Why Kerala matters

It has proven surprisingly difficult to explain regional variations in Covid-19 prevalence. Whenever you find one factor that seems important, a counterexample crops up.

Vietnam is one of the big success stories, with the nation of 97 million people not having reported a single fatality. Even if a few cases were missed, that’s pretty impressive.

But the explanation for that success is over-determined. A young population? Tropical weather? BCG vaccine? Effective test/trace/isolate? Mask wearing? Less obesity? Luck?

The Economist has a new article that discusses two success stories, Vietnam and the southern Indian state of Kerala:

Kerala was the first place in India to be impacted, and its caseload soared in March. But as India’s caseload continued rising rapidly higher, Kerala’s peaked and then began declining sharply. Why?

Like Vietnam, Kerala has a young population, BCG vaccination, and a tropical climate. But so does India! That’s what makes the Kerala story interesting. At the very least, it suggests that public policy (or at least culture) plays an important role:

Kerala’s state government has been similarly energetic, from the chief minister, its top elected official, giving nightly pep talks to village-level committees working to set up public hand-washing stations. Aside from showing logistical efficiency in monitoring cases and equipping its health system, it has also emphasised sympathy and compassion for people affected by the pandemic. The state has mobilised some 16,000 teams to man call centres and to look after as many as 100,000 quarantined people, ensuring they do not lack food, medical care or simply someone to talk to. Free meals have been delivered to thousands of homes, as well as to migrant workers stranded by a national lockdown.

Both Kerala and Vietnam are keenly aware that the danger is far from over. Until there is a vaccine or better treatment, Vietnam will remain on alert, says Mr Pollack. Kerala, for its part, is preparing for a huge influx of expatriate workers returning from the economically battered Arab Gulf countries. More than 300,000 have requested help getting home via a state website.

This last point is important. Migrant workers in places like Singapore and the Gulf have been hit hard by the Covid-19 epidemic, so Kerala is certainly not out of the woods.

Nonetheless, the Kerala example suggests that any explanation of Covid-19 prevalence is likely to be complicated. It’s not that age, climate, and BCG vaccines don’t matter, but lots of other things matter too.

Kerala is not a particularly prosperous place, but it does have India’s highest “Human Development Index“, which looks at things like health, education, extreme poverty, etc. On the other hand, hard hit places like Sweden and Belgium also do well with this index. It’s complicated.

Kerala is what Americans would call a “blue state”. But I wouldn’t make too much of that either, as in America itself many of the blue states have been among the hardest hit. It’s complicated.

But at least Kerala makes things a bit less complicated. It’s not like nothing can be done in a country such as India. There are things that work. Whether other states have the required “state capacity” is another question, but at least we know there are some things that matter.

Off topic: New Zealand has gotten a lot of attention for reducing its active caseload to 45. But there’s another success story that’s less well known. The western 60% of Australia is comprised of three states/territories, with the wildly original names of Western Australia, Northern Territory and Southern . . . oops . . . South Australia. (Why not “Southern”?) They currently have a grand total of 4 active cases in an area about half the size of the USA. And even that figure is falling fast. Yes, this is a thinly populated region. But even so it has almost as many people as New Zealand. If I could get there, I think I’d move to Perth right now. After all, I’m working out of my house in any case. But the Aussies wouldn’t want a disease-ridden American like me.

In 1991, I spend a very enjoyable semester (January – April) on the Gold Coast of Queensland.



50 Responses to “Why Kerala matters”

  1. Gravatar of dtoh dtoh
    17. May 2020 at 18:29

    IMHO, there are a lot of factors that affect transmission, and they can combine exponentially. In a country where a couple of factors are mitigated, transmission rates can drop dramatically.

    Regarding Vietnam, they did a few things that I think we’re significant.

    – Shut their border with China very early on.
    – Conducted aggressive contact tracing.
    – They also shut schools early, (but I’m not sure how much impact that had.)

    Combined with a warm climate and BCG vaccinations, they had very good results despite crowded and not very hygienic dense urban populations.

    I think to understand transmission, you also need to look at random/rare events where one person infects 50 or more other people. That has a huge impact on progression of the epidemic, and can overwhelm the ability to do effective contact tracing and isolation. This seems to have been the cause of the spike in Korea.

    To me Japan is the really interesting case because it has a comparable climate, demographics and economics to places in North America and Europe, and it had sufficiently high community spread and total cases to make contact tracing ineffective, and yet without significant testing and almost no government mandated restrictions, the mortality rate was 1/50th of comparable places, and it appears like it will eradicate the virus (0 new cases in Osaka and only 5 new cases in Tokyo yesterday.)

