Numbers regarding school reopenings

One of the greatest points of disagreement in the media, politics and at home is over the reopening of schools.  On one side of the discussion is that school is critical to the development and well being of children.  Schools provide instruction in important subjects, develop social and emotional skills, safety, reliable nutrition, mental health therapy, physical activity and also allows parents to go to work.  The other side of the discussion is if reopening of schools is safe for the children, teachers and general public.

There are many countries that have reopened their schools and their methods and results should be lessons for the US. https://www.usnews.com/news/best-countries/articles/2020-07-22/how-countries-reopened-schools-amid-the-coronavirus-pandemic

In summary, many countries have demonstrated that it is possible to open schools without causing spikes in cases and more importantly without causing spikes in deaths.  Children are 8 X more likely to die from fly/pneumonia than covid 19.

Denmark was one of the first countries to reopen schools after they shut them down.  Denmark reopened their schools on April 15 for children 2-12.  The measures they implemented appear to be successful as there has been NO increase in covid 19 cases and no serious outbreaks in schools.  On May 18 those aged 12-16 were allowed to return to using the same protocols.

Similarly, schools in Germany, Finland and Norway have reopened without significant spikes in the number of new cases and more importantly, no increases in deaths.

South Korea and Israel are examples of countries that reopened, closed and reopened  In both cases, there was a general increase in the number of covid cases that coincided with the reopening of schools.  However, in neither country was in shown that it was the reopening of schools that caused the general increase in covid.  In both counties other restrictions to the public were also lifted at the same time schools was reopened.  For instance, in Israel, groups of upto 250 were allowed to meet at the same schools reopened.  Schools are now open in both of these countries.

The big question everyuone is asking is “is it safe for children to return to school?’  Often this question is  addressed by the number of children who may become infected.  Although, no one wants any child to get sick, the facts are that people (and children) under the age of 26 have a significantly higher risk of dying from flu than dying from covid 19.

From 2007-2017, 172 million people died from flu and pneumonia.  This is an average fatality rate of 60,000/year.  However, the real detail is in the age of the people effected.  By the numbers, children between 5 and 14 have a 1 in 200,000 chance of dying from fly/pneumonia but a 1 in 1.5 million chance of dying from covid 19.

The following shows the relative risk of death from covid 19 vs pneumonia/flu.  Note that those under the age of 15 have 4 to 9 times higher risk of dying from flu/pneumonia than covid.

Evidence is mounting that children are less susceptible to Covid 19 and are less likely to transmit the virus to others.  When children under 15 test positive for covid 19, almost 40% have no symptoms and majority develop fevers and fatigue but recover. https://pediatrics.aappublications.org/content/145/6/e20200702

The data from around the world is consistent in showing that children are at lower risk from covid than from the flu.  However, there are still concerns about the risk to teachers, staff and student families.  It is likely teachers and staff will be the sources of infection, not the victims.  The results from many countries who have reopened their schools since April and May clearly show that there are ways to reopen schools without causing an increase in the number of cases or the number of deaths due to covid 19.

The current CDC estimate is that the overall fatality rate of covid is .65%.  However, this number is dominated by the fact that the fatiality rate of people over 65 is 5.6%.  The fatality rate of those under 64 is lower than that or flu/pneumonia.

The fatality rate of children who tested positive for covid is .03%.  Or, 99.7% of children who get covid 19 will recover.  This fatality number is much lower than many other diseases and causes for children.

As a last calibration, it is interesting to note that even in this year of the global pandemic, there are still more deaths attributed to pneumonia/flu than covid 19.  Covid 19 is to be respected and avoided but our overall understanding of the disease, use of social distancing, masks, testing and improving treatments have lowered the fatality rates down to levels of other diseases that we have learned to endure without shutting down our society. https://freopp.org/estimating-the-risk-of-death-from-covid-19-vs-influenza-or-pneumonia-by-age-630aea3ae5a9

Covid 19. Latest news on Hydroxychloroquine Treatment

There has been much controversy over the effectiveness of hydroxychloroquine as a treatment for Covid 19.  The story was confused after two publications that not only showed that HCQ was ineffective, but may even be more dangerous than no treatment at all.  Both of these papers were published in well respected, peer reviewed journals, The Lancet (United Kingdom) and the New England Journal of Medicine (United States).  Based on these studies, the World Health Organization (WHO) and many countries stopped the use of HCQ.  However, since that time, both journals have RETRACTED the publication due to errors and presentation of data that were deemed misleading.

However, more recently another publication has shown convincing and verified data that strongly suggest that HCQ is very effective against covid 19 if prescribed at the right time in the right dose.


The two retracted studies were published in the Lancet and the New England Journal of Medicine.

Due concerns regarding the paper after the publications, the editors of the journals requested more detailed information from the authors.  The Lancet editors stated “The study was withdrawn because the company that provided data would not provide full access to the information for a third-party peer review, saying to do so would violate client agreements and confidentiality requirements.”

The reviewers were unable to conduct “an independent and private peer review” and withdrew from the process, The Lancet said.

Similarly, the NEJM stated “because all the authors were not granted access to the raw data and the raw data could not be made available to a third-party auditor, we are unable to validate the primary data sources underlying our article, “Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19.”1 We therefore request that the article be retracted. We apologize to the editors and to readers of the Journal for the difficulties that this has caused.



This means that the articles that lead to the announcement that hydroxychloroquine was ineffective could not be verified making the results highly questionable.

Fortunately, another publication was soon published and has withstood investigation



A team of physicians had their publication accepted by the Journal of Infectious Disease in June.  Their study including 2514 covid 19 infected patients showed that HCQ significantly reduced the mortality rate.  The mortality rate without treatment was 26.4%.  The mortality rate with HCQ was 18.1%  These results were statistically significant.

All patients were in the Henry Ford Health System in Detroit, Michigan.  All patients were hospitalized through the emergency department.  All patients were over the age of 18.  HCQ was given beginning on day 1 of admission.  The majority of patients had body mass index values >30.

There were actually 4 groups of patients.  A group that received no mediation, received HCQ alone, received azithromycin (AZM) alone  or HCQ + AZM.  AZM is antibiotic that is used to treat a variety of infections and has been suggested as a covid 19 treatment.

The following table summarizes the number of patients and their comorbidities fot each treatment group vs NO treatment.

 HCQ vs No TreatmentAZM vs No TreatmentHCQ+AZM vs No Treatment
Hazard Ratio.3401.05.294

Treatment with HCQ reduced the chance of death by 66% and the use of HCQ+AZM reduced the chance of death by 71% compared to no treatment.  AZM alone slightly increased the risk of death.

This is in direct contrast to the two retracted publications and indicate that the early use of HCQ may be an effective method to reduce fatalities, even in patients with comorbidities and high body mass index.

The study needs to be repeated in a larger number of hospitals.  It is not known if HCQ will prevent infection if taken prior to infection or if covid 19 will increase recovery rates in patients that do not die.

There is still research that must be done, but this is an important finding that provides another treatment against covid 19 fatalities.


Covid 19: How to interpret increase in infections.

