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Do you know if outside-the-home includes hospital transmission? That could skew things severely.
Found my source.
What regulators spotted a couple of years ago is that banks were buying very focused packages of insurance that would pay off in exactly the scenarios of the stress tests. They had no commercial reason whatsoever, and were in fact probably quite expensive pieces of insurance to purchase. But it meant that the bank could, with a really straight face say, 'Well, you know what? In this stressful scenario we'd be totally fine.' And what's going on under the table is, 'Yeah, because our bet that this scenario would happen would pay off, and we'd suddenly get an extra half a billion extra dollars.'
I had misremembered the insurance as cheap.
Having savings is boring and unleveraged. Buying insurance against an *extremely specific* scenario does even better on the tests and costs much less.
My impression was that if anything these tests were making it worse, but I don't have the reference to double check.
A journalist suggests (and I find credible) that some shortages are due to demand moving from business-to-business to business-to-consumer supply chains much faster than supply can. E.g.,
- Business toilet paper has different fiber content, the rolls are much larger, and many more rolls are sold at a time.
- Restaurant/cafeteria bananas are small and sold in units of 150, consumer bananas are larger and sold in bunches of < 10.
Presumably these could be retooled eventually, but whether that's even a good idea depends on how long the shut down lasts.
EDIT 4/6 : At least one B2B provider is retooling to allow consumers to purchase from them (not an endorsement, I have not used the service).
I dug into this here and found at least a quarter of US produce harvesting is mechanized, which makes me less nervous.
Effect of Economic Downturns on Fertility
The effect of economic downturns on births is surprisingly complicated. On one hand, people have less money and kids are expensive*, which you would expect to lead to fewer children. On the other hand, a reduction in employment expectations reduces the opportunity cost of children, which you would expect to lead to more.
For the rest of this article, I will by default be referring to WEIRD countries.
Based primarily on Economic recession and fertility in the developed world and spot checking its sources, my conclusion is that modern recessions temporarily decrease per capita births, but by and large do not change cohort fertility (i.e. women have the same number of total children they would have had without the recession, but later). Some trends:
- The reduction in births is seen mostly in younger women (20-24), not older women (30-34), suggesting this is a voluntary decision incorporating knowledge of ability to have children in the future.
- The effect is much larger for first births than subsequent births, suggesting this may be more about union formation than post-union decisions to have children (this could also explain the age-related effects)
- The change seems to be driven more by change in situation than by absolute status, i.e. there isn’t a strict relationship between per capita GDP or unemployment and fertility that holds across countries, but in countries where children and women have the same status, people will react similarly to a change in circumstance.
- Male unemployment is universally bad for fertility.
- Female unemployment depends on the era (used to be positively associated with fertility, now is negatively) and on a woman’s socioeconomic status (richer/better educated women’s fertility is more procyclic than poorer/worse education women’s).
- Generous unemployment insurance or non-employment-linked maternity benefits unsurprisingly raise the birth rate during a recession.
Specific numbers are hard to give because every country, demographic, and recession is different, but as an example, this article estimates ~9% decrease in fertility in 2013 in the US.
* This is in societies where children are economic sinks. In situations where they are assets, you would expect the reverse.
My full notes are available here.
Thanks to Eli Tyre for research assistance.
Note that Prime Now, Amazon Fresh, and Amazon Pantry are all different services with different availabilities, and I can often find things on Prime Now that aren't on Fresh (haven't even tried with Pantry). Delivery slots haven't been abundant but can typically be found within 2-3 days.
I think you're being too modest, but I've removed it since you think it's been eclipsed by something better.
What happens to suicide rates in a recession?
They rise, primarily in unemployed men.
The long version
I linked to this study above, but for completeness:
A review found that out of 38 studies:
- 31 of them found a positive association between economic recession and increased suicide rates.
- 2 studies reported a negative association,
- 2 articles failed to find any association
- 3 studies were inconclusive.
Unfortunately they didn't share the effect size for most of these studies. Looking at other sources (notes here), I found anywhere from a 4% increase (across Europe and the Americas during the 2008 recession) to 60% (among men in Russia during the 1991 crisis). Studies typically found a much larger effect in men than women, sometimes finding no change in the female suicide rate at all. Different studies found different effects on different age groups; these felt too subdivided to me and I ignored them. Unsurprisingly, unemployment was positive correlated with suicide.
