Friday, April 10, 2020

A Scott Gottlieb Resource

I'm sure many readers are familiar with Dr. Scott Gottlieb. Gottlieb's expertise is obviously in the medical field, but his bachelor's degree was in Economics, so he probably has a far better understanding of economic related issues than most doctors. He has also had extensive experience working in the federal medical bureaucracy. Most recently he was FDA commissioner for the first two years of the Trump administration, and he's currently a resident fellow at the libertarian oriented American Enterprise Institute (AEI). He's unlikely to be a NeverTrump.

A lot of people, including myself, are pondering the question of how soon and how safely we can "reopen" the country, to try to mitigate the damage to the economy and to the social fabric more generally. Gottlieb at AEI has come up with a detailed proposal in that regard. That's important, because he's likely to have the ear of influential legislators as well as officials in the Executive Branch--including the White House. He's been out and around discussing his proposal, trying to drum up interest and discussion.

I haven't read it all. I do know that Gottlieb is recommending a state by state approach--as each state fulfills certain conditions to "reopen" they will be evaluated separately. So it's not an "all or nothing" approach. I think that type of flexibility is highly desirable and would even like to see whether that approach could be extended to even more flexible geo-political agglomerations--for example, multiple country areas extending across state lines. Obviously that would involve administrative difficulties, but it's a thought.

With regard to the state by state approach I will note one point of disagreement I have with Gottlieb (that I'm aware of). He states that the virus has achieved "community spread" (as opposed to socially localized outbreaks) in ALL state. I'm at least skeptical of that, even though Gottlieb has almost incalculably more information at his disposal.

On the other hand, one point that I'm very pleased to learn that he agrees with me on--and is part of why I doubt that "community spread" is a nationwide reality--is that he believes that we will learn that only a very small percent of the population has even been exposed to the virus. The number he gives as an upper range is only 5%. In other words, not even within shouting range of the 40-60% we'd need to achieve any meaningful herd immunity.

So, to begin, if you want to keep tabs on Gottlieb, this is his Twitter feed:

Here is his "reopening" plan:

National coronavirus response: A road map to reopening

And here are the "key points"

Key Points
  • This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health approach away from sweeping mitigation strategies as we limit the epidemic spread of COVID-19, such that we can transition to new tools and approaches to prevent further spread of the disease.
  • The authors outline the steps that can be taken as epidemic transmission is brought under control in different regions. They also suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.
  • In each phase, the authors outline the steps that the federal government, working with the states and public-health and health care partners, should take to inform the response. This will take time, but planning for each phase should begin now so the infrastructure is in place when it is time to transition.

And finally, two tweets with embedded videos of interviews with Gottlieb. You'll see he's a well informed guy who comes well prepared to discuss any aspect of this crisis:


  1. Interesting questions from Codevilla, at :

    "The most important fact about COVID-19, its true mortality rate, is the number who die of the virus, *divided* by the number infected by it. No algorithms. Simple arithmetic.

    In short, Fauci, et al., are showing themselves to be typical of our bureaucracy: over-credentialed, entrusted with too much power, and dangerously incompetent.

    Learning the true figures, about precisely what danger the virus poses to whom, must begin by taking into account one thing we know for sure about COVID-19: that many, if not most, of those infected by this unusually contagious virus, show few or no symptoms. This suggests eventual near-universal contagion.

    But we don’t know, *how many* of these asymptomatic people there are. Hence, meaningful epidemiological testing must include a *random representative* sample of the population, regardless of whether they are presumed to be infected, or not. The numbers, resulting from monitoring what happens to the health of individuals in this sample over a few weeks, would tell exactly *what percentage of people*, in each category and subcategory, suffer what consequences, from whatever contact with the virus they happen to have.

    As it happens, a sizable chunk of such data is about to come into existence. The virus is rampant, among the 5,000 or so personnel aboard the aircraft carrier USS Theodore Roosevelt. Everyone aboard is being tested. By the time that is done, as the ship sits off Guam, and it returns to the United States, we will have a good *idea about the rate of infection*, and some factual notion of *what happens to those infected* —at least among the sailors’ demographic group.

    The question of lethality is not resolved by mere counting of individuals who test positive and die. We have some data showing that COVID-19-positive people who suffer from certain diseases are likelier to succumb than others who suffer from other diseases or who are otherwise healthy.

