## 28 April 2020

### When Does COVID Kill?

DISCLAIMER: I am not a doctor or an epidemiologist. I am someone with a mathematics background who likes to analyze large data sets. I'm making a conjecture based upon what I've read about COVID-19 and this post is meant to be thought provoking, especially for those who have a better capacity to evaluate the data properly, and not as a definitively conclusion that should be acted upon. I am engaged in hypothesis generation, not in empirical proof of a hypothesis at this point.

Are COVID deaths primarily due to the interaction of select pre-existing conditions and a COVID infection?

COVID death risk is very strongly influenced by age. But, the association is made partially because it is easiest to analyze statistically.

Another way of conceptualizing the data, and I don’t know how much this has been formally analyzed, is that the true relationship could be between select pre-existing conditions and morbidity and morality risk, with age serving as proxy for the likelihood of having one or more of the risk enhancing pre-existing conditions.

Hints For A Pre-Existing Condition Theory Among The Young

In this frame, it makes a lot more sense that the young, who are normally viewed as having weaker overall immune systems than those in the prime of life, are so little affected. It also is a good fit when you dig down to who in particular among the young dies or suffers serious impairment.

For example, among the young who have died in Colorado are premature infants already in ICU, the child with severe epilepsy only responsive to CBD after whom the strain of marijuana known as Charlotte’s Web is named, a girl a couple of years behind my son in high school who was in a wheel chair and had respiratory issues, etc.

Anecdotal and small sample studies seem to show that mortality is heavily concentrated among those with a short list of pre-existing conditions (ca. 70%-90%+). It also isn’t unreasonable to suspect that many or most of those who die without any of the pre-existing conditions on the short list also have pre-existing conditions that are less common in the general population (and hence don’t make up a huge share of the total), or have pre-existing conditions that are undiagnosed, or not recognized as relevant.

Those conditions are most rare in the 5-14 age group, which has none of the congenital conditions that kill within the first five years of life (especially the first year or two), but are at an age before anything else with a genetic cause crops up. This is because this is an age group that faced strong continuing selection from infectious diseases or other causes, prior to vaccination and antibiotics, even in non-epidemic periods. Those who die in that age range overwhelmingly die without reproducing first, unlike those who die in their 30s or later, so genetic conditions that increase mortality in that age range are subject to especially strong selective pressure.

Hints For A Pre-Existing Condition Theory Among The Elderly

It is also worth noting that deaths among the elderly, despite age itself being statistically a huge risk factor, are heavily concentrated among those in nursing homes and assisted living facilities, i.e. among those who almost by definition have some impairments or serious pre-existing conditions already. Admittedly, some of the risk is from high density institutional living in what are predominantly pretty non-medically and sloppily run facilities that do not enough to prevent infections from spreading. But, the percentage of the dead in these institutions seems to be running at 35%-70% (in Colorado where I live it is 63%), but they are a much smaller share of the total elderly population. They make up about 5% of the elderly population, which in turn makes up about 15% of the total population, so about 0.75% of the total population accounts for about 35% to 70% of the dead.

The mortality rate of the roughly 14% of the population that is over age 65 but is not in a nursing home is much, much lower. So, it is’t just the elderly who are dying, it is the elderly who have pre-existing conditions, often serious ones. Pre-existing conditions are much more common in the elderly, whose bodies are breaking down due to old age on multiple fronts. But, these conditions are not universal or uniformly distributed by any means.

How frail are people in nursing homes?

One way to quantify that is by looking at death rates for nursing home residents pre-COVID.
In a study of elderly Americans who moved to a nursing home for their final months or years of life, 65 percent died there within one year, according to an investigation by researchers at the San Francisco VA Medical Center and the University of California, San Francisco.
In the study, which appears in the online Early View section of the “Journal of the American Geriatrics Society,” the researchers found that length of stay before death in a nursing home was associated with differences in gender, net worth, and marital status.
Men had shorter lengths of stay before death than women, residents with higher net worth had shorter lengths of stay than those with lower net worth, and residents who were married or otherwise partnered had shorter lengths of stay before death than those who were single, says lead author Anne Kelly, MSW, a social worker at SFVAMC.
“It’s a matter of resources. People with more access to care and resources were able to stay in the community for longer before moving to a nursing home than those with less access,” explains Kelly. “One reason that men had shorter stays before death than women might be that women tend to outlive men, and so by the time a woman moves to a nursing home her partner is more likely to have died, whereas men are more likely to have a spouse or partner to care for them at home through the end of life.” . . .
“One quarter of all deaths in the United States occur in nursing homes, and that figure is expected to rise to 40 percent by the year 2020,” says Smith. . . .
Smith describes the average and median length of stay before death as “surprisingly brief.” The implication, he says, is that “we need to engage nursing home residents in planning conversations about end-of-life care and treatment preferences very soon after they are admitted. We have only a brief amount of time to address their concerns before they become seriously ill.”
For the study, the authors analyzed data on 1,817 nursing home residents who died between 1992 and 2006. The residents were participants in the Health and Retirement Study, an ongoing nationally representative longitudinal study of health, retirement, and aging sponsored by the National Institute on Aging.
The average age of participants when they moved to a nursing home was about 83. The average length of stay before death was 13.7 months, while the median was five months. Fifty-three percent of nursing home residents in the study died within six months.
Men died after a median stay of three months, while women died after a median stay of eight months
From Steve Tokar, "Social Support is Key to Nursing Home Length of Stay Before Death", Patient Care (August 24, 2010) (emphasis added).

The mortality differences based on sex in COVID deaths (about 60% are men) also mirrors the sex differences in survival durations for nursing home residents.

The good news is that the proportionate impact of COVID on lost years of life may be much more modest than it is in the raw number of deaths. Lots of people who are dying of COVID had short life expectancies, in a large share of cases, median life expectancies of less than a year. Many people who die of COVID would have died of something else in the near future if they hadn't died of it.

Does This Help Explain The Geography Of COVID Outbreaks?

Western Europe and North America have been much harder hit by COVID than most of the rest of the world, especially when considering deaths per million people, a measure that is insensitive to testing rates and the extent to which testing is targeted well.

The pre-existing condition theory might help to explain this pattern.

First, the "age pyramid" in most of the rest of the world is much more bottom heavy. Most other countries have more young people and fewer older people, proportionately.

Second, many countries outside Western Europe and North America don't warehouse their sickest of the sick in nursing home-like facilities with the very least healthy of old and disabled in them. This reduces transmission and infection rates among the very vulnerable.

Third, it is also probably a reality in most of the world that most people unwell enough that they would be admitted to nursing homes in Western Europe and North America, instead die at home a few months to a year or so on average than they would have with the comparatively intensive paramedical attention that they receive in a nursing home. So, the group of people with an odds ratio of death from COVID on the order of 50 to 100 times that of the general population makes up a much, much smaller share of the total population in places outside Northern Europe, like India, Indonesia, and Africa.

