Covid (Coronavirus) in Minnesota: An FAQ

UPDATE 14 April 2020: I am no longer updating this post regularly, but I will try to continue posting links to my other Covid-in-Minnesota coverage for those who use this FAQ as a landing page:

• 13 April 2020: Covid Bombshells at the Minnesota Modeling Presser
• 19 April 2020: Two Cheers for Governor Walz
• 9 May 2020: Covid and My Inner Skeptic (not too Minnesota-focused)
• 12 May 2020: Where Are Minnesota’s Tests?
• 21 May 2020: Minnesota Surrenders

Before we get into the details, how is Minnesota doing in the battle against coronavirus so far?

We’ve done okay.

We took significant state action to reduce the virus’s spread at a relatively early point in our epidemic. When we closed our schools, there were under 100 known cases in Minnesota and no deaths. (Italy had over 3,000 cases and over 100 deaths when they closed.) When our stay-at-home order went into effect, there were nearly 400 diagnosed cases and 4 deaths. 4 dead meant the real case count was likely over 4,000, far too many to easily control… but we were still in far better shape than Italy or New York City or even Louisiana. (Louisiana had 837 diagnosed cases and 20 deaths when it finally imposed a stay-at-home order yesterday.)

There are some indications that we have started to bend the curve of viral growth downward. My projections from a couple weeks ago were underestimates for a while (indicating disease growth over 33%/day), but, on Wednesday, they became overestimates. That could indicate slower disease growth thanks to social distancing measures, which generally take about two weeks to have an impact. It could also indicate that it is growing so fast that our testing can’t keep up. We should know in a little while, once the current week’s diagnosed cases start turning into deaths.

Gov. Walz and the state deserve credit for acting early and decisively to slow the growth of the disease.

What are our options from here?

There are three general strategies we can choose from. Different governments differ on many of the details, but the three broad strategies are very distinct:

1. DO NOTHING: We could stop all (or nearly all) our efforts to prevent the spread of covid, allowing it to run its course until we acquire herd immunity. Nearly everyone would catch covid, and many of us would die. But it’s worse than that: our hospitals would run out of beds, equipment, and staff. That means some people would die due to lack of medical treatment.
   
   According to modeling by the University of Minnesota, 74,000 Minnesotans would die if we followed this strategy. According to modeling by Imperial College London (which makes slightly different assumptions), 2.2 million Americans would die.
   
   However, many believe this would be the least economically damaging path.
   
   
2. MITIGATION: We could implement limited social-distancing and stay-at-home orders for a moderate period of time. Our goal would not be to prevent the infection from running its course, but merely to slow it down, so that our hospitals are not overwhelmed. Nearly everyone would catch covid, and many of us would die — but not as many, because we would all have hospital beds to be treated in.
   
   According to modeling by the University of Minnesota, 55,000 Minnesotans would die under this strategy. According to modeling by Imperial College London (which makes slightly different assumptions), 1.1 million Americans would die.
   
   
3. SUPPRESSION: We could implement strong social-distancing measures and periodic lockdown (“shelter-in-place”) orders for a longer period of time. These would have to be strong enough not just to slow the virus’s advance, but stop it and force it into retreat by depriving it of new hosts.
   
   Once the number of patients has been reduced to nearly zero, you change gears: suppression methods end, but, in their place, you implement robust and universal testing and temperature checks, followed up by mandatory quarantines for anyone found infected. This way, you prevent the disease from growing out of control again. The government must be vigilant until a treatment or vaccine is found, but life can mostly go back to normal for most citizens. For this reason, you might also refer to the suppression strategy as the “suppress/test/contain” strategy.
   
   Wuhan implemented a very strong version of this during their epidemic, and, with the caveat that statistics from the Chinese Communist Party are often dishonest, it seems to have worked. After eight weeks, coronavirus cases have fallen enough that the CCP is beginning to end quarantine. Other countries have implemented suppression, including the U.K., but we haven’t seen the full results yet.
   
   The University of Minnesota did not model a suppression strategy. However, according to modeling by the University of Washington, only 1,420 Minnesotans would die under a suppression strategy. According to modeling by Imperial College London, only about 100,000 Americans overall would die under a suppression strategy (if implemented nationally). Since Minnesota has about 1.7% of the U.S. population, that very roughly works out to 1,700 dead Minnesotans.
   