That 60% increase in Russia corresponded to an additional 30 deaths per 100,000 people per year, at a time when the overall death rate was 1300 deaths per 100,000 people. That 4% Europe/Americas increase represents 5000 deaths total, across three continents.
My understanding is the stress tests for big banks aren't very good- they encourage the bank to shore up against exactly the scenario they know will be tested, and no other. So I'm not very hopeful about them for grocery stores.
Produce will have trouble being picked because farms frequently rely on temporary immigrant workers, and the necessary immigration is banned. This is already happening in Europe, and seems likely to affect the US shortly. Even if it were not, migrant worker conditions seem pretty rife for disease transfer, so I'd expect a big hit to productivity even if they did show up.
Long term I expect this to shift consumption to things that require less human touch in harvesting, like grains and legumes.
ETA: Apparently Canada thought to exempt migrant farmworkers from the travel ban, but with air travel shut down is having much the same problem.
ETA 4/2: This paper words things in a confusing way, but: in 1997, 75-80% of vegetable-acres and 55-60% of fruits-acres grew a type of produce that has at least a 50% chance of being harvested mechanically. That's helpful for knowing what could be mechanically harvested in a labor shortage, but I assume it's too late for farmers to change plans this year. So the actual range (in 1997) was somewhere between 37.5-80% and 37.5-60% of vegetables and fruits, respectively, and has presumably gone up since.
Reasons this number could be wrong:
- Mechanization likely to have increased in the last 20 years
- Mechanical harvesting doesn't actually mean zero labor, someone has to run the machine.
- It's likely that some amount of labor will be found, one way or another
My conclusion is that in the US, if labor shortage is the only problem this year variety will fall, prices will rise, and there will be more emphasis on processed produce, but it's not likely to be a crisis.
One example: (I think, but have not hardcore verified, that) recessions tend to noticeably reduce births. This ends up being really great for the kids who were born into sufficient money, because when they mature there's less competition for top colleges, jobs, etc.
Interesting. My impression is that recessions can start many different ways but typically kick off the same self-reinforcing cycle, so that unhappy economies end up being very alike as well.
Economics Explained argues that I'm wrong, and this recession was caused by high leverage on mediocre bets, just like the last two.
UChicago professors use survey data to estimate 1/3 of jobs can be done at home, accounting for 44% of payroll. See here, scroll down to "How Many Jobs Can Be Done At Home?"
There are already different strains identified, seems plausible some are worse than others.
What percentage of the economy is "essential business?", according to most shelter-in-place laws?
Ballpark: 40m, out of 160m total.
I made a spreadsheet, using the CA definition but numbers for all of the US. It's not perfect- some industries I couldn't find at all (communications is the biggest blank space), the divisions used by the statistics don't map perfectly to the divisions used by the CA definitions, most numbers are from 2018, etc. But it's a start.
I suspect there should be numbers somewhere we can look for how many people were laid off in the first 2 weeks,
3.3m people filed for unemployment insurance in America in the last week. The previous record was 700k in 1982, when the population was 230m
Early Appearance of Symptoms
Tl;dr COVID-19 might start with a cough, or a fever, or both, or occasionally maybe neither. It might start suddenly or slowly. It might remit and then come back worse.
This was hard to figure out. Most academic/medical papers start with the person’s first contact with the medical system, which is too late, so I looked at social media and news reports. These are obviously going to be biased towards people with symptoms severe enough to be interesting, but not so severe as to die. I also restricted myself to test-confirmed cases, which because I was also looking at mostly American sources biases things towards severe cases. And I’m counting on people to represent themselves honestly. So there’s a lot going against this sample.
In total I found 11 cases, plus two notes from doctors doing front line work. You can see my and Eli Tyre’s notes on every case here and the symptom tracking spreadsheet here. Both are messy and no work has been spent making them comprehensible to others.
From this very small and biased sample:
- 36% of people started with a cough on their first day (55% if you count two people who had very mild symptoms on day 1 and developed a cough on day 2)
- 64% started with a fever.
- 18% of people started with both on the same day.
- 18% started with neither symptom (but developed a cough on day 2)
- 78% eventually developed a cough
- 91% eventually developed a fever. The only person who didn’t eventually develop a fever I think might be a false positive, because his symptoms were very weird.
