[thu2111]

That >100% of beds can be occupied with COVID should raise some questions about those stats.

ICU beds are flexible, it's more of a designation than a hard constant. Sweden doubled their ICU capacity in a few weeks without much difficulty back in March. So it's normal for ICU to run near "capacity" because it'd be kind of wasteful if it didn't.

Remember also that "COVID patient" means "patient who tested positive for COVID", it doesn't mean that's the primary thing wrong with them. Hospitals are super-spreading sites, lots of patients turn up for something uninfected and pick up COVID in hospital. So the stats have to be interpreted carefully, even if you accept the premise that poor planning in the hospital system is justification to tell people they can't go outside. Also consider that COVID spreads inside, not out!

[phobosanomaly]

As an alternate perspective, that >100% of beds can be occupied by people with COVID could terrify you. People in gurneys lined up along hallways, PPE running low, overflow tents in the parking lots, nurses WAY over ratio handling more patients than is safe, doctors burned-out and scared.

So, any patient in a hospital that tests positive should be going into a negative-pressure room so that the hospital doesn't become a super spreader event. When you get too many patients, it becomes impossible to actually do that, and it gets kind of scary both for people with non-COVID issues, as well as the staff. Doctors, and nurses, and ER techs, and social workers, and respiratory therapists, and security, and janitors, and radiology techs, and CNAs aren't disposable.

The other issue is that you need doctors and nurses to run the ICU. Critical care physicians and nurses are in high demand all over the country right now, and LA may not be able to double their number of ICU specialist staff on a week-by-week basis.

Sweden has a universal, socialized healthcare system, so they are able to allocate resources nationally based on demand. In the United States, it's a checkerboard of private, nonprofit, and county facilities, each with different structures, policies, health record systems, profit sources, etc. so planning and coordination becomes very complex.

Again, the order does not prevent people from going outside, there is a long, long list of exempted activities in the actual order.

I have turned this problem over in my head a lot, and I really can't think of a good alternate policy approach specific for the highly dense urban setting of LA city proper. I don't have a good answer along the lines of 'this is what they should be doing instead.'

[thu2111]

People in gurneys lined up along hallways, PPE running low, overflow tents in the parking lots, nurses WAY over ratio handling more patients than is safe, doctors burned-out and scared.

'Terrified' is all relative, right? Such things are reported in recent years with nobody panicking like in 2020:

https://www.nbcnews.com/health/health-news/saline-solution-s...

“This is a serious situation and right now we are at the limits of our conservation and adaptation strategy,” said Dr. Paul Biddinger, director of the Center for Disaster Medicine and vice chairman for emergency preparedness at Massachusetts General Hospital in Boston. “We have seen an increase in the number of flu cases compared to last year. If this continues the current trend, we are worried that this will stress our system and make us run out of IV fluids,” added Dr. O’Neill Britton, chief medical officer at Mass General.

https://time.com/5107984/hospitals-handling-burden-flu-patie...

"Hospitals Overwhelmed by Flu Patients Are Treating Them in Tents"

A lot of things that are actually not that alarming and do not cause mass deaths, have been recast this year into apocalyptic end-of-days events that must not be allowed to happen at literally any cost. It's not rooted in anything hard or real, it's to do with the scale of the original projections (which were all wrong).

[phobosanomaly]

Happy to hear your alternate policy proposal.

If you were mayor of the City of Los Angeles, what would you do differently, and what would be your justification to the citizens for your policy?

Do you feel the policy you outlined would be judged to be significantly better than the current policy by the majority of voters of the City of Los Angeles?

If so, how much better, and measured by which metrics?

Do you feel that there would be pushback against your policy by City Council, Public Health Officials, Public Safety Officials, or other key stakeholders?

What would be the risks if your policy was wrong and you had misjudged the situation? What would be your contingency plans?

If your policies are workable, let's get them concisely outlined and email them to some key interest groups so that they can start getting them out to the public and key stakeholders.

Do you have experience in Public Administration and Public Health? If you're an epidemiologist or city official, your credentials will give your policies more weight and your knowledge and experience will be highly valued since it likely takes into account a variety of 'Chesterton's Fences' that a layperson wouldn't have considered.

Even if you have no knowledge of the field, you might have some great ideas.

[thu2111]

Policy proposal in three parts:

1. I'd observe Sweden and follow the actions of Tegnell, as Sweden has had a pretty good pandemic so far.

2. To placate those who are worried I'd focus on raising hospital capacity as much as possible.

3. I'd get a grip on testing. Doctors are all trained not to do indiscriminate testing without any other signs of problems, a lesson that has been forgotten now. I'd end mass testing entirely and focus all testing on people who present with symptoms (this would still be a high level of over-testing because COVID symptoms were worked out by looking at anyone who tested positive so is polluted by a lot of FP noise).