  2. Gravatar of Mark Mark
    17. May 2020 at 18:56

    All of the Southeast Asian countries seem to have been doing very well. Vietnam gets more attention, but Cambodia is an interesting case too. It also has no deaths and only 122 cases. But back in February, I was constantly reading about how Cambodia was being complacent and how this risked seeding an outbreak (see: https://www.nytimes.com/2020/02/17/world/asia/coronavirus-westerdam-cambodia-hun-sen.html). Cambodia never banned travel from China, never closed its major tourist attractions, and even got praised by Trump on Twitter for allowing a cruise ship to dock that had been turned away by all other countries in the area. Yet Cambodia is doing just as well as Vietnam. I would not be surprised if there were some protective factor common to that part of the world.

  3. Gravatar of Matthias Görgens Matthias Görgens
    17. May 2020 at 20:27

    Dtoh, Japan is indeed an interesting comparison. Most of its climate is quite a lot warmer than most of Europe’s climate, though. But not sure how much of a difference it makes.

  4. Gravatar of Benjamin Cole Benjamin Cole
    17. May 2020 at 21:13


    Something is up with Vietnam. Cambodia and Thailand. COVID-19 is hardly an epidemic in those three countries. Thailand in particular had heavy tourism and business relations with China, about 1 million visitors per month. Myanmar also has very low C10 counts,. Laos has zero reported deaths.

    The extremely low fatality rates in SE Asia suggests previous exposure to C10 or very similar virus.

  5. Gravatar of msgkings msgkings
    17. May 2020 at 21:27

    @Mark: I think you’re onto something here, it seems logical that part of the world would have some resistance to diseases from the same part of the world. Isnt that what we talk about when we say Europeans brought massive disease to the New World, because people there were particularly susceptible to outside disease?

  6. Gravatar of art andreassen art andreassen
    17. May 2020 at 21:50

    Scott: Have you seen Glen Greenwald, The Intercept, May 14, “New Documents From The Sham Prosecution of General Michael Flynn…..”?

  7. Gravatar of Left Outside Left Outside
    17. May 2020 at 23:23

    “Blue State”?!?!? its red. Its literally been run by communists for decades.

    And communists are good at building state capacity in the developing world, much better than liberal or conservative factions. And the communists in Kerala take their social responsibilities seriously.

    Pretty hard to replicate. But the communist developing world has done well handling a pandemic and the capitalist developing world has not.

  8. Gravatar of Mark Z Mark Z
    18. May 2020 at 00:26

    I don’t have access to the Economist, is there publicly available data for all the states in India?

    I’m not yet convinced public policy matters more than luck and circumstance, but I’ll throw a hypothesis out there: maybe there’s an optimal Goldilocks level of what we in the 1st world call ‘development,’ where you have enough will and ability to ‘do stuff’, but are not so ‘developed’ that you have to spend weeks doing paperwork before you can do anything if you’re allowed to do it at all, and then spend months wrapped up in litigation over what you tried to do.

  9. Gravatar of dtoh dtoh
    18. May 2020 at 00:41

    @Matthias Görgens

    Average March Daily High Temperatures (C)

    Sapporo 4
    Frankurt 11
    London 13
    Paris 13
    Tokyo 14
    Osaka 14
    Fukuoka 14
    Madrid 16
    Rome 17

  10. Gravatar of Jason Jason
    18. May 2020 at 01:24


  11. Gravatar of Todd Kreider Todd Kreider
    18. May 2020 at 02:13

    Asia had far fewer H1N1 swine flu deaths in 2009 than the U.S., which had between 9,000 and 18,000 deaths:

    China 660
    South Korea 170
    Japan 100

    Thailand 190
    Malaysia 77
    Vietnam 55
    Taiwan 35
    Philippines 30

    Australia 70 to 170, some say 1,400
    New Zealand 19

    It’s not as if Asians are super geniuses when it comes to virus. Something odd is going on now as it did in 2009/10. The huge discrerpency in recorded Australian deaths and the suspicion that as many as 1,400 may have died from the Swine flu leads one to think that classification has something to do with the wide disparity with the 12,5000 swine flu deaths in the U.S.

    Austrealia with 25 million people, has 2,500 to 3,200 seasonal flu deaths a year while Japan with 125 million has 3,000 seasonal flu deaths a year or about five times fewer. This discrepancy holds up with the U.S. as well. It’s possible Japan counts flu deaths differently but also consider that 40% in the U.S. are obese and 10% are morbidly obese compared to 3% are obese in Japan and well under 1% are morbidly obese. On a per capita basis, the U.S. has 2.5 times as many heart failure patients, who are much more susceptible to the flu. Japan is also much cleaner than the U.S. or Australia.

