COVID-19 Part 7: New York and Massachusetts Continue to Improve - Sweden Is Less Clear - Monitoring Georgia 17 Days After Lifting Restrictions
The science of COVID-19 explained by a doctor.
By Anthony Lee, MD
Faculty, Harvard Medical School
As we make our way through this pandemic, the large number of cases in the United States has caught our attention and prompted much discussion. In Part 7 of this series, we continue to see New York and Massachusetts reliably decline in the number of daily deaths. As we assume that the pandemic in these states is on the mend, we will no longer track the number of daily new cases.
Likewise, Ireland and the UK have not seen increases in daily new cases or deaths over the last 3-5 weeks, so we will no longer follow them. However, as these countries begin easing lockdown measures, this may change.
In Figure 1, the plot for "The Rest of the United States" (US minus NYS or US-NYS) is compared to those of Sweden and Georgia.
On the left of Figure 1, the cumulative number of cases increased at different rates by location. On the right of Figure 1, the number of daily new cases are declining in Georgia and the Rest of the US, while it plateaus in Sweden.
COVID-19 Part 6: Massachusetts Tops New York in Daily Casualties While Sweden Seems to Magically Improve
The science of COVID-19 explained by a doctor.
By Anthony Lee, MD
Faculty, Harvard Medical School
As we make our way through this pandemic, the large number of cases in the United States has caught our attention and prompted much discussion. In Part 6 of this series, we continue to see Ireland and the UK consistently decline in number of daily deaths. If we assume that the pandemic in these countries is on the mend, tracking the number of cases is no longer fruitful.
Likewise, Italy, Belgium, and Northern Ireland have not seen increases in daily new cases, or deaths, over the last 3-6 weeks so we will no longer follow them. However, as these countries begin easing lockdown measures, this may change.
Please note that this report will only consider confirmed COVID deaths.
As explained in Part 4 and Part 5, it's the case density (cases per 100,000 people) that matters and not the total number of cases. The higher the number of cases per 100,000 people, the more dangerous that location is. For example: riding in a subway car. If a specific location has a high case density, it's more likely that riding on a subway car in that location will have more infected passengers compared to a subway car in a different location.
In Figure 1, Plots of New York City and New York State are compared to Massachusetts, "The Rest of the United States" (US minus NYS or US-NYS), and Sweden.
On the left of Figure 1, Massachusetts' cumulative number of cases continues to rise. On the right of Figure 1, the number of daily new cases in Massachusetts is declining. However, its daily new cases now exceed that of NYS, which started to decline 15 days prior.
A doctor at Harvard Medical School updates us on the outbreak.
By Anthony Lee, MD
Faculty, Harvard Medical School
As we make our way through this pandemic, the large number of cases in the United States has caught our attention and prompted much discussion. In Part 5 of this series, we see Italy, Belgium, and Northern Ireland continue to reliably decline in the number of daily deaths. In these countries, tracking the number of cases is no longer of interest as we assume that the pandemic is on the mend. However, as these countries begin easing lockdown measures, this assumption may change.
Regarding numbers of daily new cases and daily deaths, countries have been adding discovered deaths from homes, nursing homes, and other care facilities at various points in time. These countries include Belgium, the UK, Ireland, and the US. On various web sources the data has all been adjusted. Cases that remain "probable" are excluded here as they are not confirmed to be COVID related.
As explained in Part 4, it is the case density (cases per 100,000 people) that matters and not the total number of cases. The higher the number of cases per 100,000 people, the more dangerous the location. An example would be riding in a subway car. If a location in question has a high case density, it is more likely that riding on a subway car in that location will have more passengers on it who are infected compared to riding in a subway car in a less densely infected location.
In Figure 1, we know that for cases per 100,000 population basis, the NYC and NYS curves are very steep. When plotted with other locations, the plots of the other locations are squashed significantly to obscure meaningful information. Therefore, the plots of NYC and NYS have been removed to better understand what's going on elsewhere.
However, for the rates of change chart, NYC and NYS plots were left in, as they didn't substantially squash the other plots. Also, note that within the last week, US and NY data (cases and deaths) were updated (values increased). This reflects all dates from early March, shifting their curves a bit leftward.
On the left of Figure 1, one can see that Massachusetts is experiencing the largest surge in cases experienced so far, and Massachusetts is now the epicenter of case growth. But to maintain a perspective, New York State still carries 29% of all cases in the US and 9.5% of all cases in the world, but this is slowly decreasing. By contrast, Massachusetts carries 5.6% of all cases in the US and 1.8% of all cases in the world, and this is slowly increasing.
On the right of Figure 1, Massachusetts has surpassed NYC and NYS in the number of daily new cases per 100,000 population. Comparing the shapes of the plots between NYS and Massachusetts, they seem to be similar. This may indicate that Massachusetts may have also experienced its peak number of new cases, although it's too early to tell.
