Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. The Centers for Disease Control and Prevention is conflating the results of two different types of coronavirus tests, distorting several important metrics and providing the country with an inaccurate picture of the state of the pandemic. We’ve learned that the CDC is making, at best, a debilitating mistake: combining test results that diagnose current coronavirus infections with test results that measure whether someone has ever had the virus. The upshot is that the government’s disease-fighting agency is overstating the country’s ability to test people who are sick with COVID-19. The agency confirmed to The Atlantic on Wednesday that it is mixing the results of viral and antibody tests, even though the two tests reveal different information and are used for different reasons. This is not merely a technical error. States have set quantitative guidelines for reopening their economies based on these flawed data points. Several states—including Pennsylvania, the site of one of the country’s largest outbreaks, as well as Texas, Georgia, and Vermont—are blending the data in the same way. Virginia likewise mixed viral and antibody test results until last week, but it reversed course and the governor apologized for the practice after it was covered by the Richmond Times-Dispatch and The Atlantic. Maine similarly separated its data on Wednesday; Vermont authorities claimed they didn’t even know they were doing this. The widespread use of the practice means that it remains difficult to know exactly how much the country’s ability to test people who are actively sick with COVID-19 has improved. “You’ve got to be kidding me,” Ashish Jha, the K. T. Li Professor of Global Health at Harvard and the director of the Harvard Global Health Institute, told us when we described what the CDC was doing. “How could the CDC make that mistake? This is a mess.” Viral tests, taken by nose swab or saliva sample, look for direct evidence of a coronavirus infection. They are considered the gold standard for diagnosing someone with COVID-19, the disease caused by the virus: State governments consider a positive viral test to be the only way to confirm a case of COVID-19. Antibody tests, by contrast, use blood samples to look for biological signals that a person has been exposed to the virus in the past. A negative test result means something different for each test. If somebody tests negative on a viral test, a doctor can be relatively confident that they are not sick right now; if somebody tests negative on an antibody test, they have probably never been infected with or exposed to the coronavirus. (Or they may have been given a false result—antibody tests are notoriously less accurate on an individual level than viral tests.) The problem is that the CDC is clumping negative results from both tests together in its public reporting. Mixing the two tests makes it much harder to understand the meaning of positive tests, and it clouds important information about the U.S. response to the pandemic, Jha said. “The viral testing is to understand how many people are getting infected, while antibody testing is like looking in the rearview mirror. The two tests are totally different signals,” he told us. By combining the two types of results, the CDC has made them both “uninterpretable,” he said. The public-radio station WLRN, in Miami, first reported that the CDC was mixing viral and antibody test results. Pennsylvania’s and Maine’s decisions to mix the two tests have not been previously reported. Kristen Nordlund, a spokesperson for the CDC, told us that the inclusion of antibody data in Florida is one reason the CDC has reported hundreds of thousands more tests in Florida than the state government has. The agency hopes to separate the viral and antibody test results in the next few weeks, she said in an email. But until the agency does so, its results will be suspect and difficult to interpret, says William Hanage, an epidemiology professor at Harvard. In addition to misleading the public about the state of affairs, the intermingling “makes the lives of actual epidemiologists tremendously more difficult.” “Combining a test that is designed to detect current infection with a test that detects infection at some point in the past is just really confusing and muddies the water,” Hanage told us. The CDC stopped publishing anything resembling a complete database of daily test results on February 29. When it resumed publishing test data last week, a page of its website explaining its new COVID Data Tracker said that only viral tests were included in its figures. “These data represent only viral tests. Antibody tests are not currently captured in these data,” the page said as recently as May 18. Yesterday, that language was changed. All reference to disaggregating the two different types of tests disappeared. “These data are compiled from a number of sources,” the new version read. The text strongly implied that both types of tests were included in the count, but did not explicitly say so. The CDC’s data have also become more favorable over the past several days. On Monday, a page on the agency’s website reported that 10.2 million viral tests had been conducted nationwide since the pandemic began, with 15 percent of them—or about 1.5 million—coming back positive. But yesterday, after the CDC changed its terms, it said on the same page that 10.8 million tests of any type had been conducted nationwide. Yet its positive rate had dropped by a percent. On the same day it expanded its terms, the CDC added 630,205 new tests, but it added only 52,429 positive results. This is what concerns Jha. Because antibody tests are meant to be used on the general population, not just symptomatic people, they will, in most cases, have a lower percent-positive rate than viral tests. So blending viral and antibody tests “will drive down your positive rate in a very dramatic way,” he said. The absence of clear national guidelines has led to widespread confusion about how testing data should be reported. Pennsylvania reports negative viral and antibody tests in the same metric, a state spokesperson confirmed to us on Wednesday. The state has one of the country’s worst outbreaks, with more than 67,000 positive cases. But it has also slowly improved its testing performance, testing about 8,000 people in a day. Yet right now it is impossible to know how to interpret any of its accumulated results. Texas, where the rate of new COVID-19 infections has stubbornly refused to fall, is one of the most worrying states (along with Georgia). The Texas Observer first reported last week that the state was lumping its viral and antibody results together. On Tuesday, Governor Greg Abbott denied that the state was blending the results, but the Dallas Observer reports that it is still doing so. While the number of tests per day has increased in Texas, climbing to more than 20,000, the combined results mean that the testing data are essentially uninterpretable. It is impossible to know the true percentage of positive viral tests in Texas. It is impossible to know how many of the 718,000 negative results were not meant to diagnose a sick person. The state did not return a request for comment, nor has it produced data describing its antibody or viral results separately. (Some states, following guidelines from the Council of State and Territorial Epidemiologists, report antibody-test positives as “probable” COVID-19 cases without including them in their confirmed totals.) Georgia is in a similar situation. It has also seen its COVID-19 infections plateau amid a surge in testing. Like Texas, it reported more than 20,000 new results on Wednesday, the majority of them negative. But because, according to The Macon Telegraph, it is also blending its viral and antibody results together, its true percent-positive rate is impossible to know. (The governor’s office did not return a request for comment.) These results damage the public’s ability to understand what is happening in any one state. On a national scale, they call the strength of America’s response to the coronavirus into question. The number of tests conducted nationwide each day has more than doubled in the past month, rising from about 147,000 a month ago to more than 413,000 on Wednesday, according to the COVID Tracking Project at The Atlantic, which compiles data reported by state and territorial governments. In the past week, the daily number of tests has grown by about 900,000. At the same time, the portion of tests coming back positive has plummeted, from a seven-day average of 10 percent at the month’s start to 6 percent on Wednesday. “The numbers have outstripped what I was expecting,” Jha said. “My sense is people are really surprised that we’ve moved as much as we have in such a short time period. I think we all expected a move and we all expected improvement, but the pace and size of that improvement has been a big surprise.” The intermingling of viral and antibody tests suggests that some of those gains might be illusory. If even a third of the country’s gain in testing has come by expanding antibody tests, not viral tests, then its ability to detect an outbreak is much smaller than it seems. There is no way to ascertain how much of the recent increase in testing is from antibody tests until the most populous states in the country—among them Texas, Georgia, and Pennsylvania—show their residents everything in the data. from https://ift.tt/3bWCKMx Check out http://natthash.tumblr.com
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The thwarted swimmers feel like beached mermaids. People who love swimming have been writing to Bonnie Tsui, the author of the recent swimming ode Why We Swim, to tell her how much they miss the pool, the beach, or the lake, now that they’re quarantined. For lots of people, swimming feels like not just a summer pastime, but a ritual that cleanses the body of temporal woes. According to researchers Tsui interviewed, when people rank the enjoyability of different forms of exercise, swimming routinely comes out on top. Water is both comforting and energizing; it clears the mind and buoys the soul. “It’s something that for me is not just the enjoyment; it’s also the tonic of it,” Tsui told me. “It is the medicine that I need to feel like a better person.” [Read: The healthiest way to sweat out a pandemic] Tsui, who lives in Northern California, considers herself fortunate. Though the local community pool where she typically swims four days a week has been closed since March 15 because of the pandemic, she’s still able to swim in the San Francisco Bay. But this summer, millions of American swimmers won’t be so lucky. They’ll be hot, pool-less, and—thankfully, but perhaps not happily—safer from COVID-19 for it. Even in areas where public pools do open this summer, swimmers may have a very different pool experience than they’re used to. For the time being, a pool day might feel less like a mini-vacation and more like a weird exercise class, complete with masks. The coronavirus can’t remain infectious in pool water, multiple experts assured me, but people who come to pools do not stay in the water the entire time. They get out, sit under the sun, and, if they’re like my neighbors, form a circle and drink a few illicit White Claws. Social-distancing guidelines are quickly forgotten. “If someone is swimming laps, that would be pretty safe as long as they’re not spitting water everywhere,” says Angela Rasmussen, a virologist at Columbia University. “But a Las Vegas–type pool party, that would be less safe, because people are just hanging out and breathing on each other.” In areas with few confirmed coronavirus cases, it’s tempting to simply throw open the pool gates and hope for the best. Outdoor areas, like pools or parks, are thought to have a lower risk of coronavirus transmission than indoor spaces. Many Americans have had enough of quarantining, and a few summer pool days may help release our pent-up energy ahead of another potential wave of shutdowns in the fall. For many kids, the pool is summer’s highlight—a natural gathering place and a chance to exercise when it’s too hot to do much of anything else. And indeed, certain pools and water parks in states such as Texas and Georgia have made plans to open this summer, though some will operate at reduced capacity. Earlier this month, the Centers for Disease Control and Prevention offered some suggestions for how pools can stay open without turning into viral hot spots. But not only do the guidelines seem far-fetched, if followed, they are likely to make for a somewhat strange pool season. For example, the agency said, pool operators could space lounge chairs six feet apart and disinfect them regularly. They could encourage people to wear masks when they’re outside the water—tan lines be damned. And strangest of all, the CDC recommends somehow keeping people six feet away from one another while they’re in the water. [Read: What you need to know about the coronavirus] These are just suggestions; the actual restrictions for swimmers will be up to local public-health authorities and the pool managers themselves. Experts I spoke with offered some more ideas, such as allowing people living at odd- and even-numbered addresses to come to the pool on different days, to facilitate social distancing. Pools could set up a reservation system for lap lanes and keep people from loitering around the pool. Some cities are opening just their largest pools—perhaps because their bigger size would better allow people to spread out. But these restrictions come with