  12. Gravatar of @dtoh @dtoh
    18. May 2020 at 04:18

    @Todd Kreider

    I can’t speak as well to the other countries in Asia, but my read on Japan is:

    – Universal neonatal BCG vaccinations. There’s good research that it provides protection against other respiratory diseases and a clear correlation with lower mortality from Covid. (Incidentally the percentage of asymptomatic TB carriers among elderly Japanese is relatively high.)

    – Good hygiene (that got even better)

    – Lower average household size so less transmission in families.

    – Japan limited travel from China early on (Japan normally gets more Chinese travelers than any other country.)

    – Aggressive contact tracing.

  13. Gravatar of Michael Rulle Michael Rulle
    18. May 2020 at 05:28

    Japan Today had an interesting essay on their low rate. They immediately dismiss standard tropes like better social distancing etc. The bottom line is they don’t really know why. Several government health officials were quoted who speculated on potential reasons, but all admitted these could not explain the massive difference In deaths between Japan and most of the world. But as we know, it is not just Japan—-it is that entire region (China, HK, Taiwan, S.Korea, Malaysia and Singapore,——plus as Scott has pointed out——Vietnam as well.

    When we compare this to NYC’s 1700 deaths per million it is mind boggling. Queens has the most Chinese and the highest death rate in The US——so I doubt ethnicity has anything to do with death rates.

    Japan has low test rate as well. One official speculated that the real rate of infection could be “10-30” times higher. But no one quoted said the death rate was understated by any significant degree.

    One potential death difference could be how Counting is done. The article in Japan Today did not mention how deaths are counted. We all know of the SanDiego official who lowered deaths from 180 to 5 if the deceased had only Covid 19 with no co-morbidities. Do we know how deaths are counted elsewhere?

    We know the US has the most liberal counting method possible, as does Europe.

    The fact that we do not know this is pathetic. How many journalists and health officials in the world do we have? Just like the world has PPP and Nominal GDP, it would be useful if public health officials tried to at least make estimates based on different methods that are used.

    I have become increasingly more angry rather than curious. I am very curious, but it is hard to not be irritated at how bad the media and the government has performed on the most basic issues on what has worked or not worked. Does anyone believe NYC’s death rate is evidence of shutdown “working” ?

    While Scott has kept politics by and large out of his commentary—-a good thing—-the general media and officials seem to view this entire horror show thru the lense of politics.

    We know next to nothing about this virus.

  14. Gravatar of James Alexander James Alexander
    18. May 2020 at 05:45

    Add in that Kerala had a women, a former science teacher and Communists Party of India (Marxist) as Health Minister. IMO the biggest thing is that the authorities (whether politicians of health experts”) realised early on that “it isn’t flu”. Western European countries ex-Germany just didn’t “get it”.

    It’s a great read too.

  15. Gravatar of Michael Rulle Michael Rulle
    18. May 2020 at 06:38

    Interesting article on reaction to the 68-69 flu in American Institute of Economic Research (Aier.org) on May 1. Similarities and differences.

  16. Gravatar of Michael Rulle Michael Rulle
    18. May 2020 at 06:44

    I support Australia’s desire for an independent “investigation” of what has happened re: Covid 19

  17. Gravatar of Todd Kreider Todd Kreider
    18. May 2020 at 06:48

    @dtoh “– Aggressive contact tracing.”

    I’d say this one is half incorrect. Contact tracing hardly existed in the first weeks apart from Wakayama prefecture, although that likely expanded.

    I think much of the difference in 2009/10 was that the U.S. and Canada significantly increased flu numbers from 2003 by using computer models whereas Asian countries did not and so stuck with pre 2003 flu death counting conventions.

    A CBC article from 2012:

    “For proof of how models keep changing their estimates, look back at Canada’s flu files. More than a decade ago, flu was estimated to kill about 500 to 1,500 Canadians every year. But in 2003 Health Canada changed models, and the estimates jumped to “700 to 2,500 per annum.” The 2,500 deaths at the upper end of that range quickly became the lower end, when an even newer model was tried in 2007, pushing the upper limit to 8,000 based on the severe flu seasons of 1997 to 1999.”

    “Influenza prevention has become an industry fueled by poor science and propelled by conflicted decision makers,” Jefferson said. “This is the significance of the upward creep that you have been witnessing and the chasm that now exists between policy makers and evidence.

    “The proof of what I am saying is in the answer to the question: How many die every year? Answer: maybe 300 or maybe 9,000. We are not sure. If you do not know, how can you have such a costly policy and most of all how can you evaluate it?”


