Your Community and COVID-19: How to Make Sense of the Numbers Where You Live
Have you felt a bit like an armchair epidemiologist lately? Maybe you've been poring over coronavirus statistics on your county health department's website or on the pages of your local newspaper.
If the percentage of positive tests steadily stays under 8 percent, that's generally a good sign.
You're likely to find numbers and charts but little guidance about how to interpret them, let alone use them to make day-to-day decisions about pandemic safety precautions.
Enter the gurus. We asked several experts to provide guidance for laypeople about how to navigate the numbers. Here's a look at several common COVID-19 statistics along with tips about how to understand them.
Case Counts: Consider the Context
The number of confirmed COVID-19 cases in American counties is widely available. Local and state health departments should provide them online, or you can easily look them up at The New York Times' coronavirus database. However, you need to be cautious about interpreting them.
"Case counts are the obvious numbers to look at. But they're probably the hardest thing to sort out," said Dr. Jeff Martin, an epidemiologist at the University of California at San Francisco.
That's because case counts by themselves aren't a good window into how the coronavirus is affecting your community since they rely on testing. And testing itself varies widely from day to day and community to community.
"The more testing that's done, the more infections you'll pick up," explained Dr. F. Perry Wilson, a physician at Yale University. The numbers can also be thrown off when tests are limited to certain groups of people.
"If the tests are being mostly given to people with a high probability of having been infected -- for example, they have had symptoms or work in a high-risk setting -- then we expect lots of the tests to be positive. But that doesn't tell us what proportion of the general public is likely to have been infected," said Eleanor Murray, an epidemiologist at Boston University.
These Stats Are More Meaningful
According to Dr. Wilson, it's more useful to keep two other statistics in mind: the number of COVID tests that are being performed in your community and the percentage that turn up positive, showing that people have the disease. (These numbers may or may not be available locally. Check the websites of your community's health department and local news media outlets.)
If the number of people being tested is going up, but the percentage of positive tests is going down, Dr. Wilson said, that's a good sign. But if both numbers are going up – the number of people tested and the percentage of positive results – then "that's a sign that there are more infections burning in the community."
It's especially worrisome if the percentage of positive cases is growing compared to previous days or weeks, he said. According to him, that's a warning of a "high-risk situation."
Dr. George Rutherford, an epidemiologist at University of California at San Francisco, offered this tip: If the percentage of positive tests steadily stays under 8 percent, that's generally a good sign.
There's one more caveat about case counts. It takes an average of a week for someone to be infected with COVID-19, develop symptoms, and get tested, Dr. Rutherford said. It can take an additional several days for those test results to be reported to the county health department. This means that case numbers don't represent infections happening right now, but instead are a picture of the state of the pandemic more than a week ago.
Hospitalizations: Focus on Current Statistics
You should be able to find numbers about how many people in your community are currently hospitalized – or have been hospitalized – with diagnoses of COVID-19. But experts say these numbers aren't especially revealing unless you're able to see the number of new hospitalizations over time and track whether they're rising or falling. This number often isn't publicly available, however.
If new hospitalizations are increasing, "you may want to react by being more careful yourself."
And there's an important caveat: "The problem with hospitalizations is that they do lag," UC San Francisco's Dr. Martin said, since it takes time for someone to become ill enough to need to be hospitalized. "They tell you how much virus was being transmitted in your community 2 or 2.5 weeks ago."
Also, he said, people should be cautious about comparing new hospitalization rates between communities unless they're adjusted to account for the number of more-vulnerable older people.
Still, if new hospitalizations are increasing, he said, "you may want to react by being more careful yourself."
Deaths: They're an Even More Delayed Headline
Cable news networks obsessively track the number of coronavirus deaths nationwide, and death counts for every county in the country are available online. Local health departments and media websites may provide charts tracking the growth in deaths over time in your community.
But while death rates offer insight into the disease's horrific toll, they're not useful as an instant snapshot of the pandemic in your community because severely ill patients are typically sick for weeks. Instead, think of them as a delayed headline.
"These numbers don't tell you what's happening today. They tell you how much virus was being transmitted 3-4 weeks ago," Dr. Martin said.