- 27% had digestive symptoms (mostly nausea)
- ⅓ of recovered people had been hospitalized.
On the other hand, this pre-print found that only 44% of patients had a fever on admission to the hospital, and 88% ever had one. The fevers can be intermittent. Both that paper and the doctor I just linked to report very high occurrence (85%+) of lymphocytopenia (low white blood cell count), but that is not very useful to diagnosing yourself, and it’s not clear when it starts.
Known scientific source Business Insider says that most cases start with fever. They do not mention their source.
Commonly Repeated Things I Don’t Believe
You may have heard that 80% of cases are mild. Keep in mind that that paper defined mild to include mild pneumonia, which I would classify as at least moderately severe.
Similarly, the paper reporting 50% of patients appeared at the hospital with digestive symptoms counted “loss of appetite” as a digestive symptom. Only 19% presented with a more definitely gastroenteric complaint like nausea or vomiting.
I can't rule out it being 65%, or even higher. I would judge it as pretty unlikely, since I expect many of the asymptomatics on the Diamond Princess to in fact be presymptomatic.
What percentage of infections never develop symptoms?
Epistemic Status: Pretty confident in my uncertainty, expect more data to become available that eventually resolves the question
Tl;dr: Anything from zero to half of coronavirus infections are asymptomatic, but we currently can’t narrow it down much more than that.
One way to estimate the number of asymptomatic cases is to PCR test a bunch of people and see what percentage test negative. There’s three obvious problems with that:
- Unrepresentative samples- if you did this in the US the asymptomatic rate would be severely depressed because symptomatics are prioritized in testing.
- Some of those people might go on to develop symptoms later.
- The test could be wrong.
The most representative sample I know of is the Diamond Princess cruise liner, because everyone on board was tested, giving us some kind of reasonable denominator. It’s still not a random sample of the population, because cruise takers skew old-but-healthy-for-their-age, but it’s a start. Of that population, 3,063 tests returned 634 positive results, of which 306 were asymptomatic. But this only solves problem 1, a bit.
This pre-print uses statistical modeling to try to sort those into presymptomatic and true-asymptomatic cases, but has a weird math error I’m trying to get clarity on. I e-mailed the English-speaking author on 3/24 and will update if I hear back, but until then, here’s the problem: the model uses an incubation period of 6.4 to predict that 18% of C19 infections are true-asymptomatic (as opposed to merely pre-symptomatic). But when they let that vary from 5.5 to 9.5 days, they get a range of 20% to to 40%. That only works if percent-asymptomatic is a non-monotonic function of incubation period, and that would be extremely weird..
Even if that model is correct there’s still the problem of unreliable tests. This paper estimates that “almost half or more” of asymptomatic positives among people, tested in China, because they were in close contact with a known case, were false positives and the person never had the virus. Unfortunately the English abstract doesn’t specify how they came to this number, and the original article is in Chinese, so I can’t even attempt to translate this to other populations.
[EDIT 3/28: This paper has been retracted]
This news article based on “classified Chinese government data” says that ⅓ of people who tested positive asymptomatic, but doesn’t specify whether they were monitored to see if they stayed asymptomatic.
My best hope for better data on this is South Korea, thanks to its aggressive testing and monitoring strategy. Unfortunately I haven’t found any of their results, despite spending 30 minutes looking.
Interesting. Where is 30% coming from? Also, do you mind if this gets moved to Answers?
I've moved this to [edit by Raemon: "comments"] because it doesn't show reasoning (a requirement I've now made explicit, but which wasn't at the time it was posted). Happy to move it back if that's addressed.
That tweet says "WHO does not recommend against the use of of ibuprofen." . Where are you seeing them agree with France?
You're right, I changed it.
Front line medical professionals can volunteer for this prophylactic hydrochloroquine + other treatments study: https://www.covidtrial.io/
I am interested in helping with content and structure.
This post was edited on 3/22 to add answers
This post was edited on 3/23 to add new questions to the agenda and swap out the spotlight questions. (Thanks to elityre and romeostevensit for suggestions)
This post was edited on 3/30 to add two answers to "What are the basic epidemiological parameters of C19?"
This post was edited on 4/6 to:
- Add What are the costs, benefits, and logistics of opening up new vaccine facilities? to questions
- Add a discussion of postural drainage under "how to improve home care?"