There has been an increase in the number of covid 19 cases in the US in the past 2 weeks.  In some states, there have even been single day record high number of new cases reported.  However, it is important to consider other factors in addition to the number of new cases to assess how the return to the activities of ‘normal’ activities is effecting our society.

The key concepts in this blog are:

  1. In 39 states, there is an increase in the number of Covid 19 reported cases.
  2. The total number of tests are also increasing, so this increases the reported cases.
  3. There are more reported cases than there number of new tests-so infections are rising.
  4. The age group of the infected people is MUCH lower, less than 30 years old.
  5.  There is existing hospital capacity to handle the current increases
    1. Texas hospitals are at around 75% capacity
  6. The number of deaths from covid 19 have been continually DECREASING
  7. Younger patients and drugs like Remdesevir shorten the length of hospital stays.
  8. The curve is still flattened in that hospitals are not over capacity and deaths are way down.

Public Policy

Given that there is a rise in covid 19 infections, what should the public policy be?  We know much more about the disease now than we did in February.  Some point to consider:

  1. Where are the infections? If the infections are localized, then it is not necessary to shut down or place strict controls on businesses, travel, restaurants etc. in areas where infections are low.
  2. Localized areas of infection should be analyzed to find where the infections are coming from. For instance, if the people who get infected did not go to the beach, then there is no reason to close the beaches just because there were a lot of people on the beach.  The same is true for bars or other places where larger number of people gather.  If it is where the infections are occurring, then those places need to drastically change their practices or close. Recall that in New York 66% of infected patients were stay-at-home.New York Covid. Most new infections occuring in the home.
  3. Hospitalizations should be closely monitored. It is possible that there may be areas where hospital capacity could become an issue.  However, our past experience is that additional hospital beds and equipment can be set up quickly where they are needed.  Recall that even at the peak of infections a few months ago, thousands of beds were placed in NYC, but never used.
  4. People must maintain discipline of social distancing, hand washing and wearing face masks. Failure to do these things will insure the infection will continue to thrive, regardless of shut downs and stay-at-home orders.

In particular, the most important data regarding covid 19 are the number of deaths and the number of hospitalizations.  It is reminded that the stay-at-home orders, closing of stores and businesses and limiting travel were meant to prevent an overload of the hospital system.  Fortunately, even at the peak of the virus infections in February and March, there were no incidences where hospitals could not accept patients.  There was never a shortage of ventilators.  Thousands of temporary hospital facilities around the country including the USN Comfort and Mercy went unneeded.

Although the reports of increasing number of new cases is concerning, the new cases are not generally causing significant hospital utilization and the number of deaths has been consistently decreasing and is at all time low since February.

We should not be surprised at the increase in cases as people leave their homes.  Further, the new cases are predominantly in the under 35 age group.  This group has much lower fatality rates and hospitalization rates than people over the age of 65.

The number of increasing cases in the younger population suggests that they may not be practicing social distancing or wearing face masks as much as the older population.  It is possible that better compliance would lower the new case rate.

Not all all states report covid 19 data in the same way, nor do they all report the same statistics.  However, the data from California clearly illustrates the effect of age and covid infections.

AgeCases% CasesDeaths% Deaths% Population

There have been 5422 fatalities from Covid 19 in Ca.  However, 86% of the deaths have occurred over the age of 70.  Only 6% of the fatalities have occurred in people under the age of 50.

Another way to express is that 11% of the population tested was over 70 but they accounted for 86% of the fatalities.  Conversely, 66% of the people tested were under 50 but only accounted for 6% of the fatalities.

The following shows the increase in reported US new cases in the past 2 weeks.

As will be discussed below, the median age of those that tested positive in Florida was 30 years old.  This is a critical fact as the number of new infections is occurring in a mucy younger group of patients who can resist the disease better (more asymptomatic), require less hospitalization and have very low fatality rates.

In this same time period, there has been an increase in the number of people tested.  This increase contributes to the increase in the number of cases.

However, it is clear that the number of new cases is more than just due to the number of increased tests.  The number of tests has been increasing steadily since the end of April.  The sudden increase in cases can not be due to increased testing alone.

Fortunately, the nature of the increasing number of cases appears to be different from that encountered just a couple of months ago.


In February, the key concern regarding the covid 19 virus was the possibility that the number of cases would be more than the hospitals could handle.  There was also concern over the possibility of a shortage of ventilators and other protective equipment.  Fortunately, even at the peak of covid 19 infections and deaths in April there was NOT a shortage of hospital beds, ventilators or protective equipment.  The number of cases and deaths began decreasing and in the past month, most states lifted parts of their lockdown, business shutdown and stay-at-home orders.

The reopening of beaches, bars and other venues allowed large numbers of people to gather for the first time in months and often social distancing and face masks were not being used.  Further, large numbers of people were participating in protests and other rallies where, again, masks and social distancing rules were not followed.

Although the exact reasons are not known, it is clear that in many (not all) states, the number of cases has increased.  Fortunately, the number of hospitalizations has generally not increased.  Despite record number of new daily cases in some states (eg Florida, Texas), hospitalizaitons only slightly increased.  More importantly, the number of deaths from covid 19 is at the lowest level since February.

Note: the spike of deaths on Jun 20 was due to a single day ‘correction’ report from New Jersey which changed recording methods.

Two states Florida and Texas have been in the news because both states relaxed restrictions early and have had some of the highest number of new cases.

There was clearly and increase in cases on 6/23 but the number of cases seems to be decreasing again.

The following chart shows that the number of deaths has remained steady or slightly decreased since the beginning of June.  Florida has reported 168 deaths/million which ranks 30th in the US.

More importantly, the median age of people who were infected as 29 years old.  This is a very important change as age is closely associated with both hospitalizations and deaths.  The young age of those who are newly infected is likely the reason that both hospitalizations and deaths are down in Florida.

However, the increase in cases does suggest that younger people may not be maintain social distancing and/or wearing face masks.  In recognition of this, Florida has temporarily closed bars this weekend.

Similarly, Texas has also shown a recent increase in cases.

Similar to Florida, the number of deaths has remained constant despite the increase in the number of cases.  Florida also has fatality rate of 89 deaths/million, which ranks it 44th in the US.

Although the number of cases in the US is higher than the European union.  The Fatality rates are comparable.

The recent increases in Texas has created areas where hospitals are nearing, but not over capacity.  Overall. It is estimated that 75% of the hospital beds are being utilized.  Should the need arise, more beds can be added to most hospitals and as demonstrated in NY, thousands of beds can be added in days and two hospital ships can be brought in.

The unknowns are the length of hospital stays with a younger group of patients.  Also, the drug Remdesevir, not available a month ago, reduces the length of hospital stays 25-30%.  All of these factors will influence if there are more patients that can be handled.


In over half of the states, there has been a significant increase in the number of covid 19 cases.

Although some of this increase can be explained by increased testing, the number of new cases can not all be accounted for simply by the number of tests.

Fatality rates are at the lowest number since February despite the number of increased cases.

There has only been a small increase in hospitalizations during this time of increased new cases.

The age of the people getting infected is much younger than just a few weeks ago.  The median age of new infections in Florida was less than 30 years old.