Sweden is on a surge that seems to be higher than the previous one. The UK and Ireland seem to have a decreasing number of daily cases. But the UK may be under-testing as their deaths per 100,000 population are higher than that of Ireland (see Figure 2).
Figure 2 shows that Italy's maximum daily deaths occurred on 3/28, 19 days after lockdown and this continues to trend downward. In Ireland, the maximum daily deaths occurred on 4/25, 29 days after lockdown and 14 days after their peak number of daily cases. In Northern Ireland, the maximum daily deaths occurred on 4/23, 27 days after lockdown and 5 days after their peak number of daily cases (not shown in the charts). Sweden is on its 5th surge, possibly the largest so far.
As the majority of cases and deaths in NYS occurred in NYC, it would be expected that the peak numbers of daily new cases and daily deaths would occur at about the same time. This happened on 4/9-10, 23-24 days after social distancing began.
For "The Rest of the United States" (US minus NYS or US-NYS), the maximum number of deaths is unclear as the curve has been relatively flat with a few very small peaks that may be statistically insignificant. We do know that the maximum daily new cases occurred on 4/24, 38 days after the start of social distancing.
Massachusetts is on its 6th surge, which may be the largest so far in terms of daily deaths. Referring back to its plot in Figure 1, the peak number of daily new cases occurred a week ago. And we know that deaths follow cases. We are hopeful that this surge will mark a subsequent decline in the number of daily deaths.
After 44 days of social distancing, the question must be asked: Why are we still surging in daily deaths? Also, from Parts 1 and 2 of this series, Massachusetts began social distancing at the same time as New York. However, we had a much less number of cases at that time, giving us a 2-week head start advantage over New York. Yet we are experiencing a pattern similar to New York, but delayed by 15 days.
Perhaps our close proximity to New York may explain this in part. It could also be explained by a possible longer latency time between being infected and expressing symptoms. Our policy is to test only those with symptoms, so this may make sense.
Sources of data: Worldometer.com, Spectrum News NY1, New York State Department of Health, Massachusetts Department of Public Health, HSC Public Health Agency
As of this writing, New York State contains approximately 33% of all cases in the United States and 10% of all cases in the world.
By Anthony Lee, MD
Faculty, Harvard Medical School
As we make our way through this pandemic, the large number of cases in the United States has caught our attention and prompted much discussion. Part 2 of this series will not only update the first article, "COVID-19: Tracking the Changes," but will describe the trends of cases and deaths and their rates of change. It will also differentiate between New York State and the rest of the United States.
To recap: we have been following the pandemic in Italy, New York State, New York City, Massachusetts, Sweden, the United Kingdom, Ireland, Northern Ireland, and Belgium in terms of cases per 100,000 population and deaths per 100,000 population, as well as the rates of change of these numbers.
Last week we looked at the number of daily new cases and the number of daily deaths to see if they were increasing or decreasing. We looked at the numbers for hard, non-ideological proof.
Superimposed on the charts were markers indicating when designated locations enacted social distancing or lockdowns and showed the effects of these measures on the number of new daily cases and daily deaths.
Although the popular media tends to treat the United States as a single location, if we separate New York State from the rest of the United States, two different stories emerge.
This article will view the number of cases and deaths on a per 100,000 population basis to describe the density of cases and reveal the true severity of the pandemic in a specific location.
As of this writing, NYS contains approximately 33% of all US cases and 10% of all cases in the world. The US has roughly 583,500 cases with a population of 331 million people, or 176.2 cases per 100,000 people. In contrast, NYS has roughly 195,000 cases with a population of 19,540,000. This represents a very disturbing 998 cases per 100,000 people, which is significantly worse than the US combined.
If we isolate NYS from the rest of the US, the number stands at 124.7 cases per 100,000 people. In contrast, Italy has 159,516 cases and a population of 60,480,000, or 263.8 cases per 100,000 people. In other words, from the perspective within a particular location, NYS is nearly 4 times as severe as Italy, and Italy is roughly twice as severe as "the rest of the United States".
Separating NYS from the rest of the nation achieves two things. First, it provides a more accurate picture of what is happening in most of the US and shows that the overall situation is not apocalyptic. Second, and more importantly, it allows us to focus on the true severity of what is happening in NYS. This will help us make decisions about how to deal with the pandemic's true epicenter.
Below are the updated charts. "The rest of the United States" is represented by the label "US-NYS (US minus NYS)". Because of time differences, US data lags behind that of Europe and the UK. Therefore, plots are likely to be limited to the day before a report is published. In some cases, late reporting from European countries and the UK may also limit plots to the day before.
Figure 1. Cases per 100,000 population by location and correlated rate of change.
