Why There Are More People With COVID In Your Town Than You Think
Other posts I have written to help us interpret the pandemic.
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To my friends and family: I am writing to give you an update on the pandemic and my current assessment. I am going to try and provide more periodic but shorter updates so we may all stay as safe as possible, keep our friends and families safe, and really understand the rapidly changing pandemic in the best possible way.
Knowing me, you may not be surprised that I have studied the problem for the last 12 days. 18 hours a day some days. The longest was 20 hours in one day. Angi and the kids have not been happy with me. I’m not going to lie; I’ve been consumed by the pandemic. I talked to nurses in Seattle. Talked to some of the smartest data people & scientists I know that are working on the problem. Talked to the CEO of Providence Health Care. Talked to business owners who are pivoting their business to help the healthcare industry. DM’d with people in Italy. I needed to know what was really happening and like many complicated problems, I dove headfirst into it.
Pandemics are complicated and prone to incorrect fact pattern analysis and catastrophic errors in decision making because many people grossly misunderstand what is happening until it’s too late. And with pandemics how we respond and when we respond, really, really matters.
So this message is for my friends, family and loved ones so they may stay informed and use what I have learned to interpret the rapidly unfolding events in the best possible way to make the best decisions for them and their loved ones. But anyone else can read along and it might help you understand and be better prepared too.
If you are reading along, my name is Jason Warner and I am the CEO of a SaaS software company in Bend, Oregon. Before the pandemic unfolded, I wrote a very concerned post on Facebook regarding the fact that everyone I knew seemed to be misunderstanding what was really happening. I rang the alarm bell, so to speak, before 99.9% of people saw that the pandemic was a really big problem. I’m not a blogger and it was my first post. That post, like this one, was for my friends and family but has since been read 4.4M times.
All my concerns in the first post turned out to be true. All of the math I laid out was true.
I have a lot more concerns today than I did when I wrote that freak-out post 12 days ago. Most people still don’t get what’s happening and what comes next.
In every post I’ll share what I am doing for my family based on where things sit as of that day.
Things I believe are critical to understand, and will be addressing in the coming days (to receive them please follow me on Facebook):
1.) Why there are WAY more infected people in your town than you think
2.) Why soft lockdowns are worse than full lockdowns, based on math
3.) Why the States, cities, and towns that haven’t locked down will be harder hit than the others, in simple math
4.) More things we continue to misunderstand about the pandemic
5.) My cofounder at the software company built a dashboard so you may track the stats in your state, including test counts. We hope to push it out in the next day or two (maybe today).
6.) Four issues that make the actual numbers of COVID infections in America far worse than are being reported and what that means
7.) An explanation of why the impact on you, me, our families, our livelihood and our country is going to be far worse than Italy
8.) What’s really happening in Seattle and what the nurses want you to know
9.) Why the numbers you keep seeing are still not the right numbers to focus on
10.) Why this virus is a SuperVirus and unlike other viruses
Finally, pandemics are complicated, high risk problems that most people don’t understand. This is one reason I dug into this so deeply. This one is going to bring our country to its knees. There will be a lot for all of us to learn from this and how we chose to respond as a nation.
Alright, here goes:
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WHY THERE MAY BE WAY MORE PEOPLE INFECTED WITH COVID IN YOUR TOWN THAN YOU CAN IMAGINE
Pandemics are complicated to understand. Here’s one example why:
- We can’t identify people who are carriers of COVID because we don’t have enough tests and…
- most people do not display symptoms or if they do, they won’t think it’s COVID (even today) because the symptoms are mild, so mild, and many continue to spread the virus even with the soft lockdowns in place and…
- preliminary evidence suggests that COVID carriers have the greatest viral loads in the first days after they catch the virus [source], before any symptoms develop and…
- the virus has been spreading exponentially for longer than you think and…
- it takes carriers of COVID a week or two to get really sick and require hospitalization which is when most towns actually test them, and they are adding them to the count of CONFIRMED cases and…
- from talking with the nurses in Seattle they think a lot of patients are waiting to go to the ER because they are terrified, so there are more people growing sicker and sicker with COVID at home than we think so…
- when all these COVID patients get really sick and need help, and finally go to the hospital in your town, it’s way more than you can imagine, and it overruns your hospital in ways that are hard to fathom.
