It’s Not All About the Deaths

Sometime today the United States will “officially” cross the line to over 200,000 deaths from COVID-19. It’s sort of an arbitrary milestone because I’m pretty certain that we’re not really capturing all of the excess deaths that have happened this year as a result of the impact of this illness. But it’s going to happen and there’s going to be lots of discussion about all of the people who are dead who didn’t need to die this year.

I’ve written about this before and I will continue to write about this: it’s not all about the deaths. Those are bad and my heart goes out to each and every person who lost someone this year that they didn’t have to lose. Absolutely horrible.

But this country is in for a much bigger reckoning and that’s around the long-term health consequences for those who get COVID19 and survive.

Craig Spencer has an excellent Twitter thread about this very issue here. It was also turned into a Washington Post article here but that’s behind a paywall.

As horrible as it is to say, we will likely adjust fairly easily to the lost lives. It’s what humans do. Losing my father when I was 18 was devastating to me but I’ve managed to live a life for 25+ years without him.

Is it as good a life as it would’ve been? No. But humans are largely resilient and so we carry on and move forward.

But the societal impacts from those who survive but have lasting health consequences are going to be significant. I already mentioned this one before, but I’ll mention it again because it’s one I know well: kidney failure.

There are definite impacts on kidney function from this illness. And there are hints that the type of impact this illness has on kidney function could, long-term, lead to kidney failure. It may not be immediate. The gap between impact and outcome with kidney failure can be a decade or more. My dad got sick around the age of six but didn’t lose his kidneys until his early twenties, for example.

When I was young and my dad was dialyzing (which is what you do when you don’t have kidneys, you spend four hours three days a week having a machine filter your blood for you, see more here) there weren’t widespread dialysis options.

When we lived in the mountains of Colorado my mom had to dialyze my dad at home. And when we lived in the Denver Metro area my dad had to drive thirty minutes each way to reach Denver Presbyterian hospital which I believe was the only dialysis center available at the time.

Planning any vacation was contingent upon there being available dialysis wherever we were going. We had one memorable vacation where we got to our destination and my dad had to take all our spending money to fly home because the dialysis center he’d scheduled with couldn’t dialyze him after all.

That’s changed in the 20+ years since he passed away. There’s now a dialysis center that would’ve been five minutes from the last home we lived in. I don’t know this for a fact but I would assume the increased availability corresponds to the increased levels of diabetes in this country which can cause kidneys to fail.

So dialysis is more readily accessible now as demand for it has grown, but as that demand increases even more due to the fallout from COVID19 this country will need to increase the supply of dialysis centers and nurses again. And there’s a huge cost to dialysis.

My dad grew up believing he would die when he lost his kidneys because there was no way that he would be able to afford those treatments. Fortunately for him there were changes made (to Medicare I think it was) that made it possible for him to dialyze without needing to pay the full expense of doing so. According to the link I provided above, 80% of the cost of dialysis is subsidized by the government.

Which means a reckoning is coming because increased demand for dialysis means increased governmental costs to provide that care.

That’s just one of the long-term health consequences of getting this illness. Add in heart problems, chronic fatigue, and reduced mental capacity that impact individual productivity and you have a society-level crisis coming.

The more people who get this illness, the more people who are going to need a higher level of long-term medical care, many of whom will not be able to hold the types of jobs that can provide that care through private insurance.

Which means we as a society will have to make a decision.

Either we decide we’re heartless bastards and that those who got sick due to a failure of government are on their own to suffer and die. Or we finally bite the frickin’ bullet and start talking about real baseline universal medical care and social services.

(You can tell from my wording there which I believe in. I’m alive only because our government provided enough support for my dad to dialyze and I grew up with one of the best fathers in the world because of that continued government assistance. I like to think that between my dad’s contribution to society as a business owner and father as well as my brother’s and my contributions we’ve more than made up for that.)

It would be nice if we were the type of country that believes in stepping up and helping our fellow man out, especially when we have the wealth in this country to do so.

But I expect that we’re not. I expect that we’d rather see images of someone with a fifty-room mansion and a million dollar Maserati and pretend that’s possible for everyone than agree that maybe taxes should be raised on that Maserati owner so that children aren’t orphaned because their parents can’t afford adequate healthcare.