their own drawbacks. People might get frustrated that their designated pool “day” falls on a rainy Sunday rather than a sunny Saturday. And social distancing at pools can be hard to enforce. It’s not really possible to get small kids—some of the most enthusiastic pool-goers—to keep their distance from one another. At the pool, even normal adult behavior tends to devolve into joyous anarchy: If you spot your friend as you’re dipping in and out of lap lanes, are you really going to not stop and say hi? Plus, there’s the fact that lifeguards can’t keep a six-foot distance from someone they’re trying to rescue. [Read: Why some people get sicker than others] It’s enough to make some experts think we should just avoid pools entirely this summer. “I don’t know that there’s a safe way for them to reopen, at least not in the way we’ve classically used pools,” says Aubree Gordon, an epidemiology professor at the University of Michigan. “I don’t think it’s a good idea for people to be lounging around outside of pools right now.” She thinks that this summer we should make the choice to forgo pools—amazing, life-restoring, but, admittedly, not life-or-death pools—to reduce the likelihood of another outbreak. “We may have to keep some things that are nice to have closed or reduced so that we can have the things that are essential open and functioning,” she says. Perhaps realizing these risks, some cities have decided to keep pools closed throughout the summer. New York City Mayor Bill de Blasio has said the city’s pools will remain closed all summer, and he’s even warned New Yorkers that he will go a step further and have swimmers plucked out of the water at the city’s beaches. Several other cities, including Roeland Park, Kansas; Cedar Rapids, Iowa; Portland, Oregon; and Evansville, Indiana, have also announced that they will keep their pools closed all summer. [Read: America’s patchwork pandemic is fraying even further] I thought about all these closures and restrictions as I talked to Tsui. Like her, I love swimming. Though doing laps is great, I like all the other parts about it, too. I get depressed when I think about a summer without reading my book in the sunlight, my legs half-submerged, the pool water slicing through the humidity. Then I think about the chlorinated air—perhaps carrying a viral droplet—sweeping into my lungs. Tsui asked me if I’d be willing to adjust the pool experience for a pandemic-friendly version, in which I perhaps come at an appointed time, swim a few laps, then don my mask and head home right away. In essence, all of the social aspects of swimming would go away, leaving a tedious husk of exercise and caution. Is it even fun to be in a pool if you have to be sure to stay six feet away from everyone? I’ll take what I can get, I told her, but I won’t be happy about it. from https://ift.tt/2LGF8fs Check out http://natthash.tumblr.com Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. There was supposed to be a peak. But the stark turning point, when the number of daily COVID-19 cases in the U.S. finally crested and began descending sharply, never happened. Instead, America spent much of April on a disquieting plateau, with every day bringing about 30,000 new cases and about 2,000 new deaths. The graphs were more mesa than Matterhorn—flat-topped, not sharp-peaked. Only this month has the slope started gently heading downward. This pattern exists because different states have experienced the coronavirus pandemic in very different ways. In the most severely pummeled places, like New York and New Jersey, COVID-19 is waning. In Texas and North Carolina, it is still taking off. In Oregon and South Carolina, it is holding steady. These trends average into a national plateau, but each state’s pattern is distinct. Currently, Hawaii’s looks like a child’s drawing of a mountain. Minnesota’s looks like the tip of a hockey stick. Maine’s looks like a (two-humped) camel. The U.S. is dealing with a patchwork pandemic. The patchwork is not static. Next month’s hot spots will not be the same as last month’s. The SARS-CoV-2 coronavirus is already moving from the big coastal cities where it first made its mark into rural heartland areas that had previously gone unscathed. People who only heard about the disease secondhand through the news will start hearing about it firsthand from their family. “Nothing makes me think the suburbs will be spared—it’ll just get there more slowly,” says Ashish Jha, a public-health expert at Harvard. Meanwhile, most states have begun lifting the social-distancing restrictions that had temporarily slowed the pace of the pandemic, creating more opportunities for the virus to spread. Its potential hosts are still plentiful: Even in the biggest hot spots, most people were not infected and remain susceptible. Further outbreaks are likely, although they might not happen immediately. The virus isn’t lying in a bush, waiting to pounce on those who reemerge from their house. It is, instead, lying within people. Its ability to jump between hosts depends on proximity, density, and mobility, and on people once again meeting, gathering, and moving. And people are: In the first week of May, 25 million more Americans ventured out of their home on any given day than over the prior six weeks. I spoke with two dozen experts who agreed that in the absence of a vaccine, the patchwork will continue. Cities that thought the worst had passed may be hit anew. States that had lucky escapes may find themselves less lucky. The future is uncertain, but Americans should expect neither a swift return to normalcy nor a unified national experience, with an initial spring wave, a summer lull, and a fall resurgence. “The talk of a second wave as if we’ve exited the first doesn’t capture what’s really happening,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. What’s happening is not one crisis, but many interconnected ones. As we shall see, it will be harder to come to terms with such a crisis. It will be harder to bring it to heel. And it will be harder to grapple with the historical legacies that have shaped today’s patchwork. I. The Patchwork ExperienceA patchwork pandemic is psychologically perilous. The measures that most successfully contain the virus—testing people, tracing any contacts they might have infected, isolating them from others—all depend on “how engaged and invested the population is,” says Justin Lessler, an epidemiologist at Johns Hopkins. “If you have all the resources in the world and an antagonistic relationship with the people, you’ll fail.” Testing matters only if people agree to get tested. Tracing succeeds only if people pick up the phone. And if those fail, the measure of last resort—social distancing—works only if people agree to sacrifice some personal freedom for the good of others. Such collective actions are aided by collective experiences. What happens when that experience unravels? “We had a strong sense of shared purpose when everything first hit,” says Danielle Allen, a political scientist at Harvard. But that communal mindset may dissipate as the virus strikes one community and spares another, and as some people hit the beaches while others are stuck at home. Patchworks of risk and response “will make it really hard for the public to get a crisp understanding of what’s happening,” Rivers says. In one future scenario, the nation splinters. When national news diverges from local reality, “suspicions about whether the epidemic was a hoax will find fertile ground in places with a more ambiguous experience of the disease,” says Martha Lincoln, a medical anthropologist at San Francisco State University. Confused people will retreat to the comfort of preexisting ideologies. The White House’s baseless attempts to claim victory will further divide the already fragmented states of America. “In the face of medical uncertainty, people make decisions by returning to their own groups, which are very polarized,” says Elaine Hernandez, a sociologist at Indiana University Bloomington. “They’ll want to avoid being stigmatized, so they’ll follow what people in their networks are doing [even if] they don’t really want to go out.” Prevention is physically rewarding in the long term, but not emotionally rewarding in the short term. People who stay home won’t feel a pleasant dopamine kick from their continued health. Those who flock together will feel hugs and sunshine. The former will be tempted to join the latter. The media could heighten that temptation by offering what Lincoln calls “disparity in spectacle.” Fringe exceptions like anti-lockdown protests and packed restaurants, she says, are more dramatic and telegenic than people responsibly staying at home, and so more likely to be covered. The risk is that rare acts of incaution will seem like normal behavior. “There’s a natural saturation point for images of health systems in crisis,” Lincoln adds, and newly overwhelmed hospitals might be ignored in favor of fresher narratives. The local media are better positioned to pick up the nuances of a patchwork story, but of the counties that had reported cases of COVID-19 by early April, 37 percent had lost their local newspaper in the past 15 years. If the virus does indeed resurge and states need to shut down again, people may not comply, because they’ll be misinformed and distrustful. A second future is also possible. “When this outbreak began in China, everyone said, Thank God it’s not here,” Jha says. “It moved to Western Europe and people said, They have government-run health care; that won’t happen here. Then it hit New York and Seattle, and people said, It’s the coasts. At every moment, it’s more tempting to define the other who is suffering, as opposed to seeing the commonalities we all share.” But as the virus spreads, Americans may run out of others to discriminate against. “Crises are political only until they are personal,” wrote the journalist Elaina Plott, in a piece about a Louisiana woman who convinced her conservative friends to take the coronavirus seriously after her own husband fell sick. Similarly, President Donald Trump’s claims that the virus will go away on its own will ring false to supporters who know someone fighting for breath. There are signs that this is happening. While Trump’s popularity predictably surged during the crisis, his “rally around the flag” boost was a blip compared with the prolonged peaks of other leaders. Polls have also shown that pandemic partisanship is narrowing, with Democrats and Republicans more united in how seriously they view the threat. Beth Redbird, a sociologist at Northwestern University, has been surveying 200 people a day since mid-March, and “70 to 75 percent of people support most social-distancing measures,” she says. “Those are really large numbers in a society where 52 percent is often viewed as huge support. We rarely see that outside of authoritarian polling. Americans are by and large reading information in a very similar way.” Economic indicators support this view. Even in conservative states, activity plummeted before leaders closed businesses, and hasn’t rebounded since restrictions were lifted. As such, Redbird doesn’t share the widely held fear that Americans have become inured to social distancing and will refuse to suffer through it again. The bigger risk, she says, is that demoralizing bouts of shutdowns and reopenings will nix any prospect of economic recovery. “You only get to say Go out, trust me once,” she says. “They won’t believe you the second time.” Both possible futures are confounded by three aspects of COVID-19 that make the pandemic hard to grasp, and that are amplified by the patchwork effect. First, the disease progresses slowly. It seems to take an average of four or five days, and a maximum of 14, for an infected person to show symptoms. Those symptoms can take even longer to become severe enough for a hospital stay, and longer still to turn fatal. This means that new infections can take weeks to manifest in regional statistics. May’s declining cases are the result of April’s physical distancing, and the consequences of May’s reopenings won’t be felt until June at the earliest. This long gap between actions and their consequences makes it easy to learn the wrong lessons. Second, the pandemic is shaped by many factors. Social distancing matters, but so do testing capacity, population density, age structure, wealth, societal collectivism, and luck. Many countries that successfully controlled the coronavirus used masks; New Zealand did not. Many had decisive leaders; Hong Kong did not. It is easy to look at a patchwork and create just-so stories about why one place succumbed while another triumphed. But no single factor can explain differences across nations or regions. Third, the disease spreads unevenly. Some cases infect no one, and others infect many. In Washington State, a choir member infected 51 fellow singers during a few hours of rehearsal. In Ghana, a worker in a fish factory infected 533 colleagues. These “super-spreader events,” which are rare but pivotal, become especially important when cases dip. They mean that an untroubled region may continue that way for some time, but that once cases start growing, they can really grow. If a state reopens and sees no immediate spike in cases, is that because it was justified, because insufficient time has passed, because other things went right, or because unlucky super-spreader events haven’t yet happened? In a patchwork, these questions will be asked millions of times over, and many answers will be wrong. The COVID-19 pandemic is not a hurricane or some other disaster that will come and