I'm losing my perspicacity!

[cincinnatus_c]

So here's a hypothesis: a lot of the difference between how COVID is dealt with in the US and how it's dealt with in Canada (and the rest of the developed world) is a result of the fact that governments are not responsible for hospitals in the US like they are in Canada. In Canada, health care is one of the provinces' two main businesses, along with education. The people who run hospitals in Ontario lean more or less directly on the provincial government and are technically public servants of the province. If Ontario hospitals are in crisis, the Ontario government is in crisis. This I assume--am I wrong?--is not the case in the US: if the people who run hospitals in, say, the state of New York (which still has a higher per capita daily infection rate than Ontario does, and way higher per capita daily death rate) think their hospitals are in crisis, that isn't automatically the problem of the New York state government. Naturally the New York state government might take an interest in it, but it's an interest that it can balance against competing interests. The Ontario government, on the other hand, has only one other interest--education--generally taken to be legitimately competing at anything like the same level with its interest in the public health care system. And the way things have played out have gone to show that in the public mind, the interests of health care absolutely and completely trump the interests of education. This does not create, but it does heighten, the problem that "listen to the experts" means listen to the experts on what COVID, specifically, is going to do, whose #1 interest is specifically in what it is going to do to the health care system, and whose most basic particular interest in that lies in what it's going to do to hospitals. (The way "public health" has fallen so completely under the sway of the-COVID-the-whole-COVID-and-nothing-but-the-COVID when the staggering costs of lockdown-type COVID-mitigation strategies in terms of the kinds of things public health people have been calling "social determinants of health" in the last couple of decades--which were expressed in a lot of public health response to the BLM protests of 2020 (and which I heard a bit of coming out of public health people last September, before it was completely overwhelmed, about the importance of getting kids back in school [ETA: and I guess maybe a bit of this is spontaneously emerging in the public consciousness in Ontario in the backlash against the provincial government's do-all-the-wrong-things-but-moreso response to our third wave here])--is pretty ... striking. If you ask me.)

Another hypothesis, which would explain a lot of the difference between American and Canadian public attitudes toward COVID right now: Americans by and large would not take it as given, like Canadians seem to be currently assumed to do, that if every patient who shows up at a hospital is not guaranteed the best care the hospital is normally able to provide, then the hospital is in crisis (and therefore the jurisdiction it serves has arrived at its "worst-case scenario").

I have been meaning to say for months and months that I find it astounding that I had heard literally no one suggest (but then the Ontario government did last week) that we ought to immediately begin expanding ICU capacity so that the system has much greater "surge capacity". This seems an obvious solution to a problem that, at root, hinges on the fact that ICUs in Ontario can--it turns out--handle around a thousand people (not a thousand extra people due to an emergency, a thousand people altogether) at any given time out of a population of nearly fifteen million. Of course, the province wants the hospital system to run efficiently. Slack capacity is inefficient--until you need it, and then lack of slack capacity makes your entire society extremely fucking inefficient.

Anyway, thankfully I can write all this here, because almost no one will read it here, which means that almost no one will take me to be making points I don't mean to make, as opposed to the ones I do mean to make, whatever those might be. [ETA: I saw on twitter a while ago some guy addressing the question why he bothers writing a blog when only a few hundred people read it. One thing you learn about a lot on twitter is how vastly different other people's expectations of and for themselves are from your own. Or at least I do, but then I learn about that pretty much everywhere I look, so.] [ETA 2: if you really want to hear something that might make you think I'm making a point I don't mean to make, let me tell you this: as of a couple of months ago, every resident who had ever tested positive for COVID at my father's old folks home and had subsequently died, including people who had been officially counted as "recovered" from COVID, was counted as a COVID death. I have no idea what exactly that might mean, because I have no idea what the baseline death rate in that place is. But I was ... struck by that.]

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Currently under my porch: 0.6. Currently at Belmont Lake: 1. High there today: 7.9, at midnight. If it is not snowing now it will be soon, which will make tomorrow the second "can you believe it's snowing again!" day of the spring so far. U Waterloo first-time-to-20-degrees contest ended April 8 this year, breaking the string of three straight years it ended in May; that's the earliest it has ended since 2012, when it ended on March 16.