The increase number of new cases in younger people may reflect the need to reinforce the continued need for social distancing and the wearing of face masks.

Covid 19. Implact on Health Care

Although it is appropriate that almost all the news about Covid 19 is about new cases, and the second wave, there is not much said about how the covid 19 policies that limit medical treatment are effecting the population.  The short answer is that there is likely to be a very large consequence for not going to the doctor for checkups, diagnostics and elective surgeries.  It is estimated that, between March and June,  more than 80,000 cases of the five most common cancers in the US will not be diagnosed because of covid 19 disruptions in elective treatments.  Screenings or breast, prostate, colorectal, cervical and lung cancer were down 39-90% during the week ending on April 10.  The delay in diagnosis and treatment can result in as many as 34,000 excess deaths due to cancer in the US.

Additionally, the number of admissions to oncology outpatient clinical have decreased up to 50%.  It is expected that the majority of the cancers not diagnosed will be breast cancers.

Cancer screenings generally take place in a doctor’s office or at diagnostic centers run by larger health systems.  However, there has been great variability system to system, state to state on how these facilities have responded to cancer screenings due to covid 19.  Some have simply closed, while others open for ‘emergencies’ only.

Cancer patients may be longer term, and somewhat hidden consequence of covid 19.  This is a lot of people not getting cancer diagnoses.

In a more general sense, it is estimated that there will be 28 million who will have had their surgeries cancelled because of covid 19.  The long term health consequences of delaying these surgeries is yet to be determined.  This corresponds to over 70% of all elective surgeries being cancelled.  Of these surgeries, an estimated 2 million will be cancer related surgeries.  Elective surgeries have an extraordinary influence on hospital revenues.  In many large hospitals, elective surgeries account for nearly 50% of the revenue.  The loss of elective surgeries deprives hospitals of their largest source of income.

In the UK, it is estimate that over 40,000 surgeries are cancelled each week elective surgeries are not allowed.  It could take well over a year to catch up on the backlog of surgeries.

It is estimated that there has been up to a 70% decrease in patient visits to doctors from February through April.  In the past month, this has rebounded to the level where there are 30% fewer visits to the doctor than in February.

The moratorium on elective procedures jeopardizes the financial integrity of health care systems that are disproportionately reliant on elective procedures as a revenue source. In response, the U.S. Congress passed the Coronavirus Aid, Relief, and Economic Security Act (CARES), a $2.2 trillion bill with $100 billion designated to hospitals and $350 billion designated to small businesses including private orthopedic practices . Although these relief programs may alleviate some of the economic burden, the legislation is not comprehensive, and it will not resolve all financial losses accrued by health care systems and orthopedic practices. Without the revenue from elective procedures, many orthopedic practices have had to furlough employees and withhold surgeon salaries. Mayo Clinic has announced a projected $900 million shortfall, with employee pay adjustments and furloughs .


Covid 19. Reopening: How to interpret Covid 19 statistics and the effect of age.

There are so many things happening around the country that covid 19 has almost gotten lost in the news.  This is the latest update on the statistics.

The news headlines may be somewhat misleading.  There are many headlines that reporting an increase number of covid 19 cases.  However, the question is, how do we interpret these numbers?  What numbers are indications of trouble to come and what numbers suggest that we are on the road to recovery?

The main headline has been that on Jun 12, 21 states reported an increase in the number of covid 19 cases.  However, a more granular look at the data provides some better insight.

Recall that the main reasons for a lockdown and stay-at-home orders were to minimize deaths and not to overflow hospital capacity.  The purpose was never to simply reduce the number of cases.

A reminder that at the peak of the Covid 19 infections in April, there were no hospitals that were overly full.  In fact, extra hospital beds provided by the USN Comfort in NY, USN Mercy in Los Angeles and thousands of temporary hospital beds in New York, New Orleans and other cities were not utilized.

 Further, in March and April that were predictions that said that we would be short on ventilators and that several thousand more would be needed.  These predictions turned out to be untrue.  There was never a ventilator shortage anywhere.

Not everyone will get infected.

A seldom reported experience is that some people appear to be immune to the covid 19.  This is seen on people who have been isolated on cruise ships and military carriers.  It appears on the cruise ships between 50-70% of the people get infected, the rest do not.  On a French aircraft carrier, 60% of the sailors got infected.  However, there were no deaths and only of the 1074 infected sailors required hospital type care. https://Berenson, Alex. Unreported Truths about COVID-19 and Lockdowns: Part 1: Introduction and Death Counts and Estimates . Kindle Edition.

Who is dying from covid 19?

In a previous blog, it was reported that 42% of all covid 19 deaths occurred in nursing homes.  However, deaths can also be analyzed as function of age.  World wide, median age of people who died  from covid 19 is 81 years old.  That is, half of the people who died who died from covid were 81 years old or older.42% of covid 19 deaths were in nursing homes and assisted living facilities

In New York, as of May 28, almost 40 percent of the 23,700 reported deaths occurred in people over 80. (https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Fatalities?%3Aembed=yes&%3Atoolbar=no&%3Atabs=n)

In Minnesota, the median age of the 1,000 COVID deaths is almost 84. More people over 100 have died than under 50.http://(https://www.health.state.mn.us/diseases/coronavirus/stats/covidweekly22.pdf)

The flip side of the risk to the elderly is that younger adults and especially teenagers and children are at extremely low risk from SARS-COV-2. In Italy, a total of 17 people under 30 have died of the coronavirus. In the United Kingdom, four people under 15 have died. In New York, 14 under 20 and 102 under 30. Worldwide, it is almost certain that more people over the age of 100 than under 30 have died of SARS-COV-2. Many more children die of influenza than coronavirus; in the 2019-20 flu season, the Centers for Disease Control received about 180 reports of pediatric flu deaths. It has received 19 reports of coronavirus deaths in children under 15 so far.

How to interpret increasing number of cases.

There were no patients that were denied access to medical care or ventilators due to overcrowding.

It is difficult to interpret reports simply on the number of covid cases.  This is because each area has a different and changing number of tests being run.  In general, there are more tests being run each day than the day before.  This alone could account for the increase in the number of cases.  For this reason, a better assessment of our ability to cope with covid 19 cases are the hospitalizations (number of people sick enough to need hospital care) and the number of covid 19 caused deaths.

Questions you should ask yourselves when reading about covid 19 statistics, especially number of cases.

  1. Where are the increases in cases occurring? In isolated, bounded areas or are they evenly distributed.  Recall from earlier blogs that 42% of all covid fatalities occurred in nursing homes.  Also, in each state there were just a few counties that accounted for well over half to two thirds of the number of cases is the state.  Am I in area where there are lot of cases?
  2. Who is getting infected? Especially, what age group?  We now know that the vast majority of fatalities were in people over the age of 70 with pre existing conditions.  The fatality rate of people under is not higher than many other diseases and causes of deaths.
  3. It has been over a month since protests involving thousands of people that were not practicing social distancing and/or wear masks. Are any increases in cases due to this?
  4. Are the number of hospitalizations going up so fast that the hospitals can’t handle the number of patients?
  5. Is the fatality rate going up or down?


