What doctors on the front lines wish they’d known a month ago
nytimes.com
nytimes.com
Is this a technique that went out of vogue since my childhood, only to be replaced with a reliance on sedation and ventilators, and is it making a comeback due to the lack of ventilators?
Or it it because proning unconscious, intubated patients is hard work and requires three nurses? I can imagine that being difficult to do when your ICU is swamped. Here's what that looks like: https://www.youtube.com/watch?v=E_6jT9R7WJs
I think in this situation, it’s letting these patients be managed without sedation or intubation.
Where do you get the idea they didn’t?
https://edition.cnn.com/2020/04/14/health/coronavirus-prone-...
I think it's just as likely that maybe the knowledge is unevenly distributed, and if a doctor at the hospital is aware of it then it may spread, but may not spread beyond that hospital easily. It also may not spread until there are cases that benefit from it so other doctors can observe or hear about it.
Just like in software engineering, there are things that are taught, and then there are things that are learned over time, imparted by a mentor, or spread through a group. Doctors seem to have a better handle on this, as they do residencies to learn a lot of the practical skills that are hard to teach in a classroom, but that does probably lead to those skills learned in residency being fairly variable.
Proning is great! It keeps people alive. We are doing a lot of it. It's not new.
There are also problems associated with proning, including but not limited to: body habitus, loss of airway, hypotension, loss of venous access. I imagine that proning isn't always an option for some patients, and was basically told as much by an ICU attending last week.
I guess I'm trying to say that proning isn't a magic bullet, it's just one of many tools in a doctor's toolbox to try and save lives.
I'd hope this could be a generally applicable lesson after the pandemic. In less overwhelming times, the medical best practice is once someone is in hospital, prescribe the statistically best treatment even if it costs 100 times as much in resources and manpower. Now they go for simpler treatments because the resources aren't available to support the others, at least when the benefit is marginal.
But hospital resources are always stretched to the limit in some way. If you can treat a patient with 100x less intervention from doctors and nurses, you can instead treat 100x more patients, or build 100x more hospitals, or spend some of your hospital money on public health initiatives, all of which would improve overall health outcomes.
It may be news to (some) doctors, but that is not a lesson this pandemic taught us. In cost-utility analysis (https://en.wikipedia.org/wiki/Cost–utility_analysis), different interventions are compared against each other and against the “do nothing” approach.
This may make sense where hospital beds/ICU/medical professionals to capita ratio is low such as in low income neighbourhoods and countries but otherwise it’s mostly just useful for emergency planning.
The proper solution tends to be higher amounts of hospitals, mental health centers, supplies, preparation for outbreaks, etc. The actual hard stuff.
Otherwise this mostly amounts to doctors trained to use a generalized but dangerous hammer in worst case scenarios, in the face of what looks like a terribly difficult situation with no other solutions, and finding out more refined soft procedures like proning and flipping people on their sides works better for certain types of epidemic viruses.
I’d be wary to practically apply this beyond the next viral epidemic.
No other emergency grows exponentially.
Nuclear detonation, dirty bomb, power outage, hurricane, tainted food, etc. At worst they grow linearly at a high rate.
Consequently, highly contagious pandemic response must be fundamentally unlike any other response.
There are references to this bearing out in their prior wargaming of scenarios. All players (mistakenly) escalated linearly based on intuition.
When in reality you're talking about needing 10x resources every week, ceteris paribus.
[1] https://int.nyt.com/data/documenthelper/6879-2020-covid-19-r...
This epidemic might be an opening to shift the current equilibrium of over-medication and over-use of expensive treatments with questionable efficacy.
The proper solution could be changing the incentives structure in the medical system. From profit and executive compensation aligned structures that over-sell services and drugs into something that is connected with long-term public health.
https://en.wikipedia.org/wiki/Extracorporeal_membrane_oxygen...
Positive pressure ventilators however cover a wider range of medical issues though at increased risks.
External oxygenators are really a last resort which should be avoided whenever possible.
There are only a few hundred ECMO machines in the US. I suspect that’s less due to cost, and more due to the limited number of patients per year for whom ECMO has a good chance of being a net benefit.
And the way this "statistically best treatment" is calculated doesn't take into account complications from the treatment! Examples: complications from financial stress to cover the costs of the treatment, side-effects of the therapy unrelated to the original condition, infections with drug-resistant strains of hospital bacteria.