go, signaling an obvious moment when recovery can begin. It is not like the epidemics of fiction, which get worse until, after some medical breakthrough, they get better. It is messier, patchier, and thus harder to predict, control, or understand. “We’re in that zone that we don’t see movies made about,” says Lindsay Wiley, a professor of public-health law at American University. II. The Patchwork ResponseA patchwork was inevitable, especially when a pandemic unfolds over a nation as large as the U.S. But the White House has intensified it by devolving responsibility to the states. There is some sense to that. American public health works at a local level, delivered by more than 3,000 departments that serve specific cities, counties, tribes, and states. This decentralized system is a strength: An epidemiologist in rural Minnesota knows the needs and vulnerabilities of her community better than a federal official in Washington, D.C. But in a pandemic, the actions of 50 uncoordinated states will be less than the sum of their parts. Only the federal government has pockets deep enough to fund the extraordinary public-health effort now needed. Only it can coordinate the production of medical supplies to avoid local supply-chain choke points, and then ensure that said supplies are distributed according to need, rather than influence. Instead, Trump has repeatedly told governors to procure their own tests and medical supplies. Michael Kilkenny of the Cabell-Huntington Health Department, in West Virginia, says his state found itself short on swabs, disinfectant, and protective equipment; unable to compete in the global market; and abandoned by the White House. “It felt terrible,” he says. “We’ve been making homemade masks, or using bleach solutions. We had to fend for ourselves.” While reporting on pandemics in the Democratic Republic of Congo in 2018, I heard health-care workers repeatedly joke that the 15th article of the country’s constitution is “Débrouillez-vous”—French for “Figure it out yourself.” It’s a droll resignation that when resources are scarce, the government won’t fix your problems, and it’s on you to make do. The U.S., a country that’s more than 400 times wealthier, has seemingly adopted “Débrouillez-vous” as national policy. Even health officials in well-off states aren’t comfortable with a situation in which preparedness has more to do with wealth and connections than need. “We have everything we need,” says Angela Dunn, the state epidemiologist for Utah, where Governor Gary Herbert moved quickly to buy and secure tests and supplies. “But we did it in a very capitalistic way, and that’s not the best way to deal with a pandemic.” States have tried to level the playing field on their own. Wyoming ended up with few cases but a glut of testing reagents, which it provided to Colorado and Utah when those states saw spikes, Dunn says. “There’s a small barter system, but it’s not sustainable and it doesn’t work at scale,” she says. “I don’t know if Colorado is lacking supplies. If they have a huge spike, that’ll impact Utah. It’s in our interests to make sure everyone’s protected, and without federal coordination, that’s hard to do.” In some cases, the federal government has actively undermined the states. Charlie Baker, the Republican governor of Massachusetts, tried to buy protective equipment, but was thrice outbid by the federal government; he ended up using the New England Patriots’ jet to fly 1.2 million masks over from China, many of which turned out to be faulty. When Larry Hogan, Maryland’s Republican governor, procured 500,000 tests from South Korea, he kept them guarded in an undisclosed location so they wouldn’t be seized by the feds. This is not federalism working as intended, where different tiers of government work together. Instead of devolving control to the states, the Trump administration has ceded the U.S. to the virus. The U.S. now heads into summer only slightly more prepared to handle the pandemic that cost it so dearly in the spring. According to the COVID Tracking Project at The Atlantic, the U.S. is now testing 366,000 people a day—a record high. But experts estimate that the country needs 500,000 to several million daily tests. Here, too, a patchwork is apparent. An analysis by NPR and Harvard’s Global Health Institute showed that in early May, only nine states were doing sufficient testing, and another 31 weren’t even halfway to their requisite threshold. “I would have hoped for more, considering the cost of that time,” says Natalie Dean, a statistician at the University of Florida. Stay-at-home orders were necessary but ruinous, economically and emotionally. Their purpose was to buy time for the country to catch its breath, steel its hospitals, and roll out a public-health plan capable of quashing the virus. Many such plans exist. Umpteen think tanks and academics have produced their own road maps for dialing society back up. These vary in their details, but are united in at least having some. By contrast, the Trump administration’s guidelines for “opening up America again” are so bereft of operational specifics that they’re like a cake recipe that simply reads, “Make cake.” The Centers for Disease Control and Prevention prepared a more detailed guide but was blocked from releasing it by the White House, according to an Associated Press report. The guidance it has released seems carefully worded to avoid the term guidelines, as if it’s “trying to fly under the radar,” Wiley says. “The abdication of federal responsibility has left states with little choice but to ease the most disruptive physical-distancing measures without the testing data that would make us more confident that cases won’t rapidly surge.” The Trump administration “isn’t known for consistency of messaging, so we’ll never put our full faith in that,” says Kilkenny of West Virginia. “We pretty much ran our own state here.” At the time of this writing, only five states and the District of Columbia are still under some form of lockdown. A few, such as Alaska, Hawaii, and Montana, eased restrictions after their caseloads had fallen to low single digits. Idaho is reopening cautiously, despite being one of the less affected states. Georgia went all in on April 24, reopening gyms, restaurants, theaters, salons, and bowling alleys at a point when it had five of the 10 counties with the highest COVID-19 death rates nationwide, and was testing just a fifth as many people as it needed to. By contrast, Utah revived businesses a week later, when it had more than enough tests for everyone with symptoms, all their contacts, high-risk groups, and even random slices of the populace. Still, Dunn, the state epidemiologist, is nervous. “If we could stick it out for even a couple more months of stricter social distancing, it would do us a world of benefit,” she says. “There are embers everywhere, and they could ignite any moment.” Some states never put their fires out at all: Texas, Alabama, Kansas, Arizona, Mississippi, North Carolina, Wisconsin, and others all reopened while cases were still rising. “It’s inevitable that we’ll see stark increases in infections in the next weeks,” says Oscar Alleyne of the National Association of County and City Health Officials. The experiences of other countries support that view. Success stories like South Korea, China, Singapore, and Lebanon all had to renew or extend social-distancing measures to deal with new bursts of cases. And they had all restrained the virus to a much greater extent than the U.S., which despite having just 4 percent of the world’s population has 31 percent of its confirmed COVID-19 cases (1.5 million) and 28 percent of its confirmed deaths (92,000). In a connected country, flare-ups that begin in reckless states can easily spread into more cautious ones. Cellphone data, for example, reveal that after Georgia businesses revved back into action, more than 60,000 extra visitors poured in from neighboring states every day. Genetic studies show the risks of such movements. By using patterns of mutations to reconstruct the pandemic’s path, researchers have shown that most of New York’s cases likely stemmed from one introduction from Europe in mid-February. Most of Louisiana’s cases arose from just a couple of introductions from within the U.S. Just a few travelers can spark substantial outbreaks in new places. To mitigate such risks, about two dozen states have asked out-of-town arrivals to self-quarantine for 14 days. But tighter restrictions would be a logistical and legal nightmare. States can regulate what happens within their borders, but have limited powers to control travel across them. Congress could potentially do so, but it’s unclear if the courts would uphold any restrictions. The right to travel is supported by Supreme Court precedents, but in 1965, the Court ruled that said right “does not mean that areas ravaged by flood, fire or pestilence cannot be quarantined” if unlimited travel would jeopardize the safety of the nation. Legality aside, domestic-travel bans are of limited use. Even China’s extraordinary quarantine of Wuhan merely delayed the virus from reaching other parts of the mainland by three to five days. Much like social distancing, such measures only buy time. The better strategy is not to try and prevent the virus from traveling, but to build a public-health system nimble enough to catch it when it arrives. Don’t build one big wall; instead, ready a thousand nets. In this, the U.S. is also behind. Prevented health threats are less visible than present ones, which means that successful public-health departments tragically make the case for their own diminishment. Since 2008, underfunded local departments have lost more than 50,000 jobs. Even now, Cincinnati’s health department has furloughed 36 percent of its staff. “How can you have a system that’s meant to be at the front line of the defense while it’s losing the staff it needs?” Alleyne asks. Some states are trying to make up for these losses by hiring battalions of contact tracers. These people will call every infected person, talk through their needs, ask for names of anyone they’ve had close or prolonged contact with in the past two days, and call those contacts, too. The process isn’t complicated, but it is laborious. Experts have estimated that the U.S. needs 100,000 to 300,000 contact tracers, and the nation has been slow to recruit them. Selena Simmons-Duffin of NPR reported that only North Dakota had recruited enough as of May 7, although six more states and the District of Columbia were set to. Things are improving, though. When Danielle Allen of Harvard canvassed several mayors in mid-April, they weren’t taking contact tracing seriously. When she spoke with them again in May, “they were on top of it,” she says. “I was blown away by how much changed in three weeks.” New York State alone is planning to hire 6,000 to 17,000 contact tracers, while California is aiming for 20,000. “This really is the best tool we have to manage the pandemic until we have a safe and effective vaccine,” says Crystal Watson at the Johns Hopkins Center for Health Security. Will this system, combined with mask wearing and hand-washing, be enough to contain a patchwork pandemic? Complicating matters, people with COVID-19 can spread the coronavirus before showing symptoms. And yet, that hasn’t fazed other countries. South Korea has been rightly praised for its success, and though one nightclub-goer recently sparked a surge of at least 168 cases, the country seems to have contained this new outbreak too. Basic public-health measures have similarly worked in countries as diverse as Iceland, Jordan, Singapore, Germany, and New Zealand. And they have suppressed epidemics of the past, from smallpox in the 19th century to Ebola in 2014. “Some silver bullet isn’t going to save us. We can save ourselves,” says Gregg Gonsalves, an epidemiologist at Yale. “We have very old-school tools that beat fucking smallpox.” But those very old-school tools must also contend with old-school problems, which are difficult to recognize, let alone beat. III. The Patchwork LegacyThe current patchwork is not random. Nor is it solely the consequence of America’s actions in 2020. It has emerged from a much older, deeper patchwork. U.S. policies that evicted Native Americans from their own lands have long left indigenous peoples with insufficient shelter, water, and resources, making them vulnerable to infectious diseases like smallpox, cholera, malaria, dysentery, and now COVID-19. Up to 40 percent of the 170,000-person Navajo (Diné) Nation have no running water; they can’t effectively wash their hands. About 30 percent have no power; they burn coal or wood for heat, resulting in irritated lungs that are vulnerable to a respiratory pandemic—a problem exacerbated by uranium mining on their lands. Chronic underfunding has saddled them with crowded living conditions through which the virus easily spreads, dispersed health-care facilities that are low on beds and ventilators, and high rates of chronic conditions that increase the odds of dying from COVID-19. “The lack of basic services on the reservation isn’t due to our choosing to live this way,” wrote Wahleah Johns, a Diné woman, in The New York Times. “It’s because treaties and federal policies dictate how we live.” Thanks to traumas that accrued over generations and stressors that accrue over individual lives, the Navajo Nation has more per capita cases of COVID-19 than any U.S. state and nine times as many per capita deaths as neighboring Arizona. While Arizona has loosened its distancing restrictions, the Navajo Nation has been