Wednesday, April 22, 2020

Known Knowns, Known Unknowns and Unknown Unknowns

There is a famous quote from Donald Rumsfeld when he was Secretary of Defense,
"Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don't know we don't know. And if one looks throughout the history of our country and other free countries, it is the latter category that tend to be the difficult ones.'
This wasn't a new idea, it has been applied to planning theory since at least the 1950s. It is distilled in the idea of "the fog of war" where decisions are made on the information you have while clearly understanding that the situation is in flux and any decision may be wrong because there are thing you don't know and you know you don't know them. If we could interview the Japanese Admiral at the Battle of Midway, he would have some insight into the nature of this problem.

Unknown unknowns are just that. I don't know what they are, neither does anyone else.They are impossible to account for.

Known unknowns are easier to identify, allow for data gathering and planning, and sometimes reveal unknown unknowns in the process. Here are some of the known unknowns in the current Covid19 pandemic and the response.

1. Percentages of infected persons in various populations, city, suburban, and rural.
2. Lacking good data on #1, percentages of infected that become seriously ill.
3. Lacking good data on #1, percentages of infected that die.
4. Effective treatments for infected to mitigate the effects of the disease.
5. Effectiveness of current social distancing in halting or slowing spread of the disease.
6. Is it possible to create a vaccine.
7. Effectiveness of a possible vaccine.
8. Do humans develop an immunity after exposure and recovery.
9. Will natural viral mutation result in repeated waves of disease in the future.
10. Will it be possible to restart the economy.
11. What are the long term effects of the shutdown on the country.
12. Lacking good data on #1 and #5, when is the right time and what is the timeline to restart the economy.

There are others, one through twelve I came up with. Put yours in the comments. I will edit the post and add to the list.

Update 4/23/20:  Here's additional input from the comments, thanks to everyone who contributed. If I paraphrased your input and you feel it was incorrect, please comment again with your specific input in consise form and I will revisit this again.

13. What will signal that it's time to return to business as usual (Libertyman)
14. Edit unknown #1 for more detail. Percentages by age groups as well (Tim Wolter)
15. Effectiveness of available treatments and when in the disease course are the treatments most effective (Old NFO)
16. How many people with other diseases will die because hospitals stopped treating all other diseases and shutdown all non virus wards to other surgeries and treatments (HMS Defiant)
17. How many healthcare systems will be impacted by the loss, critical loss of doctors and nurses to both death from virus infection and a decision to call it quits to the practice of medicine and long term availability rates of hospitals shut down by loss of staffing (HMS Defiant)
18.  How many healthcare systems will simply close down once the virus goes into reduction only to be needed next winter as the 'new influenza type killer corona virus roars back to life just like the flu does every year (HMS Defiant)
19. Corollaries to #2 and #3 need to account for comorbidities, e.g. those who died because of the virus, and those who died with the virus (Eagle)
20. What are the significant comorbidities, how significant, do they overlap (Eck!)
21. What are secondary effects on the social order, focusing on oil, oil storage, and production (Differ)
22. What is the cost in lives of reopening the economy (Aesop)
23. What is the cost in lives if we remain shut down (Phelps)
24. How would we achieve herd immunity (ADS)

53 comments:

libertyman said...

My thought is, what event would trigger the reopening, back to business as usual, everything is fine scenario? A downturn in a curve of dubious value anyway? A vaccine? A test ? What exactly has to happen to signal a return?
An "all clear" siren going off?

I sure don't know, and I don't know that anyone does.

Pachydermis2 said...

Add to point one, percentages of infection in full range of age cohorts. Very important in deciding whether control measures should be focused on preschools or nursing homes.

TW

Old NFO said...

Effectiveness of interim treatments (HCQ/Z-pac/other) and application timeline for most effectiveness (e.g. symptomatic, hospitalized, on vent)

HMS Defiant said...

How many people with other diseases will die because hospitals stopped treating all other diseases and shutdown all non virus wards to other surgeries and treatments?
How many healthcare systems will be impacted by the loss, critical loss of doctors and nurses to both death from virus infection and a decision to call it quits to the practice of medicine and long term availability rates of hospitals shut down by loss of staffing?
How many healthcare systems will simply close down once the virus goes into reduction only to be needed next winter as the 'new influenza type killer corona virus roars back to life just like the flu does every year?

I remember building Time Phased Force Deployment plans based on notional units that existed in literature but had no equipment of their own and yet the head mucks from the Fleet planning staff ordered us to treat such units as fully deployable and capable units in our plans. Kind of a waste of time and effort really when you think about it. We knew there was nothing there really but had to play like the unreal was real.

Eagle said...

Corollaries to 2 and 3 need to account for comorbidities, e.g. those who died because of the virus, and those who died with by the virus. We need to understand the seriousness of the virus irrespective of any other conditions.

Re. 1, the statistics should include the number of those infected who recover both with and without inpatient or significant outpatient care. This number is important to determine whether the existing medical facilities might become overwhelmed by admissions to hospitals (e.g. "is our current triage protocol working").

Glen Filthie said...

It's easy with this stuff to get diverted and led down any number of rabbit holes. It's easy to get your ego and emotions in this too... and once that happens - you won't get any rational consensus. Basic math and biology have gone out the window with this one, and it doesn't help that the experts can't agree.

Looking at the big picture, the situation can be much simplified.

A. Where are all the bodies? If this disease was as deadly as the fear mongering says, the corpses should have started stacking up as early as the beginning of March. Clearly, the transmission rate was not what the shrieking hysterics said it was, ergo this bug is not what they said it was either.

B. No, half assed lockdowns and social distancing doesn't work. On my blog, I have a few vintage pics from the Spanish Flu epidemic in 1918. They are all wearing masks and gloves, they did the quarantine thing, they burned the clothing of the infected - and the flu went through them like a hot knife through butter. When the pros are working with super bugs, they do it in negatively pressured labs, with full hazmat suits, air locks, and decontamination procedures out the wazzoo! People are not understanding how superbugs work. Masks, hand washing, dollar store masks, and cheap rubber gloves will not stop a super virus.

C. We can pretty much ignore anyone trying to pass himself off as an authority or an expert with all the facts. The experts - with teams of professionally trained staff, with multi-million dollar labs and multi-million dollar budgets - aren't agreeing on anything that has to do with this. More than a few of the self proclaimed experts have already discredited themselves.

