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In mid-April, Minnesota Governor Tim Walz said this: “The plan to re-open is very, very clear: Test, trace, isolate and then open back up, and continue this until we get a vaccine.”
At the time, many people in the opposition accused the Governor of moving the goalposts. They said that the original goal of the lockdown had been to "flatten the curve" and ensure that our hospitals were not overwhelmed while we learned more about the virus (and how to fight it). Walz's new goal of test-trace-isolate, they said, had come out of the blue.
Those critics were correct. Gov. Walz's original goal was to mitigate the covid epidemic, not to suppress it through testing and tracing. He was quite explicit about that. (I've been a test-trace-isolate guy from early on, and I was very upset about Gov. Walz's original strategy.) Walz changed his strategy from "mitigate" to "suppress" in mid-April, and I was ecstatic.
This is important, because your overall strategy makes a huge difference in both the final death toll and the timing of mitigation measures. For example, both "flatten the curve" and "test-trace-isolate" may require periods of overall shutdown, but with very different end points.
Under a "flatten the curve" strategy, you impose a lockdown in order to delay the epidemic. You expect everyone to get infected eventually, but you lock down until you have enough medical supplies to absorb the wave. Then you lift the lockdown and let the wave hit, confident that, while a lot of people are going to die, at least they'll have a hospital bed to die in -- and a fighting chance to live.
By contrast, under a "test-trace-isolate" strategy, you impose a lockdown in order to shrink the epidemic, not just delay it. You keep things locked down until you get your active case count down to a manageable level. Then you use large-scale testing, aggressive contact tracing, and stringently enforced isolation periods to bring your few remaining cases down to zero. Then you hold it near zero, using the same containment strategies, until there's a vaccine. (The more tests and tracers you have, the bigger the number you can call a "manageable level" of cases.) This is most often referred to as the South Korean model.
Something interesting about this: in a "test-trace-isolate" suppression strategy, you don't really care too much about what how many hospital beds you have. Your goal is to destroy the epidemic; if you succeed, you won't need that many beds. Likewise, in a "flatten the curve" mitigation strategy, you don't really care about tests and contact tracing; since you're not trying to contain the virus, knowing its progression is helpful but not essential.
On April 9th, Gov. Walz had a decision to make. His initial stay-at-home order was set to expire the next day. He chose to extend it for several weeks, ultimately pushing it out to May 18th. Why did he do this?
When Minnesota first imposed its stay-at-home order, Minnesota had only 235 ICU beds available statewide, and believed that it would need thousands more. Obviously, a delay to get more ICU beds and ventilators was appropriate.
However, by April 9th, when Gov. Walz extended the stay-at-home order, Minnesota expected to need between 2,600 and 4,000 ICU and ventilators beds at peak (in July) -- and it already had 2,770 beds up or ready to go. We also had 2,458 ventilators available. With three months left to create another 1,230 beds, there was no strong "flatten the curve" reason to extend the lockdown. If everyone's going to get it eventually, and you already have enough hospital beds (or you're at least on course to have enough by peak), then staying in lockdown is not just pointless, but damaging. Lockdowns carry extreme economic and social costs. They have to be for an extremely compelling purpose. If our goal was still just to "flatten the curve," then there was no justification, on April 9th, for an extension to the stay-at-home order.
But, you may recall, I was agitating very loudly in early April for an immediate extension of the stay-at-home order into May. That's because my goal was not to "flatten the curve," but to crush it with testing, tracing, and isolating. And, from that strategy's perspective, we were in dire shape on April 9th. We were conducting barely more than 1,000 tests per day (in a state of 5.6 million people), and our testing capacity had plateaued there for over a week. Worse, almost 10% of those tests came back positive. If we really had control of our epidemic, only about 2% of our tests should come back positive.
We had no contact tracers beyond Minnesota's regular contact-tracing staff (equipped for minor outbreaks of HIV or tuberculosis, not this), but over 1,600 cases, with hundreds of thousands of contacts needing tracing. Cases were not at a manageable level. If our goal was to get test-trace-isolate up and running, we had no choice but to extend the stay-at-home order.
Around the same time, the White House endorsed the test-trace-isolate approach with their new CDC opening-up guidelines. The CDC guidelines said that you shouldn't reopen until you have robust testing and a steady 14-day decline in cases in your state. We had neither.