'Reproduction Value': It May Be Revealing
You're not likely to find an available "reproduction value" for your community, but it is available for your state and may be useful.
A reproduction value, also known as R0 or R-naught, "tells us how many people on average we expect will be infected from a single case if we don't take any measures to intervene and if no one has been infected before," said Boston University's Murray.
As The New York Times explained, "R0 is messier than it might look. It is built on hard science, forensic investigation, complex mathematical models — and often a good deal of guesswork. It can vary radically from place to place and day to day, pushed up or down by local conditions and human behavior."
It may be impossible to find the R0 for your community. However, a website created by data specialists is providing updated estimates of a related number -- effective reproduction number, or Rt – for each state. (The R0 refers to how infectious the disease is in general and if precautions aren't taken. The Rt measures its infectiousness at a specific time – the "t" in Rt.) The site is at rt.live.
"The main thing to look at is whether the number is bigger than 1, meaning the outbreak is currently growing in your area, or smaller than 1, meaning the outbreak is currently decreasing in your area," Murray said. "It's also important to remember that this number depends on the prevention measures your community is taking. If the Rt is estimated to be 0.9 in your area and you are currently under lockdown, then to keep it below 1 you may need to remain under lockdown. Relaxing the lockdown could mean that Rt increases above 1 again."
"Whether they're on the upswing or downswing, no state is safe enough to ignore the precautions about mask wearing and social distancing."
Keep in mind that you can still become infected even if an outbreak in your community appears to be slowing. Low risk doesn't mean no risk.
Putting It All Together: Why the Numbers Matter
So you've reviewed COVID-19 statistics in your community. Now what?
Dr. Wilson suggests using the data to remind yourself that the coronavirus pandemic "is still out there. You need to take it seriously and continue precautions," he said. "Whether they're on the upswing or downswing, no state is safe enough to ignore the precautions about mask wearing and social distancing. 'My state is doing well, no one I know is sick, is it time to have a dinner party?' No."
He also recommends that laypeople avoid tracking COVID-19 statistics every day. "Check in once a week or twice a month to see how things are going," he suggested. "Don't stress too much. Just let it remind you to put that mask on before you get out of your car [and are around others]."
Tapping into the Power of the Placebo Effect
When Wayne Jonas was in medical school 40 years ago, doctors would write out a prescription for placebos, spelling it out backwards in capital letters, O-B-E-C-A-L-P. The pharmacist would fill the prescription with a sugar pill, recalls Jonas, now director of integrative health programs at the Samueli Foundation. It fulfilled the patient's desire for the doctor to do something when perhaps no drug could help, and the sugar pills did no harm.
Today, that deception is seen as unethical. But time and time again, studies have shown that placebos can have real benefits. Now, researchers are trying to untangle the mysteries of placebo effect in an effort to better treat patients.
The use of placebos took off in the post-WWII period, when randomized controlled clinical trials became the gold standard for medical research. One group in a study would be treated with a placebo, a supposedly inert pill or procedure that would not affect normal healing and recovery, while another group in the study would receive an "active" component, most commonly a pill under investigation. Presumably, the group receiving the active treatment would have a better response and the difference from the placebo group would represent the efficacy of the drug being tested. That was the basis for drug approval by the U.S. Food and Drug Administration.
"Placebo responses were marginalized," says Ted Kaptchuk, director of the Program in Placebo Studies & Therapeutic Encounters at Harvard Medical School. "Doctors were taught they have to overcome it when they were thinking about using an effective drug."
But that began to change around the turn of the 21st century. The National Institutes of Health held a series of meetings to set a research agenda and fund studies to answer some basic questions, led by Jonas who was in charge of the office of alternative medicine at the time. "People spontaneously get better all the time," says Kaptchuk. The crucial question was, is the placebo effect real? Is it more than just spontaneous healing?
Brain mechanisms
A turning point came in 2001 in a paper in Science that showed physical evidence of the placebo effect. It used positron emission tomography (PET) scans to measure release patterns of dopamine — a chemical messenger involved in how we feel pleasure — in the brains of patients with Parkinson's disease. Surprisingly, the placebo activated the same patterns that were activated by Parkinson's drugs, such as levodopa. It proved the placebo effect was real; now the search was on to better understand and control it.
