COVID-19: A Data-Driven Analysis
By
John Mauldin and Mike Roizen, MD
Should you wear a mask in public? This seemingly simple question
immediately generates emotional, political, and social anxiety.
It is just one of many provocative questions COVID-19 is forcing
upon us. They should be simple, data-driven policy issues but many are not.
Today’s letter is in a different format from the usual Thoughts from the Frontline.
As long-time readers know, I am in frequent (and lately almost daily) contact
with Dr. Mike Roizen, emeritus head of wellness at the famous Cleveland Clinic,
member of the Cleveland Clinic’s leadership team, and author of many books
which, thanks to Oprah (he was her doc), have together sold 28 million hard
copies. Today we write a joint letter to you. It may be controversial, but that
comes with the territory.
Mike and I became online friends over 15 years ago and then he
became my doctor and a good friend. He keeps me healthy and I feed his economic
information addiction. A perfectly reasonable symbiotic relationship. We have
been sharing information on the coronavirus crisis, on which he is an advisor
to several state governments.
So today, we’re going to look at some actual data, both medical
and economic. Spoiler alert: The unintended consequences of our response may be
more threatening than the actual virus, unless we begin changing some things
son.
Double Effect
We’ll start by looking at both direct effects of the coronavirus,
and its secondary effects.
The direct effects come from both the virus itself and—critically
important—from people
avoiding healthcare because they fear exposure to the virus at a healthcare
facility. Studies are beginning to show the latter group may be
larger than the former.
Then there are secondary health effects related to our response to
the virus. These secondary effects are largely due to the economic
consequences. We are seeing both “deaths of despair” and health consequences
due to changes in the healthcare system, such as closure of some rural
hospitals and the rise of telemedicine. The effects are visible, but the
absolute data isn’t.
Another thing we don’t fully understand is regional variation. The
virus obviously strikes some areas harder than others.
For example, total COVID-19 deaths as of May 28 in Texas, Florida,
and California combined were 7,877. Those states have 27% of the US population
but so far less than 8% of the COVID-19 deaths. The hospitals of those regions
were not taxed, and many ICU beds were empty as elective surgeries were
cancelled. Healthcare facilities generally had adequate protective equipment.
Contrast that with New York, Connecticut, and New Jersey where
deaths as a percent of population were much higher. Medical facilities were
stretched to their limits and had to reuse protective equipment. New York City
had 24,000 “excess deaths” from March 11 to May 2, of which
only 14,000 were confirmed COVID-19 cases.
New York City, with 2.5% of the US population, had 29.2% of the
country’s excess deaths. If you exclude New Jersey and New York state, US
excess deaths were only about 10% more than normal—compared with 5% for
Germany, 25% for France, and 40% for Italy. There is a lot of speculation about
why, but no definitive data.
And it is not simply population density. Hong Kong is far more
dense and has a fraction of the deaths as New York. We don’t know why regional
and state statistics vary so widely. Again, lots of speculation.
Think COVID-19 is just another flu? The CDC data say otherwise.
Excess deaths are a very real thing. (H/T Rob Arnott)
Data: Centers for Disease Control and Prevention
The good news? If you are not in New York, New Jersey, or
Connecticut, and are under 50 and healthy, your odds of dying from COVID-19 are
low, in the range of a car accident. But that doesn’t mean you can ignore the
risk, because you are around people who don’t have your luck. Any of us could
be asymptomatic carriers. Plus, we are seeing longer-term side effects from the
virus. Even if you survive, you don’t want to risk getting it (see below).
A second thing we do not understand about this virus is whether it
generates enough of an immune response to prevent reinfection and how long that
immune protection lasts. For that reason, even sophisticated antibody testing
will not be very beneficial until we know more.
This also means vaccine development will require larger and longer
tests that show decreased infections in the randomized group that receives an
active vaccine as compared to the placebo group. That will take longer. Ugh. We
all want faster but… we have to be safe and sure.
For the record, we are both firm believers that, with 100+ “shots
on goal” happening from various groups around the globe, we will have a
vaccine. It is too soon to know how many of these efforts will succeed but we
think at least one will.
Moving on to what we do
understand…We are learning some of the factors influencing death from SARS-CoV-2: More than 70% of Ohio deaths have been residents in long-term care facilities. It is not uncommon if you are in an LTC facility to have one or more comorbidities and/or a compromised immune system. Because of residents’ close proximity, these places are like petri dishes for the virus. And not just here: over half of Sweden’s deaths have been in care facilities.
Ohio and a few other states track where the hospital patients came
from, which many states (like New York) do not. Ohio data is thus more reliable
in terms of determining which portions of the population are at risk. The data below
(through Thursday) shows deaths by age, then separately those of all ages who
died in LTC facilities and prisons.
