Monday, March 23, 2020

The lockdowns cometh

This paper appears to be the primary rationale behind the nationwide lockdowns that are being gradually imposed by governments around the world:
The optimal timing of interventions differs between suppression and mitigation strategies, as well as depending on the definition of optimal. However, for mitigation, the majority of the effect of such a strategy can be achieved by targeting interventions in a three-month window around the peak of the epidemic.  For suppression, early action is important, and interventions need to be in place well before healthcare capacity is overwhelmed. Given the most systematic surveillance occurs in the hospital context, the typical delay from infection to hospitalisation means there is a 2- to 3-week lag between interventions being introduced and the impact being seen in hospitalised case numbers, depending on whether all hospital admissions are tested or only those entering critical care units. In the GB context, this means acting before COVID-19 admissions to ICUs exceed 200 per week.

Perhaps our most significant conclusion is that mitigation is unlikely to be feasible without emergency surge capacity limits of the UK and US healthcare systems being exceeded many times over. In the most effective mitigation strategy examined, which leads to a single, relatively short epidemic (case isolation, household quarantine and social distancing of the elderly), the surge limits for both general ward and ICU beds would be exceeded by at least 8-fold under the more optimistic scenario for critical care requirements that we examined. In addition, even if all patients were able to be treated, we predict there would still be in the order of 250,000 deaths in GB, and 1.1-1.2 million in the US.

In the UK, this conclusion has only been reached in the last few days, with the refinement of estimates of likely ICU demand due to COVID-19 based on experience in Italy and the UK (previous planning estimates assumed half the demand now estimated) and with the NHS providing increasing certainty around the limits of hospital surge capacity.

We therefore conclude that epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound. Many countries have adopted such measures already, but even those countries at an earlier stage of their epidemic (such as the UK) will need to do so imminently.
Basically, the less strict the measures, the more likely it is that the number of people requiring treatment will overwhelm the available medical serves at the peak. Hence the term "flattening the curve" which refers to the peak of the bell curve. Different nations are at very different risk in this regard; Germany has 25,000 ICU beds with full respiratory support, or one for every 3,312 people, vs 4,000 for the UK, or one for every 16,610 people.

The USA has 32,000 ICU beds, which puts it right in between at one ICU bed for every 10,000 people. This means that if the mitigation calculations are correct, the medical resources would be overwhelmed by a factor of 8x, thereby leading to fatalities in excess of 2 million. The suppression measures are expected to reduce that by three orders of magnitude, which is why it is safe to expect that they will be imposed, sooner rather than later, in the US, the UK, and other countries that have not yet officially adopted them.

UPDATE: As expected, the UK announced a three-week nationwide lockdown.



Blogger Attila is my bro March 23, 2020 11:14 AM  

Lockdown already here in NY. Mob capo Andrew Cuomo has declared a "business pause".

No idea how long it will last. No one is talking about it. This is massively crashing the economy. The only silver lining is a simultaneous crashing of tax revenue.

Blogger MDN March 23, 2020 11:24 AM  

In 2009 during the Swine Flu pandemic the Chief Medical Officer of the UK was predicting upwards of 50,000 deaths in the UK, with 3,300 as the best case scenario.

Actual Deaths:241

Blogger MDN March 23, 2020 11:34 AM  

"The major challenge of suppression is that this type of intensive intervention package –
or something equivalently effective at reducing transmission – will need to be maintained until a vaccine becomes available (potentially 18 months or more)"

This is insanity. They are recommending we to stop the world for at least 18 months(!) until SCIENCE can save the day with a vaccine

Blogger Johnny March 23, 2020 11:34 AM  

There is good reason to believe that the cure for malaria, Chloroquine, is effective treatment for the CoronaVirus. Trump is pushing it even as the FDA wants to proceed at its normal slow pace. And the press the usual, including google search, is all anti Trump all the time. Despite the fact that the drug has been in heavy duty use in Africa for decades, the pretend thing now is that the drug is highly dangerous. It has its side effects, but if you are in an ICU unit dying, it is not that big a risk. Our popular media has become as disgraceful as the Chinese Communists. All politics all the time.

Blogger Brett baker March 23, 2020 11:40 AM  

This is better than the "Tell us the truth, man! We can handle it. We're all going to die, aren't we?" we get from some quarters.