  18. Gravatar of Todd Kreider Todd Kreider
    18. May 2020 at 06:49

    Also from the CBC article:

    “Back then a flu expert told me that the pandemic would be a rare opportunity to check the true death toll from flu, because, for the first time, there was widespread lab testing, a national reporting system, and all eyes were on potential flu-related deaths. The final count: 428 deaths, which is much closer to the seasonal average of around 300 recorded in the vital statistics tables than to the 2,000 to 8,000 deaths estimated for the average flu season by the computer models.

    “So how did the models rate after a real life test? “The predictive models of 2009 of influenza have actually been a complete failure,” respiratory-infection expert Jefferson said.

  19. Gravatar of ssumner ssumner
    18. May 2020 at 08:39

    dtoh, I doubt whether shutting the border with China had any significant effect. The part of China just across the border from Vietnam was also affected only mildly by the epidemic. Guangxi and Yunnan each had only two deaths. So that’s not the issue. (Not to say shutting the border was a bad idea—it was a reasonable precaution.)

    Vietnam did get a number of cases early on, just the like the US. The difference is that while the US allowed a few cases to become 10 million, Vietnam did not. The domestic response was totally different.

    Mark, I agree, and today Cambodia has zero active cases, vs. 60 in Vietnam. Surely that’s an undercount, but if it were a big undercount it would be showing up in lots of new cases.

    msgkings. Well, we know that Wuhan people are highly susceptible!

    Art, The fact that Trump’s buddies don’t get prosecuted by the Feds shows that the US has truly become a banana republic. Do you think they’d refrain from prosecuting your or I if we’d lied to the FBI, just because of other irregularities? Not a chance.

    I’ll take a letter signed by 2000 experts from both parties over a single reporter.

    Left Outside, Yes, that’s why Venezuela is doing so well.

    Mark Z, Before you jump to luck as an explanation, consider the following. If someone had told me that one Indian state did really well and asked me to guess which one, I would have guessed Kerala. There are about 25-30 Indian states. How likely is it luck?

    Todd, This is easy to explain. The US has only a few thousand recorded flu deaths each year. The much bigger number you see in news stories come from models that try to estimate actual flu deaths by multiplying reported deaths by something like 6, to pick up deaths not reported as flu. Perhaps other countries are merely including actual reported flu deaths.

    Michael Rulle, I did some posts about 6 weeks ago arguing this was mostly a white country disease, and couldn’t get anyone interested.

    James, I agree. Readers should keep in mind that “Marxist” in India doesn’t mean the same thing as in China or the Soviet Union.

    Todd, Very good comments on the flu data.

  20. Gravatar of Bill Bill
    18. May 2020 at 08:43

    Southern Australia? You mean like Southern Vietnam? Or New Southern Wales? Or Southern Kensington in London? I could go on…………..

  21. Gravatar of art andreassen art andreassen
    18. May 2020 at 09:38

    Scott: Do you know anything about Glen Greenwald?

  22. Gravatar of Jason Jason
    18. May 2020 at 09:42


  23. Gravatar of Mark Mark
    18. May 2020 at 09:55

    Jason, the Chinese explanation that they destroyed the virus samples for biosecurity reasons shows that the destruction of those samples was at most an example of overzealous regulation, not a nefarious intent to hide anything. In fact, given the possibility of a lab leak, it seems that China is put in a damned-if-you-do-and-damned-if-you-don’t situation: allow such viruses to be widely studied in private labs and get blamed for risking a leak, or restrict such viruses to the most secure facilities and be accused of hiding samples.

    US regulators have also prevented private labs from researching their own tests and only allow facilities to handle these viruses if they meet biosecurity requirements. This is even a plot point in the movie Contagion, where it is portrayed as overzealous regulation rather than intentionally trying to hide anything.

  24. Gravatar of msgkings msgkings
    18. May 2020 at 11:10


    Are they? A lot less than NYC and Milan and Madrid people it seems.

  25. Gravatar of msgkings msgkings
    18. May 2020 at 11:15

    @ssumner again:

    I mean, doesn’t my comment support your ‘white people disease’ comments? Asians perhaps are better at fighting off diseases that originate in Asia. Just like Europeans were resistant to diseases that they brought to the New World.

  26. Gravatar of Todd Kreider Todd Kreider
    18. May 2020 at 13:06

    Scott wrote: “Todd, This is easy to explain. The US has only a few thousand recorded flu deaths each year.”

    Prior to around 2001 to 2003, the U.S. would report flu deaths as low as 500 a year during a mild season.

