Wednesday, April 8, 2020

We need an exit strategy – now!

Data indicates the U.S. is achieving the goal it set out to accomplish.  The national objective was as follows:

The United States’ immediate and primary objective in response to the COVID-19 pandemic is to compress the peak of infections (commonly called “Flattening the Curve”) in order to avoid denying critical care to the afflicted as a result of insufficient hospital staffing, hospital beds, Intensive Care Unit (ICU) beds, and ventilators.  Social distancing is the primary strategy to achieve this objective.

Data tracking indicates the curve of COVID-19 illness is flattening in many countries of Europe and in the United States.  In the U.S., hospital beds, ICU beds, and ventilator capacity are meeting need and improving as the number of patients requiring these services is declining and options for treatment expand. Production of personal protective equipment and ventilators is increasing to meet need.  Care capacity to treat infected patients is increasing as hospitals reallocate resources, old hospitals and other spaces are converted to active service, field hospitals are opened, and hospital ships are deployed.

The U.S. objective stated above assumed a very high risk that healthcare capacity would be exceeded responding to the SARS-CoV-2 virus that causes Coronavirus Disease 2019 (COVID-19).  Models indicated the virus would spread wider and faster than other viruses, its symptoms would be more debilitating, and it would be more deadly than other viruses.   The models were just that – MODELS. 

Post-COVID-19 research and analysis will determine how accurate those predictive models were.  For now, gratitude is in order that the virus impact is less severe than was originally predicted.  Whether that results from our social distancing strategy, or the virus is just not as vicious as predicted, or seasonal weather change is having the same impact on SARS-2 as it does on many other viruses is fodder for another day.  For now, cautious victory can be declared, and cautious and prepared gradual rescinding of many social distancing restrictions can begin.

Maintaining social distancing to the extent it is currently in practice can cause tremendous social harm.  The “Disaster Distress Helpline” at the Substance Abuse and Mental Health Services Administration last month saw call volume increase 9 times over March 2019 and officials are warning of a national mental health crisis.   The National Suicide Prevention Lifeline set a record last month for call volume.  Those saved and sustained by addiction programs such as AA and NA are at greater risk of relapse despite attempts to move support online.  The United Nations this past weekend called for “urgent action to combat the worldwide surge in domestic violence.”

The social distancing strategy is negatively impacting U.S. economic activity.  Some estimates indicate up to $10 trillion of  $20 trillion in U.S. annual economic activity could be lost.  This suppression of economic activity cannot be sustained without damaging families economically and creating dangerous social ills.   The longer the suppression continues the greater the potential damage and more difficult the recovery.   Vulnerable low wage hourly earners without benefits will suffer the most economically.  The National Multifamily Housing Council reports only 69% of tenants paid any rent between April 1-5 as compared to 82% the previous year.  Small businesses will struggle to survive.

The Department of Labor reported 4/3/2020 the unemployment rate rose to 4.4% from 3.5% in March.  An additional 1.7 million lost their jobs.   The Labor Force Participation Rate, a measure of the percentage of Americans 16 and older who are working or looking for work, sank to 62.7 from 63.4.   On April 4 Labor reported 6.6 million jobless claims had been submitted in the past week with 16.8 million filings over a three week period - yet another very concerning historical record.  

The U.S. economy is fast approaching 20 million job losses through April as predicted by economists.  Many states have more stringent rules in effect – in some cases into June.  Goldman Sachs estimates the unemployment rate will rise to 15% and GDP drop 9% in the first quarter and an additional 34% in the second quarter.  James Bullard, President of the Federal Reserve Bank of St. Louis, said the unemployment rate could reach 30% and GDP drop 50%.

These predictions are not inevitable.  Change in policy can diminish the impact and duration of these very scary numbers just as social distancing may have changed the course of COVID-19.
A gradual reduction of social distancing must begin – soon.   This does not mean all restrictions lifted immediately on a given date.  As Dr. Anthony Fauci recently said, “this isn’t like a light switch on and off…It’s a gradual pulling back on certain of the restrictions to try and get society a bit back to normal.

There must be built into any plan the ability to change direction and delay dates of implementation. Military planners call this maneuver space. A gradual lifting of restrictions can reflect regional differences of COVID-19 status. 