Blogger rikjames.313 March 23, 2020 11:42 AM  

In our state the governor really wants to be Biden's vice president. For that reason she imposed a partial shutdown on everyone but exempted churches to keep the black vote. The churches, as expected, were full in Detroit and the other inner cites.

So she just ordered everyone to stay home as a cover for closing churches. Under the terms of her order it lasts until Jewish Passover ends.

Blogger Ominous Cowherd March 23, 2020 11:45 AM  

Going to guess that most of us did some back of the envelope calculations several months ago, and figured most of that out. Act early, or your actions don't really matter. Act late, and you find you can't act at all, because everything fell apart.

Blogger Baseball Savant March 23, 2020 11:56 AM  

Kind of not related, so mods feel free to delete this comment or not post it, but has anyone had any updates on the Junior Classics? The original page said delivery in March of 2020 but I'm guessing that is off with all the Kung-Flu going on. I was just curious if anyone had any information.

Blogger Stilicho March 23, 2020 11:57 AM  

What's your source for 32k icu beds in US? I saw a report last week that stated around 68' icu beds in US. I will have to see if I can find it again.

Additionally, other hospital rooms can be converted to icu-lite as it were for less serious cases that still require hospitalization. Limited number of ventillators still poses a problem. Italian-style age based triage will be used when numbers hospitalized requires it.

Blogger Stilicho March 23, 2020 12:10 PM

This suggests around 100k total beds with around 60k suitable for use for cchinese virus case (obviously other needs for ICU beds will need to be considered as well).

Blogger Gravedigger March 23, 2020 12:13 PM  

Gas is the cheapest in like 20 years and now we aren't allowed to go anywhere.

Blogger Homesteader March 23, 2020 12:23 PM  

Issue is TOTAL ICU beds (95,000, U.S), vs. AVAILABLE ICU beds (8-10% ? depending, at any one time).

Against a U.S. adult population of about 209,000,000..

(10% of total ICU beds)= 1 ICU bed for every 23,200 adult americans,
Depending on the vacancy rate.

Blogger crescent wrench March 23, 2020 12:24 PM  

The small business community is already gagging on its last breath due to the draconian measures, with unemployment claims hitting 07/08 crash levels over the course of a week or so.

What's the over/under on the number of people who could die in the civil unrest and suicide epidemic caused by a depression?

Blogger Wadly March 23, 2020 12:24 PM  

Wisconsin to "lock down" tomorrow according to a Gov Evers tweet.

Blogger Oswald March 23, 2020 12:30 PM  

What other measures are they going to take down the road that we are not seeing yet?

Blogger JonM March 23, 2020 12:31 PM  

It has already come to America. The State of Hawaii has issued a 'shelter in place' order effective as of 4PM today.

Hawaiian Airlines will effectively cease operations as of Thursday.

Blogger Lyon March 23, 2020 12:34 PM  

The phrase "shelter in place" is being droned into us here in North America. There has been a pattern in this region where an idea floated one day is the rule the next. Locally, for example, the mayor requests compliance on such and such, and a day or two later it's mandatory. The very word "lockdown" is in the headline of various news reports from the "Authorities"... doctors, politicians, the usual suspects.

Blogger JohnofAustria March 23, 2020 12:47 PM  

Yeah, but even that seems to assume that we'll have that many cases requiring that level of treatment. Which I have yet to see demonstrated. South Korea's numbers seem to show high-security cases will be a fraction of a percent.

Blogger Silly but True March 23, 2020 12:52 PM  

It makes sense. What’s the next solution once hospitals are overwhelmed: families watching their loved ones die agonizingly before their eyes in home quarantine, then placing dead bodies outside front door for later pickup.

In 2020, there’s no politician who wants to see that solution in effect.

They say elections have consequences; in this case, it’s meant the future elections are impacting what’s being done now.

Blogger Steb March 23, 2020 12:59 PM  

This comment has been removed by the author.

Blogger VD March 23, 2020 1:03 PM  

South Korea's numbers seem to show high-security cases will be a fraction of a percent.

Because South Korea already took the measures that the USA is now contemplating. They didn't even have to mandate most of them because Asian culture is much more compliant than Western culture.

Blogger VD March 23, 2020 1:04 PM  

has anyone had any updates on the Junior Classics?

Delay of at least two months, but probably not much more than that.