  27. Gravatar of bb bb
    18. May 2020 at 13:26

    Our views seem to be converging. I’d add that aspects of Japanese lifestyle might be helping as well. Last time I checked, there wasn’t much obesity in Japan.
    I think Kerala is telling in that much of the contact tracing was done without large amounts of testing. They seem to had success simply contact tracing people with fevers, which is adjusting my priors a bit. But they maintained contact with the contacts to ensure they actually quarantined and even provided housing to quarantine where needed.
    I don’t get the sense that much contact tracing is happening where I live.
    I still find Germany to be interesting. WHile they are not having anywhere near the success of Asian counties, they are doing way better than other western countries. And they are opening back up successfully (so far).

  28. Gravatar of Rajat Rajat
    18. May 2020 at 14:19

    And Perth has virtually the same climate as LA, Scott! Average annual temperature of 66F and 8.8 hours of sunshine: https://en.wikipedia.org/wiki/Climate_of_Perth. I personally find Perth pretty insipid, but it’s closer to Asia at least. Where’s Saturos when you need him?

  29. Gravatar of Todd Kreider Todd Kreider
    18. May 2020 at 14:38

    @bb “I still find Germany to be interesting. WHile they are not having anywhere near the success of Asian counties, they are doing way better than other western countries.”

    Germany’s lockdowns weren’t as severe as the rest of Western Europe yet Japan didn’t lockdown at all except social distancing was encouraged several weeks after the virus was there. The result will still be around 7 times as many deaths per capita as in Japan by June.

    3% of Japan is obese compared to 40% of Americans but more importantly, there are fewer than 0.5% morbidly obese (BMI>39) in Japan while there are 10% who are morbidly obese in America.

    (Trump is a svelte obese man with a BMI of 30 or so.)

  30. Gravatar of Mark Z Mark Z
    18. May 2020 at 15:49

    @mdgkings, the distribution of hospitalizations for coronavirus in NYC by race seems to be pretty close to the general breakdown of the city’s population (https://jamanetwork.com/journals/jama/fullarticle/2765184). Asians are modestly underrepresented, but (oddly) whites, blacks, and hispanics are all also slightly underrepresented among hospitalizations, indicating the only group that is overrepresented is people of mixed or unknown race.

  31. Gravatar of dtoh dtoh
    18. May 2020 at 16:31


    “Our views seem to be converging. I’d add that aspects of Japanese lifestyle might be helping as well. Last time I checked, there wasn’t much obesity in Japan.”

    The first time I went to Japan (many years ago now) I took a bus tour of Tokyo for tourists. The tour guide kept talking about our upcoming approach to the National Diet Building. I was curious and when finally we arrived and saw the huge and imposing Diet Building, I finally turned to my Japanese friend and asked “What is the obsession with diets when there aren’t any fat people in this country.”

    Completely agree that contact tracing is very important (especially when numbers are relatively low), but I don’t think testing significantly aids that effort.

  32. Gravatar of Purple Mutt Purple Mutt
    18. May 2020 at 16:38

    I really think it’s just masks.

    Vietnam is fully masked: https://www.cnn.com/videos/travel/2020/05/15/life-after-lockdown-vietnam-lon-orig-tp.cnn/video/playlists/travel/

    So is Kerala (although I don’t know if this held by early April): https://english.manoramaonline.com/news/kerala/2020/04/29/face-masks-compulsory-in-kerala-from-thursday.html

    So is Japan, by the way.

  33. Gravatar of dtoh dtoh
    18. May 2020 at 16:56


    You said…

    I doubt whether shutting the border with China had any significant effect. The part of China just across the border from Vietnam was also affected only mildly by the epidemic. Guangxi and Yunnan each had only two deaths.

    Obviously they also stopped air travel from all of China. I wasn’t just talking about the land border. (Until the shutdown there were half million Chinese air travelers coming into Vietnam….. per month.)

    Vietnam did get a number of cases early on, just the like the US. The difference is that while the US allowed a few cases to become 10 million, Vietnam did not. The domestic response was totally different

    If it was the domestic response that made the difference, how do you explain Japan? Minimal testing. No mandated lock-downs or restrictions.

    I agree, and today Cambodia has zero active cases, vs. 60 in Vietnam. Surely that’s an undercount..

    I’m not so sure. All of the active cases in Vietnam were sick expatriates (or airline) crew who were brought back to VN on repatriation flights and moved immediately to quarantine. There have been zero new domestic cases in Vietnam in over month now. The only difference with Cambodia is that Cambodia doesn’t have the means to bring their ex-pats home.

