I think an argument can be made the government ordered lockdowns (stay at home / shelter in place) orders were appropriate in March when we knew much less about who was most vulnerable, and did not have a well vetted treatment protocol / decision tree or any known therapeutics.
Given the tremendous public health and economic costs of lockdowns, the fear of the unknown (e.g. predicted 2% demographic wide CFR) may have justified the multi-trillion dollar cost, and an unknown number of lives lost, due to lockdowns.
Forced mandatory lockdowns today would be unethical and actually counter-productive. Given our vastly increased knowledge of the highly stratified risk profile of SARS-CoV-2, the public health case cannot be ethically made to forcibly confine the general population to their homes; separating them from their livelihoods, their community, their ordinary healthcare, and their mental and physical wellness routines.
Anyone can always choose to self-isolate based on their own personal risk factors and risk tolerance. Government programs could better support at-risk populations which are self isolating by focusing on the minority of people who are acutely at-risk.
> I think an argument can be made the government ordered lockdowns (stay at home / shelter in place) orders were appropriate in March when we knew much less about who was most vulnerable, and did not have a well vetted treatment protocol / decision tree or any known therapeutics.
Sure. Lockdowns bought us time.
> Forced mandatory lockdowns today would be unethical and actually counter-productive. Given our vastly increased knowledge of the highly stratified risk profile of SARS-CoV-2, the public health case cannot be ethically made to forcibly confine the general population to their homes; separating them from their livelihoods, their community, their ordinary healthcare, and their mental and physical wellness routines.
I mean, partly. We know that sticking to outdoors, wearing masks, etc. helps a lot. So we should try to avoid situations such as offices with central AC, indoor restaurants, indoor gyms, etc.
That is not confining people to their homes, just using what we've learned so far to reduce infection rates in the least painful way.
"I mean, partly. We know that sticking to outdoors, wearing masks, etc. helps a lot. So we should try to avoid situations such as offices with central AC, indoor restaurants, indoor gyms, etc."
We don't "know" any of this, except in the sense that it gets repeated a lot, uncritically. The actual published data is mainly anecdotal and/or ambiguous.
Consider restaurants -- South Korea still doesn't consider them to be high-risk facilities, and they're largely open:
That case, in particular, is enlightening about the quality of the data: they blame the transmission on aerosols, but can't rule out droplet or surface contamination, either. It's a judgment call. Most of these stories are like this. The famous "Chinese restaurant" case-study that is cited all over the place to justify shutting down restaurants presents a grand total of nine infected (even though 73 "close contacts" in the restaurant were not infected), of which three may have possibly been infected at home:
Then you have studies like this, which suggest a fairly low attack rate (3.5%), even if you're sitting right next to an infected passenger on a train, for hours:
The authors characterize this risk as "high"...but is it, really? I mean, clearly, being in a sealed tube next to someone for hours increases the risk, but how far are we willing to go for a risk that can be characterized in fractions of a percent for face-to-face interactions that aren't measured in hours?
I feel like people don't know these numbers, and most people would be shocked if they did.
> in March when we knew much less about who was most vulnerable
If this is the falsehood we need to perpetuate in order to let guilty politicians save face and restore a semblance of sanity to our society, then so be it, but let's be unambiguously clear, this statement is incorrect.
The correct statement is: researchers knew, leaders ignored them, and media distorted them.
The WHO China joint mission released both CFR data (3.8%) [1] and IFR estimates (0.3%-1%) [2] in February, based on ~44,000 confirmed cases. They were both broken down by age and very similar to later studies based on other cases. There were no surprises after February, unless you were reading news headlines instead of actual research.
Very similar age curve to the IFR estimates you posted.
It was already very clear in February that this disease rarely killed anyone under 60, or even 70. Leaders just didn't listen.
To use the USA because I know it best, the first big cluster of fatalities was at a nursing home in Kirkland, WA which wasn't up to code.
So leaders had hard data based on tens of thousands of cases showing that this disease was dangerous to the elderly, and not so dangerous to everyone else. And then the first outbreak kills a bunch of elderly people. Amazingly, they responded to this by locking down the general population, and failing to take targeted measures which would protect the elderly (not sure right now but at one point 50%+ of US Covid deaths were in nursing homes).
It's the biggest failure of leadership in our lifetimes.
It’s not just leaders, but constituents as well who propped up the overly heavy-handed/authoritarian response to COVID. Even pointing out just the flaws inherent to relying on skewed CFRs from limited testing would result in friends/colleagues viciously attacking me for not being “compassionate” or speaking out of turn for not being a public health expert.
Some of this behavior I observed may have been due to our proximity to Kirkland (the early nursing home breakout), but there was an element of mob mentality, a perfect storm of ignorance + fear + reliance on authority, that I was shocked and dismayed to experience. After a short while, I just stopped discussing COVID with anyone because of the utter inability of people to calmly discuss complex issues and engage in a joint truth seeking mission.
Unfortunately even with all we know now, I don’t think people have revisited how COVID should be managed or how the risks should be perceived, in part due to politicization of the issue and in part due to anchoring bias. Our leaders are supposed to lead the masses through such events without such flaws, but for all the claims from leaders about “listening to science” and “looking at data”, they’ve simply failed us as you pointed out.
As the other commenter replied: thank you for facing this head-on! Your statement now is commendable.
Also — for anyone wanting to get accurate science reporting in the US (about COVID specifically, but I'd also say more generally), definitely check out NPR's large collection of recurring podcasts. I knew those numbers the grandparent commenter posted back in Feb, thanks to NPR's great reporting, and watching this pandemic play out has felt like dramatic irony. NPR has been on the ball with accurate science reporting for years, and it's a crying shame that their audience is dwarfed by those of cable networks.
no, npr has not been balanced at all. the scientists and doctors they choose for their shows have been carefully curated to amplify the dangers and fear. they mention masks incessantly, even when it's completely irrelevant ("here is carrot farmer, don majors, sowing his fields. not wearing a mask, i might add!")
they don't even pretend to be balanced any more, especially anything related to politics, and the covid response is squarely political at this point. npr no longer holds any esteem regarding science reporting or balance.
Yeah, I recall when NPR had an "expert" on All Things Considered who advised holding your breath when walking by someone on the street (this was back in March/April, when they were doing "the conversation" segments during the national lockdown).