Blogger peacefulposter March 23, 2020 1:12 PM  

The God Emperor is already talking about loosening the lock down as the cure is worse than the disease.

Blogger Steb March 23, 2020 1:16 PM  

If anything good comes out of this for the UK, please let it be us finally accepting that 'our NHS' is fundamentally broken.

Both us and the Americans need to find out what the Germans are doing and copy them!

Blogger Stilicho March 23, 2020 1:18 PM  

)(10% of total ICU beds)= 1 ICU bed for every 23,200 adult americans,
Depending on the vacancy rate.(

When checking the total number of icu beds, I found another study which found chronic overuse of ICU beds, primarily for elderly patients for end of life care (supply creating its own demand, icu beds were available, so they used them). So I suspect the percentage of available beds is much higher than 10% especially once they stop using them for end of life care.

Blogger Jay Will March 23, 2020 1:22 PM  

Draining the swamp is taking on a whole new meaning.

Blogger Kiwi March 23, 2020 1:34 PM  

I found it difficult to get actual data on how many ventilated beds we had in NZ. A report from The Ministry of Health (2005), showed us below Germany, which looked to be the gold standard. Hence, I mused that Germany was doing well because of their bed per person ration.

As countries report their beds in a different manner I haven't been able to work out exactly how many isolated and ventilated beds America has. I heard Trump mumble something about 10 000 respirators and 2000 more coming/being made, which I thought was very low. He may have been talking about something entirely different.

We're officially on lockdown in 24hrs and our trigger number was 102 cases/5M population. Following the 2005 report mentioned above, we were supposed to bring up our health system to the German standard but I'm not sure we have. My guestimate is, at worse, we had 1 isolated and ventilated bed per 16000.

I'm guessing we triggered at a similar ratio to America, as we seem to be following their every move, but until I sift through the data to find accurate bed numbers I'm just speculating.

Blogger Kiwi March 23, 2020 1:39 PM  

Re South Korea: Some Kiwi who are there say it's wonderfully calm and no panic buying etc like in NZ. They are happy with their choice to stay.

Blogger JohnofAustria March 23, 2020 1:42 PM  

Yeah, that's the absolutely maddening thing. The idea of indefinitely drawing this out instead of calling it is nuts.

Blogger Silly but True March 23, 2020 1:45 PM
AHA: “ AHA data: According to the AHA 2015 annual survey, the United States had 4862 acute care registered hospitals; 2814 of these had at least 10 acute care beds and at least 1 ICU bed. These hospitals had a total of 540,668 staffed beds and 94,837 ICU beds (14.3% ICU beds/total beds) in 5229 ICUs. There were 46,490 medical-surgical beds in 2644 units, 14,731 cardiac beds in 976 units, 6588 other beds in 379 units, 4698 pediatric beds in 307 units, and 22,330 neonatal beds in 920 units. The median number of beds in medical-surgical, cardiac, and other units was 12, with 10 beds in pediatrics and 18 in neonatal. Fifty-two percent of hospitals had 1 unit, 24% had 2 units, and 24% had 3 or more units.”

HCRIS: “ In 2010 there were 2977 acute care hospitals with ICU beds. In these, there were 641,395 total acute care beds with 103,900 ICU beds (16.2% ICU beds/total beds). From 2000 to 2010, the number of critical care beds in the United States increased by 17.8%, from 88,235 to 103,900. However, the majority of the growth in critical care bed supply is occurring in a small number of U.S. regions that tend to have large populations, fewer baseline ICUs per 100,000 capita, higher baseline ICU occupancy, and increased market competition. Additionally, between 2000 and 2010, the greatest percentage increases were in neonatal beds (29%), followed by adult beds (26%); there were minimal changes in pediatric beds (2.7%). Of the 103,900 ICU beds in 2010, 83,417 (80.3%) were adult, 1917 (1.8%) were pediatric, and 18,567 (17.9%) were neonatal. In total, there were 33.6 beds per 100,000 population, 35.5 beds per 100,000 adult beds (age > 18 years), 2.7 beds/100,000 pediatric beds (age 1-17 years), and 470 beds/100,000 neonatal beds (age < 1 year).

ICU days: HCRIS analysis showed that there were 150.9 million hospital days, including 25 million ICU days in 2010 (16.5% ICU days/total days). Medicare accounted for 7.9 million ICU days (31.4%) and Medicaid 4.3 million ICU days (17.2%).

