Hacker News Reader

Comment by rich_sasha | Hacker News Reader

As others say, this is way too much to say "meh", but I do think it needs a rethink of the lockdown strategies.

Lockdowns kill people; people with cancer, people who need surgeries, people who lose income to support themselves. Clearly, so does Covid, and we need to balance it.

Can we do better, as societies, if we aggressively protecting old and vulnerable people, and let fitter people continue with their lives? This can avoid the economic collapse of lockdowns, bring about some degree of herd immunity, and yes, trading some lives saved by lockdown for lives saved by "normality".

Suppose 70% of the society is under 50, and has a IFR of 0.1%. Take UK (65mn people), and suppose everyone in that group gets it. That would lead to 45k fatalities (very close to what was already experienced), plus herd immunity, and lack of economic collapse. It's clearly not so simple, but it's start.

I'm in no position to question the research, but I spoke once to a professor of respiratory diseases at UCL, who quoted that mild Covid cases often do not register in antibody testing (for reasons unclear), so I wonder if even the 0.3% is an overestimate.

View on HN

This is more or less what Texas has decided to do. I’m in California, but my entire family is there, and many of my younger family members are going about their lives relatively normally.

At least one of my cousins caught it and their whole young family (parents 30’s, kids <10) were fine. My 90+ year old grandparents are obviously being kept very isolated. Their kids (my parents’ generation - 60’s) are being careful, but not cancelling their entire 2020.

Everybody hated on Texas because of the Lt. Governor’s over the top declaration of sacrificing grandparents for the economy, but there are definitely aspects of their approach that I prefer to what’s happened in California.

You have no idea how it would affect you or your family members until it does. This person lost 8 family members. https://www.cnn.com/2020/10/14/us/phoenix-arizona-aguirre-fa...

"Then, despite all precautions against the virus, a family member got sick. Then another and another and another. Now, seven months after the shutdown, seven people in Ricardo Aguirre's extended family and his father, Jesús, 67, have died of Covid-19 complications."

Two observations: First, this happened despite all precautions. Secondly, extended families can be hundreds of people, including many elderly. Lastly, in a large-enough population you will inevitably find clusters that are more affected by some illness than the average person. That's why you need to observe solid data, not a media spectacle, to come to rational conclusions.

> First, this happened despite all precautions

... in this family.

Florida went even further and removed all state level lockdown orders on September 25. So far it's too early to tell what effect that will have on the death rate. Case numbers are roughly flat.

https://www.worldometers.info/coronavirus/usa/florida/

I'm not advocating for other states to follow Florida's approach. But it serves as a natural experiment. Depending on what happens to their daily death rate over the next couple weeks that will tell us a lot about the effectiveness (or lack thereof) of lockdowns.

>Depending on what happens to their daily death rate over the next couple weeks that will tell us a lot about the effectiveness (or lack thereof) of lockdowns.

It's already been more than a couple weeks since September 25th; how many more "couple weeks" do we need until we can draw a conclusion?

For patients who are going to die, that typically happens about three weeks after initial infection. After the lockdown orders will lifted it still takes a while for businesses to reopen and for people to change their behavior. There are delays in state level data reporting.

So I would say that if we don't see a sustained rise in death rates in about three more weeks from today then that would confirm the "null hypothesis" of lockdowns being ineffective. Or if they have a major spike in deaths then that would indicate that lockdowns are effective.

Well, you'd need a couple weeks before you expect to seeing measurable impact on cases/hospitalizations and another couple weeks before it starts really showing up in deaths. The daily data is noisy to start with so it's hard to eyeball trends, but it looks like cases have started to trend up recently and deaths are still mostly flat, which is about what you'd expect at this point in time if the lockdown that was lifted was having a significant effect on limiting COVID impacts.

> Depending on what happens to their daily death rate over the next couple weeks that will tell us a lot about the effectiveness (or lack thereof) of lockdowns.