A key part of the effect can be the beliefs, expectations, context, and "rituals" of the encounter between doctor and patient. Belief by the doctor and patient that the treatment would work, and the formalized practices of administering the treatment can all contribute to a positive outcome.
Conditioning can be another important component in generating a response, as Pavlov demonstrated more than a century ago in his experiments with dogs. They were trained with a bell prior to feeding such that they would begin to salivate in anticipation at the sound of a bell even with no food present.
Translating that to humans, studies with pain medications and sleeping aids showed that patients who had a positive response with a certain dose of those medications could have the same response if the doses was reduced and a dummy pill substituted, even to the point where there was no longer any active ingredient.
Researchers think placebo treatments can work particularly well in helping people deal with pain and psychological disorders.
Those types of studies troubled Kaptchuk because they often relied on deception; patients weren't told they were receiving a placebo, or at best there was a possibility that they might be randomized to receive a placebo. He believed the placebo effect could work even if patients were told upfront that they were going to receive a placebo. More than a dozen so call "open-label placebo" studies across numerous medical conditions, by Kaptchuk and others, have shown that you don't have to lie to patients for a placebo to work.
Jonas likes to tell the story of a patient who used methotrexate, a potent immunosuppressant, to control her rheumatoid arthritis. She was planning a long trip and didn't want to be bothered with the injections and monitoring required in using the drug, So she began to drink a powerful herbal extract of anise, a licorice flavor that she hated, prior to each injection. She reduced the amount of methotrexate over a period of months and finally stopped, but continued to drink the anise. That process had conditioned her body "to alter her immune function and her autoimmunity" as if she were taking the drug, much like Pavlov's dogs had been trained. She has not taken methotrexate for more than a year.
An intriguing paper published in May 2021 found that mild, non-invasive electric stimulation to the brain could not only boost the placebo effect on pain but also reduce the "nocebo" effect — when patients report a negative effect to a sham treatment. While the work is very preliminary, it may open the door to directly manipulating these responses.
Researchers think placebo treatments can work particularly well in helping people deal with pain and psychological disorders, areas where drugs often are of little help. Still, placebos aren't a cure and only a portion of patients experience a placebo effect.
Nocebo
If medicine were a soap opera, the nocebo would be the evil twin of the placebo. It's what happens when patients have adverse side effects because of the expectation that they will. It's commonly seem when patients claims to experience pain or gastric distress that can occur with a drug even when they've received a placebo. The side effects were either imagined or caused by something else.
"Up to 97% of reported pharmaceutical side effects are not caused by the drug itself but rather by nocebo effects and symptom misattribution," according to one 2019 paper.
One way to reduce a nocebo response is to simply not tell patients that specific side effects might occur. An example is a liver biopsy, in which a large-gauge needle is used to extract a tissue sample for examination. Those told ahead of time that they might experience some pain were more likely to report pain and greater pain than those who weren't offered this information.
Interestingly, a nocebo response plays out in the hippocampus, a part of the brain that is never activated in a placebo response. "I think what we are dealing with with nocebo is anxiety," says Kaptchuk, but he acknowledges that others disagree.
Distraction may be another way to minimize the nocebo effect. Pediatricians are using virtual reality (VR) to engage children and distract them during routine procedures such as blood draws and changing wound dressings, and burn patients of all ages have found relief with specially created VRs.
Treatment response
Jonas argues that what we commonly call the placebo effect is misnamed and leading us astray. "The fact is people heal and that inherent healing capacity is both powerful and influenced by mental, social, and contextual factors that are embedded in every medical encounter since the idea of treatment began," he wrote in a 2019 article in the journal Frontiers in Psychiatry. "Our understanding of healing and ability to enhance it will be accelerated if we stop using the term 'placebo response' and call it what it is—the meaning response, and its special application in medicine called the healing response."
He cites evidence that "only 15% to 20% of the healing of an individual or a population comes from health care. The rest—nearly 80%—comes from other factors rarely addressed in the health care system: behavioral and lifestyle choices that people make in their daily life."
