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I personally think we need a county-by-county approach. There is a high variation of the infection at local levels. All the news is currently about how bad New

I personally think we need a county-by-county approach. There is a high variation of the infection at local levels. All the news is currently about how bad New York is and it's true but we're not all New York. http://www.countycovid19.com/ http://www.countycovid19.com/

ajross 7y ago
It's true that regions are different, but I don't see how that translates. Can you be specific? How would a plan for Queens County, NY differ from one for Waukesha WI, except in trivial stuff like dates? Some outbreaks are smaller, but you'll note that they all leveled off at roughly the same time and on the same schedule. That's because we locked down on "New York's schedule"[1]. If we didn't, these places which seem to have "handled" the outbreak would look like New York. The plans should absolutely be regional in that the lockdown rules should be based on infection rate thresholds, etc... But to do that they all need exactly the same per-capita testing resources. It's the same plan. [1] Really that's not true. We locked down on Seattle's schedule, because they moved first on most things. Seattle had by far the biggest early outbreak, but peaked earlier, peaked lower, and is now one of the better managed areas in the country. Cuomo gets all the attention but it's really Jay Inslee who saved us all.
- bcrosby95 7y ago
  Jay Inslee and the Seattle Flu Study. Without the flu study going against medical guidelines (along with the guidance of the CDC to adhere to those guidelines) and testing some of their samples for COVID-19 (which isn't what they were collected for), Washington's timeline would have been pushed much further back.
- 333c 7y ago
  Don't forget Newsom, who issued the first state-wide shelter in place order. That has been invaluable in keeping California safe(r).
- timr 7y ago
  Different regions have dramatically different population densities, and don't necessarily need shelter-in-place rules. In NYC, shelter-in-place is probably the only feasible way to reduce social interactions when case-count is exploding, but in Boise, where people mostly live in detached housing and drive cars and cases are measured in the hundreds, it might be sufficient to eliminate large gatherings and shut down restaurants. It's not just a matter of thresholds. For all the various politicians are talking about "following the science", there's very little actual science backing up these measures. We're pretty much making it up as we go, and you would be hard-pressed to find "scientific" justifications for most of what we're currently doing.
  - ajross 7y ago
    > don't necessarily need shelter-in-place rules Is there a cite for that? Because that's not the way the data looks. Everywhere was growing with roughly the same exponent before lockdown. The numbers were bigger in NY because it grew longer pre-detection, but there's no reason to believe that everywhere else was any different. Really this disease's growth constant looks shockingly consistent almost everywhere in the world. > It's unclear to me why we're making these policies at a federal level. We... aren't. Literally every existing lockdown regime is being enforced at the state level or lower. For the Boise example you mention, the relevant regulation is a stay in place order from Gov. Little in late March. Edit to show the point better: Go here (easily the best visualization site, FWIW), scroll to the bottom where you can see a log chart of per-capita infection rates normalized to a single "start time" metric, and compare the Idaho chart with the New York one. https://91-divoc.com/pages/covid-visualization/ https://91-divoc.com/pages/covid-visualization/ They are almost exactly the same chart, modulo a vertical offset and a kink in NY data in the second week (which consensus says is the testing backlog finally catching up). If Idaho's detached housing and automobile dependence was reducing its rate of infection spread, it should be visible in the slope of this line. And it clearly isn't.
    - timr 7y ago
      "Everywhere was growing with roughly the same exponent before lockdown." No, they weren't. You're just asserting that this is true. There's effectively no way to know what the doubling rate was in a place like Boise before the national lockdown, because the numbers were in the low single digits: https://covid-19.direct/metro/Boise?tab=glance https://covid-19.direct/metro/Boise?tab=glance But even ignoring that...the site you're linking to shows a wide range of slopes on the per-state graph. You just think they look the same, because the log Y-axis compresses dramatic differences in scale, particularly near the origin. New York, NJ, Michigan and Louisiana are well above the diagonal line, while states like Wyoming, Montana, Vermont, Maine etc. are all well below it.