Also, the ventilator and assoc. monitors need to be redesigned such that rotating the patient easily/automatically repositions the equipment with the rotation.
[i] www.arjo.com/en-us/products/medical-beds/critical-care/rotoprone/
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Error 1001
DNS resolution error"(4) Salvage therapy: for patients with severe ARDS, a recruitment maneuver is recommended.
When human resources allow, prone ventilation should be carried out for 12 hours or more every day. "
https://www.chinalawtranslate.com/coronavirus-treatment-plan...
There's simply a shocking degree of arrogance from the West to refuse to learn even the most basic things from Asia about this.
For example, people are finally grudgingly admitting that CT scans could play a useful role in diagnostics after months of CDC & ACR denialism: https://www.statnews.com/2020/04/16/ct-scans-alternative-to-...
edit: More details in Jack Ma Foundation produced Handbook of COVID-19 Prevention and Treatment
(3) Prone Position Ventilation Most critically ill patients with COVID-19 respond well to prone ventilation, with a rapid improvement of oxygenation and lung mechanics. Prone ventilation is recommended as a routine strategy for patients with PaO/FiO2 < 150 mmHg or with obvious imaging manifestations without contraindications. Time course recommended for prone ventilation is more than 16 hours each time. The prone ventilation can be ceased once PaO/FiO2 is greater than 150 mm Hg for more than 4 hours in the supine position.
Prone ventilation while awake may be attempted for patients who have not been intubated or have no obvious respiratory distress but with impaired oxygenation or have consolidation in gravity-dependent lung zones on lung images. Procedures for at least 4 hours each time is recommended. Prone position can be considered several times per day depending on the effects and tolerance.
https://www.alibabacloud.com/universal-service/pdf_reader?cd...
There is no "shocking degree of arrogance from the West" but there may be a failure of adequate reporting, in this article and others, of what we are doing in hospitals.
Watch as Western countries start discovering as they roll out their automated contact tracing apps how little the tech plays a role in an effective contact tracing system.
There's a lot of parameters in the "design space" of contact tracing. If you're objecting to simply the most extreme version of it, then duh, anyone would, including the Chinese.
In the first stages of Corona we did a lot of old school contact tracing.
There's many different ways of doing contact tracing that involve myriad tradeoffs. Every Asian country that has rolled it out has had negotiations between the citizens and the government over the various dimensions and how to balance between competing concerns (yes, even China). Every country has landed in a slightly different form of contact tracing based on existing resources, societal norms and degree of urgency.
It's shockingly arrogant to assume that Asian citizens haven't grappled seriously with these issues and, even if they have landed in a different position than you would prefer, that the conversations they're having don't have any value.
I've yet to read a single English language piece on Asian contact tracing that has accurately described how contact tracing works on the ground in a nuts and bolts way across multiple countries. Instead, all I read are exoticised, fetishized pieces that focus on technological bells and whistles or highlights a bunch of theoretical privacy violations that either aren't a big deal in practice or easily gotten around with some simple design tweaks.
Then, you get people who go off half cocked and make sweeping statements about an entire category of methods while having done literally no research on how it actually works in a real world context.
That does not mean there are other voices in the West. But I do not know what you are looking for, and what you think is bad information.
Each approach has different pros & cons when it comes to privacy and effectiveness. Which one specifically do people think is acceptable and unacceptable?
Not sure it is Western arrogance rather than standard medical arrogance.
The video accompanying the NYT piece (5m:37sec) one doctor says:
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is insane for a new disease.
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
The problem is that Covid-19 is caused by a NOVEL virus which has no evidence base. There should be at least some skepticism regarding the applicability of previous studies.
Starting at 1min https://youtu.be/rfkbv_WQtn0
I thought it was just official health care, public institutions talking thru public media?
Reduce hospital load, reduce healthcare costs, get rid of the need to flatten the curve.
(Waiting for a my job to begin, waiting for my son to get his surgery)
This. A policy of flattening the curve will probably have to last for one or two years until either a vaccine is found or there is enough herd immunity. This will not only destroy our economy but the isolation will be a psychological challenge for many as well.
We have to take one step back and think why we wanted to flatten the curve in the first place. And that is because our hospitals don't have enough capacity. So why don't we do something about that? IMO that, in combination with some moderate curve flattening, is the only acceptable solution in the long term.
We are flattening the curve, yes, initially because hospitals don't have capacity, but the root of this issue is the exponential nature of infection transmission.