To better align treatments and maximize their effectiveness, Jonas has created HOPE (Healing Oriented Practices & Environments) Note, "a patient-guided process designed to identify the patient's values and goals in their life and for healing." Essentially, it seeks to make clear to both doctor and patient what the patient's goals are in seeking treatment. In an extreme example of terminal cancer, some patients may choose to extend life despite the often brutal treatments, while others might prefer to optimize quality of life in the remaining time that they have. It builds on practices already taught in medical schools. Jonas believes doctors and patients can use tools like these to maximize the treatment response and achieve better outcomes.
Much of the medical profession has been resistant to these approaches. Part of that is simply tradition and limited data on their effectiveness, but another very real factor is the billing process for how they are reimbursed. Jonas says a new medical billing code added this year gives doctors another way to be compensated for the extra time and effort that a more holistic approach to medicine may initially require. Other moves away from fee-for-service payments to bundling and payment for outcomes, and the integrated care provided by the Veterans Affairs, Kaiser Permanente and other groups offer longer term hope for the future of approaches that might enhance the healing response.
This article was first published by Leaps.org on July 7, 2021.
New tech helps people of all ages stay social
In March, Sonja Bauman, 39, used an online platform called Papa, which offers “family on demand,” to meet Mariela Florez, an 83-year-old retiree. Despite living with her adult children, Florez was bored and lonely when they left for work, and her recoveries from a stroke and broken hip were going slowly. That's when Bauman began visiting twice per week. They take walks, strengthening Florez’s hip, and play games like Connect Four for mental stimulation. “It’s very important for me so I don’t feel lonely all day long,” said Florez. Her memories, blurred by the stroke, are gradually returning.
Papa is one of a growing number of tech approaches that are bringing together people of all ages. In addition to platforms like Papa that connect people in real life, other startups use virtual reality and video, with some of them focusing especially on deepening social connections between the generations — relationships that support the health of older and younger people alike. “I enjoy seeing Mariela as much as she enjoys seeing me,” Bauman said.
Connecting in real life
Telehealth expert Andrew Parker founded Papa in 2017 to improve the health outcomes of older adults and families. Seniors can meet people — some their grandkids’ age — for healthy activities, while working parents find retirees to watch their children. These “Papa Pals” are provided as a benefit through Medicare, Medicaid and some employer health plans.
In 2020, Papa connected Bauman, the 39-year-old Floridian, with another woman in her mid-70s who lives alone and has very limited mobility. Bauman began driving her to doctor’s appointments and helping her with chores around the house. “When I’m not there, she doesn’t leave her apartment,” said Bauman. The two have gone to the gym together, and they walk slowly through the neighborhood, chatting so it feels less like exercise.
Parker was driven to start Papa by the problem of social isolation among seniors, exacerbated by the pandemic, but he believes users of all ages can benefit. “Many of our Pals feel more comfortable opening up with older members than their same-aged friends,” he said.
Other platforms aim for similar, in-person connections. Generation Tech unites teens with seniors for technology training. And Mon Ami, which provides case management software for aging and disability service providers, has an app that connects isolated older people with college-age volunteers.
Making new connections through video
Several new sites match you with strangers for real-time video chatting on various topics, such as finding common ground on political issues. Other video platforms focus on intergenerational connections.
S. Jay Olshansky, a gerontology professor at the University of Illinois-Chicago, recalls the first time he saw Hyunseung Lee, an 11-year-old from Seoul, through his computer screen. The kid was shy, but Olshansky, 67, encouraged him to ask questions. “Turns out, he was thirsting for this kind of interaction.”
They’d connected through Eldera, a platform that pairs mentors age 60 and up with mentees, using an algorithm, for video conversations. “The time and wisdom of older adults is the most important natural resource we can give future generations,” said Dana Griffin, Eldera's CEO. “Connecting through a screen is the opposite of social media.”
In weekly meetings, Olshansky noticed Lee’s unique interest in math. “There’s something special in you,” Olshansky told him. “How do we bring it to the surface?” He suggested Lee write a book on his favorite subject, and the preteen ran with it, cranking out 70 pages in two weeks. Lee has published his love letter to theorems on Amazon.
