shouldn’t be surprised, I guess. We have deep eugenicist roots in this country. As I wrote elsewhere, the Nazis got a lot of their initial ideas and even laws directly from us. We had mandatory sterilization laws long before they were implemented in Germany and the last ones were not removed from the books until the 1950s. However, involuntary sterilization remains a legal practice in the United States to this day. It just normally requires a court order rather than a blanket law. A lot of race theory and the racism it supports is based on eugenics. Racism and eugenics are intertwined and threaded throughout our society.

So I shouldn’t be surprised. I know this is who we are. I know this is who we have always been. In this instance, though, the sheer callousness toward mass death and suffering astounds me. That’s what this perspective entails. Yes, the outcomes become immensely worse if our hospitals are overrun. The direct deaths from COVID-19 grow dramatically because there isn’t capacity to save everyone that could otherwise be saved. And because the health care system is overwhelmed all cause mortality also spikes. Lots more people die when the hospitals are overwhelmed.

But even if it were feasible to allow the virus to spread through the population without containment in some sort of controlled manner so that it did not overwhelm our hospitals, that would mean millions of people would die and millions upon millions more would suffer tremendously and some subset would have permanently damaged health and wellbeing from the disease. In the US, we have a population of 330 million people. The absolute best case is that COVID-19 has a 1% mortality rate. It could be as high as 3%-4%, but let’s assume the lowest possible estimate. That’s up to 3.3 million people dead. Let that number sink in. But it’s worse even than that. An estimated 10% of victims will be seriously ill and require hospitalization. The typical term of hospitalization is 10 or more days with incredible suffering. And we are already seeing that some of those who survive suffer permanent chronic and disabling effects. That’s not surprising. SARS-CoV-1 and MERS demonstrated the same thing. So that’s up to 33 million people hospitalized, on the verge of death, and possibly permanently disabled.

And that’s in the United States alone. With a global population of 7 billion, even if herd immunity could be achieved with as small a percentage as 60% of the population immune, that means at least 42 million people globally will die. As far as I’m concerned, anyone who can consider that an acceptable outcome is a morally deficient human being.

On this issue I wholly agree with Dr. Richard Beck in his post on moral fragility. “We like to think we’re moral, loving people. We are not. Our affluence had masked our depravity.” The fact that we have contemplated trading lives for money demonstrates that depravity, even if we ultimately move away from the morally reprehensible choice. However, we are not moving away from it. A significant portion of our citizenry, even crossing ideological lines, have embraced their depravity and are trying to justify it as somehow moral.

However, even for those willing to make that morally depraved tradeoff, it does not appear feasible to have some sort of controlled spread. This virus is far too contagious. I’ve been watching the estimates of the median rate of transmission creep up from day one and they started at levels supporting exponential curves. The rate of transmission is called R0 or R-naught. The R0 of a virus represents the median number of people each infected person will infect without any controls or mitigation in place. The most recent study I’ve seen has been prepublished by the CDC’s own journal, Emerging Infectious Diseases. It’s scheduled for the July issue so it is still in review and may change, but it’s as credible as any preprint can be.

High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2

The study calculated an R0=5.7 for SARS-CoV-2. For comparison, seasonal flu has an R0=1.3. One of the most infectious diseases, measles, has an R0 of 12-18.

I want to let that sink in for a moment.

The first implication should be clear. The idea of controlled spread of a disease that contagious represents magical thinking. There is no way to allow slow, controlled spread through a population even if you’re willing to make the immoral trade of a large number of human lives for whatever monetary or economic benefit you believe you’ll receive. Once the virus is allowed out of containment, it will spread in an uncontrolled manner every single time.

The second implication should also be clear. There is no path to any sort of herd immunity absent a vaccine. The paper provides the formula for herd immunity. In its simplest form, it’s just 1-1/R0. For R0=5.7, that requires 82% of the population to be immune. And that’s moving up into the 95% required for herd immunity to measles, something we were only able to achieve through a vaccine.

And, of course, the talk of immunity revolves around the naive assumption that exposure to the virus results in some sort of natural, lifetime immunity to it. There is nothing that indicates that’s a reasonable or likely assumption and quite a bit of early evidence that it is wrong. A lot of people with light exposures don’t have the right sort of antibody cells that encode immune system memory. But that’s true even of some who were seriously ill. They are finding that others do have the right sort of antibody but there isn’t yet any data that indicates the degree of natural immunity or how long it lasts. It’s good there appears to be a mechanism that produces the antibodies with memory. If there weren’t, it’s my understanding that a vaccine wouldn’t be possible. But it does not appear to operate at all evenly across the human population as a result of infection and recovery. A well-designed vaccine would have a much higher and more consistent rate of effectiveness. The early data also present a clear warning: If you’ve had COVID-19 and recovered, DO NOT assume you are immune! Wait until tests and supporting data clearly support the likelihood that you personally are immune.

So what do we need to do? The answer is not a mystery. It’s perfectly straightforward. We need to do what most other countries are already doing or preparing to do. First we must suppress the initial outbreak. That means a full lockdown until virus levels fall to whatever our capacity in an area to perform the second step might be. (That will not be consistent around the country.) We have not yet suppressed the initial outbreak anywhere in the United States. We are still at step one across the entire nation.

The second step is containment: test, trace, and isolate (TTI). It requires extremely widespread and easily available testing with reasonably rapid results. Some places, like nursing homes, will require multiple rounds of 100% testing of staff and residents. Health care workes require regular universal testing. Everyone working in close, frequent contact with others must be tested regularly. Test. Test. Test. As much as possible of the entire population in a region must be tested over time and continually retested. Every positive must be isolated until they are recovered and all their contacts who might possibly also have been infected must be traced, tested, and isolated as well.

If TTI fails in an area and containment is broken, the virus will begin to spread again in an uncontrolled manner. Once that happens and testing detects it, the area must immediately go back into full lockdown mode until the new outbreak is once again contained. However, even with full TTI in place, it is not likely that all restrictions will be able to be relaxed anywhere.

That cycle will continue until a vaccine is discovered and through vaccination herd immunity is achieved without mass death and suffering. That is and has always been the only moral choice and if this virus is as contagious as it appears to be, it’s also the only practical choice.

Those who do not follow those steps will see their hospitals overrun and their death rates skyrocket precisely as we saw in Italy, Spain, and New York. It’s not a question of if; it’s a question of when. And right now, the ‘when‘ is only weeks away for many parts of this country.