Could very high exposure rates explain deaths among the quite small percentage of deaths among healthy younger people?

There are cases of seemingly healthy people dying of COVID with no apparent pre-existing conditions. But, the other common thread there in many of those cases seems to be extremely high levels of exposure. For example, ER doctors and COVID ward nurses, and public transit workers in areas with very high infection rates, seem to make up many of these cases.

## 27 April 2020

### Change, Some For The Better In Saudi Arabia

Crown Prince Mohammed bin Salman has made some reforms that restrict practices that are widely recognized as putting Saudi Arabia among the "uncivilized" countries of the world (he has also relaxed some restrictions on women's rights and expanded democracy at the local government level while retaining an absolute monarchy nationally). But, he's also taken actions that belong in a modern version of the television series "Game of Thrones."

Even with the reforms, Saudi Arabia will still have one of the highest rates of capital and corporal punishment in the world, still criminalizes conduct that is legal in most of the world, and remains one of the most totalitarian countries in the world. But, steps in the right direction are still welcome ones.

It remains to be seen if his policies, reforms and tactics, will be, on balance, positive or negative ones.
"Saudi Arabia's King Salman has ordered an end to the death penalty for crimes committed by minors, according to a statement Sunday by a top official. The decision comes on the heels of another ordering judges to end the practice of flogging, replacing it with jail time, fines or community service and bringing one of the kingdom’s most controversial forms of public punishment to a close.
King Salman's son and heir, Crown Prince Mohammed bin Salman, is seen as the force behind the kingdom’s loosening of restrictions and its pivot away from ultraconservative interpretations of Islamic law known as Wahhabism, which many in the country still closely adhere to.
The crown prince has sought to modernize the country, attract foreign investment and revamp Saudi Arabia’s reputation globally. He's also overseen a parallel crackdown on liberals, women's rights activists, writers, moderate clerics and reformers. The 2018 killing of Saudi writer Jamal Khashoggi in Turkey by agents who worked for the crown prince drew sharp criticism internationally.
The latest royal decree by King Salman could spare the death penalty for at least six men from the country’s minority Shiite community who allegedly committed crimes while under the age of 18, including Ali al-Nimr, who had participated in anti-government protests. Such activity carries terrorism-related charges in the kingdom for disturbing order and disobeying the ruler. In a document seen by The Associated Press, the royal decree orders prosecutors to review cases and drop punishments for those who've already served the maximum 10 years. However, the decree states that terrorism-related cases of minors will be tried differently. . . .
He said “more reforms will be coming,” and that the two decisions “reflect how Saudi Arabia is forging ahead in its realization of critical human rights reforms even amid the hardship imposed by the COVID-19 pandemic." The decree expands on a previous order by King Salman issued in late 2018, which set a maximum 10-year prison term for minors in certain cases, except for crimes punishable by death. Now the 10-year maximum applies to all crimes by minors, with the possible exception of terrorism-related crimes. . . .
Saudi Arabia's Supreme Court recently issued a directive to end flogging as a form of punishment sometime in April, according to another document seen by The Associated Press. The public spectacle of whipping a handcuffed prisoner for often non-violent crimes had drawn some comparisons to the types of punishment carried out by extremist groups like the Islamic State. . . . The Supreme Court document said the decision was in line with the kingdom's reforms and developments in the realm of human rights as directed by King Salman and overseen by the crown prince. .. .
While some crimes, such as murder, may carry fixed punishments under Saudi Arabia’s interpretation of Islamic law, or Shariah, many other offenses are considered “tazir," meaning neither the crime nor the punishment is defined in Islam. Discretionary judgments for “tazir” crimes, such as flogging, have led to arbitrary rulings with contentious outcomes. Muslim countries generally do not practice public flogging. “This is a good step but we are still waiting to see if existing lashing sentences will be reversed and expunged,” al-Ahmed said."
From ABC News

## 23 April 2020

### Family History, European History, Heredity And My Weight

As part of my weight loss program with Noom.com I also purchased a weight loss focused genetic test, took it and sent it off. I got a notice that my sample was received today by Orig3n, their commercial consumer grade DNA testing affiliate. I've already had DNA testing done by 23andMe and already known my family history with respect to most of the relevant issues, and family history is really still more powerful than DNA testing for discerning hereditary influences on complex traits.

I'll compare what I know from family history and a previous genetic test to the latest appraisal.

What do I know before receiving those results?

Myself

When I graduated from high school, I had a body mass index of 23.4 right in the middle of the "normal weight" range of 18.5 to 24.9. I wasn't particularly mindful of my diet, although I had lots of home cooked family meals, but I was moderately active.

I was on the town's reaction center's summer swim team from late elementary school until through junior high school, and was on the high school swim team in the summer of my senior year. I also played soccer for many years in elementary school. In terms of athletic performance, I was dismally bad (as in pretty much the worst on every team I participated in for both swimming and soccer), but I was a good sport and tried my best. I was Cub Scout and then a Boy Scout (ultimately earning the Eagle Scout rank my senior year in high school), with the activities and outdoor hiking, camping and boating that this implied, and was involved in every theater production at high school and many of the community theater productions. I also biked around town for transportation and as a paper boy until I could drive late in my sophomore year of high school and in in senior year in high school (I was a foreign student in New Zealand during my junior year in high school and also fairly active then).

Once I was on my own, in college and then in law school, and then as a young lawyer, I was far more sedentary, although I walked to get places around campus, and ate with abandon when I had unlimited food available at the dining halls for all three years of undergrad and my first year at law school, and wasn't a weight conscious cook for myself. I put on a lot of weight in school, and then gradually added more over time.

The DNA test I took previously noted a couple of weight related genetic risk factors noting that my "genes predispose you to weigh about 4% more than average" (based upon a risk score derived from 760 different genetic markers) and that "people of European descent with genetics like yours have an estimated 32% chance of developing type 2 diabetes at some point between the ages of 49 (your current age) and 80." My expected weight for my gender, height, and age implies a BMI of 27.8 (in the overweight, but not obese range).

Something on the order of 46.4% of American men my age in the United States from the general population are obese (defined as BMI 30.0 or more) without regard to genetics (estimating the cross tabs, adjusting for race as well would bring it down to about 46.1%), so the median is almost surely "overweight" (BMI 25.0 to 29.9) rather than being in the "normal range". About 11.5% of Americans my age in the United States from the general population are severely obese (defined as BMI 40.0 or more), as I was for several months in late 2017 and early 2018, although severe obesity is significantly less common (about a third less) in men than women (so the rate of severe obesity for men my age is probably closer to 10%), even thought men are more likely than women to be obese at all.

Also according to the DNA test that I took previously, my "weight is likely to be similar on diets high or low in saturated fat with the same number of total calories." I am correctly predicted to be lactose tolerant, and so far as I know, all of my genetic relatives are lactose tolerant.