Their science reporting on the whole has not been great, but some programs (e.g. Science Friday) are better than others.
ha, exactly, the producers agressively filter for the messaging they want from their guests, no matter the veracity or plausibility of their claims.
and agreed, science friday is better than their entire stack of daily news coverage of science-adjacent topics. marketplace, planet money, and hidden brain are pretty good for business/economics.
This is a novel virus - meaning noone initially has natural immunity to it. This is why the infection rate needs to be slowed via lockdowns etc. Even if it was no more deadly than the regular flu (it's not - it's at least twice as bad), social distancing, masks etc would still be necessary because our medical infrastructure cannot cope with getting all the cases at once.
> This is a novel virus - meaning noone initially has natural immunity to it.
This has then been proven to be an incorrect assumption, due to cross-reactivity with existing coronaviruses. While this does not prevent infection (or it is likely it does not), it may explain why some people did not experience symptoms, or very light symptoms.
But CFR isn't the only decision input: CFR is only relevant when you can easily isolate some groups harder than others, or else unchecked spread in e.g. the low-CFR age group of children will inevitably reach the elderly as well. E.g. people who work in elderly care can be parents as well, making the infection chain required from lowest to highest CFR age groups very short.
BTW, back in February many then-current spread models where extremely optimistic in hindsight (e.g. aerosol spread was virtually ruled out "because if aerosol was a factor, spread would be much faster than observed", they simply didn't know about other spread-slowing factors), we now know that non-blanket spread control is actually harder.
The virus seems to be able to have long lasting effects in otherwise healthy people who survive, albeit I find it hard to find a legitimate study about the prevalence of this rather than popular "news".
>The virus seems to be able to have long lasting effects in otherwise healthy people who survive, albeit I find it hard to find a legitimate study about the prevalence of this rather than popular "news".
There isn't a study showing a significantly higher prevalence of adverse long-term effects compared to other respiratory viruses among healthy infectees.
My concern around this is that if long-Covid like symptoms are common with other respiratory illnesses, then how have we been missing them for so long?
Honestly, one thing we might get out of Covid is a better understanding of some chronic illnesses that we currently don't treat well (like Chronic Fatigue Syndrome, for instance).
This is another area where the headlines are far ahead of the actual science.
So far, the "long-lasting effects" have mostly been self-reported, based on surveys of people who self-select as "long-haul covid victims". Moreover, when you look at the list of symptoms, they mostly sound like depression and/or lingering cold: headache, fatigue, cough, insomnia, etc.
There have been a handful of studies based on NMR surveys that report cardiac inflammation, but several of these have been debunked completely, and the others are of questionable methodology (i.e. using ML methods to auto-find "abnormalities" in libraries of NMR scans, and reporting everything they found).
It's not to say that there won't be people with long-term symptoms, or even that there won't be people with severe long-term symptoms -- that happens all the time, for viruses we consider innocuous. The question is: at what rate, and how much risk is there relative to all other risks?
Nobody has come close to answering that question, but it seems fairly unlikely to be of high risk, considering that we've now had 34M cases worldwide, and we're not seeing huge numbers of debilitated people overwhelming hospitals.
I dunno man, my sister had Covid in the first wave, and she has lung abnormalities that were not present before (confirmed via Xray, I believe).
They don't appear to be that major, but it's concerning that someone young and healthy (mid 30's fit but with a chronic kidney condition for 10 years) has long-term impacts from it.
I think the real concern around long-Covid stuff is that they may be chronic conditions which will present over the next 5-10 years. I agree that they're unlikely to be acute, given that hospitals haven't been overwhelemed.
Pneumonia can do very similar stuff. It is not widely known because of antibiotics usage, but even if treated it hits your lungs really hard and you can take up to a year before recovering.
A family member had the misfortune of getting one twice (at a distance of many, many years), and it took quite a while to recover.
I got a really hard pneumonia few years ago. It took several days in hospital to find an antiobiotic which actually worked, and I was in pretty bad shape in ER when it finally started to work.
It took 10 weeks to recover back to work, and over a year before lungs were back to normal, confirmed by x-ray.
Pneumonia can be deadly, even for healthy young adult.
Yeah, most people aren't aware of it, but that's exactly the problem with this object fixation we've been doing as a society...when all you do is look at Covid, you can easily convince yourself that Covid is unusual and terrifying.
I personally still have a wheeze (slight, but it's there) from a cold I had years ago. If someone asked me to self-report it as part of a "long-haul rhinovirus" study I might, but nobody ever looks for that.
It is true that if you multiply the age-specific IFR by the age-specific US population then you get a number which is ~2 million. That assumes infecting 100% of the US population, which is impossible. A naive worst case scenario is more like 1 million US deaths.
If you could protect just everyone who is 80 years and older (that's 4% of the total population) then that naive 1 million number falls by about half to 500k.
If you could somehow reach herd immunity by only exposing the least vulnerable of the overall population, you would get there with less than 30,000 deaths.
Even those numbers are assuming there is zero latent immunity, which we now know is not true.
The argument is not to "stand by". The argument is we need to be much smarter, because the interventions are not free, in dollars or in lives (US Federal deficit is looking to hit $4 trillion this year, versus 2019's $1 trillion) and the interventions are also not effective as we've already seen over 200,000 deaths.
Don't agree at all - your own data disproves your argument.
"It was already very clear in February that this disease rarely killed anyone under 60,"
CFR 0.5% for 40-49
You do realize that 40 is not that old? And that 0.5% CFR is really quite high?
Are you maybe one of those '22 and feeling indestructible' people? How could someone possibly talk about 0.4 CFR and greater CFR for an age-diverse population and not realize how extremely dangerous that is?
And it's 'quite serious' for probably 8-14% of those - and that they may get life-long consequences?
And the CFR jumps quite high when there is a lack of medical facilities?
And the R0/transmissibility is really quite high, not like some 'rare disorder' - it's something that without suppression almost all of us will contract. The 'young and partied' are now becoming walking Death Adders, it's a 'systematic issue' and not very helpful to point out that 'some are less likely to die' just as they are the 'root cause of spread'.
Even if was just to 'protect the elderly' a the shut down was easily warranted.
There are 200 000 deaths from COVID more than US Combat Deaths in Iraq, Vietnam, Korean wars combined - in just a few months.
This is the most devastating and deadly thing to happen to America in at least a century, the lock-down was reasonable, there were probably even other measures we should have been taking.
Social distancing on an interpersonal social level is 'economically inexpensive' for god sakes, we're more resilient than to have to be able to 'party' every week or few.
