Vaccinating people who have had Covid 19: Why doesn't natural immunity count in the US ?

The US CDC estimates that SARS-CoV-2 has infected more than 100 million Americans, and evidence is mounting that natural immunity is at least as protective as vaccination. Yet public health leadership says everyone needs the vaccine. Jennifer Block investigates

When the vaccine rollout began in mid-December 2020, more than one quarter of Americans—91 million—had been infected with SARS-CoV-2, according to a US Centers for Disease Control and Prevention (CDC) estimate.1 As of this May, that proportion had risen to more than a third of the population, including 44% of adults aged 18-59 (table 1)

The substantial number of infections, coupled with the increasing scientific evidence that natural immunity was durable, led some medical observers to ask why natural immunity didn’t seem to be factored into decisions about prioritising vaccination.234

“The CDC could say [to people who had recovered], very well grounded in excellent data, that you should wait 8 months,” Monica Gandhi, an infectious disease specialist at University of California San Francisco, told Medpage Today in January. She suggested authorities ask people to “please wait your turn.”4

Others, such as Icahn School of Medicine virologist and researcher Florian Krammer, argued for one dose in those who had recovered. “This would also spare individuals from unnecessary pain when getting the second dose and it would free up additional vaccine doses,” he told the New York Times.5

“Many of us were saying let’s use [the vaccine] to save lives, not to vaccinate people already immune,” says Marty Makary, a professor of health policy and management at Johns Hopkins University.

Still, the CDC instructed everyone, regardless of previous infection, to get fully vaccinated as soon as they were eligible: natural immunity “varies from person to person” and “experts do not yet know how long someone is protected,” the agency stated on its website in January.6 By June, a Kaiser Family Foundation survey found that 57% of those previously infected got vaccinated.7

As more US employers, local governments, and educational institutions issue vaccine mandates that make no exception for those who have had covid-19,8 questions remain about the science and ethics of treating this group of people as equally vulnerable to the virus—or as equally threatening to those vulnerable to covid-19—and to what extent politics has played a role.

The evidence

“Starting from back in November, we’ve had a lot of really important studies that showed us that memory B cells and memory T cells were forming in response to natural infection,” says Gandhi. Studies are also showing, she says, that these memory cells will respond by producing antibodies to the variants at hand.91011

Gandhi included a list of some 20 references on natural immunity to covid in a long Twitter thread supporting the durability of both vaccine and infection induced immunity.12 “I stopped adding papers to it in December because it was getting so long,” she tells The BMJ.

But the studies kept coming. A National Institutes of Health (NIH) funded study from La Jolla Institute for Immunology found “durable immune responses” in 95% of the 200 participants up to eight months after infection.13 One of the largest studies to date, published in Science in February 2021, found that although antibodies declined over 8 months, memory B cells increased over time, and the half life of memory CD8+ and CD4+ T cells suggests a steady presence.9

Real world data have also been supportive.14 Several studies (in Qatar,15 England,16 Israel,17 and the US18) have found infection rates at equally low levels among people who are fully vaccinated and those who have previously had covid-19. Cleveland Clinic surveyed its more than 50 000 employees to compare four groups based on history of SARS-CoV-2 infection and vaccination status.18 Not one of over 1300 unvaccinated employees who had been previously infected tested positive during the five months of the study. Researchers concluded that that cohort “are unlikely to benefit from covid-19 vaccination.” In Israel, researchers accessed a database of the entire population to compare the efficacy of vaccination with previous infection and found nearly identical numbers. “Our results question the need to vaccinate previously infected individuals,” they concluded.17

As covid cases surged in Israel this summer, the Ministry of Health reported the numbers by immunity status. Between 5 July and 3 August, just 1% of weekly new cases were in people who had previously had covid-19. Given that 6% of the population are previously infected and unvaccinated, “these numbers look very low,” says Dvir Aran, a biomedical data scientist at the Technion–Israel Institute of Technology, who has been analysing Israeli data on vaccine effectiveness and provided weekly ministry reports to The BMJ. While Aran is cautious about drawing definitive conclusions, he acknowledged “the data suggest that the recovered have better protection than people who were vaccinated.”

But as the delta variant and rising case counts have the US on edge, renewed vaccination incentives and mandates apply regardless of infection history.8 To attend Harvard University or a Foo Fighters concert or enter indoor venues in San Francisco and New York City, you need proof of vaccination. The ire being directed at people who are unvaccinated is also indiscriminate—and emanating from America’s highest office. In a recent speech to federal intelligence employees who, along with all federal workers, will be required to get vaccinated or submit to regular testing, President Biden left no room for those questioning the public health necessity or personal benefit of vaccinating people who have had covid-19: “We have a pandemic because of the unvaccinated ... So, get vaccinated. If you haven’t, you’re not nearly as smart as I said you were.”