Occupancy: Occupancy rates were calculated from HCRIS (days/possible days) data. In 2010, hospital and ICU occupancy rates were 64.6% and 68%, respectively. Occupancy rates vary by hospital size, with higher occupancy rates associated with larger hospitals.”

Anonymous Anonymous March 23, 2020 1:52 PM  

This document published by the German government in 2013 described their plans for a pandemic.

No doubt there’s one like it in every western nation.

Professionally I’ve worked for about 20 years as a project manager and consultant so I have no objections to planning.

But this plan describes responses to a corona virus breaking out of Asia in February, having a high transmission and mortality thus requiring lockdowns of communities, business closures, massive economic hardships and basically everything that is now being done and experienced.

Now one could say that sometimes we get lucky and our worst case scenario is a good match for reality, and this our plans are spot on, and yes that’s possible.

What perturbs me the most about the matches between this highly theoretical plan and the new corona virus is that the document goes on to say that these measures may be required for years.

International tourism will be dead (except for the elite).
International trade of any kind drastically reduced (except for the largest companies).
Most small business will be extinct, as will many of their owners, families of same etc.

On the bright side, when the elite go skiing there’ll be no queues, the air will be clean, and the whales multiplying.

So, there’s that.

Blogger Vagn J March 23, 2020 1:55 PM  

Why do you say it is a bell curve?

It is not the result of a stochastic process.

Blogger JohnofAustria March 23, 2020 1:55 PM  

Well, that's highly unlikely anyways, as the asymptomatic rate is something like %80+, and less than 1% need hospitalization.

Anonymous Anonymous March 23, 2020 1:55 PM  

Gas is the cheapest in like 20 years and now we aren't allowed to go anywhere.

Gas is cheaper than it’s been in 20 years BECAUSE we aren’t allowed to go anywhere.

Cause and effect, my love.

Blogger JohnofAustria March 23, 2020 1:57 PM  

Right, I meant that people seem to be operating as though half the people who get it go to the hospital, when the rate is way lower, like less than 1% (although still above capacity if clustered).

Blogger Zastavnik Džemo March 23, 2020 2:02 PM  

At this point I think they are just intentionally destroying economy so they can blame next financial crisis on Corona.

Blogger Kiwi March 23, 2020 2:04 PM  

@MDN Here we had 19 deaths from swine flu. The infection rate for corona is around the same in the same amount of time. We were one month closer to winter then and we didn't shut the borders like this last time, so it could be travelling a lot faster. Also, last time it was in the community two weeks after it reached this level of cases, and the, at the time, containment strategy was abandoned and we moved to community care.

I find it a useful metric. I've looked at the American data too.

Blogger Baseball Savant March 23, 2020 2:14 PM  

Delay of at least two months, but probably not much more than that.

Thanks VD

Blogger Mjoll March 23, 2020 2:34 PM  

Oregon just pulled the trigger. No end date either until Ol' Kate calls it.

Blogger Calvin809 March 23, 2020 2:55 PM  

The MN governor is about to hold a press conference. The teachers here have been working on getting remote learning set up.

Blogger History Diver March 23, 2020 2:58 PM  

According to the Swedish intensive care registry Sweden had 526 available ICU beds in 2019. This is a pathetic 1 ICU per 19,240 inhabitants or so.

They are trying to expand capacity at moment but it is a slow going because the limiting factor is materials such as respirators. To be compared with 1993 when Sweden had a total of 4300 respirators ready to be deployed.

Blogger JohnofAustria March 23, 2020 3:02 PM  

Boy, talk about a hysterical reaction, amirite???

Blogger RJ March 23, 2020 3:04 PM  

What other measures are they going to take down the road that we are not seeing yet?

1. Everyone is confined to their homes. National guard units will deliver your ration every week.
2. Everyone receives a 3am visit from the Corona vaccination team. You WILL accept the Bill Gates Mark of the Beast vaccination.

Blogger Jack Amok March 23, 2020 3:04 PM  

Strangely enough, Inslee is resisting calling it in WA, even though he has a bunch of people asking him to.

Blogger RJ March 23, 2020 3:05 PM  

Gas is cheaper than it’s been in 20 years BECAUSE we aren’t allowed to go anywhere.