Indeed, I was diagnosed with Type II diabetes in the spring of 2018 although I have since returned to non-diabetic status following a bit more than sixty pounds of weight loss on what amounts to basically a paleo diet, with a low to moderate amount of low impact exercise. I gained about twenty of those pounds back in the fall of 2019 and winter of 2020, which is why I returned to a diet program again. But, I've since shed almost all of the weight that I gained back during the lockdown in March and April of 2020. I've also done, as predicted, about equally well on my previous diet, which was high in saturated fat, and my current one, which is low in saturated fat.

My father's side

My paternal grandfather, Gale, was not at all heavy, although he was a hands on farmer engaged in manual labor most of his life, primarily growing typical Northwest Ohio crops like corn on a cash crop basis in addition to having a garden for personal consumption, with animals limited to a working horse for some of the time my father and uncle were growing up, and a small number of food animals for personal consumption. He was primarily or completely Northern German in origins with his patrilineal ancestor migrating to the U.S. in 1847 (he was born in 1901) and the moving not too long after that to Ohio. His origins were with leather workers and were more urban than my mother's family, even though he ended up being a farmer in the U.S.

My paternal grandmother, Mildred (born in 1904), was on the heavy side. She has significant Irish ancestry (50%, I  think), probably from after the Irish Potato famine. So, she may have experienced selective pressure to accumulate weight to survive famine, although I know less about her background.

Neither my father nor my uncle were heavy and both had desk jobs. My father was a professor, my uncle was a treasurer for the local school district and the family's church, among other book keeping/accounting professions, although he was not a CPA.

My uncle Lowell was slim as was his wife and his four children, although some of that may be because he and one of his daughters had Type I diabetes which caused their family to be very mindful of their diets and very careful about the added sugars in the American diets that were helping to make the rest of the nation obese. At least a couple of Lowell's children were far superior to either my brother or myself athletically. One of Lowell's children had children, and her children are also not heavy (and neither is her husband).

Both my father and his brother died of pancreatic cancer, although there is circumstantial evidence to suggest that any common cause for this had an environmental, rather than a hereditary cause.

So, phenotypically, my father and his brother don't seem to have inherited any dominant tendency towards obesity, although it is plausible that they had something recessive, or at least, phenotypically invisible genotype that might incline someone to obesity.

My brother, who is considerably taller than I am, has almost always been less heavy than me, although certainly not slim as an adult, despite the fact that he works out quite diligently (e.g. biking a considerable distance to work most days) to help him resist becoming too heavy.

My previous DNA test revealed that my father was basically a Northern European mutt. He had British/Irish ancestry more or less in line with, but a little low to reflect his Irish ancestry through Mildred (he was about 20% British/Irish with some broadly Northern European ancestry probably also traceable to Mildred's Irish parent) with a locus correctly in Ireland. My father's remaining ancestry from France and Germany in Northern Europe, and broadly Northern European ancestry with small percentages of Scandinavian and Southern European descent (less than 5% combined).

The service's effort to localize the French-German ancestry was not very accurate, predicting, predicting Switzerland as most likely, although its second choice, the region of Hesse, Germany, wasn't too far off from my father's ancestors actual German homeland. But, given that Northern Europe has far less genetic substructure than Finland (which is very distinctive from the rest of Germany and has lots of sharp internal substructure) this isn't that serious of fault from the test's perspective.

My mother's side

My mom was not extremely heavy, but was at least overweight and probably low stage obese, and struggled with diet after diet all her life and had blood sugar deficit issues.

Her mother, one of her sisters and two brothers were on the heavy side, as are many of my cousins on that side (her other sister, Kay, contracted M.S. in college which atypically influenced her weight). At least one of my first cousins on my mother's side who is heavy also has sleep apnea. Many of my more distant American Swede Finn relatives are also on the heavy side.

My mom's father had an extremely active lifestyle as a lumberjack and subsistence farmer that might have counteracted a tendency to be heavy.

Both of my mothers parents were descended exclusively from Swedish speaking Finnish people from roughly the same part of Finland about midway up the Baltic Sea coast in the late 1800s. My great grandfather, if I recall correctly, was a first generation immigrant who came to the U.S. and promptly arrived in the Upper Peninsula of Michigan at the age of fifteen or so, the first in his family to do so, although multiple siblings came after him. He was motivated by economic distress in Finland.

Finland has suffered at least two famines that killed 33%+ of the population each in the last 325 years and often had lean times due to cold temperatures and limited growing seasons. Also, my ancestors in Finland were poor peasants who probably did a lot of manual labor to survive in the same small town for hundreds of years (the family on that side is now middle class by the way and some of my relatives have migrated to Helsinki, which is Finland's political and commercial capitol).

As I explain in a post at this blog's sister blog:
Swedish domination would continue for centuries, and in the Reformation, the Swedish sided with the Protestant Lutherans against the Catholics and had their own round of witch hunting in the 1600s, including as well a short lived effort to establish a Swedish colony in America near the Delaware-Pennsylvania area from 1638-1655 CE, with at least half of the colonists coming from Finland.
Very hard times followed for the next quarter century resulting in the death of a third of the population in a four year long famine, followed by the death of half of the population in a twenty-one year long war. The population of Finland fell by about two-thirds in a single generation.

"In 1696–1699, a famine caused by climate decimated Finland. A combination of an early frost, the freezing temperatures preventing grain from reaching Finnish ports, and a lackluster response from the Swedish government saw about one-third of the population die."
"Soon afterwards, another war determining Finland's fate began (the Great Northern War of 1700–21). The Great Northern War (1700–1721) was devastating, as Sweden and Russia fought for control of the Baltic. Harsh conditions—worsening poverty and repeated crop failures—among peasants undermined support for the war, leading to Sweden's defeat. Finland was a battleground as both armies ravaged the countryside, leading to famine, epidemics, social disruption and the loss of nearly half the population. By 1721 only 250,000 remained."
Constitutional monarchy with a powerful parliament followed in Sweden, but "Finland by this time was [still] depopulated, with a population in 1749 of 427,000." Potato farming (which was a dietary staple of my ancestors) arrived after the 1750s.
In 1809, Finland was annexed to Russia with the assent of a popular assembly.
Mass migration to the United States in the late 19th century was also accompanied by hard times at home in Finland.
Finland secured independence in 1917, followed by a brief civil war in 1918, as a result of the Russian revolution.
It is hard to know exactly what was happening in Finland at the time, as it was part of Russia and not distinguished statistically, but the Swedish population fell by 44 percent in the twenty-year period from 1871-1890, with mass migration to the United States as one major factor in that, no doubt driven by "push factors" at home.

My previous DNA test accurately predicted my ancestor's home region about the size of a large county accurately. The previous test also revealed that despite the fact that my ancestors were Swedish speaking Finns that they have very little Swedish ancestry and were almost pure blooded Finnish.