Hyunseung Lee, age 11, of Korea, and U.S. college professor Jay Olshanksy, 67, discuss math, strategy and Hyunsung's budding career as a book author during their video chats through a platform called Eldera. (Photo by Dana Palmer/Eldera)
Lee’s parents told Olshansky that their son has become more assertive — a recurring theme, Griffin said. “Confidence is the number one thing parents tell us about.” Since Eldera’s inception last year, the number of mentors has grown exponentially. Even so, Griffin said the waitlist for mentors typically numbers 200 kids.
Another site, Big and Mini, hosts video interactions between seniors and young adults; about 10,000 active users have joined since 2019, said co-founder Aditi Merchant.
Users often bring the benefits of their video interactions to their real-world relationships. Olshansky views Lee as an older version of his grandkids. “Eldera teaches me how to interact with them.” Lee, high on confidence, began instructing his classmates in math. Griffin noted that a group of Eldera mentors in Memphis, who met initially on Eldera, now take walks together in-person to trade ideas for helping each other’s Eldera kids solve problems in their schools and communities.
“We’ve evolved into a community for older adults who want to give back to the world,” said Griffin. Other new tools for connection take the form of virtual reality apps.
Connecting in virtual reality
During pandemic isolation, record numbers of people bought devices for virtual and augmented reality. Such gadgets can convince you that you’re hanging out with friends, even if they’re in another hemisphere. Lifelike simulations from miles away could be especially useful for meaningful interactions between people of different generations, since they’re often geographically segregated.
VR’s benefits require further study, but users report less social isolation and depression, according to MIT research. The immersive, 3-D experience is more compelling than FaceTime or Zoom. “It’s like the difference between a phone call and video call,” said Rick Robinson, Vice President of AARP’s Innovation Labs.
“When VR is designed right, the medium disappears,” said Jeremy Bailenson of Stanford.
Dana Pierce, a 56-year-old government employee in Indiana, got Meta's VR headset in May, 2021, thinking she’d enjoy it more than a new laptop. After many virtual group tours of exotic destinations, she has no regrets. Her adventures occur on Alcove, an app made by Robinson’s Innovation Labs. He co-created it with VR-company Rendever and sought input from people over age 50 to tailor it to their interests. “I’m an introvert,” said Pierce. “I’ve been more socially active since getting my headset than I am in real life.”
Tagging along with her to places like Paris are avatars representing real people around the world. She’s gotten to know VR users in their 70s, 80s and 90s, as well as younger people and some her own age. One is a new friend she plays chess with in relaxing nature settings. Another is her oldest son. He lives 90 minutes away but, earlier this year, Pierce welcomed him and his girlfriend to her virtual house on Alcove. They chatted in the living room decorated with family photos uploaded by Pierce. Then they took out a boat to go VR fishing — because why not — until 2 a.m.
“When VR is designed right, the medium disappears,” said Jeremy Bailenson, a communications professor who directs Stanford’s Virtual Human Interaction Lab. He’s teaching a class of 175 students entirely in VR. After months of covid isolation, the first time the class met, “there was a big catharsis. It really feels like you’re in a big crowd.” Like-minded people meet in VR for events such as comedy shows and creative writing meetups, while the Swedish pop group ABBA has performed this year as digital versions of themselves (“ABBA-tars”) during a virtual concert tour.
Karen Fingerman, a psychologist and director of the Texas Aging and Longevity Center at the University of Texas-Austin, supports the idea of VR for social connection, though she added that some people need it more than others. Hospitals and assisted-living facilities are using products such as Penumbra’s REAL I-Series and MyndVR to bring VR excursions to isolated patients and seniors. “If you’re in a bed or facility, this gives you something to talk about,” said Gita Barry, Penumbra’s executive vice president.
Pierce uses it on most days. She may see another adult son, who lives with her, less often as a result. But VR helps her manage real-world stressors, more than escaping them. After a long workday, she visits her back porch on Alcove, which overlooks a pond. “It’s my little retreat,” she said. “VR improves my mood. It’s added a lot to my life.”
Some seniors are using more than one technology. Olshansky and Lee discuss strategy while playing Internet chess. And Olshansky recently began using VR. He sees his sister, who lives far away, in a virtual beach house. “It’d be a great way to interact with Hyunseung,” he said. “I should get him a headset.”
A version of this article first appeared in The Washington Post on December 3, 2021.