We have to be smart about this but all things considered we have no choice.
What we 'could have done differently' was probably a) react sooner b) move more aggressively in elderly care c) wore masks and d) had a plan for this ready beforehand instead of making it up as we go along.
Edit: Please do the calculation given: 1) your stated CFR rates 2) the 'herd immunity threshold' of 60-80% of population infected 3) an aggressive R0 meaning that this would happen quite quickly 4) adjustment to CFR given overflowing hospitals and lack of available staff - and the numbers are excessively bad, at very least millions dead, which is a monumental risk.
Look, terabytes of back-and-forth in internet comments has happened over this. The calculation you are asking to do is not a realistic scenario. The pandemic is gonna come out to be on the order of one year’s worth of smoking. People have been dying totally preventable deaths due to cigarettes at that rate your entire life.
"The calculation you are asking to do is not a realistic scenario."
Yes - with the original lock down, with extensive social distancing measures - the 'end result' will be in the same order of magnitude as 'smoking' (actually much more) - but without suppressive measures it would be apocalyptic.
It's entirely plausible to estimate: it's in the order of millions of dead in a short period. It would probably be the 'worst disaster in US history by a long shot'. Probably worse than all wars in including Civil War and WW1 + WW2 combined.
FYI The UK and Sweden were estimating 60-80% of the population infected in order to get 'herd immunity' - so given the IFR/CFRs stated above ... that's millions of Americans dead, and just as many with lingering effects.
some emergencies in life call for one to gather up the courage and valor to storm normandy beach, believing death to be very likely imminent. this emergency calls for patience and stoicism. life is a numbers game. I almost died a few hours ago on my way to the mountain view costco for some fruit, sausages and croissants. a vehicle ran a red light and passed between my car and the car i was following through the intersection. I need my car to enable my lifestyle, but I wear my seatbelt, not that a seatbelt would’ve saved me tonight. I’m 40 years old, and covid may well take me if i’m so statistically unlucky, but I’ll wear my mask, avoid air conditioned crowded indoor spaces and social gatherings IRL. I hate this pandemic for stealing a year or three of my life, but I will continue to try to manage my risks, recognize what threats I can, and look for enjoyment and fulfillment in the areas of life that are available to me in the present. I look forward to resuming my normal patterns of life, whenever appropriate.
I seriously doubt this CFR holds with an overwhelmed health care system. Since then effective treatments have been discovered and saved the lives of many who would have died if gotten sick earlier. Now we are most likely just 2-3 months away from a vaccine and big preventable outbreaks seem stupid.
And Medium censored anyone trying to point this out, I remember a very extensive report back then showing what we know now and they got deleted. Twitter lit up with arm chair pathologists demanding the user be banned etc.
Yes, Medium’s censorship of the numerous well evidenced and mildly worded posts analyzing COVID information was utterly disgusting. It was predicated entirely on demanding blind faith from the public that authorities were 100% correct. Obviously the WHO’s track record during COVID was anything but correct.
You're saying exactly the reason I haven't been concerned about the virus since day one. Early reports truly weren't that earth shattering when one looked at the numbers.
I truly encourage everyone reading the parent's post spread this information.
"Early reports truly weren't that earth shattering when one looked at the numbers."
I don't understand how someone can say this.
COVID has a reasonably high CFR/IFR - you see the data there.
Notably, as well, the R0 is very high, it transmits very easily.
There have been 200 000 deaths in a few short months and without aggressive suppression it would easily be in the millions.
In what world do 'millions of dead Americans and and out of control pandemic' not seem 'earth shattering' when it would be easily the worst disaster in American history (if it isn't already)?
'When one looks at the numbers', especially the totality of 'the figures' such as R0, % serious cases, lingering risk factors (and they are not new to me, these are figures I had assumed most HN readers would be somewhat familiar with) ... it's very bad.
sars-cov-19 has shattered my expectations for the ability of hn commenters to assess risk and model threats. it makes me wonder if i’m not half a psychopath for only caring about the quality of the information i have access to and the correctness of my conclusions which I then put into practice with a view towards my own personal good health going forward, as well as the health of my partner. i’m thankful every day that I don’t have kids.
Wow, it's not that bad. Our clumsy leaders are 'mostly right', and whether you're in Nigeria, New York or New Zealand ... we're going to make it through this.
This pandemic, left unchecked - would kill a lot of people, but we've made a lot of changes, it's going to be ok.
It's worth considering that 'detailed information' is not something we're going to communicate to the public, that's too complicated - and - that our systems are not designed for this level of control. Truly well organized authoritarian states probably have a big advantage right now.
I’ve barely been able to keep my dog from going nuts with the quarantine + the California smoke we’ve had to deal with for months now. That and many other reasons. I don’t begrudge anyone their family decisions, but my partner and I definitely made the right one for our situation.
I think "doesn't help anyone" is a bit of a stretch, since many tech workers actually did quite well during the lockdown, since they were forced to spend less due to a lack of options.
I'm in Ontario so what is being discussed does have an affect on me and I really don't know if a lockdown is the answer. What I do know is our Premier (Doug Ford) is a fuck up. We should be much more prepared by now and this lock-down talk is him panicking because we have no way better way to manage outbreaks.
If they can't afford to self-isolate on their own, they also can't afford to self-isolate under government orders. Locking everyone else down doesn't help those who are at risk afford isolation, it actually makes it much more difficult because the government has less money to work with to support those who are at risk.
What you (Edit: not _you_ in particular, but what a country does by making self-isolation opt-in) are doing here is shifting the blame of who is responsible.
If the government says that you must stay home for public health, then it is reasonable to expect that the government assists in covering costs associated with that.
As soon as the government says "You can go to work if you feel it best, the choice is up to you" a non-trivial amount of people are going to be forced to go back to work, whether they feel like they should or not. Because "you're allowed to, staying home was your choice", these people will not be compensated for making the public-safety choice.
I don't know about you, but I wouldn't want to be in a situation where the person who is making my lunch (or stocking grocery shelves, etc) should have stayed home, knows they should have stayed home, but couldn't afford to stay home because "it's not mandatory".
Then the government should compensate those who are staying at home because they are at risk. If the choice is between locking everyone down and compensating everyone, and just compensating those who are at risk the second option is obviously cheaper.