    Sorting out causes of death is properly a medical judgment. The doctors who are scaring the hell out of the country in general might better spend their time using their medical skills to sort out the virus’s specific consequences—and recommending what currently available drugs may keep the sick from dying."

    1. I read somewhere today that about 500 sailors are known to be infected. So 10%--which is not good news. However, that ship is not as good a sample as Codevilla thinks. I'm sure the crew is disproportionately male, and it appears that males are much more susceptible for genetic reasons--very interesting article on that in NYPost today.

      Also, I don't believe most medical people accept Codevilla's contention that the virus is "unusually contagious". It IS quite contagious--compared to SARS-Classic, but NOT when compared to the usual flu. I believe that's why Gottlieb says the infection rate will end up being surprisingly low. It's also why social distancing is apparently proving very effective. Again, because of the unusually close quarters on any navy ship, the infection rate--whatever it is--will probably be artificially elevated.

      The greater infectiousness of most flu viruses compared to SARS is part of why epidemiologists spent years preparing for a new and deadly flu pandemic rather than preparing for a novel SARS virus.

  2. The testing for antibodies in CA should give us a working answer. Some folks in CA believe the virus came over here in fall of 2019, and that there is, consequently, herd immunity out there.

    We shall see.

  3. is now showing number of tests for the US! Nice change, as I rework my spreadsheet.

    US probably has about 19 Million infected, based on taking the amount of deaths and multiplying it by 1,000 by something Steve Sailer figured out. 330 Million US population, so about 6% infected.

    1. So, a bit higher than Gottlieb's estimate of 5%. Still not within a shout of level's required for 'herd' immunity. Also an indication that it's more virulent than SARS-Classic but nothing like as virulent as seasonal flu. However, because of its higher mortality rate, not something you want to become endemic in the country. However, that horse may now be out of the barn.

      I assume that also means that the most infections are where the most infections are, which is pretty common sense. So, as we progress to wherever we're going, the deaths will mount where they're currently taking place.

  4. For numbers, checking sewage seems the best bet. MIT did one study, and the Dutch another. This just has to be expanded.

    Every state seems to have diagnosed cases now.

  5. More Codevilla, from :

    "… Trump knows, that the number of confirmed cases means nothing, because *most infections do not* result in “cases,” and hence, that the real number for infections is surely higher, possibly by an order of magnitude. Also, the counting of deaths from COVID-19 is being revised downward, because many of these deaths result from other causes and are attributed to COVID-19, only because the person happens also to have tested positive. The smaller numerator, and the *enormously larger* denominator, means that the real lethality rate is a fraction of one percent. That is why, the curves Fauci, the medical establishment, the media, and Democratic governors cite, for keeping the country shut down, mean nothing.

    Trump also knows, that this establishment is hurting Americans, by *restricting the use* of hydroxychloroquine —while physicians on the front lines, and millions of people who feel endangered, are benefiting from it, or yearning for it. Yet, in the face of criticism from the establishment, *he has muted* his statements, of what he knows to be true about it….

    … One thing is certain: That the ruling class savors the grip on us, that it has achieved during the past three weeks— above all, the presumption that we must quietly *accept non-legal* decrees from on high….”

    1. How does Codevilla explain why the Chinese cratered their economy? Was it all a ploy to allow the Chinese ruling class to get a grip on the the people over there? Oh, wait ...

      This is all too vague. Check out Ray's ref to Steve Sailer guesstimating 19M infections. That's not far off what Gottlieb's estimate would be. Then if you factor in lethality rates comparable to what the Koreans think they've figured out, you still come up with some nasty numbers.

      Answer: The Chinese sh*tcanned their economy because they knew this virus is a big problem.

  6. Questions I have:

    1. How is Coronavirus actually spread.
    2. What really works to reduce the spread
    3. With the stay at home order, what impact is this having in the spreading?
    4. With the stay at home order, how is it spreading?
    5. What can we learn from Taiwan?
    6. What impact weather / temperature on the spread?
    7. How effective are treatments? Quinine, vitamin c, Asthma medicines?
    8. How is 3rd world doing?

  7. "because they knew this virus is a big problem."
    Possible, but, Commies being Commies, there are always other possibilities, related to "never let a crisis go to waste".
    Jon Rappaport suspects, that they knew their economy was tanking anyway, so they trotted this virus out, to deflect attn. from their policy failures.