(Notes: Estimates of proportion of 70–79 & 80+ deaths “in” and
“not in” LTC facilities based on extrapolation of data from 4/29 to 5/06, and
actual deaths in LTCFs. (There may be small statistical variances. We don’t
know the ages of the people who died in prisons, but presume they are largely
under age 70.)
We assume the higher mortality rate for 60–69 is because they have
not yet gone to LTCFs and that the seemingly lower rate of older groups is
because their age cohorts are disproportionally found in the LTCF death data.
Mortality risk does indeed increase with age.
So outside of those in confined spaces, the risk of dying
from COVID-19 for the rest of the Ohio population was approximately 51
deaths per million people. But
like the seasonal flu, SARS-CoV-2 deaths are much higher in those over age 70,
especially with uncontrolled high blood pressure or severe obesity, even if not
in a long-term care facility.
Clearly, the older you are the more at risk you are. While we all
technically knew that, the data here is from a large database and is pretty
incontrovertible. In the future, we all know we must do better at LTC
facilities. We also know that is easier said than done.
We also know how “you can protect you” if you are at risk, and
what you need do to protect others:
How You Can Protect You:
- Physical distancing as much as reasonably possible and
isolation for high-risk populations
- Washing your hands
especially before touching face and eating
- Heat or re-heat food to 140 for 15 min.
- PPE: hats, N95 masks, and even gloves for high-risk
populations
How You Can Protect Others:
- Physical distancing: 6+ feet
- Cloth or N95 masks, plus special gear for certain
occupations
- Seek testing and quarantine yourself with symptoms like
cough, fever, diarrhea, etc.
With over 100,000 deaths and rising, we need to do much better
planning for a recurrence that is likely in the fall/winter or, if we avoid
that, for the next new virus. This is especially so for hospital and ICU
facilities, and understanding that the risk is mainly in the elderly, those
with immune dysfunction, and those in LTCFs.
We can’t stress this enough: If you are in a high-risk population
(age, high blood pressure, obesity, compromised immune system, etc.) you need
to take precautions not only to protect yourself from getting sick—if you work
or live around those at risk, you need to take precautions to protect them,
too.
Secondary Consequences
The economic consequences are really secondary effects of the
lockdown.
You know them: 40 million unemployed, an enormous GDP drop, a huge
government reaction, with the Fed doing everything it can, and Congress adding
trillions in deficit spending.
The secondary medical effects are due to the response to economic
effects and to fear: We do not have solid enough data on the deaths of despair
to see if they outweigh COVID-19 deaths. But anecdotally, we are seeing an
increase in suicides, opioid use, an increase in alcohol-related deaths
(alcohol tax revenue has increased over 25% in places, and cigarette tax revenue
up over 10%). Methamphetamine use has jumped as well.
In addition, many cancer patients are avoiding diagnostic testing
and even chemotherapy visits. Dr. Scott Atlas, a physician and a senior fellow
at the Hoover Institution, and his team have combed through public health
records and actuarial tables to put a number on the devastating non-economic
consequences of the virus lockdowns. They believe “they will be far beyond what
the virus itself has caused.” Their report makes sober reading:
“Lives also are lost due to delayed
or foregone health care imposed by the shutdown and the fear it creates among
patients. …Emergency stroke evaluations are down 40 percent. Of the 650,000
cancer patients receiving chemotherapy in the United States, an estimated half
are missing their treatments. Of the 150,000 new cancer cases typically
discovered each month in the US, most—as elsewhere in the world—are not being
diagnosed, and two-thirds to three-fourths of routine cancer screenings are not
happening because of shutdown policies and fear among the population. Nearly 85
percent fewer living-donor transplants are occurring now, compared to the same
period last year. In addition, more than half of childhood vaccinations are not
being performed, setting up the potential of a massive future health disaster.”
This is echoed graphically in a Washington
Post article.
By mid-May, almost 94
million adults had delayed medical care because of the coronavirus pandemic,
the Census Bureau reported in its Household Pulse Survey. Some 66 million of
those needed but didn’t get medical care unrelated to the virus.
The Post’s
data shows hospital traffic has collapsed:
Source: Washington Post
As have revenues:
Source: Washington Post
One result of this financial stress: 1.4 million healthcare jobs
disappeared in April, according to the latest monthly government jobs report.
Those included nearly 135,000 jobs lost at hospitals, more than 243,000
at physician offices and more than 503,000 at dental offices.
The Cleveland Clinic received $199 million from the federal
government for its shutdown of normal care, but still lost $230 million in
April—it would have been $429 million without that aid—and lost another $120
million in the first half of May. Still, even with government help, revenues in
just a short period for all hospitals are down more than $1 trillion on an
annualized basis. That has to come from somewhere, either cuts or increased
costs or…?