When you have survival rates of 98.5%...or higher... what you have is just another chit house flu. I am confident enough that I will leave the bean-counting, I-dotting, and t-crossing to the experts... but for me the verdict is in. I am digging out the murdercycle and going for a burn today. No quarantines, or social distancing necessary. It's time to chill out, be happy that this isn't what we thought it was... and get back to work.

Eck! said...

This bug is in the class of we don't know what we don't know
yet.

Comorbidities are a red herring of a sort. We do not know exactly what those are and how they interact, make that #13 known unknown.

Its also a red herring because most people over a certain (we are not sure what) age have them and many younger do as well apparently being fat alone is in that category.

All of the curves seen are those plus projected (Not actual) case possibilities so they are inputs to "what if?" tests. Run enough of those and you get the intersection of the "Oh shit" vector or what pilots call the coffin corner where anything you do results in departure from controlled flight. Its the focused do not do that, ever.

Run the projections for two cases there is immunity granted by
the bug and not there is not all other factors constant. The
latter without mitigation runs away and the former becomes diminishing either though death or immunity. The latter
means vaccine is harder and more uncertain and more people
die along the way.

Proper use of models and the resulting projections are the
what if test for cases we can define even with weak or no data.
We can put our best knowledge and experience there and see
how that information impacts the result. Virus transmission
is like neutrons for fissioning atoms in uranium, keep them
far apart and nothing bad happens, crowd them close enough
and it takes off and maybe becomes self sustaining or worse.
The simple part of that is more neutrons is danger ours and
more potentially sick people wandering around contacting others
is as well. For a virus NYC is that example population density
is a big factor. That is how we know maintaining distance and hygiene are the only preventive tools we have right now. This
was established by public health people at the turn of the
century as we enters the 20th that is with TB, spanish flu and
a host of others.

I've done well as an engineer on the idea there are things I
know, things I need know, and those that are yet unknown to
me what they might even be. The latter is the one that can
and will bite me on the ass.


Eck!

Eck! said...

GF

If we apply your case C to your cases A and B you have or are discredited or profess misinformation.

You have no facts, no information and the pictures are interesting but
I live in the 1918 epicenter and their pictures are how isolation and quarantine did work compared to Philadelphia where they didn't.


Eck!

Glen Filthie said...

Ummmmm…. you realize, Eck, that if a cheap dollar store dust mask could prevent an epidemic - the 1918 Spanish Flu epidemic wouldn't have happened at all, right...?

GAH.

Whatever. Fill your boots you guys! as for me... I have a motorcycle calling me, and in the immortal words of Principal Skinner..."Go to hell, children!!!".

:)

Differ said...

Second order effect: wholesale oil price is low (-ve?) We are running out of storage. What happens when you have to shut down refineries? Very few new refineries built in last few decades. Restarting tired old equipment ALWAYS results in problems. Expect fuel shortages as we try to ramp back up.

Aesop said...

1) The observed CFR for this virus seems to be running somewhere around 3%, as I originally guesstimated (and clearly identified it as such), based on the 1-5% average of coronavirus fatality in the wild prior to this outbreak.
2) There is no patent cure for this.
3) A functional vaccine will take between 1-∞ years to develop and distribute, IOW, it may never come, but at the rosiest, it'd be next spring.
4a) If the rosiest wild estimates of unvetted tests and peer-unreviewed surveys, using statistically invalid samples are correct, SARS-CoV-2 has penetrated, at most, about 4% of the U.S. population.
4b) A more rational estimate is that it has only penetrated to about 0.5% of the population of the U.S., to date.
5) In a population where it went hog wild, because it was treated as nothing to worry about until it was everywhere, and where things like the subway used by millions daily is still running, it created nearly half of the (currently 45K) deaths experienced.
6) There are about 900K hospital beds in the entire U.S.
7) There are about 70K ICU beds.
8) There are about 60K ventilators.
9) It takes 2-3 years to train a respiratory therapist, and each one can supervise about 4 vents.
10) About 60-75% of the beds available are occupied by other patients 24/7/365, because we run the health care system as lean as a passenger airline (i.e., at <95% occupancy, it goes broke).
11) The average CFR for annual seasonal flu is 0.1%, since ever in living memory.

Those are the facts you have to date.

So plug all that in, and tell me, with existing technology, whether or not you want to kill between 25X and 200X more people, or some smaller amount, by unilaterally ending lockdowns with no universal testing, and why or why not.

If your answers is "Let's not do that", tell me how you do anything more sensible than testing everyone, with a validated and accurate (say >98%) test, to determine who is either clean, or over this and no longer contagious, before letting anyone of them back into the population-at-large pool to play.

That's the actual decision facing both POTUS and 50 governors, right now.

Feel free to bring up the economic factors, which while significant, have killed exactly zero people to date, as opposed to 45K and counting.

Go.

Aesop said...

As for Glen's comments about masks, rather than belabor a brevity limited blog comment, I'll post a thorough explanation, guess where.
The short answer is that gloves and N95 masks work.
IF functional morons don't bugger it up by failing to scrupulously follow aseptic technique. Which failure they will deliberately accomplish, beyond any possibility of doubt.

Which is why gloves and N95 masks won't work, for most of the U.S.: because the general population is too stupid to follow basic rules.

(I favor giving 100% of them the chance, but the punishment for morons should be leaving them to die in their own stew, on the modern-day equivalent of COVID Island or stadium quarantines, with care given only by the other morons, until they test negative and get out, if they can pass the aseptic technique exam with a score of 100% on the first and only try. Otherwise, they stay inside until the pandemic is completely over. Call it the Typhoid Mary/Gilligan Rule.)

Phelps said...

Feel free to bring up the economic factors, which while significant, have killed exactly zero people to date, as opposed to 45K and counting

This is the only part I dispute. There IS a cost in lives to the shelter in place orders. Any time there is an increase in unemployment, there is a jump in suicides. (Yes, it is irrational. Suicide is an irrational act.). There is also an increase to domestic violence and child abuse, fatal and subfatal.

These are factors that must be considered if we are going to be pragmatic. Shelter in place kills people too. Whether it is more of less than the virus depends on the CFR.

B said...
This comment has been removed by the author.
Knightsofnee said...

All I know is that I here The Purge Sirens off in the distance.

Aesop said...