Less than you might think, because we know the value of lockdowns for an contagious respiratory disease varies based on conditions, including the current infection and immunity rates on the local population, for which we have inadequate surveillance pretty much everywhere. It also varies by the degree of enforcement, which is also inadequately measured but probably was lowest in the same places that are inclined to remove lockdowns entirely. So we're missing lots of data necessary to interpret both the local meaning and the meaning for other places of any numbers that come of a one-jurisdiction top-level policy change.

'Lockdown' is only one artifact of net social distancing.

People's individual decisions to distance probably are the most important factors - in soft-lockdowns, some people might not have trouble having parties, hanging out with friends etc. but depending on the culture, directives by government, the level of 'fear' from the daily results ... people may adjust their behaviour.

I wish there was much more study on exactly what social distancing means in material reality, not just 'policy'.

The sad reality is that broad, indiscriminate lockdowns are the only real tool available to some "world powers". We know we can manage the covid pandemic with ubiquitous testing and targeted temporary lockdowns. But there is no testing capacity.

Which means ... it's not really possible to rethink the lockdown strategies. Given a choice between a thing that directly kills people, and something that more people die from in indirect ways, people are always going to default to preventing the direct deaths.

It's not even clear that lockdowns prevent deaths. A recent peer-reviewed study found lockdowns aren't associated with a statistically significant decrease in the number of deaths; what matters is social distancing: https://www.jpost.com/israel-news/social-distancing-more-imp...

It feels to me in some cases there is a bit of a point of principle here: "look, we're inflicting so much pain on everyone, just to make sure you're safe".

If an evil alien race came and threatened to kill everyone unless we isolate everyone over 45, I'm sure humanity could do it.

If we can't be smart about fighting the pandemic, that's a super sad statement about humanity's ingenuity.

We could do age-based lockdowns. Stores near me have ~2 hour periods in the day where you can only shop if you're 65+, I don't see why they can't make that the only time 65+ people are allowed to enter.

One of the more... interesting things about Covid-19 is that the countries everyone thinks are stuck with indiscriminate lockdown as their only tool due to lack of testing capacity actually have the most testing capacity, and the one everyone points to as a mass testing success story has about an order of magnitude less in per capita terms and is likely severely limited in their ability to actually detect cases as a result. It's the result of cached facts from like 6 months ago that have never been refeshed because the media have carefully avoided drawing attention to the new information in order to preserve their narrative, whilst using language that leads people to think it's still true.

Do you have details? A quick glance here shows low positive test rates in the countries that seem to be doing the best. Low positive test rates seem like adequate testing.

https://ourworldindata.org/coronavirus-testing

Low positive rates are an indicator that a country is having to do more testing to locate their cases than a country with a similar amount of cases, but higher positive rates. Nothing more, nothing less. At best, it indicates that the country has a relatively low infection rate (which is why countries that are doing better have low positive test rates), at worst it's because they're testing the wrong people.

Think about it this way. Currently, countries like the US or much of Europe tend to offer testing to anyone with mild potential symptoms that are caused by many common diseases. If they ever reach the point where Covid-19 cases make up such a substantial proportion of people with those generic symptoms as to affect the number of tests required, the country is in really deep, Lombardy-level trouble. The idea that the level of testing required depends on the size of the outbreak is nonsense created to continue the narrative that Western countries like the UK and US are still failing on testing and that's why we have so many cases well past the point it should've been put to bed. It made sense as a metric of testing aggressiveness in February when everyone was looking for cases linked to travel from China, since it tended to indicate how wide a net countries were casting when doing this, and a little bit back in March and April when many countries were only testing people with serious and obvious symptoms. Not so much these days.

(Note also that South Korea doesn't routinely offer testing to people with mild symptoms. Anyone can get tested if they pay out of pocket for it, but it's discouraged and at a tenth of the testing capacity of most Western nations I don't think they could handle many people demanding it. Which means they can't reliably detect cases not linked to ones they already know about, and of course those unlinked cases grow exponentially... Makes meaningful comparison of case figures and test positivity figures hard.)

