Saturday, July 25, 2020

New Cape Cod Canal Bridges – Yay

The Army Corps of Engineers and the Commonwealth of Massachusetts signed a memorandum of understanding to partner in the planning and construction of two new bridges to replace the Sagamore and Bourne Bridges that now span the Cape Cod Canal.  This is good news. It is another step taken toward a needed change for which many have advocated for decades.  

Despite the news of progress, one must lament the snail’s pace by which such things are achieved.  The quicksand of regulation, litigation, and political and bureaucratic decision-making took so long to arrive at this point.  One fears that the long drawn out process will carry over into the next steps and the two new bridges will not be completed until far into the future - 2050 is not unthinkable.

The federal and state memorandum indicates that both agree that funding is a federal government responsibility, but it will be up to Congress to appropriate the funds.  The Massachusetts Department of Transportation will be lead agency in bridge delivery.  When completed the Commonwealth will own, operate, and maintain the new bridges.

Over the past two decades many have advocated the replacement of the bridges.   It has taken that long to reach a decision to simply move forward with a plan to replace the bridges.  A wide variety of possible alternatives to the two aging bridges were proposed and considered.  The Army Corps concluded earlier this year through a Major Rehabilitation Evaluation (MRE) study that the bridges can no longer be maintained, and two new bridges are needed. 

Conceptual designs envision two new cable stay bridges (Zakim is a cable stay bridge) inshore of the existing bridges.  Each would have two through lanes in each direction plus an enter/exit lane in each direction, a ten foot shoulder, and a 10 foot pedestrian lane.

Given that it took almost ten years after serious discussion of bridge replacement began to reach this point, one should not get too excited about quick summer Cape Cod departures on Sunday morning coming any time soon.   

The Cape Cod Canal was built to improve the safety and economics of shipping.  Myles Standish proposed connecting two rivers in the present canal region as early as 1627.    George Washington had the same thought, but to protect Colonial shipping in the Revolutionary War.   August Belmont was a wealthy financier who in 1904 took the vision of many others and made it reality by forming a company to build the Cape Cod Canal.  About 15-20,000 vessels pass through the canal each year saving them approximately 135 miles of transit around Cape Cod.   Large barges and ships transport decreasing cargo tonnage with each year.   Traffic is overwhelmingly pleasure craft today.

Early bridges across the canal were largely an afterthought.   However, with the advent of auto travel in the early 20th century, a new reality quickly changed priorities and the current Sagamore, Bourne and Railroad bridges were built.
The three bridges were authorized in September 1933.  Work began three months later.  About 900 men earning about one dollar per hour constructed the bridges in 18 months for a total cost for all three bridges of about $4.5M.

Applying inflation those three bridges would be constructed for about $84 million today.    Wages would be about $19 per hour today rather than $1 in 1935.  Wages will be a lot higher cost in the project than just inflation.  Federal law will demand prevailing wage on the project and Massachusetts politics will ensure union labor is used in all aspects of the project.  

Of course, the construction is not going to cost $84 million.   The Army Corps of Engineers estimates slightly more than $1 billion to replace the two road bridges in their bridge study (see table right). However, last year they reportedly estimated $1.45-1.6 billion.

Government project cost estimates are consistently well below projections.  A total cost of  $2 billion would not be surprising.  The Big Dig will stand very evident in debates about funding.

The three original bridges were constructed in 18 months!  A decision was made in September  1933.  Construction began in December 1933.   In June, 1935 the bridges opened.  Eighteen months is obviously not achievable in the modern era and context.  

Expect about ten years of pre-construction work.  Financing of the project requires action by Congress that is not assured.  Preliminary engineering will be done to support a full environmental impact study.  Some work has already been done in this regard.  After the environmental impact study is complete and approved there will be further permitting requirements.  Assuming everyone with something to say will get a chance to hold up the project, as is normal practice, construction may not begin for ten years. 
One would think this could go a little faster given that the sighting is right next to the existing bridges, but that is not how things work in the real world.  So, actual construction might begin about 2030 if all goes smoothly.   

One would think modern building techniques and equipment would predict faster construction, but it will not compete favorably with 900 men heating rivets and rigging iron with the aid of some early crane equipment in 1935. 

The Leonard Zakim Bridge in Boston was built as part of the Big Dig.  It is of similar type proposed and its span is similar to the Canal bridges.  It took six years.  

Anticipate a sequential construction project that allows lessons to be learned in constructing the first bridge to apply to the second.  A construction process will likely be on the order of 5-7 years for the first bridge and 4-6 for the second bridge.

