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  • Josh Schiffer

March 14, 2020

Thanks again for positive feedback. I am so glad my comments have been helpful. For those who wish to disseminated this info, it seems like the best way to share the posts while not losing the links is to copy & paste into your own posts rather than sharing. My amazing wife’s birthday is tomorrow, and we plan to celebrate. However, I am asking her to spare an hour to help me set up a personal website to archive my posts. I really want to be able to share this with friends and colleagues who are not on facebook.

---------------------------------------------- At some point, I want to write a bit about silver linings. We are very early in this and I do not in any way wish to minimize the tragedy which has happened, and that which is coming. However, it is unmistakable that there is good emerging from all of this. On a personal level, I have reconnected with great friends over the last week from high school, college, med school, the Osler marine days & from the Seattle downwinding community. Today we had a virtual happy hour with 2 old B’more friends and laughed to the point of tears. I am so grateful for this. I will write more about societal silver linings on another day.

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Projections for the US. Trevor makes a very rough projection of 20,000 infected right now in the US (https://twitter.com/trvrb/status/1238643295300898818).

A few thoughts about this: - He uses the sparks / fire analogy to emphasize that the new fires which are being detected all started 4-8 weeks ago, not 3 days ago. Imagine where we could be if many or even most of these small fires were extinguished weeks ago. - Seattle has the most infected people, not because our epidemic is faster but because we were seeded the earliest allowing the longest period of exponential growth - 20,000 feels like a big number, but also a small number (~1/15000 of the US population): just remember the doubling time is ~6 days. If we do nothing, then we are at ~5-6 million (~1/50 of the US) in 2 months & >50 million (~1/6) in 3 months. This would destroy us and is not an option.


Asymptomatic transmission. This concept is about to get a lot of attention because of articles like this (https://www.cnn.com/…/coronavirus-asymptomatic-s…/index.html). - I posted a medrxiv article here a few posts ago that showed the generation time in China (time from infected to infecting) was slightly less than the incubation period (infected to symptomatic) meaning that some transmission occurs before people become symptomatic. That article estimated that half of transmitters were not yet symptomatic. The outbreak in Boston at the Biogen conference which I also described apparently started with asymptomatic people. - I have no doubt that asymptomatic transmission is a real phenomenon. As I mentioned before, this is not surprising. Many if not most viral respiratory illnesses have this property. Plus, it is now obvious that many infected people, particularly the young, feel pretty well throughout the course of illness. Throw in human subjectivity about what constitutes feeling ill and it all amounts to a set up for asymptomatic transmission. - I don’t think that this is a reason to panic. Just because asymptomatic transmission occurs, and will continue to occur, does not mean that it causes enough transmissions to sustain local epidemics. Coughing and sneezing promote droplet dispersion of the virus and are still likely critical to the virus’ success at the population level. I think we can get the reproductive number < 1 with our current strategies despite this phenomenon. China and Korea are proof that this is so. - In the paragraph above, I am thinking about this like a public health official might where the goal is always to get R<1. This is the most important perspective because the public health official is trying to save thousands of lives not just one. - However, if you are considering your own family’s specific situation, then asymptomatic transmission is a reasonable source of anxiety. Even after R<1, there will be weeks of new cases and deaths as the epidemic dies out. So for those of you thinking about protecting individual family members, vigilance remains key. Our only tool is social distancing which ideally is applied broadly, not just to contacts who are exhibiting symptoms or may have had an exposure


Practical matters. In general, in this feed, I have tried to focus more on the science of the pandemic as it applies to the global population, rather than giving specific advice to people about the specific ways to navigate this crisis. As I mentioned in a previous post, the uncertainty associated with previously mundane decisions can feel paralyzing and often there is no right answer Today I received a few inquiries about this particular article (https://medium.com/…/social-distancing-this-is-not-a-snow-d…). I realize this stems from the fact that people are looking for practical guidance on how to plan for the next 1-2 months.

Asaf’s suggestions are jarring for sure. Overall, I agree with his perspective and advice. I do think drastic measures are in order. Our evidence for social distancing comes from China and it represents an extreme implementation of this policy. We do not know if a lighter version, as currently implemented in Seattle, will work. This information is coming for us in a couple of weeks. Amazingly, France and Spain took a more dramatic strategy today and also shut down all non-essential business.


It is all just very challenging. Our family is trying to isolate ourselves, but also still support local businesses (ordering takeout) and maintain our own mental health with exercise and limited outside social engagements.


Nice graphics on flatten the curve. The Post has done a phenomenal job with their coverage. Kudos. https://www.washingtonpost.com/…/2…/world/corona-simulator/…


Incredible science. The crystal structure of the viral spike protein that enables it to enter cell is already solved. This was done at breakneck, unprecedented speed. Just wow. https://science.sciencemag.org/content/367/6483/1260


And finally a post that was shared to me from Vietnam from a friend of an old friend (https://www.facebook.com/StephenConroy/posts/10103856591461672) I do not know Stephen but I appreciate his sentiments. I lived in Vietnam right after college and recently visited with my family. I have a deep fondness for the country. Vietnam is in your face and at times absurd. The people are funny, generous and above all, no BS. It does not hurt that the food is the best on the planet.


On first glance, it would seem miles easier to contain COVID in Seattle than Hanoi or HCMC. Seattle is wealthier, a tech hub, deeply atomized, overflowing with infectious diseases expertise and has a uniquely dedicated and effective public health department. The major cities in Vietnam are some of the most crowded in the world and continue to suffer from grinding problems with extremely poor areas, and pollution and traffic, that must be experienced firsthand to be fully grasped.


Yet, the differences cannot be more vivid. It is not true that Vietnam happened to win once, and the US happened to lose once. In the battle against SARS-CoV-2, Vietnam has won dozens of matches and remains undefeated. The US has lost dozens of matches and to my knowledge, remains winless. Remember that each spark in a new location represents an opportunity to succeed or fail. Vietnam shares a huge border with China and presumably had virus introduced into the country hundreds of times in December: each time it was eliminated quickly before spreading in the population. In the US, every time the virus has entered a major city and did not burn out stochastically, it has taken off.


Think about it. These results are not chance. They are destiny. If we do not humbly use this failure as an opportunity to learn from other countries and other cultures, then we have lost our minds.

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