Comments

[the_siobhan]

When Darrell was in ICU there were a couple of times where they had to move him to another room because the capacity was overflowing. They put him in the recovery room for outpatient surgery, which was empty at night but during the day it was very loud and shouty.

Mt Sinai was going through renovation at the time and I was under the impression that was reducing their capacity, but the ICU wasn't huge by any means.

[cincinnatus_c]

Yeah, I guess COVID is making a lot of these kinds of things more widely known that had mostly only been known by direct or near-direct experience. The weird thing to me is that that doesn't seem to be producing any general sense of scandal (Ontario can only handle maybe 500 ICU patients more than normal without the system "collapsing"?! ... and we haven't really done anything about that since COVID started?!?!) or urgency to do things differently. Which is sort of the inverse of the COVID-truther take that goes "hardly anyone gets critically ill from COVID so what are we freaking out about?"--it turns out the hospitals can handle hardly anyone getting critically ill from anything before they "collapse", so why aren't we freaking out about that?

[meanwright]

Maybe it's the Cool Ranch Doritos. If you're going to be cool in a crisis, you need the CRDs..it's in the name.

Although I hate Cool Ranch Doritos, I was eating them earlier on in the pandemic, and it helped enormously. The thing that got me angry was the breaking my routine, making my life harder because they were over scared by their own innumeracy and watching too many pandemic movies (which has always been "watching any pandemic movies" in my view).

Of course, for me it was had to decouple the facts about the COVID situation and the work situation. Since I had to move everything on-line, I've basically been making 200 slides a week for a year. And because of student reactions and random format changes, they were one-use. On top of that, there was writing on-line homework (which is basically coding) and tests (writing an on-line test us like slowing writing five regular tests because of the anti-cheating measures; and then the grading is harder). So, I've barely had any time for myself, while simultaneously feeling like the students are doing even less than they normally would. I've been tired and angry for a long time. I didn't realize how tired I was until a month and a half ago when I cycled through to the videos just after the original lock-down in March, and I noticed how much more lively my voice was exactly a year earlier. Freaky and annoying.

I think that because we've done less damage to our country due to decentralization, we have fewer tradeoffs to make now. The places that are most hysterical in the US right now are the places where they over-reacted early and often, hurting people by impeding them from making a living and keeping them from caring for themselves. By giving people as much choice as possible, they feel more in control of their own fate, and they get less scared. That's bad for politicians, that's bad for newspapers, but that's good for us.


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There are public hospitals all over the place in the US, including ones associated with cities and public universities, although there are fewer than there should be because currently operating hospitals have veto rights on bringing new ones in.* Still, it looks like for bed capacity, the number of beds is similar. In Houston, just the Texas Medical center has 1330 beds, normally and another 875 or so surge capacity. And that's mostly university affiliates (although Baylor is private). And there are other hospitals, especially in the suburbs. If we include "Greater Houston" (which has about the same population as Ontario, and the same size and population as MA***), then in addition to the smaller hospitals like the ones around me, there is UTMB in Galveston. It's hard to get a good aggregate number, but you can look at a few tens of percent higher for the entire area (UTMB has 160, the other 70-80 hospitals are smaller entities, and many have none).

But, with a larger area to cover, you'd want to have more capacity in Ontario than in Greater Houston, not less.

The problem with using democratic command allocation of resources over the free allocation of resources is that the command allocation is much more sensitive to hysteria than free allocation. This is especially true right now. For whatever reason, the world is much more hysterical than it used to be -- only it's so hysterical that it's perilous to laugh at it. We react too strongly to the current crisis (and there are several actors for whom there must always be a crisis to exploit), and it's hard for a controlled system to roll back after a crisis because of the concentrated interest problem.

So, if you're in a hysterical country, you don't worry about the costs of your policies or how you're going to pay for them or even if your metric is the right one. If people are still getting sick, everyone has to stay home.

The hysteria has been bad, but I'm glad it's been less hysterical here than elsewhere. Fortunately, many places in the US were able to be reasonable about the lockdowns, able to pick a target (keeping ICU beds available) and modify their actions accordingly. It was nice to see the federal system almost work for once. Certainly, the hysterical elements in our society tried to undermine reasonable accommodations, e.g. read the Times' account of Texas' ICU crisis (where the normal capacity was reached) early on. Rather than actually find out what was happening, they took a reasonable approach and tried to turn it into a crisis, whether through misfeasance (innumeracy) or malfeasance (deliberate misunderstanding) is unknown. They are reporters, after all, and they need a master's degree to do a job that 50 years ago was done by people with a high school diploma.