The headlines are that on Jun 12, 21 states reported increases in covid 19 deaths, but only 9 of these reported increased hospitalizations.  Further, in general the number of total US deaths is decreasing.  As seen in the chart below:


It is also important to note that it has been over 2 weeks since the first protests involving thousands of people who were not social distancing and many were not wearing masks masks.  To date, there has been no increase in hospitalizations or deaths in any areas where these protests took place (Minneapolis, New York, DC etc.)  This is yet another indication that covid infctions are depending on location, age and other factors – stay-at-home and lockdowns effectiveness is being questioned more and more.

I have provided from three states for discussion, California, Texas and Florida.

From the chart below, it appears that the number of cases has increase in past week.


However, the following chart shows that the number of deaths has NOT increased during this same time period and remained more or less unchanged for weeks.  The number of hospitalizations has NOT increased with the increasing number of new cases.

It is also reminded that the cases in Calfirornia are very location dependent.  Of the 150,267 cases reported in Ca, 72,023 have occurred in Los Angeles (48%).  Of the 5062 covid 19 fatalities in Ca, 2890 have occurred in Los Angeles (57%).  The county with the second number of fatalities is Riverside with 383 deaths.  It very much makes a difference where you live.

NEW YORK.  New  York has received the most attention throughout the covid 19 crisis because it leads the nation as the state with the most cases and the most deaths.  However, the following charts show that there has been a dramatic decreases in both cases and deaths for New York.





TEXAS.  Similar to Ca, the number of cases in Texas has increased but the number of deaths has not.  There has been an increase in hospitalizations for Texas, but they are well under their maximum number of beds available.  There were over 2000 covid 19 hospitalizations in the past 2 weeks but there are over 31,000 hospital beds in the states.  There is substantial hospital space in Texas so time will tell if the number of serious cases continues to rise.  It is a very good sign that the number of deaths has not increased during this same time period.

Similarly, Florida reported the highest single day number of new cases, 2500.  However, the number of deaths did not increase correspondingly, More importantly, there was not a signficant increase in hospitalizations.




42% of covid 19 deaths were in nursing homes and assisted living facilities

The United States has reported 102,294 deaths from Covid 19 on 5/29/2020.  Each day that passes, more is learned of the virus and how it exactly impacts our society.

A very surprising fact became apparent this week, that was not previously noticed or highlighted..

42% of covid 19 patients were in nursing home or assisted living facilities.  This is an incredible statistic, as the number of patients in these places only account for 0.6% of the total US population.

Nursing homes are residential facilities for those needing 24/7 on-site medical supervision; assisted living facilities are for those not needing 24/7 medical supervision.  An estimated 2.1 million people live in nursing homes and the vast majority (>90%) are over the age of 65.

This finding has many important implications.  First although it has been known for some time that the most at risk group was over 65 with some pre existing conditions, it turns out that being in a nursing home is a significant risk factor.  This means the fatality risk of not being in a nursing home is lower.  Less than 1% of the population accounts for 42% of all covid 19 deaths.

Because nursing homes are remain ‘hot spots’ for covid deaths and cases, it may be difficult for some states or area to achieve mandates such as no covid deaths for a number of days.  The deaths may be limited to within specific nursing homes and not a reflection of areas outside the nursing home.

In addition to maintaining social distancing and handwashing, it remains prudent ot wear a mask if you are around others and most important, elderly in nursing homes and restricted spaces should receive extra care and attention to avoid infection.

In the US, two states, New York and New Jersey and nursing homes have contributed to well over 50% of the covid deaths.  This raises the question regarding the overall effectiveness of general  business shutdowns and stay-at-home policies.  Only additional data and study will be able to sort this all out.

There are an estimate 49 million people in the US over the age of 65.  Over 80% of the US covid 19 deaths are from people over the age of 65.  This would correspond to 81,000 deaths.  This corresponds to a fatality of .2%/million people over 65.

However, the fatality rate of being in a nursing home is 6.76% or 30x higher than not being in a nursing home.

The following presents the percentage of deaths that occurred in nursing homes for all 50 states.  The highest fatility rate was in Minnesota where an incredible 81% of covid deaths occurred in nursing homes and the lowest being NY with 20%.  Interestingly, NY has a low percentage of covid 19 deaths in nursing homes because the number of deaths in NY outside of nursing homes is also the highest in the nation.  This will be discussed in further detail below.

Looking at this another way, nn the basis of covid 19 nursing deaths/million people, New Jersey has the highest with 954 deaths/million and Wyoming is the lowest with 7.  This can be seen in the map below.

Some comments on some key individual states.


Nursing home and assisted living covid 19 deaths account for almost 40% of the 2400 of the states covid deaths.  There are an estimated 155,000 people living in Florida nursing homes.  This is .07% of the population of Florida accounting for 40% of the deaths.



49% of all Covid 19 deaths in California occurred in nursing homes or assisted living facilities.  387 nursing homes have reported deaths with many of them clustered around Los Angeles.

The highest nursing home death toll in the state remains at Redwood Springs Healthcare Center in Tulare County, where 28 residents have died.



In Minnesota, 80% of the covid 19 deaths have occurred in nursing homes and assisted living facilities.  The number of residents in these institutions are less than 1% of the population of Minnesota.

 New York

On May 10, there were an estimated 5300 covid 19 deaths in New York nursing homes and assisted living facilities.  This is almost 3x more than the deaths in the entire state of Florida.  However, so many have died outside of nursing homes (highest in the country), that the percentage of covid 19 in NY nursing homes is one of the lowest in the country.


The U.S. is not an outlier in terms of its nursing home-related COVID-19 fatalities. A study by researchers at the International Long Term Care Policy Network of fatalities in Austria, Australia, Belgium, Canada, Denmark, France, Germany, Hong Kong, Hungary, Ireland, Israel, Norway, Portugal, Singapore, South Korea, Spain, Sweden, and the United Kingdom found that 40.8 percent of reported COVID-19 fatalities took place in nursing homes.

Final note:  I am NOT trying to downplay the seriousness of Covid 19.  Each death tragic.  However, these discussions are hoped to provide information about the numbers and comments you receive by other means in some context.  Also, it is hoped that this information will lead to better policies, decisions and improved health of our country.

Covid 19. Curve is flattened. Hospitalizations Down!

In March, the public was told that closing of nonessential businesses and stay-at-home orders were necessary to ‘flatten the curve’ for Covid 19 cases and deaths.  Besides saving lives, flattening the curve was thought to be necessary as computer models predicted that our hospitals and emergency rooms would not be able to treat all the people necessary.  Along with stay-at-home orders and mandatory business closures, emergency hospitals were built and Navy hospital ships were dispatched to New York and Los Angeles.

This is a long blog that will provide the basis for the observations:

  1.  The curve of covid 19 cases and deaths has flattened
  2.  Hospitalizations are decreasing and the health system was stretched but not overwhelmed
  3. 7 states that did not have shutdowns and stay-at-home orders continue to have low numbers of covid 19 cases and deaths.
  4. Several states have begun to reopen businesses and there has been no signficant overall increase in cases or deaths

It is critical that people continue to social distance, wash hands regularly and wear masks in crowded areas or in enclosed spaces.