forced to tighten its orders. Black Americans have fared little better. After the Civil War, white leaders deliberately kept health care away from black communities. For decades, former slave states wielded political influence to exclude black workers from the social safety net, or to ensure that the new wave of southern hospitals would avoid black communities, reject black doctors, and segregate black patients. “Federal health-care policy was designed, both implicitly and explicitly, to exclude black Americans,” wrote the journalist Jeneen Interlandi for The New York Times’ 1619 Project. This is one reason why the U.S. still relies on employer-based insurance, which black people have always struggled to access. Such a system “was the only fit for a modernizing society that could not abide black citizens sharing in societal benefits,” wrote my colleague Vann Newkirk II. Over the past century, every move toward universal health care, and thus toward narrower racial inequities, was fiercely opposed. The Affordable Care Act, which almost halved the proportion of uninsured black Americans below the age of 65, was most strongly fought by several states with large proportions of black citizens. Last year, when the Global Health Security Index graded every country on its pandemic preparedness, the United States had the highest overall score, 83.5. But on access to health care specifically, it scored just 25.3. (Out of 195 countries, it tied with The Gambia for 175th place.) That is at least partly the consequence of letting segregationist tenets influence the allocation of health care. “The resulting arrangement all but guarantees an inadequate national response to a national crisis,” wrote Amy Kapczynski and Gregg Gonsalves of Yale. In almost every state, COVID-19 disproportionately infects and kills people of color—a pattern that Ibram X. Kendi has called “a racial pandemic within the viral pandemic.” Pundits have been quick to blame poor health or unsafe choices, without considering the roots of either. Racism in policing means that many black people don’t feel safe wearing the masks that would protect their neighbors. Racism in medicine means that black patients receive poorer health-care than white ones. Racism in policy has left black neighborhoods with less healthy food and more pollution, and black bodies with higher rates of diabetes, heart disease, stress, and what the demographer Arline Geronimus calls “weathering”—poor health that results from a lifetime of discrimination and disadvantage. “When America catches a cold, black people get the flu,” says Rashawn Ray, a sociologist at the University of Maryland. “In 2020, when America catches COVID-19, black people die.” These inequities will likely widen. Even before the pandemic, inequalities in poverty and access to healthcare “were concentrated in southern parts of the country, and in states that are politically red,” says Tiffany Joseph, a sociologist at Northeastern University. Not coincidentally, she says, those same states have tended to take social-distancing measures less seriously and reopen earlier. The price of those decisions will be disproportionately paid by black people. Vulnerability to COVID-19 isn’t just about frequently discussed biological factors like being old; it’s also about infrequently discussed social ones. If people don’t have health insurance, or can afford to live only in areas with poorly funded hospitals, they cannot fight off the virus as those with more advantages can. If people work in poor-paying jobs that can’t be done remotely, have to commute by public transportation, or live in crowded homes, they cannot protect themselves from infection as those with more privilege can. These social factors explain why the idea of “cocooning” vulnerable populations while the rest of society proceeds as normal is facile. That cocooning already exists, and it is a bug of the system, not a feature. Entire groups of people have been pushed to the fringes of society and jammed into potential hot zones. Of the 100 largest clusters of COVID-19 in the U.S., nearly all have occurred in prisons, meatpacking plants, nursing homes, and psychiatric or developmental-care facilities. (The only exceptions are a naval vessel and three power plants; the infamous Grand Princess cruise is only No. 148 on the list.) These places, along with homeless shelters and immigrant detention centers, are hubs for outbreaks that can easily spread to the surrounding communities. Prisons and nursing homes have staff and visitors who live in nearby towns. Large prisons, in particular, are usually situated in rural areas with small community hospitals that can be easily overrun by an outbreak. And many employees in nursing homes and meatpacking plants are immigrants who care for the nation’s elderly and process its steaks while also being cut off from health care by the Trump administration’s policies. They are both more likely to get sick, and less likely to get better. This point cannot be overstated: The pandemic patchwork exists because the U.S. is a patchwork to its core. New outbreaks will continue to flare and fester unless the country makes a serious effort to protect its most vulnerable citizens, recognizing that their risk is the result of societal failures, not personal ones. “People say you can’t fix the U.S. health system overnight, but if we’re not fixing these underlying problems, we won’t get out of this,” says Sheila Davis of Partners in Health. “We’ll just keep getting pop-ups.” Leaders can specifically place testing sites in poor, black, and brown communities, rather than the rich, white areas where they tend to be concentrated. New York Governor Andrew Cuomo, for example, is turning 24 churches in low-income areas into testing centers, while Maryland Governor Larry Hogan placed a testing facility in the heart of the predominantly black Prince George’s County. Officials can remove people from risky environments: Leann Bertsch, who directs the North Dakota Department of Corrections, has argued that prisoners should be freed if they are over 50, have serious illnesses, or are within two years of parole or release. A bipartisan group of 14 senators has made a similar call for decarceration. Policies can also support people in protecting themselves. Essential workers earn low hourly wages and cannot afford to miss a shift, even if they have symptoms. “The only way to prevent them from going to work is to give them paid sick leave,” Ray says. The same goes for a minimum living wage, hazard pay, universal health care, stipends for people who are self-isolating, debt moratoriums, rent freezes, food assistance, and services to connect people with existing support. The pandemic discourse has been dominated by medical countermeasures like antibody tests (which are currently too unreliable), drugs (which are not cure-alls), and vaccines (which are almost certainly at least a year away). But social solutions like paid sick leave, which two in three low-wage workers do not have, can be implemented immediately. Imagine if the energy that went into debating the merits of hydroxychloroquine went into ensuring hazard pay, or if the president, instead of wondering out loud if disinfectant could be injected into the body, advocated for health care for all? “We have decades of social-science research that tells us these things work,” says Courtney Boen, a sociologist at the University of Pennsylvania. “It’s a question of political will, not scientific discovery.” And while a vaccine will protect against only COVID-19 (if people agree to take it at all), social interventions will protect against the countless diseases that may emerge in the future, along with chronic illnesses, maternal mortality, and other causes of poor health. “This pandemic won’t be the last health crisis the U.S. faces,” Boen says. “If we want to be on better footing the next time, we want to reduce the things that put people at risk of being at risk.” Of all the threats we know, the COVID-19 pandemic is most like a very rapid version of climate change—global in its scope, erratic in its unfolding, and unequal in its distribution. And like climate change, there is no easy fix. Our choices are to remake society or let it be remade, to smooth the patchworks old and new or let them fray even further. from https://ift.tt/2WMcWxY Check out http://natthash.tumblr.com Many of our isolated lives fit the normal criteria for depression, but of course these aren't normal times. So, when the world is this depressing, how do you tell when you're actually depressed? On this episode of Social Distance, clinical psychologist Jennifer Rapke joins James Hamblin and Katherine Wells to explain how to think through mental health questions in the time of COVID-19. Listen to the episode here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: Can you introduce yourself for our listeners? Jennifer Rapke: Sure, this is Dr. Jennifer Rapke. I'm a clinical psychologist and I am currently the chief of Child Psychiatry Consultation Services at Upstate Golisano Hospital in Syracuse, New York. Wells: So what are your days consist of right now? Rapke: Right now, we're still trying as a hospital to keep as few bodies on site as possible. So my days are sometimes at home doing virtual work and sometimes on site. But our role in the hospital is to work with any kids under the age of 18 that are coming in with a mental health chief complaint. So they're here for depression, anxiety, suicide, all kinds of things. Wells: And is your work essentially the same as it was in pre-Corona world? Or are you kind of doing or experiencing something different now? Rapke: That's a hard question. My answer is always: it depends, as a psychologist. The content is technically the same. Our role in the hospital is still the same, but our method of doing that is very different right now. Normally, I'm physically in the hospital five days a week, so virtual is all new for us. And we're also really only seeing people when they absolutely have to be here, so the cases we're seeing are a little bit more severe. James Hamblin: When we talk about depression, often the medical system has the job of distinguishing: is this a context-dependent situation where it's going to go away and at what point it becomes a pathology? I understand it is a spectrum, but you as a clinician and you have to decide whether or not someone gets that diagnosis in their chart or doesn't. There's kind of a black line that has to be drawn because of the way the system is arranged at least. And I'm wondering if that line has changed for you at all in the current situation. Rapke: I see it on a continuum. All of us have varying levels of depression at different points in our life. All of us have varying levels of mood swings at points in our lives. When does it get to the point where, as a profession, we draw this line? The DSM is the main way we do that, where you have to meet certain numbers of criteria, but I never want a family to feel like that discounts their experience. So I don't in any way want people to misunderstand that, just because we don't say that it gets this code doesn't mean that that discounts their experience. Just to go back, it has changed a little bit. At what point would we just talk to a friend? It's very similar to medical triage, but it's sort of developing what those levels are. Can I call a friend and feel better, and that sort of changes things? Or have I called all the friends, baked all the cookies, and I still can't seem to get out of this funk? That's sort of the first level. If getting up and going for a walk, doing things that would normally help me feel better, talking to somebody that always helps me... If that doesn't do anything, now we're to the next point of: how long have I been feeling this way? Has it been just today? Or has it been lasting several days, where I really can't seem to get myself out of this state? At that point, you really need to reach out to somebody, whether you have a pastor or a good friend that has a little bit of experience or knowledge. It's at that point that maybe you need to reach out and do a little bit of screening, maybe even go online to some of the screeners online—some of the reliable ones through your local hospital. And then I think at that point, if that screener comes up, if your friend who normally can snap you out of it thinks this is more than your normal funk, then it's time. You definitely have to reach out to somebody, whether it's a hotline, your pediatrician, a counselor you've talked to in the past. Wells: Those three levels you were describing for kind of self assessment of how severe things are. Do those change, given the fact that so many people are going through traumatic experiences right now, like job loss and the family death in the family up to housing and food insecurity, like does it change how you think about those levels or. Rapke: I think those levels maybe are the same all the time. I think the pace of those levels probably changes right now. Because normally you can leave the house, you can go somewhere, you can do fun things. And if you can't do that right now, that probably speeds up the timeline a little bit, because the resources that you would have to try to snap yourself out of it are more limited. Wells: Something Jim and I have been talking about a lot, and I've been joking about it is like: we're all so depressed. It's a depressing time. Everything's horrible. Of course, we're depressed. But I feel like this is a good reminder that, of course this is a depressing and sad situation and there's so many things