I understand that low infection rates don't follow testing. But low infections rates _also_ means there are adequate tests for infections. What I was after was any kind detail about these countries being test constrained. Links, etc. Anything like that?

> The idea that the level of testing required depends on the size of the outbreak is nonsense created to continue the narrative that Western countries like the UK and US are still failing on testing and that's why we have so many cases well past the point it should've been put to bed. It made sense as a metric of testing aggressiveness in February when everyone was looking for cases linked to travel from China, since it tended to indicate how wide a net countries were casting when doing this, and a little bit back in March and April when many countries were only testing people with serious and obvious symptoms. Not so much these days.

There's plenty of evidence of long-term damage even in young and barely symptomatic cases - it's not a binary "dead/not dead" outcome.

What if the virus causes substantial disease burden years to decades down the road? We can't know, and should take every precaution to prevent its spread.

For example? I haven't seen a single paper showing such long-term consequences in healthy people are significantly more likely than from other viral infections. We'd especially expect to be seeing a large number of such cases in Sweden, should it be common, given they had no lockdown and a large number of infections.

Of course you haven't seen papers describing long-term effects, simply because the virus hasn't been around long enough for any long-term conclusions.

Therefore there are no studies saying there are NO long term effects either.

There are clues that long term effects/permanent effects even in mild cases may exist. E.g. some six scuba divers with mild symptoms/asymptomatic progression were checked afterwards (Innsbruck, Austria) and had what looked like permanent lung damage. Then again, the sample size here is far too small and the cohort far to "exotic" to draw any conclusions yet.

> Of course you haven't seen papers describing long-term effects, simply because the virus hasn't been around long enough for any long-term conclusions.

So you'd support locking down based on something for which we don't have any evidence yet?

We have seen evidence that the virus kills. That alone warrants action. In the beginning, the general lockdowns were fine, simply because we didn't know enough yet to come up with better solutions, and frankly didn't really have the time to rectify this before taking any action. Now whether or not to lockdown and what to lockdown can be applied more fine-grained. Of course, everything is still in flux, and some decisions will turn out to be wrong later. The entire response is trial-by-error, for lack of alternatives

In regards to potential long term effects, those should be a concern as well when making decisions, yes. Not the only concern of course, but not something to be ignored either.

>That alone warrants action.

In only warrants action if we're sure the negative consequences of the action won't be greater than the negative consequences of the viral deaths.

Interesting.

On one hand we have clear and ample evidence that the virus kills, and even more so when the health system of a country gets overloaded.

On the other hand we have a bunch of hypotheses arguing that lockdowns kill, etc, but no clear evidence for that yet. E.g. suicide rates are up on some locales like Japan and the UK, but down in others like Germany. (I am not disputing theses hypotheses as false, btw, as there is ample evidence that in order situations of e.g. economic turndown or e.g. isolation severe adverse effects occurred/occur; tho it remains to be seen what damage there actually will be)

Given how you seem all about the evidence, this should give you pause.

I agree that the effects of measures have to be weighted against the good of measures - namely "curve flattening". However, I still do think that the initial lockdowns were warranted as a short term measure, and that future, more fine-grained (hotspot) lockdowns are warranted.

Then there are other measures, such as facemasks... some people dispute the effectiveness... But really, that's a no-brainer now; even if it turns out the masks are not effective at all, the worst that came out of it really is mild discomfort wearing them (exceptions for medical conditions of course apply) - and some morons shouting at each other for either wearing a mask or not wearing a mask.

It appears however, that the whole strategy of "learning of living with Covid" might turn out to be unrealistic, we'll be forced to go for virus eradication route. NZ and TW, and partially CN did it, and they are doing very good.

I wouldn't know about China, because frankly, the data they release is fishy. NZ and TW do better, but mostly because of travel restrictions (and people do not like to travel anyway right now for the most part) and because they are islands. Doing the same for the big islands of "Eurasia" and "America" and Africa seems less feasible.