Gov. Walz extended the order in large part to buy us time to get that testing, get that contact tracing, and get us into that 14-day decline in new cases. If his new plan worked, then we would not just be delaying covid-19; we would be defeating it. This was a noble goal that I completely supported.
He should have explained this pivot to the citizens of Minnesota better. Hell, Gov. Walz should have admitted that the pivot existed at all. (He did not, which in turn fed a lot of suspicion of Walz in groups already primed to distrust him, like Reopen Minnesota.) But I thought it was the right call anyway. Based on Minnesota's own modeling at that time (as well as most other models based on actual viral characteristics, not to mention the consensus of epidemiologists), suppressing and containing the virus with testing and tracing could save tens of thousands of lives -- a meaningful fraction of all the lives in Minnesota.
Fast forward to May 13th. That day, Gov. Walz announced that the stay-at-home order would finally end on May 18th, to be replaced by the much more relaxed "Stay Safe MN Phase I" plan. You might think that this was because Minnesota had met the milestones it had to meet for test-trace-isolate to work, and was now ready to face the virus head-on. But you would be wrong.
As of May 13th, Minnesota did not meet any of the test-trace-isolate milestones. In fact, by almost every measure, we were less prepared for test-trace-isolate on May 13th than we were on April 9th!
On April 9th, we'd had 1,600 active cases. On May 13th, we had over 10,000 active cases, far too many to trace effectively, even with an army of tracers. The CDC guidelines said we should reopen after our new case counts had consistently dropped for 14 days; our cases had consistently risen over the previous 14 days!
On April 9th, we knew we were missing a lot of cases, because 7% of the tests we did came back positive (we needed to get that down to 2-3%). On May 13th, despite a huge increase in testing capacity (from 1,600 tests/day to nearly 5,000), our positivity rate had gone up, to 11%! The increase to 5,000 tests/day had been delayed for several weeks, and that was enough for the virus to get out ahead of us again.
Finally, our urgently-needed army of contact tracers was still stuck in the legislature, where "liberty-minded" Republicans were trying to write conscience clauses into the bill in order to make testing optional, even for confirmed contacts! (Any half-decent Catholic would have reminded them that "There is no true freedom except in the service of what is good and just," but more on the Republicans later.)
Meanwhile, we had made even less progress on the "flatten the curve" front. Between April 9th and May 20th, the state's supply of ventilators grew only modestly (to 2,840, with 850 more on back order), and our ramped-up ICU bed capacity appears to have shrunk to 2,385. I didn't track PPE's, so maybe we made big progress there, but I doubt it. I received this note from a friend (and all-around terrific person) who is also a nurse serving on the front lines -- and I'm going to quote it in full:
1. The hard data. Are the numbers going down significantly? No Pretty steady. [Hospital name] continues to have around 50-60 active cases or rule out cases. We have not ended up like New York, however, so I think people believe it is all going to be fine.
2. We really don't KNOW that much about this disease yet. We don't know why some people are asymptomatic carriers and some people die. We know that a person's comorbitities play a part of it but it doesn't explain many of the young, healthy people who have succumbed to this disease.
3. Hospitals are actually NOT that prepared to take care of large volumes of covid patients. Our ICUs are filled with them now despite people quarantining. We have two other hospitals, [hospital you definitely know] and [other well-known local hospital] taking overflow COVID patients. What happens when there are no more beds, no more vents, no more masks for the staff. People start dying a lot faster
4. Nurses are actually NOT well protected. I work on a medical surgical floor so I am not issued an N 95 mask. (I bring my own that my family got for me.) N95s were recommended one time but there are not enough of them so the standards were lowered.
5. Staff at hospitals have not been notified when a coworker has contracted COVID. Even when we have been working closely with that person.
6. Reusing equipment: The nurses that actually GET the N95s are told they have to reuse them. There are NO studies showing how effective they are after many days of use.
7. Reusing gowns: The straw that tipped the camel's back was the new "reusing gowns" standard. The hospital is telling us that when we go in an isolation patient's room we are so step out of the room when we are done and hang the gown in the hall. It doesn't take a microbiologist to tell you that will likely start spreading the germs by contact no matter how careful people are. I am currently refusing to do this and [personal details redacted].