One way to structure reduced social distancing is by industry as defined by the Bureau of Labor Statistics.  There could be a progression of implementation across industries.  Dates here are nominal for purposes of demonstrating one possible time progression example:

  • April 20:  Health Services, Natural Resources and Mining, Construction, Manufacturing, Trade Transportation and Utilities (much in these sectors remains operational already)
  • April 27:  Information, Financial, Professional and Business Services (again, much in this category remains operational through work at home)
  • May 04:   Retail Trade (Does not include Leisure and Hospitality and Travel)
  • May 11:   Education Services (K-12 only)

Leisure, Hospitality and Travel will require the greatest caution and hence the most detailed consideration.  Some leisure, such as outdoor park and trail enjoyment can be opened almost immediately with common sense planning.   

Places of social gathering in large numbers may take a few to several months before restrictions are fully lifted.   Large social gatherings must also be considered in time dimension.   There are large social gatherings that take place in one space of time, such as a sporting or entertainment events. Another example would be the expected return of the churn of restaurants and bars.

Transitioning will not be easy.  The U.S. population is bombarded daily with headlines that are frightening.  We have also become a risk averse nation that thinks all risk can be eliminated.  It cannot.   It will be difficult to step forward in  uncertainty and fear.  Psychological barriers may be the most difficult to overcome.

Politicians may exercise excess caution.  They do not want to be wrong.   They do not want to be seen as making a mistake.  They will need encouragement and courage to exercise leadership in this transition.  Pointing fingers of blame for past responses and actions based on imperfect information is folly.  Better to begin a transition from social distancing and conduct a stem-to-stern rigorous analysis of the COVID-19 pandemic to build resilience and strength to fight the next battle.  There will be other viruses/infections and possibly worse.  We cannot shut down our economy every time a model says a virus could be very bad.

Many current personal practices of hygiene and contact should be encouraged to continue.   For example: hand washing and cleaning surfaces; avoiding handshaking; avoiding casual hugging of friends and acquaintances; and avoiding closed spaces to avoid potential dense virus presence. (Go outside as often as possible and open windows in the home and office whenever possible as the weather improves!)

Mission creep is a tendency we must avoid.  Our objective was never to eliminate the virus.  Our objective was never to eliminate infections.  Our objective was never to eliminate all risk.  None are possible. 

A new offensive strategy against the virus may be necessary.    We must accept that all risk cannot be eliminated and focus on managing and mitigating risk and building public health capacity.  Rather than broad public restrictions on movement and gathering we could shift to a more targeted offensive strategy against spread with increased testing, sampling, targeted surveillance, and resourcing to very vulnerable populations - such as elder care facilities. 

This is going to be hard.  But we must do it.  The first step is to make a plan of transition.  It must reflect true risk as we know it now, not at as it was predicted in early models and provide a timeline for transition.  Hopefully, we will begin that process very soon and united. 

Saturday, April 4, 2020

Nursing homes need greater focus in COVID-19 battle

It is clear that age is a major factor in COVID-19 morbidity.  It is clear that underlying health status is a major factor in COVID-19 morbidity.  It appears the place one resides (SETTING) is also a major factor.  Specifically, reporting indicates nursing homes and other elder care facilities are the major setting source for COVID-19 outbreaks leading to death.  Data collection and reporting must increase immediately to identify and report the setting in which COVID-19 is contracted and immediate policy implemented to prevent and mitigate vulnerability in the short term.  In the long term, the nation must dramatically change and improve residential elder care or rethink the current model.

There are about fifteen thousand nursing homes with nearly 2 million licensed beds in the United States.   These facilities "appear" a hotbed for COVID-19 deaths.  “Appear” because there is no available repository of data to validate this hypothesis.  The Centers for Disease Control (CDC) does not release the names of nursing homes or the number of residents who have contracted COVID-19 when outbreaks occur - but it should.  There is some media and state reporting from which one can extrapolate the extent and severity of the problem.

The first such case occurred at the Life Care Center of Kirkland in King County, Washington where 81 residents, 34 staff members, and 14 visitors contracted COVID-19.  Of these cases, 23 patients and visitors died.  A more recent example is unfurling at the Commonwealth of Massachusetts’ state run Soldier’s Home in Holyoke, MA where 21 have thus far died.

At least 400 nursing homes across the country have COVID-19 outbreaks.  The number is increasing daily.  No doubt, there will be a correlation between this growth and a climbing number of deaths reported from COVID-19.

Elders over the age of 65 with underlying disease or immune suppression are disproportionately vulnerable to COVID-19.  But those in long term care settings are far more vulnerable because of the lack of effective infection prevention, mitigation, and control at these facilities.   Their presence in these facilities is the proximate cause in many of their deaths, not their age or underlying health.