It’s no wonder people misunderstand what is really happening. The key with this pandemic is that it spreads too fast, faster than any of us can imagine, due to exponential math, and it spreads invisibly, because here in America we don’t have anywhere near enough tests and most carriers are asymptomatic.
I have already talked about how the count of CONFIRMED cases means little because there are not enough tests. So the virus has been spreading invisibly and exponentially, because many people don’t display symptoms or have mild symptoms (and barely any tests). But one problem is that the key figure we use to see what is happening with the pandemic is CONFIRMED cases. It’s a big problem in our overall societal understanding.
Since I wrote the first post (12 days ago of this writing) the virus in most locations has increased by at least 1600% (2 x 2 x 2 x 2, since it’s been 12 days and the virus count doubles every 3 days until lockdown, so 4 doubling periods). 16 times more infection than 12 days ago in your town and mine. Imagine if you invested $1,000 and 12 days later it was worth $16,000.
Some of the growth rate above is because we have finally started testing more people. We had so few tests to begin with, hardly anyone could get a test.
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COVID spreads like lightning. It moves faster than we can think or move as humans, because it spreads exponentially, even with partial lockdowns and social distancing. But you can’t see it and you can’t envision it because our brains only process information linearly.
[If the above doesn’t make sense to you read my other posts.]
“I’ll say it over and over again,” Dr. Fauci said. “When you’re dealing with an emerging infectious diseases outbreak, you are always behind where you think you are if you think that today reflects where you really are.” — Dr. Anthony Fauci [Source]
VO EUGANEO, ITALY
Let me tell you about a little town in Italy called Vo Euganeo, to illustrate how quickly the virus has been spreading invisibly through your town. You just can’t see it, because of a lack of testing and the lack of symptoms. Most infected people don’t know they are carrying the virus. As you read, do these two things: Pay attention to the timeline.
Apparently Vo Euganeo had the good fortune of being able to test 100% of residents. They didn’t have enough tests, either though. It was early in the pandemic, and they too were not able to test everyone just like us in America today. This was because at the time they were only testing people if they had been to Wuhan, China. Because tests were in short supply. So you had to meet certain criteria to get tested, like today in America. But through luck, they took a flyer and tested one person, and he had COVID.
Here’s the account, translated in English [source]:
Didn’t you think it was coronavirus?
“Initially not, the doctor had reassured us. In the hospital, however, they could not understand what caused the inflammation in the lungs that prevented him from breathing. They asked us if he had traveled, if he had a passion for the garden …” .
Why this question?
“To understand if he had been in contact with toxic fertilizers. The doctor who followed the case told us that he could not be tested for the virus because the protocol did not provide it for patients who had not returned from China, or had had no contact with at risk. And who could have imagined that Vo had become an outbreak? “
Then what has changed?
“In the end, the doctor managed to convince her superiors of the opportunity to swab him, since everything else had been excluded. They did it on Thursday the 20th. And it was COVID.
So here is a patient, gravely ill, but no one thought it was COVID because it seemed impossible. The virus moves faster than our brains can think. So we misjudge its speed.
The mayor of Vo then made a leadership decision and said, “Everyone will be tested immediately!” It was a huge wake up call for the entire town.
The town immediately initiated 100% testing — all citizens got tested for COVID. This also created a very effective, nearly perfect virus transmission interruption (lockdown), because, and I am guessing here, that 100% of citizens got the message to quarantine loud and clear when a swab was stuck deeply up their nose and there was a death in town.) This is a good case study to understand, because we have few other reliable datasets where testing is so comprehensive and therefore revealing.
Here’s the timeline regarding Vo Euganeo:
January 31: Italy identifies what they think is first COVID carrier in Rome.