- djrogers 7y ago
  > except in trivial stuff like dates? Dates are not trivial when people's very livelihoods are at stake.
  - ajross 7y ago
    You know what I meant. You can write the same plan for different regions with parameters. There's no inherent regional interest that requires every county government in the US staff its own disease control department.
toddh 7y ago
Problem is the travel between counties, at least in CA. There's a lot of travel that could cause reinfection.
- bb2018 7y ago
  I'm not too sure reinfection is as important mathematically as some think when you realize the goal will be to operate below a threshold of cases, not eliminate covid entirely.
  - jandrese 7y ago
    The problem is that Covid-19 spreads extremely fast in unprepared populations. It only takes one unaware person to infect hundreds. Check out what happened in South Korea where they had the problem contained until one woman decided to go to church.
    - SpicyLemonZest 7y ago
      The woman went to a very large church, with over 1,000 people in the room. Such large gatherings won't be allowed for a while.
      - macintux 7y ago
        A few religious leaders seem intent on making those large gatherings happen, regardless of prevailing medical and legal advice.
      - jandrese 7y ago
        Churches are usually exempt from the shelter in place rules. Thankfully most are still observing the rules, but it's not because the government is forcing them to.
  - joe_the_user 7y ago
    Reinfection is only unimportant if you don't have a large number of people who are going act to reinfect. If you do have a large number of infections, then of course refection is going to matter. And we do have a large number of cases in the most affected counties. Basically, just like you don't want to overwhelm hospitals, you don't want to overwhelm your contact tracing infrastructure
dickjocke 7y ago
In the live address they said that most implementations will be left to the county and local govts. The state isn't giving any specific guidance on masks, for example, leaving that to specific locales.
- hilbertseries 7y ago
  LA county now requires anyone entering an essential business to wear a mask.
  - ravenstine 7y ago
    Pretty sure that's just the City of Los Angeles, not the county. I haven't been to any grocery stores outside DTLA that required masks. (though 7-11 did)
  - petsormeat 7y ago
    As is Sonoma County, today.
  - clairity 7y ago
    this is probably a little overly cautious relative to the actual reduction in risk (you'd have to be especially unlucky to get infected just from regular breathing in a grocery store), but not terribly unreasonable, particularly for those with co-morbidities. but i routinely see people with masks and gloves on while walking outside. not shopping, or going to shop, just walking. it's so odd, and frankly, wasteful.
    - impendia 7y ago
      > frankly, wasteful. I think I disagree. It seems that face masks are quite effective in reducing the spread of illness. For example, look at the numbers in South Korea, Japan, etc. (where mask-wearing is common) compared to ours. Masks don't need to do 100% of the job -- rather, we would hope that in combination with moderate social distancing, better hygiene, improved testing, etc. we could reduce the rate of transmission. If each infected person spreads the illness to an average of only 0.9 others, then it won't do much more damage. Now, from an economic angle, the US government just passed a $2 trillion stimulus package, which works out to about $6,000 per American. There are calls to spend much more money. Suppose we spend 5% of this on face masks, so $300 per American. Currently, face masks can be bought at $20 for a box of 50 on Amazon. That gets 750 face masks to every American, at a cost that is cheap relative to the other costs of Covid-19. And this is ignoring economies of scale. If the government decided to distribute free face masks in every school, every restaurant, in every theater, etc., then it could produce them at much cheaper than 40 cents each. All in all, it seems like a potentially good investment.
runawaybottle 7y ago
In all sincerity, New York wasn’t Wuhan either. If I were any any other state, I’d absolutely limit travel from NY and screen them.
- joe_the_user 7y ago
  Really? New York current has quite a few times the casualties of all of China (10834 vs 3341) with a small population than Wuhan and the casualties haven't stopped there. New York by itself has one of the high casualty levels in the world by any measure.