After months of enduring business closures, travel restrictions, stay-at-home orders, and the stoppage of nonemergency medical care,  the ‘curve’ has flattened.  It is difficult to make hard conclusions based on the number of reported cases as the total number of tests are going up daily, so it is difficult to tell if there is an increase in the number of reported cases because more people are getting infected, or if the increases are simply due to running more tests.  However, the number of deaths and hospital utilization are two better assessments of how we are doing against covid 19.

On 5/23/2020, there were 98685 reported US deaths attributed to Covid 19.  Note that this number is an estimate.  Several states have revised their fatality reports to lower the number of deaths due to covid 19.  This was done to separate those patients who actually died from covid 19 from those patients who died for other reasons, but tested positive for covid 19.

A granular look at the data shows that New York and New Jersey account for 41% of these deaths even though they only have 9% of the US population.  They are clearly not behaving like most of the other states.  The states with the 4 highest deaths/million people are:

StateTotal DeathsDeaths/millionPopulation (millions)
New York29112149619.5
New Jersey1108312488.9

These 4 states account for 50% of the total US deaths and represent 12% of the population.

It is also reminded that 7 states did not have a statewide ‘lockdown’ and stoppage of businesse.  These states were Arkansas, Iowa, Nebraska, South Dakota, North Dakota, Utah and Wyoming.  All of these states have a low number of cases and mortality rates in comparison with the other states.  These states did close selective activities such as schools, tattoo parlors and gatherings of more than 10.  However, other businesses were allowed to stay open and follow CDC guidelines for social distancing, masks, etc.

There has been no significant increases in deaths or hospitalizations since Georgia, Texas and Florida began their phasing in plans for reopening businesses in the beginning of May.  The following charts shows that overall, the number of daily deaths is decreasing.  The ‘curve’ is definitely flattening.  The reopening of businesses has NOT resulted in an increase in the effects of covid 19.

The 5 states with the highest number of deaths are:

New York281341446
New Jersey102601155

There were 7 states that did not have statewide shutdown of nonessential businesses.  These states did shut down schools and limited crowd sizes.  Some selected businesses were shut down, but, by in large, businesses were allowed to decide whether to follow health guidelines and stay open.

StateDeathsDeaths/millionPopulation (millions)Rank Deaths/mil
North Dakota4255.838
South Dakota4450.940

There has always been concern that when stay-at-home orders are removed, that there would be an increase in the number of cases, deaths and hospitalizations.  Since Georgia, Texas and Florida began to lift restrictions at the beginning of May, there has not been a general increase in cases, deaths or hospitalizations.

Texas began it first phase of business opening on May 1.  The daily deaths from May 1 to May 14, appear to be about the same as between April 14 and May 1 (before the reopening of business).   As reported in a blog about New York, the distribution of cases through Texas varied greatly.   There are 254 counties in Texas that have reported a total of 1527 deaths on 5/23/2020.  However, like in most states, the covid 19 cases are not evenly distributed around the state.   Three counties (Harris, Tarrant, Dallas accounted for 40% of the cases and 53% of the deaths.  7 counties account for 60% of the deaths. 153 counties have reported fewer than 50 cases and less than 10 deaths.  If you live in Texas, it makes a difference where you live.

Texas has a reported deaths/million value of 46.  This ranks Texas 40th in this category.  (NY is first with 1446 deaths/million).  The following graph indicates that the average deaths/day in Texas has been decreasing for the past week, even as more businesses open.

Florida has reported a total of 2233 deaths.  Like Texas, 3 counties account for 54% of the deaths.  Similarly, the data looks similar for Florida after the beginning of phase 1 opening on May 4.  The following graph shows the 7 day average of deaths/day is the lowest it has been since the early April.  Florida reports a fatality rate of 91 deaths/million.  This ranks Florida 28 out of 50.

It is interesting to compare this data against 3 states who have maintained stay-at-home and business shutdown orders.  These states have announced that they will maintain their stay-at-home orders for another month or more.

StateDeathsDeaths/millionRank deaths/mil

These values are comparable to those states that have begun to reopen businesses.  Again, it is reminded that these are averages for the entire state.  Within each state, there are a few ‘hot spots’ that have a higher number of deaths and there are many more areas which have very few deaths.


The number of covid 19 patients being hospitalized is decreasing in most areas.  It is important to remember that a large factor in issuing mandatory business shutdowns and stay-at-home orders was to avoid overwhelming the healthcare system predicted by computer models.  Fortunately, the models have been largely incorrect.  There have been no reported cases where a patient could not be admitted to a hospital or have access to a ventilator if needed.   Emergency hospitals set up in New York, Louisana, and California were essentially not needed.  The hospital ships USN Comfort in New York and USN Mercy in Los Angeles received very few patients.

At the current levels, even if there is a modest increase in cases due to business reopening., there appears to be sufficient available space in hospitals.

Early assessment of business reopenings.  The early indications are that there has not been a significant increase in the number of cases, deaths or hospitalizations in Georgia, Texas and Florida.  Those 7 states that did not have business shutdowns or stay-at-home orders continue to exhibit low numbers of infections and deaths.

In each of these states, there are definitely ‘hot spots’ that still have high numbers of infections and deaths, but the majority of the states seem to have decreasing number of cases and deaths.  How these states are managed will determine the success reopening.  Each state must establish a plan that reflects the level of infection and fatalities of local areas.  This means that not all parts of each state will be operating under the same guidelines.   ‘Hot spots’ must be reopened more carefully and monitoring will be key.

When businesses open, it will be the people that determine the success of reopening.

People must maintain social distancing.

People must continue to wash their hands regularly.

If you are feeling sick, don’t go out or go to work and don’t; come into contact with anyone.

Wear a mask if you are an enclosed space particularly if you can not maintain social distancing at all times.

The indications are that businesses can safely open if people remain vigilant and follow the guidelines.

The ‘curve’ has been flattened and the hospitals are not overwhelmed.  Given that these were goals of the shutdown, business reopening should begin cautiously and the people must be responsible for their own actions.




Covid 19 Testing. The good, bad and unknown.

One of the most talked about issues around Covid 19 is testing.  Everyone seems to want a test.  However, little is said about the details of the tests, such as kinds of tests, good/bad tests and what do you do with the results.  The answers to these questions will help answer the questions about how important the tests are to reopening of businesses of keeping a business open.

A reliable, fast diagnostic needs to be established and available to manage the reopening of businesses.  The ability to identify infections before they become clusters, or clusters before they become outbreaks will be significant in how successful we will be in reopening businesses.

The tests.  There are two kinds of tests being talked about in the news and the reporting does not always make it clear which test they are talking about.  In most cases, they are talking about a DIAGNOSTIC test.  A diagnostic test will determine whether or not the Covid 19 virus is present at the time of the test.  The other kind of test is generally termed a serology (blood) test.  The serology tests determine the presence of antibodies that are created if the patient had been been previously infected with Covid 19.