February 13 (13 days later): Adriano Trevisan, a 77 year old living in Vo Eugaeo is admitted to the hospital. NOTE: Vo is 500 kilometers/310 miles away from Rome, where the first case in Italy was confirmed, only 13 days prior.
No one suspects Covid in Vo. Mr Trevisan had not traveled nor was he around people from Wuhan. After testing for “everything else” a caregiver escalates the request to test him up through the chain of command at the hospital. The patient was dying so they decided as a last resort to run the COVID test. And the test was positive: Mr Trevisan had COVID19.
February 21 (1 day later): First COVID death in Vo Euganeo. Mr Trevisan, dies. This is 21 days into the outbreak in all of Italy.
100% of the 3,341 residents in Vo get tested immediately and go on no social contact/rest in place. A few fudged, but most residents were scared so they stayed home and didn’t fudge.
2 weeks after lockdown, they tested 100% of residents again. The virus was nearly eradicated. It was actually down to 0.25% of the population. But this is not the only big conclusion we can draw from Vo Euganeo.
Yes, lockdown works, if you really do it and really stop the virus from transmitting to other humans. The virus can’t transmit if you don’t get it or give it to another human being.
If I yelled “Freeze!” and everyone in your town stopped in place, like the childhood game, in ~2 weeks the virus would be all but eliminated from your town.
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THE RESULTS FROM TESTING 100% OF RESIDENTS IN Vo Euganeo REVEAL A VERY BIG PROBLEM WITH COVID19:
Only 3 weeks after the first COVID positive person was identified in the entire country of Italy, 3% of the population was already infected in a town 300 miles away from that first case.
90 positive test cases (3,341 residents) — 2.7% of population of Vo Euganeo, Italy.
Maybe it happened like this, based on the virus doubling every 3 days for 21 days:
1 x 2 x 2 x 2 x 2 x 2 x 2 x 2 with a few subtle variations. Grab a calculator. Do the math.
So before you say, “but that’s a small town, my town is larger” I would point out the following: The virus transmits from person to person. The disease spreads in proportion to the number initially infected in a population and how easy it is for those infected to spread it to others. It’s easier to spread the virus in a city that relies on mass transit like a subway than it is to spread in a small town like Bend, Oregon where I live. But if your town had a large influx of infection, maybe a wedding, or work function, or 50 travelers from New York, a few weeks ago, the count of ACTUAL cases will be much greater than you imagine. Or, if the early cases in your town were not tested, or otherwise went undetected due to the fact that the virus presents like the flu or pneumonia, and they care conserving tests, the number may be much greater.
Imagine this made up scenario where I live in Bend, Oregon, a town that is 33x larger (about 100,000 people) than Vo Euganeo:
Let’s say the first carrier of COVID arrived in Bend March 3rd. She was carrying the virus, went to a party with 20 people, and infected 12 people. Or maybe 3 people arrived on March 3rd, and they all had the virus and infected 5 people. It doesn’t matter. 12. 15. It doesn’t matter.
Over the next 3 weeks in Bend, up to today’s date (March 25, 2020) the virus spread as it typically did before the rest in place was ordered in Bend on Monday:
12 x 2 x 2 x 2 x 2 x 2 x 2 x 2 = 1,536 cases, or about 1.5% of Bend’s population.
15 x 2 x 2 x 2 x 2 x 2 x 2 x 2 = 3,840 cases, or about 4% of Bend’s population.
We have 10 confirmed cases as of this writing.
It would not shock me if we had 3,000 people in Bend with the virus, or 3% of the population, like Vo Euganeo. As of yesterday, we have 10 cases. Nobody knows. Because lots and lots of people are not tested, even if they have symptoms.
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MORE EVIDENCE:
One of the approaches I take to solving problems is approach them from “top down” and “bottoms up” approaches. “Top down” is easy, you look at the data and charts and graphs and interpret the data and trends. But the problem with a pandemic is that:
- there are too many charts, data and graphs and we get overloaded and…
- we can’t tell what charts and graphs and data to believe and…
- the numbers are changing FAST and…
- all the data is really, really crappy, sometimes lagging, often false or misleading, and remember the virus is moving at lightning speed.
