Recently I described how I monitor the disease indicators published by government agencies, and how I’ve set a threshold of 6 people hospitalized per hundred thousand residents for deciding when to relax out of “outbreak mode” and eat and sing indoors.  So then, when to go back into outbreak mode and start taking precautions again?

I need to stress again here that I am not a doctor or an epidemiologist.  I’m not qualified to make these decisions, and I wish we had guidance from experts.  Unfortunately, the experts are assuming that everyone cares only about themselves and provide no guidance for people who care whether they pass these diseases on or develop long term conditions.  I do care, so I’m figuring this out as best I can.

Hospitalizations and deaths are trailing indicators: after infection it can take weeks for people to become sick enough to go to the hospital, and longer to die.  That means we need to look at leading indicators like case counts and wastewater concentration.  I’ll talk about wastewater in a future post.

Case counts are less reliable than hospitalizations and deaths, because they depend on the number of tests administered.  As we know, the number of tests dropped precipitously when President Biden declared an end to the State of Emergency and stopped reimbursing for tests. Providers tend to administer tests when they think people might be sick, so if they don’t anticipate infections they may not find them.

Case counts could be inaccurately low, so we should always keep an eye on hospitalizations.  There’s a chance that case counts could be inaccurately high, but if that happens, the worst that could result is that we think an outbreak is more severe and take too many precautions.  Of course, it’s better to err on the side of caution.

So if we’re looking at case counts, what is a good threshold for going into outbreak mode?  This turned out to be a lot more complicated than I thought, but let’s start with the basics and assume that all the data is three weeks old.

I looked at the seven outbreaks we’ve had since the the first wave (when we didn’t have good tests) and found the point when the 7-day average of COVID hospitalizations in New York City went above 6 per lakh per day.  Then I looked at the case rates for the day three weeks earlier:

Outbreak	First day with hospitalizations > 6.2	Cases 3 weeks earlier
Fall 2020	2020-11-10	55.4
Fall 2021	2021-08-03	30.8
Winter 2021	2021-12-01	70.8
Spring 2022	2022-05-01	172.8
Fall 2023	2023-09-05	85.5
Winter 2023	2023-12-14	55.4
Summer 2024	2024-07-12	57.5

As you can see, there’s a fair range of variation.  But let’s pick a rate that’s in the more common range, say 60 cases per lakh population per day.  How much warning would that give us?

Outbreak	First day with hospitalizations > 6.2	First day with cases > 60	Days notice
Fall 2021	2021-08-03	2021-07-18	16
Winter 2021	2021-12-01	2021-11-03	28
Spring 2022	2022-05-01	2022-03-13	49
Fall 2023	2023-09-05	2023-08-02	34
Winter 2023	2023-12-14	2023-11-20	24
Summer 2024	2024-07-12	2024-06-20	22

It looks like anywhere from 2-7 weeks, usually about three weeks, which is basically what we want.  If we see a case rate above 60, that means that the hospitalization rate is likely to go above 6, and may already be above 6.  That’s a sign that it’s time to go into Outbreak Mode.  For me, that means moving karaoke online, avoiding indoor dining and social events, and wearing a mask in all indoor public spaces.

Keep in mind that COVID is only one of many infectious respiratory diseases that can kill or disable.  I chose the rate of 6 hospitalizations per lakh per day because that was what we were prepared to tolerate during the 2018-2019 influenza season.  The hospitalization and death rates we care about are for all these diseases, but flu and RSV are not as well documented as COVID.  Hospitalization rates for flu and RSV are reported nationwide, but the local reports for New York only give absolute numbers for cases and hospitalizations for those diseases.

What I tend do do is to estimate a ratio based on the total case counts for all three diseases, or on the nationwide hospitalization rates.  If RESP-NET is reporting that there are as many flu and RSV hospitalizations as COVID hospitalizations nationwide, I’ll assume that that applies to New York.  If New York’s flu and RSV report shows that there are half as many positive tests for flu and RSV as for COVID, I’ll go into outbreak mode at 40 COVID cases per lakh instead of 60.

Stay tuned for that post about wastewater concentrations!

There are three kinds of attitudes towards the spread of a disease like COVID-19. You can be indifferent to the suffering of others, you can be in favor of eradication, or you can give up. Recently I’ve noticed that more and more of the people I know have given up. At first I was puzzled that so many people refused to talk about our failure to eradicate the disease, but over time I’ve come to understand that this is just what most people do.

First, I want to talk about how we’ve failed on COVID. And when I say “we” I mean all of humanity, but specifically the United States, and more specifically New York State and New York City.

Before I get to our failures, I want to give a nod to our successes. Shutting down non-essential in-person businesses in the spring of 2020 allowed us to “flatten the curve” of hospitalizations. Our hospitals were under severe strain, but we did not get to the point where we needed to use the Javits Center or the Navy hospital ship. After that, the restrictions on indoor dining and avoidance of other indoor in-person activities helped us to keep hospitalizations and even deaths relatively low until the vaccine rollout.

Our record after that has been pretty dismal. Over 800,000 people have died of COVID in the United States since the first vaccine was administered on December 13, 2020, more than twice as many as had died before. Thousands of people have been reinfected with COVID again. Thousands suffer from long COVID. We have failed them.

Our worst failure, of course, is the failure to completely eradicate COVID. We live in an era where humans have eradicated smallpox from the world, eliminated polio and guinea worm from most countries, and are aiming to eliminate malaria and other diseases. We have successfully eliminated the first SARS coronavirus, the cause of the 2002–2004 outbreak, and have made progress against MERS. We had the power to eradicate COVID, and we failed.