And regardless, I think the vast majority of those who are at risk were not working before the pandemic, so do not really need to be compensated. More than 60% of people who have died so far in Ontario are in long term care facilities. Over 85% of people who have died in Ontario are in their 70's or older (so likely retired). So the number of at-risk people we are talking about here is actually pretty small.
Then the government should compensate those who are staying at home because they are at risk.
Maybe, but it's wishful thinking, never going to happen. Think of the outcry against the $600 unemployment supplement where some people received more than they were making previously, not to mention arguments that it incentivized staying unemployed.
Do you think governments have some kind of magical money well? Every cent they spend has to be paid by someone and if no one is earning how are they going to pay taxes?
Besides obviously if everyone is in lockdown, how are you going to buy food in a closed store with empty shelves? Do you think the government can just write a law and bread appears? People actually have to do a lot of work to make it.
> If they can't afford to self-isolate on their own, they also can't afford to self-isolate under government orders.
Well this is true now, now that CERB is over. But before, those that were eligible, received 2000 a month from the government.
> government has less money to work with to support those who are at risk
There are now talks about a serious wealth tax on the rich to help fund future covid efforts that will allow those that can't afford to self isolate, to be able to.
You’re absolutely right. Unemployment benefits should absolutely be available to anyone who can’t do their job as a consequence of choosing to shelter-in-place.
Countries can much better afford to offer unemployment benefits to the “at-risk sheltering” population than they can to offer the same benefits across their entire working population. Most working age people are not at high risk.
Provided you’re not paying people more to not work than they would earn working, you can let the market decide.
As if the tooth fairy is going to pay if there’s a general lockdown. Either the government forces employers to keep paying their workers so they all get fired or the businesses go under, or they allow them to curtail wages. The government can’t afford to pick up the tab.
Of all possible responses to the GP, I think yours is the dumbest and least helpful. You've combined two strawmen, a false choice, and the least charitable interpretation of the GP into a single brain-dead one-liner.
The "economy" you speak of is not merely investment income for wealthy people, or whatever other expendable construct you made for yourself. It is our livelihoods. It's how we feed our children, provide shelter, education, security, and hope for the future. A destroyed economy destroys lives, and carries as many or even more risks to our physical and mental health as does the virus itself.
I'm someone who cares about people. The choice is not simply between the elderly and the economy, and we have enough tools and resources such that we don't have to sacrifice any group for any other. But if your strawman + false-choice were our reality, your priorities are fucked up. If, theoretically, you'd be willing to sacrifice the health and wellbeing of the vast majority of the worlds population to whom this virus is no more a threat than a severe seasonal flu, to preserve the few reamining years or months of life for the "elderly" (whatever that means to you), I would honestly feel justified in calling you heartless and irrational.
The current solution is to sacrifice the jobs, opportunities, mental health, education, and futures of the young, where the young is anyone not retired. Why should new graduates lose their offers and join a massively setback economy with 40 mil unemployed, millions of families lose labor income, pupils lose a year of education while forcing their parents into a difficult situation of trying to work while their children are home alone all day, businesses shutter and many shutdown, all compounded with the mental health effects of vast isolation, loss of social events, and outings - because the elderly, relatively rich retiree can't stay home for a few months instead while we make a vaccine and slide checks under their door?
In the same breath: "Yeah let's sacrifice out old for the economy!", you simultaneously encourage the current situation: sacrificing the current and future prospects of the entire rest of the population for no other reason than you believe the old can't quarantine without taking everyone else with them? The economy isn't just some GDP numbers and the DOW - that crap helps the hefty 401(k)s of the retirees anyway, it's people's jobs, savings, ability to afford food, rent, and vacations, and so on.
USA has had a 7 day average of around 40000 new cases a day for the month of september, and around an average of 750 deaths a day (more actually but for sake of argument.) That's a 2% CFR.
In the early summer, the CDC published a study estimating that the confirmed cases were 6-24 times lower than the actual cases. With testing continuing to ramp up, I suspect the gap has narrowed, but some significant multiple is still likely the case here and an order of magnitude is not outside the realm of possibility.
If 90% of cases are unsymptomatic or have minimal symptoms we'd expect an order of magnitude underreporting of cases, assuming people were only tested when they go to the doctor/hospital.
If 90% of cases are unsymptomatic and not showing up in the cases, then 75 million people in the US will have already had covid, and you're also getting 400 thousand new cases a day.
That's not how CFR works. CFR is fatalities from known cases. If you're thinking about infection rate, you need to look at IFR, not CFR. If you want to compare one disease to another, you need to compare CFR to CFR, and IFR to IFR.
Back then, we were told that the lockdown was a temporary measure to avoid overloading the hospital infrastructure. We needed to allow time for hospitals to add beds, respirators, etc. “Flattening the curve”.
Then the goalposts were moved.
What is desperately needed is an honest, open discussion of costs and benefits.
Its true also that there were some very scary predictions based on early models that turned out to be flawed. We do know quite a bit more now, but we don’t seem to be applying it.
The goal posts were not changed. Once the curve was flattend, the lockdowns were lifted, and measures relaxed.
While we did manage to flatten the curve in spring, growth is back on an exponential curve in Canada, which means the threat of overwhelming the health infrastructure is still looming. A sweeping lockdown may not be the best answer, but measures needs to be taken to slow the growth.
Exponential growth is no joke. Hospitals are more prepared,
but exponential growth means that even if you double the hospital capacity, they will still be outmatched rapidly if nothing is done to slow down the spreading.
"The goal posts were not changed. Once the curve was flattend, the lockdowns were lifted, and measures relaxed."
I think you should tell that to the residents of New York City, who only today got back the privilege of eating indoors (and only at 25% capacity). The governor wouldn't have granted that, had he not been sued (twice). The case count has been flat since June:
If you count cases by specimen date (when they were taken) and not by reporting date (when the results were known), the picture is a little different: while high, cases seem (too early to be sure) to have plateaued around the end of August.
Hmmm, interesting. Its very difficult to make comparisons with wave 1 though, as we presumably had the same number of asymptomatics, but with the much lower levels of testing, we didn't find any of them.
The third wave will probably be a lot easier to model (god, I wish I was joking on that).
I find this talk of first/second wave misleading. This is not the flu for mortality, and it is not an influenza virus. It spreads differently.
Some people at my institution in fact have argued that you should not use flu-derived models, but instead model the spread and the outbreaks in similar ways to SARS and MERS, which rather than big "waves", had a series of spaced outbreaks. At an internal seminar they showed that at least their models for the Bergamo area seemed to be consistent with the actual data.