I will have to stop here. Please let me know if you have any questions. I would like to help. I am just not sure how much I should talk about on my facebook page by myself vs with the union because I don't want to lose my job.
Please share it with anyone you want to. Just don’t name me at this point. I’m not fired yet and it’s probably best to keep it that way.
On May 13th, Gov. Walz looked at all these indicators blinking red on his test-trace-isolate strategy, and even at the lack of progress on the original "delay until we have enough supplies" strategy... and he announced that the state would be opening up anyway, in just five days.
On April 9th, we declared war on COVID-19, planning to drive it out of our state. We then spent the rest of April and early May losing that war. On May 13th, Minnesota surrendered.
We are no longer following a test-trace-isolate strategy. We are consciously allowing the virus to begin to grow again, despite the fact that we do not have anything like a manageable case count nor the infrastructure needed to get it there. Our goal is not to contain it, but only to slow it down as it gradually spreads to the entire population. As Gov. Walz put it, "We need to keep this virus at a simmer, not a boil." But, for a few lovely weeks in April, our goal had been to take the virus off the stove altogether.
In short, covid-19 is no longer invading our state. Gov. Walz has accepted it as an occupation force.
There's a lot to mourn here.
First and foremost, we should mourn the people who are going to die under the restored "flatten the curve" strategy that takes us toward herd immunity. In the absence of a vaccine or treatment, herd immunity only develops in one way: mass infection and widespread death. Keeping it to a "simmer" only saves a few lives on the margins, whereas we all hoped that full on testing and tracing could protect the great majority of Minnesotans.
Second, we should mourn the small-business owners of Minnesota who spent April suffering needlessly. We were trying to do something really important throughout the month of April. If we had gotten our testing capacity up faster, if we had gotten case counts to fall, if we had gotten contact tracing set up, we could have scored a huge win for Minnesota's economy by suppressing the virus. But we failed, and now we've given up. The virus won, and that will now have significant economic repercussions, in addition to the major damage done by a month of extra lockdown in pursuit of a failed strategy. While the initial three-week stay-at-home order was essential, as far as I can tell, the enormous sacrifices Minnesota business owners made from April 10th to May 18th were for nothing.
Third, we should mourn the idea of Minnesota. We have a deep-seated idea of ourselves as "the state that works." We understand ourselves to have an unusually functional and responsive state government; our DMV's are not so bad; we balance our budgets (albeit with a lot of sturm und drang most years) in a more-or-less responsible way; our schools score very high on standardized tests; bipartisan cooperation seems unusually high compared to other purple states; and we have a good track record of weathering recessions unusually well.
Many theories have been offered about why Minnesota works so much better than the rest of the country, but most of us agree that Minnesota is an especially competent state -- especially when it comes to medicine. We have the Mayo Clinic! We have Medtronic! We have the U of M's CIDRAP! And we have 3M, which supplies the whole world with PPE! We had every expectation that we would whip this virus into next Tuesday while the rest of the country would struggle to keep up with us. I sure did.
We failed. Abjectly. In terms of tests per capita, deaths per capita, cases per capita, and degree of social distancing, Minnesota is firmly mediocre compared to our sister states. And this mediocrity cost us a victory over a virus we expect to kill 30,000 people. Now we just have to pray that our models are wrong.
So please do mourn. And please do go ahead and hold it against Gov. Walz that he didn't level with us about all this. In April, he moved the goalposts toward testing. In May, he moved the goalposts back and gave up on saving a lot of Minnesotans. In neither case did he acknowledge what he was doing.
Somebody on Facebook asked me, "Well, what would YOU have done in Gov. Walz's shoes?"
"Been honest," I answered.
I think that's important, especially when a governor is building his reputation (as Gov. Walz is) on being a straight-shooter. He's been very good at explaining the things he chooses to explain, yes, and I recognize his schoolteacher appeal. I'd certainly take Walz over Cuomo any day. But, on very broad strategic questions, Walz has been evasive and inconsistent, fueling resentment and resistance that we really can't afford right now.
Except that wasn't really what my questioner was asking, was it? He wanted to know what policy I would have chosen if I had been in Gov. Walz's shoes on May 13th. And... that's a harder question.