Cause and effect, my love.

That's not it, you moron. Russia and Saudi Arabia are engaged in a price war. It has almost nothing to do with the current panicdemic.

Blogger Damelon Brinn March 23, 2020 3:09 PM  

A couple EMTs on /pol/ said they think their call volume is down because the people who normally use the ambulance as a taxi service aren't calling because they don't want to get hauled in with the corona patients. One said when they show up all gowned and masked, people tend to get better all of a sudden when they find out there's no non-corona hospital to be taken to.

That could explain why emergency rooms are emptier than expected too.

Blogger Stilicho March 23, 2020 3:23 PM  

@silly but true: those were the 2 docs I rferred to up above. Looks like 32% availability of ICU beds at normal rates and thats before any triage. So roughly 20k icu beds open right now with more available if triage necessary a la Italy.

Blogger English Tom March 23, 2020 3:24 PM  

@Crescent Wrench

Dont forget to factor in the murder rate as everyone gets on each others nerves during lockdown.

Went shopping today and most places refusing to accept cash. Card payments only. A digital currency on the way peeps. All those drug dealers with millions in paper notes stashed are going to be fucked!

Blogger Stilicho March 23, 2020 3:25 PM  

20k open right now for adults. Pediatric beds might be converted if not needed for children adding to supply.

Blogger Kat March 23, 2020 3:36 PM  

Joe Pilot on twitter says that independent medical practices are about to go belly up since they can't in good conscious bring in any but the sickest of patients in order to curb the spread.

He also says that most hospitals are critically low on PPE but that they are otherwise not seeing the surge in COVID cases. He's optimistic about the medical capacity, but the economic impacts :/

OTOH farmers, co-ops, and farmer's markets are BOOMING right now. Demand for local agricultural connections and the awareness that we need local ag seems to be increasing.

I don't know how this will all get put back together - Joe Pilot seems to think the mega hospitals will be the winners - but certain sectors of the economy seem like they'll come out ahead.

And if this makes a lot of people rethink education then PTL!

Blogger Gettimothy March 23, 2020 3:47 PM  

Screw lockdowns. Hug Nancy Pelosi, hug Chuck Schumer, hug a neocon! George Bush? Cmere baby let me give you a hug. Hugs for the ruling class, the jet set.

Blogger Brett baker March 23, 2020 3:49 PM  

They charge enough taxes to pay for semi-decent health care, and then make people pay for private insurance if they want nice health care. Also, their doctors spend a year and a half less in college than ours do.

Blogger Rex Leroy King March 23, 2020 4:00 PM  

Baseball Savant wrote:Kind of not related, so mods feel free to delete this comment or not post it, but has anyone had any updates on the Junior Classics?

VD wrote:has anyone had any updates on the Junior Classics?

Delay of at least two months, but probably not much more than that.

Work is underway on all ten volumes. It may please you to know that homeschooled children are participating in the typesetting.

Blogger KPKinSunnyPhiladelphia March 23, 2020 4:02 PM  

Wisconsin shutting down? You mean Fond du Lac? Baraboo?

Sorry, this is insane.

Blogger Akulkis March 23, 2020 5:05 PM  

"Gas is the cheapest in like 20 years and now we aren't allowed to go anywhere."

Not being allowed to go anywhere is *WHY* gas is cheap. Low demand leads to low prices.
In other breaking news, water is wet, and ice is cold.

Blogger Hammerli 280 March 23, 2020 5:08 PM  

@23: Yes. I figure that the economy and the electorate can stand perhaps three weeks more of shutdown. After Easter, it all comes apart. Either the shutdown worked, and is no longer needed; or it failed, and is no longer needed. In any event, it will be time to get back to work.

Blogger Centurion Revolt March 23, 2020 5:45 PM  

"Give up your freedoms so you don't catch the virus. By the way, you're probably going to catch the virus anyway; we're just trying to level off the cases."

Blogger bramley say Enoch woz right March 23, 2020 5:56 PM  

Here we go here we go here we go, here we go here we go here we goooo-ooo!!

Blogger Akulkis March 23, 2020 7:01 PM  

Boomers: How dare they shut down our party-party-party lifestyle! "

Blogger Akulkis March 23, 2020 7:09 PM  

"There has been a pattern in this region where an idea floated one day is the rule the next."