The "solution" will be vaccines combined with some adjustments on how people live for the foreseeable future. Until the next pandemic comes along.

I am not quite sure I buy "it is an island argument". There is very little political will I am sure, but virus doe not care about the politics. If winter death toll will be very high, it might trigger very drastic shifts in the policies. Vaccines might turn out to be not efficient enough as well.

I haven't seen any evidence, but there was a paper published recently that said that the lung damage dealt by covid is usually healed in ~3 months.

It doesn't even have to be worse than post-viral syndrome caused by other severe viral infections for it to be a problem. There's little immunity to COVID-19 and it's highly contagious.

This is like saying "COVID isn't worse than the flu" - even if it was true, having another flu-sized disease burden would already be bad, so it's a bit of a weird goalpost.

That being said, there's a lot of literature describing post-covid symptomes and hypothesized mechanisms of action, like [1]. The virus has been around for less than a year, so a quantitative comparison with something we have studied for decades makes no sense.

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320866/

>It doesn't even have to be worse than post-viral syndrome caused by other severe viral infections for it to be a problem. There's little immunity to COVID-19 and it's highly contagious.

But it does make it highly inconsistent to adopt policies so extremely destructive to economic and mental health when the same wasn't done for other viruses with similar long-term effects.

We have a chance at eradicating COVID-19, unlike other viruses that have been endemic for decades.

How would we eradicate a virus that has animal hosts? If the prevailing origin hypothesis is correct then the virus is presumably still circulating among horseshoe bats.

SARS-1 has been eradicated in humans;its precursor still probably is circulating among bats.

That depends on what you mean by "little immunity". Many people appear to have some immunity based on prior exposure to similar coronaviruses. That won't prevent infection but tends to reduce disease severity.

https://www.jci.org/articles/view/143380

That "some immunity" is clearly insufficient, because people who actually got infected with Covid itself and then again with Covid, in many if not most cases have more severe symptoms. In fact, the scarce evidence suggests Covid might be a subject to Antibody Enhancement; that would mean that every next infection will get worse and worse. In any case, Coronaviruses have long be known to cause very short term immunity. Even more importantly, constant reinfection may debilitate the organism so much, that even a healthy person will eventually fall into the risk group.

That is unscientific fear mongering. As with any virus there will be some outliers. But in general there is no evidence of widespread antibody enhancement. Reinfections are rare, and most reinfected cases have minor symptoms.

https://www.jimmunol.org/content/early/2020/09/03/jimmunol.2...

> That is unscientific fear mongering.

Please be careful with your words. What I said is clearly scientific, because it can be falsified.

> most reinfected cases have minor symptoms.

This is clearly not true. See https://www.thelancet.com/journals/laninf/article/PIIS1473-3...

The article you linked is extremely old, July 17, when there was no reinfections known.

Besides, it is already known, that MERS and SARS both cause Antibody enhancement in animals, with paradoxical results - lower viral load, but severe damage

https://en.wikipedia.org/wiki/Antibody-dependent_enhancement...

This is a very important point. We don't know enough about long term effects yet.

In the same vein, we do not even know if herd immunity really is a thing here, and what thing it would be. E.g. the guy from Hong Kong who got reinfected (first time severe symptoms, second time no symptoms) was probably infectious the second time again. Herd immunity only works if the people who are immune are not infections and therefore cannot (re-(infect each other and more importantly the vulnerable population.

Herd immunity has never happened without a vaccine.

https://en.wikipedia.org/wiki/Herd_immunity

> Herd immunity was first recognized as a naturally occurring phenomenon in the 1930s when A. W. Hedrich published research on the epidemiology of measles in Baltimore, and took notice that after many children had become immune to measles, the number of new infections temporarily decreased, including among susceptible children.

(To be clear, though, I don't think the herd immunity strategy is a good one for COVID-19.)