So, I suspect that there was some strong natural selection in favor of an ability to store calories for hard times over the last ten generations on my mom's side, which was good in a place where they did hard labor daily and had lot of food insecurity, that isn't as suited for a land of unlimited food, uninterrupted food security, and lifestyles more sedentary than any of my ancestors.

## 21 April 2020

### Golf

Golf courses will reopen in Denver tomorrow. As far as coronavirus risk goes, done in a responsible way, it can be pretty low risk.

My inlaws are about as good as you get as amateur golfers. My daughter was captain of the golf team and even got a golf scholarship to college.

This said, I don't get the value of the sport. Personally, I would not be troubled in the least if every single golf course in the state were bulldozed and converted to open space, campgrounds, parks, and even housing.

Golf courses are water hogs in the arid west.

Golf is also the physical personification of inequality. They take large tracts of land for the benefit of a few. It takes an immense amounts of leisure time to play eighteen holes, or even nine, which few people have to spare. And, it isn't a cheap sport in terms of money. The equipment isn't super cheap. The fee to play on a public course isn't trivial. And many people join country clubs with membership dues of upwards of \$10,000 a year and selective admissions just to play.

As I understand it, the public golf courses in Denver pay for themselves, but that ignores the property tax free opportunity costs associated with the idle land. I don't know if country clubs, which are generally organized as non-profits, pay property taxes on their golf courses or not.

I suppose it is a "lifetime" sport that one can engage in for your whole life, not that there aren't other alternatives. I'm sure that my class biases and values are showing. But, in my humble opinion, a world without golf would be a better world.

## 19 April 2020

### A Month And A Half Of Pandemic Living

My first post at this blog about COVID-19 was on March 6, 2020 and the virus was something happening abroad or just starting to get my attention in the weeks before then. It has had an impact on my daily life for about a month and a half now. I'll take this post to write a bit about my personal experiences without looking at the bigger picture.

Health

We've been fortunate. No one in my family has gotten sick or needed urgent or emergency care.

I've lost nineteen pounds since the lockdown started on March 16, mostly assisted by signing up for a sixteen week program with Noom.com early into the lockdown. The lockdown has made it easier to eat health, home cooked foods and fit in time walking. I'm still not down to the low point I reached when losing more than sixty pounds after reaching a peak weight on April 2, 2018 when I had a BMI in excess of 40 (severe, category III obesity) and a type II diabetes diagnosis. I gained a lot back this past fall and winter. But, I could easily get there in two to four weeks. Five pounds beyond that and I would be the lightest I've been since January 1, 2004, the farthest back I've been able to locate good weight records so far.

I wasn't an athletic kid, but I had a BMI of 23.4 (well within the "normal" range of 18.5 to 24.9) when I graduated from high school despite having dropping high school athletics after spending my freshman year on the high school swim team and performing dismally. And, while I don't have good records from graduating from high school until 2004, I'm pretty sure that I put on most of that weight in college where I had unlimited dining hall food and few limitations of any kind in life, and more in law school, then steadily inched up after that point with no organized exercise or diet planning.

My current goal is less ambitious than getting back to the weight and fitness level I had when I was eighteen years old. I'm attempting to get down to the merely "overweight" category (BMI of 25 to 29.9), and to bring my H1C markers used to diagnose diabetes back down to the normal range where I was before inching up over the last few months into the just barely "pre-diabetic" range. This would be the lightest I've been in more than twenty years (assuming a counterfactual straight line weight gain from graduating from high school to 2004 which under estimates how fast I gained weight in college), to a point I haven't been since before my children were born.

Fitness-wise has been tougher for my wife who was training for the Colfax marathon, was regular at the gym and yoga studio, and has been swimming laps at least five days a week for a quarter century or so. The gyms, the yoga studios and the pools are all closed. Appointments with someone providing running tips couldn't be continued. The marathon itself that was her goal has been postponed indefinitely; so have all other competitive races in the country. She can't even go in person to buy new running shoes (something for which ordering over the Internet isn't a good substitute). And, Denver's premier park, Washington Park, where she has been doing most of her long run training, has become too congested with other people who aren't observing social distancing properly to run except when its too cold, cloudy or extremely early in the morning, to train for long distances. So, she's been stuck with streaming yoga sessions over the computer, furtive shorter runs at odd moments, using a few small dumb bells, and a little bit of in house cardio to workout videos.

My son has squeezed workouts and some physical therapy exercises in with a pull up bar he ordered, an improvised piece of work out equipment cobbled together from two dining room chairs and a garden hoe, and some improvised parallel bars put together with two other dining room chairs and towels.

Work and School

The biggest change was that every school, college and university in the country has switched over to remote learning. My daughter had an SUV at college in Maine and loaded up everything it could carry for an early final departure from college in her final semester. En route, we had to line up an emergency stop for her at a car repair shop after a check engine light came on and they found something that wouldn't have waited for the three thousand mile trip home. Commencement festivities and family gatherings whose arrangements had just been put in place were canceled. She stopped by her brother's college in Rhode Island to pick up him and his things, and then they drive home to Colorado for several days as the country shut down behind them. The last restaurants in Ohio were shut down a couple of hours after they had dinner there. Soon enough, they were settled in, and kept self-isolated for the better part of a couple of weeks since no one observed social distancing or was careful as they said their goodbyes and several people at each college had been diagnosed with coronavirus.

Now, they are getting a half a semester glimpse of what college is like without the campus life component. They are showing up to classes by videoconference, reading textbooks and novels, writing essays and taking open book tests. My daughter's job as a teaching assistant is ongoing, although her second job as a multicultural affairs secretary has ended (with full pay for the full semester) and a couple of one credit classes that had to be in person were terminated on a pass-fail basis. In about four weeks, my daughter will be a college graduate and my son's freshman year will be completed.

My daughter has, in theory, a job lined up that starts in August as a community organizer which hasn't been withdrawn yet, and had been looking for a summer job. My son had had a summer job lined up teaching computer science at a University of Denver summer program which is now in limbo, and it isn't entirely certain that classes will restart on campus as usual in the fall.

My wife works mostly as a promotional model, brand ambassador and doing special events. Her entire industry has been completely shut down. She wasn't necessarily working the maximum number of jobs she could have while marathon training, but she was working regularly until there were no jobs at all. She's doing some online classes in the house to get certified for certain kinds of work (e.g. serving alcohol) since they were available at a discount, but workwise, she's dead in the water as are all of her professional peers, many of whom aren't lucky enough to have a working spouse to keep the family's head above water economically and some of whom have reached the point of relying on food banks and not paying rent since their own incomes have gone to zero, while looking for temporary work in grocery stores and cleaning jobs. Gig workers, prior to the CARES Act, weren't even eligible for unemployment payments.