> Anyone can always choose to self-isolate based on their own personal risk factors
Nobody can self-isolate 100%. The strong may only need supplies, but others will also need care or medical assistance. This puts an upper limit on individual isolation. The good news is that isolation compounds: reaching 99% in isolation, in an environment of zero general isolation is much less valuable than reaching 95% in an environment where everybody else does as well.
Lifelong damage to the lungs and other organs should come into the equation before jumping to conclusions, it could be within an acceptable range for you but so far the data for that is pretty much non-existent so you can't know for sure.
We have studied tissue damage for a lot longer than Covid-19 has been around and in many cases presumably know which kinds will eventually heal and which kinds won't.
"Anyone can always choose to self-isolate based on their own personal risk factors and risk tolerance."
The problem with this statement is that COVID is not a 'personal' issue. It's a systematic issue. Your disease affects everyone.
To put in a different kind of 'Liberty / Responsibility' context - how about we allow anyone who contracts COVID to sue the person they got it from for damages!
Then how many people are going to go out, and how careful they are going to be?
While we may not need 'shelter in place' for <70 populations, we are inevitably going to face social distancing etc..
We need to 'get smart'.
...
And 0.5% IFR already at the age of 50 is scary.
In this 'new era' there are a lot of people over 50 probably nearing 40% of the population or something like that.
Honestly I don't find it to be newsworthy that you can find 21 doctors to sign just about anything. They are people, and people believe all kinds of stuff.
Interesting that on one (lockdown) side is mostly doctors in University Health Network and Unity Health Toronto (arguable the top hospitals in Canada), and the other (don't lockdown) letter is mostly professors at McMaster and University of Toronto (arguably the top medical schools in Canada).
Probably just circulating petitions within their networks. The numbers are small enough that this could be little more than grabbing some colleagues through the intranet.
Interesting. How's the discussion between those groups going there?
The chasm here in Germany seems to range between a majority of epidemiologists and virologists advising on sensible measures going forward and a few economics folks, a bunch of private clinic doctors and a vocal group of clearly right wing / conspiracy people. The latter group either sings the tiring "it's just the flu" or "people die for many reasons anyway" song and can be seen on Twitter, discovering basic epidemiological models in real time. Their arguments are very similar to those of flat earthers honestly, precluding any notion of a grounded debate on what measures are sensible in order to keep the health system in working order and shield those that are vulnerable.
>Their arguments are very similar to those of flat earthers honestly, precluding any notion of a grounded debate on what measures are sensible in order to keep the health system in working order and shield those that are vulnerable.
From the opposite perspective, the people who keep insisting that measures like that are necessary to "keep the health system working" in spite of Sweden providing a strong counter-example (no lockdowns or masks, but deaths have steadily trended downards, there wasn't a second wave, and it isn't even in the top ten deaths-per-capita countries now) seem anti-science.
Yeah, I've read your other posts here. Note that I did not argue for a complete lockdown in my post but a grounded discussion of effective measures. This "but Sweden" argument is exactly how much of this discussion reads like a bunch of political nonsense.
The UK tried a Sweden, saw it wasn't working, and switched policies. Sweden itself didn't have a full on lockdown but it's had other measures put in place (e.g. restriction of public gatherings that last I checked were now more restrictive than Germany) and we have plenty of places were heavier local outbreaks clearly led to the negative implications we want to avoid going forward (e.g. NYC, Italy). You're free to call that anti science but absolutism in the face of many unknowns isn't scientific either.
Swrdish culture, support systems and economic incentives, and consequently behavior in the absence of mandates, and the Swedish health Systems, aren't the same as, for instance, the American versions of each of those. So, it makes little sense to assume that the behaviors necessary to protect the Swedish health system are identical to those which would be necessary for a dissimilar country, or that even if they were that they would necessarily be acheived by the same policies.
The proof of this is that, Sweden, without a firm mandatory lockdown, experienced pretty much all the economic consequences of one—because without a mandate for lockdown, Sweden acheived the near behavioral equivalent.
I wonder if the Covid-19 lockdown actually harmed many (non-hospital) doctors financially, people can't make an appointment with them. Of course there is online but you can't charge much for no operations performed
I love how people say ‘Just listen to the experts’ and then go pick and choose the experts they say what they want. No no not these experts, listen to these ones.
I think any topic of "settled science" has expert detractors. But a lockdown can't be a matter of settled science because it it a question of priorities and tradeoffs, not of science. That is outside the domain of science and firmly in the domain of politics and economics.
It only becomes a domain of politics and economics if you ignored the settled science for too long like it happened in the US, in countries like South Korea, Vietnam or New Zealand where they have now near zero cases it was as never a politics or economics issue.
>South Korea, Vietnam or New Zealand where they have now near zero cases it was as never a politics or economics issue.
How can you claim this when South Korea's response was completely different than Vietnam and New Zealand's (no forced lockdown/stay at home orders in Korea)? If they were all following settled science, presumably all those countries would have responded the same?
Absolutely false, South Korea isolated the people with the disease after making very fast and swift vast amount of tests per day (30.000) after a joint effort with the private sector and such proceedings could be perfectly be labeled as "isolation"[0] which is exactly what a lockdown is.
No, because they caught their cases incredibly early, and were entirely willing to aggregate pretty much all data they could get to track spread, and do things that would have caused riots in different cultures (like the US).
I mean, look at how little people trusted the Google-Apple contact tracing model vs South Korea where they actually track everyone using QR codes and get mobile data to trace chains of infection.
It's a very different culture, and it appears to be based on their more recent experience of pandemics (like MERS and SARS). Note that Montreal has done pretty well here too, and was one of the few places in the West with a SARS outbreak.
I really don't like how all the media seems to be focused on case counts, they started rising significantly a couple of weeks ago in Ontario, and yet hospitalization are still only ~15% what they were at the peak. Hospitalizations are definitely going up, and probably will continue to do so, but I see headlines talking about how we are breaking the record number of cases, without acknowledging that comparing case counts between now and a few months ago is useless.
I've been largely supportive of Ontario's lockdowns so far, lets not overreact just because our testing capacity has increased. And whatever happened to flattening the curve to ensure hospitalizations stay below capacity? I still haven't heard what the new plan is, obviously in many places we are locking down much longer than is required to just keep hospitals below capacity.