- Rename "What will the economic effects of a 3 week quarantine be? 3 months?" to "
What will the economic effects of COVID-19 be?" - Add existing child questions to this question:
- Add What is the impact of varying initial viral load of COVID-19? to questions
- Update spotlight questions
Good point, I changed it.
This is great, thank you.
It seems like the biggest gap is that it can't detect what the non-COVID fever rate "should be" in the presence of interventions like social distancing and intense handwashing. So something ends up looking normal when it's really "decreased fever from decreased flu from social distancing + increased fever from COVID", which I would guess is what's going on in the bay and Seattle.
I say this as someone who was at one point extremely good with one kind of gun: guns take a lot of training to be useful for self defense. If you don't already have that training, I'm extremely skeptical they will be useful to you.
Epistemic status: I am not a doctor. This is based on a combination of the most rigorous medical lit searchers I could do over several hours, and individual reports that may or may not be based on anything. Wherever possible I’ve provided links to my sources so you can form your own opinions.
This is based on my best knowledge right now. I could be missing things, or new information could come to light, in which case I will update this as quickly as possible (and appreciate holes being pointed out).
Before you get sick
Uncontroversial
- Buy zinc lozenges (acetate or gluconate)
- Buy electrolytes in some form.
- Buy a thermometer.
- Take your temperature several times over several days to get a sense of your baseline.
- Buy a pulse oximeter if you can’t trust your subjective sense of “am I getting enough air?”, e.g. if you get panic attacks.
- Measure your oxygen saturation several times over several days to get a sense of your baseline.
- Look for COVID-19 related drug trials in your area, so you will have the information if you need to join one later
- Form care arrangements (for yourself, pets, kids, parents, etc) with people who will be able to follow through.
- You’re already quarantined, right?
- Buy gloves and masks for the person taking care of you (yeah, this is kind of aspirational at this point)
- Buy something to bring down your fever (an antipyretic). France is recommending against NSAIDs and against ibuprofen in particular. I will be very surprised if that ends up being born out (and WHO agrees with me), but if you believe them, you’ll want acetaminophen. If you don’t, any NSAID will work
- Buy pseudoephedrine (the real stuff, which is behind the counter in the US. Sudafed PE is useless).
Controversial
- Research drugs you might like to take if you got sick. I am deliberately not linking to more information on this because nothing is sufficiently certain right now that I feel comfortable recommending it to people who haven’t done their own research.
- Find a sketchy online pharmacy and buy drugs and medical equipment you feel confident self-administering.
At The First Sign of Illness
What are the signs?
That's an excellent question, but the more I research it the less confident I am in any particular answer. My eventual conclusions will be going up at this question, although right now I think the answer is going to be "feel sick? then maybe."
Uncontroversial
- Start taking zinc lozenges (gluconate or acetate. The terrible taste and loss of sense of smell says it’s working, unless you already lost your sense of smell to COVID).
- Set up your environment so it is easy to frequently drink small amounts of liquid, ideally with electrolytes.
- Rest, rest, rest
- Look for RCTs and drugs you might want to ask your doctor for, if you haven’t already.
- Restrict contact with other members of your household. Even if you've already exposed them, dosage matters, and you can spare them as much exposure as you can.
- Alert your care team. If anyone seems flakey, start looking around for new members.
- Check in with your doctor. They probably can’t do anything, but maybe you’ll get a test out of it, and that’s useful to your friends.
- Contact anyone you had contact with to warn them. Ask them to contact people they’ve contacted recently. Hopefully the number is small because you’ve been practicing good isolation.
- Take pseudoephedrine if you have unpleasant sinus pressure.
Controversial
- Do any research you told yourself you would do between buying sketchy drugs or medical equipment from sketchy online retailers and actually using them.
- Start any drugs acquired from sketchy online pharmacies that you have researched thoroughly enough to be willing to accept the consequences of your choice.
While Continuing to be Sick
- Continue to rest and hydrate, with electrolytes.
- Monitor your temperature. Let your fever play out unless it’s over Nº, at which point it’s legit dangerous to you and you should take the antipyretic you bought.
- I went looking for an exact value for N, but couldn’t find good studies on it, especially in adults. I was taught 103ºF, some people say 104ºF, that’s probably the range.
- (Optional) monitor your oxygen saturation.