There is an abundance of research that proves long-term care facilities are contaminated with Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C-Dif) and other communicable disease sources.  Regulations to control communicable disease in these facilities are inadequate and the federal government, which pays for at least 65% of long term care patients through Medicaid, is conflicted between providing care and the cost of paying for it.

These problems of communicable disease extend outside the long-term care facilities.  Many of these facilities, in the name of efficiency, have hospice, long term care, and rehabilitation patients commingled in the facility sharing rooms, equipment and staff.  There is frequent cycling back and forth to hospitals in ambulances that go out into the community.   These problems are known.  Unfortunately, because the problem is difficult and costly to address those directly involved in providing or managing care shrug their shoulders in reluctant acceptance.

COVID-19 is not the last pandemic.  In a world where travel is abundant and dense urbanization inevitable there will be more and worse such pandemics.

Now is the time for rigorous examination of the lack of resilience in much of our medical treatment system, but particularly in long term care facilities.   In the name of “efficiency” we have accepted patient placement in high risk facilities where communicable diseases are tolerated as a part of doing business.  Treatment of underlying diseases, general health, and comfort are impaired by these communicable diseases.  Often they hasten death, just as COVID-19 is hastening, if not causing death now.    Adding insult to injury many patients are dying alone - their families unable to be with them.

It is largely in the name of efficiency that this situation exists.  Rooms are shared.  Staffing is minimized.  Hospitals must discharge as quickly as possible to rehab.  We prize efficiency in business and government.  But resilience is just as important.  We have ignored that too long.   We can do a lot better and we must.

Thursday, February 6, 2020

A Trump vs Sanders contest may be needed

A general election contest may be necessary between President Donald Trump and Senator Bernie Sanders in 2020.    The United States is going through a tumultuous rejection and realignment of its political culture that may well climax with the 2020 presidential election.   Pitting the two non-party populist candidates with opposing political philosophies in a head-to-head contest will break the two major political parties and determine if the political center of American culture will be reset much further left or remain a conservative right majority.  The fight is a necessary one to conclude a rejection of two parties that are more similar than not in creating division and failing to address the interests of the American people.

Wednesday, January 1, 2020

Let’s rethink nuclear power

Nuclear power will play an essential role in the energy future of the United States and the world.  There is an increasing recognition by scientists, entrepreneurs, and policy makers that it offers unique characteristics that can provide an abundant, safe, and clean energy source indefinitely.  Despite a decline in the existing nuclear power industry, a renaissance is underway in new safe nuclear reactor designs and technologies to fuel the next century, while rapid advances in fusion power research portend a revolution to begin within the next two or three decades in the nuclear industry.  Now is a pivotal time for leadership, a national focus, the allocation of resources, and a revamping of federal and state regulatory models to accelerate development that will transform the energy portfolio of the U.S. and the world.

Many people in the United States reject nuclear power based on fear.  It is time to face that fear and reconsider nuclear power as a primary contributor to the nation’s energy portfolio.  Now is the time to reassess because there is both vulnerability and opportunity looming.   The vulnerability - existing nuclear power infrastructure is old and presently unprofitable – causing decline in a major component of our nation’s energy portfolio.  The opportunity - there is a tremendous amount of innovation taking place around modern, safe, and small fission nuclear power design that is very promising.  In addition, progress in fusion research is real and substantial, and accelerating.

Tuesday, October 22, 2019

Syria - deja vu all over again

Almost one year ago I posted "Goodbye Syria and good riddance" on this blog.  President Donald Trump had ordered a withdrawal from Syria in what seemed to many to be a non-consultative rash and reactionary move.  His then Secretary of Defense Jim Mattis disagreed and ultimately resigned in large part because of the decision.  

At that time I agreed with the President's decision and continue to support his efforts to withdraw from these interminable military deployments.  Last year I was critical of the way in which the decision was made.  It reportedly lacked consultation with allies and even within the President's own Administration.   Trump eventually relented to across the board pressure to remain though there was a decrease in the number of forces by half.

The same arguments are being made that the decision this time was made hastily without adequate preparation and consultation.  A lot of the criticism is simply the knee jerk reaction of the President's haters.  No matter what he does it is wrong and they seek political advantage.   But as in December of last year, there is significant opposition from two other sectors - Republican leaders and the defense bureaucracy. 