A5 least that gives you a warning of what policy is on the way. Enough time to make small adaptations without the ability to take advantage of the situation, not evade it.
Could be much worse. The situation is fluid, and because we have done quarantines since the Boomers were children, nobody left in government even has memories of how to run these things.
What most of them and us remember is, "Johnny got the chicken pot? HEY KIDS, everybody go over and play at Johnny's house to keep his spirits up!"

Blogger Akulkis March 23, 2020 7:17 PM  

"Why do you say it is a bell curve?

It is not the result of a stochastic process."

Just roll with it. The point isn't the shape of the curve -- the point is to keep the number of cases active at any one time (vertical) small, even if that means extending the durstion (width).

Blogger Avalanche March 23, 2020 8:39 PM  

@9 " Limited number of ventilators still poses a problem."

Lots of folks keep bringing up ways to increase the "ventilator availability" -- they've been lauding that nurse who figured out how to hook 7-9 patients to one ventilator... but without a trained, educated, and preferably experienced respiratory therapists to MONITOR all these ventilators, what's the point?! And even if they draft nursing students -- or even family members! -- to 'watch and call for help' -- how can respond?! If seven folks are being ventilated by one machine, and three of the 'watchers' call for help? What then? First come, first serve?

Italy has gone to: "you're over 60? No respirator for you!" Why does anyone think we're not going to have to go there too? All this 'saving granny' must have some purpose OTHER than: expend all our resources to save folks who cannot be saved. Is it to keep the focus ON the old, so the virus gets a better spread before everyone begins to notice the young are no less jeopardized? Sure, the older and co-morbids have a grater death rate -- but that's true for ANY thing that comes around, even heavily polluted days!

I self-isolated three weeks ago because I have 3-4 things that might make me more likely to react badly: if you have not watched Medcram#37 -- and learned about high blood pressure meds and their effects of creating more ACEII receptors in lungs? -- maybe go do so. Or not.

Blogger Avalanche March 23, 2020 8:47 PM  

@30 Great (scary) ICU bed numbers.

Ever been to an ICU? It's NOT private rooms with negative pressure. It's a ward with wide aisles and space between the beds to put crash carts, ventilator, and the like. 8-10-12 desperately sick folks -- **all in one room** so nurses can keep a close on eye on the them all at the same time.

Now, bring in a highly contagious patient needing an ICU bed... OOPS! The numbers don't reflect adequately the availability of contagion rooms.

Blogger Jack Amok March 23, 2020 8:49 PM  

Strangely enough, Inslee is resisting calling it in WA, even though he has a bunch of people asking him to.

Whelp, not resisting it any longer. "Stay at home" for WA too. I don't suppose pictures of hundreds of people at popular day hikes helped. Or the spike in Search-and-Rescue calls for stranded hikers. A bunch of people treated it like a coronacation.

Blogger Jack Amok March 23, 2020 9:16 PM  

I'm not sure what percentage of ICU beds are typically occupied by car crash victims, but King County car crashes are down 75% from the same week last year, and there were zero deaths vs 12 for the same week in 2019.

Oh, and gas is cheap, but all the gas stations in our town were out of it today. Hmmmm....

Blogger furor kek tonicus ( *autistic screeching* ) March 23, 2020 9:41 PM  

59. Akulkis March 23, 2020 7:01 PM
Boomers: How dare they shut down our party-party-party lifestyle! "

Boomers: +60 years old and all the responsibility of a Spring Break college student AND a higher STD rate.

don't worry, all you NABALTS.

we promise to pillow you last, and with all the tender loving care with which we were raised.


Blogger Unknown March 23, 2020 9:44 PM  

The lockdowns will end when the toilet paper runs out.

Blogger Akulkis March 24, 2020 10:13 AM  

The toilet paper isn't going to run out. The plants aren't shut down, and we have a perpetual supply of pine to pulp down as feed stock.

Blogger JohnofAustria March 24, 2020 1:48 PM  

I'm still highly dubious of the numbers behind their death and case prediction coming anywhere near what actually happens.

Blogger Boaty Bear March 25, 2020 5:27 PM  

This ^

Meanwhile, the Rothies print loads o money

GE spends it on
Destroying the Dems
Ending HT
Scamdemic reparations
The Wall

He then tells them to FO using EOs 13818 and 13825 in particular.

is my guess while everyone's having one.

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