@Phelps,

There's no dispute.
I'm not saying shelter in place is consequence-free.
I'll tell you frankly that other than COVID patients, what we're seeing in droves now is overdoses and drunks, by the busloads.
("$1200!?! I can buy a sh*tload of booze/dope with that!!!")

Suicides are suicides. Crazy people are crazy. QED.
If you're not going to count them in discussions of gun deaths, gun bans, and waiting periods, don't dragoon them into any arguments about stay-at-home rules.
Fair is fair.

But post the actual numbers, not imaginary ones, and let's both compare apples to apples, and not to pineapples.

Then we can talk about whether they died because of stay-at-home, or because they were mentally imbalanced and suicidal for years/forever.

Otherwise, unless and until I see bloat-bellied orange-haired kids starving in the streets, I'm giving well-deserved short shrift to how unbearable a less-than-two-month stay-at-home is to date. This country throws away more food annually than most countries on the planet even eat.

The point at which we have to do something we shouldn't like, because the disease is killing less people than the lockdown, is still open to discussion. But we're nowhere close to that point yet, nor likely to be for some good time. It's both theoretical, and a boogieman, not an actual thing.

I'm open to evidence on the point at which that changes, as I expect you are.

ADS said...

Every piece of information I've read on this disease indicates that young, healthy people have an extremely low chance of serious symptoms or fatalities from COVID-19. The risk factor increases sharply with age and comorbidities such as hypertension, obesity, and diabetes. I've seen no information anywhere that contests the above. Yes, some young healthy people will die from it, but some young healthy people die from seasonal flu as well and we don't panic. The number of occurrences reflects the tiny percent chance applied to the huge population number.

Given the above, it makes sense for nursing homes to be locked down. It makes sense for the old and/or infirm to shelter in place. It makes no sense to keep the huge population of working-age adults in the low-risk category at home watching netflix while the economy crashes and burns, except to mingle at the grocery store and other essential outside locations.

Unless I'm wildly misinformed, there are two ways to resolve a pandemic: Burn out or herd immunity. If everybody was locked into their homes with no contact with the outside world for a quarantine period that guarantees death or recovery of all infected people, then the pandemic is over because transmission was impossible and the all-clear can be sounded.
To go the other way and get herd immunity, a sufficiently large percentage of the population must be exposed to, contract, and recover from the disease. To achieve this, you would actually want to increase the rate of exposure to hasten the onset of herd immunity, with the caveat of not overwhelming the medical system with patients or suffering unacceptable fatalities.
I propose that the group of young healthy people who are extremely unlikely to notice the infection, let alone die from it, as shown by all available data, be sent back to normal life to be exposed to, contract, and recover from the illness so that we gain herd immunity as swiftly as possible.
In the mean time, the high-risk population can shelter in place until such time as herd immunity renders transmission low enough to emerge, and/or a vaccine becomes available, and/or a course of therapeutic treatment is discovered that reduces the risk to acceptable levels.
I should be at work. My retired Boomer parents should be limiting their exposure. My Greatest Generation grandmother should be taking extreme precautions.
What we're doing now is the worst possible reaction: Torpedoing the economy, destroying small businesses, destroying the service industry, destroying the just-in-time distribution of consumer and industrial goods, forcing millions onto unemployment, running up huge deficits, interrupting the schooling of children, bankrupting airlines and all downstream businesses, and severely impacting the ability of farmers to harvest and process our future food supply, so that we limit the transmission of this disease...
...except a huge portion of the population has nothing to worry about from this disease, and essential workers are going to work anyway, and everybody is still congregating at grocery stores/walmart and being exposed...
...and if transmission is being slowed at all, it's having the opposite effect of the desired outcome of herd immunity...
...and "flattening the curve" may prolong the duration of the lockdown to 6, 9, or 18 months depending on who's paper you're reading...
It becomes obvious that a broad-reaching not-really-a-lockdown lockdown leads to a variety of unacceptable conclusions to this emergency and should be reevaluated. We desperately need more testing and more data, but in the meantime we can use what we have to make more sensible guidelines tailored by location and risk factors.

Clayton W. said...

I always loved the Donald Rumsfeld quote. I was a senior in High School when he said that and it was perfectly understandable. Except to the press corps.

AFAIK, there are only 2 ways to stop this:
1. Strict quarantine of every man, woman, and child for 24 days. Every single contact resets the clock. If a person can't have strict isolation, then the time doubles for each additional person. Throughout the entire world. In other words, it is not going to happen.
2. IIF (If, and only if) getting the disease offers immunity, then we have to release the lockdown to the extent that we can keep the infection rate below that that crashes the healthcare system. Since a vaccine won't be available for at least a year after it is developed, that means we will have to just take our lumps.
3. If the Wuhan Virus mutates MORE than the normal flu and we can't develop a vaccine, well, this will end up being the new normal, as painful as that is. Modern healthcare, and sanitation systems even more so, has reduced our disease rate by a huge margin. That could be over.

We are already seeing fissures in our infrastructure because of the lockdown in food and medicine. Manufacturing will be next as spare parts become unavailable. The government has spent ~6 trillion dollars, 25% of GDP, for a months worth of crisis. Extend that for 18 months, as Dr. Fauci recommended, and it will be on the order of 100 trillion dollars. That is a LOT of inflation.

Glen Filthie said...

This is why people get frustrated with you and start calling you names, Aesop.

Run a cash register at the supermarket and follow perfect aseptic technique. Dig a ditch with sweat pouring down your face. Work outside in the rain. Tear down an engine. Stock shelves. Be the cop that has to get that drugged up, alcoholic homeless howler monkey under control. That is all in addition to the stupid people you want to lump us in with.

Earlier you said that California had minimal casualties while NYC had orders of magnitude more. You ascribed that to good aseptic technique. Now you are saying everyone is too stupid to make it work. So which is it? You say that New Yorkers are stacked on top of each other and using packed subways and that is the reason for the fatality stats. Are you going to tell me there is no mass transit in California? That there are no tightly packed urban centres? This is why I tell you to either make sense, or leave me alone.

Also, tell me how I am supposed to pay the taxes, that pay your wages, when I can't make a living?

Go.

McChuck said...

Well stated.

The State Pen in Marion County, Ohio should be a good Petri dish. Prisoner population of 2564, 1828 infected, 2 deaths so far. Plus the (uncounted) staff has 109 positives and one death.

There are only 21 people hospitalized for the Kung Flu in the county, according to reports from the weekend.