- Continue to eschew human contact as much as possible.
When should I seek medical attention?
This depends in part on how functional your medical system is. If you’re in a place where you can get a drive by test and your doctor will order you experimental drugs over the phone, maybe do that. If you’re in the US, I don’t expect calling a PCP to do much even if you have one, which many people don’t. So your choice is “When do I go to the hospital?” keeping in mind that the hospital is well over capacity and that if you don’t have COVID going in, you’re likely to catch it there.
So I personally wouldn’t go to a hospital unless I clearly needed something I couldn’t get at home, which basically means oxygen or whatever they do when your fever is dangerously high for too long, which means “when I struggle to breathe” or “when my temperature is over Nº and antipyretics won’t bring it down”.
In a few places above I advise you to call your primary care physician, knowing full well many people don’t have one and that there’s not a lot they can do for COVID. That’s more ass-covering and future-proofing than anything; I’d feel really bad if it turned out they could do something and you missed out because I told you not to.
Of the initial 26 in the treated group:
- three patients were transferred to intensive care unit,
- one transferred on day3 post-inclusion
- one patient died on day3 post inclusion
- one patient stopped the treatment
no one left the control group.
"We left out four patients who got definitively worse" seems like a big flaw in the analysis.
My understanding is that asymptomatic spread is pretty common.
I'm looking for opinions on this video, by a virology professor. which so far is my favorite explanation of basic coronavirus science. It covers basic things others didn't (that there are literally no enzymes in a coronavirus capsule, it's just mRNA), and some more specific things that I really wanted to know (like where in the lifecycle chloroquine and azithromycin appear to be disruptive). Before I crown it king, I'd like to get feedback on how easy-to-understand and useful this is for other people.
Caveats: spends a fair amount of time on things I found interesting but not on a straight path to usefulness, like swine flu.
Other contenders are
- Medical Microbiology Chapter 57: Coronaviruses (less technical of the two I've read, although still aimed at biologists)
- Coronaviruses: An Overview of Their Replication and Pathogenesis
- Chapter 28 of Fields Virology, which I haven't read yet.
AFAIK Pedialyte is a perfectly good solution for the problem of electrolytes, if maybe on the expensive side. I've heard more complaints about its flavor than the other options, but if you know you like it that's not an issue. The liquid form is also bulky, so if it were me I'd get a powder or drops, but maybe you have lots of space in which case it doesn't matter.
But do you really think LessWrong should be going for something more comprehensive than that
...no, for the reasons you state. And I'm not sure why you think I do. Having found those I wasn't planning on actively searching for a better answer (although I'm looking forward to checking out both the chapter you recommend and the posts you are writing).
The way they're describing things- decrease in flu like symptoms with fever over X, affects this immunoglobin but not these- makes me think they're drawing their targets after shooting it. Do you know if they preregistered or otherwise showed good faith on this?
There was a twitter thread I didn't save that said:
1. we have vaccines for cat and dog CVs
2. Human CVs are unrewarding to vaccinate against because they only cause 30% of colds, so you can only advertise a reduction, not total prevention, of colds.
Find an RCT for COVID-19 treatment. This seems like a good compromise between "buy drugs from a sketchy foreign pharmacy and base dosage on a handful of papers" and "I dunno, my GP seems pretty on the ball".
One place I have found to find RCTs is https://clinicaltrials.gov/ . Normally I would verify the details of how to join but I assume they are busy right now. If you do try this, please report back.
Take zinc at the first symptom.
Other people (Scott, PhilH, knzhou Cochrane Review) have gone into the science before and I don't have much to add to their research, but here's my adaptation for COVID-19 in particular.
My synthesis:
- The method of action is zinc ions attaching to your throat. So pills are useless. It has to be a lozenge.
- This implies that zinc is only helpful with infections of the throat, not nose or lungs. According to a source I can't find because I read it before starting the links DB, COVID-19 often starts in the upper respiratory track and becomes dangerous when it moves into the lungs. If that's true, a good zinc lozenge might inhibit COVID-19 from turning serious even if it can't prevent infection entirely (note that under this model you would still be contagious and should take appropriate precautions).
- Chris Masterjohn claims only zinc-gluconate and -acetate work. I don't know if this is true, but the only studies I found used gluconate and acetate, so it seems wise to prefer them.