Diagnostic Testing.  Most diagnostic tests use a method abbreviated RT-PCR (Reverse Transcription-Polymerase Chain Reaction) that will detect the presence of the DNA from the virus.  There are several manufacturers of these tests around and THEY ARE NOT THE SAME in reliability.  The difference in testing methods and reliability should be remembered when analyzing data from different sources.

In most cases, the testing being discussed are the results of diagnostic testing.  That is, diagnostic methods are used  when the daily number of confirmed cases is provided.  For instance, diagnostic tests were used to report the 1,391,316 confirmed cases of Covid 19 in the US (5/12/20).

A diagnostic test will determine if a virus is present at the time of testing.  It can not tell if the person was infected and then recovered nor is it predictive of if the patient will get the disease tomorrow or any time in the future.    If you are showing severe symptoms, you should go get medical attention whether or not you have been tested.  If you are feeling ill in any way, you should stay-at-home regardless of whether or not you are tested.  If you test negative, there are also uncertainties.  You may have been infected just before the test and the virus has not spread enough to be detected, or you could get infected tomorrow.  If you have no symptoms but are positive in a diagnostic test, you are among the 80% of infected people who have no or minor symptoms.

Serology – Antibody Testing

Serology tests are blood-based tests that can be used to identify whether people have been exposed to Covid 19 by looking for specific antibodies.  The mechanisms for antibodies was topic of an earlier blog regarding vaccines.  Covid 19 Vaccine. Where are we in the process? How will they work? What’s taking so long? The presence of antibodies would indicate that the patient had been infected with Covid 19.  As mentioned above, because the vast majority of people who are infected have no or minor symptoms, antibody testing is the only way to determine how many people are actually infected.  Earlier blogs have indicated that the actual number of people infected as determined from antibody testing is up to 20x higher than the number of infections detected with diagnostic testing.New York: Nearly 3 million infections – not 276,000

It is important to know:

  1. It is not known if the presence of antibodies makes the patient immune from further infection.
  2. If the patient does become immune to Covid 19, it is not known how long the immunity will last.
  3. The immediate benefit from antibody testing will be to determine how many people were infected.

Specificity and Sensitivity.  These are KEY factors in the reliability of tests but are seldom discussed in the news.   Specificity is a measure of how reliable the test is.  In other words,  if the test indicates you have the disease, do you really have the disease?  Or is the test somewhat unreliable because it can provide a positive result when you don’t have the disease.  This is termed a false positive result.    Specificity is a measure of how many false positives a test will give.  A test with a specificity of 80% means that only 80% of those who tested positive actually are positive.  20% show an incorrect positive result.

Sensitivity is a measure of how reliable the test is, if the test says that you are negative.  It is a measure of the false negatives.  A test with a sensitivity of 90% means that 90% of the people who test negative, truly do not have the disease but 10% of the negatives are really positives and have the disease.  Some of the reports from South Korea suggests their test had a sensitivity of 80-85%.

Each test should be evaluated for both it’s specificity and sensitivity.  It is possible for a test to have a high specificity but a low sensitivity.

These seem like details, but a 5% false negative means that if 1,000,000 people test negative, there are really 50,000 people who are actually infected.  Labs, doctors and patients should be very aware of the specificity and sensitivity of the tests they are administering.  There are over 20 different tests being conducted around the world, each with it’s own, sometime unknown specificity and sensitivity.  This makes comparative data very difficult.

As the choice of what test to run is determined locally (state, county, hospital), differences in specificity and sensitivity between tests likely exist.

There is an old joke in testing labs about what level of service a client can request. For each test, you can choose how fast you get the results back, how accurate the results are and the cost of the test.  Unfortunately, you can only choose two of the three choices.  This is true for Covid 19 testing as well.

Test Approval Process.

It would normally take more than a year or more to get a diagnostic test to get FDA approval.  This is because of the number of patients and time in clinical trials that are required to demonstrate sensitivity and specificity.  Under the FDA Emergency Use Authorization guidelines, manufacturers only need to test 30 laboratory samples and demonstrate 95% specificity (positives) and 100% sensitivity (negatives).  That means that the test must detect 95% of the samples that contain the virus.  A 100% sensitivity means that there can be no false negatives.  I am unaware of any test whose accuracy has been evaluated by an independent organization (eg not the company who manufacturers the test).

For diagnostic tests, it is important to know that the virus used in these laboratory tests are not from patients but from lab sources.  It is also not clear that all labs are using the same concentration of virus in all of their tests.  Last, the tests are conducted under laboratory conditions without issues of sample collection and other factors present when testing patients.  There is no requirement that any clinical data from patients be part of the Emergency Use Authorization approval process.  This does not mean that the tests are unreliable, it just means the tests have not been as fully evaluated as they would have in an non-emergency environment and we don’t know the number of false positives and negatives we are getting (other than the data supplied by the manufacturer).

There are also factors not related to the actual diagnostic test that can effect the test results.

  1. When the patient was infected.  If the patient was infected very recently, there may not be enough of the virus to detect.
  2. Where the virus is. Most tests are from nasal swabs.  However, as the disease progresses, the virus moves into the lungs, so the viral load in the nasal passages goes down.
  3. Incorrect sample collection. If the nasal swab is too superficial (not deep enough) then the virus may not be detected.
  4. Rapid testing after collection. The tests usually must be run within 8 hours, unless it is refrigerated in which case it much be tested within 72 hours.  Testing outside the windon decreases the chance of detection.

More attention must be paid to determine the specificity and sensitivity of all tests.  Too many false negatives will release infected people into the population and too many false positives can overwork or overload the health care system.  The situation is made more difficult with the increasing number of new tests being introduced in the US and around the world.

The same specificity and sensitivity issues apply to the Serology-antibody tests.  Again, there are over 20 different tests of this type being run around the world.  Like the diagnostic tests, they are being approved for use under emergency use authorization so specificity and sensitivity values are being supplied the manufacturer who makes the tests under laboratory conditions.  This does not make the tests unreliability and I am not criticizing the manufacturers, but independent evaluation under normal clinical evaluation guidelines should be done.

It is a difficult time as development and distribution speed is now prioritized over normal safety and effectiveness procedures.  This undoubtedly has allowed the use of some tests that would not have been approved under more normal conditions.

There are two examples of what can happen if specificity and sensitivity are not well established.  In May, the United Kingdom reported that it had purchased 2 million antibody test kits from China for $20 million (₤16 million).  However, the purchase was apparently made before independent UK analysis was done.  When the kits were received, independent tests showed both too many false positive and too many false negatives.  The 2 million kits are useless. https://www.bloomberg.com/news/articles/2020-04-07/new-test-hopes-dashed-as-u-k-finds-antibody-kits-don-t-deliver

The city of Laredo, Texas also bought 20,000 antibody test kits from China for $500,000.  These kits were not approved by the FDA in any way.  The city took a risk to secure antibody testing.  Once received, the tests, like the ones purchase in the UK, turned out to be unreliable and useless.  The kits were, nonetheless, seized by the FDA.