Ominous Cowherd said...

Some of the exposed aren't getting this, and some who get this never get sick. Why is that? Those are two known unknowns.

Are we using the right measure for the danger this disease presents? CFR is probably the wrong measure, since cases are a politicized, cherry-picked, subsidized number that is ignoring the actual outcomes of most who are exposed, and most of the subset who actually contract the disease but are never diagnosed because they never get sick.

I'm going to propose a different metric for disease, Exposure Fatality Rate, EFR. A disease with a 100% death rate to which only one in a million are susceptible has a one in a million EFR, even though the CFR is 100%.

The thing that the doomers are ignoring is the lesson from the Plague Princess: out of 3,700 people on the ship who stewed in the virus for a week or more, 7 died. The EFR was 7/3,700=0.0019, or 1.9%. If all 330,000,000 of us get exposed, that's about 620,000 deaths, assuming no treatment other than basic life support. Remember, the Japanese had no idea how to treat those elderly cruise passengers, and today we have a much clearer picture of how to treat this.

The numbers looked a lot better on the aircraft carrier: 5,000 on the ship, 1 died. Them's pretty good odds. If all of us are exposed, that's 0.0002*330,000,000=66,000 deaths, not exceptional for a flu season.

The Plague Princess gives us the worst case, upper limit number if we don't use the HCQ+Azithromycin+zinc cure. If we use HCQ++ early and often, the Theodore Roosevelt numbers are a better predictor. Either number assumes EVERYBODY gets exposed. If we take New York-level non-precautions, with most of us crowding into subways every day, we still won't be able to expose everybody.

Odds are pretty good that about 20% of us have been exposed by now, going by Aesop's doubling numbers. About one fifth that number have contracted the virus, around 4% of us. That's around 13 million who would test positive, though most will never know they have it, never get tested. With 45,000 deaths, that's an EFR of 45,000/(0.2*330,000,000)=0.0007, or 0.07%. That's better than the Teddy Roosevelt by far, and it's as solid as any of the numbers that are going to be thrown around in these discussions. Remember also that the Leftys have been discouraging or forbidding the Trump Cure, which maximizes the death rate in areas they control, like New York. If we use the Trump Cure early and often, even that low percentage may be a high estimate.

The argument for continuing the lockdown hinges on a huge death toll if everyone is exposed. That's no longer a reasonable assumption. We cannot justify taking any precautions beyond those we would take for a normal flu season, based on the information we have.

TechieDude said...

I'm sure someone covered this "known unknown".

Sure, a yuge percentage don't get it. 80% or so get it and are asymptomatic, or have mild symptoms.

We don't know that number, and can only get it with testing everyone, which won't happen. But what we do know is they are contagious.

Another thing we know is that the average person, at least in my area, isn't fully sheltering at home. We also know that gloves and n95 masks work if used correctly. We also know, and I observe, they aren't being used, and if the average mook is using one, he's doing it wrong. Seen N95 masks on guys with bushy beards, old ladies who's jowls create gaps, knuckleheads wearing them on their chins. I've seen all manner of masks. My wife makes them and I have to participate in the mask kabuki like a woman dressing in a burka in a mooslim neighborhood because, well, it's just easier that way. I'm sick of being castigated by flunkies that won't serve me because I have no mask, when the one they are wearing wrong won't help anyway. I complained to the wife who said it's better than nothing. It isn't. It's the same as nothing.

I'm pretty much in the camp of a number of virologists that I've read or seen on interviews. It's a respiratory virus. It's going to do what it does.
Given what I've seen of the population at large here in DFW, I think if you were going to get it, you're going to get it. You got that ticket to misery the moment kungflu hit the shores.

The shelter in place, which would work if everyone did it, only delays the inevitable the way it's being done. It's going to burn out how it burns out, only difference is time. The way we're going, it'll still be here a year from now.

Jerry said...

Another issue that no one is addressing is COVID 19 statistic inflation. So many are allegedly dying from COVID 19 rather than stroke, heart disease, cancer, etc. that we are left with either the patently illogical conclusion that COVID 19 is somehow curing these diseases or there is a financial reason for miscounting these deaths. A reasonably facile statistician can sort this out.

John said...

I've always liked the Rumsfeld quote, but, as a fan of symmetry, I've always felt there should be an acknowledgement of the "Unknown Known" category.

For example, in the early days, we knew nothing about the co-morbidities that contribute to a severe reaction to Covid-19. As time went on, we found out that age, diabetes, obesity and compromised lung function can mean a death sentence for a person.

BOOM, people in good health feel more secure and optimistic about surviving a bout of this, but also now we can make more accurate predictions of total deaths based on our existing statistical data of the health of the population.

I feel the acknowledgement of Unknown Knowns is a reminder to keep one's mind open to position changes based on new information as it becomes available.

Not sure this makes sense as I've written it.

Peter B said...

South Korea's cumulative cases today is 10,702 with 240 dead. That's a CFR of 2.2%.
The CFR for the US minus NYC is 4.6; NYFC is at 10.5%.

In other good news, recovered patients from multiple countries are testing positive for the virus at (so far) up to two months past their apparent clinical recovery. Or "recovery."

Ray - SoCal said...

Seems to be the side effects of having Covid 19 are unknown. I am hearing stories of long term damage to lungs, and other internal organs. I don't know if this only applies to some patients, and not other.

Another unknown is the effect of virality (how much you are exposed) has on how bad you get Covid 19. This may explain why NYC got hit so bad (subways).

In the US, what is best practices for disinfecting an area for Covid 19. Taiwan seems to have this figured out.

Effect of temperature and humidity on Covid 19

Impact of Genetics on susceptibility of people on Covid 19.

Do certain vaccines (TB), reduce the severity of Covid 19.

In the US, best practices for keeping employees at a business safe.

Best practices for keeping Covid 19 out of nursing homes. My guess is these are a huge source of infections in the US.

Best practices for modifying HVAC systems (add a UV Filter?), to reduce Covid 19.

Good news is these are being figured out in the US.

Borepatch said...

Peter B, the CFR is essentially meaningless because almost nobody is being tested and a very large number of infected people seem to be asymptomatic. If an extra ten time as many people catch the virus and recover after having no symptoms, the CFR for NYC is 1%. If it's 20 times as many who have caught it and recover, the CFR is 0.5%.

For NYC which is the worst place in the USA for the virus.