Optimistically, the first bridge could be open as early as 2035 and the second in 2040 when the existing bridges are over 100 years old.   One can only imagine the condition of the existing bridges 15-20 years from now. 

Hopefully, the many peripheral construction projects that can be done earlier and have a major impact will be performed before the actual bridge construction.  This would include things like exit ramp changes in anticipation of the new bridges.

Why does it take so long and cost so much now to accomplish these types of projects?   Largely it results from regulatory change of all varieties.  Regulation exists for a reason and it is not inherently bad.   But can it become so excessive that a state or nation finds itself almost paralyzed in achieving anything of consequence?   

Of course, much needed change in labor rules occurred in the early 20th Century.  Men were making $1 a day with no benefits at all in 1935.   There was little concern for safety.  There was no need of an environmental impact study back then and permitting was probably not even in place at that time.   Needed change occurred in this regard throughout the 20th Century.   But maybe it has gone too far and is a little too stringent.  Maybe it has become counterproductive in its extremes to solving problems.  The Trump Administration has issued executive orders and regulatory changes to shorten the completion requirement of Environmental Impact Studies to two years for major projects.  That could accelerate the project.

One wonders about this when it takes 30 years from when people began seriously discussing the need for new bridges and the projected completion of the project.  The amazing accomplishment of 900 men in 1935 building three bridges that will have a 100 year life span in 18 months seems in contrast an even greater achievement than was thought.

Assessing State COVID-19 Performance

I perform my own analysis of data from multiple reputable sources to better inform myself about COVID-19.  I share some of that analysis here. I am not an epidemiologist or government official.  My analysis is my own personal pursuit of better understanding in an often unclear and conflicting reporting environment. Some of my blog readers may find it interesting and maybe even helpful.  It is a layman's work, so keep that in mind.  In this specific post I use the following sources:  The Covid Tracking Project : Rtlive ; and the Bureau of Labor Statistics.

First, I created the Venn diagram at right to provide a context for my writing.  As is the normal course in present day America there are those that try and divide by making every issue an either/or binary choice for political alignment.  I reject that.  The COVID-19 pandemic is complex and at least three areas - public health, rights and responsibilities, and economic impact - should be a part of any pandemic policy.  A skeptical public should take responsibility for demanding balance and evidence of efficacy in policy.

The lack of depth in media reporting is what instigates my own analysis.  There is an overwhelming inclination in government and the media to report raw numbers of COVID-19 cases and deaths. Raw numbers tell us little to nothing of value. What does a statistic mean if it is not compared or contrasted with something else to measure its relative impact, value, threat, or risk? It is in comparisons where we find value and knowledge. For example, one can compare states to measure relative performance and gain insights into policy effectiveness or compare a state's performance over time to reveal trends within a state.

The tables that follow rank states in order of performance largely by comparing them based on the percentage of their population that has died, is currently hospitalized, has been tested, etc.  Using the percentage of the population comparison normalizes the measurement, unlike a raw number.  The color coding breaks the states down into 20% increments displayed red (worse) to green (better).   

The State Name column assumes the same color code as the percentage of the population that has died with COVID-19 (% POP DEATHS) and retains that color code in all tables.


In my judgement the most important reflection of a state’s performance throughout the pandemic is the percentage of its population that has died with COVID-19.  This table is sorted by that statistic (% POP DEATHS), but also contains related variables.

There are statistical definition, collection and reporting issues that cause uncertainty in reporting COVID-19 deaths.   For example, early cases may not have been detected, and a death is reported for anyone who dies "with" not necessarily "from" COVID-19.  The % POSITIVE DEATHS column reflects the percentage of people tested positive for COVID-19 that died in the state.  This can reflect disproportionate institutional elderly deaths in a state or reflect on how well a state's health care system responded to the virus.  The % Tot US Deaths column reflects the percentage of all United States COVID-19 deaths that occurred in a state.  Note that the worst performing eleven states represent 23% of the U.S. population but 56% of the deaths from COVID-19.

The morbidity of COVID-19 still cannot be calculated.  Morbidity is calculated by dividing the number of deaths by the number of cases.  We still do not have an accurate number of cases. There are many more cases of COVID-19 that go undetected than are detected.  The head of the Centers for Disease Control said that there may be ten times as many cases as are detected and a recent report indicates it could be in a range of 6 to 24 times the reported cases depending on the state.   See previous blog posts I have written to understand better the uncertainty of collecting and reporting data about COVID-19.