It is unfortunate that the new regime is using COVID as a cover to get through bad policies (and is spending money it doesn't have). But at least they aren't trying to take over the states' roles.

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* There are far too many of these cartels in US law. For example, if an HBCU has a program that's unique to an area (e.g., a pharmacy school), it can prevent another program from being offered at nearby schools (for most of the country, basically the same city; where population density is high, neighboring cities could be affected; e.g., a school in south Baltimore could block GWU from instituting a program).

*** I could have sworn I made a "**." This is out of order, anyway. This Massachusetts factoid reminds me that we shouldn't be make DC a state. It should be retroceded to Maryland like Arlington was to Virginia, if you want to give them a senator. Delaware, which lacks a raison d'etre, should also be ceded to Maryland because it looks stupid. And, New England should be accreted into a single state. Rhode Island and Connecticut are each smaller than my back yard.

[cincinnatus_c]

Ontario has about twice the population of Greater Houston (and of Massachusetts), 14M+ to 7M+. So, for Greater Houston, the TMC alone has probably more than twice Ontario's per-capita ICU capacity.

I think from Canada it's hard to get a handle on how COVID has been dealt with in the US as opposed to here ... because on one hand, you guys have had way more COVID than we have (and we have more right now, but that's very likely to reverse again over the next month or two as more Canadians get vaccinated and more Americans don't), and you have all these loud anti-masker/anti-lockdown voices (not to mention outright conspiracy loons, which we have a some of too, but not nearly as many I don't think), including governors, but then on the other hand you have all these states with outdoor mask mandates, and this extreme pro-mask, pro-lockdown tribalism among a lot of Democrats. COVID is politically polarized in Canada to an unhelpful degree, but nothing anywhere near how it is in the US--I've had to travel to my father's house in suburban Toronto a number of times during COVID, and I've been somewhat surprised that outdoor mask-wearing has never caught on there (but it helps in Toronto that the restrictions are coming down from a Conservative provincial government that most Torontonians don't like, so I think what political polarization there is is having some paradoxical effects there)--and in Canada we've tended (on this as on many things) to focus on your right pole and ignore the left one.

I suspect that this relative lack of polarization in Canada at least partly explains why government restrictions/mandates seem to make a difference here, while in the US apparently they don't--we're less dug into our pre-existing positions here and more open to taking direction for a perceived common good (though we're maybe not far behind you in that breaking down). On the other hand, from what I see personally, literally no one is actually taking direction from the government beyond what is being enforced ... but the sample of what I see personally is obviously skewed in several ways, so ... ¯\_(ツ)_/¯

I guess if you were gonna go re-dividing states according to some balance between population and area, Texas would be what, five, six, seven states? You'd get lots more senators out of it, but somehow I can't see the Great State of Texas going for that. ;)

[meanwright]

Th differences I'm seeing here are quite interesting:

(1) People who are fully vaccinated in almost empty buildings wearing masks, even after the mandate was lifted.
(2) People who aren't refusing to go into shops that have signage asking people to wear a mask -- even to just get take out.

Both of these sets of people are very conservative (knowing them or overhearing comments). The first group wearing the masks because it's still suggested, even if not "required" (more on that later), the second not willing to violate arbitrary rules, even if they aren't enforced. Following whatever the current guidance is seems to be more a personality thing than a political thing.

To be honest, anything the government didn't enforce, e.g., masks, was honored in the breach. No one was wearing masks, even though it was "required." Except at work or the grocery store. They would wear the masks walking around, but as soon as they sat down, the masks came off so that conversation could ensue-- even though that's probably riskier and creating more risk for others than just walking in, buying some stuff, and getting the fuck out.

I found that people's idea about how bad the pandemic was at any given time was based on how much was being enforced. At the height, in December/January, people actually said "I thought that was over." And for them it was, because they were using a pretty good heuristic: the strength of the restrictions corresponds to the current likelihood that I'll encounter the virus.

Basically, the restrictions were used as a way to determine if the judge or the governor really meant it.

And usually, that's a good heuristic for severity of the infraction.