The good news is that elective surgery at the Cleveland Clinic is
back to 85+% of its pre-shutdown level. Note: “Elective” surgery is still
necessary. It generally includes surgeries that are not needed immediately, but
otherwise very important, like knee or hip replacements, or cataract removal.
Decreased access to medical care could occur as workers lose
employer-sponsored health coverage due to layoffs (nearly 27 million according
to one
study) and by rural hospitals going out of business. On the positive side,
telemedicine has been pulled forward, and will increase access for many. At the
Cleveland Clinic, telemedicine visits went from 3,000 in February to over
200,000 in April—while much is being done to encourage that to continue, more
patients are also choosing personal visits now.
Finally, some unexpected but possibly good news.
Contrary to common belief, the sun’s UV rays do not necessarily
kill bacteria and viruses. UVA and UVB—what the sun provides—are very weak
killers of bacteria and viruses. UVC, also provided by the sun but filtered out
almost totally by the ozone layer, is what kills viruses and bacteria.
UVC at certain wavelengths is dangerous to humans but is sometimes
used in sanitizing equipment like New York City subway cars (at night in the
MTA barns). However, certain types of UVC light will kill bad invaders without
damage to people.
Work on devices to do this was already underway before COVID-19.
Could such lights make all of us safer? I (Mike) am asking a company that makes
them to study whether dining and medical exam rooms could be made safer with
these lights. Not to mention public sports venues. Both of these would be
enormous game-changers and could happen pre-vaccine.
Even if We Get a Vaccine…
The most discouraging statistic for preventing the virus from
killing Americans came from a new AP-NORC poll that found only about half of Americans say
they would get a COVID-19 vaccine if one is developed. That’s surprisingly low
considering the global effort going into a vaccine. African Americans and
Hispanics are even less willing, even though the virus is proving more
dangerous to those groups. Clearly people will need convincing to roll up their
sleeves.
The virus should be convincing enough. Yes, while most people who
get COVID-19 have mild cases and recover, doctors are discovering the
coronavirus attacks in far sneakier ways than pneumonia—from blood clots to
heart and kidney damage to a life-threatening inflammatory reaction in
children. Whatever the final statistics show, health specialists agree the new
coronavirus appears deadlier than the typical flu. Yet the survey suggests a
vaccine would be no more popular than the yearly flu shot.
The pandemic is also causing global issues. The director of the
World Food Program says the number of people facing hunger has doubled to 265
million because of COVID-19. But not all is dire overseas. In spite of our
frustration with China, they managed to test 10 million people in one week in
Wuhan this last week—1.4 million a day.
So, to go back to our opening question, we conclude there is a
mask paradox:
Wearing a mask in confined spaces in public venues and enclosed
spaces, while not perfect, will help protect you and those around you. But it
will also help in other ways.
We have to get the economy moving again, which means people have
to participate by leaving home to visit stores, restaurants, etc. They have to
feel safe doing so. Wearing a mask, while admittedly annoying and
uncomfortable, gives others confidence, especially older people. And typically,
they have more disposable income, and we all need them to be confident and
participate in the economy.
Said another way: Seeing crowds of unmasked people is frightening
to a large part of the population. It encourages them to stay home and cut
spending. This further delays economic recovery. We will get back to normal
much faster if we all cooperate and help the vulnerable people return to
society without undue fear.
Finally, remember: Your immune system is a highly organized and
responsive unit. It is designed to protect you. So help it: Get your flu shot as
soon as it is offered this year. No matter how great the Cleveland Clinic is as
a health mecca, not to mention the other great healthcare facilities
nationwide, they do not have enough capacity to handle a major flu epidemic and
a recurrent COVID-19 outbreak at the same time.
Bottom Line
We have to open up the country, from both a medical and economic
perspective. Continuing lockdowns may cause more deaths for other reasons. The
economic pain is real and obvious.
But we have to open up smartly. We have to realize who is at risk
and take care of them responsibly. We need to be more aware of our neighbors
and their needs, doing what we can to help. We have to create a sense of
security for everyone, even if that means minor personal annoyances that we
might think unjustified.
Without everyone participating, the economy and public health are
at risk. We had serious problems with healthcare access before this virus. It
is going to get worse if we don’t work together.
Things will get better. There will be a vaccine. But we have to
buy the time to get to that point and that means we all need to do our part.
Feel free to send questions for Dr. Mike to: drroizen@mauldineconomics.com.
You can respond to John either here
or on the website.
You believing we can handle this analyst,
John
Mauldin
Co-Founder, Mauldin Economics |
0 comments:
Publicar un comentario