METRO DEATHS | NY area likely to pass 10,000 deaths

Italy's lockdown.

April 3, 2020—On a Zoom chat this morning, someone asked about the future for the U.S. and New York City economy. I suggested that  it depends on how we manage the pandemic at the NY City, State and Federal level.

The number to watch, I said, is the death rate, because by now everyone is aware that the "confirmed cases" number is dependent on how many tests are done. Shortages of testing kits reduce the number of confirmed cases but also, by delaying proper care and isolation, contribute to higher death rates. The number of cases is not a good measure of the outcome of the disease.

Chart 1. Virus Cases by Country, David
Leonhardt, NY Times, March 31, 2020.

Whichever measure we use, the  prognosis for the United States is for the disease to worsen before it gets better.

Let's look first at the number of cases. Did the United States get ahead of the curve between the time that the disease started in China and then spread to Italy? The chart at right, by David Leonhardt in the NY Times on March 31, suggests not.

In fact, by this point in the progress of the virus, China and Italy and even Spain were both doing better based on cases. But this chart is subject to testing bias. If the United States is "not flattening," the reason may simply be that the United States has stepped up the rate of testing.

Deaths in a democratic country are hard to fake or hide. People are paid to track them. A death from the coronavirus follows a gruesome pattern that should now be not hard to diagnose. Population numbers are closely watched. So, horrible though they are, the death rates are "good"  measures of the spread of COVID-19.

Table 2. Top lines, NY Times Upshot 
table, March 27, 2020.

The table at right shows the top seven lines of a table published as an Upshot in the New York Times. As the accompanying text in the story points out, the death rates lag cases, so they are not the best measure of the challenges being faced at the moment in the hospitals.

Because China was ahead of Europe, and Europe has been ahead of the United States, in facing the coronavirus, the Lombardy and Wuhan death rates are worth looking at as a guide to what might happen in the New York City area.

If there is a bias in the death rates in Lombardy and Wuhan, it is probably on the low side:

• Yes, Italy has an unusually elderly population, second in the world after Japan. This would tend to raise the death rates relative to New York — the median age in Lombardy is about 45, whereas it is 38 in New York. But Lombardy numbers may be considerably understated because many deaths that did not occur in hospitals were not counted by the health care reporting system — i.e., they might not have been counted if they occurred where people live, even if they were in nursing homes. 
• The Wuhan numbers may also be undercounted. A classified U.S. report suggests that C.I.A. insiders believe that Chinese cases and deaths from the virus may have been systematically underreported.

What do the death-rate numbers tell us? It is not in the Upshot story, but if the progress of the disease in the New York area matches that of Lombardy, we can expect a death rate of approximately 0.5 per thousand applied to a New York City metro area population of 20 million, or 10,000 deaths.

Chart 2. New York deaths higher than
Lombardy at same point. Upshot,
NY Times, April 3, 2020.

The math is not hard to follow. Lombardy suffered 5,000 deaths, in round numbers. It has half the 20 million population of the New York City Metro Statistical Area.* So one would expect, all else equal, that the New York metro area would end up with double the Lombardy deaths, or 10,000.

Today, April 3, the New York Times published another Upshot chart showing how we are doing on death rates relative to the Lombardy region. It should not make us complacent.

Upshot shows on the chart that the NY City death rate until the last observation has been doubling every two and a half days. It has been on a trajectory well above Lombardy's for a week, until the latest day. Governor Cuomo has noted in his 11 a.m. daily updates a marked improvement in the State trajectory in the last few days. If he is right, it is a breakthrough and he should get credit for it. The Governor's recent moves have improved the odds that the State's hospital system will be able to handle the coming peak load of patients. Meanwhile, we should watch the numbers carefully. It still seems likely that the New York metro area will exceed Lombardy's death rate.

* The NY metro is the statistical area (MSA), not the Combined Statistical Area (CSA), which would add another 3 million people. The NY MSA is composed of four Metropolitan Divisions; one of them is Nassau-Suffolk, two counties that together constitute Long Island as a Metropolitan Division.