Figure 1 shows the effects of lockdowns and social distancing. It took Italy 12 days to finally flatten the curve of daily new cases. This trend has been continuing for the last 23 days, producing the trailing edge of the pandemic in Italy.
It took Belgium 11 days to reduce the number of daily new cases, and they have also continued on a downward trend for the last 15 days.
Ireland required 7 days of lockdown to reduce their daily new cases. This trend continued over the next 4 days, but then a new surge of cases occurred. The same holds true for Northern Ireland, where 6 days of lockdown reduced the number daily new cases. This trend continued over the next 5 days, but then a small surge of cases emerged.
Sweden maintains a low and flat trajectory despite loose social distancing. This might be accounted for by lack of testing.
The UK and "the rest of the US" (as defined above) remain on low and flat trajectories due to their respective social distancing policies.
NYS and NYC cases are rising dramatically, even in the face of a shortage of testing. Testing has increased in Massachusetts over the last 3 weeks and is reflected in the figure. In the weeks leading up to lockdown protocols NY has been about 5-8 days behind Italy, while Massachusetts has been around 21-23 days behind.
Although NY and Massachusetts started social distancing at the same time, Massachusetts had a roughly 2-week head start ahead of NY. However, this margin has narrowed to about 6 days. Interestingly, the curve of Massachusetts now seems to shadow that of NYC with similar slopes and slope changes.
Figure 2. Deaths per 100,000 population by location and correlating rate of change.
Figure 2. shows rising deaths by location.
In the rates-of-change chart, the number of daily new cases flattened are delineated by date.
From the point of delineation rightward, we see when daily deaths begin to decrease. This lag time varies with locations. Italy's lag time was 7 days. This hasn't reliably occurred yet in Belgium. Although we see a decrease in deaths in Ireland, this is most likely temporary, as the country has seen a surge of new cases; and death plateaus follow new case plateaus. The same is true for Northern Ireland.
I will update numbers and discuss their implications in future installments.
Sources of data: Worldometer.com, Spectrum News NY1, Massachusetts Department of Public Health, HSC Public Health Agency
How do we contextualize an unprecedented moment in American history?
As a healthcare worker with more than three decades of training and clinical work under my belt, I have a few thoughts about this moment in American history:
The Metaphor of War is Inaccurate
This is an undeclared war against the coronavirus. What healthcare workers are going through is war. With such strictly limited resources, we must apply wartime strategies to care for as many people as possible.
As our Mayor, Bill De Blasio, said in today's briefing, "this is a war with many-many fronts. The only way to get through it is to use our military, all HCP (Health Care Personnel). [To create] a national enlistment of all doctors and nurses and move them to areas of need as it arises around the country."
De Blasio is urging the president to enlist all doctors and nurses across America. Indeed, we're not only at war, we are on a battlefield.
In wartime, people hunker down together - especially those most vulnerable. Not so with this virus. Social distancing causes even the sick to care for themselves in isolation, as they check in with others by phone.
The "mask or no mask" question
On the streets and in grocery shops, neighbors in self protection mode aggressively condemn each other for not standing the mandatory 6 feet apart. After close to three weeks of social distancing, why only now are we being asked to wear non-medical masks when going outside.
As a nurse, when I hear the word droplets, I follow precautions, I wear a mask. Any health care worker who doesn't receive the flu vaccine is required by law to wear a mask from the beginning of flu season in October through May or June in all patient areas in the hospital - elevators, patient rooms, hallways, and in clinic.
However, during these perilous times and with supplies stretched thin, the medical field is our first priority. The public has been repeatedly asked to spare PPE (Personal Protective Equipment) for medical people.
Healthcare Workers Are To COVID-19 as Fireman and Police Were To 9/11
Doctors and nurses working frontline without proper PPE is like rushing into a burning building in a tee-shirt, jeans, and bare feet. Are we being asked to do something that was not asked of our firefighters on 9/11?
But every evening at 7pm in NYC, #Clappingforcarers erupts in a massive round of global applause. What a profoundly glorious acknowledgement of Health Care and Essential Workers. Walking home from my ten hour shift at an Upper East Side hospital, I stand on 3rd Ave overwhelmed with this outpouring of gratitude that brings tears to my eyes. I am in awe of how life affirming this is. And how many beautiful people are recognizing our bravery and duty to care.
We Don't Know What We Don't Know
We don't know. We don't know how this virus works in the body . . . how long it takes an individual to fully recover and no longer shed it. We don't know when it will be safe to socialize again.
On Monday, the US Navy hospital ship Comfort sailed into the west side docks with 1,000 beds. As of Thursday, they've only filled 20 beds due to a tangle of military protocols and bureaucratic hurdles. Frustration is growing because this isn't relieving our overburdened hospitals at all.
But here's the don't-know-what-we-don't-know of it, the world's top researchers do not fully understand how this pathogen works although we're months into the existence of this virus.