happening that are worthy of mourning, but clinical depression is not necessarily feeling sad because something bad has happened. It sounds like you diagnose less on the initial feeling and more on the ability to cope with the feeling? Rapke: There are specific content criteria for depression or anxiety. But the big thing that really distinguishes that continuum where we all have some level of sadness and depression is: is it impairing our functioning? Are we able to still take care of our children, to take care of our pets, to do whatever job or tasks we're needing to do? Maslow's hierarchy of needs is a thing I go back to all the time. One of the weekends that I worked on the crisis line, I spoke to this woman who is in a lot of distress and I said: you are trying to care for all of these people around you and do all of these really concerned things, but you're also concerned that you guys don't have enough food and that you guys don't have clothes or diapers for the baby or formula. Let's take care of these things first, because in Maslow's hierarchy of needs, the base of the pyramid—and you can't function without a good base—is food, water, shelter. So if I can't feed myself, if I can't feed my family, if I can't have a roof over my head, if I can't have basic clothing to keep myself warm and survive, I can't do other things. So anytime I have someone that's in crisis, that's how I organize their concerns: let's focus on the basic core things and make sure that you feel secure in that. And then maybe you'll feel more capable of doing these other things. So the takeaways are functioning, distress, and then: am I about where everybody else is? I think that's where the Covid question comes in. Are we all clinically depressed or are we all just adjusting to a really stressful situation? Hamblin: It sounds similar to how an internal medicine doctor doesn't want to see someone coming into the hospital already in multi-organ failure and delirious. It would have been much easier to know that person at their baseline and see them a bit earlier, and in psychiatry it's never ideal to hear from someone for the first time when they can't go to the food pantry or can't get off their couch and can't do the things they know they normally be able to just because they're in the depths of depression. At the same time, we have a lot of people feeling these symptoms, and it sounds like if we put the entire burden on the mental health system and had everyone who was in the early stages of these symptoms reach out, there would be an overwhelming wave. And so, things like food and housing insecurity—these things that might be at the root of some of the hopelessness and despair people are feeling—are systemic issues that we can't put all on mental health care later because people can't deal with these circumstances. It's the circumstances that we can fix. Otherwise, we'll just see this flood as it builds up in people who meet these criteria, but we could have prevented it. Rapke: Yeah, ideally we would be doing more primary prevention. The ratio would be more about doing the food and shelter and water and housing first, and then that would trickle down to other stuff. Secondary prevention is sort of a targeting of risk populations. And then tertiary prevention is you're just trying to not make it worse. Unfortunately, most of the time we're doing tertiary. I would love to see as a society, as a community, more primary efforts. But that's really complex, especially right now when resources are super tapped. from https://ift.tt/3bK1F5O Check out http://natthash.tumblr.com On this episode of Social Distance, James Hamblin and Katherine Wells talk to Adrienne LaFrance, the executive editor of The Atlantic who wrote the June cover story about the QAnon conspiracy theory, as part of “Shadowland,” a project about conspiracy thinking in America. They discuss the viral disinformation campaigns creating even more uncertainty about COVID-19. Listen to the episode here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: A listener named Ashley wrote into the podcast asking about an alarming video she came across online that she couldn’t get out of her head. She sent us a link to the video, which has since been taken down, but is called Plandemic. This video has gotten a lot of attention, and to discuss it, we decided to call Adrienne LaFrance. Adrienne, what is this Plandemic video? Adrienne LaFrance: It's a conspiracy theory positing that a secret group of elite world leaders unleashed the coronavirus on the global population as part of a plot to either enact population control or force people to get vaccinated. There is no evidence to support any of it. Wells: How widespread is this video? Is this just something on the fringe of the internet? LaFrance: It's really difficult to quantify the reach of these sorts of theories, but it's clear that it quickly spread very quickly across the internet. It's murky how many people saw it in communities that are either QAnon-friendly or otherwise fringe communities, and then how many further saw it because it started getting more media attention as news organizations felt compelled to debunk it. Wells: For the uninitiated, what is QAnon? LaFrance: QAnon is a conspiracy theory. The basic premise is that Q is a military insider who has proof that a secret group of world leaders are working with the deep state to torture children and that Donald Trump is aware of this and working to fight them. Q posts clues on the internet known as “Q drops” that advance these ideas. It's a real-time, participatory conspiracy theory. Wells: Is the Plandemic video directly related to QAnon? LaFrance: It's extremely QAnon-esque. It borrows a lot of the same language and narrative structure, if you can call it that. The same people who promote QAnon are now promoting Plandemic. The video fits very squarely within the QAnon worldview. Wells: One of the claims made in Plandemic is that the virus was made in a lab, potentially by the U.S. and Chinese governments. Did the virus come from a lab? LaFrance: Not to my knowledge. But this is an advantage of conspiracy theorizing, because people can always say they’re just asking questions. It's premised as a desire to find the truth, but with a total rejection of empiricism. When you encounter conspiracy theorists and present them with facts that don't fit into their worldview, they'll reject them. But then they'll still say they’re only trying to find the truth. It’s a brain-melting contradiction that I encountered in reporting the QAnon story and see in the Plandemic universe as well. Wells: Jim, is the idea that the virus originated in a lab a legitimate question? James Hamblin: When people ask that, they're often asking it with innuendo, implying that the virus was made deliberately. As best as science can know, there's no evidence that this was manufactured by people for deliberate purposes or released in a deliberate way. It is impossible to know if there was potentially someone studying this virus in some lab and it somehow was not contained, but that does not seem likely and we don't have any evidence that that happened. But like so many conspiracy theories, it's just a negative that we can't prove. It's really hard to prove that something 100 percent did not happen. All we can say is there's no evidence to suggest it did. Wells: Is it common that kernels of legitimate questions are embedded in conspiracy theories? LaFrance: On the one hand, any question is legitimate, right? So, making a world view all-encompassing enough that it answers or cleanly resolves something that's otherwise inexplicable has some appeal. There are people who claim that terrible events like terrorist attacks or mass shootings didn't happen. One could imagine the emotional appeal of explaining away a terrible reality. But when I talk to people who study conspiracy theories, they often say that a desire for coherence is not the driving thing that contributes to a propensity to believe in absurdities like this. Wells: Do conspiracy theories like QAnon or the Plandemic have consequences? Why do they matter? LaFrance: They matter because they represent a mass rejection of reason and enlightenment values and empiricism. They discount all of the ways we've learned to understand our world. It's a rejection of reality, and it’s dangerous when we can't agree on a common set of facts that make up the world we share. For Plandemic, the extent to which it's challenging science and the efficacy of vaccines is extraordinarily dangerous, because people will decide not to get vaccinated or get their children vaccinated. That presents a very real public health threat. With QAnon, I think a lot about Pizzagate, which was a precursor to QAnon that shares a lot of the same core beliefs about a secret cabal of elite, high-profile politicians, celebrities, and CEOs abusing children ritualistically. Someone who had been really drawn into this conspiracy theory drove from his house in North Carolina to Washington, D.C. and took weapons into a local pizza shop, ready to uncover what he thought was the secret child-abuse ring. Of course, he didn't find it because it didn't exist. But he did fire his weapon, and there were families and kids sitting there eating pizza. No one was hurt, but that's obviously still a very frightening and real outcome. Hamblin: Obviously, we all want answers. It's much nicer to have things wrapped up in a nice little package, but Plandemic is not even a nice little package. It doesn't even provide a motive. It makes less sense than what I'm hearing on the news. What do you think is drawing people to things like this? LaFrance: When I talked to the QAnon true believers, I kept language that borrowed from an end times worldview. There's a lot of picking apart the Book of Revelation and talking about a battle between good and evil and casting Donald Trump as a savior. There is this very strong spiritual aspect of it that I wasn't aware of before I started following it really closely. Hamblin: Do you have a solution? LaFrance: I hope journalism will help a little. It's especially tricky for the people who see their loved ones sharing stuff that is so patently absurd and dangerous, because we know that just confronting someone doesn't work. You can't just tell someone how ridiculous they're being and expect them to trust you more. Wells: A listener actually wrote in about experiencing this, because her mom is being sucked into coronavirus conspiracy theories. When she tried to send her mom accurate journalism about the pandemic, her mom texted, the media needs to shut down and then 80 percent of the world's problems would be gone, and then two pink heart emojis. LaFrance: In the course of my reporting, I talked to Joseph Uscinski, a professor of political science who has been studying conspiracy theories for ages. It came up in one of our conversations that his mom had started believing in QAnon. Wells: He's a conspiracy theories expert. And his mom believes in QAnon? LaFrance: Yes. I talked to both of them, and they understand that their worldviews are at odds. They don't try to convince each other. But to me, like, if even your conspiracy theory experts son can't convince you, how are the rest of us supposed to do it? I think it's on all of us to be disciplined in how we share information and vet the things that we encounter. I also think that platforms have a much bigger role to play in making sure that the informational environment is not harmful to all of us. from https://ift.tt/369s9MK Check out http://natthash.tumblr.com Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. How many coronavirus tests have been conducted in the United States? For the first time since February, the federal government has an answer. The Centers for Disease Control and Prevention now say that 10,847,778 coronavirus tests have been conducted nationwide. These tests have found about 1.4 million positive cases. These figures come from a new CDC website that appeared online last week with little fanfare. It marks an important but much belated development for the nation’s premier public-health agency, which has struggled to manage a pandemic that has killed more than 81,000 Americans and plunged the U.S. economy into a recession. Not since February 29, when the nationwide death toll stood at five, has the CDC published anything close to a comprehensive daily count of tests. For the past 11 weeks, the COVID Tracking Project at The Atlantic has been the country’s only reliable source for national testing data. (The tracker compiles the number of tests reported by each U.S. state and territory daily.) While the CDC has provided only occasional and rudimentary tallies of total tests, data from the COVID Tracking Project have been used by Johns Hopkins University, governors and members of Congress, and the White House. [Ezekiel J. Emanuel and Paul M. Romer: Without more tests, America can’t reopen] With the new CDC site, the federal government is providing regular testing data again, and for the first time ever, it is doing so on a state-by-state level. But an initial analysis of the CDC’s state-level data finds major discrepancies between what many states are reporting and what the federal government is reporting about them. In Florida, for example, the disparity is enormous. The state government reported on Friday that about 700,000 coronavirus tests have been conducted statewide since the beginning of the outbreak. This count should be authoritative: Governor Ron DeSantis has ordered hospitals and doctors to report their test results to the Florida Department