But whatever way we go with this, I expect COVID will be the final push that means people can’t politely ignore that choice we keep making. We won’t be able to keep pretending that people deserve what they get and that society has no role in creating that outcome.

So, yes, 200,000 or more people have died in the United States this year than needed to. And that is a disgusting travesty.

But it’s important to also think about the 7 million* or more who’ve likely already been infected and will have long-term health consequences from this.

(*Right now the stats show just under 7 million reported cases in the U.S. but there’s pretty widespread agreement that we’ve drastically undertested and that the number of actual cases is anywhere from 6-20 times that number. Factor in the fact that perhaps 30% of patients are going to see life-impacting long-term health consequences and 7 million becomes a conservative estimate.)

Bottom line: Stay safe. Take this seriously. And if you’re American perhaps consider who you want in power if it turns out you’re one of the ones who gets this and needs dialysis or heart surgery or can’t work the way you once could.

Latest COVID Thoughts

I just put up a post on my personal FB page reminding my friends and family to continue to take this COVID thing seriously and shared with them an article that I thought was excellent by Ed Yong at the Atlantic.

I’m in the United States and I’d say that to most people it’s pretty clear that we have not handled this whole thing well. We’re closing in on 200,000 deaths from this (perhaps higher when you look at excess mortality) and the truth is we could’ve probably had only a few thousand deaths if we’d handled it differently.

Things like acknowledging the fact that a virus does not care what country you are from so a travel ban that does not prevent or isolate Americans coming from a geographic region with high-risk is going to fail to contain spread of the illness.

Or really locking down for a short period of time to prevent spread instead of what my state at least did which was still have takeout delivery and road construction and all sorts of other activities that were not in fact essential but did allow for potential spread.

(My state has actually done fairly well but I think that’s more down to population density and travel patterns than anything else.)

But what I wanted to throw out there in this post is how this illness plays into a number of human weaknesses and how we really have to actively fight against them to understand what we’re dealing with and to do so effectively.

For example, it’s very hard to see what isn’t there. So when a health measure, like a temporary lockdown, works we can’t see that it worked. Because the fact that it worked creates an absence of the event it was trying to prevent. I know some people, for example, argue that MERS wasn’t that big a deal. But perhaps it wasn’t that a big a deal because all of the health measures that were meant to contain it actually contained it.

Because those measures worked, we don’t see what they prevented. And we then inaccurately draw a conclusion that whatever measures were used to prevent that spread were not needed.

This has happened with the lockdowns. They were needed. They helped slow things down so that we didn’t have five NY/NJ/CT-style outbreaks going on at the same time early on.

That leads to the second issue most of us face with this illness. And that’s the issue of exponential spread. I pointed out on FB a few weeks ago that while it wasn’t making the news Hawaii was experiencing the highest growth rate in infections based on reported data. But that was at 50 cases a day so no one much cared. But they were doubling cases every two weeks at the time. Unchecked that 50 becomes 100 becomes 200 becomes 400 becomes 800 becomes 1600 becomes 3200.

It’s very hard to look at a low number and think that if you do nothing it will become a very big number. We can understand doubling. But get much past that, and we just don’t go there naturally.

It’s also very hard to understand the delay between cause and effect with this illness.

Recently some idiotic Stanford professor said that the U.S. fatalities were going to hit 170K and then just stop. I posted on FB that I wished the man would shut up and stop devaluing my degree because it was clear that he was wrong.

Why was it so clear when we were sitting around 150K fatalities at the time? Because, given the number of daily cases that had been reported prior to that point in time we already had enough infected people who were going to die to bring that number above 170K.

And we were infecting 50K new people a day still. Some of whom were going to become ill, get hospitalized, and die.

That man was completely missing the delay between infection and death that comes with this illness. I’d bet that delay can be as long as 45 days in some cases but is probably more like 25 days in a more typical case. So anyone focused on case numbers instead of death numbers is a month behind reality.

Also, most of the models being used fail to account for the interaction between human choice and disease spread. People are trying to use a basic regression approach to something that is more like game theory. (And I’m not a stats person so I may have just phrased that very wrong. But basically the idea is we can’t take what’s happened over the last two months, plug it into a model, and say this is where we’ll be two months from now without factoring in psychology. Because the outcome two months from now is driven by the actions of millions of individual actors making personal choices. Any good model of future outcome needs to factor in human behavior choices not just disease metrics, something that is very challenging to do.)