If we have the ability to build hospitals at a rate to match O(2^n) time then we can let everyone out and declare quarantine over! But as you know, an O(2^n) algorithm is extraordinarily hard to keep up with once n approaches any large number.
That's the curve we're trying to flatten - by changing the approach, changing the "algorithm" so to speak, by not allowing people to interact so they have less chance of infection.
If you are able to build a new hospital in a week, and then continue building a new hospital every day after that and then one every hour after that, and then a new hospital every few seconds after that, then you have a chance to keep up with an exponential curve (well, until the virus runs out of people to infect, so until it reaches 100% of the global population).
But unless you are hoping for a vaccine to be invented soon, which would of course be wonderful, you have to face the other scenario and that is that we have to slowly build up herd immunity. Herd immunity means that people have to get infected and a percentage of that will have to go to the hospital. No matter how you manage it, bigger hospital capacity simply means that you are able to reach herd immunity more quickly.
What does her immunity actually mean though? What other diseases do we try to tackle using herd immunity? How many deaths would make herd immunity acceptable or not acceptable?
There are 350m people in the US. We need to get about 60% of them to have had covid-19. That's 210m people. We don't know how fatal covid-19 is yet, so here are some lower numbers:
0.1% = 210,000 deaths
0.2% = 420,000 deaths
0.5% = 1,050,000 deaths
This disease has to be handled with intelligence and common sense, not with rethorics and dogma's.
Do you have any evidence to support that it would keep coming back? As far as I know there's only very small anecdotal evidence of people getting reinfected and we simply have no way of knowing yet whether the average person's immunity will last weeks, months or years.
IF (and that's a big if), the infection fatality rate really were just 0.1% (i.e., regular flu), then yeah I think letting this thing run its course is the reasonable thing to do.
In my mind, the reason for the lockdowns is because we don't know the morality rate yet, and so we should be cautious in case it's 1-3% how it was looking at first.
I could turn the question around on you, and ask what fatality rate makes the "run its course" strategy reasonable to you? No deaths?
It turns out that getting the number of infected down close to zero would also be good for the economy.
I don't understand why so many people think that the best possible plan is for everyone to get infected. The best possibilities involve a few percentage points of the global population getting infected, no where near everyone.
Respiratory viruses, once endemic, have never been completely suppressed. Even China is seeing a resurgence in cases. What we’re doing now isn’t sustainable or ethical, and we have to move on to smarter tactics soon.
My point is that if we move forward as if letting lots of people get infected is a 'smarter tactic', it's going to be worse in all ways. More death, more economic damage.
Since it looks like we’re close to this (even in places like NYC that are sitting on a vent stockpile) we can start loosening the economy back.
The point of “flattening the curve” is not — and was never — to reduce the area under the curve. This is a contagious respiratory virus, and it’s going to spread until there is herd immunity. Maybe there will be a vaccine in 12-18 months. Maybe not. But regardless, we can’t go on for that long with over 30% of society out of work.
Most people are going to get this virus. If you don’t understand that, you are scientifically illiterate. You are pushing on the ocean to prevent the tide.
Trying to forestall the inevitable by keeping us all locked in our homes will inflict such massive economic and social collateral damage that it’s simply unthinkable. We won’t stop the virus, and we’ll burn down our society trying.
Umm, no.
The number of people who pretend South Korea does not exist is too damn high these days...
We have managed to eliminate one human virus in history: smallpox. And we only did that through mass vaccination.
We have never eliminated a respiratory virus, nor have we ever developed a successful vaccine against a coronavirus, despite huge financial incentives to do it.
The inevitable outcome here is herd immunity. Maybe we’ll get there by vaccine, but not for a long time.
We had 18 new patients yesterday.
(I'd normally write a snarky comment here, but the numbers speak for themselves.)
I was going to make a comment on this article about the meme being too effective, in that it convinced people that the only point was to reduce the load on the medical system. Of course the goal is to reduce the load on the medical system, but that's step one, to get though the first wave of infections and to a situation where the spread is potentially controllable.
There's talk of multiple strains or of it mutating in ways which aren't necessarily more deadly but make reinfection possible independently of the currently found 2% who seem to be testing positive again after "recovering" from covid
Then the powers that be will realize just how deep of a shit situation we are in. The people who are protesting now are likely infecting themselves or will soon know a loved one with this and soon they will personally realize how stupid they were to protest this. It's only a matter of time...