Key metrics are hospital loads and excess deaths. It would be acceptable for the latter to go up by, say, 3x the level a normal flu season would see before starting to impose any population controls.

Pushback: of course there would be. They've all been told by "experts" who know nothing about disease that millions will die unless everyone is locked in their homes right now because exponential growth always lasts forever, don't you know, and they're all terrified of seeming to place anything above health outcomes. But if I were the mayor then they'd ultimately report to me, I guess (I don't live in the US so don't know much about mayoral politics).

The risk if the policy was wrong would be hospitals would get over-full. The contingency plan would be to buy capacity from hospitals in further away regions and invest in rapid buildouts of ambulances, helicopters etc to make it easy to shift capacity around and load balance between hospitals, including to neighbouring regions that disagreed. But I don't think that's likely because we know what happens if you ignore the projections: basically nothing. Look at Swedish all-cause death stats for the year. It'll come in a bit higher than 2018, probably a few percent higher. Nothing important.

W.r.t emailing key interest groups. It's way too far gone for that. People have been proposing rational and sensible alternative plans for the last 8 months, they're all ignored.

I have no experience in public health or epidemiology, thank god. If I did I wouldn't be able to consider alternatives because I'd be a part of the public sector/academic system in which personal reputation as a 'nice guy' or 'clever specialist' is the primary determinant of personal success. I'm much happier in the private sector where what matters is getting results, not the perception of niceness or reasonableness or cleverness.

[phobosanomaly]

Sweden seems to be grappling with the fallout of that approach:

"Health officials in Sweden have warned that intensive care units (ICUs) in and around Stockholm are under severe pressure and close to capacity for the first time during the pandemic."

"Although the city’s hospitals could increase the number of beds allocated to ICUs, there are insufficient specialist staff to support them, said Björn Eriksson, director of Region Stockholm Healthcare."

https://www.bmj.com/content/371/bmj.m4833

Again, placing a gurney in a closet doesn't make it an ICU bed. You need specialized staff, which are in short supply.

Consider the scale as well that you'll be working with as mayor of LA:

The population of the city of Los Angeles proper is 3.8 million, but the population of the greater LA area (19 million) is almost twice the population of the entire country of Sweden (10 million). Los Angeles has to make policy with limited control inside of a very complex environment.

The homeless population of Los Angeles is estimated to be around 66,000 people. That's twice that of the entire country of Sweden.

The state of California, alone, has 40 million people, and open borders with Arizona, a state with nearly the population of Sweden (7 million) and zero state-level mask restrictions.

Los Angeles County is currently seeing 134 deaths per day from Coronavirus, even with California in lockdown.

https://www.latimes.com/california/story/2020-12-16/l-a-coun...

> "The risk if the policy was wrong would be hospitals would get over-full."

This is not the risk. The risk is that thousands of people would die, both from Corona and the fact that hospitals will be closed to all patients Corona or not.

> "They've all been told by "experts" who know nothing about disease that millions will die unless everyone is locked in their homes right now"

300,000 people have died in the United States so far as a result of Coronavirus. People are projecting we might reach a million by the end of 2020. If we continued on the current trajectory that would be an almost certain bet.

> "The contingency plan would be to buy capacity from hospitals in further away regions and invest in rapid buildouts of ambulances, helicopters etc to make it easy to shift capacity around and load balance between hospitals, including to neighbouring regions that disagreed."

Who would pay for this? We have a private healthcare system, not a public one. The City of LA is not in the business of purchasing and operating helicopters for medical use. There is no budget for that. Private companies like Reach handle the overwhelming majority of medvac and transport helicopters in the U.S.. Ambulances are operated by a checkerboard of private companies and City/County fire. We don't have a socialized, universal healthcare system so it's basically impossible to coordinate resources like this. How would you 'buy' capacity? Billing is through private insurance. Would the city agree to pay all costs related to patients in a hospital in another county? I bet the hospitals wouldn't agree to that since it's almost guaranteed they wouldn't get paid.

One thing that limits the ability to transpose Sweden's policies on the United States is the sheer scale here. California is massive. The U.S. is massive. Individual states are the size of whole European countries, they effectively operate as a schengen area with no restrictions on the flow of people, and spotty mask compliance depending on where you are. And forget grand ideas of coordinating from one city or county to the next. Our system is private, and private companies get to do whatever they want. Unless they're going to be well-paid for something, you can bet they're not going to go along with it.

> "I'm much happier in the private sector where what matters is getting results, not the perception of niceness"

I don't know that putting California, and Los Angeles in another lockdown is being interpreted as niceness here. Lots of people are pissed, people are losing their businesses, but many many people are also dying and becoming very ill. Both Newsom and Garcetti are making some very difficult choices to get results.