It is not my intention to criticize the incredible speed at which these highly complex tests are being developed. I have not discussed the actual technology, but it is quite incredible.  We usually just see a box or a device without knowing the complex test that is going on inside.   The balance of speed of development and reliability is a point the world is trying to find.  The purpose of this blog is to discuss the factors involved in testing that have not been often discussed and to provide some background to the daily news regarding testing.








Covid 19 vs Spanish Flu: A Societal Comparison

Although a century apart there are often comparisons made between the Spanish Flu of 1917-18 to today’s Covid 19 pandemic.  Often, the experiences of the Spanish Flu have been mentioned/used as justifications or reasons behind Covid 19 policies.

Despite being the epidemic that caused the most American deaths, the details of the Spanish Flu are not well known and the details of how the disease was handled are even less well known.  This blog provides a brief summary of the history, effects and management of the Spanish Flu, and the lessons that can or can’t be learned from the experience.  This discussion will not compare the technical differences between the two diseases.

The actual number of cases and deaths due to the Spanish Flu are not known because of relatively poor record keeping at the time, it was a global pandemic and it happened in the midst of World War I.  However, many estimates indicate over 500 million people worldwide were infected and somewhere between 30 and 100 million died.  In the US, it is estimated that 25 million (28% of the population) were infected causing 670,000 deaths.  In contrast with Covid 19, the Spanish Flu was most deadly for those ages between 20-40.  The mortality rate for 15-34 year olds in 1918 was 20x higher than any other previous year.  The mass movement of millions of soldiers and conditions of World War I contributed to the wide spreading of the disease.  An estimated 50% of the US soldiers who died in Europe during the war died from the Spanish Flu.

This is a long blog, but if you read on, there are 5 sections.  The history section is a bit long but you can skip down to the other discussions as your interests guides you.

  1. History of the Spanish Flu
  2. How the Spanish Flu was handled by the Government
  3. 1917 vs 2020.
  4. Quarantines
  5. Lessons Learned

History It is important to note that Spanish Flu happened during World War I. At the beginning of World War I in 1914, President Woodrow Wilson declared that the US would remain neutral in the conflict.  However, in 1917 there were a series of incidences of involving US lives and ships being destroyed by Germany which led to the US declaration of war on April 2, 1917.  However, preparation of US troops was well underway before the declaration was made.  The war would play a large part in spreading the disease around the world.

It is not specifically known what the original source of the Spanish Flu was. That is, it is not known where the first case in the world appeared.  There are theories that the disease began in France in 1916 or China of Vietnam.  Many theories also suggest that the disease could have started in the US (although it is not known how it got to the US).  One of the earliest (some say the earliest) report of this disease was January 1917 in Haskell County, Kansas.  An outbreak of an unknown disease was so severe that it was reported to the US Public Health Service.  This is believed to be one of the first recorded notices anywhere of an unusual respiratory disease.  Several men from Haskell went to a military, Camp Funston in central Kansas.  On March 4, days after they arrived the first soldier known to have the what we now call the Spanish flu, reported ill.  Within 2 weeks, over 1000 soldiers on the base were admitted to the hospital with thousands more sick in the barracks.  38 soldiers died.  It is likely that infected soldiers from here infected 24 of 36 large training camps, sickening thousands and killing hundreds.  Many of these infected soldiers then brought the disease to Europe.  In June 1917, 14,000 US troops landed in France. By May 1918, a million US soldiers had landed in Europe.  By the end of the war on November 11,1918 more than 2 million American soldiers had served on the battlefields of Europe.

The ‘first wave’ outbreak at Camp Funston and in Europe through early 1918 did not cause serious concern because although many were infected, there were relatively few deaths.  For instance in 1918 the British Grand Fleet reported over 10,000 sailors had fallen ill but only 4 had died.  It was not until the King of Spain, Alfonso XII, contracted the disease that the disease became noteworthy.  Spain was also neutral in the war and was free to publish information about infections without censorship from other countries.  Because most of the early detailed reports were from Spain, it became known as the Spanish Flu (even though it did not begin there.)

In August 1918, the second wave, more deadly than the first, began in areas of Europe.  It is speculated that the ‘first wave’ virus had mutated into a more lethal version.

In late August 1918 military ships departed from the English port of Playmouth carrying troops with a virulent form of the Spanish Flu and went to cities like Brest, France, Boston, USA and Freetown Africa.  In Boston, shortly after their arrival sailors and civilians marched together through the streets of Boston for a ‘Win the War Rally’.  Soon, the surrounding Boston area and New England would feel the full force of the disease.  In September 1918, a Navy ship from Boston carried infected sailors to Philadelphia.  Although sailors began to die within days of arriving at Philadelphia, city officials did not truthfully report the deadly disease.  In fact, they publicly dismissed the seriousness of the disease and  on September 28, they famously held a large parade in the middle of the city attended by an estimated 200,000 people.  Within 72 hours of the parade, every bed in Phialdelphia’s 32 hospitals were filled and in a week, 2600 Phildadelphians had died of the Spanish flu.  A week later another 4500 had died.  By March 1919, over 15,000 Philadelphians had died from the disease.

The disease spread all over the country from the Atlantic to the Pacific and from Canadian to Mexican borders.  Spain, Britain and France were all particularly hit hard with the disease but the disease also spread to Asia, Africa, South American and the South Pacific.

It is highly likely that the war conditions contributed significantly to the spread of the disease.  First, millions of soldiers from the US were transported to Europe.  Once in Europe, soldiers and civilians were often in cramped, damp and crowded conditions making the spread of disease easy.  The poor sanitation and malnutrition also helped to spread the infection. Further, there were vast movements of people both civilian and military due to fighting. During the summer of 1918, many troops returning home brought the disease back to the countries they came from.    All of these factors likely contributed significantly to spread of the disease.

It is interesting to note that is speculated that President Woodrow Wilson was infected during the Versaille Peace Conference at the end of the war.  This possibly contributed to Wilson accepting some surprising terms in the treaty.

Overall, the Spanish Flu is likely to be deadliest epidemic in the history of world.  Estimates are that 1-3% of the world’s population died from the Spanish Flu.  So many younger people died in the US in 1918 that the average US life expectancy was reduced by 10 years.

It is not clear why the second wave of the virus was so much more lethal than the first.  There is some speculation that there may have been a mild and deadly version of the virus, but this has not been definitively confirmed.  In the ‘developed’ world, the mortality rate was generally believed to be about 2%.  In other counties, the mortality rate has been estimated to have caused up 14% of a population (Fiji islands) to die.

Eventually, toward the end of 1918 the number of deaths caused by the virus began to decrease.  This is believed to be because there were so many people that had already been infected and/or the virus may have mutated again to be less invasive to the lungs.  It eventually ‘devolved’ to be part of the seasonal flu.  There was never a vaccine developed for the Spanish Flu.


How was the Spanish Flu handled by the state and federal government? There was no national policy for dealing with the Spanish Flu. It was left to the states to come up with how and when to deal with the disease.   It was common practice for politicians, administrators and those responsible for the public safety to deny, deceive or out right lie about the dangers of Spanish Flu. City and government officials did not disclose the danger to the general public so that public spirits would not be diminished and that support for the war would be encouraged.  That’s why the parades in Boston and Philadelphia were held despite the fact that city officials were aware of the potential danger from the Spanish Flu.