   However, because suppression involves the greatest amount of social distancing for the longest period of time, it is believed to be the most economically damaging approach.

What strategy is Governor Walz adopting for Minnesota?

To his credit, Gov. Walz sat down for a twenty-five minute discussion with the state where he laid out his plan. If you live here, you should watch it.

Walz has picked MITIGATION as Minnesota’s strategy. That means his plan allows almost everyone to catch covid, but we’ll all have hospital beds, giving us a considerably better chance at surviving covid than we would without hospital beds.

Walz’s office, according to its own projections, expects that, if this plan is successful, 50,000-55,000 Minnesotans will die of covid by the end of this year. (And that’s if it’s successful.) That’s approximately 1% of Minnesota’s total population.

To Gov. Walz’s discredit, he did not divulge this number to the People he serves. The Minneapolis Star Tribune was able to obtain the number several days later.

If we remain on track for 50,000 deaths, won’t Governor Walz extend the stay-at-home order? Didn’t he say that was a possibility?

Governor Walz says he will extend the stay-at-home order if we are not hitting our goals for production of ventilators and ICU equipment, because the goal of his strategy is to make sure that everyone who needs a ventilator and ICU equipment gets it. So if we remain on track for 74,000 or 64,000 deaths, Gov. Walz is likely to extend the order.

However, Governor Walz will not extend the stay-at-home order simply because we remain on track for 50,000 deaths. In his strategy, 50,000 deaths is the goal.

I repeat: since reducing Minnesota’s death toll to 50,000 is the intent, Gov. Walz will interpret evidence that we are on track for 50,000 deaths as a success, not a red flag.

Some of my friends have had a hard time wrapping their heads around this. They cannot believe that Governor Walz would choose a strategy where 50,000 Minnesotans die (mitigation) when he could choose a different strategy which, according to available models, would save more than 90% of those lives (suppression).

Why is Governor Walz choosing mitigation over suppression?

I’m going to start by quoting the Governor directly, so you know I’m not messing with his words.

Just to be clear: shelter-in-place simply moves the date out. It doesn’t do a thing in terms of reducing infection rates unless we have either a vaccine or therapeutics or increased ICU capacity, you’re still going to get the same results, just at a later time.

…If I put on shelter-in-place indefinitely, what that would do, would buy more time, but it would not reduce the infection rates that would eventually be coming. It would not. The minute that we came off of that, barring a vaccine, numbers would shoot back up and ICU usage would be overrun.

So the attempt here is to strike a proper balance of making sure our economy can function, protect the most vulnerable, we slow the rate to buy us time and build our capacity to deal with this…

…The only thing we’re able to flatten a little bit — and this is what we’re trying to do at this point in time, our medical experts believe it, and our private sector partners believe it — the only thing we’re able to flatten is the ICU usage and its capacity…

…if we chose to shelter-in-place for five months, I think all of us understand what the implications would be, and all that would happen is, if we didn’t do this surge of capacity, is we would move these lines to the right and still be in the same position. I don’t believe it’s prudent to try to shelter in place until a vaccine is there. I don’t believe that, in the long run, the damage that’s done to the economy allows us to have those resources necessary as we get smarter and get more information about who can be quarantined and how we can build up the production lines.

It appears that Governor Walz believes that suppress/test/contain is either

(a) impossible,
(b) too expensive, or
(c) both.

Whether it’s too expensive is, of course, a judgment call. Think of the 100 Minnesotans you love most. Now imagine one of them is going to die under Gov. Walz’s mitigation plan. Imagine that same person would be saved under suppress/test/contain. (This shouldn’t be too hard to imagine, because it’s going to be our reality in a few months.)

Are you willing to lose your job to save that person’s life? Are you willing to sacrifice your kid’s education for a few months? Are you willing to see your retirement account plunge this year? Are you willing to shelter-in-place for weeks on end?

I am. You may not be. That is up to you, based on your circumstances.

But Gov. Walz also seems to think that, aside from being very expensive, suppress/test/contain is impossible. He keeps saying things like, “We can’t flatten this,” and that suppression “would move these lines but we’d still be in the same position;” that coronavirus cases “would shoot back up” as soon as we lifted a stay-at-home order.