- I need to stop chewing my lozenges to make the process faster.
- I hope you already bought the right kind because it's all sold out right now.
Caveats:
- "A cold" can be caused by coronaviruses, rhinoviruses, or other. None of the studies I skimmed tried to different between causes. It's possible that zinc works amazing for rhinoviruses but does nothing for coronaviruses, or is amazing for some coronaviruses but not SARS-CoV-2.
- The loss of sense of taste and smell says it's working.
Should I take zinc prophylactically?
My first-principles, completely unverified guess is that if you take zinc all the time your body will adapt and it will become less useful. Also you will lose your sense of smell. I'm not taking it while in isolation, but I definitely would if I was a medic or grocery clerk right now.
I read a lot of recommendations for electrolytes but found all of the explanations kind of vague, so I did 2 hours of digging (plus more research from Eli Tyre). This is what I found
What are electrolytes?
An electrolyte is a substance that produces an electrically conducting solution when dissolved in a polar solvent, such as water. When applied to humans and health, it typically refers to sodium (Na+), potassium (K+), calcium (Ca2+), magnesium (Mg2+), chloride (Cl−), and is used for nerve signals and maintaining the right osmotic pressure in cells.
How does illness affect electrolytes?
Electrolytes are lost in sweat, including from fevers, environmental heat, and exercise. They can also be lost through diarrhea and vomiting- a big problem with bulimia.
Additionally, too much fluid can throw your electrolyte balance off, so if you’re following the advice to hydrate without taking electrolytes, you can make things worse.
What’s so bad about low electrolytes?
Your nerves will be worse at firing, leading to cramps, mental issues, and cardiac issues.
In extreme cases it can lead to spasms of the muscles in the throat (leading to difficulty breathing), stiffening and spasms of muscles (tetany), seizures, abnormal heart rhythms, and kidney failure (hypocalcemia, hypoatremia, hypokalemia). But you’re not going to let it get that far.
More speculatively, because calcium-based signalling is a key component in immune response activation, low calcium may weaken your immune system.
How speculative is this?
Not. Electrolytes are part of the standard routine in hospitals for COVID-19 and fevers in general.
Can I hurt myself with this?
Yes, but not easily. There is a level at which too much of any electrolyte is bad for you. My experience and the experience of many people I know is that you can tell by taste- electrolyte-enhanced water tastes amazing when you need them and unpleasantly salty when you don’t. Also barring certain specific problems like hypothyroidism, your body is pretty good at evening out your electrolytes as long as you give it the raw materials and time, so this is another reason to space out your fluid consumption.
The theory seems sound, what about the practice?
I looked for RCTs of electrolyte supplementation vs. not, but what I found was mostly studies of different types of rehydration therapies, always in children, and most for diarrhea induced imbalances rather than fever. The best I found was this meta-review showing isotonic IV fluid led to low sodium less often than low sodium IV fluid did
If you’re curious about the pediatric diarrhea studies...
How much do I need and when do I need it?
The literature was not very forthcoming on this, and I’m not a great person to ask because I put salt in my water by default. My folk wisdom is to add it to your water that you should also be drinking to taste.
Thanks to Eli Tyre for help with the research for this comment.
I ended up being pretty happy with both of the following, although neither was complete.
- Medical Microbiology Chapter 57: Coronaviruses (less technical of the two, although still aimed at biologists)
- Coronaviruses: An Overview of Their Replication and Pathogenesis
I was feeling rudderless trying to do actionable CV research without a grounding in its basic science, so I took a step back to build a foundation. These are the top sources that were useful to me:
- Medical Microbiology Chapter 57: Coronaviruses (less technical of the two, although still aimed at biologists)
- Coronaviruses: An Overview of Their Replication and Pathogenesis
These have also been added to the links DB
Do you know of places that would make good use of donations? If so, I strongly encourage you to write them up, ideally as an answer here.
I also think a top-level post making the case for or against focusing on COVID vs. (other?) X-risk is a great idea.
That group also was only 1.4% smoker, while china-normal in 2015 was 27.7% (almost all of whom were men). I wonder if people worried they'd get worse care if they admitted to respiratory co-morbidities?
Fixed, thank you.
We want to include more things exactly like this in the DB, thanks for posting. Is there a particular on ramp page we can link to? I worry if people go to the front page they will bounce off.