After all, surrender is sometimes the best option. It's dumb to keep on fighting when you can't win. When General Lee was cornered near Appomatox Courthouse, he could have turned and fought... but all this would have done is gotten thousands more Confederate and Union boys killed for a war that was already over. Surrender is never easy -- you have to wake up the next morning having lost a war, burying dead soldiers who died for a failure -- but, sometimes, you can't justify any other choice. On the other hand, you must take care not to turn into Steward Denethor, who surrendered out of sinful despair. (I confess I often picture Minnesota's foremost infectious-disease expert, the relentlessly gloomy Dr. Michael Osterholm, with Denethor's visage.) The costs of continuing to fight must be prudently weighed against the potential benefits.
The costs of the stay-at-home order were extreme. We still don't know their full impact, but we can already see that (aside from covid itself) they were the single worst thing to happen to American society since at least World War II. Millions are suffering right now. The consequences of the past two months will reverberate for generations.
Minnesota shouldered these huge costs in hopes of suppressing this disease, partly at my prompting, but, I must be honest: we didn't seem to be making any headway. Despite all our efforts, despite closure and reasonably widespread compliance with social distancing, despite ramp-ups in production, despite close coordination with testing centers, cases were up, positivity rates were up, test numbers were consistently missing our goals, and there was no end in sight.
A test-trace-isolate model requires that the virus be slowed so much that its effective transmission rate (rt) falls below 1 (meaning the average person who catches it infects fewer than 1 other person). According to the U of M's modeling released during the day on May 13th, even with the full lockdown in place, rt was still over 2.2. (This was partly due to lower-than-expected compliance with the order.) At one point last week, Minnesota topped the standings at rt.live, making us the state with the fastest-growing epidemic in the country -- despite setting what seemed to be all the right policies.
Perhaps there was more that could have been done in April and early May to fix this before it was too late. I wasn't in the governor's phone calls with testing centers and production sites, I don't know everything he was privy to. But, faced with the brute fact on May 13th that an extra month of stay-at-home had not gotten us any closer to containment (and had actually taken us further away)... I don't know quite what I would have done.
It takes a lot to convince me to let a lot of people die. But the evidence available to the public on May 13th was pretty strongly indicating that those people were doomed to die anyway, and that every additional day of lockdown was destroying the livelihoods of other people -- apparently, for little reason. I find it hard to be upset with Gov. Walz for abandoning a test-trace-isolate strategy that wasn't working. Would I have given it another week, maybe two, to see whether a little more time would help us turn the corner? I don't know. I never will.
I just know that we surrendered to covid, I know that most of the media are talking around the fact that we surrendered to covid, and I know that I'm crushed about it.
In Other News: I have largely been able to ignore the Republicans in this crisis because, here in Minnesota, they haven't mattered. The Governor is a Democrat and sits at the apex of his enumerated powers due to the emergency. He is protected by a Democrat-controlled State House. Republicans have been mostly sidelined, although they seem determined to neuter the contact-tracing bill.
I don't want to pay them much attention right now, because they're such an embarrassment. I wrote a bit the other day about Sen. Scott Jensen, the shameful senator from Chaska. But it's not just him; it's the entire MN GOP delegation to Saint Paul. And I think we've reached a point where their obstruction and antics are having enough of an effect on Gov. Walz's political calculus that something needs to be said.
The Minnesota GOP has acted like a caricature of Republicans in a comic book, a comic book written by people whose hatred of Republicans is so reflexive it never occurs to them that they're painting villains so cartoonish the readers can't suspend their disbelief in them. It's like Sen. Gazelka read Alan Moore's idea of a Republican and said, "Yes! That is what I should be emulating right now!" The MNGOP's behavior has been infuriating and humiliating and, throughout this crisis, I've never been so grateful for their impotence.
They could have been a force for good, critiquing the governor from the pro-life Right (as I did). Instead, they turned into a bunch of libertarian cranks high on conspiracy theories and Facebook memes spread by angry grandmas, talking about imminent herd immunity and assailing models they don't bother to understand in a vain attempt to justify their rush to reopen everything now. I can hardly believe that the Senate GOP caucus is real, because they are just such a gift to the prejudices progressives have always had about them.