MASKS AND BREATHING AIDS | Updated June 2, 2021

June 2, 2021—The Centers for Disease Control has issued mask guidelines that supersede suggestions I posted here a year ago. Here are the latest guidelines: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html.

A Mechanical Ventilator. But we learned that
ventilators are a last resort, because 
intubation has serious risks of its own.

March 21, 2020–New York State Governor Andrew Cuomo today gave an enlightening speech about the COVID-19 challenges stressing the need for masks in the millions, and ventilators, of which the Governor says there are 6,000 in the State and 35,000 are needed. 

(Update October 21, 2020: A survey of more than 200 U.S. mayors earlier in 2020 indicated a shortage of 139,000 ventilators. 

But ventilators are no longer such a priority. Preferred treatment avoids using full-scale ventilators except as a last resort. Ventilators require intubation that is risky. Intermediate equipment such as use of oxygen or sleep apnea machines is less invasive and sometimes works. 

Masks are ranked here according to quality: https://bit.ly/2HmrnUu.)

New York State suffers from a shortage of both
I. Protective Devices (masks and face coverings) and
II. Mechanical Aids, i.e., devices for putting oxygen into the lungs.

This post details these two types of equipment.  This is a lay summary to fill an information vacuum that existed, when first posted, in a field replete with changing and contradictory instructions for hospital staff. If you have a better explanation of any of the equipment that follows, balancing simplicity with precision, or something else to add, please comment or send me a note – john @ cityeconomist.com.

I. PROTECTIVE DEVICES: (A) THE N95 MASK, (B) HIGHER-STANDARD MASKS AND (C) THE CLOTH FACE COVERING. 

A fabric mask is worn by three groups of people: (1) health-care workers and anyone with COVID symptoms, who are expected to wear an N95 mask if they can get them, (2) higher-standard masks for special situations, and (3) lower-standard masks of "cloth face coverings" for people with no symptoms who are in public places.

A. The N95 Mask. The top-quality commonly used working mask in the United States is the N95 mask. The "N" comes from the National Institute for Occupational Health and Safety (NIOSH), which sets standards for protective equipment in the workplace. The 95 references the fact that the mask filters out 95 percent of particulates. 3M makes a lot of them. The higher standard is N99. Availability: The shortage of masks is acute, but this shortage may ease in two weeks and be over (at least in New York State) in three weeks, because the call has gone out to collect and make these masks, and many groups and people are responding. Governor Cuomo of New York has been working on putting millions of masks in hospitals in New York City and the rest of the state. The masks are simple in concept, but the N95 standard requires (1) a tight fit, and (2) a very fine screen, because the coronavirus is microscopically tiny and can get past a casually handled mask. They are easy to put on and are used by both medical staff and patients, mostly to contain any viral infection they have as well as provide a defense against a virus from someone else. Governor Cuomo said that new masks are a priority for hospitals to meet the first waves of patients from their expanded testing.  There is already a shortage of masks in New York City. The N95 masks I have seen are supposed to be used only once (although they can be set aside for a month and then reused safely after the SARS-CoV2 virus has died), but doctors at Brooklyn's Kings County Hospital Center report that because of a lack of masks they have been reusing masks for up to a week, disinfecting them with hand sanitizer between shifts. The masks are relatively cheap to buy (prices have been as low as 80 cents each but, with the pandemic, Governor Cuomo says that he has had to pay as much as  $7 for an emergency order, as state governments have been bidding against one another for them. The Congress should pass a waiver of these masks from President Trump's new China tariffs – perhaps all medical supplies should be exempt from tariffs during a pandemic.

Other related masks are:

• The "N45" Mask. The "N45" mask, referred to in a tweet by Mia Farrow, is fictional. It does not exist.

It would mean a mask that filters out only 45 percent of particulates, which is not very effective. The origin of the "N45" mask reference appears to have been facetious, referencing that our current president is the 45th. Probably a lot of homemade masks for the public (see below) are as low as the N45 standard would be, but no manufacturer would advertise it.

• Masks Comparable to the N95. The equivalents of the N95 masks in Europe are the FFP2 and FFP3 face masks (see Postscript below for a test of the equivalence of the two standards). An Asian standard has been reported, KN95, which also screens out 95 percent of particulates; such masks are widely sold in the United States and have recently been accepted by the FDA as equivalent to N95 masks. (P.S. June 2021: The Centers for Disease Control says that perhaps 60 percent of KN95 masks currently sold in the United States are counterfeit and do not meet NIOSH N95 standards. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html .)

B. Higher-Standard Masks and Respirators.  The NIOSH N99 standard is higher but less commonly used, probably because such a fine screen might be hard to breathe through and might interfere with work. Respirators with Intake Filters: A respirator with a protective intake filter is used to protect a medical staff member working in an area with chemicals or germs.  It looks like a World War gas mask. It typically has a replaceable or cleanable filter. It is not something one sees on COVID patients, but people on the staff of an ICU might prefer to have a respirator with a mechanical filter than a mask. However, it is NOT recommended for the general public, because it may protect the user, but allowing exhalation means that other people are not protected.  Availability: There is no reported shortage of such respirators for a wide variety of uses. They are more expensive than surgical masks. They are bulky and require maintenance and training in use. Many are available online at a wide range of prices. They are not recommended for public use by the Centers for Disease Control: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html.

C. Cloth Face Coverings: Masks for the Public. In Asian countries, 80 percent of the public wear face masks in public. People are convinced that the masks make them safer, and indeed infection rates are much lower than in the West. A mask debate has been raging in the United States. Those who argue that containing the virus means everyone should wear a mask in public have been gaining adherents. One conclusion from the little research that has been done on mask-wearing is that if only 20 percent of the public wears a mask, it won't make much difference, but if 50 percent does, it will make a substantial difference. Masks for the public do not have to fit as tightly or have such a fine screen as the N95 mask. Their purpose is in part to remind people not to keep touching their face. These masks are simpler in design and can be made more cheaply, even homemade. The quality can be high if several layers of filtration are used. It is a good craft project for families. The CDC is now calling them "Cloth Face Coverings" to distinguish them from NIOSH-rated and similar quality masks. Availability. Simple versions of masks can be made by hand. YouTube videos show how; here's a link from the office of Rep. Carolyn Maloney, D-NY12 with ideas.

Resources. Below are some sources of information on creating or collecting masks and other equipment for coronavirus medical personnel, who are the priority at the moment:

• Governments and companies race to make masks for the coronavirus fight (NY Times): https://www.nytimes.com/2020/03/21/business/coronavirus-masks-hanes-trump.html.
• What coronavirus doctors and nurses fighting the pandemic wear (HuffPost): https://www.huffpost.com/entry/nurses-doctors-wear-coronavirus-pandemic_l_5e73bd19c5b6eab779447292. 
• Are homemade masks better than no protection? (Medscape): https://www.medscape.com/viewarticle/927259.
• The Netherlands recalled defective masks made in China, about 600,000 of which had been distributed to local hospitals, the health ministry said. Earlier, Spain and Turkey complained of faulty rapid-testing kits from China. (Medscape): https://www.medscape.com/viewarticle/927259.
• Austria makes masks compulsory as protection debate shifts.
• Four European countries make masks mandatory.
• The crucial missing Coronavirus Protection Guideline https://www.youtube.com/watch?v=hVEVve-3QeM
• How Czech Republic Maintains Low Contagion https://www.youtube.com/watch?v=T2dOs-LhJaQ
• How to make your own mask https://www.youtube.com/watch?v=4FB--BOyTiU

II. MECHANICAL BREATHING AIDS: (A) The Ventilator, (B) Oxygen Tank and mask, (C) CPAP machine, (D) BIPAP and Vapotherm machine.

A. The Ventilator (also called a "medical ventilator" or a "mechanical ventilator") provides breathing assistance to patients for whom providing oxygen is not enough. It's what is required for COVID-19 patients who have a serious case. Unlike previous flu infections, which did not require a ventilator for as long or as many people, the COVID virus can require use of a ventilator for many weeks and for a significant portion of those who are sick. A “ventilator” (mechanical ventilator) is a machine that takes over the work of breathing for a patient with primary respiratory failure due to lung disease or secondary respiratory failure due to central nervous system disease, anesthesia or drug overdose. Ventilators are connected to the patient via an endotracheal tube (“breathing tube”) that is placed in the patient's trachea (“wind pipe”). Ventilators remove carbon dioxide and deliver oxygen to maintain physiologic homeostasis (normal blood pH). Clearly, such a machine requires expertise to operate. New York startups are working hard to develop a simpler ventilator that will be cheaper and easier to use. Availability: Scarce. The cost for a ventilator is about $7,000, but prices vary widely based on location of manufacturer and demand. They are cheaper in China. In New York State some hospitals are already doubling up on ventilators because they are not just expensive but are hard to buy. Governor Cuomo suggested on March 21 that they might be adapted so that two patients can be on one machine, and some innovators are experimenting with more than two. They are also not easy to use and training staff takes time that no one has during the pandemic. If the hospitals are not ready, difficult triage decisions will have to be made. Governor Cuomo has put out a call for all medical ventilators not in use as he seeks to buy more and create more emergency beds. He has also noted that the competitive bidding among the states could be ended by invocation of the Defense Production Act by the President. He has said that the New York hospitals will run out of ventilators in the second week of April, right before Easter. Most recently he has been saying that only 20 (sometimes he says 20-30)  percent of ventilator patients survive. The National Health Service in Britain says that one-third survive. However, of those who survive, a large portion, perhaps one-third, suffer from trauma or scarred lungs or trachea.

B. The oxygen tank doesn't reliably get oxygen to a COVID patient. It is the first mechanical resource for a person who has trouble breathing. But a COVID patient's problems are all the way in the lung, and the oxygen from a tank is is fed through the nose or mouth with plastic tubing, a regulator and a face mask or nasal prongs. The good news is that it is relatively inexpensive ($1,000-$2,500 range) and is relatively easy to learn to use. One of my late uncles had his own oxygen tank for years.  Availability: There seems to be no shortage of oxygen tanks in the United States, or of people who know how to use them, but they are not ideal for treating a COVID patient because the virus finds its way to the lungs. If and when ventilators are scarce, oxygen tanks might have some role.

C. A sleep apnea or CPAP machine blows ambient air into the lung like an oxygen machine. (CPAP stands for "continuous positive airway pressure.") It can be a lifesaver for someone who has breathing problems at night in bed. It has a computer-chip-controlled air flow regulator, a tube and a mask; many models include a humidifier. It is not a substitute for an oxygen tank, which in turn is not a substitute for a ventilator. However, conceivably innovators will be at work adapting equipment where there are shortages of ventilators. (A problem with CPAP machines, as David notes below in a comment, is that the exhale part of the cycle would spew viruses into the air; this would have to be modified.) Some new models might replace an oxygen tank regulator, for example. Meanwhile, it is not an alternative to a ventilator for someone hospitalized with COVID-19. Availability: Too bad the CPAP machine isn't ready yet to replace oxygen tanks or ventilators, because these machines are much less expensive, about $1,000, and are widely available. Reportedly some innovators are working on bridging the gap between the CPAP machine and the oxygen tank, and the CPAP machine and ventilator.

D. BiPAP and Vapotherm machines. When patients with respiratory illness need assistance to breathe, multiple respiratory care options are available before physicians resort to intubation and use of a ventilator—including nebulizers, high flow nasal cannulas and bi-level positive airway pressure (BiPAP) machines. The risk from them again is airborne transmissions to healthcare workers. Vapotherm's high velocity therapy provides mask-free non-invasive ventilatory support," says  the product's website. High velocity/high flow therapy, properly fitted and applied, is associated with a low risk of airborne transmissions. A North Fork, L.I. hospital worker has laid out $10,000 to purchase such a machine for her hospital's ICU. (I have no idea whether the Vapotherm machine does the job and is appropriately priced; I am still trying to find out.)

Three general comments:

• Experimentation with several breathing aids will surely generate gradations that could reduce the excess demand for ventilators.
• For the moment, the challenge is to get something basic to hospitals. Some day maybe engineers who design these products so they are easier to use and designers will make them look better. Maybe they could help make ventilators look less like a gas pump and more friendlier both for the patient and the person who operates it. 
• Meanwhile, the pandemic will provide lots of time for families to experiment with interesting fabrics for their homemade masks and for medical-device people and apparel designers to work together on Zoom to make the look of the business of defeating illness more imaginative.

Postscript 1: The big brands have been stepping up to make the N95 and other masks that are in short supply. LVMH is using a Chinese distributor to order 40 million FFP2 (European standard) for France. https://www.businessoffashion.com/articles/news-analysis/lvmh-to-supply-france-with-40-million-surgical-masks-to-tackle-shortage. 

Postscript 2: Here is a 2009 study comparing the filtration effectiveness of NIOSH N95 and the European-standard FFP2 and FFP3 masks. https://www.ncbi.nlm.nih.gov/pubmed/19261695

Ann Occup Hyg. 2009 Mar;53(2):117-28. doi: 10.1093/annhyg/men086.

Comparison of nanoparticle filtration performance of NIOSH-approved and CE-marked particulate filtering facepiece respirators.

Rengasamy S1, Eimer BC, Shaffer RE.

Abstract

The National Institute for Occupational Safety and Health (NIOSH) and European Norms (ENs) employ different test protocols for evaluation of air-purifying particulate respirators commonly referred to as filtering facepiece respirators (FFR). The relative performance of the NIOSH-approved and EN-certified 'Conformité Européen' (CE)-marked FFR is not well studied. NIOSH requires a minimum of 95 and 99.97% efficiencies for N95 and P100 FFR, respectively; meanwhile, the EN requires 94 and 99% efficiencies for FFRs, class P2 (FFP2) and class P3 (FFP3), respectively. To better understand the filtration performance of NIOSH- and CE-marked FFRs, initial penetration levels of N95, P100, FFP2 and FFP3 respirators were measured using a series of polydisperse and monodisperse aerosol test methods and compared. Initial penetration levels of polydisperse NaCl aerosols [mass median diameter (MMD) of 238 nm] were measured using a method similar to the NIOSH respirator certification test method. Monodisperse aerosol penetrations were measured using silver particles for 4-30 nm and NaCl particles for 20-400 nm ranges. Two models for each FFR type were selected and five samples from each model were tested against charge neutralized aerosol particles at 85 l min(-1) flow rate.

PANDEMIC | Avoiding Layoffs–Wage- or Work-Sharing

Automaker Shutdowns Raise Specter of
Mass Layoffs. How to Head Them Off?

March 19, 2020–The economic disaster threatened by the social distancing required by the COVID-19 pandemic could be exacerbated by widespread corporate layoffs. 

Yesterday, Ford Motor, General Motors and Fiat Chrysler Automobiles agreed to UAW demands to shut down North American plants to prevent the spread of the virus. They  suspended factory operations through the end of March. The closing of auto factories by U.S. automakers could be a sign of what is to come.

To reduce this threat of mass layoffs in the face of the pandemic, the United States might consider a program that has had some success in Europe. 

That is, to enact a Federal and State Wage Sharing program, by which the Federal Government pays for, say, 30 percent of worker salaries during the active period of the coronavirus. State governments could opt to pay for another 30 percent.

President Obama looked at this idea in 2014 but did not implement it. The U.S. Unemployment Insurance system is based on a person being totally laid off. The state unemployment insurance systems provides partial replacement income to such workers. The Austrian and German "short-time working" (Kurzarbeit) programs provide government assistance to workers to allow private employers in a recession to offer their employees a reduction in working hours and pay, in lieu of layoffs.

"Ich war dabei" means
"I was there."

The idea is that instead of laying off 30 percent of workers because orders are not coming in, all workers are retained and their hours are reduced instead of the headcount. The government wishes to avoid the cascading effect of layoffs, as workers without incomes stop spending money in their communities and may lose their work habits and skills, making it harder for companies to start up again in good times.  

The governments support this program by making up some of the difference in salary for the workers, with the possibility of providing full pay for fewer hours if employees are enrolled in training programs during their extra time off. The program offers these advantages:

• The employer is better able to pursue a no-layoff policy by having to pay workers less.
• For example, if the company was planning to lay off 30 percent of the workforce, the same saving might be achieved by shaving 30 percent off the workweek of 100 percent of employees.
• Employees can use the time off to take training, take a vacation, or even pursue a long-postponed personal hobby or startup.
• The government program makes up most or all of the pay loss by the workers. They are paid to stay home.
• This benefits the country by sustaining the incomes of the workers, so that they don't have to cut back spending in their communities.
• As a temporary measure, it benefits the business because it eliminates the cost of recruiting new workers when business picks up again.
• It increases the morale and loyalty of workers to the company, and they are less likely to move away or apply to a competitor or change their occupation.
• By keeping employees on the payroll, the skills of workers are maintained.  

The Austrian short-time program is arranged between the national Chamber of Commerce and the labor unions. They negotiate the types of staff to be covered, the maximum period, conditions for layoffs and the nature of any training programs that will be part of the program.

The German government's program in 2009 budgeted €5.1 billion to replace some of the lost income of over 1.4 million workers, i.e., approximately €3,600 per worker. The program was cited that year in a report by the Organisation for Economic Co-operation and Development (OECD) report, which said that the short-work program had saved nearly 500,000 jobs during the recession.

To recap, the advantages of the program are that it maintains worker skills and buys time for management to determine eventually (if the hard times continue) how many workers they can keep on their payrolls. It encourages managers to decide in favor of retaining workers, and thereby reduces the threat of widespread layoffs. For the duration of the COVID-19 disease, companies could envision a no-layoff policy.  This maintains the stability of corporate paychecks, community incomes and tax payments. By keeping together skilled work groups, it makes recovery easier. 

The program does not solve all the problems presented by the COVID-19 virus, of course. It does not address the problem of maintaining the incomes of those without jobs. It costs money, even if it is limited to the period of the COVID-19 disease. It is only for a short-term recession or a pandemic or a similar catastrophe. It would probably best be administered through state unemployment insurance programs.

Governor Cuomo has said that the numbers of infected people will peak in six weeks, based on the progress of the virus in other countries. So in a best-case scenario, payments in a wage-sharing program would continue for about 10 weeks. If recovery from the disease did not start by May or early June, the program might have to be extended or renewed.

Paul Krugman recommended the Kurzarbeit concept in 2010, noting that Germany's growth rate in GDP was slower than that of the United States, but its employment rate did not fall as much. The employment rate, or employment-to-population ratio, is a more reliable number than unemployment because it doesn't depend on subjective phone surveys of each household member's intent to find a job.

I wrote about the Short-Time Working program (Kurzarbeit) in March 2014. This "Wage-Sharing" proposal is similar to the "Work-Sharing" program outlined in a June 2014 Brookings report, Encouraging Work Sharing to Reduce Unemployment, by Katharine G. Abraham (University of Maryland) and Susan N. Houseman (Upjohn Employment Institute). Wage-sharing looks at the spending side for corporations, providing government subsidies for the wages. Work-sharing looks at the arrangement from the perspective of the employees, i.e., sharing the cuts in factory work among all the workers. Two sides of the same coin. 

Abraham and Houseman proposed that the federal government subsidize state work-sharing payments during economic downturns. They suggested making work sharing a requirement for state unemployment insurance systems. They would modify federal requirements for state work-sharing plans that discourage employer participation. They also recommend providing states with adequate funding to administer work-sharing programs. Reportedly more than half of the states have work-sharing plans on the books but they lack adequate federal funding or interest among companies.