The hospitalization occurs later in the chain. This time period could be compared with February. In a month hopitalizations will be up.
The case count is very misleading. The maximum number of new cases is limited by the maximum number of tests processed. Current figure is 700/cases 40,000 tests. The only way to increase the 700 cases is to increase maximum tests processed daily or pick more likely positive people to admin the test to. There could be 100,000 getting sick each day but the case count will only reflect a shadow of that information.
It is actually hard even to make sense out of hospitalization numbers. In my country, hospitalized people are counted as "positive hospitalized" even if they are positive (due to mandatory test prior to admission) but had to go to the hospital for a completely different reason.
Likewise, a region during August mandated mandatory hospitalization for most of the people positive to the virus, therefore inflating hospitalization numbers.
Unless reporting is either standardized (unlikely) or harmonized (possible) it is always going to be hard to make sense of the numbers.
Right, and just because hospitalizations are 15% what they were at peak, doesn't mean that the case count at peak was correct -- there were likely many more unconfirmed cases at peak, as testing was not yet widely available.
What’s happening now might be that more and more people are getting tested, not because they had serious symptoms, but because they need to show a positive test for some travel or other requirement, of they are just being careful because they have older family members etc. So there would appear to be more cases, even if there were in reality fewer people getting seriously sick from Covid.
The hospitalization rates generally lag about 2 weeks and they are not going up very much.
Province of BC has a lot of very detailed data on who gets it for what reason (they contact trace everything) and it's definitely younger people getting it right now.
Google 'Dr. Bonnie Henry'.
I think the media is purposefully underreporting the hospitalizations for the national interest and it's probably a good thing. The 'Freedom / Liberty' crowd hates to hear this kind of stuff, but the reality is, people are not very smart, even educated people can be easily misinformed and make bad decisions, which is why in a crisis we need constant behavioural reinforcement.
It's been 2 generations since the Western world has had a crisis in which everyone has had to participate and 'play their role' so it's almost out of living memory, but I suggest this is normal.
Smart people can read more and use the Internet for more detailed information.
Not sure if these doctors have followed what has been happening in Melbourne, Australia.
We have been in lockdown since early June and went from 700 cases per day to 15 per day so it has technically worked. However, it has completely destroyed businesses and affected a lot of smaller retailers. Our premier has been called "Dictator Dan" by most of murdock media including WAPO but the support among public has stayed strong. Suppression is a good strategy when the world is devoid of a vaccine.
If the virus hasn't been stopped completely all you are doing are dragging feet indefinitely (with all the catastrophical damage that comes along with it).
It hasn't worked - literally nothing had qualitatively changed since day 1 when I said that exactly this would happen. All we have is better testing methods and a ravaged economy, yet fundamentaly we are at square zero.
There is an important win: A bunch of people who would have died are still alive.
That said, the right strategy is to focus on hammering the virus to zero quickly through old-school epidemiology techniques. If we had done so early, the problem wouldn't be this bad. It would have been expensive, but less-expensive than our present path.
The bright side of combating an exponential foe: Once you start to win, winning gets easier.
A lot of people that shouldn't and wouldn't have died are dead. Even more are unemployed, starving, homeless and in severe distress as a direct consequence.
I sincerely doubt that it would amount to a net win, after everything else and all the externalities get factored in (it's never done unfortunately)
Those are the effects of moving society online. New winners and losers will emerge. A strong social safety net is helpful transitioning the losers back to productive winners. This was going to happen over a longer period of time anyhow.
Medical decisions in the USA suggest that the statistical value of a “quality-adjusted life year” is ~$128,000 on average. Obviously the question of “life years” is critical in this context. Everyone would be in favor of sacrificing more to save healthy children than people who are 80+. (No one wants to see anyone die needlessly, but the children can live happy lives for another half-century.)
That's the value of an average life. Health economists at e.g. the NHS actually use https://en.wikipedia.org/wiki/Quality-adjusted_life_year, to account for the fact that e.g. an 80 year old has fewer years of life left than a 10 year old.
About zero, really. Unless some of those 80+ year olds are prominent scientists, etc.
The numeric value $1 billion means $1 billion worth of human labor or energy. The amount of this energy is finite, and it's around $80 trillions currently. We can multiply it by 10-100, the exact number doesn't matter, what maters is that it's not a lot bigger than $1 billion. Saying that saving a human life is worth any dollar amount, is same as saying that our society, all 7-something billion people, should spend all their energy on saving that one life.
A human body is really just a vehicle, like a car. When it approaches 80 yo mark, it's worth about nothing. It's just some people believe, with religious rigor, that they're bound to this car forever.
I don’t think experts honestly thinks you can hammer the virus to zero though based on our knowledge of human behavior.
Case in point, HIV has killed around 50 million over the past few decades, and we know exactly how it spreads, and it is quite easy to stop. If we can’t stop HIV, without a vaccine there is no way we can stop something airborne (which we now know SARS-CoV2 is).
And some people died because of lockdown due to cancelled medical treatments/surgeries they've conveniently called elective/can wait/etc. And what is happening to those suicide rates as people get ruined and desperate. And how many will die if the economy collapse goes out of control and there will be nothing to prevent those deaths.
Do you actually have any info on those topics? If not how can you claim that it worked. Maybe it had just delayed inevitable but at higher overall cost.
Are your people (and yourself) more concerned with human lives than children getting an education and not falling behind? If so, how long should children suffer? As long as it takes?
Take a look at the provincial breakdown. The Atlantic provinces are in a position where kids are going to school, restrictions are being lifted, and the number of cases are in the single digits per week. For the most part, there is not spread within these provinces so efforts can focus upon verifying that people coming into the province aren't infected and ensuring the population complies with far less extreme measures so that the virus does not gain a foothold in the region yet again.
Even parts of the country with a far greater number of infections than the Atlantic provinces are seeing numbers stabilize (e.g. Alberta) or decline (e.g. British Columbia). This is not the case in Ontario, where the spread is essentially uncontrolled. Measures need to be put into place because the living will continue to suffer as long as that spread is uncontrolled, and yes the loss of life matters as well. A few weeks to stabilize the situation will ensure that lives are not lost needlessly.
Learning online will put them ahead of their peers. The world is moving remote. Children will be better served by learning how to interact and learn online. It will be a skill they use in the future. This has given them an opportunity. Some children are excelling in this new format.. teaching your kids how to excel in this environment will push them ahead.