That's like asking why does everyone think the best plan is for the sun to rise tomorrow morning.
It's not a "plan", it is fact. Everyone (to some level of precision) will be either have anti-bodies from infection or have been vaccinated (or the unrealistic enough to ignore; remain in isolation their entire life).
We don't have a choice in that. We can try to alter the parameters (rate, timing, etc.) of that. But, that is the limit of our control.
We don't run massive test and trace programs against cold viruses because they are relatively less harmful. We easily have the resources to run a massive test, trace, isolate and support program against COVID-19, and we can eradicate it using those methods.
And if a vaccine comes out before suppression is complete, so much the better.
The fact that we have only ever eradicated a pandemic by using vaccines is no reason to not try doing it without one. It's very hard to understand why people aren't screaming to spend a few hundred billion dollars to start doing this right now, as the payoff is essentially incalculable.
I think some people must consider the economy to exist in a vacuum. But economics is based on confidence in the future.
A robust, unified, can-do response would do wonders to shore up that confidence.
When the work pays off with a better outcome, it's foolish to look back and criticize the planning for worse outcomes, especially when the tools to manage the infection are pretty limited (social distance works well, but it's a brutal tool, so you want to use it only as necessary).
The predictions of what would have happened had no lockdown been introduced then haven't materialized precisely because the lockdown have been executed.
That is no argument that the lockdown haven't been needed.
Had the model's predictions been more accurate we could have found a better middle ground when it comes to lockdown. Every job saved and individual financially secure is one more person who can contribute to the community's well-being. I think it's pretty safe to say in retrospect that the lockdowns need not have been as draconian as they were. We had the hospital capacity to have less severe lockdowns and we should have done that. While we can't change the past, we can certainly look at how our models failed and rework our approach in the future. Anything else is irresponsible.
What you state now reflects exactly how many casual observers have problems to understand the exponential nature of the epidemics: if one observes the doubling time of three days, and that is what has been observed, this means only that the difference between needing 10k ventilators and needing 40k ventilators is only 6 days -- less than a week! Nobody can wait to actually need them to order them and get them delivered in so short time frames!
It was surely not possible to predict reliably how would have people reactd to which kinds of measures requested of the people, and the exact impact to the slowing down the spread (when exactly would doubling time get to be how much longer as a response).
Having an error of just 6 days in the middle of the exponential growth is not so negative if you are attempting to allocate resources to avoid tens of thousands of unnecessary deaths. And that statement of needing 40k ventilators is not what prevented some "better middle ground".
The "better middle ground" was surely possible to achieve by simply treating the epidemics much earlier as a serious issue and not acting as it is "just like flu" or would "disappear" overnight before anything has to be done.
Are we perhaps using less mechanical breathing devices here i Sweden?
Edit: this didn’t come out right... couldn’t find total icu death rate but have read stories about high mortality in NY.
Couldn’t find this data for us/ny.
It seems like there’s been a high focus on ventilator supply so I was just guessing a lot of severe icu cases would be put on one.
I have no idea, but would like to know.
If there was dishonest statistical comparison, this is the one.
In the UK it seems to be 50%.
Ventilators seem to exacerbate the condition for covid patients.
Sweden seem to have better success with intensive care than average.
Are we perhaps intubating less.
Train of thought ^.
I was assuming the 80% death rate was intubated ventilation.
From a glance, the US averages 3x the incidence rate of obesity as Sweden. Obese patients with existing health problems will result in substantially worse outcomes from Covid-19.
Also the swedish study is from 2012, so it's probably slightly higher now.
https://www.sciencedaily.com/releases/2016/06/160604050632.h...
The trajectory of cases and deaths in Sweden does not seem special to me, generally they seem to follow similar curve as other countries so far.
Certainly doesn't seem to be well outside of the range of outcomes in other countries at any rate. From what I've read--no first hand knowledge--it's also a bit hard to interpret the effect of Sweden not locking down. Apparently, at least around Stockholm, many people were staying home and not traveling. On the other hand, in at least some places, people were still going to bars and the like so it's a bit of a mixed bag. Almost certainly not business as usual but also likely a fair bit looser than a lot of places with more formal lockdowns. (And there's even quite a bit of variance there.)
https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports
This link opens a PDF download: https://www.icnarc.org/DataServices/Attachments/Download/c9b...
