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The 4 questions... for tonight.

March 23, 2020

Humans, 

Tonight I will give you my thoughts on four questions I keep getting asked...


How long are we going to be physically distant? 

I don't know the future but since so many people ask me, I would like to give you my thoughts on how this is going to play out eventually. If you haven't had a chance to read about the Hammer and the Dance yet, I recommend you go read this first. I really like that terminology and visualization, and it is a model that we are hopefully starting to follow in this country. We are not going to be physically distant forever. At one point the cost-benefit ratio of distancing will no longer be in balance. There are costs of remaining 100% distance forever (for instance, the economy will go from a recession into a depression, and there will eventually be widescale social/mental collapse). On the other hand, there is a cost to remaining 100% social (lots of people dying unnecessarily because our healthcare system will collapse). We are going to end up somewhere in the middle. I personally think the Hammer will be in terms of weeks, and The Dance will be in terms of months - if we can get our act together.


Will everyone be on the same restrictions forever? 

This is essentially a nuanced conversation about the Dance. The cost/benefit to some people will be different than the cost/benefit to others. Eventually, there will need to be some strategy that will take into account three questions... 

What do you do for a living? How much social interaction does it take? Are you a yard person (less interaction) or an Uber driver (lots of interaction)? Could it be modified to add distance? Do you need to interact with only young healthy people or older and high-risk people? Is your job essential to keeping our society running, or is it a role that can be sacrificed temporarily until we get this curve under control? (btw - thank you both to the people providing the essential service and to those who have sacrificed their position for the time being)

How badly do you need to do your job? Do you have no savings? Are you or those you support one month away from not having a home or food?  

How bad is it if I get Covid? How old are you? Do you have a comorbid condition (diabetes, heart disease, heart failure, lung disease, immunocompromised)? Or, is someone that relies on you that is older or otherwise high-risk? 

    • Example 1- If you are the only caregiver to an 80+ yr old parent and you're retired or work from home, then your cost/benefit ratio would be heavily skewed to maximizing your physical distancing (The last thing you want to do is to give Corona to your eighty-year-old parent when you can maintain your livelihood and care for you both with very little social interaction). 
    • Example 2 - If you are a 25-year old with no savings, you can't make a living at home, you never interact with anyone over 60 yrs of age or with compromised conditions, and you have a job that is pretty isolated, then you will likely be able to err toward relaxing your physical distancing earlier.


What is the real problem with the lack of tests?
 

Yes, there is a huge problem with the lack of tests. However, it is not going to change the type of care you will individually receive by a doctor. As best we can tell, the tests are only 70% accurate. So, a person needs 2-3 negative tests before they would be deemed "Corona free." The people I saw with cold-like or flu-like symptoms today got the presumptive diagnosis of Covid-19 and were told to self-isolate and come back if they got worse (particularly if they got short of breath). 

To a doctor sick is sick. Here is what I mean. Even if we had a 100% accurate, instantaneous, and limitless supply of tests, as a doctor, I would still send you home if you are well, and I would admit you to the hospital if you were sick - regardless of your test results. (I know for you physicians out there you are saying but wait... I could use it to risk stratify blah blah. I'm trying to make a point for the non-medical. The test does not cure you or treat the actual disease). 

The lack of current testing is bad because we don't know how bad the problem really is or where it is really located. Without this information, it is nearly impossible to create a plan that will be effective across an entire population of people. It's also a little harder to figure out which healthcare providers should stay in the game and which should sit on the sidelines. Certainly, if we could test every single person instantaneously with a 100% accurate test, this ordeal would be over in a few weeks. We would know exactly who needs to be isolated and who among us can stop physically distancing, and the virus would die out. Unfortunately, that is impossible.

What is the solution? 

Time. We need time. Physical distancing is the only way to make more time. It is a guarantee that true physical distancing will flatten the curve. There is no way the virus can magically jump from person to person. Simply put, the virus needs humans to interact in some way. The better and faster we distance ourselves from one another, the quicker we will affect the curve. We will never actually eliminate the sicknesses, but we only need to flatten the curve below the capacity of the healthcare system. Once we do this, then the cost-benefit ratio of flattening the curve changes significantly and then how flat should we try to get it is a really complicated question that I would love to watch really smart people debate.   

On the one hand, if we go too far, we will certainly experience too much of the negative economical and psychological consequences of distancing. However, if we don't go far enough, there will definitely be too much unnecessary suffering from people not getting the treatment they need because of an overloaded system. 

One thing is for certain, the flatter the curve the more time we have and...

  • time will also allow us to learn what are the high-value distancing restrictions that provide the most benefit vs. the low-value ones that may be overkill (This is the proverbial "Dance.")
  • time will let us increase our healthcare capacity. It will allow us to get the ventilators, the make-shift hospitals, and the safety equipment to the right places.  
  • time will let us figure out if there is a drug combo that works. 
  • time will let us create a vaccine. 


I don't know when we let off the Hammer. I know this it's not fully down yet in most places. My gut feeling says once it is the Hammer is down for weeks not months.  

In the meantime, all I'm asking is that each of you stop and think.

  • Think - how important is the physical interaction you want to go do and how much damage can it do? Is there an alternative? 
  • Think - how important is isolation for you and how much benefit is gained by it?
  • Think - how will by decisions affect both me and those around me? 


Please stay emotionally connected and physically distant,

Greg