But we simply don't know how many people have caught the virus. The data are very incomplete.

Ken said...

Per Borepatch above, the inclusion of "died with" in "died of" doesn't increase my confidence in the published CFR data.

Sarin said...

#25?
Willingness and ability of John Q. Public to learn how to use PPE appropriately?

#26?
Number of qualified instructors available to teach John Q. Public?

#27?
Number of available fit test-sites/locations/instructors?

#28?
Number of available N95 for John Q. Public? Will they be at a premium price?

Retired .mil. Spent time on the pointy end of the spear and then moved into a more cushioned job as a CBRN guy. Teaching 18 - 45 year olds how to don/clear and M40 or M50 mask, MOPP gear etc... I've been exposed to VX and Sarin, hence the moniker. Had a pot of Sarin literally boiling in my face in Mopp IV, courtesy of the CDTF. Was testing the efficacy of the detection equipment in real-world scenarios, but I digress.

Not advocating for teaching full-on asceptic technique. Too nuanced and most of it beyond the capability set of John Q. Public; I'd advocate that if we can teach zero-attention span kids how to safely don/clear a gas mask, we can do the same for an N95 mask. The problem is the fitting situation and availability of the PPE.

Phelps said...
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Aesop said...
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Aesop said...
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ASM826 said...

Aesop,

You can't shut down commenting on your page and just move over here and pick back up. It's one or the other. Open your page back up to comments or I will turn off the free ice cream here.

So it's not ad hominum, it's straw man, but I'm not having it get to the tossed insults.

Night driver said...

SOMEONE DESPERATELY needs to point out that we have YET to do ANY QUARANTINING for this specific bug.

There are NO homes with "QUARANTINE" signs on them, and residents forced to stay home with no visitors except the County Health Nurse who tests for the bug on a schedule.

"Shelter in Place" is NOT a quarantine.

"Stay Home" is not a quarantine.

Quarantines WORK (cf American Samoa and Samoa)

BUT you actually HAVE TO QUARANTINE!

Is EVERYONE too young to remember Tuberculosis Sanitaria and Quarantines? Or Diptheria Quarantines??
How about the "Silent Summer" with respect to Polio? I was born in the spring that BECAME the "Silent Summer" and my family was careful to make me understand how THAT went since I had family members wearing braces and such.

And herein lies MUCH of the issue. We have YET to get serious on this bug.

We will cross the 50K deaths milestone this weekend, likely Saturday afternoon. Just a tough flu year, eh??
Except that a difficult flu year does this in 8-ish months and this has done it in 3 and isn't done yet.

FredLewers said...

https://www.foxnews.com/us/new-york-antibody-study-early-results

Ominous Cowherd said...

@Night driver, to quarantine, we would have to know who has the disease. That requires testing everybody. We're not there yet. By the time we are both ready and able to do that, the virus may have fizzled out, perhaps because everyone who can get it has gotten it.

Aesop said...

Fair enough, ASM, we'll stick to just the facts.

1)Glen is correct: aseptic technique is simply not possible in a host of workplace endeavors, thus mask-and-glove solutions, aren't. Exactly as I stated on my blog.

2)Glen's allegation that I ever said California's infection and death numbers were better than NYFS's "because of aseptic technique" is absolutely factually and totally incorrect. In fact, it's not even close. I will refrain from ascribing motive for such an obvious and egregious error, so simply verified. If he or anyone wishes to further dispute this, they should kindly link and/or post the relevant quote.
Aseptic technique has to do with how one dons and doffs PPE. I have yet to see it done properly in the wild in CA, or anywhere else, outside of the health profession, or perhaps industry clean rooms.

3) New York has nearly double the population density of San Fran, 4 times the population density of Los Angeles, and 7 times the population of San Diego, nearly 30K people per sq. mi. in the Five Boroughs. There is nothing like the NYFC Subway anywhere in CA, nor is such practical nor necessary. That, and NYFC keeping their subway open non-stop during this pandemic, as opposed to shutting it down, is clearly part of the reason why they're Pandemic World HQ. Holding an open-air Chinese New Year festival, with tens of thousands packed into NYFC's Chinatown, just before the height of this breaking, probably hasn't helped them either.
That was stupid, and it's cost them 16K people dead, thus far.

4) Glen, you live in Canada. So you obviously don't pay any U.S. taxes. Nor do U.S. taxes pay my wages; the insurance of the 50% of patients I see who actually have it does, and I therefore want them to get back to work as soon as possible. Ideally, without exploding this outbreak, crashing the medical system, or dying of Kung Flu.
Whether your prime minister allows you to work or not is, to me, a matter of general indifference, and has nothing whatsoever to do with paying my salary, but I'm sorry it's inconveniencing you.

5) Please stop putting words in my mouth that I didn't say. It's impolite, at best, even assuming a simple error. At worst...

Aesop said...

@McChuck,

In the county you cite, 86% of the infections and 100% of the deaths in that entire county occurred entirely within the prison population.
In short, people (overwhelmingly younger healthy males, BTW) locked in cells much like a cruise ship, are driving the entire outbreak there. Which outbreak, rather obviously, had to be imported there by staff and/or other outsiders, the residents of the penitentiary being the dictionary definition of stay-at-home lockdown.

In a more diversified population, i.e. the entire state of Ohio, there are thousands of more cases, and hundreds of deaths.

If your point is that Kung Flu is little threat to jail and prison populations, and that therefore we should stop letting prisoners go because of this, I applaud you.

If you meant to have 18-45 yr. old males stand in for the entire state, your statistical analysis would appear to require further refinement.

But you have made a sterling case for locking up, prison-style, all prison-age males to nip this outbreak - at least among them - in the bud in similar fashion. I suspect that was not the intention of your post.

Aesop said...

And I'm sincerely sorry (though I understand ASM's rationale) Phelps' linked post, and my reply, particularly the parts related to some WHO study of dubious veracity, was also a casualty.

No swipe at Phelps whatsoever, but the study itself, due to some fairly obvious and massive internal flaws, claimed to show via circular reasoning, that unemployment (such as during our current shutdown) might have led to as many as 18 additional deaths by suicide per month in the entire United States, six months ago. That would be before this outbreak began, to put a point on it.

Which pure comedy gold on behalf of psychologists at WHO should not go unrecognized. This is why generally, when psychologists write a survey, you generally have solved the nationwide shortage of TP.