To better understand how a state is performing currently one can look to testing, lagging 7 day averages of cases, percentage of the population that is hospitalized, and other variables.   In the table below several of these variables are indicated in columns.  It is sorted by the percentage of the state population that is currently hospitalized (% POP in Hospital).   This variable is used because others, such as cases (% Tested Positive), are influenced by many other variables, such as testing volume, and are not necessarily predictive of the intensity of either hospitalizations or deaths.  

Hospitalizations is a critical data element because one major goal in regulating the rate of virus spread is to prevent overwhelming hospitals.   There is no standardization among states or at the federal level of data reporting on hospitalizations.  Kansas still reports nothing.   The timeliness and extent of hospital data variables (e.g. percent bed capacity used, ICU, demographics of patients, etc.) reporting is different in every state.   It is essential that this change.  The threat of overwhelming a state or regions hospital capacity cannot be assessed without detailed data on a number of variables.

I will use Florida as an example as it has been the subject of much media attention because it has seen a dramatic increase in cases.

Florida increased its testing significantly in recent weeks to average nearly 100,000 tests daily.  The percentage of those tested that are positive is about 13-14% over the past two weeks.  That was a significant increase.  It is true, as some have stated, that if you increase testing you will increase the number of detected cases because we know we may be missing many infected people who have no symptoms and do not get tested.  However, that does not entirely explain the increased percentage of positive tests - there is likely increased spread. Florida's increasing number of cases lowered it from number 18 to number 47 in state ranking over the past few weeks.

Many states are increasing testing.   The purpose of the testing is to underpin Contact Tracing.   A person is tested and state authorities are supposed to use the report of that positive test to reach out to anyone who had contact with the infected person, test them and isolate them, in order to slow virus spread.  This only works if there is a quick turn around of tests.  If the test result is not reported within 48 hours it's value is greatly diminished in the contact tracing effort.  Labs are overwhelmed with the increased volume of testing in many states and there are reports of up to two weeks in the turn around of test results.

Contact tracing is critical to a strategy to throttle spread of the virus, but it's effectiveness is questionable and its reporting of detail to the public is rare.  This issue is deserving of serious governmental and journalistic inquiry.   When a governor says he/she is shutting down beaches the first journalist with the opportunity should ask, "Governor, can you provide us with the number and circumstance of infection and spread on a beach based on contact tracing evidence?" 

In another indicator of the increased spread in Florida there is an increase in hospitalizations.  Florida is in the unenviable position of last place in hospitalizations today as indicated in the table below.   The spread and impact is largely, once again, in the Miami-Dade, Broward, and Palm Beach county areas. The state is challenged to ensure that spread does not keep increasing and overwhelm the hospitals. Will lower average age of cases and better treatments result in a much shorter stay in the hospital with less serious interventions?   If the length of stay is shorter the number of new daily cases that can be tolerated is greater and the issue becomes one of churn.  The number of hospitalizations has been decreasing in recent days.

Despite increased cases and hospitalizations Florida is ranked in the middle of the pack among states for deaths.  It has gone in recent weeks from number 25 to number 29 in rank for the percentage of its population that has died with COVID-19.   Deaths have and will increase with increased spread, but how much?  Thus far, it is not the same as it was in the early days of COVID-19 because the population that is getting infected is younger, healthier and does not suffer such severe consequences as older patients, particularly those in institutional settings.  In April the median age of those infected in Florida was 65.  It dropped to about 35 in June and rose to and steadied at about 41 right now.


Any state that is pounding its chest crowing about its recent performance should be very cautious.   We still do not know a lot about the virus.   Social distancing and other actions to control spread can work, but to what extent is not known or measured. Many variables are at play, so there is a great deal of uncertainty about why or whether cases will rise or fall in any state.  

One data element that may help to predict spread intensity is the Effective Reproduction Number or Rt.   Rt is the average number of people who become infected by an infectious person. If Rt is above 1.0, the virus is spreading and the higher the Rt above 1 the faster it is spreading.  When Rt is below 1.0, the virus spread is slowing.   Twelve states had an average Rt below 1 on July 24, an increase from seven in the past week or so.  There is a trending of improvement for many states while others are declining.   This could make the case increases of the previous weeks in many states a blip rather than a trend.   It may also portend blips in states that currently are thinking they are doing well.  It is the nature of what we are doing - throttling, assessing, and reacting in order to maintain balance between COVID-19 suppression, economic expansion, and protection of constitutional rights.