- The count of CONFIRMED cases is close to meaningless, because most people can’t get a test. Yet everyone talks and looks at confirmed cases as if it helps us understand. It actually hurts us because we think things aren’t as bad as the really are. You should start considering counts of deaths. The count of fatalities is going to become more directionally accurate and telling than CONFIRMED cases as the pandemic progresses.
“Bottoms Up” analysis is what I learned on a farm growing up as a kid: get your hands dirty. When I led Recruiting for Starbucks North America, if I wanted to know what was going on in field operations I went to the field. It’s useful context to codify the trends and assumptions you are making about the data if you use a bottoms up approach with any problem. This is why I talked to the nurses and frontline staff who are doing the work on the front lines.
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So I talked to a nurse off the record on the West Coast about current testing protocols: This nurse had a 59-year-old patient come into the ER with all three COVID presentations (cough, fever and lower respiratory issues that made it very difficult to breathe, so much so that it was affecting the patient’s mobility). The nurse told me, “The patient has COVID. It’s obvious. I asked my manager to test the patient. I was told, “the patient doesn’t meet the criteria for a test because the patient is under age 60.” So this patient was sent home to self-isolated and was not counted as a CONFIRMED case. The patient’s family or friends were not tested. The people the patient has interacted with over the last week were not tested. This is happening in many markets across America due to a shortage of tests as of today.
So the virus continues to explode, growing invisibly and exponentially in your town and mine. And the numbers being reported in your town are far less than the actual numbers.
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Where I live, in Bend, Oregon, we have tested few people. Less than 1 person per 100,000 residents:
Twelve days ago, I estimated that multiplying by 10 the current CONFIRMED cases in your town would be a good estimate to consider the actual count of COVID cases in your town.
10x is now far too low based on what I have learned. Nobody knows because there are not enough tests. Hardly anyone has been tested. And many, many of them have COVID.
The bottom line:
Vo had 1 confirmed case and in reality 90 people had COVID. Only 3 weeks after the first case in all of Italy was identified.
90 times more infected people than CONFIRMED cases.
They only discovered it because they had the opportunity to test everyone. A lot of hospitals would not have run the test. Because they were only testing those that had been to Wuhan. This virus spreads exponentially and it spreads invisibly, because we test so few people in America. The virus moves faster than humans.
So if you have 10 cases confirmed like we do in Bend, draw your own conclusions. Maybe it’s 20x or 30x or 50x times CONFIRMED COVID infected counts, or if your town is like Vo, 90x, or some other number, some of whom are still running around, some of whom are resting in place, some of whom are fudging, some of them who are still going to work, many of them going to Dutch Bros for drive through coffee based on what I saw yesterday in Bend, not knowing they have the virus, feeling fine, until some of them and the people they infect begin to get really, really sick and overrun St Charles or your local hospital.
Data suggests somewhere near ~15% of COVID afflicted people may require hospitalization to get well. We have 80 ventilators at St. Charles. Some are already in use. Maybe 50 beds available. We are already out of masks. And not enough PPE. If Bend is like Vo, we may have 900 COVID infected people, 90 times the CONFIRMED case count, and 135 Bendites (people who live in Bend we call Bendites) who may need hospitalization in the next 2 weeks. Maybe we have more. Maybe we have less.
These are my assumptions and my assumptions alone. But I am able to infer them from math, but I don’t have time to illustrate it all for you. Conceptually, we can infer the math from the following sources which are multiplicative (multiply them all together to get a sense for how understated CONFIRMED cases might be):
- Acute Case Only Tested Factor — Mostly, the only people who are tested and get counted in America are the really, really sick people, who are estimated to be 15% of cases (so multiply CONFIRMED case counts by 6.67 to adjust for the other 85%)
- Test Lag Result Factor — USA test results are still taking 2–7 days in many markets, according to the nurses with whom I spoke, which further understates the USA actual case counts. I know because I asked the nurses. Other markets have fast test results. When something bad is doubling every 3 days, a 7 day delay is a real problem. (so multiple by some factor, difficult to estimate so I noted it and excluded it from my estimate).