If that qualifies as an ad hominem on the pointy-bearded geniusii at WHO, I plead factual accuracy as an absolute defense against any charge of slander or libel.

Aesop said...

And for ASM826's list of Known Unknowns:

Q.: How accurate, if at all, are the current antibody tests?
Q.: Are they specific solely for antibodies to SARS-CoV-2, or are they, in fact, just measuring that someone may have had a cold last month or last year?
Q.: Apart from presence of antibodies (which may only indicate exposure, not actual infection), what level of antibodies, if any, confers immunity from further/future infection?
Q.: What percentage of persons with antibodies are still actively contagious?

For all the surveys:
Q.: What antibody test was used, and how accurate and specific for SARS-CoV-2 (and nothing else) is it known to be?
Q.: Are they a statistically valid sample (i.e., generally, more than 2000 people controlled strictly for age, race, sex, and with accurate and valid sub-groupings for cardiac disease, COPD, diabetes, hypertension, and any other relevant co-morbidities?
Q.: Was the sample achieved via actual random selection, or was it skewed by selection bias, either deliberate or inadvertent?
Q.: Was the survey peer-reviewed and vetted, both statistically and medically?
(I note in passing that of the three U.S. surveys of which I'm aware, the Stanford survey, the L.A. County Survey, and the NY State survey, a total of zero of them meet all of these requirements, and most of them don't meet any at all. Such basic survey requirements are considered the minimum score to not being laughed out of the room by both any statisticians, and/or any medical experts, worthy of their positions.)
(cont.)

Aesop said...

(cont.)
Separate line of thoughts:
Q.: What happens if you hold an End-of-Kung Flu Party, and nobody comes? Do you abandon them? Ignore them? Compel them? Who has the right to force someone sheltering from sincere concern for their own life, to go out into the plague-fest you've created? Or to bleed and tax them into having to do it? Doesn't that violate the Thirteenth Amendment? (Not to mention common decency and traditional ethics?) If wild tigers man-eating tigers are roaming the streets, is government's duty not to kill the tigers, rather than force the citizenry to walk the streets to earn the money to pay their taxes? isn't that just the 21st century version of "Let them eat cake?"
How did that work out for Marie Antoinette?

Suppose you sequester/cloister/any-other-term-of-art "vulnerable" populations in any lifting of lockdowns and stay-at-homes:
Q.: Who pays for them? What about the ones young enough to work, too young for Soc. Security, but old/impaired enough to be at serious risk?
Q.: How do they eat, go to the doctor, get their medicine, etc.?
Q.: Do we make them "disabled", until further notice?
Q.: Who takes care of those too old and debilitated to care for themselves already (i.e. 90% of the population of SNFs and convo hospitals)?
Q.: How do you ensure the perpetual virus-free status of the people assigned/selected for the preceding duty?
Q.: How long, and ending when, do you maintain that effective solitary confinement-for-life?
Q.: What do you do if there's never a viable vaccine?
Q.: What do you do if we go through this again, because of another novel virus, or because this one mutates into one for which previous treatments/vaccines are ineffective?
Q.: What about if this becomes like colds and flu, but with the virulence noted to date, and you're never immune?
Q.: Who has the right, and constitutional authority, to decide for everyone, absent neither their express consent, nor their informed input, about subjecting all of society to this or any future pandemic?
(It's not strictly a question, but for any answer to the above, I want someone to show their work.)
Q.: Does any individual have the right to flout legitimate public health concerns, and endanger other (especially other vulnerable) individuals?
Q.: Does any government have the right to force anyone, majority, minority, or individual, to contend with public health risks beyond their personal control?
In short, what gives anyone the right to either shove anyone into the wood chipper, or bar them from coming near it?(I repeat, show all work.)
Do the needs of the many outweigh the needs of the few, or the one?
Or is it the other way around?
Where does your ability to swing your arms connect with someone else's nose?
These are fundamental questions in any form of government, let alone in a democratic republic, and like the abortion issue, all I see and hear are people shouting past each other, while failing to engage on the merits of the debate.
And they are both heart-attack serious, and exactly germane to the debate of the last two months, and the next fifty years.

Historian said...

A few points to ponder, raised elsewhere, but reposted here for the sake of the discussion:

Comparisons between regions, or even states, assume that the treatment regimens are the same. Differing treatment regimens make a big difference in clinical outcome. Hydroxychloroquin/Azithromycin/zinc sulfate given early in the course of infection appears to show excellent results. Given later in the progression, not much effect (in some locations, better in others. May relate to viral evolution, see below) Clinical recognition of the viral attack on hemes and the corrosive effects on lung tissue and structure from the Fe2+ ions liberated by the millions, with the use of blood transfusions to improve O2 sat has made another difference. Covid19 does not cause cytokine storms a'la 1918; it just looks that way. Ventilators are not a solution to the problem this virus creates in the bodies of those severely infected, and those places and clinical teams which recognize this are seeing significant improvement in outcome. Those that don't, don't.

Some locations appear to be testing more widely than others. In the state where I work, only 'symptomatic' patients are tested. In south Korea, they test anyone who wants a test. The difference in outcome is obvious, but the point is that limiting testing skews the data, and limits the options available.

Comparisons of outcomes between regions, or even between different hospitals in the same county, assume the quality of care is uniform. It is emphatically not the same, and quality of care makes a difference in outcome. You will not get the same care from Bellevue today as you might from Cheyenne General, or from UVA hospital. As noted above, ventilators will not treat the root issue for this infection, which is the attack on hemoglobin and the release of hematin (iron ions) in the lungs, destroying lung function.

It is not just treatment protocols, but also staff morale, rest, and support that make a difference. Organizations that have superior clinical and non-clinical staff support provide superior care. The willingness and ability of health care organizations to spend money during this epidemic when revenues are severely down is a factor in this. When hospitals are laying off support and clinical staff, that affects not only staff morale but effectiveness, as well. Nurses (and doctors!) doing terminal cleans because the environmental services staff contracts were all cancelled are nurses and doctors not providing patient care.

It is known that this Chinese virus is highly mutable, as one might expect from a RNA virus, and that different clades vary significantly in speed of onset and infection severity. There are a number of major variants of this virus in circulation with more being found every day. Assuming that all areas of the globe, or even the US, have the same clade of this disease, would be a mistake, another argument strongly favoring more testing and genetic sequencing, to tell clinicians what clade they are dealing with.