As an attorney, my job is, in theory, an essential service and I could go into the office. But, with one person in my office officially diagnosed and hospitalized with coronavirus, two more who have almost certainly gotten sick with it even though testing has not been available, and one more person who might have had a mildly symptomatic case, all but one of us in my office have been working from home as much as absolutely possible. I've made three or four trips into the office in the last month to pick up papers and books that I need to do my work and have made a couple of stops by my assistant's apartment where he is in isolation with a probably case although not officially tested, to drop off things he needs to do his job.

In normal times, working at home is extremely productive and what I do when I need to work without the interruptions of office life. Lately, it has been more challenging. Instead of being alone in the house with my wife out working out or running somewhere for hours at a time, all four of us are sharing our small house pretty much 24/7. Home cooked meals for four every day mean that the kitchen is usually busy. After a long period of time when the other half of parts of our triplex were empty, they are now full of people and pets too increasing the hum of activity. Little earthquakes like a refrigerator that broke down have had more of an impact when restaurants are closed and trips to the grocery store are an ordeal with hit and miss results.

It isn't just that there are more distractions at home either. Constant developments in the news that affect your cases and clients and daily life steal away your attention. And, there is a learning curve to go from occasionally doing a specific project at home for a day or a weekend, to running an entire practice with no one in the office that way. It hasn't been a really steep learning curve as the nature of practicing law has been trending in ways that support that for a while, but it is still a change that you have to adapt to.

All this is to say that while business has continued not entirely unlike the way that it usually does, that it hasn't been quite business as usual, or as productive as usual, under the circumstances, working almost entirely from home.

Daily Life

My life before was pretty dull. Go to work, hang out in the house, open swim at the rec center once or twice a week, eat out or watch a movie now and then, do chores. In that respect, my life has changed the least day to day. The precinct caucuses in Colorado were held shortly before the virus had invaded our everyday lives.

I make the family grocery runs, which are an endeavor since you never know what will be available, with masks my daughter has sewn by hand. When I get home, the groceries are wiped down with Clorox wipes or washed with soap, and my clothes go straight to the laundry. At my daughter's urging we bought some essentials like toilet paper and wipes before they completely vanished from the shelves for several weeks, although still not in true hoarding quantities.

I have a scarce stash of hand sanitizer in the car (from my daughter's car that she hasn't used since she returned except to take it to the shop) that I wipe down the steering wheel an other controls that I touch with after being out. Sanitation standards in our house are way up too with door handles and the like being bleached regularly.

Partially as an excuse to get out, and partially because it is one productive thing I can do while everything else is closed, I've gotten all three of the family cars completely caught up with deferred maintenance. We were planning to sell her SUV this summer anyway are looking into the best way to do that and find a more fuel efficient replacement (it gets 13 miles to the gallon) as her long anticipated graduation present for graduating from college in three years instead of four (saving heaps of money on tuition, etc.).

Liquor stores and marijuana dispensaries remain open, and we are well stocked, in part, because of an emergency restock run I sent my assistant on when for two hours it looked like Denver was going to close both down indefinitely as non-essentially businesses and it then changed its mind.

I've been to the pharmacy a couple of times with mask on, my temperature screened, and other unusual precautions.

I managed one trip to the bank before their lobby hours were all closed and have learned to do my banking via a mobile phone app.

Food delivery options are open, but we haven't used any yet. Eating and drinking out has been confined to a single cup of coffee in the last month. My wife and I had one last restaurant meal the night before they were ordered to close. But, we have baked several kinds of bread and otherwise engaged in more ambitious cooking than we have in years at home.

In person visits with friends and family are almost completely over, although we are now having regular multi-person videoconferences with my wife's extended family. A girlfriend of my son from high school, whom he'd been planning to go on a date with in Boston a few days after he was forced to leave, has become his "one friend" whom we've opened our stay at home social circle of in person contact to include and welcome into our home. This makes everything feel slightly more normal and its nice to hear about how this has affected her family, interrupting wedding plans, for example, in the wake of her older sister's engagement.

Everyone in the family is in touch with their friends but only via phone and the Internet. We together followed the story of one of my daughter's college friends whose parents had recently relocated from the U.S. to Taiwan as she managed to catch a last company sponsored chartered flight to get her from Maine to Taiwan as international flights were cancelled en masse, followed by a long and very strict quarantine there as someone coming from a country where the pandemic was more out of control. Most of our friends are experiencing lives much like ours, although things have been particularly tricky for friends with blended families.

We all try to get out for a walk in the neighborhood once a day. I've done the eight o'clock howl several times, although no one else in the family has yet. We've talked with our neighbors about as much as we usually do. Trash collection and street sweeping have continued as normal.

Most stores are closed but a steady stream of packages full of things we might have picked up in person before, show up on our porch, where porch pirates are no longer a concern because we and our neighbors are always home.

I've streamed videos, but only marginally more than I did before, and still read books either downloaded electronically from the library or ordered online with credit card points.

Not overloading with the constant stream of bad news and stupid decisions by our President has been perhaps one of the most difficult parts.

## 17 April 2020

### China's Economy Contracts

BEIJING — The coronavirus outbreak has brought China’s extraordinary, nearly half-century-long run of growth to an end — a stark reminder of the enormous task ahead for world leaders trying to restart the global economy.
Chinese officials on Friday said that the world’s second-largest economy shrank 6.8 percent in the first three months of the year compared with a year ago, ending a streak of untrammeled growth that survived the Tiananmen Square crackdown, the SARS epidemic and even the global financial crisis. The data reflects China’s drastic efforts to stamp out the coronavirus, which included shutting down most factories and offices in January and February as the outbreak sickened tens of thousands of people.
From here.

First of all, I note that on September 27, 2012, I predicted that "China's Great Depression Will Start Post-2014 And Pre-2024." I have stood by that prediction continuously since then. It looks like 2020 has turned out to be the year, although whether this will be a "Great Depression" or merely a serious recession, remains to be seen.

Second, the United States has clearly been more hard hit by COVID-19 than China by almost any measure, including deaths per million people (108.5 v. 3.3), diagnosed cases per million people (2095.4 v. 59.4), with the U.S. rates growing steadily. The death rate per diagnosed case in the U.S. is currently similar to that of China (5.18% v. 5.60%) but is rising rapidly in the U.S. (it exceeds 7% in Michigan and bellwether New York State), while holding steady in China. So, the U.S. will almost surely suffer significantly more than a 6.8% decline in its GDP over a three month period, shifted forward two or three months because the coronavirus hit the U.S. later than it did China.

Economists at the Fed are predicting a 7% GDP contraction in the U.S. for the first quarter of 2020 (roughly the same as China's) but that includes less than a full month of full force coronavirus impact that China was in the full throes of battling for the entire quarter.

## 15 April 2020

### Democrats More Committed To Voting In 2020 Than In Past Years

Republicans consistently vote at high rates. Democrats are more flighty. But, going into the 2020 general election, early indications are that Democratic turnout will be very high, which could be very bad news for Republicans across the board.