I also think most humans tend to approach crises in a linear fashion. A hurricane hits, it’s destructive, we rebuild, done. A wildfire burns, it’s destructive, we put it out, we rebuild, done. But that’s not how this illness works. It’s not: illness strikes, we lockdown, it goes away. It’s ongoing and cyclical.

I have yet to come up with the perfect imagery on this one but on FB I mentioned it’s like having a leaky water balloon and every time you take your finger off the hole in the balloon it starts leaking again. Until we can get this disease to low enough levels within the population, every single time we let up too much there will be a flare up.

That’s why we’re seeing rolling outbreaks across the country. Because one area gets an outbreak, takes the steps to get it under control, and gets things back down to something manageable but at the same time another area that hasn’t been seeing much of a problem lets up on its controls and gets a surge in cases.

That’s going to continue as long as there’s enough of the disease in the population to spread easily across geographies.

Which leads to another issue we’re all facing. It’s hard to give up your old habits for something so nebulous. Like a summer vacation. I had multiple friends on FB take out-of-state vacations this summer. They just couldn’t give up what they were used to doing for something that they weren’t experiencing personally. Here in Colorado they’re talking about having fans in the stands for Broncos games this winter. Football is more important than containing this illness.

I mean, really? Is it so hard to let go of something non-essential that you’d risk endangering your entire community for it? (Answer: Obviously in America it is.)

And that’s a big part of the problem. Even though almost 200K people have died this year that didn’t need to, this illness is very nebulous for most of us.

I don’t have friends in healthcare. I don’t have friends who work grocery store or meat packing jobs. My social circle is one that has a fair amount of privilege. Meaning that most of the people I know are working from home, able to order in grocery delivery, and hiring au pairs or tutors to homeschool their children.

They (and I) do not personally know the people who are dying. Because society is stratified enough that it’s not obvious to the average suburban upper middle class white person that this illness is killing as many people as it is. It doesn’t seem real. It doesn’t seem significant unless you are the one treating the ill patients or in a community that has been significantly impacted.

And that brings me to the final issue. Which is that people are too focused on deaths and not focused enough on long-term health consequences. We aren’t considering what happens in a society where millions become infected and perhaps as many as 1/3 of those people have lasting heart damage or lung damage or kidney damage or brain damage. We aren’t understanding what happens to a society where that many survivors struggle with long-term fatigue that impacts their ability to work.

It’s like what I said in an earlier post about skydiving. I thought it was die or have fun. Only when I realized the far bigger risk to me personally was a significant injury with long-term consequences did I truly understand the risk I was taking every time I jumped out of that plane.

So, bottom line here. We’re not naturally equipped to mentally understand the scope of what we’re dealing with. It requires concerted and ongoing effort to grasp the potential effects and the impact. And it’s a challenge to remain vigilant for as long as we’re going to need to remain vigilant. But we need to try. Because letting this thing burn out of control is going to create the type of damage that lasts for generations.

Type I vs Type II Errors

I often think about life situations as Type I versus Type II errors. I’m sure how I apply this is probably not consistent with how true statistics uses it, but oh well. Wikipedia has an entry on it if you want to go there. (It uses words like null hyphothesis though so be forewarned.)

For me how I think about this is that for every choice I make there are two risks. One is that I act on something I think is true and it turns out to be false. The other is that I don’t act on something because I think it is false and it turns out to be true.

In the current COVID-19 crisis, mask wearing is an example of this. Early on there was discussion that virus particles were so small that mask wearing wasn’t really effective. Now pretty much all of the experts are recommending it and saying it helps. I can definitely see that having a cloth barrier between me and others will prevent some spread but I’m still curious about the small particles issue.

However, despite my ongoing skepticism, ever since they started recommending masks, I’ve been wearing one. Because to me I’d rather take on the risk of wearing a mask and finding out I didn’t need to than the risk of not wearing one and realizing later I should have.

If I wear a mask and it has absolutely no impact and does nothing to protect me from getting sick, it also doesn’t do me any harm. It’s uncomfortable and annoying to wear a mask, especially now that I ordered a more robust one online instead of hand-crocheting one that had some breathing holes built into it, but all that does is reminds me that I really shouldn’t be out and about more than is necessary anyway.