This does not appear to be in line with the consensus among America’s epidemic experts.

Which experts think suppression is a viable strategy?

Gov. Walz says that the experts he’s talking to don’t think it’s possible to bend the curve of the epidemic downward far enough to suppress it. I don’t know what experts he’s talking to, and I don’t know whether he’s seeing the news from South Korea or Wuhan.

But here are a few experts who think suppression is a viable strategy, despite what Gov. Walz claims:

• Caitlin Rivers, PhD, MPH, an epidemiologist at Johns Hopkins Center for Health Security (@cmyeaton)
• Scott Gottlieb, MD, former FDA commissioner (@ScottGottliebMD)
• Tom Inglesby, Director of Johns Hopkins Center for Health Security
• Trevor Bedford, PhD, viral phylogeographer at Fred Hutchinson Cancer Research Center (and discoverer of covid-19’s community spread in the U.S.)
• Dr. Patrick Walker and Charles Whittaker, epidemiology, Imperial College London
• Chen Shen, Nassim Nicholas Taleb, and Yaneer Bar-Yam, risk scientists (@nntaleb)
• Marc Lipsitch, epidemiologist and director of the Harvard Center for Communicable Disease Dynamics (@mlipsitch)

Didn’t those Imperial College guys say that suppression would need to last for 18 months? Gov. Walz mentioned sheltering-in-place until there’s a vaccine. Is that really what we’d have to do to save all those Minnesotans?

“Those Imperial College guys” — led by Professor Neil Ferguson, an epidemiologist who is director of the MRC Centre for Global Infectious Disease Analysis (@neil_ferguson) — did indeed release a horrifying paper a couple weeks ago. It suggested that the only way to avoid huge death tolls would be to follow very strict suppression measures for 18 months. I grappled with this paper at some length last week. I concluded that the only reasonable thing to do, given the impossible choice, was to attempt a full-spectrum suppress/test/contain approach.

A few days ago, before Parliament, Prof. Ferguson endorsed exactly that approach. The initial Imperial College paper, he explained, was based on the assumption that there would not be enough tests to go around. Rapid scaling-up of British testing capacity has convinced him that the South Korean suppress/test/contain strategy is the most likely approach going forward.

So who are the experts who might be telling Gov. Walz that suppression is impossible?

Although some experts believe suppress/test/contain will be extremely hard (and I strongly suspect they’re correct), the only prominent public-health authority I can think of who (like Gov. Walz) considers the strategy impossible is:

• Dr. Michael Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy.

Mind you, Dr. Osterholm does not appear to believe that suppression is impossible in principle. As he wrote in this week’s New York Times, Osterholm is just very pessimistic about American supply chains. Suppress/test/contain depends on tests, and Dr. Osterholm doesn’t think we’ll be able to manufacture enough tests in time. Thus, he contends, the strategy is doomed to failure.

It is unclear to me whether Dr. Osterholm’s medical expertise includes American supply chain analysis.

However, it so happens that Dr. Osterholm is, by far, the most prominent epidemiologist within the state of Minnesota. Dr. Osterholm is widely and deservedly respected by Minnesotans, and the Center he directs is at the University of Minnesota, just a few miles from Gov. Walz’s house. I have routinely shared Dr. Osterholm’s interviews about the virus with friends and family, encouraging them to take it seriously before everyone was taking it seriously–and they didn’t necessarily listen to me, but they listened to Dr. Osterholm.

So it is perhaps not surprising that the governor’s plan mirrors the opinion of the state’s most prominent expert.

Nevertheless, Gov. Walz does Minnesotans a grave disservice by failing to present the broad spectrum of views among American epidemiologists; by failing to even model the possible impacts of suppress/test/contain in Minnesota; and by consigning some 50,000 Minnesotans to the morgue without even attempting a strategy that could quite possibly save nearly all of them.

[Editor’s Note: I will add to this FAQ as necessary. Basically, if I see enough of you asking a question, I’ll try and answer it here.]

UPDATES:

Well, what do YOU think we should do, James?

I’ve tried to limit this post to factual reporting, but you can probably tell that I am alarmed by Governor Walz’s current strategy. If you agree, then I suggest signing my petition to Governor Walz (and the heads of both houses of the state legislature) requesting and demanding a shift in strategy to suppression, in line with the increasingly detailed plans articulated by many experts in the field.

