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The DQYDJ Weekender, 4/05/2020

August 22nd, 2020 by 
PK

Hey folks! Welcome back to the Weekender. 

Once again, this one will be dominated by COVID thoughts – skip if you're overloaded; I'll be posting more real content in the coming weeks.

Let me remind you again: in Weekenders, I shoot more from the hip. In this post are my contemporaneous thoughts on this wild worldwide pandemic.

I'll use incomplete data, make some dubious logical leaps, and expect to be wrong—at least a few times.

I hope my notes and thoughts are valuable to you. If not, know that they are useful for me – even looking back now to the last edition has been instructive.

Okay, let's do this.

What's New This Week?

Thankfully, the Center for Disease Control finally put out guidance suggesting Americans use a cloth face mask – especially in viral hotspots. The Surgeon General walked back earlier advice not to wear a mask and even made a video on how to make one:

(Umm... I have questions. But good!)

I'll tell you, this mask nonsense has been infuriating to watch. We've strongly suspected that masks help stop viral transmission – combined with SARS-CoV 2's ability to spread from asymptomatic (or presymptomatic) people. This was a no brainer even if it didn't help you avoid it when healthy. 

Virtually all the evidence from similar diseases – take your pick from influenza strains and even SARS-1 – showed masks help us non-infected folks. Here's a Google Doc with 30+ mask studies for you to peruse. It appears this new one in Nature is the one that finally convinced the CDC to move.

Now with this new guidance, you still need to keep social distancing, avoiding and batching trips, staying at home, and doing everything else to prevent infection with COVID-19. 

Masks are like a seat belt – at the margins, some people will feel invincible with a mask. However, overall, mask-wearing is going to help when we eventually all emerge from our lockdowns.

Also new: here in California, it's official - our kids are homeschooled for the remainder of the year. The whole state is under a stay-at-home order [PDF] (ex-essential services and workers) through May.

And how are those orders working? Google released a (creepy?) tool that shows how well people are following stay at home orders. Check it out!

What's the situation today?

According to The COVID Tracking Project, as of this evening here are the effects of COVID-19 in the United States:

  • 9,558 people have died
  • 41,559 people have been hospitalized (with ~23,000 still in a hospital)
  • 333,747 have tested positive
  • The United States is testing ~ 140,000 people a day

We've come a long, sad way since the last update when only 60 people in America had been lost to the disease.

Tonight we also got an update to the IHME model the White House and Coronavirus Task Force is tracking closely. It now predicts:

  • Most states are on track to not overwhelm their hospital beds and ventilators (this doesn't mean no hospitals will be stressed, however)
  • The United States seems to be tracking towards between 49,431 and 136,401 deaths, with the most common outcome at 81,766 deaths
  • The worst day country-wide is tracking to around April 16, at around 3,130 deaths

Worldwide, COVID-19 has sadly claimed at least 69,501 lives and infected at least 1,274,976 people.

What don't we know?

We've learned quite a bit about COVID-19 in the last few weeks. However, there is a ton we still don't know.

(Reminder here – I'm not a Doctor of any kind, let alone an epidemiologist. Read my cites and form your own opinion.)

Why COVID-19 is Dangerous

One weird thread I've been tracking in the last week is that COVID-pneumonia isn't like the ARDS we assumed in past weeks. Perhaps it's closer to altitude sickness?

Some Doctors started a Google Doc discussing what this means for treatment. My hope here is Doctors find a therapy that drops the mortality rate even more. But this disease is crazy, see these two Twitter threads: one – two (yes, her heart rate is 137 and O2 is 54%!).

At least one pre-print points to COVID-19's effects on heme metabolism as a possible cause of its severity. Keep an eye on this one as it suggests some possible treatments.

How Contagious and Is Dangerous COVID-19? 

A few weeks ago, we assumed the CFR of COVID-19 is somewhere around 1%, and R0 – the predicted spread per person – was around 2.2.

Both measures can be manipulated by human behavior! All of our precautions – stay at home, wear a mask, etc. – lower R0 since we aren't around people to infect each other. And mortality will improve if we find new and better treatments.

But here's a thought that's been making the rounds – what if R0 is well higher than 2.2-2.6? What if it's in the 3s? 4s? (Remember, to a new population, the spread looks like an exponential – so those are large jumps.)

There is *some* evidence pointing to that. In some larger surveys, more people have COVID-19 antibodies than you might expect. While initial studies parroted by the WHO suggested very few people avoided symptoms completely, a recent study out of China suggested 4/5 of cases were asymptomatic.

Now, some of those cases are presymptomatic – people will go on to develop some symptoms. However, maybe there are many symptom-free carriers. Hey, many of us thought that about children a few weeks back (and that turned out to be correct!), so it's not far fetched.

Unfortunately, there are counterfactuals too. Castiglione D'Adda in Italy looks to have reached herd immunity, with ~70% of their population having antibodies. Unfortunately, they lost around 1.3% of their overall population in the last couple of months.

Yes, demographics. But if R0 is indeed much larger than we estimated, for the models to hold, mortality would be a bit lower.

But: I think this theory is wrong. I believe the transmissibility guess is roughly decent, and maybe 20-40% of people are asymptomatic. Happy to be proven wrong, though!

How to Fight and Treat COVID-19

Last time, we talked about Vitamin D and Zinc. Those are still no-brainers. 

It's becoming increasingly clear that blood sugar & diabetes have a significant role to play – consult with your doctor, of course, but do what you can to improve your diet. I found this video on hyperglycemia and the immune system useful:

Also, anything you can do to protect your lungs, do it. (Stop or limit smoking, vaping, etc.)

As for hospital treatments? Still nothing definitive, at least proven out by an RCT (more on this in a sec). 