(17th April 2020)
> To date, ICNARC have been notified of 6664 admissions with confirmed COVID-19, either at or after admission to critical care, by critical care units in England, Wales and Northern Ireland. Of these, early data covering the first 24 hours in the critical care unit have been submitted to ICNARC for 6313 admissions of 5578 patients (Figure 1 and Figure 2). Of the 5578 patients, 2936 have outcomes reported and 2642 patients were last reported as still receiving critical care (Figure 3). The largest number of patients (1924) are being managed by the three London Operational Delivery Networks (Figure 4). Please note that Figure 2 and Figure 3 are affected by a variable lag time for submission of data of about 1-3 days (shaded grey)
[...big snip...]
> Critical care unit outcomes have been received for only 2936 (of 5578) patients, of whom 1499 patients have died and 1437 have been discharged alive from critical care (Figure 8 and Figure 9).
There's probably some more stats about critical care capacity here: https://www.england.nhs.uk/statistics/statistical-work-areas...
https://en.wikipedia.org/wiki/Obesity_in_the_United_States
"The obesity rate has steadily increased since the initial 1962 recording of 23%. By 2019, figures from the CDC found that more than one-third (36.5%) of U.S. adults[5] and 17% of children were obese.[6] A second study from the National Center for Health Statistics at the CDC showed that 39.6% of U.S. adults were obese as of 2015-2016 (37.9% for men and 41.1% for women).[7]"
A lot (100s) of deaths where old people have died of flu-like symptoms is counted as covid deaths. Teating has not been possible until just recently.
Likely an ICU patient in Sweden is in really bad condition seeing we have something like 90 ICU spots on 2,4 million people in Stockholm.
For example, in the Netherlands, in a blood test about 3% of the population was found to have antibodies, while the number of people confirmed to have corona via tests is at 0.15% of the population. We're looking at a 1:20 confirmed/actual rate.
That tells you testing is way off, about 20x so. The total tests performed is roughly similar to the US by the way, about 1 in 100.
Then there's death rates. The Netherlands currently saw 2 in 10.000 confirmed deaths from corona. This is about double the rate in the US. However if we look at excess deaths compared to a 3-year average for the same period (2017-2019) we see about triple the amount. Apparently 2 in 3 die of corona without it being tested or confirmed. (likely in nursing homes where mortality rates are often around 30% per year, and it's not uncommon for staff to find a patient died in their sleep for example).
And the Netherlands is a small country with high-quality public infrastructure. It's quite likely that it is among the countries with the best record-keeping system, and is among the countries with the highest tests per population, and even here we see massive undercounting of infections and deaths.
It's good to keep looking at the numbers, but only with a huge caveat. I'm actually completely flabbergasted that the media report on infection numbers without ANY mention of a confidence interval, standard deviation or some kind of uncertainty measurement, as well as some basic stats around testing methodologies, in particular when reporting cross-country comparisons. This should be the norm, but instead we just get country comparisons, world maps and graphs displaying wildly inaccurate and limited data (which is absolutely useful, but criminal to report without caveats). Apart from a mention about 'Chinese data isn't reliable' or 'India isn't testing much, so the problem may be far greater', there's really no consistent discussion about this. There's lots of standard statistical tools to express uncertainty which have been used in science for decades, but they're completely absent in our reporting or discussions at the moment.
https://twitter.com/CT_Bergstrom/status/1251344851984986118
https://twitter.com/CT_Bergstrom/status/1251346572656304128
> In the supplement they say 2 out of 371 + 35 known negative samples tested positive. This means that the 95% confidence interval for the false positive rate is [0.06%, 1.77%]. In their samples from Santa Clara County they had 50 / 3,349 = 1.5% test positive.
https://bnonews.com/index.php/2020/04/the-latest-coronavirus...
It isn't ideal, but this environment may make it much easier to rejig care standards.
The large number of patients with very similar symptoms would make it straightforward to test ideas out. I would also expect that the dire nature of the situation also makes it practical to experiment in a way that would not be possible normally.
It'll be harrowing and traumatic for the doctors, but the circumstances are conducive to promote swift learning about respiratory diseases. The fast way to learn is to be able to break a thing in many different ways. Not normally practical for health due to legislation and community outcry.
> I'm arguing for evidence-based medicine, which is something we all purported to agree with before the outbreak hit.
> We have large randomized controlled trials. The patients in those trials had met the same diagnostic criteria that are current patients meet. We should apply the results of the trials.