Further, my understanding is that genengineered virii, like this one, tend to be more unstable than their naturally evolved forebears. The virus infecting patient A may not be the same virus once A infects B,C,D, E and F. In fact, each person is their own petri dish for evolving viral clades. Many pathogens evolve towards lower lethality, but not all, anthrax being a prime example; several of the known clades of this virus appear, from early reports, to be much more lethal than the strains from Wuhan.

Cont-

Historian said...

-cont.

Infectious bolus matters a great deal, apparently. Early studies suggest that if you get a few viriions in your system, your native immune response may suffice. If you get a faceful of sneeze from an obviously ill infected person, you are more likely to get a bad case yourself. (this suggests that even imperfectly worn PPE can be better than nothing; if it reduces your viral load 60% that may be the difference between a cough and a runny nose, and a trip to the ICU. Or the morgue.)

However, exposure to one clade apparently does not necessarily confer immunity to another clade, reference the mutability of this disease. This ought to come as no surprise; how many times in your life have you gotten a 'cold' (another corona virus)? dozens? hundreds? Except this genetically engineered cold virus kills 1+ percent of the folks that get it. Long term, and by that I mean years to decades, it MAY be that this disease will evolve toward lower lethality and/or that human immune response becomes robust enough to make this just another cold. We'll see.

Lastly, genetics of the human population in an area make a difference, and so do the human demographics. It is known that some ethnic groups show more susceptibility to this damnable disease.

All of the above factors, and probably many others, play into case resolution, one way or another. In some locales, with overwhelmed hospitals and staff facing large outbreaks, deaths may come quicker than in places where staff are on their top form, having the chance to tailor care to the individual based on specifics of the clinical presentation as assessed through thorough lab testing and possibly even genetic sequencing.

Then there are the political aspects. We have no idea what the real numbers are from China, for example, or from the US, come to that. We know that the CCP routinely lie about everything, and especially about infectious outbreaks, but we have no way to know what the real numbers are. We know that the death stats from NYC are probably understating their death toll, while other locations may overstate their rates, while at the same time undercounting cases is going on to a variable extent worldwide. And it is not just China, it's everywhere.

We are not likely to know what the 'real' CFR is until well after the fact, if ever, and variations based on the above factors, and likely others, should be expected. Such information takes large scale seroprevalence studies, genetic sequencing of known cases, and enough time for all the cases to resolve, or at least to be able to set a timeline for date of infection, and so forth. At best, it is likely that this will take years, not weeks or months.

Speculations in advance of data may suggest reasonable hypotheses to be tested, but cannot themselves be conclusive. This problem is compounded by the recent epidemic of 'made-up science' by people whose lack of moral fiber and basic truthfulness corrupt the scientific process. It is very hard to sort out the truth from the corruption; there is a very great deal we do not know.

There are, however, a few things we do know; we do have a reasonably effective treatment regimen, and we are gaining understanding on why it works, politically motivated naysaying notwithstanding. That is a step forward. We know testing helps, and rapid testing is becoming more available, another step forward. Like most diseases, turning the Chinese Communist plague from a potentially lethal threat into an annoyance is an ongoing process made up of a number of small steps, not a single massive development. It will take time.

Cont-

Historian said...

-Cont.

In short-
this Chinese virus is highly infectious but for most clades is mostly not a problem for those infected, ~95% to 99% of the time. If you are the unhappy recipient of a severe case, it can be very bad news, depending on how good, and how well rested, and how well informed, your physician and care team are. Ebola it ain't, praise be, but anyone who has seen a previously healthy younger person who is moderately ill go downhill and die in the space of 12 hours is not likely to dismiss it as "not as bad as the flu." We have seen about 50,000 deaths so far in this country; the exact real number will likely never be known, but in round numbers, we've had a years worth of a bad flu year in a month or so, with only somewhere between 0.5 % to maybe 5% of the population exposed so far.

How bad is it really? Nobody really *knows*. We have a pretty good idea of the range of how bad this can be, but there are a lot of factors in play, see above. Wait a few years for the furor to die down if you want *knowledge*. Until then, prudent people would do well to avoid getting this bug. As noted above, you don't know what you'll get or how many times you'll get it.

With regard to all who seek the Light,
Historian

McChuck said...

Aesop -
My point is that young (under 50) people in reasonably good health have almost nothing to fear from this disease. https://www.businessinsider.com/coronavirus-death-age-older-people-higher-risk-2020-2?op=1

These are the people needed for the continuation of society. Old people are nice to have around, but not necessary.

Sacrificing most of the young to save a few of the old is how you destroy a society and a nation.

Yes, yes, I already know I am unpleasantly realistic.

Aesop said...

Not at all, sir.

"Old people are nice to have around, but not necessary."

Just spitballing, but I'm willing to bet a few hundred thousand CEOs and senior corporate management types would like to have a word or two with you regarding that contention.

And "sacrificing the young" is laying it on a bit thick, wouldn't you say?

Jerry said...

I read an interesting article this morning that the French are experimenting with nicotine patches after noticing that smokers have a significantly lower fatality rate than non-smokers.

Glen Filthie said...

Aesop listen. I did not put words in your mouth, because quite frankly, I got better things to do and I don't hate you enough to bother. You are speaking out of both sides of your mouth, and I am not going to wade through reams of snark to prove it.

How about We'll stick with what you've said right here. No, clinical grade masks won't stop the virus. To stop the virus cold, you need an airtight seal around your mouth, nose and eyes- preferably your entire body. I believe you may have said that in your ramblings before too - so which is it, and why do you keep changing your stance? We both know all it takes is one of those things in your mouth or sinuses or even your eyes - and the disease is off to the races. Right?

Likewise, your theory about crowding and population density are nonsense. Pandemics don't need sardine packing to progress. A real pandemic will spread on a bus, or an LRT, or a trolley or in an office whether it is in Sandiego, SanFran, LA, NYC or even Aaaaaaadmontin, AB. The exact same way it did with the Spanish Flu of 1918, when Alberta was still mostly bush with a few dirt roads and everyone got around on foot and horseback.

You keep calling me names and insulting me and 'proving me wrong' with your numbers. Welp, I called BS on your numbers about 3 weeks ago, and in that time, you not only missed the mark with your numbers by inches or feet - you've literally missed it by light years. Now you are telling me to shut up again, listen to you and your numbers this time because it's different somehow. Fair enough - how so? This time our blog hosts are questioning those numbers too. Are they idiots?