There is anecdotal evidence for the malaria drugs hydroxychloroquine and chloroquine in combination with azithromycin. And you can't buy the (OTC) related compound quinine: as of today, it's out of stock almost everywhere online.

(That drug family is President Trump's favorite – keep an eye on it, and know some hospital systems are trialing it now.)

Remdesivir still looks promising, but its results are technically still anecdotal as well. Interestingly, Gilead Pharmaceuticals is confident enough to ramp production – just today they said they want to be producing 1,000,000 drug courses a week by 20201.

Some new threads since last time that might be promising:

No RCTs, sure, but this is a hopeful section.

Moving Trains, Evidence, and War

One weird dynamic I've seen play out is the tension between people insisting on full RCTs for everything and people pointing to potentially effective interventions that might work. Whether we're talking repurposed malaria drugs, masks, supplements, or public health interventions, you have one group insisting it isn't real until you have a well-designed massive randomized trial that only looks at COVID-19.

Hey, that's great, I'm not knocking RCTs. But, in the immortal words of Howard Zinn (RIP), "you can't be neutral on a moving train." 

This is a war. Sometimes you need to go on the best current evidence or option and adjust later. When the astronauts on Apollo XIII were running low on oxygen, they didn't wait for a clinical trial of CO2 scrubbing machines, they hacked together life support.

For me, this philosophy manifested itself most obviously in our personal mask habit – we've been wearing them since early February!

The downside of not waiting for a COVID specific mask trial? We look silly – oh, and by the way, we avoid many other viruses and bacteria. The upside? I stave off a COVID infection or even death!

When looking at some of these interventions, at least from an early April perspective, you need to pick your battles. If I come down with COVID-19 and a doctor offers me hydroxychloroquine and azithromycin, you better believe I'll try it. 

Sure, it might turn out HCQ has only a small effect, or even no effect! But as of today, there are still reasons to hope or suspect it has a positive impact. And look at the downsides – for HCQ those are overdose, heart effects, and retina damage. The downsides of doing nothing are again – potentially – death. 

Until we get that RCT or another, better option (one of them may even be listed above!), I'll take what we've got.

A Vaccine for COVID

Trials are ongoing. Unfortunately, you can't speed this up much – a SARS-1 vaccine misfired and made mice react violently to a viral challenge. We need to get this right since these are drugs never before used in humans.

One thing you can do though is try a ton of vaccines at once, then crown winners. That's the path Bill Gates and his foundation are taking – they will fund seven vaccine candidates, even though they know only 1-2 will be chosen.

Who can you trust?

The last couple of months have been depressingly enlightening. While we're in a better situation now – roughly ten weeks into cases in the US! – the failure to respond appropriately to COVID-19 was embarrassing and deadly. Hell, the new mask guidance is only three days old!

But here's the thing – nearly everyone failed. And we'll all have time to reflect more later, but it's instructive to look at how this has played out thus far. (Who knows who will attempt to celebrate their brilliance later, right?)

Could we trust Politicians? Of course not – even this week, NYC's Mayor Bill de Blasio and Georgia's Governor Brian Kemp mentioned they didn't know there was asymptomatic spread. (This is an advisor failure too, sure, but not a good look.) When we look back at all the public events in late February and early March, it's sad how many communities were behind what was needed.

Could we trust other parts of the government? Well, the CDC failed on the mask guidance, they were unable to make early tests, and have generally dropped the ball multiple times. The FDA has been slow to remove its unnecessary roadblocks – famously, we only had early COVID-19 data because Dr. Helen Chu of Seattle ignored the government's mandates and tested for COVID in Washington.

Could we trust the WHO? No again, they got it wrong at every turn and are still wrong on mask guidance as of today. They were wrong about person-to-person transmission, asymptomatic carriers, closing off travel, and more. 

Could we trust the media? Not even close – through early March, much of the press carried water for the WHO and CDC, pushed the "the flu is worse" narrative and even viciously attacked people – and entire industries – who were preparing. 

Some journalists are now pretending they were taking it seriously! "Oceania had always been at war with Eastasia," indeed. 

I have some journalists (and media company co-founders) top of mind. Still, I won't link – listen to the Balaji Srinivasan interview on This Week in Startups for an infuriating roundup.

Okay... then who has done well so far (in the United States)?

This section is more important – I want to highlight people and groups who aren't cranks (or perma-bears) and have done well. Of course the bears called it, just like 12 of the last 2 recessions!

The Governors of Washington and California, Jay Inslee and Gavin Newsom, have done well. FEMA and the Navy have done well with field hospitals and hospital ships, and the National Guard is doing well in the states. The rest of the military has done well buttressing our procurement and logistics moving equipment and PPE around. 

The public health departments in various counties (especially in the Bay Area) also look good – I know because I'm here. 

Zeynep TufekciAlexis Madrigal, and Natasha Khan took this seriously on the media side. Outside the press Twitter, Balaji Srinivasan has been great, along with Naval Ravikant and Nassim Taleb. I'll also repeat my recommendation to follow Claudia Sahm. On the health side, Scott Gottlieb and Trevor Bedford have been great, plus Dr. John Campbell on YouTube.

Until Next Time

This situation is truly surreal. To know that I'm writing here in the Bay Area and – wherever you are – we're sharing a strange collective experience is wild. 

It's a lot to process, and I hope you're doing well. Researching a ton, talking to people, and (of course) writing these notes has been helpful for me. Not everyone has the same style of coping, but if you're reading this, maybe writing down your thoughts in the moment will help you too.

Also – thank you so much for your emails after the last one. We're truly all in this together, and I hope you and yours stay healthy.

This, too, will pass – and when we return to talking about investing, income, net worth, and savings, it's going to be with a new appreciation for how quickly things can change.

Don't Quit Your Day Job...

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