  - lhopki01 7y ago
    Higher reported casualty rate.
  - webninja 7y ago
    New York started their business closures and stay at home orders 2 weeks after Seattle and California closed down. That’s why they ended up with so many more cases and deaths than the former two.
    - vkou 7y ago
      New York on lockdown is also busier then Seattle on a regular day. Have you seen any of the photos of the packed subway trains, a week and a half into the lockdown? Seattle doesn't see that sort of thing even in rush hour. Likewise, if you live in a highrise in New York, you're going to be taking the elevator to go get groceries. Usually with other people...
  - djrogers 7y ago
    Any comparison using the officially reported death toll in Wuhan at face value is of no value whatsoever.
    - dsl 7y ago
      Have you been on site in Wuhan? Collected any data? Where can we get a copy?
joe_the_user 7y ago
I live in Nevada County, which apparently has a very low infection rate (34 cases, none in the last week) but if you open this county, what prevents folks from other countries from flooding in and bringing more infection? This county was previous a tourist mecca so it would be especially inviting. But any county that was open would be an appealing destination for the closed counties.
- thaumaturgy 7y ago
  Nevada County is a particularly good example here of one of the failings of a county-by-county approach because Sierra Nevada Memorial Hospital there isn't really equipped to deal with a large number of critical care patients, and neither are many other rural counties. It would take far fewer cases to incapacitate Nevada County's health care infrastructure than Placer County or others to the west.
  - swsieber 7y ago
    > because Sierra Nevada Memorial Hospital there isn't really equipped to deal with a large number of critical care patients That makes me think its sterling example of why we need a county-by-county. Don't just base it on infection levels though, as you pointed out. Include hospital support, ppe levels, interconnectedness, etc.
- jshevek 7y ago
  I see this as an argument for a county-by-county approach in which the specific circumstances of the county are taken into account.
  - rconti 7y ago
    When I turn on the news at night, I don't see the information for the county I intend to visit once it's deemed safe(er) to travel. I see the information for where I live.
    - gnicholas 7y ago
adelHBN 7y ago
Thanks for sharing the link. But how do you enforce stay-at-home policies or any rigorous public health policies, in populated counties that border each other, such as San Francisco and San Mateo counties, or LA and Orang counties.
- SpicyLemonZest 7y ago
  The county health officials would presumably coordinate with each other, as San Francisco and San Mateo are already doing.
  - adelHBN 7y ago
    But to your point, San Mateo is not closing off 280 and 101 to stop S.F. traffic. And the Governor has issued a stay-at-home policy to the San Francisco Bay Area, not just one or two cities. So that's why I think area-wide policies work better than county-by-county policies. We could have San Diego area ban and policy, L.A./OC/San Bernardino, Santa Barbara/Ventura/San Louis Obispo... you get the picture.
    - SpicyLemonZest 7y ago
      Yeah, that makes sense to me. (And presumably the Bay Area is going to keep moving in lockstep as it has been.) It'd just be silly if Tuolumne County had to stay sheltering in place because of conditions in the LA area or something.
    - cmrx64 7y ago
      It was not the _Governor_ who issued those orders in the bay area, it was the local county health officers acting under the authority granted them by the state legislature. This wasn’t some top-down fiat. I am grateful that my local officials have decided to act in solidarity in this instance, but it wasn’t a structurally certain outcome.
- jshevek 7y ago
  I think you are asking specifically about the enforcement issues that derive from neighboring populated counties with different policies? Neighboring counties can and should coordinate to address this, possibly choosing to enforce the same policies even if they have different infection rates, as they did for the initial lockdown in the bay area. This doesn't prevent us from using a county-by-county approach in other areas.
xienze 7y ago
Agree completely, it seems like everyone wants to treat every municipality as NYC, just scaled down. I’d like to see county-by-county assessment, with added common sense restrictions like elderly and sick people self-quarantining, which I think at this point people are familiar and somewhat comfortable with.