Democrats’ intention to vote is also rising more than it is among Republicans, both nationally and in historically competitive battleground states like Wisconsin that Trump narrowly won in 2016, according to more than 66,000 U.S. adults who took the Reuters/Ipsos online poll in the first quarter of 2020 or 2016.
The highly motivated opposition is another sign of trouble for Trump, who saw his chief argument for re-election - a soaring economy and record-low unemployment - evaporate amid a health crisis that has put millions of Americans out of work. Even before the pandemic, Trump struggled to woo independents and moderates he would need to win November’s election, and recent polls showed Trump trailing presumptive Democratic nominee Joe Biden by several points nationwide, as well as in battleground states such as Arizona and Michigan.
According to the Reuters/Ipsos poll, 70% of Democrats said they were “certain” to vote in the upcoming presidential election, 9 percentage points higher than in the first quarter of 2016.
Among Republicans, the increase from 2016 was much smaller – 3 percentage points – with 71% saying they will vote in November.
From here

### Colorado's Democratic U.S. Senate Primary Update

The Democratic nominee for U.S. Senate must replace incumbent Cory Gardner in the general election in 2020 is the Democrats are going to take back the U.S. Senate, and Colorado is a much more Democratic leaning state than it was six years ago when Gardner was elected, who is doing poorly in favorability ratings and head to head polls.

While the polls are stale, Hickenlooper led Gardner 53-40 in an August 2019 poll and also had a commanding lead over Gardner in other polls in August and October of 2019 (53-42 in October 2019) (also here). Polling as of March 5, 2020 suggested that no other U.S. Senate seat is more likely to change parties than Colorado's.

A leading pundit has stated that the U.S. Senate race in Colorado "leans Democratic" noting that "Gardner’s 48%-46% victory in 2014 over then-U.S. Sen. Mark Udall came in part from a strong performance in Congressional District 6. Since then, the district has voted in much greater margins for Democrats."

The Cook Political Report rates the U.S. Senate race in Colorado as a mere toss up, but it is very hard to see hard evidence supporting that conclusion which is too bullish on Garnder's chances.

As of January 31 to February 4, 2020, a poll from the Rocky Mountaineer, a progressive research group showed that: "37% of all voters approve of Gardner’s job performance, less than the 44% who approve of Trump. Among “very conservative Republicans,” 99% approved of Trump, compared to 76% who approved of Gardner."

Most pundits and polling suggest that Colorado will be a relatively safe state for Joe Biden relative to Donald Trump in the President election in November. Colorado backed Democrats by safe margins in the Presidential races in 2008 (Obama), 2012 (Obama) and 2016 (Clinton). See, e.g., here. So, if Gardner is a weaker candidate than Trump in the eyes of Colorado voters, and either Democratic nominee is a stronger candidate than Biden in the eyes of Colorado voters, Gardner's odds of prevailing in the U.S. Senate race are poor indeed. And, Gardner has done basically nothing so far to put political distance between himself and the unpopular Donald Trump, or to court moderate voters in Colorado.

Voter registration has shifted towards Democrats in Colorado since 2014, the state has supported Democrats for statewide office since then. Democrats control both houses of the state legislature in Colorado. The 6th Congressional District is now held by Democrat Jason Crow.

The Democratic party's nominee will be chosen via a mail in primary ballot which must be received by June 30, 2020. There are two ways to get onto the primary ballot. The caucus process culminates in the state Democratic party assembly on Saturday is one way onto the ballot. The other way onto the ballot is to petition onto the ballot.
The race to take on Gardner has included 21 candidates over the past year and a half, the race dwindles to an assembly that pits only former House Speaker Andrew Romanoff, educator Stephany Rose Spaulding and tech entrepreneur Erik Underwood. Romanoff won the U.S. Senate preference poll held at Democratic precinct caucuses on March 7 with 55% of the vote, ahead of Hickenlooper's 30%. Zornio [who announced she was dropping out of the U.S. Senate race today] was third with 6.4%.
Former Gov. John Hickenlooper is assured a place on the June 30 ballot by turning in more than enough petitions to qualify on March 16. Lorena Garcia has submitted petitions and awaits word from the Secretary of State's Office if she has enough valid signatures from qualified voters in each congressional district.
From Colorado Politics (order of paragraphs changed).

Neither Stephany Rose Spaulding nor Erick Underwood have any meaningful chance of getting the 30% support needed to make it onto the Democratic primary ballot from the state assembly, let alone winning in the primary if either of them made it onto the ballot.

Andrew Romanoff will definitely get the top line spot on the Democratic U.S. Senate primary ballot by finishing in first place at the state assembly. John Hickenlooper will also be on the ballot as his petition to do so got sufficient signatures and was approved a month ago, although since he will not be the top finisher in the state assembly, he will not get the top line.

UPDATE (April 18, 2020): The state assembly results (per Morgan Carroll, the state party chair) are as follows:

END UPDATE

So, the only uncertainty is whether Lorena Garcia will manage to have enough signatures to make it onto the primary ballot. This may be an even odds proposition. There isn't even a 1% chance, realistically, that Lorena Garcia will be the nominee. Romanoff and Hickenlooper are at the top of the A list of potential Democratic party candidates, have strong name recognition, and both have wide support among likely Democratic primary voters. Lorena Garcia is almost completely unknown at the state level in Colorado and doesn't have the pre-existing base of support or top level experience that Romanoff or Hickenlooper do, and will be hard pressed to raise any meaningful campaign funds for her bid for the U.S. Senate nomination, even though many Democrats in the abstract would like to have a female woman of color as a nominee.

Hickenlooper easily led Romanoff in primary oriented polling in July and August of 2019.

Romanoff, who was the former Speaker of the State House from a seat representing the Washington Park neighborhood in Denver is the progressive candidate in the race.

Hickenlooper is in the "moderate Democrat" slot who is tarnished most strongly in the eyes of those on the left by his ties to and support for the oil and gas industry in which he was employed as a geologist before he entered the real estate development and restaurant business, after which he became Denver's mayor, and then Colorado's governor. Hickenlooper will almost surely receive more campaign finance support than Romanoff in the Democratic primary, in part, because he has been endorsed by the Democratic Senatorial Campaign Committee to the dismay of grass roots Democrats in Colorado who take umbrage at the national party meddling in their state party primary. Hickenlooper led Romanoff in campaign contributions by roughly 10-1 as of February 3, 2020 (pre-caucus).

Both men are remarkable individuals in terms of personal charisma, talent and political aptitude.

Romanoff's background, running in state house races, has been in face to face, knocking on doors style campaigns which he works harder at than anybody. His previous bid to win the 6th Congressional District, a bellwether for the state, failed, in part, because he didn't transition well to mass media oriented campaigning. Hickenlooper run his races for Denver mayor and Colorado governor with clever campaign ads and by presenting well on television and in the mass media arena that will be critical in a statewide campaign against Gardner.