The concept makes no sense. As soon as a carrier hits a group that does not have widespread immunities, you will get a disease cluster.

Not only do you have to have a huge portion of the population exposed to the disease, you need to maintain that proportion indefinitely AND will still deal with occasional flair ups among vulnerable communities.

That's not what most people think when they hear the word "immunity".

I guess I should have said 'Successful herd immunity'. The sentence after what you quoted is:

"Mass vaccination to induce herd immunity has since become common and proved successful in preventing the spread of many infectious diseases."

While I agree, we must always consider the impact of lockdown. This is what is missing to me in the current strategies. For example, how do the rare, and very significant, long-term health issues compare to the fairly prevalent mental health issues caused by lockdown, unemployment etc?

I'm in no position to make that call, maybe lockdown is still the right answer. But we absolutely must do this analysis seriously, publicise the results and debate it widely.

> What if the virus causes substantial disease burden years to decades down the road? We can't know, and should take every precaution to prevent its spread.

This is the precautionary principle selectively applied, and it’s what’s so wrong with the “lockdown” debate.

What if lockdowns cause substantial health problems years to decades down the road? We can’t know that either. Acting like Covid is the only thing whose aftereffects might be worse than we can tell right now is ignorance.

You’re proposing “aggressively protecting old and vulnerable people”. ...so does that not mean a strong lockdown for those people?

> and lack of economic collapse

In your model you’re calling for a strong lockdown of 30% of the population. How is that not going to have a powerful negative impact on the economy?

Also, as a practical matter, I doubt society will accept a strategy that minimizes the impact of covid-19 on one group of people at the expense of another group of people when the other group of people are politically powerful (and, not incidentally, a great number of various types of leaders are part of the other group).

> You’re proposing “aggressively protecting old and vulnerable people”. ...so does that not mean a strong lockdown for those people?

> In your model you’re calling for a strong lockdown of 30% of the population

Why ask a question and then assume an answer?

Precautionary measures for the elderly can be food delivery, direct financial support, free N95 masks, free healthcare, priority vaccination, etc.

Food delivery and direct financial support don’t protect people from getting covid by themselves. They would help people isolate... so you’re still talking about locking people down to protect them.

Free N95 masks would help to the extent it increases the number of people wearing them. But that’s hardly aggressive. Aggressive would be mandating that old/vulnerable people wear masks (which is another form of lockdown).

Free healthcare would help with the financial situation of those that get the virus and survive, which isn’t exactly the goal.

Priority vaccination... well, there is no safe and effective vaccine. Maybe that will be a good path six months from now. But if we had one, the goal would be to vaccinate everyone. Priority would be nice, but would ultimately only shorten the months-long window for infection (vs those without priority) by a matter of weeks. So that would be helpful, but not a game changer.

> Lockdowns kill people

Agreed. But what causes lockdowns? An uncontrolled pandemic. What does uncontrolled pandemic also cause? Collapse of healthcare infrastructure, which is a civil emergency that also results in countless deaths.

Lockdowns, as implemented in places like the US, are a reactive measure because of a system-wide failure to adopt and maintain proactive measures needed to control things. You don’t arrive at “herd immunity” without them, but mass deaths, both from the disease and being unable to receive other routine or emergency healthcare.

I'm not demonizing lockdowns. They have a use, for sure, and they save lives. I just mean, they have their own downsides too, and we should use new data to evaluate how we implement them.

It is now clear societies cannot really afford full, long-term, unconditional lockdowns. We have to pick and choose what we do, stratifying by age/health conditions seems a good way about it to me.

Nowhere outside of places New Zealand and Taiwan has had long-term, unconditional lockdowns, and nowhere in the US has reached anywhere near this level of restrictions. I live in a state that ostensibly had “extreme” lockdowns and whole cities and communities decided themselves exempt from the orders with zero consequences.