Hang on. I heard Dr. Fauci predicted 100,000-200,000 deaths nationally, and Dr. Birx confirmed that this morning. You’re telling me to expect 50,000 in Minnesota alone — a quarter or half of all deaths nationally? How can that be? Are the models really that different?

Very reasonable question! Minnesota has only 1.7% of the national population, so, however many people are going to die nationally, we should only have about 1/50th of that, tops!

Dr. Fauci’s comment in his interview was very short and off-the-cuff, so it’s hard to know what was in his head. Dr. Birx’s comments were more detailed but still did not include detailed modeling assumptions.

However, from context, I believe that the estimate of 100,000-200,000 dead is based on the assumption that the country will adopt a nationwide suppress/test/contain strategy, instead of the mitigation strategy Gov. Walz supports.

If a mitigation strategy were adopted nationwide instead, we would expect to see over a million deaths nationwide. (This is more or less what the Imperial College model showed.) In that scenario, 50,000 dead in Minnesota would be a lot less egregiously out-of-line. (1.7% of a million is 17,000.)

There are differences in all models, of course, but not vast ones. The conflicting comments appear to mainly reflect differences in Dr. Fauci’s and Gov. Walz’s strategies, not their models. 

I just saw a model that said Minnesota will only have a little more than 1,000 coronavirus deaths!

Ah, yes, the University of Washington model. I’ve mentioned this elsewhere in the FAQ, but I’ve received enough questions about it to justify giving it its own q&a.

Something very important about this model that you don’t necessarily find unless you read the fine print: it’s a model of the suppression strategy. I’ll let them explain:

For states that have not yet implemented all of the closure measures, we
assumed that the remaining measures will be put in place within 1 week.

This study has generated the first set of estimates of predicted health service utilization and deaths due to COVID-19 by day for the next 4 months for all US states, assuming that social distancing efforts will continue throughout the epidemic.

Our estimate of 81 thousand deaths in the US over the next 4 months is an alarming number, but this number could be substantially higher if excess demand for health system resources is not addressed and if social distancing policies are not vigorously implemented and enforced across all states.

So this is a model that assumes that any states that haven’t gone to full shelter-in-place mode yet will do so within seven days, and that all states will remain fully shut down until the epidemic is over, either because a cure or treatment has been found or because covid has been suppressed enough for us to move to the test-and-contain phase. Either way, the University of Washington model assumes full shutdown of the economy until, at the very least, mid-May.

If we do that, we could indeed achieve some very low death counts. I suspect we can’t actually get down quite as far as this model says, because of the reasons Carl T. Bergstrom noted here, but it seems not unreasonable to believe that strong suppression measures could reduce Minnesota’s fatality rate below 3,000… rather than the 50,000 currently projected.

What other states are adopting a suppression strategy?

You have to give Gov. Walz credit: he has been much more clear about Minnesota’s long-term strategy than have the executives of other states. Wisconsin’s government has consistently been somewhat more aggressive than Minnesota’s on COVID-19, and it seems poised to extend its stay-at-home order… but I could not find any clarity from Gov. Evers’ office about what Wisconsin’s long-term plan is. It looks like suppression? Or maybe it’s just panicked mitigation. I don’t know, and nobody else seems to, either.

That’s true across many different states. At least Gov. Walz had the decency to tell us the plan, even if he concealed the full horror of it.

(If Gov. Evers has announced his long-term strategy somewhere, please drop me a link.)

That being said, there are several states that have adopted very long-lasting shelter-in-place or stay-at-home orders. These orders are not consistent with a mitigation strategy, and strongly indicate that the state intends to hunker down until COVID-19 is either contained or defeated. The states I have in mind are:

• Virginia (stay-at-home until June 10th)
• Delaware (stay-at-home until May 15th)
• California (Gov. Newsom’s initial order lasts into May, but he has said he expects it to be extended for “many months”)

There may well be others that have already indicated their shutdowns are going to last well into May… but the rapidly evolving situation, combined with fairly weak reporting of expiration dates, combined again with governors who may find it less politically painful to issue a series of “extendable” three-week orders instead of a single three-month order, all adds up to a situation where it’s very hard to see exactly what each state’s long-term strategy is.