    And, what if they wanted a Mao-style excuse, to launch a new Cultural Revolution.
    And, ....

  8. I read Codevilla's article, and I get Mark's point about China shutting down, and I agree with both.

    Many small businesses, and others, are about to go out of business. Landlords with tenants not paying rents are in bad shape.

    The problem is nobody knows enough yet to answer basic questions on how to make the US safe enough to re-open. The US can't afford the current state. And we can't act like Taiwan, because we have COMMUNITY SPREADING and not enough tests to be like South Korea.

    My guess within a week or two we will know enough to safely open some areas. The measures required to be unexpected, that's why I think it will take a week or two to get a plan together. There is going to be a lot of give and take. Some areas could re-open sooner. The good news is our understanding of Coronavirus is improving dramatically, treatments I think are improving, and the death rate seems to be leveling off a lot lower than the initial models.

    What is Required to Re-Open:

    1. Understand how the Corona-virus Spreads - Good data is coming out of Germany
    2. Understand if masks helps - Czech Data should help
    3. For NY, figure out how to make the subways safe (Taiwan and Japan may have this figured out)
    4. Guidance on businesses on what they need to do, so they don't become disease spreaders
    5. Restaurants - Guidance on what they need to do so they don't become disease spreaders.
    6. Better models on what counties are at risk
    7. Figuring out how to protect medical facilities, so they can re-open for non Corona-virus services. How many people are dying due to lack of surgeries, cancer testing, chemo, etc?
    8. Why do some people, such as Mark's son's boss's friend, 40 years old, healthy, die. There seems to be degrees of Coronavirus. Perhaps, as was done with Smallpox during the revolutionary war, people can get slightly infected if they are the ones that won't get super sick, and become immune? Or is it impossible to become immune? Can people then get immunity cards? And high risk people are sheltered - depending on their location?
    9. Is herd immunity a possibility?
    10. Figure out how to protect people in rest homes, rehab, etc. places. My guess is Taiwan has some good processes.
    11. Figure out how to re-open schools. I think Taiwan again has some good processes for this. Basically everyone wears a mask.
    12. 5 Minute test should be in rapid use, and this may change the approach.
    13. Is Stay at Home working? If not, why?
    14. What is needed to allow travelers from abroad? So the US does not introduce new disease vectors? My guess is all entrants will get 5 minute tested.
    15. Disseminate best practices for medical treatments

    I doubt the US is going to keep shut down till there are no cases.

    Note: Trump can make recommendations, but it's each State's Governors call on when to re-open, and what are "necessary businesses".

    1. There are quite a few anecdotal accounts out there that describe how hotspots get started. WaPo had one about a funeral and a wedding in Chicago--lots of hugging and closeness over a couple of days. Similar thing in Georgia. Sailer has a link to an account of a hot spot in Germany--started at Carnival time. All similar stuff. It's not that this spreads as easily as flu, so don't expect high percentages of infection if social distancing is used.

      I agree that some places could probably reopen now. The question is to explain what's going on to keep people on guard while tracking things down.

  9. Similarities in and differences between coronavirus 2019 and flu by Lisa Lockerd Maragakis, M.D., M.P.H., Johns Hopkins Medicine:

  10. Perhaps you meant
    "It's not that this spreads as easily as flu, so don't expect high INCREASES IN infection, if social distancing is REDUCED."

    1. No, I meant what I wrote, although what I wrote isn't as clear as I should have made it.

      In any event, we shouldn't expect infection rates comparable to what we experience as "seasonal flu" simply because COVID is not as virulent as that. What it is is more deadly than flu. By using social distancing we can mitigate the spread (infection rate) and in that way mitigate mortality (case fatality rate). However, reducing or not implementing social distancing will make it possible for the virus to spread to something closer to the full extent of its (lower) virulence. That, in turn, leads to more deaths. The key in fighting this pandemic--since there's as yet no vaccine and only limited availability of antiviral drugs--is to limit the spread. Because of the greater lethality of COVID even a low rate of infection, compared to seasonal flu, will lead to mortality greater than most of the worst seasonal flu epidemics--unless something is done (social distancing) to reduce the infection rate.

      This, as I've argued, is why Trump really had no choice. If he had really known what was coming in November he could have quarantined the US from the world, but he didn't have that information until mid to late January when he was occupied with Impeachment Theater. IMO, he acted very promptly and showed good judgment in listening to Navarro and instituting travel bans.