There was policy that started with President Woodrow Wilson that authorized, even encouraged lying to the public.  When the United States entered the war, Woodrow Wilson created the Committee on Public Information, which was inspired by an adviser who wrote, “Truth and falsehood are arbitrary terms. The force of an idea lies in its inspirational value. It matters very little if it is true or false.”

Official government posters and advertisements urged people to report to the Justice Department anyone “who spreads pessimistic stories…cries for peace, or belittles our effort to win the war.”  The real fatalities and illness of the Spanish flu fell into this ‘pessimistic story’ category.

An example of this is that the director of Public Health in Philadelphia, continually reassured the public that the illnesses being reported were ‘contained’ or would be decreased and that it would ‘nipped in the bud’.  Under these misdirections,  he authorized and put on the large parade that infected thousands of Philadelphians.  Across the country, the lie that disease was nothing to worry about was commonly told my officials.  This lie was told in large cities like New York and Los Angeles as well as less populated areas like Arkansas.  Even the U.S. Surgeon General Rupert Blue said, “There is no cause for alarm if precautions are observed.”

Eventually, the people caught on because the true effect of the Spanish flu could not be hidden.  For instance, 53% of San Antonio, Texas got infected and death could come quickly and dramatically.  It was also evident how serious the disease was when towns ran out of coffins and people could not be buried fast enough.

It was only when the threat of the flu could not be denied that procedures to try and curb the infection (flatten the curve in today’s terminology) were put into place.  Each state and city had their own instructions but they included a mix of the following procedures.

  1. Wear masks
  2. Don’t shake hands
  3. Stay in doors
  4. Closed schools and theaters and limited public gatherings

There were places that instituted these practices early, such as San Francisco, St. Louis, Milwaukee and Kansas City.  These early adopters had 30% to 50% lower disease and mortality rates than cities that enacted fewer restrictions and/or started their restrictions later.  It should be noted that other than schools, theaters, churches and bars there were few other businesses that were forced to shutdown.  Compliance to these restrictions was highly variable from city to city and enforcement was often a problem.

1917 vs 2020.

The world is a difference place now that it was in 1917.  In 1917 the world was at war and millions of people were being moved to fight or flee from the war in Europe.  The conditions of the war overcrowding, dampness, malnutrition provided ample opportunity for infections to spread.  Millions of people were transported into and out of the US that were infected with the Spanish flu.  Especially, after the war infected soldiers returned to their homes all over the US.  The movement of millions of people in a short period of time is exactly the opposite of a travel ban.

The political atmosphere was generally not to tell the truth regarding the disease and to downplay it’s seriousness.  This lack of candor was accompanied by organizing large gatherings of people despite knowing that there was a serious infectious disease in their presence.  It was not easy for the public get accurate information about the effects of the Spanish Flu.

There was a shortage of doctors compared today but the shortage was made even worse in the US as a large number of doctors were in the Army and overseas.  There were also fewer hospital beds per capita in 1918.

The 1917 level of medical knowledge and medical technology was very low compared today.  The ability to test for the disease was virtually nonexistent in 1917.

Social distancing and masks appear to have been effective in 1917 and appear to be effective now.  However, the shutdown of nonessential businesses around the world has never been done before.  Given all the other societal and technical differences between 1917 and now, it is not clear how effective a nationwide shutdown of businesses in 1917 would have been with hundreds of thousands of infected people returning home.

Unlike the situation in 1917, there is a lot of information regarding Covid 19 from around the world easily accessible via the internet and television.  Unlike 1917, the statistics of Covid 19 are posted often and the public has direct knowledge of the effect of the disease in their city, county and state.


The most effective efforts had simultaneously closed schools, churches, and theaters, and banned public gatherings along with the use of masks.  There were no large scale shutdowns of other businesses, although some places staggered business hours.  At later stages of the epidemic, they tried to isolate those who had the disease but I can not find many efforts to quarantine (isolate) those who were not infected.


Public officials in charge of public health must be honest with the public and give truthful assessment of the disease.

Disease must be recognized and mitigating policies must be put in place to slow the spread of the virus.

You can slow down and reduce infections if you do social distancing and wear masks.

No gatherings of large numbers of people if you can not also social distance and wear masks.

We should be wary of how decisions are made and be aware if a decision is politically driven or public health driven.

There were many societal differences between 1917 and 2020.  The main difference being World War I and the associated movement of people, along with crowded and poor conditions.  The 1917 public was not well informed of the number of infections and number of fatalities caused by the Spanish Flu.


New York Covid. Most new infections occuring in the home.

66% of recent admissions to New York were patients who were staying at home.

Yesterday (5/5/20), Governor Andrew Cuomo reported on results of studying patient information of recent Covid 19 admissions to New York hospitals.  The data was from 1300 patients who were admitted for Covid 19 at 100 hospitals across the state.  It was very surprising that the majority of these patients were adhering to the stay-at-home policy.  The results raises the question of how beneficial stay-at-home polices actually are.

A granular look at the results provide the following:

83% of the patients surveyed were either retired (37%) or unemployed (46%). 

17% were employed.

4% said they were taking public transportation.

18% of the patients came from a nursing home. 

The vast majority of the patients were over the age of 51.

The ethnic distribution is provided in the table below.

Ethnicity% Population% Covid Infected

These results are opposite to what was expected.  It was expected that a high percentage of the new covid 19 patients would be essential workers (not stay-at-home) or those that took public transportation.  Those that were employed and/or taking public transportation were the least effected people. It was unexpected that 83% of the patients would be retired or unemployed.

New York has ‘flattened the curve’ by showing decreases in infections, deaths and hospitalizations.  For instance, for the entire New York state, there were 15,021 hospitalizations on May 22 and there were 8656 on April 6.

Public transportation was not associated with new covid 19 cases.  This result is in line with Japan’s low infection and death rate despite running a fully operational and heavily used mass transportation system.The Japan Experience: No mass shutdown. No mass isolation. Fewer cases and fatalities. What can we learn?  The results also suggest that blacks may have a higher risk factor as blacks had 21% of the new infections but are only 14% of the population.  The number of patients coming home from nursing homes is also very high.  These are people who are at the most at risk and should be the most protected.

A warning that this study was based on only 1300 patients but it raises important questions.  A larger number of patients would have to be surveyed to confirm these surprising results.  Also, there needs to be more granularity to the data.  For instance, the type of dwelling, single family home, apartment, condo, number of people in the same residence etc.

This is not an argument against stay-at-home policies.  The study is too small and not detailed enough to come to this conclusion.  However, it does indicate that it may not be as simple as ‘stay-at-home and you won’t get infected’.  In fact, this study suggests that in this group of patients, if you stayed-at-home you were more likely to be infected.  Perhaps this is not an ‘all or nothing’ policy.  Unclear why stay at home does not appear to be currently effective in NY but Japan with no stay-at-home policy has low infection and death rates.  Only a larger, better designed study will answer this question.

For now, this is another piece of the puzzle.