ajross 7y ago

It's true that regions are different, but I don't see how that translates. Can you be specific? How would a plan for Queens County, NY differ from one for Waukesha WI, except in trivial stuff like dates? Some outbreaks are smaller, but you'll note that they all leveled off at roughly the same time and on the same schedule. That's because we locked down on "New York's schedule"[1]. If we didn't, these places which seem to have "handled" the outbreak would look like New York. The plans should absolutely be regional in that the lockdown rules should be based on infection rate thresholds, etc... But to do that they all need exactly the same per-capita testing resources. It's the same plan. [1] Really that's not true. We locked down on Seattle's schedule, because they moved first on most things. Seattle had by far the biggest early outbreak, but peaked earlier, peaked lower, and is now one of the better managed areas in the country. Cuomo gets all the attention but it's really Jay Inslee who saved us all.

bcrosby95 7y ago
Jay Inslee and the Seattle Flu Study. Without the flu study going against medical guidelines (along with the guidance of the CDC to adhere to those guidelines) and testing some of their samples for COVID-19 (which isn't what they were collected for), Washington's timeline would have been pushed much further back.
333c 7y ago
Don't forget Newsom, who issued the first state-wide shelter in place order. That has been invaluable in keeping California safe(r).
timr 7y ago
Different regions have dramatically different population densities, and don't necessarily need shelter-in-place rules. In NYC, shelter-in-place is probably the only feasible way to reduce social interactions when case-count is exploding, but in Boise, where people mostly live in detached housing and drive cars and cases are measured in the hundreds, it might be sufficient to eliminate large gatherings and shut down restaurants. It's not just a matter of thresholds. For all the various politicians are talking about "following the science", there's very little actual science backing up these measures. We're pretty much making it up as we go, and you would be hard-pressed to find "scientific" justifications for most of what we're currently doing.
- ajross 7y ago
  > don't necessarily need shelter-in-place rules Is there a cite for that? Because that's not the way the data looks. Everywhere was growing with roughly the same exponent before lockdown. The numbers were bigger in NY because it grew longer pre-detection, but there's no reason to believe that everywhere else was any different. Really this disease's growth constant looks shockingly consistent almost everywhere in the world. > It's unclear to me why we're making these policies at a federal level. We... aren't. Literally every existing lockdown regime is being enforced at the state level or lower. For the Boise example you mention, the relevant regulation is a stay in place order from Gov. Little in late March. Edit to show the point better: Go here (easily the best visualization site, FWIW), scroll to the bottom where you can see a log chart of per-capita infection rates normalized to a single "start time" metric, and compare the Idaho chart with the New York one. https://91-divoc.com/pages/covid-visualization/ https://91-divoc.com/pages/covid-visualization/ They are almost exactly the same chart, modulo a vertical offset and a kink in NY data in the second week (which consensus says is the testing backlog finally catching up). If Idaho's detached housing and automobile dependence was reducing its rate of infection spread, it should be visible in the slope of this line. And it clearly isn't.
  - timr 7y ago
    "Everywhere was growing with roughly the same exponent before lockdown." No, they weren't. You're just asserting that this is true. There's effectively no way to know what the doubling rate was in a place like Boise before the national lockdown, because the numbers were in the low single digits: https://covid-19.direct/metro/Boise?tab=glance https://covid-19.direct/metro/Boise?tab=glance But even ignoring that...the site you're linking to shows a wide range of slopes on the per-state graph. You just think they look the same, because the log Y-axis compresses dramatic differences in scale, particularly near the origin. New York, NJ, Michigan and Louisiana are well above the diagonal line, while states like Wyoming, Montana, Vermont, Maine etc. are all well below it.
djrogers 7y ago
> except in trivial stuff like dates? Dates are not trivial when people's very livelihoods are at stake.
- ajross 7y ago
  You know what I meant. You can write the same plan for different regions with parameters. There's no inherent regional interest that requires every county government in the US staff its own disease control department.

toddh 7y ago

Problem is the travel between counties, at least in CA. There's a lot of travel that could cause reinfection.

bb2018 7y ago
I'm not too sure reinfection is as important mathematically as some think when you realize the goal will be to operate below a threshold of cases, not eliminate covid entirely.
- jandrese 7y ago
  The problem is that Covid-19 spreads extremely fast in unprepared populations. It only takes one unaware person to infect hundreds. Check out what happened in South Korea where they had the problem contained until one woman decided to go to church.
  - SpicyLemonZest 7y ago
    The woman went to a very large church, with over 1,000 people in the room. Such large gatherings won't be allowed for a while.
    - macintux 7y ago
      A few religious leaders seem intent on making those large gatherings happen, regardless of prevailing medical and legal advice.
    - jandrese 7y ago
      Churches are usually exempt from the shelter in place rules. Thankfully most are still observing the rules, but it's not because the government is forcing them to.
- joe_the_user 7y ago
  Reinfection is only unimportant if you don't have a large number of people who are going act to reinfect. If you do have a large number of infections, then of course refection is going to matter. And we do have a large number of cases in the most affected counties. Basically, just like you don't want to overwhelm hospitals, you don't want to overwhelm your contact tracing infrastructure

dickjocke 7y ago

In the live address they said that most implementations will be left to the county and local govts. The state isn't giving any specific guidance on masks, for example, leaving that to specific locales.

hilbertseries 7y ago
LA county now requires anyone entering an essential business to wear a mask.
- ravenstine 7y ago
  Pretty sure that's just the City of Los Angeles, not the county. I haven't been to any grocery stores outside DTLA that required masks. (though 7-11 did)
- petsormeat 7y ago
  As is Sonoma County, today.
- clairity 7y ago
  this is probably a little overly cautious relative to the actual reduction in risk (you'd have to be especially unlucky to get infected just from regular breathing in a grocery store), but not terribly unreasonable, particularly for those with co-morbidities. but i routinely see people with masks and gloves on while walking outside. not shopping, or going to shop, just walking. it's so odd, and frankly, wasteful.
  - impendia 7y ago
    > frankly, wasteful. I think I disagree. It seems that face masks are quite effective in reducing the spread of illness. For example, look at the numbers in South Korea, Japan, etc. (where mask-wearing is common) compared to ours. Masks don't need to do 100% of the job -- rather, we would hope that in combination with moderate social distancing, better hygiene, improved testing, etc. we could reduce the rate of transmission. If each infected person spreads the illness to an average of only 0.9 others, then it won't do much more damage. Now, from an economic angle, the US government just passed a $2 trillion stimulus package, which works out to about $6,000 per American. There are calls to spend much more money. Suppose we spend 5% of this on face masks, so $300 per American. Currently, face masks can be bought at $20 for a box of 50 on Amazon. That gets 750 face masks to every American, at a cost that is cheap relative to the other costs of Covid-19. And this is ignoring economies of scale. If the government decided to distribute free face masks in every school, every restaurant, in every theater, etc., then it could produce them at much cheaper than 40 cents each. All in all, it seems like a potentially good investment.