  34. Gravatar of dtoh dtoh
    18. May 2020 at 17:03

    @purple mutt

    Vietnamese only wear masks when riding on motorcycles to block out the exhaust fumes. Other than that they rarely wear masks except for a few people at the peak of the Corona panic.

    Up until a few weeks ago, there were 15 million daily subway riders in Tokyo not wearing masks.

  35. Gravatar of msgkings msgkings
    18. May 2020 at 17:10


    I meant Asians in Asia, not Asian Americans. I don’t see why this theory isn’t getting more play. Every school book talks about how the main reason the population of the New World was decimated after the Europeans arrived was lack of resistance to their diseases. Seems almost obvious that people in the region of the world where these viruses seem to propagate have more resistance.

  36. Gravatar of Daniel Daniel
    18. May 2020 at 18:24

    Western Australia is like Tatooine, it’s a massive desolate hot and arid place, Perth is one of the most remote cities in the world, being 2100km from Adalaide next closest places are East Timor and Jakarta before Sydney, my friend was staying in a small town in WA for a year, and some days it would get to 50C (122F), though Perth is a little cooler (45C), population density and the ability for the virus to survive for long periods is a must, Wuhan is a temperate humid climate. COVID is not airborne, it travels in water droplets suspended in the air, which wouldn’t survive for 2s in low humidity for very long.

    Again, NZ is also a low density nation with low population, I think trade can actually reveal a lot here, being a country with high demand and supply for tourism or business meetings makes your city more vulnerable to the disease, is it no wonder that New York was hit so hard? Most cases in NZ were linked to a farming conference in Queenstown.

    Western Australia and New Zealand are islands (WA is an island separated by sand), it’s literally easier to row a boat from NZ to Sydney than walk from Perth to anywhere else in Australian really.

    @msgkings You’re looking at it all wrong, immunity comes from existing pathogen in the population of HUMANS, this is a virus from a BAT or some other NON-HUMAN creature. Europeans had resistance from HUMAN pathogens, not European-animal pathogens, some guy in Japan doesn’t magically gain resistance to a pathogen because some guy in Wuhan got sick.

    Eurasians are resistant to Eurasian pathogens because those weak to these pathogens were killed off thousands of years ago…Like Alexander the great, Also note that I said Eurasia because there was enough trade (and war) for the last 4000 years between the east and west that we are probably pathogenically homogeneous, because the black plaque spread through out Eurasia and North Africa, which is why it was only The New World contact that caused epidemics, and not dutch trade with Japan 400 years ago.

  37. Gravatar of msgkings msgkings
    18. May 2020 at 19:25

    @Daniel: Thanks, terrific answer, I appreciate it.

  38. Gravatar of Purple Mutt Purple Mutt
    18. May 2020 at 19:30


    If you watch the linked video, the Vietnamese are clearly wearing masks all the time right now, which is the relevant point.

    Citation needed on your claim that Japan has many unmasked subway riders. The pictures I’ve seen and the stats I’ve heard both point to near-universal mask adoption over the past two months.

  39. Gravatar of dtoh dtoh
    18. May 2020 at 21:02

    Purple Mutt

    I left VN early-March. No one was wearing masks at that time. No one’s wearing them now. There was a one month shut down in April when people were required to wear masks outside, but the epidemic had long since peaked at that point. The CNN video is almost entirely scooter riders, people in special quarantined areas or a short period when the stay at home was first lifted.

    I count everyday in central Tokyo. Mask usage peaked a couple of weeks ago at 80%. Before that it was below 60% for most of March and April. 41 million (commuter train/subway) riders a day in Tokyo times 40% is roughly 15 million unmasked riders per day.

  40. Gravatar of Purple Mutt Purple Mutt
    18. May 2020 at 22:21

    Can you post a picture/video of the subway? Otherwise I don’t believe you.

  41. Gravatar of bb bb
    19. May 2020 at 07:36

    When I first heard about Wuhan back in January, and started doing some reading, contact tracing is what all the pros were talking about. Rather than travel bans, they proposed traveler screenings, followed of course by contact tracing. Over the next few months, I began to adopt the term test and trace, but I agree with you that contact tracing can be done with limited testing, as is shown in S Korea and Germany, my two favorite use cases in that I think we could adopt their practices easily and benefit immediately. Japan is fascinating, but it’s not clear that there is a lesson from Japan to could help us now.
    I do still believe that the lockdowns saved tens of thousands of lives, particularly in large metropolitan areas. I’m personally grateful that we have lockdowns where I live. I also now believe it’s reasonable to start lifting the lockdowns in many/most locations (not mine quite yet), but it would be so much safer if we had contact tracing in place.
    I might also eat more sushi just in case.