I genuinely don't mind that you have a different take on the situation. I'm happy to just sit and discuss this stuff.

[thu2111]

Again, placing a gurney in a closet doesn't make it an ICU bed. You need specialized staff, which are in short supply.

You use non-specialised staff, which is what they were willing to do earlier in the year.

I think there's a huge expectations gap that's developed here. It's not just in Sweden, the same can be seen in other countries: doctors are arguing that anything abnormal at all should be justification for sweeping lockdowns. Lockdowns are utterly destructive and evil partly because they relieve the healthcare sector from any expectation to increase capacity. They just say "no we won't" and everyone loses their minds as if that's the last word.

I think frankly we also have to remember that doctors aren't angels. They are ordinary people who can exaggerate, lie or lose perspective like anyone else. For example in Switzerland doctors recently complained to the government that the healthcare system was about to collapse. A few days later the official dashboard added hospital capacity graphs which showed the system was running at 75% load and when COVID patients started turning up outside of ICU, the total number of beds went up to preserve the headroom. 75% load is very low, it's typical for ICUs in other countries to run at 90%+ utilisation even in normal times. So one must ask, how can they be claiming they're stretched past breaking point when there are so many free beds? Either the national statistics are wrong, or they are wrong, or the stats are hiding important details.

From reading an interview with them (in Switzerland) it became clear that there were a few sources of problems:

1. Basically all COVID patients are very, very old. Past the average life expectancy. The doctors were arguing that they had to increase the number of staff per patient because the cases were so "complicated". This can be seen another way: yes, life extension is quite complicated. Of course if you feel like you should battle to extend every life by another six months and there are no limits to how much effort should be made, or how many sacrifices must be made by others, then it will seem like a lot of cases are incredibly complex and only the most specialised staff are acceptable.

2. They were in denial about hospital-caused infections. They even said nosocomial infections were a "taboo topic". Hospitals are by now generating a large fraction of all cases but they weren't discussing how to fix that, they were just ignoring it. Why bother when they can demand society self-destruct at their behest and the government will do it?

3. They weren't discussing how to increase capacity at all. Anyone could come up with a dozen ideas for what to do in a crisis, especially doctors. They weren't interested.

4. Their attitude to the destruction of public life they were creating was simple. It was words to the effect of, businesses can be rebuilt but a life can't be brought back. In other words they don't recognise that tradeoffs in healthcare exist. In fact, most of the businesses they destroy will never come back, they'll be as dead as the patients - and then who will pay the health insurance premiums? The doctors appeared as oblivious to that question as they were to questions of infection control or capacity increases.

The risk is that thousands of people would die, both from Corona and the fact that hospitals will be closed to all patients Corona or not.

How do you figure hospitals would be closed to all people? Are you saying you think the rate of discharge would drop to zero? Why? There are no situations in which hospitals would become closed to "all people", even if they became full. There'd still be a steady stream of discharges and deaths that free up capacity for new admissions.

300,000 people have died in the United States so far as a result of Coronavirus

No they haven't, not even close: they have died with the virus but many of those were simply relabelled.

Look at Sweden: 2020 will have total all cause deaths a few percent higher than previous years once December is counted. It's not a big number for a supposedly deadly global pandemic. A lot of COVID deaths are ambiguous.

Who would pay for this? We have a private healthcare system, not a public one. The City of LA is not in the business of purchasing and operating helicopters for medical use. There is no budget for that.

Are you really going to cite procedural and budget issues when the chosen alternative is to lock people in their homes and totally destroy the tax base? Lockdowns are such a totally extreme policy that basically anything is cheaper and more politically plausible than that.

I mean you're acting like the government paying hospitals for work is totally unthinkable even though the level of borrowing required to pay for lockdowns is astronomically higher than any hospital bill could ever be. Yes! Buy beds in nearby areas where hospital loads are lower! For crying out loud this is an utterly trivial thing to do compared to what's really being done. Lockdowns are perhaps the most expensive form of virus mitigation anyone could ever invent, literally anything is going to be cheaper than that.

As for size, none of my proposals are scale-dependent. I'm not sure why being bigger would matter.

I don't know that putting California, and Los Angeles in another lockdown is being interpreted as niceness here

Amongst the establishment it certainly is. I am 100% certain that Newsom etc are convinced that they're making the moral choice, the "nice guy" choice and if they told the hospital system to do whatever it took to increase capacity but no, we aren't going to lock down, they'd be pummelled from all sides with accusations that they were heartless, cruel monsters who cared only about money.

Sure, for the people on the receiving end it doesn't seem nice but the people making these decisions and pushing for them are all insulated from the effects by government power. No government health officials are getting pay cuts this year.