I have no ego about my appearance these days, so there’s no vanity issue for me. And I’m not out a lot, so it’s a minor inconvenience to address a potentially significant risk.

If I don’t wear a mask and it turns out a mask could have protected me, then I’ll likely get sick. Maybe I’ll be one of the lucky ones and it goes away fast and there’s no lasting damage. But maybe I spend 90 days in the hospital, lose a leg, need a double lung transplant, and still end up dying like just happened to a perfectly healthy man who was younger than I am. Or maybe I don’t even need to go to the hospital but I have long-term breathing complications that I struggle with for years.

In this scenario–do I wear a mask or don’t I–I’m going to wear a mask. Because I do not want to get this shit. Both of my parents have dealt with long-term health complications. (My brother as well although not in the “how many times are you going to be rushed to the hospital this year?” sense that both of my parents have.)

Mask wearing is a good example of this, but when you look around you’ll see that life is full of Type I vs. Type II error choices. Asking someone out or telling them you love them. Taking a job. Quitting a job. Going on a vacation. Devoting time to writing a book. There are risks on both sides of those decisions.

It all comes down to which type of error you’d rather make. The error of acting and being wrong or the error of not acting when you could’ve been right.

Some of the risks are easy to see so easy to choose between. Others, not so much. But in my opinion it’s always a good idea when confronted with a choice to weigh the potential cost of acting against the potential cost of not acting.

 

 

Skydiving and COVID-19

A few friends have pointed out to me the comment going around that stopping the shelter in place orders right now is a lot like saying, “Hey, this parachute worked so well to slow me down, let me cut it away at 2,000 feet.” And I think it’s a good analogy.

But I have a different lesson I pull from my skydiving experience when dealing with this whole COVID-19 issue.

When I started skydiving I was in my early 30s, single, with a good income, no real debts I’d leave behind, no kids, no pets, and no family members that needed me to care for them. In some respects my dying would’ve been more beneficial to my family than my living, at least monetarily.

So the risk of skydiving that I perceived at the time, which was that I would die, wasn’t a big risk to me. I figured it would go fast if it happened and then it would be over. And, sure, living longer would be nice, but if that’s how things were I wasn’t too worried about it.

But as I got more into the sport, I realized that the true risk of skydiving was not dying. It was being severely injured and requiring months of rehab and depending on others to take care of me during that time.

One of my AFF instructors had a bad opening on his parachute and it fractured his pelvis, tore his aorta, and punctured his bowel. He was in the hospital for weeks and in rehab for months. Another girl I knew got caught in the prop wash from a plane that was on the tarmac and broke her leg. There’s even a term in skydiving called “femuring” because it’s common enough to hear that someone broke a femur during a bad landing. That’s the hardest bone in the body and yet skydivers break it often enough that it’s a sports term.

That was when I really had to sit down and reconsider my risk assessment. Because it wasn’t about potentially dying. It was about potentially having long-term pain. Or potentially needing in-home care when I had no one to give that care during rehab.

When I did that I also realized that I was only as safe as the stupidest person in the plane. Or the stupidest person on the jump with me.

Only so much you can do to avoid a canopy collision. And if some idiot launches wrong out of the plane or with a loose handle that leads to an early deployment that takes out the tail of that plane you’re going down with them whether you did everything right or not.

That change in my risk assessment isn’t the full reason I quit jumping. But it definitely had an impact. I was okay with dying. I was not okay with being a living burden on my family. They didn’t deserve to pay for my risky choices.

Which brings me back around to how this ties into COVID-19.

There’s been a lot of focus on the fatality rate. And on who actually dies. In Colorado over 50% of the fatalities are people over 80 years old. The death rate in Colorado for someone in their 20s is about a quarter of one percent. Pretty negligible.

Which makes it tempting for someone in their 20s to say, “The fatality rate on this thing is so small why should I stop living my life over this?”

Now, I’m not going to rant again about how overwhelming the healthcare system impacts everyone not just those with COVID-19 and how helping to spread this illness can mean that someone with an appendicitis or a stroke or a bad accident could end up not getting life-saving care, but that’s something to consider as well.

What I want to focus on instead is what happens if you get COVID-19 and don’t actually die from it.