Either man could win the U.S. Senate race against weak Cory Gardner. Some people think that Hickenlooper is more electable, and that may be true, but the race may not be so close that this really matters given that both candidates are solid ones. This race may not be "in the bag" for Democrats in the general election, but it is probably one of the most likely in the nation to replace a Republican with a Democrat in the U.S. Senate. See also here stating: "Sen. Cory Gardner (R) is considered one of the most vulnerable Republicans in the 2020 election."

I would prefer Andrew Romanoff as Colorado's U.S. Senator whom I supported in caucus, with whom I have something of a personal relationship having worked on many of his campaigns and having contributed to more of them, and will support on my primary ballot in all probability. Colorado could use a true liberal to counterbalance Michael Bennet, the very moderate Democrat who is Colorado's other U.S. Senator. But, I also have a far less negative opinion of John Hickenlooper, who is also an extraordinary man and not as conservative as many on the left believe, than most left leaning Democrats in Colorado, and would be the more competent and political left leaning of Colorado's two U.S. Senators if elected.

### Farewell To Oil and Coal

We aren't there yet. But, the twenty-first century global economy is gradually weaning itself from coal and oil.

The Death of King Coal

The demise of coal is further along. There are basically just two main uses of coal in the economy left. It is used predominantly by utility companies to generate electricity, and to a much, much lesser extent, to make "coke" which is an intermediate product in heavy industrial processes like steel production. In almost every other application, other fuels have been substituted for it.

But, utilities are moving away from coal. Mostly this is because coal fired power plants are a leading cause of air pollution that degrades air quality for breathing (leadings to hundreds of thousands, if not millions, of deaths each year). They are also major contributors to global warming. But, alternatives like renewable energy, nuclear power and natural gas fired power plants are much less air polluting. Coal has other down sides as well. Mining it, frequently via strip mining, destroys the surface environment were it is mines. Solid waste from goal isn't just gross and voluminous. It also has non-negligible levels of toxic and radioactive waste. Mining coal leads to high rates of working injury and work related illnesses. And, the large volumes of coal that are transported, mostly by rail and barge, lead to a non-negligible number of transportation deaths.

Utilities have seen the writing on the wall and pro-actively stripped coal fired power plants out of the electrical grid at a rapid rate, mostly substituting a mix of renewables and natural gas fired plants which are cheaper to build than coal fired plants because they don't need as many expensive pollution controls. Fracking has also increased natural gas supplies. Improve technologies for generating wind power and solar power that have become economically competitive with coal have also tipped the balance. Renewables don't need emissions controls, don't have fuel costs (and hence also do not expose utilities to the uncertainties of oil and gas price fluctuations in the global markets), have seen prices decrease due to manufacturing economies of scale as they have been more widely utilized, and have seen costs fall and efficiencies rise with technological advances in wind turbines and solar power generation.

Renewables recently surpassed coal as a share of the power grid, with a dramatic drop in coal's share of the total since President Trump was elected, despite the fact that we've never had such an overtly pro-coal President. Employment in coal mining and related transportation and coal fired power plant operations have likewise dwindled, reducing the political clout of the coal industry to almost nothing outside of the two leading coal production states in the U.S., West Virginia and Wyoming, and even there coal's political clout is waning.

The cleaner electrical power grid has also made conversion of vehicles from petroleum based fuel internal combustion engines to electricity an environmentally desirable option, which it was not when coal and oil fired power plants were the main source of electricity.

While oil isn't quite as polluting as coal, it is likewise a major source of air pollution, so environmental regulations have discouraged it. Oil has also grown more expensive over time as demand has exhausted lower cost supplies of it, although the development of fracking has increased the availability of higher cost supplies and reduced U.S. oil imports greatly.

For that reason, the economy has also gradually eased away from using oil. It has several main uses.

* Oil based products like gasoline, diesel, jet fuel and boat fuel are still the predominant source of fuel for cars, trucks, trains, construction equipment, farm vehicles, military vehicles, planes, boats, ships and rocket ships. It is also a primary lubricant in those vehicles and many other industrial machines. Cars and trucks make up that lion's share of oil demand in the transportation sector.

* Heating oil is a leading means of home heating and other space heating in the Northeast United States that is built into the architectural infrastructure in a way that takes lots of time and money to replace.

* Oil is used to run electrical power plants in Hawaii and Alaska where transporting coal or natural gas to power plants is more cumbersome. Oil is easier to transport by sea, Hawaii has essentially no local fossil fuel supplies, and Alaska is a major oil production center but has few economically viable coal resources. Gasoline and diesel fuels are also used nationwide to run small electricity generators in places where the infrastructure may be unavailable like construction sites and temporary camp sites, and when utility power grids go out.

* Oil is still used as fuel or a part of an increasingly small share of heavy industrial processes.

* Oil is a major ingredient in non-organic agricultural pesticides and fertilizers.

* Oil is the primary ingredient in plastics and certain other synthetic materials like nylon.

Plant and animal derived liquid oils and alcohols, like biodiesel (derived from animal grease and cooking oils) and corn based ethanol can substitute for petroleum in most circumstances. But, the volumes of liquid hydrocarbons and fuels that can be produced economically from these sources is tiny compared to current petroleum demand. These sources might sustain niche applications, for example, as lubricants, as fuel in construction equipment, farm equipment, off road vehicles, aircraft, boats, and ships, for reduced volumes of pesticides and fertilizers, and plastics. But, these sources would be hard pressed to replace more than a few percent of current petroleum consumption.

A number of technological developments, however, could bring us to a post-petroleum economy.

Prospects For Electric Vehicles

The single biggest one would be better batteries that make electric vehicles economically preferable to gasoline and diesel fueled cars and trucks. We are at the brink of this transition. Completely plug in electric cars are now mass produced by multiple major automobile manufacturers including Nissan, BWM and the all electric firm, Tesla. Almost every major automobile manufacturer makes small electric vehicles in at least pilot project volumes and has plans to make many more.

These vehicles are living proof that the only barrier to electric vehicles is the batteries. In all other respects, electric vehicles are prefect or superior substitutes for conventional gasoline and diesel powered vehicles with no vehicle locus emissions, generally better accelerations at low speeds, much lower energy costs per mile, less noise, and fewer maintenance requirements because electric motors are simpler and having fewer moving parts that need to be maintained. Four wheel drive for electric vehicles is simply a software issue that has been solved, although not yet widely adopted.

Electric vehicle technologies also scale well. They are as well suited to industrial scale construction machinery and farm tractors as to subcompact cars.

Basically the only issue is that different electric vehicle applications have different battery or power source demands. Trains don't need batteries at all, and can be plugged in. Long haul ships and trucks need lots of range. Propeller aircraft can work but need very high energy density of their ranges are very constricted. Intracity urban transportation requires less range and less widely adopted charging infrastructure than intercity and rural transportation.