of Health. Yet the CDC reported more than 919,000 tests in the state in that same period. That’s 31 percent more tests than Florida itself seems to think it has conducted. (Because the CDC says it does not update its data on the weekends, we have, throughout this article, compared its figures against the numbers reported by each state on Friday.) When we asked the CDC to explain the discrepancy in Florida, the agency declined to comment on the record. “If this is what they’re getting, the CDC should pick up the phone and call the state of Florida and say, ‘What’s happening?’” Ashish Jha, the K.T. Li Professor of Global Health at Harvard, told us. Given the complexity and the multisource nature of the data, some variations should certainly be anticipated. But the inconsistencies we found suggest that Florida is not an outlier. Using the state numbers that match the CDC’s output most closely, in 22 states, the CDC’s reported number of tests diverges from the number reported by the state government by more than 10 percent. In 13 states, it diverges by more than 25 percent. In some cases, the CDC’s tallies are much higher than what states are reporting; in others, much lower. [Read: The four key reasons the U.S. is so behind on coronavirus testing] In New Hampshire, the CDC reports about half as many tests as the state government; in Indiana, it reports about half as many more. California has reported the results of 1,133,906 tests, but the CDC is aware of 924,696. (Some of the largest discrepancies affect some of the country’s most populous states, including not only California but Illinois and Texas.) The state government of New Jersey says that 462,972 specimens have been analyzed. The CDC reports only 409,320. Alaska, Arizona, Colorado, Kentucky, Montana, North Carolina, Tennessee, Massachusetts, and Maryland also report testing figures that differ significantly from those published by the CDC. Curiously enough, the CDC’s state and national totals for cases and deaths match up well with what we’ve gathered from states at the COVID Tracking Project. So do its national testing totals. Only when you dig into the state-level testing data—where discrepancies skew in both directions—do things begin to go awry. The data sets have one known major difference: Some states report the total number of people tested, while the CDC reports every test, even if a single person is tested more than once. A spokesperson for Indiana’s public health department pointed to this difference to explain the state’s test gap. But our analysis suggests this—or any other methodological factor—does not fully explain the widespread discrepancies. Caitlin Rivers, an epidemiologist at the Johns Hopkins University Center for Health Security, told us that one possible explanation is that the CDC could be overreporting testing totals in some states if it is including antibody-test results, which don’t track real-time infections, and underreporting in other states because of delays in paperwork. But the differences seem to be so widespread that they are unlikely to arise from a single discrepancy in how certain kinds of tests are reported. At their current rate of growth, Florida’s state-reported testing numbers would not match the CDC’s current totals for another two weeks. “This is more evidence of the dysfunction of the CDC,” Jha said. “There is not supposed to be a lot of daylight between the CDC and the states.” Jha has previously criticized the CDC for being “inexplicitly absent” during the coronavirus pandemic. Some of the mismatch between states and the CDC could be explained by the federal government’s unusual manner of collecting testing data. Generally, disease-surveillance data flow from local public-health departments to state governments, and then on to the federal government. But in April, Vice President Mike Pence asked hospitals to start reporting their COVID-19 testing data directly to the federal government. In an email, a CDC spokesperson confirmed that the new website reflected test data from more sources than just states, saying it came from hospitals, private medical-testing companies, and state and local public-health labs. [Yascha Mounk: No testing, no treatment, no herd immunity, no easy way out] The data that Pence requested fed into a piece of software called HHS Protect, which was meant to serve as a clearinghouse of coronavirus data for the Trump administration, according to a spokesperson for the Department of Health and Human Services. HHS Protect was developed by the defense contractor Palantir. The company declined to comment on the record. It’s unclear exactly when the CDC site first appeared. A CDC spokesperson told us that it went live on May 7, but the first Internet Archive cache of the page is dated May 9. The CDC did not announce the existence of the page in any statement, social-media post, or press conference. In many of the counts the CDC did provide over the past several months, it missed the large majority of tests. In early May, the CDC reported that only about half a million tests had been conducted in the U.S. But the COVID Tracking Project had tallied the results of more than 7.5 million tests reported by states by then. In late April, the White House used the COVID Tracking Project’s data in a major report on national testing strategy. It cited the data again earlier this week in a press conference. The CDC should provide the country with a single, trustworthy data source on the state of COVID-19 testing. But the fact that its data is still in such disagreement with the state-reported totals means that the CDC’s latest efforts are not of much use to politicians and the public. For now, the agency that should be a respected source of truth in this crisis is only adding to the national confusion. from https://ift.tt/2WYgBI4 Check out http://natthash.tumblr.com The most universal experience of the coronavirus pandemic in America might not be a sense of fear or anxiety, but a profound confusion over what exactly is going on. Novel pathogens are confounding by definition, and since the first COVID-19 case was confirmed in the United States, in January, information about severity, spread, and a seemingly ever-expanding list of symptoms has trickled slowly and inconsistently out of emergency rooms and local health departments. Conditions are improving in some of the country’s major cities, but outbreaks continue to grow in others, as well as in prisons and rural areas—especially those home to large meatpacking plants. Every state tests at a different rate, makes those tests available to different types of people, and counts its results differently in official statistics. As some states have begun to partially lift shelter-in-place orders and allow businesses such as restaurants and hair salons to reopen, one particularly high-stakes point of confusion has emerged: When can you tell if a state’s reopening guidelines are keeping infection numbers down, and how long do you have to wait before you feel sure? [Read: Georgia’s experiment in human sacrifice] Humans tend to think of illness as a binary. You are sick or you aren’t, which feels simple and knowable. In reality, most types of communicable disease are far less black and white: People are infected before they become aware that they’re sick. For much of the outbreak in the United States, local officials have asked people who suspect that they have COVID-19 but aren’t having serious trouble breathing to avoid seeking medical attention. That means that by the time most infections become official cases, people have spent days or weeks trying to heal on their own before seeking care. The periods of information lag with COVID-19 are longer than those of the colds and flus to which it’s often compared, which has been a central problem in containing the virus since the beginning. In order to make predictions and policy from any particular day’s case numbers, health experts have to synthesize information about testing rates, positive rates, local guidelines, and anything known about how people are responding to instructions to stay home or get back to business. And in order to make everyday decisions and assess their own risk, people have to live simultaneously in the past, present, and future. Asking the general public to think in such broad and uncertain timescales is a tall order. “The concept of an incubation period or the onset of severe disease—those aren’t things that the public is well versed in, nor should we expect them to be,” says Tom Hipper, who manages the Center for Public Health Readiness and Communication at Drexel University. As a result, keeping the slow progression of a disease in mind can be difficult for regular people trying to make sense of official statistics. “As humans, I think we like instant gratification and we like instant feedback on things,” Hipper told me. The lull between new behavior and its measurable results “can make it a little more difficult to see the connection.” [Liz Neeley: How to talk about the coronavirus] The snail’s pace at which COVID-19 infections seem to run their course makes public-health communications about the state of the current outbreak unusually complicated. The available evidence suggests that it usually takes about five days for an infected person to go from transmission to symptoms, but it can take as long as 14 days and the person infected will be contagious for much of that time. The flu, by comparison, goes from transmission to symptoms in an average of two days and a maximum of four, according to the Centers for Disease Control and Prevention, and most people are infectious for only about a day before becoming ill. Public-health experts can’t change the pace at which COVID-19 moves once a person is infected, but information doesn’t have to be delayed as much as it currently is in the U.S. The speed at which cases of the disease become known to the medical system, government monitors, and the general public depends on how hard a state or country is trying to find them. So far, the best-case scenario seems to be what’s happened in South Korea. In January and February, as the situation in Wuhan, China, deteriorated, South Korea quickly began identifying and isolating infectious travelers from the country, seeking the contacts of known cases, and testing those people before they became symptomatic. This program of testing, tracing, and swift isolation meant South Korea had something closer to real-time information about how the disease was spreading within its borders, and it was able to control the outbreak quickly. Such proactive approaches allowed South Korea, Germany, and Hong Kong to relax some of their restrictions on business and travel, and to quickly identify any new outbreaks that resulted. But even with those measures, all have experienced an uptick in new cases after reopening. [Derek Thompson: What’s behind South Korea’s COVID-19 exceptionalism?] Although no particular outcome is guaranteed, public-health experts believe that something similar will happen in the United States in the weeks to come, as states begin to reopen. But here, we won’t have the benefit of such up-to-date information to judge the country’s progress. Andy Slavitt, a health-care official in the Obama administration, theorized at the beginning of May that the U.S. won’t see the cumulative effect of any reopening spikes until June, because of the weeks it takes for one case to go from transmission to death. Crystal Watson, a professor and risk-assessment expert at Johns Hopkins University’s Center for Health Security, recently told the Associated Press that she expects the lag in the United States to be even longer: five to six weeks from when businesses reopen. Those assessments have not stopped proponents of reopening from declaring victory in states that have already eased restrictions on businesses, such as Georgia, Texas, and Colorado. Two weeks after reopening, none of them has experienced dramatic spikes. Georgia, whose governor received the most intense blowback—including from me—seems to have kept its rate of transmission largely stable in the earliest days after lifting lockdown, according to estimates commissioned by The Atlanta Journal-Constitution, with about one new transmission resulting from every newly discovered infection. But because the state backdates many of its cases to when patients first had symptoms, it takes two weeks for case counts for any particular day to be completed. Public-health experts are largely in agreement that any changes observed right now, in Georgia or elsewhere, are the result of behavioral patterns from weeks before states began to reopen. In other words, any positive effects are the result of older restrictions, not recent leniency. [Read: What you need to know about the coronavirus] The gap between how quickly some countries find new spikes and how long experts believe it will take in the United States can be attributed to a fundamental difference in case-finding strategies. Instead of proactive testing and contact tracing, the U.S. largely relies on identifying cases only when people become ill enough to seek treatment, which can take weeks after exposure. The high cost of medical care in the U.S. can extend the delay; in New York City, reports indicate that many people in the hardest-hit neighborhoods waited until they were near death to seek treatment, at least partly out of fear of the expense. People white-knuckling it through severe cases of COVID-19 at home doesn’t just harm their health, but also means that the country doesn’t know exactly how the disease is spreading or who it’s affecting until