  42. Gravatar of Todd Kreider Todd Kreider
    19. May 2020 at 08:24

    bb: “I do still believe that the lockdowns saved tens of thousands of lives, particularly in large metropolitan areas.”

    Any epidemiologist will say, however, that the lives “saved” is only a postponement by six months to a year either because 2/3 would have died anyway this year since so vulnerable or because the virus isn’t going away and will kill most of them in the fall or winter.

  43. Gravatar of ssumner ssumner
    19. May 2020 at 09:09

    Art, Yes. He’s a well known controversial reporter. I don’t care about whether Flynn is treated fairly or not. There are 100,000s of innocent people in jail right now for drug “crimes”. Flynn is just one person, and he is guilty. I care about our entire criminal justice system being perverted by Trump and his henchmen. Do you think I would have been given a pass in the same situation?

    msgkings, Don’t forget that the Wuhan lockdown was vastly more strict than in America or Europe. Read some articles about life in Wuhan during the lockdown.

    There might be a genetic difference, but look at Australia and NZ. And then Chinese areas of NYC (hit hard.) So I’m not convinced. There might also be cultural factors, or BCG vaccine, or more mask wearing.

    Todd, Interesting.

    Rajat, I once washed a rental car in Perth. (Something Greg Mankiw says never happens.) 🙂

    Mark Z. Aha! People like my daughter are the problem. 🙂

    dtoh, I think you missed my point, which explains Japan just as well as the US or Vietnam. All it takes is one case (as in Wuhan) to explode into a million or 10 million, given exponential growth. Sure, if your travel restrictions keep out 100% of cases it works. But if even a few come in it will blow up unless you have good domestic policies/practices, or whatever domestic factors you think explain Japan’s success. In America, 99.999% of cases are coming from domestic transmission, not inbound people. Our policy was to twiddle our thumbs until we had 10,000 domestic cases. If that’s your policy, they you will fail 100% of the time with or without travel bans. We were infected even before anyone contemplated travel bans. The virus was in France in December. If we’d done travel bans a few weeks sooner, we would have reached 10,000 cases a few weeks later, and 100,000 deaths a few weeks later. Who cares?

    Daniel, I once drove from Darwin to Perth, so you don’t need to explain the geography to me. Those are still impressive figures for active caseloads. BTW, almost all transmission occurs indoors, in air-conditioned rooms.

    Todd, The average Covid-19 victim dies about 11 years before they would normally die.

  44. Gravatar of bb bb
    19. May 2020 at 12:02

    I think you are overstating things when you say that 2/3 would have died later this year. I haven’t read anything that supports that large a number. In fact I read somewhere that on average they lose ten years, even if you’re rightthat still leaves 30k people and counting. Also, with lockdowns, we may have overrun the hospitals (run out of ICU beds). In Italy doctors were forced to decide which patients would and would not receive treatment. That is worth avoiding.
    And beyond overwhelming the system, we have also been learning about the virus and how to treat it, putting people on their stomachs, providing oxygen, remidsvir. I predict that the mortality rate will decline over the months. I would much prefer to be hospitalized for Covid this summer than right now or a month ago. Plus, i’ll bet that this summer it will be possible to have visitors. Not dying alone has value to me.
    I have read many interviews of many epidemiologists going back to January, and not one has suggested that the lockdows didn’t save lives. Back in January, several believed we could avoid lockdowns with contact tracing, but none of them argued against lockdowns.
    I’m guessing you don’t live in a large metropolitan area, because there are very few doubters where I live.

  45. Gravatar of bb bb
    19. May 2020 at 12:11

    I think dtoh is right about Japan. THere doesn’t appear to be any explanation for how they are doing so well. My gut says it’s a matter of time, but that’s hard to support.
    @msgking, people in the new world were not killed by novel diseases. THey were killed by diseases that Europeans had been exposed to for centuries.

  46. Gravatar of Todd Kreider Todd Kreider
    19. May 2020 at 13:02

    Scott wrote: “Todd, The average Covid-19 victim dies about 11 years before they would normally die.”

    I’m skeptical considering the study was conducted by a doctor who specializes in orthopedic surgery and sports medicine. Doctors mess us statistics in papers they publish all the time.