This is a new disease, the assumption that previous trials apply without even a bit of skepticism is fanatical.
What stats are you basing that on please? Because I can't find any stats that support this claim.
[1] https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820...
The long-term death rate of COVID-19 remains to be seen. The final verdict on how bad it was will depend on whether or not lengthy immunity is attained (including to mutations).
We do close schools here and there for a week or so when flu is getting large to get it under control. We do close hospitals for visits at this times.
Personally, I'm conservative on this, and have barely left my place in the last eight weeks. I can work from home and will suffer little even if the lockdown is quite lengthy. But not everyone is in such a fortunate position, and I think we need to consider what's happening very carefully.
Also, the thing to consider is that working class is whonis most at risk from this. Rich people have less comorbidities, can afford healthcare and are much more easily to work from home and buy via deliveries.
This is basically reason why African Americans die the most - working class can't isolate themselves so easily. They are the group to die more then same age non working class.
I think we are considering things carefully. I can’t remember the last time you saw both dem and rep governors agree on anything, yet they are all agreeing on stay at home orders and testing.
Not even the most extreme estimates I've seen suggest that NY has anything approaching 50% immunity. Reopening NY and letting people catch CV19 would double, triple, ? the death rate.
There is no suggestion that NY is special as regards total numbers. (Velocity, due to population density, assume yes.) This is not the flu.
[0] A of 2020-04-17 880 deaths per 1M population. http://91-divoc.com/pages/covid-visualization/
I agree, reopening NYC would be a mistake, but large portions of the US (especially rural areas) remain largely unaffected by this.
The average age of death in my state (MN) is 88 with preexisting conditions. Our death rate is 0.0019% (!) with a flattened curve for some time now. Most of the US is not NYC.
Minnesota death rate is, as you say, currently at 19/million, but is growing at about 10%/day. The curve fits WA state's; continuing along that curve, WA currently has 79/million and is growing by 3%/day.
The question is "How much net difference will different reopening schedules make?". The answer to that is unclear, but remaining in lockdown for six months could easily kill more people (net).
Aside from "old age", the leading causes of death (and certainly years lost) among people I knew are AIDS and traffic collisions. This virus is going to have to try a lot harder to get on that scoreboard.
It's also worth noting that "reopening" doesn't mean people will just revert to prior behavior. Most will be very careful, and some will never revert. Wuhan reopened, and their restaurants are not springing back (yet?).
> The long-term death rate of COVID-19 remains to be seen.
At the moment we count flu deaths differently to covid-19 deaths.
Counting deaths due to flu is hard. We've only just started this work for Covid-19 by putting in standards for death certification. These stats lag the real time counts by some time, and they're always higher than the real time counts.
So, we're taking a method for counting flu than over-counts, and a method for covid-19 that undercounts, and then saying "covid-19 isn't that bad".
And that's just looking at deaths. We also need to look at hospitalisation (because we want to look at all the harm caused by different illness to assess whether our measures are reasonable or not; and because iatrogenic harm is a thing) and we see that covid-19 does put a lot more people in hospital than flu normally does. And this difference is only partly explained by rates of immunisation against flu.
Now there's some controversy that UK government have been reporting other deaths as flu, basically hiding Winter deaths due, eg to poor elderly care, in flu figures. So other sources suggest far far higher flu rates; but this is going off death registrations.
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsde...
Covid19 death rates for under 50s are something of the order 1:1000, 30x the flu rate in data I've seen most recent (Worldometer) but reported rates vary considerably.
Happy for you to show it if this is wrong.
We're not going to, though, and it's becoming less clear why COVID-19 is an exception. It reminds me some of 9/11--it's flashy and freaking everyone out, which leads to irrationally conservative behavior.
That's with lock downs.
It's also hard to say what individual behavior would look like absent government orders to close businesses. Retail business could well be way down without any orders.
But, as we pass the initial peak and have better experience and surveillance, we should very carefully consider what to do next. Just locking down for a year or two is not the "safe" option.
So best to err on the side of caution until this disease is more fully understood.
Smoking habits and seatbelt habits and just about everything else is in a steady state. Nothing we can do can change those situations dramatically, we can only nudge them to a small degree slowly because those situations and habits are entrenched.
The point isn't that N people die from this so we should be cool with it because N is in the same ballpark as stuff we've accepted. The point is that we have a short window to solve the new situation before acceptance sets in.