Senate Majority Leader Mitch McConnell wrote an Op-Ed this past weekend in the Washington Post titled: Withdrawing from Syria is a Grave Mistake. McConnell says, "It will leave the American people and homeland less safe, embolden our enemies, and weaken important alliances."  I am familiar with these arguments from advocates such as McConnell, John McCain, and Lindsey Graham.  They are hawks of the traditional "America as the indispensable leader" believers.  I understand their arguments, but I ask: "At what cost?"  

The election in 2016 was decided in no small part by people who have had it with the endless wars that expend blood and treasure for questionable objectives and results.  In fact, the one sure way for Donald Trump to loose reelection is to engage in another such adventure.  The Iranians are trying to provoke him to do just that.  The defense bureaucracy would have reacted as would normally be expected but for the President saying no in reaction to the shoot down of an unarmed drone by the Iranians.  Though the President has approved further deployments to Saudi Arabia as a deterrent in response to attacks on Saudi oil facilities he has not taken the bait to engage in yet another military adventure.

Below is the post from December of last year.  It remains relevant.  Everything below this line was written in December, 2018.  Note it sounds just like this past week one year later.  I have made some additions in bold.  The original post with comments is linked here

Sunday, October 20, 2019

2020 Prognostication – Trump wins – for now

If pressed to predict the winner of the 2020 presidential election today I would predict that President Donald J. Trump will be reelected.   The prediction is based on Professor Allen J. Lichtman’s “Keys to the White House” model.   The model is a proven predictor that uses measures that are more objective than polls and pundits.  The model predicted the Trump victory in 2016 while all other methods failed.  But the prediction is only a marker in time - the present - and a lot could change.

The Democratic Party has avenues to change indicator status and the outcome in the remaining year.  However, barring a major collapse of the economy, they may only be able to change the indicators on the margins.  In that case they will need to provide a very strong candidate as an alternative to President Trump.   Can the leading Democratic Presidential candidates provide that alternative?  Read on.   
Will these be the the two candidates in 2020

Tuesday, August 13, 2019

Electric Autonomous Advertisement Pods - I mean cars

Automobiles have played a major role in American economics, history, transportation, and culture.  The industry is in transition as it moves full force to create electric autonomous advertisement pods.  Yes, you read that right – ELECTRIC AUTONOMOUS ADVERTISEMENT PODS. 

Automobiles in their early days were a statement of wealth but were quickly available to the common man with the advent of Henry Ford’s assembly lines.  John Paul Getty’s Standard Oil ensured the combustion engine would monopolize the industry over Thomas Edison’s electric vehicles.   President Dwight Eisenhower created a massive network of highways that would ensure the dominance of the automobile over all other forms of transportation and underpin suburban sprawl.

The heyday of the automobile was the 1950's and 1960's when creativity and art dominated.   The major manufacturers would introduce new model years with great fanfare.  Television reached the masses and it could be used to promote sales in many ways that created an emotional attachment to brands.  Creativity also rested with individuals that could take older cars from the 1930's and 1940's and convert them into unique artistic statements as hot rods and later muscle cars.

At a recent 4th of July parade, as the antique cars passed by, my brother-in-law and I would say as they approached, “1968 Chevy Camaro, 1934 Ford Pickup, 1957 Thunderbird, etc.”  A nephew of about 35 years of age watching the parade with his own young children said, “how do you guys know all of these old cars so well?”   I said, “in our time cars were a work of art.  When the new model year was rolled out there were themes like the introduction of two-tone paint, or push button transmissions, or rocket lights reflecting the space age.   They were things of beauty and innovation that we all wanted.  Cars today for your generation, like so much else today, are consumable items. They all look the same.  You lease them and turn them in.  Do you foresee anyone coming to a parade like this when you are our age saying, “Oh, wow, there goes a 2015 Nissan Rogue or a 2007 Toyota Corolla?”

Cars were a common shared experience for the Baby Boom generation.  Teens were bursting to obtain their license.  It was a means and a symbol of independence.  They almost immediately purchased a car for as little as $50 (my first was that price - a 1961 Dodge Dart).  They paid for the car, the insurance, and the gas.  They did everything in their cars.  On weekend nights they rode up and down Main Street, stopping for an ice cream and to talk with friends.  Boys did much of the maintenance themselves.  Girlfriends and boyfriends went “parking” at the reservoir or some other place for romantic encounters at the end of a date.  Cars were an integral part of their culture.