runawaybottle 7y ago

In all sincerity, New York wasn’t Wuhan either. If I were any any other state, I’d absolutely limit travel from NY and screen them.

joe_the_user 7y ago
Really? New York current has quite a few times the casualties of all of China (10834 vs 3341) with a small population than Wuhan and the casualties haven't stopped there. New York by itself has one of the high casualty levels in the world by any measure.
- lhopki01 7y ago
  Higher reported casualty rate.
- webninja 7y ago
  New York started their business closures and stay at home orders 2 weeks after Seattle and California closed down. That’s why they ended up with so many more cases and deaths than the former two.
  - vkou 7y ago
    New York on lockdown is also busier then Seattle on a regular day. Have you seen any of the photos of the packed subway trains, a week and a half into the lockdown? Seattle doesn't see that sort of thing even in rush hour. Likewise, if you live in a highrise in New York, you're going to be taking the elevator to go get groceries. Usually with other people...
- djrogers 7y ago
  Any comparison using the officially reported death toll in Wuhan at face value is of no value whatsoever.
  - dsl 7y ago
    Have you been on site in Wuhan? Collected any data? Where can we get a copy?

joe_the_user 7y ago

I live in Nevada County, which apparently has a very low infection rate (34 cases, none in the last week) but if you open this county, what prevents folks from other countries from flooding in and bringing more infection? This county was previous a tourist mecca so it would be especially inviting. But any county that was open would be an appealing destination for the closed counties.

thaumaturgy 7y ago
Nevada County is a particularly good example here of one of the failings of a county-by-county approach because Sierra Nevada Memorial Hospital there isn't really equipped to deal with a large number of critical care patients, and neither are many other rural counties. It would take far fewer cases to incapacitate Nevada County's health care infrastructure than Placer County or others to the west.
- swsieber 7y ago
  > because Sierra Nevada Memorial Hospital there isn't really equipped to deal with a large number of critical care patients That makes me think its sterling example of why we need a county-by-county. Don't just base it on infection levels though, as you pointed out. Include hospital support, ppe levels, interconnectedness, etc.
jshevek 7y ago
I see this as an argument for a county-by-county approach in which the specific circumstances of the county are taken into account.
- rconti 7y ago
  When I turn on the news at night, I don't see the information for the county I intend to visit once it's deemed safe(er) to travel. I see the information for where I live.
  - gnicholas 7y ago

adelHBN 7y ago

Thanks for sharing the link. But how do you enforce stay-at-home policies or any rigorous public health policies, in populated counties that border each other, such as San Francisco and San Mateo counties, or LA and Orang counties.

SpicyLemonZest 7y ago
The county health officials would presumably coordinate with each other, as San Francisco and San Mateo are already doing.
- adelHBN 7y ago
  But to your point, San Mateo is not closing off 280 and 101 to stop S.F. traffic. And the Governor has issued a stay-at-home policy to the San Francisco Bay Area, not just one or two cities. So that's why I think area-wide policies work better than county-by-county policies. We could have San Diego area ban and policy, L.A./OC/San Bernardino, Santa Barbara/Ventura/San Louis Obispo... you get the picture.
  - SpicyLemonZest 7y ago
    Yeah, that makes sense to me. (And presumably the Bay Area is going to keep moving in lockstep as it has been.) It'd just be silly if Tuolumne County had to stay sheltering in place because of conditions in the LA area or something.
  - cmrx64 7y ago
    It was not the _Governor_ who issued those orders in the bay area, it was the local county health officers acting under the authority granted them by the state legislature. This wasn’t some top-down fiat. I am grateful that my local officials have decided to act in solidarity in this instance, but it wasn’t a structurally certain outcome.
jshevek 7y ago
I think you are asking specifically about the enforcement issues that derive from neighboring populated counties with different policies? Neighboring counties can and should coordinate to address this, possibly choosing to enforce the same policies even if they have different infection rates, as they did for the initial lockdown in the bay area. This doesn't prevent us from using a county-by-county approach in other areas.

xienze 7y ago

Agree completely, it seems like everyone wants to treat every municipality as NYC, just scaled down. I’d like to see county-by-county assessment, with added common sense restrictions like elderly and sick people self-quarantining, which I think at this point people are familiar and somewhat comfortable with.