Unless they get up in front of the state and explain their plan, as Gov. Walz did. The fact that I think it’s a bad plan does not erase the fact that it’s very, very good that he told us what it is.

Is this decision a straightforward trade-off between lives and GDP? More lives saved = more GDP lost (and thus people dying for other reasons)?

No, it’s not. I noted at the top that many believe that a no-mitigation strategy would be the least economically damaging. However, personally, I am dubious. As a friend of mine wrote to me:

I haven’t seen serious economic modelers try to estimate the cost of an unmitigated outbreak. But I am very dubious of the claim. In the first place, I don’t think you could actually get everyone to just stride into the oven. I think that without socially coordinated mediation efforts, you’d nevertheless see quite significant individual mitigation efforts, which would be quite economically disruptive.

However, it’s unlikely that that kind of individual mitigation effort would contain the virus. It might protect some individuals from infection (at least in the short term), but would be too piecemeal to contain the virus. So you would still have hospital systems overloaded. The medical sector is a very large segment of the economy. How would private medical insurers be affected? How many medical professionals would die? Would this be a bonanza for hospitals and other medical megacorporations? Or would it push some into bankruptcy?

If the medical system is overwhelmed, and the disease goes unmitigated through the population, the death rate at younger ages will go up substantially. Let’s focus on 50-65, the senior managers, project engineers, administrators, fund managers. What would it do to the economy to lose 2% of CEOs? What about 5%? What happens when the one engineer who understands the whole project dies? How much of a delay will occur as others try to figure how to get things back on track, with a few % of workers at all levels gone? What about younger workers with asthma or other comorbidities?

No matter what strategy we adopt, we are in for a rapid and drastic economic recession. That’s just a fact of life in a pandemic like this one. So when we choose suppression, we are not choosing between continued prosperity and economic catastrophe; we are only choosing between two different flavors of economic catastrophe. And it is not immediately obvious which approach is least catastrophic. Cass Sunstein reports on some very early efforts by economists in this space, and they aren’t terribly friendly to the “reduce mitigation” crowd.

Economic modeling is a lot harder than disease modeling, though, so I would imagine that there are a whole lot of economists working long nights this month, and that we’ll start to see better answers soon.

Maybe if Stefan Gildemeister reads this, he can point me in the direction of some more resources on the economic trade-offs. Otherwise, I’ll keep you posted.

Is it Gov. Walz’s fault that Minnesota isn’t testing enough?

No. It’s complicated, but the main party at fault is the CDC. Gov. Walz is not the reason we aren’t testing enough.

Right now, everyone wants to be testing more, including Gov. Walz. Testing is key to suppress/test/contain, obviously, but it would also be very useful in Gov. Walz’s mitigation strategy.

We can’t test more because we don’t have the test kits, and we don’t have the capability to manufacture more quickly.

In response to the catastrophic shortage in working test kits, the FDA has removed nearly all regulatory hurdles for would-be testers, but no amount of deregulation can create manufacturing capacity out of thin air (and, as an experienced lab tech I know explains, the deregulation creates problems of its own).

Until this is rectified, a suppress/test/contain strategy can’t leave the “suppress” stage. It is likely that pessimism about America’s ability to rectify this played some role in Gov. Walz’s decision to go with a mitigation strategy instead, although he has made no public comment about this to my knowledge.

Since April 1st, Gov. Walz has given several major public presentations on Minnesota’s coronavirus response. Has he changed course at all?

No.

Gov. Walz did announce flexibility and opennness to evidence, which is very hopeful. He also announced specific goals for testing, which were missing before. But he announced no actual change in policy from the current “re-open the state sooner and accept that 1% of Minnesotans will die” policy.

The dashboards he announced are very slick, though: https://mn.gov/covid19/.

Here, for the record, are his speeches: the April 3rd update and the State of the State address. Both are reasonably good speeches that grasp the unthinkable magnitude of this catastrophe.

Those of you who have followed this blog for a long time know that I am a conservative, and it grieves me to report that the Minnesota GOP leadership’s response to this disaster has, to put it mildly, lacked seriousness. Too many Republicans deny stay-at-home orders are necessary at all. But Gov. Walz does not need to meet them in the middle. He needs to save Minnesotan lives.