Batteries are the sole barrier. There are several attributes of electric vehicle batteries that are desirable: (1) cost, (2) range and energy density,  (4) speed of recharging, (3) cold temperature sensitivity, (5) battery lifetime and charging repeatability, and (6) the environmental impact of battery production.

The current mass produced standard for electric vehicle batteries is satisfactory in many applications but still limiting.

Electric vehicles are more expensive than gasoline and diesel vehicles due to battery costs that is really only competitive cost-wise without subsidies, despite lower per mile fuel costs, at gasoline prices on the order of \$6-\$8 per gallon, when gasoline is currently selling at record lows for under \$2 a gallon in the U.S. and is at \$4 per gallon in even the most expensive U.S. markets in normal times. In Europe and much of the rest of the world, gasoline prices at twice as high or more so the tipping point is much closer. But, the long term trend since petroleum is not a renewable resource will always be up even though fracking put a short term dent in that trend.

Tesla electric vehicles have a range on a full charge comparable to a gasoline or diesel powered vehicle, but take half an hour to a full evening to recharge depending on the voltage of the charging station, compared to a few minutes to refuel an ordinary car's gas tank, and the amount of high voltage charging infrastructure in place is still modest. The energy density of batteries is also modest enough that it adds a significant share of the total weight of the vehicle, and the large volume of battery material needed drives up their cost and increases the amount of energy the vehicle needs to attain a particular range. Electric vehicle battery performance, in terms of range, is significantly degraded in frigid winter temperatures.

It appears that current electric vehicle batteries usually last at least 100,000 miles, but replacing them even once during the lifetime of a vehicle significantly adds to the lifetime cost of the vehicle, and since batteries degrade in performance gradually over time, used electric vehicles have less range per full charge.

Most electric vehicle batteries are either lead acid, or lithium based. Both are very problematic environmentally.

Progress is being made on all fronts. Electric vehicle battery prices are falling rapidly which reduces the price of electric vehicles overall. The development of batteries with more energy density, more recharging longevity, and less environmental impact is making rapid progress because of the huge potential economic payoff for doing so now that electric vehicles are approaching a tipping point.

Other changes are also being made in the context in which electric vehicles need to fit. High voltage charging infrastructure is on its way to being more standardized and more widely available. Japan, China and Europe have good passenger rail systems that reduce the need for long distance trips. There are lots of niche applications in which long range and an excellent charging station network aren't necessary. Vehicle sharing and rentals can reduce the need for peak range vehicles that are used that way only infrequently.

Other Changes

Space heating in the Northeast could transition to natural gas or electricity in a major initiative.

The power girds in Alaska and Hawaii could be shifted away from oil to nuclear and/or natural gas and/or renewables (e.g. tidal and wind power).

Organic agriculture makes a dent in petroleum demand, albeit a small one.

Reduced use of plastics makes a dent in petroleum demand, albeit a small one.

More fuel efficient vehicles, greater transit use, and urban planning to reduce transportation requirements can reduce petroleum demand.

## 14 April 2020

### ADHD and Learning Disability Rates By Race, Education and Income

ADHD and Learning Disability Diagnosis Rates In the U.S.

About one in seven children aged 3 to 17 in the United States have been diagnosed with ADHD (attention deficit hyperactivity disorder) or a learning disability. There are racial and ethnic disparities in ADHD and learning disability diagnosis rates in the U.S., but they are smaller than many people believe them to be, and are different than many people believe them to be.

Black kids are diagnosed about 15% more often than white kids, while Hispanic kids are diagnosed about 19% less often than white kids.

Kids from households in poverty are more likely to be diagnosed than those who are not, with the difference being especially great for white kids, who are 80% more likely to be diagnosed if they are poor than if they are not poor (compared to 33% for black kids and 29% for Hispanic kids).

Black and Hispanic kids are slightly less likely to be diagnosed if the mostly highly educated parent in their household has no education beyond high school (-2% and -6% respectively). White kids are much more likely to be diagnosed (+60%) if the mostly highly educated parent in their household has no education beyond high school.

Analysis

The Question And The Metaquestion

To figure out why the disparities are present, we have to consider two factors.

First, are some kids more likely to be diagnosed than others, despite having the same symptoms, and if so, why? The diagnosis of ADHD and learning disabilities is a mix of art and science and the accuracy of such a diagnosis is hard to determine objectively and with precision.

Second, if there are genuinely different rate of prevalence between subgroups, why is that the case?

Hypotheses

For example, the higher overall rate of diagnosis for black kids could be due to cultural differences being misinterpreted by teachers and psychologists as ADHD or a learning disability, or could be due to actual differences in prevalence rates (e.g. due to higher rates of lead exposure at home).

The lower rate of overall diagnosis for Hispanic kids could be due to language issues masking issues that are actually ADHD or a learning disability. But, it could also be an instance of the "fit immigrant" hypothesis at work, in which people who choose to emigrate from their home country are, on average, over a broad range of measures, more fit than those who stay at home, and parental fitness may in turn lead to greater child fitness since ADHD and learning disabilities have significant hereditary components. It could even be that actual rates are lower, but the conditions are over diagnosed for cultural reasons.

Higher rates of diagnosis for poor kids could be due to actually higher rates due to hereditary factors, since parents who had ADHD or learning disabilities are more likely to be poor than those who lack them.

But, the very high rates of diagnosis for white kids who are poor or who have parents who have no more than a high school education, relative to those who are not poor and/or have more educated parents, also suggests that teachers and psychologists see poor performance in white kids as due to a cause like ADHD or a learning disability, because they have higher expectations for those kids (whose co-ethnic peers are less likely to be poor or to have parents whose highly level of educational achievement is high school only), while they may see black or Hispanic kids who have behavior issues or trouble in school as merely "normal" because they have lower expectations for them. This could be true independent of whether ADHD and learning disabilities are over or under diagnosed. It could be that almost all white kids but only some non-white kids with these conditions are diagnosed, or it could be that lots of the white kids who are diagnosed have been inaccurately given a diagnosis that actually has some other cause.

The fact that diagnosis rates differ very little based on parental education for black and Hispanic children, and not by all that much across racial lines, could be seen as evidence that prevalence rates are pretty similar in all groups and that diagnosis rates mostly reflect that except for poor white kids and white kids in less educated households who may be over-diagnosed.

There is no statistical indication that more educated parents are pushing hard to have children who otherwise wouldn't be diagnosed tagged as having ADHD or a learning disability. But, even that can't be adequately resolved without knowing how much of the statistical differences are due to diagnosis rates relative to actually symptoms and how much of the differences are due to true differences in prevalence. My intuition from life experience is that children of more educated parents have lower incidences of actual ADHD and learning disabilities, but higher rates of diagnosis.