We don’t know enough right now to know the long-term impacts of this illness. But there are a few things about it that make me think about rheumatic fever, so I want to talk about that for a second.

I am by no means claiming that the two illnesses are related. But I’m familiar with rheumatic fever because both of my parents were impacted by it when they were children.

For my father it damaged his kidneys when he was probably five or six years old. That damage was severe enough that he ultimately lost his kidneys in his early 20s which meant dialysis or transplants to stay alive. That one illness–that did not kill him–is the reason he died at 45 instead of living a long, healthy life. It also impacted everything he did. Every moment of his life from that point forward was colored by his illness.

For my mother rheumatic fever caused heart damage which may have ultimately lead to her needing open heart surgery and a valve replacement in her early 50s.

It took over a decade from that illness for my father’s kidneys to fail. And many decades for my mom to need heart surgery. But the initial damage was done by the rheumatic fever.

So turning back to COVID-19. We do not yet know what the long-term impacts of this illness are, but they could potentially be very significant.

It is clear that this illness impacts the lungs. It is also clear that for some patients they don’t even know their lungs are being affected.

Do you want to struggle with breathing for the rest of your life every time your neighbors decide to use their fireplace? Or when your neighbor engages in probably illegal home repairs that kick dust or chemicals into the air?

That could maybe happen if you get COVID-19. (Maybe not, but we don’t know enough yet to rule it out.)

Also with COVID-19 there are a non-trivial number of patients whose kidneys are affected by the illness. I’ve read more than one report of seriously ill patients who had to be dialysed because of it. Again, maybe it’s temporary. Not every patient in a hospital setting who requires dialysis requires it for life.

But what if the illness causes lasting kidney damage? Patients who receive kidney transplants do not have a full life expectancy. You get more years than dialysis in general, but not a full life. And if that kidney damage is a long-term effect of this illness, there probably won’t be enough kidneys to go around for everyone to get a transplant, which means dialysis. My dad made it 20+ years on dialysis, but the average is closer to five years.

COVID-19 has also been shown to cause clots which if they don’t kill you can cause strokes, heart attacks, and loss of limbs. The long-term effects of having a stroke can be incredibly challenging. Or what about losing a limb due to a clot. Trust me, you don’t want to go through that.

There may also be a potential for liver damage.

Again, we don’t know exactly what we’re dealing with yet. And some of these other health implications may not become clear for years. We may only see that they were COVID-19 related when we look at the incidence of X in the population prior to COVID-19 versus after.

For all we know those “asymptomatic” patients people love to talk about could just be people with lung involvement who don’t notice the symptom. We may only know they were impacted when they go in for breathing issues a year or five or ten down the road.

So don’t be binary in how you think about this illness. It is not a choice between dying or being fine. For the younger members of the population the main outcome of this could actually be long-term health impacts to lungs, kidneys, liver, and heart.

If you won’t limit your activities because someone else might die, then limit them because you might be permanently impacted if you get this. My dad had a good life, but I’m pretty sure he would’ve rather had a life without kidney disease if he’d been given the choice.

 

 

You Can’t See What You Don’t Track or Look At

One of the key points I tried to make in Data Principles for Beginners is that if you want to work with data you first need to track the right information. Some data can never be recovered if you don’t track it up front. And some is just impossibly difficult to obtain after the fact.

I want to say that the the example I used in that book, since I’m a writer, was how many hours it takes me to write each title I publish. This is crucial for me because it takes far less time to write a non-fiction book about Excel than it does to write a 120K-word YA fantasy novel. So if I earn the same amount on those two titles it turns out my time is much better spent writing another non-fiction book than another YA fantasy novel because I get the same return with far less time spent to get there.

The reason I bring this up today is because this COVID-19 situation is a perfect example of how important data analysis is to understanding the situation. And many of the concepts I discussed in that book are playing out right now in real life.

For example, it looks like it may be important how those who analyze fatality data bucket age groups. Here, for example, is a chart from New York state:

NY State Fatality Data

Here is similar data from Colorado:

CO fatality data 20200410 morning

Note how Colorado groups anyone over the age of 80 into one bucket whereas New York splits out those over 90 into their own category? And note how in New York that seems to be important. I haven’t run a statistical analysis on those numbers to see if the difference in fatality rate between those two groups is material or not, but it looks like it might be.