Governor Charlie Baker of Massachusetts this week issued further restricting orders on the Massachusetts population and threatened more severe actions. He also placed restrictions on those traveling to Massachusetts from most other states.  Hospitalizations and deaths have been relatively low in Massachusetts in recent weeks.  Why is the Governor increasing restrictions?  One reason may be that the Massachusetts Rt has been over 1 for more than two weeks and may portend an increase in cases.  At the same time, Florida Governor Ron DeSantis may be optimistic as the Florida Rt has been below 1 for about two weeks and improving, and hospitalizations may have begun a downward trend.    


Locking down the nation for public health reasons has unintended consequences that include the decline of the economy, personal financial ruin for many, and psycho/social suffering.    The economy cannot be stifled forever or with each new virus.  Political construct narratives try to frame the debate in an either/or argument of LOCK DOWN or FULL OPEN.   What we must actually achieve is a balance of continuing economic expansion while preventing hospitals from being overwhelmed and moderating the number of deaths.

I use the table below to see how well a state is doing in moving its economy forward.   The ranking is based on the change in unemployment within the state from May to June, 2020.   

One can see the priorities of states in their performance.  For example, at state rank 51, Massachusetts had the worst unemployment rate in the U.S. in June at 17.4% and ranked 47th in percent change from May to June.  Florida ranked 32nd in state unemployment in June and 18th in change from May to June from 13.7% to 10%.   Florida is more aggressive in trying to open its economy.  Massachusetts is more aggressive in public health behavior restrictions.  Their economic numbers reflect their priorities.  Again, it is about balancing these concerns to find an acceptable outcome in all areas.


Federal and state governments have fairly broad authority constitutionally, in law, and in court precedent to take action in response to a public health emergency.  However, it is not unlimited.   There has been little challenge to the decrees of governors in the courts.   One could expect cases to begin to materialize from both civil liberty advocacy groups and individuals who question the capriciousness and lack of evidence-based-reasoning for some restrictions.

Americans do not give up their due process guarantees under the Constitution because there is a public health threat.  Restrictions have to be reasoned with evidence, targeted, non-discriminatory, and offer avenues of challenge to the individual.  A public health emergency is not a blank check for presidents and governors that ONLY considers the risk of infection and death from a virus.

The restrictions on movement between states may be ripe for challenge.  Several states have implemented restrictions on travel into their states from other states.  The latest restrictions placed by Governor Charlie Baker of Massachusetts is an example.   It is a broad stroke restriction against other states that may be illegal.  California could not ban people migrating from Oklahoma in 1941 under the Commerce Clause.   The Privileges and Immunities Clause has been used in cases to stop states from discriminating against the citizens of other states.

My point is that there is always the opportunity for abuse in emergencies.   If the restriction of rights is not tested, especially in the worst of times, those precedents will potentially stand in future emergencies as the foundation for further governmental power expansion to the detriment of individual liberties.  As Justice Jackson said about government emergency powers to detain Japanese Americans during WWII, “[it] lies about like a loaded weapon, ready for the hand of any authority that can bring forward a plausible claim of an urgent need.”    Fear cannot be allowed to turn heads from rigorous protection of constitutional rights.

Thursday, April 30, 2020

Should hard hit states reassess Covid-19 strategy?

Massachusetts Governor Charlie Baker announced this week an extension to his May 18 “Stay At Home" order.  The Mayors of Somerville, Cambridge and Peabody, MA ordered the wearing of masks in public places (indoor and outdoor) with fines for non-compliance of between $300 - $1000.  Is doubling down on a general population lock down strategy the right path going forward? Or does the overall strategy need review?

One can reasonably ask:  Is the strategy of generalized social distancing with increasing restriction appropriate going forward? Would it be more effective to target the virus directly where it is most insidious and deadly, focus resources there, and allow a gradual development of herd immunity in the general population?

Last week the Wall Street Journal reported over 10,000 COVID-19 associated deaths at elder care facilities. This number is likely to go up in both number and percentage terms. The WSJ has built its own database by contacting state departments of health directly because reporting from government sources was rare.   California released data this weekend indicating nearly 40% of its deaths come from nursing home and elder care facilities.  The World Health Organization (WHO) reports half of Europe's deaths from COVID-19 were from elder care facilities.

The Massachusetts Department of Public Health COVID-19 Dashboard indicates nearly 60% of the 3153 MA deaths occurred in long-term care facilities.   This percentage might rise as the definition may only indicate those that die on nursing home property not those that were released to home or died in hospitals after transfer from a nursing home. 