significantly later than countries that have more comprehensive test-and-trace systems or make medical care easier to access. The results of these differences are cumulative, and the delays compound one another. “If you do good things now, you see good results three to six weeks from now,” says Tara Kirk Sell, a professor at the Johns Hopkins Center for Health Security. “If you don’t do the right things now, then it takes a little while to see those opposite results.” Even in states without particularly ambitious reopening plans, evidence shows that tests and cases are being counted in ways that can mislead casual observers trying to understand how an outbreak is evolving. Virginia, for example, briefly combined its statistics for tests of active infections and antibody tests, which indicate that a person might have been infected at any point in the past. This makes tying daily testing numbers to particular restrictions or behaviors useless. [Read: How Virginia juked its COVID-19 data] The lag in COVID-19’s progression isn’t particularly long compared with the lag of chronic illnesses such as emphysema and heart disease, for which public-health experts ask people to change their behavior to reap a payoff decades in the future. But because COVID-19 is a crisis-inciting communicable disease, the lag causes more problems. Society doesn’t have to shut down to mitigate the long-term impacts of smoking or eating too many fried foods, and late-in-life chronic health conditions don’t make attending a single birthday party or funeral an existential threat. When people are asked to change their whole life in onerous ways for an eventual benefit, as is the case with the coronavirus, they can get restless waiting for information about the results. “This long delay leads to a bit of an information void,” Kirk Sell told me. “We’re not able to tie facts together as efficiently, and there’s an opportunity for misinformation to grow.” The effect of this misinformation can be magnified by the decentralized approach that the United States has taken to its pandemic response. When officials in different parts and levels of government publicly spar and contradict one another, it violates what Hipper calls the cardinal rule of good risk communication. “Mixed messaging from sources who are supposed to be on the same side is one of the best ways to get people to lose trust and question recommendations,” he said. [Read: The problem with stories about dangerous coronavirus mutations] For now, daily cases are roughly stable in most states—though whether that’s a sign of fewer infections or a side effect of testing rates remains to be seen. More information is now emerging about what might be the most important factor in avoiding an immediate second spike in cases if the country returns to some degree of normalcy: how people in each state have been behaving in the past two months, including in the weeks after lockdowns began to ease in some areas. The available data paint a picture of state leadership whose wishes are secondary to what their constituents believe about acceptable risk. According to an analysis from the data company Opportunity Insights, people and businesses in states with late lockdowns began shutting down, staying at home, and taking the precautions recommended elsewhere, such as closing nonessential businesses and limiting visits to restaurants and bars, far before their own state leadership required it. Since lockdowns were lifted in some areas, the company’s data indicate that people have been extremely slow to return to work, dining out, and shopping, in spite of anecdotal reports of the occasional packed restaurant or store. In Georgia, in-restaurant dining is still down 92 percent from pre-pandemic levels, according to data from OpenTable. Reopening itself is far less dangerous for a populace when most people decline to play along. [Read: There’s one big reason the U.S. economy can’t reopen] Kirk Sell calls signs that individuals have continued taking their own precautions in reopened states “very encouraging.” Those behaviors indicate “people having an understanding of their own risks and the situations that lead to increased risks,” she said, which is no easy feat in a situation as confusing as America’s present reality. But doing that math, and living in three different time frames, for every trip to the grocery store and every afternoon in the park or at the beach becomes exhausting, even for people who believe that their vigilance is a matter of life and death. When staying at home, wearing masks, and avoiding prolonged contact with others starts to work and the immediate danger appears to recede, people will naturally want to stop abiding by them. “The more cases go down, and the longer this goes on, the more it opens people up to the thought that perhaps this isn’t as severe as we once thought,” Hipper said. To ensure that the country stays relatively united, public-health officials will need to use accumulating information about spread and risk to help people decide which activities they can add back into their life. “We know the age ranges and the risk factors. We know that it requires close contact—having a close, face-to-face conversation or being in the same household with someone,” Kirk Sell explained. “You need to be around people for quite some time, and a short interaction is much lower risk.” That decision making, she said, is what the next phase of the country’s communication should be about. The best way to avoid an information vacuum is to fill it with things people can actually use. from https://ift.tt/3cAKXaj Check out http://natthash.tumblr.com On this episode of Social Distance, James Hamblin and Katherine Wells talk with Edo Banach, the president and CEO of the National Hospice and Palliative Care Organization. They discuss how to create an advance directive and how to broach the topic in conversations with loved ones. Listen to the episode here: Subscribe to Social Distance on Apple Podcasts, Spotify, or another podcast platform to receive new episodes as soon as they’re published. What follows is an edited and condensed transcript of their conversation. Katherine Wells: What exactly are advance directives, and who should have one? Edo Banach: In a nutshell, an advance directive says what medical treatment you want done or not done in the event that you aren’t able to communicate what you want yourself, and it says what person you want making medical decisions for you. And I recommend that everyone has one. Wells: How granular do they get? Banach: It depends on how granular of a person you are. Take me, for example. My advance directive just says, “I’m naming an agent. I’ve had a conversation with the agent. The agent knows what my wishes are.” All I need to say is, “My agent is empowered to make decisions for me.” Wells: If it’s not too personal of a question, who is your agent? Banach: Well, agent one is my wife. But if we were in a wreck together, it’s my brother. So you have a backup agent. You have to think of the worst-case scenario. The problem with the whole advance-directives conversation is that when people usually hear it, they think about Terri Schiavo; they think about what happens when someone’s in a vegetative state or at the end of their life. But that’s not usually how advance directives come up. They usually come up when someone’s lost their ability to make a decision either momentarily, like if they’ve been struck or stunned, or permanently, like if they have dementia and can’t make decisions anymore. When that point happens, who do you want to make decisions for you? If it’s the system making the decision for you, like the hospital or the nursing home, they’re going to make the decision that protects themselves first. James Hamblin: When you say “protected,” you mean that the hospital system is going to default to a place where they can’t be accused of withholding care, right? It’s about prolonging life rather than providing comfort. Banach: Exactly. Most people don’t want to prolong life at all costs. Most people say they want to be at home with their loved ones and in the least restrictive, most comfortable environment. Wells: But it’s not that simple, right? There’s lots of gray area there. Banach: Right. I’ll give you a good example. In her advance directive, my mom specified that she wanted to be on a ventilator, if it ever came to that. But in the context of COVID-19, she said, “You know what? I’ve been doing some research and I’ve realized that people with COVID-19 who are put on ventilators who already have pulmonary problems, like me, usually don’t make it, so I don’t want a ventilator for COVID-19.” But for me, I’m 44. Maybe I do want a ventilator if I have COVID-19, because maybe I’ll make it. The problem with getting too granular is that you can never foresee everything that might happen or advances in medicine that might take place. That’s the argument for just making sure your loved ones know what you want. Wells: How do you get one? Banach: If you go to our website, you’ll be able to download your state-specific form. Once you have an advance directive, you should digitize it and get it into your medical records. If it’s under your mattress or in a safe-deposit box, no one’s ever going to see it. You don’t need a lawyer. I’m a lawyer, and I think a lot of lawyers convince people that they need a lawyer to execute advance directives. You absolutely don’t. This is not rocket science. Wells: What’s a do-not-resuscitate order? Is it the same as an advance directive? Banach: Do-not-resuscitate orders are part of advance directives. Let’s say I’m 97 years old. Do I really want them sticking something in me, sending me to the hospital and possibly dying there? The answer’s probably no, because I may not make it, and if I do, my family might not be able to visit me. If what’s important to you is receiving care in the home and being with your loved ones, that’s not going to be possible. Once you get on that ambulance, you may not be coming back for quite a while. In your advance directive, you can put No. 1, do not resuscitate, and No. 2, call Betsy. She is my health-care proxy. You’ve talked to Betsy. You talked to her every year at Thanksgiving and you update her about what you want. Wells: I imagine a lot of people don’t have advance directives because it’s uncomfortable to think about and talk about. Banach: Absolutely. But the thing that we’re seeing now with COVID-19 is that what once seemed so far away is close to home for a lot of people, especially if you’re in a place like New York. I want this to be an impetus for people having this conversation. Wells: How do you have this conversation? How do you bring it up with Betsy at Thanksgiving? Banach: If it’s your parents, for example, you say, “Look, hey, Dad, if something goes wrong, who do you want to make a decision? If you don’t empower me or someone else to make the decision, then the government or the institution is going to make the decision.” Hamblin: And then he says, “I’m going to be fine. Everything’s okay. Don’t worry about me. Pass the gravy.” Banach: “Yeah. But you know what? Here’s the deal. It’s not about you. Because you know what? You’re not aware at that point. It’s about me and it’s about Mom. And it’s about, you know, brother two and brother three. We’re going to end up fighting with each other over what your wishes are.” Unless you really want your whole family to fall apart, as sometimes happens, you’re going to have this conversation. What you’re doing is letting people off the hook. You’re saying very clearly, “This is who I am; this is what I want.” Take out your smartphone. Do a video selfie. Say, “My name is Edo Banach. These are my wishes.” So if it ever gets to a debate over what I wanted or didn’t want, that’s clear. Hamblin: The main issue is that we don’t want to have this conversation, especially right now, when people are genuinely scared and alone and you’re calling them on the phone sounding like the harbinger of death. Is there a resource where people have scripts for how to approach this conversation? Banach: There are a couple. Our website has a decision guide for COVID-19, and it also has resources for how to have a conversation about advance-care planning in general. There is also a group called the Conversation Project, which aims to facilitate these kinds of conversations. Generally speaking, social workers are better at having these kinds of conversations than physicians, doctors, nurses, or lawyers. If you have any questions, those are always good resources. Wells: I don’t have an advance directive. I don’t know anything about any of my family members and wishes. In my case, the issue is not that I think my parents would not be open to the conversation. For all I know, they have advance directives. The issue is that I don’t want to have that conversation, because it means acknowledging that they will die at some point. Any advice? Banach: I would say the earlier you do it, the better. I wouldn’t frame it as an end-of-life discussion at all. End of life is grim and painful to imagine. But getting run over by a bus is possible too. A lot of people die that way. I think the right way to sort of frame it is, just in case. Especially with COVID-19, you could be fine today and not fine tomorrow. “Out of curiosity, do you have one of these things? I know it’s painful, but can we just sit down and have this discussion?” My best advice, though, is to do it all together. Whatever unit that you are, do it all together so you’re not picking on the people that are older. from https://ift.tt/2Z696Bs Check out