Online kindergarten is a disaster. 1st & 2nd grade only slightly less so. A little older than that and things get a little easier, but that's only if the kids actually have halfway decent resources. My kids are slightly older than that, manage the school work okay, but are suffering otherwise due to the isolation. My daughter has been in tears multiple times because she doesn't get to see her friends. I bought an Oculus Quest so they could play Rec Room and have some semblance of social play & interaction.
I live in a diverse area with lots of working-class people: It's not uncommon for kids in my school district to be using their parent's old phone as their online portal for distance learning. It's also not uncommon for parents who must work & can't afford child care to have an elderly relative watch their kids. Relatives that aren't always fluent English speakers, and often aren't equipped to help a kid navigate a curriculum spread across 5 or 6 different electronic systems.
If you believe minimizing death is more important than personal choice and economics then you should really be fighting to ban junk food and support laws that require everyone to exercise.
Cardiovascular disease kills 655,000 Americans each year compared to Covid's 200,000.
And then some people (myself included) factor in externalities and realize more deaths have occurred because of the lockdowns (depression, lack of medical care, malnutrition, homelessness). Some of us are even more concerned with human lives than looking at the small picture of only the benefits of lockdown.
Medical care is not fully available. Canada now has a backlog of cancer screenings estimated to last over a year to resolve. Thousands of these people will die from cancer thanks to trying to "save" them from Covid.
Funnily if we embraced this "pretend there isn't a pandemic and do whatever we want" plan these people seem to be advocating hospitals would likely be so inundated with covid patients that there wouldn't be capacity for much other medical care.
(Note that this isn't a hypothetical - we have real world examples - see New York a few months ago, or Spain.)
Generally Americans are unable to afford food for their children, so they rely on public schools to feed them. Without the school, the children go hungry
NSW isn't locked down and we managed to sit at around 15 cases per day for a good while without it spiralling out of control and have dragged it right down to 0's some days and close to it on others.
So if you assume that Victoria can contact trace almost as well as NSW, I think its fair to say it's worked because they've got to a number where contact tracing is effective.
It's worth pointing out that this would be a second lockdown, as Ontario has already started to loosen restrictions after the initial lockdown (where cases also dropped to <100 during the summer).
I feel like everyone is talking about Melbourne's lockdown as if it was their first lockdown.
This is their second lockdown. They virtually eliminated it during the first lockdown and brought the virus back in via hotel quarantine leaks (as proven by genomic testing).
There is nothing indicating that the same thing won't happen again. NSW's contact tracing team has been excellent but I have not heard anyone detail how Victoria's team is up to scratch now (a part from throwing some money at Salesforce).
There is no long-term strategy in this whatsoever, the hope is that the vaccine is available and effective before the inevitable 3rd wave hits a still highly susceptible population.
Do you have a source on that? I know that they sent some people up to see what NSW was doing but haven't actually heard them say what, if anything, they were going to adopt. There is this 'funny' article from a couple of days ago though; seems like a lot of lies and smoke:
Gladys also indicated that a large part of NSW's tracing success was the tight integration and information sharing between government agencies. Something that, if you read between the lines, is apparently not the case in Victoria.
I wonder about this hope for a vaccine, and if it is a reasonable thing to base policy on. There is still no vaccine for HIV, after several decades of trying and many billions spent. None for SARS1, Mers, the commom cold. There are influenza vaccines, but still no effective ones in terms of preventing a significant number of deaths every year.
Common cold: not worth it, and is caused by a lot of different viruses, making vaccination even harder.
SARS1: the virus was eradicated before trials could complete.
MERS: There are several vaccines in testing, however MERS comes and goes randomly, so it takes a lot of time to gather events.
HIV: Apparently there's a trial in Uganda going on since quite a while, which looks better than the past ones (which were failures), but with HIV, it takes years to see if it works or not
That said, betting all your options on a vaccine is not what I'd call sound policy. In fact, there are several drugs in the pipeline, but few if any report that.
For HIV there’s medication which practically guarantees you cannot become infected and there’s medication which will practically guarantee you will not get ill and cannot infect others.
> Suppression is a good strategy when the world is devoid of a vaccine
Part of this is just fear talking though.
My family was very concerned about the virus for the first couple months. Then people we knew in our age demographic (20s-30s) started catching it. Invariably it's been a day or two of fever and a week or so of cold symptoms.
Absolutely people who are at elevated risk because of age or pre-existing conditions should lock down to whatever extent they feel is necessary.
But the general feeling here (central Iowa) seems to be more and more that the lockdown is far worse than the virus.
Because of that, we get raked over the coals pretty well daily by everyone in the media.
But our schools are open, our universities are open, and people are more or less back to normal life. Cases are stable. Deaths are low and mostly restricted to the very old. We seem to have settled on an acceptable (to us) middle ground. I'm sure businesses are still hurting, but very few have shut their doors permanently. I get the feeling that's a very different picture than many places.
I have been following this mess. I’m an Aussie in CA.
Even when a vaccine is available it’s not going to be 100% effective. Contrast it to another RNA based virus (but faster mutating) like influenza. The annual shot effectiveness fluctuates based on what is the dominant strain socially circulating.
Therefore, the science Dan is subscribed to means Vic will be locked down indefinitely. Sure ppl love the lockdowns but the reality will hit hard when they realize there is no such thing as “pause” in the economy. It’s a hard stop followed by CPR.
What ever happened to real science; you know, the one where we learn and adapt as new information is made available. I’m pretty sure we now know a lot more about this virus, demographics most at risk, it’s disease management etc...
Comparing a not yet existant vaccine to a vaccine for a virus that's totally different is silly.
Especially comparing it to the flu, as that's a virus that mutates much more often than most viri.
In any case no vaccine is 100% effective. The goal is typically to be effective enough that the virus dies out faster than it spreads. Which solves the problem.
There are a lot of covid vaccine trials going on. The different candidates have different properties. It has yet to be seen which candidates are succesful.
While you're correct to point that out, I'm not aware of any health experts who expect that the current crop of vaccine candidates are sufficient to stop the disease from spreading. The hope is that it will spread slower and/or be less severe.
I'm definitely no expert on this, but it seems a little early to say. There's 321 candidates in development (albeit some very early stage) and none have fully passed trials yet. I think the effiacy of various candidates isn't clear yet (i may be totally wrong)
So first you denounce my statement then you agree with it (around vaccines)?