In Massachusetts, the 70 and older age group made up 86% of confirmed COVID-19 deaths with those 80 and older making up nearly 65%.   There have been no deaths in the 0-19 age group and 33 in total for those in age groups under 50.   Ninety-eight percent (98%) of those who died in MA, and for which a full investigation has been completed, had underlying conditions.

Sunday, April 19, 2020

COVID-19: Risk Assessment, Model Uncertainty, Unknown Prevalence, Unclear Mortality, Alternative Paths, and State Anomalies

The COVID-19 battle is trending favorably. There is reason to be grateful for lower death rates, less hospitalization, less ICU use, and less ventilator need than was predicted.  Those that directly engaged at great personal risk, from first responders to health care workers, deserve our thanks.  Moving forward vigilance and rigorous critical analysis is needed to understand the risk COVID-19 posed.  There is much we do not know to include:

How prevalent is it in the population?  
What is the mortality rate?
Did uncertain models overly inform and influence narrative and government policy?
What role, and to what degree, did social distancing influence cases and deaths? 
Were there alternative strategies that could have been as effective?

It is important that the nation undertake an investigation to fully understand the risks and realities of COVID-19 and assess whether or not the actions that local, state, and federal governments were in fact necessary and effective.  Shutting down the U.S. economy was an extreme action.  It is an unsustainable action that cannot become part of the standard play book for each new virus threat.  Understanding what really happened in during the pandemic is essential to ensuring future preparedness and viable strategies.

My concern is that harmful policies were taken by federal, state, and local governments that threaten our economic well being and played loose with Constitutional rights based on uncertain predictive models.  Did the governments actions stop nearly 2.2. million deaths?  Or, were the original projections simply wrong?  We do not know. We need to find out.  Our future well being may depend on it.

As the COVID-19 pandemic settles down and election season draws near some politicians are going to be patting themselves on the back for having saved thousands if not millions of lives.   If the total number of deaths by fall is approximately 60,000 President Trump can say his Administration's  actions saved between 1.44 and 2.14 million lives.  This assumes the models were correct in their predictions.  Governors can extrapolate their great success from the same numbers.  A handful of governors will have to explain to their citizens (particularly NY, NJ, MI, MA, LA, IL) why their states were negatively impacted disproportionately.  

Friday, April 17, 2020

Relative percentages to understand state COVID-19 status

President Donald Trump and the White House Corona Virus Task Force released “Opening Up America Again” guidelines on April 16, 2020.  The guidelines provide “Proposed State or Regional Gating Criteria” for proceeding to each of three phases of reduced restrictions on economic and social activity.

“Core State Preparedness Responsibilities” include robust testing and contact tracing capability, adequate healthcare system capacity to include a surge capability, and a plan to protect the health and safety of critical workers, vulnerable populations (e.g. nursing homes), and other related specific requirements.

The guidelines use criteria for transitions through the three phases based on data within a state or even county or city level, as the granularity of data is now available to those levels.  The guidelines do not set dates, but rely on states satisfy criteria to transition through each phase called “Gating.”  Beyond the underpinning Core State Preparedness Responsibilities a state would make decisions about transitioning based on an observed decrease in day to day confirmed cases and  positive tests for the virus over a two week period.

This necessary plan is adequate to begin the process of transition in balancing the risk of economic collapse with public health.  Twenty-two million Americans have now lost their jobs as the result of the Covid-19 pandemic.

I keep my own databases to analyze the risk of Covid-19. I do this to satisfy my own curiosity and analytical bent, but I also feel that there is a weakness in journalism today that forces me to do my own analysis.   I have observed an overemphasis on reporting raw numbers to indicate risk and impact with an emphasis on rounded thresholds (e.g. 1000, 10,000) that make for good headlines.  This distorts impressions and understanding.   I believe a better way to understand virus risk and impact is through relative comparison of a state against other states and the national average by calculating the percentage of a state’s residents that have been tested, have tested positive, have died, and are projected to die with Covid-19.

I set up download routines from databases that are reliable and current.  The COVID Tracking Project hosted at The Atlantic has a data file that I use to track specific numbers tested, hospitalized, and deaths.  The New York Times has a database that tracks similar data, but has an excellent graphic presentation showing the increase or decrease in cases and deaths in a day over day comparison.  The University of Washington IHME database provides model projections for hospital bed and ventilator shortfalls and anticipated number of deaths through August 4th by state.

Below are some tables I created that are sorted to show different rankings by state and the national average.  I offer these tables to my blog readers in the hope that it will help them better understand the situation in their state and appreciate that all states are different. 

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.”

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.