Democrats have control of the House for the first time in eight years. Now, they have a mandate to push for a bold agenda on infrastructure, healthcare, immigration, and voting rights.
After months of warnings, the "Blue Wave" finally came to shore. Democrats took back control of the House, gaining 32 seats, a number that could increase to 38 or 39, depending on the results of the uncalled races. With the party back in charge of the lower chamber, much of the discussion around what their priorities should be has revolved around investigating the president and his myriad of financial and political scandals. House Democrats have a clear mandate to fulfill their constitutional duty to provide oversight of the White House, but Democrats also have a mandate to address a number of major legislative issues. Though it's unlikely Democrats that will get any of these priorities pushed before the president and a Republican Senate, it's crucial that they signal to their voters what they want to done should they win the presidency and the Senate in the future.
As a candidate and in the beginning of his presidency, Donald Trump promised to tackle the nation's crumbling infrastructure. That, of course, has gone nowhere and every "Infrastructure Week" ended in some scandal, quickly becoming an ongoing joke. But the state of America's infrastructure is nothing to joke about. Infrastructure spending has long been a Democratic Party priority before Trump attempted to co-opt it. Democrats should push that issue once again, proposing a bold infrastructure plan to repair crumbling roads and bridges, modernize public transportation systems, expand access to high-speed, fiber-optic Internet, and invest in green energy projects like wind, solar, and hydroelectric power.
Such an infrastructure plan would signal the party's commitment to investing in neglected communities and funding renewable energy projects such as a broader plan to combat climate change—not to mention open the door to the many economic benefits of infrastructure spending. It would also establish a clear contrast with Trump's previous infrastructure plan that's been criticized as a giveaway to private contractors. The president has said he is willing to work with Democrats, so why not press him to keep his word? Democrats would be wise to pressure the president and his Republican supporters to prioritize infrastructure, or face political consequences.
No other issue played a bigger role in the Democrats' midterm success than healthcare. Their electoral message on healthcare was simple: Protect people with pre-existing conditions, expand coverage and stop proposed cuts to Medicare and Medicaid. Now they must deliver on these promises. House Democrats can immediately pass legislation to protect coverage for people with pre-existing conditions, pressuring Trump and other Republicans who have vowed to do the same to keep their word. With a full repeal of the Affordable Care act now temporarily off the table, Democrats should push to expand coverage and address the limitations of the ACA. These can range from introducing incremental policies that get support from more moderate Democrats, like legislation to stabilize insurance markets, to bolder policies that attract the progressive wing of the party, like allowing Medicare more power to negotiate drug prices and proposing a Medicare buy-in for 55 to 64-year-olds.
While the long-term goal for the party should be to push for a Medicare for All system, these are positive steps toward a goal that still has a lot of opposition from within the party. Finally, any budget proposed by House Democrats should reverse any funding cuts to Medicare and Medicaid. Democrats have an ideal opportunity to push for a positive vision on healthcare and continue to have the upper hand on the issue heading into 2020.
Bitter political battles over immigration, especially over funding for the border wall and the fate of DACA, will be a prominent feature of politics the next two years. Democrats are right to be alarmed over the administration's immigration policies like family separation and ending DACA, but now it's crucial they advocate for an immigration agenda in contrast to the Republican agenda. With the fate of DACA likely in the hands of the Supreme Court, Democrats must push for a long-term legislative solution. The most stable solution is the passage of the Dream Act. It would also be politically beneficial for the Democrats to bring it to the floor cleanly, without a compromise on funding for the wall. Furthermore, Democrats should schedule hearings about the family separation policy and Trump's pre-election decision to bring troops to the southern border in response to the migrant caravan. Democratic voters have become more liberal on immigration, and it's important the party signal to its base that they are willing to find solutions on the issue without compromising its core values.
Much of the post-election analysis has focused on the effects of voter suppression, notably in Georgia, North Dakota, and Florida. These voter suppression efforts have only increased since the Supreme Court struck down the section of the Voting Rights Act, which required states with a history of racial discrimination to get permission from the Department of Justice when enacting any changes in voting laws. In response, states around the country immediately passed strict voter ID laws. Fortunately, the Supreme Court decision left the door open for future legislative action. House Democrats can immediately take action and strengthen the Voting Rights Act. They would also be wise to propose legislation to make Election Day a federal holiday, or move Election Day to a Sunday, as it is in most places around the world. While Republicans are busy spreading conspiracy theories about voter fraud, Democrats should take the opposite path and make it clear they will fight continuing discrimination in voting. For strategic and moral purposes, the party has an obligation to extend democracy in every way when voting rights are under tremendous pressure.
Dan is a writer, thinker and occasional optimist in this random, chaotic world. You can follow him on Twitter @danescalona77.