It's truly horrible to watch. I was never a big uppity-up in the MNGOP, but, back in the pre-Trump days, I was a precinct chair, I served on a district's recruiting team, I did some conventions, and I was once a voting delegate to the state convention (the contentious gubernatorial nomination fight of 2014). I wasn't anywhere close to the halls of power, but I was a Republican activist. I was really proud of the MNGOP. And I care about it, even today. But this... derangement... this insistence that we have to both end the lockdowns and avoid taking any actual measures to allow us to control the disease without lockdowns (wearing masks, aggressive contact tracing)... because the whole thing is just a big overblown non-issue we'll cure through hydroxychloroquine and besides we'll have herd immunity in a couple weeks anyway... I know you guys. I know you're not crazy. So why are you acting like this? How is it that, for all my criticisms of his response, Tim Walz is the good guy in this fight?
An Alternative View: My nurse friend tells me that some nurses believe Walz's decision to reopen at this point is something of a fakeout. People -- especially those aforementioned Republicans -- have gotten pretty relaxed about this disease, and perhaps (these nurses suggest) Walz's thinking is that, if he gives into their demands and lifts the stay-at-home order, cases will skyrocket, and the state will be much more prepared to comply with a renewed stay-at-home order.
Personally, I consider this theory unlikely, though not impossible. Walz has acknowledged in the past that the costs of re-imposing lockdown after lifting it would be even more severe than the effects of the first lockdown, and I think he'll be reluctant to do that unless our hospital system is on the brink of collapse. Yet it's interesting enough to share, and I found it particularly interesting that it's a theory that comes from front-line health care workers, who do not seem to share the blithe confidence of Sens. Jensen, Gazelka, et. al.
In any event, by the time cases have increased to a point where a renewed lockdown is politically feasible, true suppression will be completely out of reach. We are truly locked on a herd immunity course now. The only hope I see for test-trace-isolate is if something like "warm summer weather" reduces transmission of the disease so much that it naturally recedes to a point where we can control it. (Or if we've somehow completely misunderstood everything about this virus.) Stay tuned, I guess.
Strategy Notes: When we were trying to crush this disease, my goal was to do everything possible to minimize infection in the greater population. I got very annoyed at people who violated stay-at-home orders.
That's no longer sensible. We are effectively playing a game of Survivor now. ~70% of us are going to get the virus. 30% of us aren't. We're all competing now to be in the 30%.
A week ago, I'd say that the packs of Wisconsin college students rushing out to bars when their stay-at-home order got overturned were selfish gits who were hurting everyone around them. Today, I'm more inclined to thank them. I'm grateful to those kids for removing themselves from the game early, since it makes it easier for me and mine to win. Just don't vote yourselves off the island so quickly that you overwhelm the hospital system, kiddos!
Personally, my current rule is that I only enter sustained close contact (>10 minutes of face-to-face time) with people who can name every node on their social graph. That means, they should know everyone they've been in sustained close contact with during the past two weeks, plus everyone those people have been in contact with, plus everyone they've been in contact with, out to infinity.
Basically, if you can name everyone you've had direct or indirect contact with, and none of them have covid or covid symptoms, then the risk that you are infected is very low. But if you've gone and done something like "gone to work" or "got a Great Clips haircut," there's very little chance you can identify your entire social graph, and a very good chance it's quite large. That's a real risk, and will likely remain so until we are past our biggest peak and approaching herd immunity. I currently expect to continue following this rule through the end of July. But, as with everything, new data may change my plans.
The Good News: This depressing post needed to end on a positive note. Despite our surrender, I think it's important to note that there are still signs that we might weather the covid epidemic better than expected. Deaths in Minnesota have started falling, for no obvious reason. Perhaps Gov. Walz's much-belated response to protect long-term care facilities? Could the warming weather be having more of an effect than we expected? Might Minnesotans choose to continue distancing measures privately, in sufficient numbers to further slow the spread? Could our models just be plain wrong? There's still a lot we don't know, and a lot of things we may reasonably be skeptical about, and things may just turn out for the best despite the colossal defeat we have suffered here.
After all, in The War of the Worlds, humanity lost the war just as we have... but mankind survived anyway, because the Martians dropped dead of unrelated causes before they could finish exterminating us. I'd rather be victorious than lucky, but I'll take lucky in a pinch.
So enjoy the beautiful weather, keep yourself and your family safe, and we'll just have to see what happens next.