    Here is the breakdown of covid-19 deaths in Wisconsin:

    80 to 89…22%
    ——————–54% over 80 with two or three co-morbidities
    70 to 79…16%
    60 to 69…5%
    50 to 59…2%
    40 to 49…1%
    0 to 39….0%

    The breakdown for New York State

    80 to 89…26%
    70 to 79…26%
    60 to 69…20%
    50 to 59…10%
    40 to 49…4%
    30 to 39…1%
    20 to 29…0.4%
    0 to 19….0.0% (11 deaths)

  47. Gravatar of Todd Kreider Todd Kreider
    19. May 2020 at 13:16

    bb wrote: “I think you are overstating things when you say that 2/3 would have died later this year. I haven’t read anything that supports that large a number.”

    That wasn’t me but British epidemiologist Neil Ferguson who gave that estimate.

    Almost no hospitals were overrun in the U.S. except a few in NYC. In Italy, very few hospitals were overrun and the ones the were made the critical mistake of admitting people with mild systems so that when the one with severe systems showed up, they needed to be housed in hallways.

    I don’t know which epidemiologists you have been listening to but the ones I listened to said on the news and on podcasts said that flattening the curve spreads Covid-19 deaths out but does not reduce them. It would be different if there was a vaccine available this year but the odds look very low for that.

    This get complicated because there is Sweden, which didn’t have
    a lockdown but people in Stockholm did stay inside whereas the 90% living outside the capital didn’t change their behavior much.

  48. Gravatar of dtoh dtoh
    19. May 2020 at 16:02

    I’m not sure that true for a couple of reasons.

    1. It’s not a case of infected or not. It’s a question of what is the rate of transmission. If through travel restrictions you can reduce the transmission rate from 1.01 to .99, then you have stopped the spread of the diseases. In the early stages, it’s a lot more dramatic because the percentage of cases originating in foreign countries is much higher, and transmission rates are also much higher when you’re sitting 10 inches away from someone for 12 hours on an airplane.

    2. Even it you don’t stop the spread, the extra weeks buy you all kinds of benefits including: a) the ability to better ramp up contact tracing, b) higher societal awareness of the risk and concomitant increase in voluntary social distancing, c) more time to implement government mandated social distancing, d) better preparation within the health care system, all of which, will reduce the rate of spread as well as total aggregate incidence.

    If you look at mortality rates, the U.S. (and particularly non-NY/NJ) has done reasonably well unless you compare it to places like Japan, Taiwan or Vietnam which have much lower natural transmission rates (because of climate, BCG or whatever.)

  49. Gravatar of bb bb
    19. May 2020 at 16:56

    – “All it takes is one case (as in Wuhan) to explode into a million or 10 million, given exponential growth”
    Everywhere has one case. I think a more valid point is that a big transmission event such as Mardi Gras, that last weekend of going out in NY, mullhouse in france, German skiers in Austria… can have a drastic effect that greatly skews the model. THere is so much left to learn. My goal is to not get covid until we know more. BTW: great discussion.
    First of all, I respect the fact that saw through my statement “I read” as “listened to a podcast”. LOL- you caught me, but saying read makes me feel smarter.
    I don’t recall names of epidemiologists, but listen to a lot of the Vox, NY Times, Tyler Cowan, The Atlantic and some other podcasts. I’ve read a number of interviews in newspapers such as wash post and NY Times. I’ll look up Neil Ferguson, but I’ll need more than one reference to be swayed that 60k of the 90k deaths would have happened in 6 months. But more studies surely will come.
    Most of the epidemioligists I listened to anecdotally talked about their own social distancing experiences. None of them declared that they weren’t social distancing. I haven’t heard any advocating herd immunity. Vaccine is the most appealing solution to latch onto, but you are right that we won’t have it this year and possibly not next. I do believe that we will get better at treating the disease. I think the mortality rate will be lower next year. I also think we will get better at reducing transmission as we learn more, and I think we will eventually have a vaccine. And for those reasons, I think flattening the curve is about more than just spreading out the pain, but also reducing the space beneath the curve. And making the experience for people who have bad cases less horrible whether they live or die is very worthwhile.
    I think you are right about Sweden- I have no doubt that people is dense areas are practicing social distancing on their own. I’d also say that Sweden’s numbers are looking good
    Add in that immunity may only last 12 to 24 months makes me think that herd immunity is a terrible plan. Are you in favor of herd immunity?
    @dtoh, I keep agreeing with you.

  50. Gravatar of dtoh dtoh
    19. May 2020 at 23:53

    Agree about the big transmission event (or super spreader or whatever, people like to call it.) This seems to have also happened in Daegu in Korea, Qum in Iran, and New Rochelle in NY. If you have a small number of cases that’s doubling every 4 or 5 days, one major transmission event skews everything and suddenly pushes the epidemic a month down the curve which can overwhelm contact tracing resources.

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