It’s also impossible to stratify people on the basis of health in the US because not everyone is cognizant of their health status or risk factors, certainly the government has no insight into these beyond the crudest levels. Age also doesn’t really work because the lack of social safety nets mean older workers have to remain employed or rely on younger cohorts in order to survive.

UK put everyone who cannot work due to Covid on 80% of their salary (sort of). So surely it could do that to a smaller cohort too.

That US cannot do it is no reason to not consider it.

Oh, certainly. Apologies for my US-centric framing. I hope the rest of the world follows South Korea, Taiwan, Vietnam’s example and not our’s. South Korea has only had limited, regional lockdowns and never closed their borders. If everyone followed their examples, lockdowns would likely be unnecessary to begin with.

The UK did this once. It's probably not going to happen again, certainly not on such generous terms, and one lockdown was not enough to stop Covid - just to delay it until right on top of the winter flu season.

Depends on the social security network, doesn't it?

It does. This is part of what I mean: if say 70% of the country can go about its business as normal, this frees a lot of resources for the state to help the remaining 30%. Stable-ish economies can foot the bill for this as well.

Simply caching away the unfit is not what I meant.

Me neither. In Europe we are lucky enough that most countries can maintain social networks for quite a while despite having mass unemployment and the like. But this only buys time. Hopefully enough.

Antibody tests do miss many cases, especially those with mild or no symptoms. Some patients are able to fight off the infection before antibodies are produced, or antibody production fades away quickly.

https://www.bmj.com/content/370/bmj.m3364

This same comment posted 3 or 4 months ago would have been downvoted into oblivion. Now it's the top comment on this article. It's good to see peoples' perspective is becoming more reasonable on this issue.

It was! I just refuse to optimise my posting for karma...

Only two states have continued preventing elective surgeries, one state (Texas) that was overwhelmed stopped but has since re-allowed them.

Around 60,000 cancer patients will be under-treated due to corona virus. The current estimates are that 10,000 people will die due to missed treatment. Just for the "fun" of it, lets assume all of them died due to under-treatment, that is still 1/4th the death toll of the virus itself.

If the goal is fewer deaths, why don't we encourage more treatment AND continue practicing social distancing? We can have both in this case.

I am 100% sure that the number of people who have died due to the lock down is a tiny fraction of those that have died of covid...

In Poland, cancer prevention literally got obliterated this year. That's thousands people whose cancers could be found early and treated, but won't be.

That's not to mention any other long-term disease.

Just the GDP drop, and the ensuing under-financing of healthcare etc, I think may well easily kill more people than Covid.

>I am 100% sure that the number of people who have died due to the lock down is a tiny fraction of those that have died of covid...

Are you sure? The economic fallout of lockdowns is pushing millions of people in poorer countries into poverty, and causing thousands of children to starve: https://www.france24.com/en/20200728-coronavirus-linked-hung...

In medicine, people like to talk about quality-of-life-adjusted years. Why? Because there's no point in making somebody live more years that are subjectively bad (e.g due to treatment side-effects), rather than less years that are subjectively good. When it comes to policy-making that affects us all, it's time to extend that to the collective level.

We need to ask ourselves, how much suffering can younger generations be expected to endure to make the older generations live statistically a bit longer? Remember, the average COVID death is in their eighties, which is already beyond life expectancy.

>Because there's no point in making somebody live more years that are subjectively bad (e.g due to treatment side-effects), rather than less years that are subjectively good.

This also applies to locking down the elderly, as lockdowns cause more loneliness, which increases the risk of mental deterioration: https://medicalxpress.com/news/2020-07-highlights-loneliness....

> that is still 1/4th the death toll of the virus itself.

That is the wrong comparison. We all die.

One better comparison could be expected years of life. The number I read was that Covid causes an expected decrease of 10 years in lifetime. What was the expected decrease in lifetime for those cancer patients because they missed out on treatment? I know you are only calculating a ballpark figure, but I suspect your ballpark is too inaccurate to be useful.

A sibling comment mentions quality-of-life-adjusted years.

Reply on news.ycombinator.com