http://natthash.tumblr.com Caitlin Flanagan joins the deputy editor Ross Andersen for a live conversation about her experience with cancer and how the pandemic has affected her outlook. from https://ift.tt/3fV5Wqr Check out http://natthash.tumblr.com Editor’s Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. The United States’ ability to test for the novel coronavirus finally seems to be improving. As recently as late April, the country rarely reported more than 150,000 new test results each day. The U.S. now routinely claims to conduct more than 300,000 tests a day, according to state-level data compiled by the COVID Tracking Project at The Atlantic. But these rosy numbers may conceal a problem: A lack of federal guidelines has created huge variation in how states are reporting their COVID-19 data and in what kind of data they provide to the public. These gaps can be used for political advantage. In at least one state, Virginia, senior officials are blending the results of two different types of coronavirus test in order to report a more favorable result to the public. This harms the integrity of the data they use to make decisions, reassure residents, and justify reopening their economies. Other differences make it hard to track the pandemic. In at least three other states, officials have lumped together probable and confirmed COVID-19 deaths; most don’t specify how they’re counting deaths. While most states report the number of people who have been tested for the coronavirus, six states say they track the number of samples that have been tested—and California and New Jersey switched methods in the last few weeks. Louisiana, Nebraska, Nevada, Vermont, and New York do not report the racial or ethnic breakdown of coronavirus cases. Even more states fail to report the racial breakdown of deaths. It is still impossible to know, for example, how many black people have died of COVID-19, though the data that does exist suggests that black people are dying at much higher levels than other groups. There are many ways that the lack of data has complicated the outbreak. Until May 12, the Centers for Disease Control and Prevention had not reported state-level testing data, leaving efforts like our COVID Tracking Project to fill that gap. The lack of reliable national testing data has made it difficult for modelers, policy analysts, and others to understand the true scope of the outbreak. Data about hospitalizations has been even harder to understand. Because the states report hospitalization counts in fundamentally different ways, there is no way to calculate the number of people who have been hospitalized with COVID-19 in the U.S. Many pandemic response efforts assumed clean, standard, accessible data would exist, but it does not. That said, Virginia’s decision to mix the results of two different kinds of tests marks a new low in data standards. The state is reporting viral tests and antibody tests in the same figure, even though the two types of test answer different questions about the pandemic and reveal different types of information. By combining these two types of test, the state is able to portray itself as having a more robust infrastructure for tracking and containing the coronavirus than it actually does. It can represent gains in testing that do not exist in reality, says Ashish Jha, the K.T. Li Professor of Global Health at Harvard. “It is terrible. It messes up everything,” Jha told us. He said that combining the test results, as Virginia has done, produces information that is impossible to interpret. The two tests have little in common. Viral tests help officials do the basic blocking and tackling necessary to contain an outbreak. If someone tests positive on a viral test, they are still infectious, so they can be told to self-isolate in order to protect the susceptible population. Public-health workers can trace their contacts to find others who may be infected with the coronavirus but who are not yet experiencing symptoms. Viral tests can also be used to monitor people who work in high-risk environments—such as a meatpacking plant—to diagnose a contagious person before they spread the disease. Antibody tests, on the other hand, allow for something closer to post-game analysis. They help officials understand the true number of people in a state or city who have been exposed to the coronavirus. But they do so on a lag: Individuals who test positive on an antibody test are likely no longer infectious, and were infected by the coronavirus at least a week earlier. The two tests do not even examine the same specimens. Viral tests analyze a throat swab, nasal swab, or saliva sample. They are sometimes called “PCR” tests, after the polymerase-chain-reaction technique used to isolate viral genetic material. But antibody tests use a blood sample. They are sometimes called “serological” tests, because they analyze the blood serum. In other words, combining positive and negative results from the two tests in the same statistic, as Virginia has done, makes no sense. But commonwealth officials say they have no choice. Other states are mixing their results, claimed Clark Mercer, the chief of staff to Governor Ralph Northam, at a press conference this week. “You can’t win” by keeping viral and antibody findings separate in public data, he said, adding that combining the two tests’ results was the only way to improve Virginia’s position in a list of states ranked by the number of tests they had conducted per capita. “If another state is including serological tests, and they’re ranked above Virginia, and we are not, and we’re getting criticized for that, [then], hey, you can’t win either way. Now we are including them, and our ranking will be better, and we’re being criticized,” he said. We could not find evidence that other states are blending test results in the way that Mercer claimed. In an email, a spokesperson for the Virginia Department of Health claimed that Arizona, West Virginia, and the District of Columbia also mingled viral and antibody results. This is false: Those three governments either separate out, or do not report, the result of negative antibody tests to the public. Other states report positive serological tests as “probable” COVID-19 cases. This is in line with recommendations published by the Council of State and Territorial Epidemiologists, a nonprofit that works with state and local epidemiologists in the U.S. At least 16 U.S. states and two territories have reported such “probable” cases, although they may not always have done so using serological tests, according to the CDC. However, Arizona, which reports a substantial number of positive serological tests on its own website, does not show up on the CDC’s list. Nor does Kansas, which explicitly states that they are including such probable cases. While including antibody tests in a state’s total creates too rosy of a testing picture for a state, reporting only probable positive cases without disclosing how many antibody tests are being completed could actually make the situation look more dire in a state than it is. The spokesperson said that Virginia planned to “disaggregate” its viral and antibody results in the future, but he did not provide a firm date. Kathy Turner, deputy state epidemiologist for Idaho and the presenting author of the CSTE standards document, did not criticize Virginia’s decision, but she did lay out why her own state decided to keep PCR and serology tests separate. “[I]n Idaho, we have decided to only display viral tests because those are the denominator we use to calculate our percent positivity rate and we are very confident what they mean,” she told us. “Additionally, we focus on the PCR tests because we can compare the percent positivity over time—before serology tests were available.” Blending the results also misstates Virginia’s success at improving this crucial metric, sometimes called the “test-positivity rate.” This measurement compares the number of people who have tested positive for the coronavirus to the number of people who have been tested overall. In April, one in five Americans who received PCR tests for the virus were found to be infected, a very high rate that suggested only the sickest people could get a test. For the past week, fewer than one in 10 tests in the U.S. have found a positive result, according to state data. Some of this improvement is certainly the result of the New York metro area’s waning outbreak. Leaders in many states, including Virginia, have cited the local test-positivity rate to justify loosening shelter-in-place restrictions. Northam has repeatedly said that Virginia’s test-positivity rate had to fall for 14 days before he would loosen restrictions. But because Virginia combines viral and antibody results, its positivity rate is unusable, said Jha, the Harvard professor. The positivity metric is only useful when describing the result of viral tests, because it is meant to provide a rough estimate of how many people infected with the coronavirus are getting tested for it. Antibody tests, which are meant to sample a broad swath of the healthy population, should not be included in it. By lumping the two tests together, as Virginia has done, states can artificially improve their test-positivity rate. Only by keeping the two types of test separate can the country—and the commonwealth of Virginia—understand the true scope of its outbreak, experts say. “You’re comparing apples to pears,” Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, told us. Viral and antibody tests “look a little bit alike, but it doesn’t let you make the comparison needed. So why not keep them separate?” Gronvall has written about the need to expand antibody testing across the U.S. She is also worried that the data are statistically meaningless, because viral tests have fewer false-positive errors than antibody tests. “There’s so much variability in the antibody tests that it’s like taking an iffy number and throwing it in with some more reliable numbers,” she said. Although combining the data from two different tests may seem like a technicality, the decision threatens to confound some of the most important questions about the coronavirus’s path in the United States. How many people are sick right now? How many people can the U.S. actually test for the coronavirus every week? Is the situation outside the New York metropolitan area getting better or worse? Answering these questions requires stable data about how many people have received a diagnostic test and how many of those people are infected. The scope of the test-mixing problem is not yet clear. No other state aside from Virginia has admitted to counting antibody tests in their overall totals. We do know, however, that large numbers of antibody tests are being completed in the U.S. but not reported to the public by most states. As test numbers have shot up, Quest Diagnostics—one of the two largest commercial laboratories in the country—reported doing only 200,000 PCR tests from May 4 to May 11, which is 180,000 fewer diagnostic tests than in the preceding week. In fact, from May 4 to May 11, the company did almost 100,000 more antibody tests than PCR ones. LabCorp, the other major commercial reference laboratory, has not released similar data, but it has stated that its diagnostic- and antibody-test capacity are about equal. Two states do report viral and antibody tests separately. In Colorado, 30 percent of tests completed so far in May were for antibodies. In Arizona, 23 percent of the total number of the tests ever done in the state have been serological. In both states, antibody tests started to be conducted en masse around April 26. This timeline matches up disturbingly well with the improvement of the national picture, which saw a sudden jump at the end of April from an average of about 150,000 tests per day to 200,000, 250,000, and now 300,000 tests per day. The White House has celebrated the improvements in testing, noting in a press conference this week that the United States does more tests per day than any other country. “We have met the moment and we have prevailed,” President Trump said. In fact, the U.S. has tested a smaller share of its population than other industrialized countries, including Italy, Canada, and Germany. “I find our testing record nothing to celebrate whatsoever,” Senator Mitt Romney, a Republican of Utah, told Brett Giroir, the assistant secretary for health, at a hearing yesterday. “You celebrated that we had done more tests, and more tests per capita even, than South Korea. But you ignored the fact that they accomplished theirs at the beginning of the outbreak, while we treaded water during February and March.” It’s possible that Virginia is alone in its reporting methodology, but until we know how many states are dumping antibody tests in their totals, the White House’s claims that the U.S. has overcome its testing plateau cannot be given full weight. It was one thing to go into the outbreak blind because of the lack of testing, as the U.S. did. It’s another to choose to cloud our vision. Antibody-testing data are an important part of understanding the outbreak; PCR diagnostic-testing data are also an important part of understanding the outbreak. But if states mix the two together, the value of that information plummets. The good news is that laboratories do report the type of tests they’ve conducted to state governments and the CDC. All states should have that data at their disposal. So should all their residents—and all Americans. from https://ift.tt/2As5kbt Check out http://natthash.tumblr.com |
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