I’m comparing RNA based viruses not diseases. If the keyword “flu” offends you because you think I’m comparing it to the flu then replace it with any RNA based virus and it’s mutation rate. You’ll realize fast that the thing called cure is only 100% effective when the mutation rates are close to 0.
> In three sets of testing data that include cycle thresholds, compiled by officials in Massachusetts, New York and Nevada, up to 90 percent of people testing positive carried barely any virus, a review by The Times found ... One solution would be to adjust the cycle threshold used now to decide that a patient is infected. Most tests set the limit at 40, a few at 37 ... Tests with thresholds so high may detect not just live virus but also genetic fragments, leftovers from infection that pose no particular risk — akin to finding a hair in a room long after a person has left, Dr. Mina said. Any test with a cycle threshold above 35 is too sensitive, agreed Juliet Morrison, a virologist at the University of California, Riverside. “I’m shocked that people would think that 40 could represent a positive,” she said. A more reasonable cutoff would be 30 to 35, she added. Dr. Mina said he would set the figure at 30, or even less.
When I used to do RT-PCR for research, 40 cycles would mean (to me) that I had nothing in my solution and I had to redo the experiment.
The precautionary principle (anti-scientific, because it assumes the worst even without evidence of such) is what drives such decisions, even if, according to Oxford's CEBM, there is little to no correlation between a PCR positive sample at 37+ cycles and actual presence of an infectious virus.
That is why antigen testing, although less sensitive, is important. A PCR test without symptoms does not tell if you have the virus you had the virus, and if you are infectious (assembled virus present in the respiratory tract) or not. Also, RNA in the throat can degrade slowly, and be present for a long time (this is not unique to this virus).
An antigen test will identify the virus proteins, and as such, a higher probability that a positive test detects an infectious virus.
The going to school /work keeping movies / bars / restaurants / massage parlours open but limiting groups / strip joints (that's happening in Ontario) feel like political compromise without any science. These powerful entities will keep their doors open the less powerful will be shutdown meanwhile they all should be shutdown or opened at the same time.
Even if it's somewhat arbitrary which kind of gatherings are still allowed, forbidding half of the gatherings still has an impact on the transmission rate.
Which means if you cut out bars but allow churches (max 25 persons in Quebec btw), you still cut down a lot of spreading.
I don't agree with keeping religious gatherings, but it doesn't mean there is no science behind these decisions.
The interesting part of this letter isn't any novel or lucid argument but what it's arguing against, which in the context of the mentioned earlier Ontario Hospital Assocation statement almost comes across as a straw man. The letter spends most of its time arguing against near-total lockdowns such as Ontario experienced from March through June even though almost nobody is currently proposing this - even the OHA statement only advocates a temporary closure of indoor venues such as restaurants and banquet halls in affected areas (albeit including large cities such as Toronto and Ottawa) - with a parenthetical warning about the harms of "rotating" school closures to childrens' health, even though this wasn't really proposed. In fact, the earlier statement explicitly proposed closing food service venues in order to prevent school closures and elective surgery cancellations. Likewise, they mention overdose deaths and social and economic determinants of health as if the broader health sector were oblivious to these or hadn't proposed any solutions. (The current government is quite conservative and broadly opposes overdose prevention, basic income experiments, social housing, etc., so these are unlikely to be realized, so perhaps this is a resigned ultra-realist approach, but in that case, why write it in the first place?)
A cynical part of me wonders whether this letter being circulated by CTV (as opposed to the motivations of those signing it, about which I have no idea) isn't just to give political cover on talk radio and TV news for the government's current wait-and-see approach, which health workers (and progressives generally) are against.
[Slightly unrelated, but potentially relevant given the "doctors say" headline: the government was recently playing radio advertisements explaining how much it "consulted" with the health sector on safely reopening schools but not mentioning the fact that it ignored the main recommendation of reducing class sizes.]
I would be curious if someone ran a health economics analysis on lockdowns.
The UK sets the value of 1 quality adjusted life year (QALY) at 20-30k GBP. Basically, if a new medical technology costs more than that they say “no, it’s not worth it” (though there are exceptions).
It shouldn’t be hard to figure out the cost of the shutdown and divide it by the number of QALYs gained.
I think it is pretty hard to compute the cost, because what's the counterfactual? Even if you don't force a shutdown people may still opt to isolate themselves and businesses may opt to close, and the degree to which they do so is probably dependent on the dynamics of the pandemic, so you're going to be pretty sensitive to modeling errors.
The problem with such attempts at a 'rational' explanation of why one or the other approach works better is that we are talking about an irrational issue. It's easy for 30-something people with no preconditions to think they can rationalize themselves out of a lockdown... but the moment their parents and grandparents start dying, all of a sudden all rationality goes out of the window.
I'm a little puzzled by their methodology, it covered noninstitutionalized folks in Indiana over the age of 12, but the majority of deaths in Indiana were in nursing homes. Looks like they were just trying to do the best with the data they could get, but it's not a great estimate.
So far, there is no good evidence that sars-cov2 causes long term lung damage at higher rates than other respiratory infections.
Several of your links are specifically about pulmonary fibrosis. Its a scary condition that has a zillion potential causes, including viral and bacterial infections of many different kinds, pneumonia of all kinds, environmental pollutants, medications, etc. And of course there is the dreaded idiopathic fibrosis -- that for which there is no identifiable cause. It won't be the least bit surprising if scientists discover that most cases of idiopathic pulmonary fibrosis are actually viral in origin.
And again, there is currently no evidence that sars-cov2 causes pulmonary fibrosis any more often than other viral infections. That might change, and the condition is truly scary, but right now the evidence doesn't justify the scary headlines.
Given the tremendous public health and economic costs of lockdowns, the fear of the unknown (e.g. predicted 2% demographic wide CFR) may have justified the multi-trillion dollar cost, and an unknown number of lives lost, due to lockdowns.
Forced mandatory lockdowns today would be unethical and actually counter-productive. Given our vastly increased knowledge of the highly stratified risk profile of SARS-CoV-2, the public health case cannot be ethically made to forcibly confine the general population to their homes; separating them from their livelihoods, their community, their ordinary healthcare, and their mental and physical wellness routines.
Anyone can always choose to self-isolate based on their own personal risk factors and risk tolerance. Government programs could better support at-risk populations which are self isolating by focusing on the minority of people who are acutely at-risk.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scena...