Hey - I am one of the few bloggers that apologized to you and is trying to see your point - none of this is personal - but it is frustrating. When I see all the noise being made - it's by the RN's. They're posing as heroes as they twerk and dance and post the vids to social media. They go to lockdown protests and sanctimoniously scold working people to stay in their homes, and don't care or are even aware that those folks are only weeks away from losing them. The other noisy group are the politicos, trying to blame a fake pandemic on Trump. It's weird. The doctors and real experts are still trying to figure out what's going on. They've been quiet as church mice. Maybe that says something...?

I see that hospital ship is pulling out of NYC now... not enough customers, I guess. Since this began, I've lost my job, my former employers lost their business... and unless I am wrong, the second round of pandemic layoffs are about to start. For now we are well. We have savings, no debts, and lots of preps... but there are tons of kids our way that have kids of their own, car payments, mortgage payments, you name it. I'd laugh at your snark, Aesop, if it wasn't so tragic. None of what is to follow was necessary.

I have no problems with your insults and cheap shots and accusations (most of 'em are probly true anyways, HAR HAR HAR) … but there are young men and women around here that will not take it lightly and would likely take it personally. You might want to watch the way you deal with people in the days ahead. Just sayin'. I'm stepping out of this because to keep arguing at this point will make ME look stupid... and that's me saying that, HAR HAR HAR!!!!

I hope I am panicking needlessly but... I see really, really think tough times coming of all this, and best of luck to you all. In the days ahead, we are likely going to want to blame men like Aesop for the economic crash about to follow... but it isn't all his fault. Anyone of us that went along with it could have informed ourselves with the click of a mouse. We could have prepped, saved when we spent, and done any number of things differently. The game has changed, and we need to change with it and get back to work!

Have a great Friday, fellas.

Great Scott said...

Glen,
I mostly agree with you. I have not been laid off yet but I know many who have.
In my county 5 have died and all were above 88 years old.
We have been staying home except for work for six weeks but the damage to the economy cannot continue.

Aesop said...

Glen,
1) You absolutely made "and you say it was because of aseptic technique" up out of whole cloth. Begging fatigue when you've got time to write reams about how you haven't got the time won't wash. You lose that one, on the merits. That's "putting words in my mouth". QED
2)"We both know all it takes is one of those things in your mouth or sinuses or even your eyes - and the disease is off to the races. Right?" See that, right there, Glen? That's you, putting your words in my mouth. That's a fail. Because NO, all it takes is NOT 'one of those things in your mouth'. The viral load makes a yuuuuuge difference. Getting a small exposure rather than a full-face infected sneeze at 2' away may be enough to trigger antibody production without leading to a full infection, because you have this thing called an immune system. People I work with routinely have positive TB antibody titers, but they've never gotten TB. This virus is no different there. That's why antibody titer tests in this pandemic don't impress me. Millions of people exposed doesn't equal millions of people infected.
As for masks, if the standard is clinical perfection, yes, you want N95 (or better) masks. Surgical masks, however, keep your cooties with you, instead of spewing them hither and yon, and that may be enough to open society up, if we can keep the Gilligan Factor under control. I'm sorry if a nuanced answer is difficult to process.
Life is shades of light and dark, plus colors, not all black and white.
3) No one, including me, said pandemics need high densities to spread. High densities make them spread faster. That's the point of NYFC. WY has more sheep and cattle and horses than people. They therefore don't have 16K dead. NYFC has few livestock, but they've got dead bodies piled up in freezer trucks. That is a function of Density X Stupidity.
4) What numbers did I get wrong? Just because you say it with conviction, doesn't mean it's true.
Do we not have nationwide lockdowns in effect?
Do you think that had zero effect on the totals?
Do we nonetheless still have 50K dead today because people didn't do them some places fast enough, or at all?
Do you understand how "If...then" statements work?
5) I told you (and told you and told you) that deaths from this virus were the least of your worries, and that the follow-on effects were going to kick everyone's ass. If you paid attention, nothing that's happening is much of a shock or surprise to you.
I also told you doing nothing would overwhelm the medical system.
NYFC did nothing. How did that work out there? Check the videotape, and get back to me.
The rest of the country here did do something, and it's made a yuuuuge difference in outbreak and outcome.
(cont.)

Aesop said...

(cont.)
6) The doctors and "real experts" have been all over the place on this. And anything but quiet. You maybe haven't been listening, but every channel has there own house rock star geniuses, pointing every which way. if they'd all actually shut the hell up until they knew something, they'd actually be "as quiet as church mice". The problem is, the Usual Suspects (Fauci, Birx, et al) have been the biggest idiots, and the media can't tell the difference between shit and Shineola. That's before we factor in their anti-Trump axe to grind, 24/7/365.

7) Throw in knee-jerk right-wing iconoclasts and shit-for-brains "I'll do whatever-in-hell-I-feel-like" jackholes everywhere from the right wing to pure anarchy, and you've got a perfect stew of idiocy all across the spectrum. Sometimes, people know more than you do, and bright people listen to them. The ones who think with their dicks are in a world of hurt right now. So are people just trying to get along, but caught in the crossfire, which sounds like you.

8) Neither I, including anything I said, nor anyone like me, got you where you are. Lockdowns nipped this in the bud, most places. One glaring failure to do them killed 16K people, so far. that that also means jobs were lost, and the economy of the Western world took a shit was unavoidable. Just walking along like this was nothing would have been a 3% death rate, everywhere. 10M people dead out of 330M wouldn't be a catastrophe, but it would've been 4X the usual daily death toll from all other causes, and wiped out all healthcare anywhere. Period. If you wanted either of those things in preference to what you got, that's its own reward, AFAIC.

9) I have a job right now, but even that won't last infinitely, even for health care. Barter-trading nursing, medical care, and medicine for eggs and bacon isn't a theoretical prospect if this lasts indefinitely.
Anyone anywhere butthurt about anything I've said is heartily encouraged to untwist their panties, and get on with their lives.

Some of us have made provision for tough times, the ones who haven't are in deep shit, and it's going to get a lot deeper, for a long time, before you or I get to wade out of it.
I'd suggest focusing on that task, and leaving off worrying about things you can't control. Blogging is a luxury, Glen. Eating isn't.