Of course, then you need to figure out why that difference exists. Maybe there was a virus that circulated for those 90+ when they were children that has given them partial immunity. Or there’s some commonality among those who live to 90+ that makes them more resilient when dealing with this. Or maybe when you’re 90+ you only bother to go to the hospital for treatment of something like this if you’re generally more healthy, and if we were to account for those who died at home during the same period the difference would go away.

But there’s no way to see that difference if that data isn’t, first, collected and, second, used for analysis. This is why it’s often very important to chart data before you create your categories so you can visually see what you’re dealing with. (I believe in the book the example I used revolved around annual income categories for bank customers. If you’re dealing with high net worth individuals using a top category of $100,000+ isn’t going to work well.)

Now maybe what we’re seeing above is just a quirk in the New York data and if you were to separate out the 90+ age range from the 80-89 age range in Colorado there’d be no difference. But the key is to be able to do so if needed (which means setting the right ranges for your dataset) and then actually attempting to do so.

(There’ve been articles about potential racial difference in outcomes as well. But without information on living situation, health care status, neighborhood pollution levels, income, etc. it’s hard to say whether it’s because of economic disadvantage, systemic racism, or something genetic. Same with the fact that more men than women seem to be dying. Without information on things like smoking history, which was one of the early suggestions that I think has since been disproven, you can’t parse out the actual cause for the differences.)

Another issue I’ve noted is the problem of comparing apples to oranges. I admire Johns Hopkins for what they’ve been doing with their dashboard but it also makes me want a strong drink. Here it is as of this morning:

Johns Hopkins 20200410

What annoys me about it is the Total Confirmed numbers on the left-hand side cannot be readily compared to the Total Deaths numbers on the right-hand side. If you look at the bottom of the total confirmed numbers you’ll see Admin0, Admin1, Admin2. These used to be better labeled. What they do is allow you to toggle between a country-level view and a more granular level of data.

By default for confirmed cases you get country-level case data.

Problem is that the death values on the right-hand side are NOT country-level data. You can now see this clearly when you look at the fifth entry in the image above which is not even for New York state, but is instead for New York city. Scroll down further and you’ll see additional entries for New York state.

There is no easy way to find the total values for the U.S. nor for the most-impacted states. It’s very frustrating. And until CNN published their U.S. tracker and Stat News published theirs (and got it working so it’s current and not weirdly delayed) I was highly annoyed by this situation. Because the data was there but it was being presented in a very ineffective and perhaps even misleading manner. (Most people don’t dig into the data they’re shown, they just take what they see on the surface so it was easy to look at the death values and assume the U.S. wasn’t as high up on the list as it actually was.)

It should be easy enough to put the same Admin0, Admin1, Admin2 category options on the death data as it was to put it on the confirmed cases data. And then the user could easily compare cases to deaths with just a glance.

Of course, as I’ve discussed before, we’re not testing enough for this data to actually be a full picture of what’s happening anyway.

There are people who have died at home who were never tested so are not part of the fatality data. There are people who very clearly have had it who also were never tested. There are people who are going to die from something else because they will either choose to stay home rather than seek care or because they won’t able to get the care they need to save their lives.

At some point in time someone with good data skills is going to have to go back and look at baseline fatality levels for a similar timeframe over say the last five years, adjust for the current year trend for the last six months or so before the virus hit, and then extrapolate the number of direct and indirect deaths caused by COVID-19 to give us a legitimate picture of the actual impact of the virus. (And of course if we’re going to give the virus blame for the indirect deaths due to lack of care we also need to give it credit for lower traffic fatalities, etc.)

Whoever does that will then have to probably back into total infection numbers once we have some idea of infection vs. fatality/hospitalization rates by region. If that’s even possible.

Of course, no good data, no good analysis. The key starting point to be able to do any of that is the data. Data is key. You have to collect the right information and in the right format. And then you have to use it effectively and ask the right questions. (Which is why one of the first chapters in that book was also about how you need subject matter experts who understand the data you’re working with not just smart people who can run a regression analysis.)

Anyway. Data and how you use it matters.

For anyone looking for the sources I referenced above:

New York

Colorado

Johns Hopkins

CNN Tracker

Stat News Tracker