- Test Per Capita Factor — Compare our rates of infection, date normalized from the date of the first deaths or first 100 or 500 infections, against Italy’s, but make an adjustment for the fact that Italy had way more testing and we have so few comparatively. On March 15th Italy was presumed to be testing 167x more patients per capita than we were (chart below). So Italy was casting a net 167x bigger than we were in America to identify COVID patients (so multiply again by a large factor, perhaps 10x-25x, nobody knows).
The biggest issue underpinning the current state of affairs is we cannot measure how many actual COVID cases actually exist in America, because we still have a lack of COVID testing. This is a gigantic issue for us as a nation. I cannot overstate it. It has led to fundamental misunderstandings of what is happening, poor decision making, and made our response far less effective.
Looking at the case counts published for your town means nothing. I wish we didn’t even report it, because it so grossly understates how many people where you live are carrying the virus today.
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What I am Doing for My Family:
The viral loads in almost all of our towns are the greatest they’ve ever been, so there are more infected people than even a few days ago. There are more people in your town with the virus than at any other point in time, as of today. A few days ago there were many people who were still working, getting together in groups, and doing other things that were transmitting the virus.
This is what I am doing for my family.
If you are in lockdown:
- stay at home and be diligent. Don’t fudge. Seriously, no non-essential contact with anyone, for anyone in your family. Not even one person, even if you think they have been diligent. For the next 20 days. There will be so much temptation to fudge with that one person. Don’t.
- Reduce all necessary trips for the next few weeks to the bare minimum. If you shop for groceries every other week instead of every week, you reduce the probability of catching the virus at the grocery by 50%. I think in terms of the math and reducing probabilities.
- Eliminate all other transmission vectors — almost all appointments can wait 20 days. Seriously.
- Avoid buildings or locations where many people visit and may transmit the virus through doorknobs and elevators, playgrounds, etc.
- I am avoiding take out and drive throughs for the next 20 days. We will all know more then.
- Be super diligent at the grocery store. It’s become one of the primary places where the virus will be transmitted, because everyone needs to go there. From a nurse I spoke with, “The grocery store requires extreme diligence. The virus is everywhere. Be careful.”
- Convince others to do the same. It’s a problem we all see: some people still don’t get it.
If you are not in lockdown:
There are many cities or states that are still not locked down or dancing around with partial measures. We will look back on this and ascertain with math that it was a catastrophic approach. This will become a huge problem for these locations, they just can’t see it yet.
Because we are an affluent nation, we forget that we have finite resources as a country. There is likely to be less resources to help you and your family, because the other states have bought up much of the resources already. For example, all the national stockpile of ventilators will be distributed to states other than your own. All the foam to create makeshift PPE is out of stock. This means you need to be more diligent to protect yourself and your loved ones.
If this is you or your town is still dancing around the issue, in addition to the above I would contact your mayor or governor and demand a rest in place order. I did that in Bend on Saturday. It’s your civic right and duty to do so, and the primary tenet of government is to protect the health and prosperity of its citizens. We are in a fight like no other so you’d better be part of the solution.
Many people, including those in government, are still misunderstanding the problem, the math, and looking at CONFIRMED case counts, which mean very little and make it seem like things are less severe than they are. Many leaders don’t fully understand the math. I know because I was on a call with an Oregon State Senator on Sunday. Many people do not understand that partial lockdowns are actually more harmful financially than a full lockdown.
I hope to address that in the next post.
Be smart. Stay vigilant. Help others.
Jason
John 16:33
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If you are good at infographics I would be interested in simplifying some of these messages. DM me on Facebook if you can help.
If you want to translate my posts please do so and DM me on Facebook if you wish to provide them. Special thanks to Marco in Italy who helped me understand the situation in Vo Euganeo and to Erez for translating the last posts into Hebrew.
Further reading: