Heaven is high and the emperor is far away
A long time ago, there were two great kingdoms. The Kingdom of the East was ruled by a cruel emperor. One day, wise men in the center of his great country noticed a threat to the kingdom. They tried to warn the emperor of evil spirits, but local officials stopped them. The threat was not addressed in time and caused great destruction.
The Eastern emperor was unhappy about not receiving the warning, but in reality he was to blame for his misfortune. He had allowed local officials to silence the speech of wise men, and this is why he failed to receive the warning in time to stop the threat.
The Kingdom of the West was ruled by a silly emperor. One day, wise men noticed a threat from afar. Evil spirits were spreading in the Eastern Kingdom, and threatening to invade the West. They tried to warn the emperor, but officials in the emperor’s court and their pet Fox blocked their way. The threat was not addressed in time, and caused even greater damage than in the East.
The Western emperor was unhappy about not receiving the warning, but in reality he was to blame for his misfortune. He had told his officials that he did not like to receive bad news, as he was convinced that he was a great ruler who presided over a happy kingdom.
PS. Good article on Japan:
The other big lesson from Japan is that masks work. Face coverings have been universal there for months, in large part because “Japanese people [already] feel comfortable wearing masks on a daily basis,” as Shigeru Omi, vice chairman of the Japanese government’s expert coronavirus panel, recently explained.
Also the Japanese wash hands often, and don’t hug or shake hands.
And this made me laugh:
But like everything else in the U.S., mask wearing is already becoming politicized and polarized. According to the latest Yahoo News/YouGov poll, a full 87 percent of Americans who voted for Hillary Clinton in 2016 say they will continue to wear a cloth mask in public after lockdown ends; fewer than half as many Trump voters (42 percent) say the same.
Mask wearing is now a political issue? Yup, we’re a banana republic.
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30. May 2020 at 16:30
OT but in the blogpark:
“In Hong Kong, since 1997, all land has become the property of the People’s Republic of China while the government of the Hong Kong Special Administrative Region is responsible for its management, use and development. In other words, every piece of land in Hong Kong (with the sole exception of St. John’s Cathedral, the only freehold property in Hong Kong) is leasehold property .
When the government decides to release land for building it usually does this by selling the land (or ‘parcel’ or ‘lot’) at an auction. ”
Hong Kong recently canceled a land auction as the bids were “too low.” This is in a place where the world’s highest rents pertain.
As the CCP cements its control over Hong Kong, I see mostly bad results. But possibly there will be more property development, somewhat alleviating the property rents young Hongkongers face.
It is a puzzle to see Western economists rhapsodize about free Hong Kong markets when all the property is owned by the CCP.
30. May 2020 at 16:34
I was very much in favor of mask wearing early on precisely because it seemed like Asian countries were having a better time of it and they wear masks. The fact that masks haven’t made any measurable difference in the US is a bit disappointing, though perhaps that’s only because during a lockdown, the places you get new infections aren’t the places you wear masks (eg in your home)(?).
But mostly it’s very disturbing that the scientific consensus went from “masks are at best unhelpful and likely dangerous because you touch your face more and are more likely to ignore social distancing” to “masks are essential” and we got zero additional data to support such a change.
30. May 2020 at 19:33
Scott,
I am still not convinced about how much difference the masks really make. The disease is prone to clustering, which means it’s not spread generically and equally through things that everyone does generically and equally, such as breathing in public. It also spreads usually to people in close sustained contact in situations where people don’t or won’t wear a mask (private events, families, during eating). So they’re worn most often in those situations that are least likely to led to transmission. Conversely, quite a great number of health care stuff even in well-equipped countries have been infected as well, which again means that close and sustained contact with a sick person is a risk, even when wearing maximum protection. And as you observed in a different post, success and failure have happened to countries and places with vastly different policies, including on masks.
Now, masks have got to have some effect at least, so they contribute – but the physical distancing and general hygiene are likely much more effective. And contact tracing, to limit the impact of super spreaders. So I am still suspecting that masks are one of the many blanket measures that have little effect but show that something is being done. We all want to take some action, and when we don’t quite know what to do, we grasp at whatever we have. And for sure they’re a great placebo: cost little, and I myself also feel much safer when wearing one. Psychology works like that.
31. May 2020 at 04:54
The article states: “Japan’s per capita COVID-19 death toll ranks among the highest in the region.”
Japan’s per capita deaths are almost identical with South Korea’s which did a lot of testing.
“Japanese Prime Minister Shinzo Abe, meanwhile, came under intense criticism for trying to bury the problem, and his popularity plummeted as a result.”
This isn’t correct. Kyodo shows the Abe administration had a 48% approval in mid January and mid February, which dropped to 42% in mid May, hardly a “plummet” and much of that is due to his corruption scandal.
“The other big lesson from Japan is that masks work. Face coverings have been universal there for months, in large part because “Japanese people [already] feel comfortable wearing masks on a daily basis,” ”
There has not been universal mask wearing in Japan for months as a poll showed 66% were wearing masks in February and there was later a shortage. That same yougov poll showed 90% mask wearing in South Korea and Taiwan.
Finally, the reason Japan has “slipped into a recession” is because the West is currently in a huge recession. The truth is nobody knows why Japan’s per capita death rate is 1/50th that of America’s despite not testing much, having no lockdowns and the government’s request that people stay home happened after Japan had almost 10,000 coronavirus cases.
31. May 2020 at 06:12
This article in the New England Journal of medicine claims masks are not useful.
“We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.”
https://www.nejm.org/doi/full/10.1056/NEJMp2006372?fbclid=IwAR3ZW0qbRYXqTwbZ3X-4655uqFO3pIr7bOBffRWxs5CML_G2lq-V4dwCb4c
31. May 2020 at 08:07
mbka, Yes, health care workers do get sick, but would they be wearing these masks if they didn’t help? Also keep in mind that asymptomatic people spread the virus, and there is almost universal acknowledgement that sick people who wear masks are less likely to infect others by talking, sneezing etc. So there’s that.
But yes, we need to do 10 things at once, as the successful countries tend to do. Avoid crowds, wear masks in stores, mass testing and tracing, don’t shake hands, social distancing, wash hands, etc., etc.
Do everything and you are likely to succeed.
Brad, You said:
“We know that wearing a mask outside health care facilities offers little, if any”
My sarcasm is not aimed at you, as this is a common view, but come on. How do the viruses floating in the air know whether they are in a hospital or a grocery store? This seems crazy. Almost magical thinking.
31. May 2020 at 08:09
Brad,
thanks. I didn’t know that article but it seems I summarized its main points, unwittingly, above 🙂
31. May 2020 at 09:20
“Also keep in mind that asymptomatic people spread the virus,”
Very rarely. The New England Jnl of Medicine article stated Wuhan showed 1% to 3% who spread coronavirus there were asymptomatic.
31. May 2020 at 11:05
Scott, I believe the point the article in the New England Journal of Medicine I referenced was making was that it takes prolonged exposure to a symptomatic person to spread the virus. Outside of a health care facility your odds of being in such a situation are very low.
I note the WHO is stating the general public does not need to wear masks.
mbka, you nailed it!
31. May 2020 at 12:21
Todd, There’s a great deal of dispute about that. I am not talking about people who are asymptomatic throughout, but rather at the point where they transmit the virus. For symptomatic cases the virus is most transmissible for 3 days before the symptoms appears and then 4 or 5 after symptoms appear.
Brad, I guess I’m not understanding your claim. Is the claim that there’s little risk of catching the virus outside of a medical facility? If not, what is the claim?
Roughly 10 million Americans have contracted Covid-19, surely most of them in settings outside of hospitals.
I must be misunderstanding you, as the claim you are making literally makes no sense to me.
31. May 2020 at 12:22
Brad, Those tens of thousands of migrant workers in Singapore who got sick—did they all catch the virus in hospitals?
31. May 2020 at 12:30
There weren’t thousands of migrant workers who got sick. They tested positive and a fraction were sick.
A study out last week showed almost no one who was asymptomatic spread the virus. I’ll try to find that later.
31. May 2020 at 13:56
Scott, I am not making the claim. The article I linked to in the New England Journal of medicine is. The claim is that spread happens with symptomatic carriers and with prolonged exposure. Wearing a mask out in public does little to prevent spread because you rarely will come in contact with symptomatic carriers for prolonged periods.
Again, the WHO is also saying masks are not needed. I personally hope the science on this proves to be correct because I would prefer to live in a world without masks.
31. May 2020 at 14:31
Scott,
I totally agree with you. Masks are effective. The scientists are (slowly) moving in with your opinion, which was right from the start.
There is now a study from Germany with hamsters (so sweet, hamsters with masks!) which claims that masks also protect the wearer himself, which is also common sense. There we have it again: Your common sense was right from the beginning.
It’s also a pity that no one has praised your analogy tale so far. I think it’s well done. The factual points are (finally) all correct and so are the character descriptions. It would make a nice short story.
31. May 2020 at 17:30
Scott,
I’d like to second Christian List and praise your story. I thought it was very well put. But I was waiting for a punchline somewhat, a conclusion, a moral to the story. What do we learn from those two emperors.
On masks again and including Brad, Todd and Christian. Obviously the virus spreads. The question is, how much do masks help for transient public contacts. The spread is cluster based, although a little less so than for SARS. There was a nice discussion on the significance of this somewhere, which I lost now. Maybe one of the MR links. One of the significant points is that if it’s clusters that are the main driving vehicle, then the key event that needs to be prevented is the jump from cluster to cluster. This is where small local networks (clusters) link to the global network, making the whole thing into a “small world” network. The clusters themselves are produced by close, sustained contact, mask or not. The links are people that attend one local cluster, then go to another. Example, speculating here, a nurse in an Italian hospital picking up the virus and then spreading it to 4, 5 nursing homes he attends as well. While wearing masks, presumably!
Since you mentioned the Singapore foreign worker dorms: the entire spread there, totaling now nearly 30,000 cases, happened after Singapore had already made mask wearing in public mandatory. And it still spreads there even though massive measures are being taken and the problem was known for close to 2 months now. I’m pretty sure those workers have been wearing masks since then too. My conclusion is that once you have a cluster, it is exceedingly hard to contain inside the zone of close prolonged contact, masks or otherwise. So the key is to avoid large cluster formation. These would be produced by mass events, in close sustained contact, such as concerts, sports events and religious gatherings, or gatherings of many people privately. Or mass dorms for that matter. Everyone wearing masks in transient situations does not address this.
So if not masks then what? Preventing potentials for large clusters (size of gatherings, essentially). Preventing small clusters from spreading it to other incipient clusters (preventing families from mixing). Isolating known cases and tracing their contacts.
Therefore, and ad Christian List as well,
no doubt masks produce some benefits, get the R0 down a little, and that is good. I just still am not convinced they produce the key benefit, given the cluster epidemiology described above. Wherever spreads have been contained I doubt masks were key. I’d speculate it was separating local networks so they can’t become “small world” global networks.
31. May 2020 at 18:11
mbka,
I’m not sure you understand what you are talking about. Aren’t all contagious diseases spread in clusters? It’s only common sense that prolonged, close exposure maximizes the risk of infection. But you have events like choir practice where 100+ are infected, clearly not everyone is in close contact with the spreader during that time.
Masks are really good at reducing infection risk- particularly from you to others. But if the risk was low to begin with, clearly a substantial reduction from very low to even more very low is not going to matter much. But why wouldn’t you wear the mask at work or at a meeting or conference, that’s indoors? There it would matter a lot since these are higher risk situations.
31. May 2020 at 18:11
Remember that Japan never shut down businesses
31. May 2020 at 21:34
Anonymous,
no, the spreading pattern of contagious diseases are not all the same. The amount of clustering is expressed by the clustering factor, k. More here – finally found my source: https://www.sciencemag.org/news/2020/05/why-do-some-covid-19-patients-infect-many-others-whereas-most-don-t-spread-virus-all#
The policy consequences of how big a factor clustering is, are large. Quoting from the above article:
and
1. June 2020 at 12:45
1. As other have noted both NE Journal or Medicine and WHO say wearing masks in public is not effective.
2. As I have said many times, there were millions of people riding the subway everyday in Tokyo without masks. With this many people “unprotected” by masks in a crowded environment, masks surely can not be the sole reason Japan has a mortality rate that is somewhere between 1/50the and 1/100th of that in the U.S. and Western Europe.
3. Others have pointed out the deficiencies in the article that you cite, but I would add that the comparison with other Asian countries is totally flawed. The only demographically and climatically comparable country is Korea. Mortality rates are similar between Japan and Korea and when adjusted for age (Korea has a substantially younger population) I suspect the mortality rate is lower in Japan.
I think the only conclusions which you can draw from Japan are…government action or lack of action has very little impact on the course of the disease.
I suspectthe major reason for the lower mortality and incidence in Japan is a higher natural immunity (BCG vaccinations?). Smaller average household size and more hand washing have probably also contributed to the lower transmission rate.
1. June 2020 at 19:55
masks: what kind of masks (cloth masks/scarf) or mid-range medical or PPE used in hospitals? the first type is expected to prevent spread from an infected person, symptomatic or otherwise. whereas the PPE is aimed at preventing the wearer to be infected.
what kind of masks were the japanese masked wearing? were the unmasked infected or not? if they were infected did the others who wear the mask where helped to not-catch the virus? again here what is the optimal % of population that needs to wear a mask to prevent it from becoming spread. Not 100% I think.
as usual the devil is in the details. and it is well nigh impossible to get the details – so one is left to modeling the millions of subway riders in japan – % wearing/non-wearing, age band, immunity levels, infected asymptomatic/infected symptomatic (should not have been riding)/uninfected, what other variables to control?
and for those claiming masks in public isn’t helping: control for no social distancing/lockdown. if you were operating as normal vs self/gov imposed lockdowns + mask. Now since people are more isolated than normal, using the data to say masks aren’t effective is, well irresponsible if not stupid. A walmart that usually sees 1000 footfalls in an hour vs a walmart that sees 100 footfalls and about 50% wearing masks. The remaining 900 footfalls are isolated/spread over temporally/taking other preventive measures (just 1 person instead of an entire family).
2. June 2020 at 04:04
@anon
No question. There are multiple attenuating factors, and the attenuation becomes exponential when you add them together. However, I don’t think you can get to the extreme differences in in the incidence and mortality with the factors that are being bandied about in the media. My gut sense of the numbers is that there has to be some fundamental difference in inherent susceptibility between different populations in order to see the very low rates of transmission, incidence and mortality that you have in Japan, other Asian countries and in some of the East European and Scandinavian countries
2. June 2020 at 10:34
Todd, You said:
“There weren’t thousands of migrant workers who got sick. They tested positive and a fraction were sick.”
How many of the 30,000 infected got sick? You say I’m wrong—prove it.
Brad, You aren’t responding to me. Do you even understand what I’m asking? I’m asking if you are claiming that almost all of the tens of millions who have contracted the virus have done so in hospitals. That claim seems insane.
Christian, Thanks. People usually prefer to respond to my postscript.
mbka, A good story leaves the punchline to the reader’s imagination.
As far as masks, I believe my risk at home is near zero. I feel my risk outside is very, very small. And I feel my risk in grocery stores is small.
So I only wear masks for 10 minutes a week, only in stores. Is that irrational?
dtoh, You said:
“As other have noted both NE Journal or Medicine and WHO say wearing masks in public is not effective.”
Yes, and the “experts” have now changed their minds. The “experts” told us that there was no evidence that masks were effective, when in fact there were many studies in a variety of settings that masks do help. Did the experts lie to prevent mask hoarding, or were they ignorant of these studies?
As I’ve said many times, it’s a mistake to compare countries along a single dimension.
I’ve always argued that a “do everything approach” is mostly likely to work. We should follow the Japanese and wear masks, stop hugging and shaking hands, don’t yell so much, etc.
But also test like crazy. And do challenge studies of vaccines. And work from home where possible. And stop taking cruises until there is a vaccine. Etc., etc.
2. June 2020 at 11:54
Scott,
I mostly agree, but I think people are generally pretty smart and generally do the right things. I think coercion can be counter-productive. There’s a limit to how much people can absorb and act on. Giving people advice on things like masks that turns out later to be wrong or uncertain hurts the credibility of the information source and makes people less likely to listen to other advice that might be right.
I’m not sure testing helps reduce transmission in the short term, but it could help to better understand the transmission mechanism. A small amount of random testing combined with life style surveys could tell us a lot about how the disease spreads. I’m surprised this hasn’t been done.
I’m amazed at the stuff that gets submitted as scientific or academic papers. There are so many glaring errors in methodology as well as just plain muddled thinking. Who pays people to produce this stuff?
2. June 2020 at 12:14
Scott,
And BTW, check out https://www.medrxiv.org/content/10.1101/2020.05.20.20107755v1 for the latest on BCG.
2. June 2020 at 17:56
Scott,
it’s perfectly compatible with rationality if you wear a mask in the store. I do so too (well… it’s mandatory here now). And when I return to the office it will be mandatory too.
From epidemiology patterns however, it would appear that your risk is vastly higher from that single random visit by, say, an old friend from the East Coast having a coffee at your home for 2 h, than the risk from all your store visits in the past 2 months, mask or not. And that matters. I’m not saying masks are bad, I’m saying they likely make people focus on areas where the danger is not coming from.
The Economist has a new article on opinions about mask effectiveness in public, South Korea’s population are about the the firmest believers in masks. Yet they are now having all these cluster outbreaks again, in that one nightclub at first, now in small churches.
Dtoh,
the BCG story might be getting interesting although I don’t quite managed to understand the article yet, this stuff really need to be peer reviewed by real statisticians first. Which answers your question on the quality of papers – public thirsty for information means, a lot of unreviewed fast lane manuscript are seen by the public. And I am still scratching my head as to why the totally unrelated BCG should have an effect.
BTW another puzzling data point on testing. Supposedly Wuhan’s 11 Mio people have now all been tested. No new cases but 300 asymptomatic carriers. That puts a big dent in speculations on abundant asymptomatic carriers.
2. June 2020 at 18:51
@mbka
The thing that gets me is that one would hope peer review is used to pick up subtle errors or omissions, but when you read some of the papers they are so moronic, you wonder how the authors got credentialed in the first place and why the don’t get fired.
Regarding BCG, there’s specific immunity and there’s general immunity. The theory (and it’s actually pretty well accepted) is that at least for certain other types of respiratory diseases, BCG provides generalized immunity. A lot of the immune response may be epigenetic which scientists don’t really understand.
https://www.nature.com/articles/s41577-020-0338-x?proof=true provides some interesting background info.
Not sure what about your point on abundant asymptomatic carriers.
2. June 2020 at 21:36
Dtoh,
thanks for that article, a lot that I did not know about this branch of research. Given they cite a lot of other possible candidate vaccines with possible non specific effects, this now begs the question whether it may have been something else besides BCG to have an effect, if any. This could be any other routine vaccine given together with BCG. I’m also still not quite over the differences between live and non live vaccines. Very hard to make sense of this.
On asymptomatic carriers – in a city as exposed as Wuhan, I would have expected more asymptomatic carriers. Plus, from Benjamin Cole here talking about cruise ships, to anyone invoking herd immunity concepts, those are all based on a lot of people getting exposed, but not necessarily sick. So that low number is puzzling.
2. June 2020 at 23:20
Another piece on superspreading and policy.
https://www.nytimes.com/2020/06/02/opinion/coronavirus-superspreaders.html?action=click&module=Opinion&pgtype=Homepage