I hope that one day we will eradicate COVID, and many of the other diseases that cause misery to humans and other animals on this planet, including diseases that we have not yet encountered. But for COVID, the possibility of eradication gets harder with every new variant.

The result is that many political and institutional leaders have told us we’ll be “living with the virus,” in ways that ensure that thousands will be dying with the virus for many years. The “reopening” of institutions to unmasked indoor activities is a cruel joke to immunocompromised people who are unable to participate. More than a billion people around the world are still unvaccinated or undervaccinated, most through no choice of their own.

What baffled me for months was the inability of almost everyone I know to acknowledge this failure.

Of course, people are plenty willing to acknowledge the failures of others. Here in New York, lots of people are willing to heap well-deserved blame on Donald Trump and his enablers. Some are willing to blame Andrew Cuomo, who deserves at least as much blame, and on other Democrats like Bill de Blasio, Joe Biden, Kathy Hochul and Eric Adams. But I have yet to hear someone acknowledge their own failures.

Remember in 2020 how we were all in this together — wearing masks, socially distancing, getting tested, even washing our hands? Of course, a lot of this was a fiction, but many of us felt like we were contributing to the effort to stop the spread of the disease. I know lots of people who for months, if not years, were diligent about eating outdoors, wearing masks, working from home, avoiding indoor entertainment.

I know some people who have continued to this day with careful measures to avoid spreading COVID. As of this writing, my family and I are still avoiding eating in indoor public spaces, foregoing in-person concerts, and wearing N95-type masks when necessary. But many others just stopped at a certain point. And what struck me was how quietly they all did it.

I’ve seen some people on social media — and on mainstream media, and even in person — announce that they were going to their first party “since COVID,” or maybe attending their first concert or conference, or giving their first interview. Some have even gotten visibly emotional about it, and talked about feeling nervous. But nobody talked about why they decided to start attending parties or conferences, or performing in theaters. Nobody acknowledged that this meant they had stopped taking precautions to avoid spreading COVID.

Some people have parroted the bullshit put out by the Centers for Disease Control and Prevention — that COVID is now “endemic,” and we have to start “living with the disease.” But they pivoted awfully quick from “we have to stop COVID” to “we’ll never stop COVID,” without going through the stage of “we have failed to stop COVID.”

What I eventually figured out — and only recently — is that people just don’t like to admit defeat. Some people are okay with acknowledging setbacks — we’re retreating to the hills, but we will be back! But colossal, catastrophic defeat, the kind that means that a million more people will die, that we may see many thousands die every year for the rest of our lives? That’s something people don’t want to think about.

The key to my understanding this was a Mastodon post I made about the recent fad of Large Language Models. I had noticed a similar pattern: that some people who were typically critical of new technologies had started incorporating LLMs into their work. I posted a critical response to an LLM post from someone I considered a friend, and was shocked that he basically told me to shut up with the criticism.

I recognized this pattern from other trends I’ve studied as well. It reminds me of a scene from Friedrich Dürrenmatt’s play The Visit (Das Besuch der alten Dame), where the character Alfred finds the entire population of his village turning against him. He realizes this when he sees them wearing new shoes, which are yellow, and in most productions of the play they are bright yellow. I’ve never seen the play performed, but my high school English teacher described Alfred seeing first one neighbor wearing yellow shoes, then another, and then looking across the stage and seeing everyone wearing bright yellow shoes. The image has stuck in my mind for decades.

I’ve also been listening to the History of Byzantium podcast, and the recent episodes focus on the capture and sack of Constantinople by the Fourth Crusade. I thought about the people of the city, seeing several emperors killed in quick succession, the harbor filled with Venetian ships, and Frankish knights parading through the streets.

It was too late to flee. What could they do but swear to serve their new lords? And once you decide to serve the new lords, why take the risk of pissing them off by showing insufficient enthusiasm?

In my Mastodon post I compared the new large language model fans to Kent Brockman, the news anchor from the Simpsons who, spooked by a magnified image of an ant crawling across the camera, immediately announces, “I, for one, welcome our new insect overlords.” What I realized recently is that the only thing Brockman does differently from real people is to react a little more quickly.

It’s important for me to acknowledge here that I don’t think that these people gave up fighting the spread of COVID, or the imposition of large language models, because they stopped caring. I think that tomorrow if they thought there was as much chance of eradicating COVID as they thought there was in 2020, they’d mask up again and stop eating in indoor restaurants.

Clearly, they don’t think that wearing a mask again will do much. And they can see that most of our leaders and the institutions they control have come down against eradicating COVID. They’ve gotten their orders from the Centers for Disease Control and Prevention, or from the boss telling them to show up at work in person.

They’ve seen the announcements for in-person conferences and job fairs, with food and drink provided indoors. They don’t want to miss out on those opportunities while less scrupulous competitors take advantage of them.

So why do I care? Why did I expect anything else? Why do I think it’s important to acknowledge failure?

I’ve worked in tech support on and off for most of the past 28 years, either as a direct support technician or as a developer responsible for fixing bugs as they are found. One thing I’ve found to be essential to providing good support is acknowledging and documenting failure. If we don’t understand why we failed, we’re just going to keep making the same mistakes again.

I remember my eighth grade Social Studies teacher telling us how in 1920 the American people were so hungry for “A return to normalcy” that they voted for a cretin like Warren Harding. But he only told us that they craved an end to involvement in World War I; I don’t remember hearing or reading anything about the flu epidemic in that class.

We need to talk about what happened: the people who wanted to sacrifice the vulnerable to preserve their profits organized and won. We need to remember how they did it and figure out how to overcome that. And we need to preserve that knowledge so that the people who are looking out for humanity in the next pandemic can be prepared.

We won’t be able to do that if we continue to live in denial.