Staying firm

Other countries do give past infection some immunological currency. Israel recommends that people who have had covid-19 wait three months before getting one mRNA vaccine dose and offers a “green pass” (vaccine passport) to those with a positive serological result regardless of vaccination.19 In the European Union, people are eligible for an EU digital covid certificate after a single dose of an mRNA vaccine if they have had a positive test result within the past six months, allowing travel between 27 EU member states.20 In the UK, people with a positive polymerase chain reaction (PCR) test result can obtain the NHS covid pass up until 180 days after infection.21

Although it’s too soon to say whether these systems are working smoothly or mitigating spread, the US has no category for people who have been infected. The CDC still recommends a full vaccination dose for all, which is now being mirrored in mandates. A spokesperson told The BMJ that “the immune response from vaccination is more predictable” and that based on current evidence, antibody responses after infection “vary widely by individual,” though studies are ongoing to “learn how much protection antibodies from infection may provide and how long that protection lasts.”

In June, Peter Marks, director of the Food and Drug Administration’s Center for Biologics Evaluation and Research, which regulates vaccines, went a step further and stated: “We do know that the immunity after vaccination is better than the immunity after natural infection.” In an email, an FDA spokesperson said Marks’s comment was based on a laboratory study of the binding breadth of Moderna vaccine induced antibodies.22 The research did not measure any clinical outcomes. Marks added, referring to antibodies, that “generally the immunity after natural infection tends to wane after about 90 days.”23

“It appears from the literature that natural infection provides immunity, but that immunity is seemingly not as strong and may not be as long lasting as that provided by the vaccine,” Alfred Sommer, dean emeritus of the Johns Hopkins Bloomberg School of Public Health tells The BMJ.

But not everyone agrees with this interpretation. “The data we have right now suggests that there probably isn’t a whole lot of difference” in terms of immunity to the spike protein, says Matthew Memoli, director of the Laboratory of Infectious Diseases Clinical Studies at the NIH, who spoke to The BMJ in a personal capacity.

Memoli highlights real world data such as the Cleveland Clinic study18 and points out that while “vaccines are focused on only that tiny portion of immunity that can be induced” by the spike, someone who has had covid-19 was exposed to the whole virus, “which would likely offer a broader based immunity” that would be more protective against variants. The laboratory study offered by the FDA22 “only has to do with very specific antibodies to a very specific region of the virus [the spike],” says Memoli. “Claiming this as data supporting that vaccines are better than natural immunity is shortsighted and demonstrates a lack of understanding of the complexity of immunity to respiratory viruses.”

Antibodies

Much of the debate pivots on the importance of sustained antibody protection. In April, Anthony Fauci told US radio host Maria Hinajosa that people who have had covid-19 (including Hinajosa) still need to be “boosted” by vaccination because “your antibodies will go sky high.”

“That’s still what we’re hearing from Dr Fauci—he’s a strong believer that higher antibody titres are going to be more protective against the variants,” says Jeffrey Klausner, a clinical professor of preventive medicine at the University of Southern California and former CDC medical officer, who has spoken out in favour of treating prior infection as equivalent to vaccination, with “the same societal status.”3 Klausner conducted a systematic review of 10 studies on reinfection and concluded that the “protective effect” of a previous infection “is high and similar to the protective effect of vaccination.”

In vaccine trials, antibodies are higher in participants who were seropositive at baseline than in those who were seronegative.24 However, Memoli questions the importance: “We don’t know that that means it’s better protection.”

Former CDC director Tom Frieden, a proponent of universal vaccination, echoes that uncertainty: “We don’t know that antibody level is what determines protection.”

Gandhi and others have been urging reporters away from antibodies as the defining metric of immunity. “It is accurate that your antibodies will go down” after natural infection, she says—that’s how the immune system works. If antibodies didn’t clear from our bloodstream after we recover from a respiratory infection, “our blood would be thick as molasses.”

“The real memory in our immune system resides in the [T and B] cells, not in the antibodies themselves,” says Patrick Whelan, a paediatric rheumatologist at University of California, Los Angeles. He points out that his sickest covid-19 patients in intensive care, including children with multisystem inflammatory syndrome, have “had loads of antibodies ... So the question is, why didn’t they protect them?”

Antonio Bertoletti, a professor of infectious disease at Duke-NUS Medical School in Singapore, has conducted research that indicates T cells may be more important than antibodies. Comparing the T cell response in people with symptomatic versus asymptomatic covid-19, Bertoletti’s team found them to be identical, suggesting that the severity of infection does not predict strength of resulting immunity and that people with asymptomatic infections “mount a highly functional virus specific cellular immune response.”25

Already complicated rollout

While some argue that the pandemic strategy should not be “one size fits all,” and that natural immunity should count, other public health experts say universal vaccination is a more quantifiable, predictable, reliable, and feasible way to protect the population.

Frieden told The BMJ that the question of leveraging natural immunity is a “reasonable discussion,” one he had raised informally with the CDC at start of rollout. “I thought from a rational standpoint, with limited vaccine available, why don’t you have the option” for people with previous infection to defer until there was more supply, he says. “I think that would have been a rational policy. It would have also made rollout, which was already too complicated, even more complicated.”

Most infections were never diagnosed, Frieden points out, and many people may have assumed they had been infected when they hadn’t. Add to that false positive results, he says. Had the CDC given different directives and vaccine schedules based on prior infection, it “wouldn’t have done much good and might have done some harm.”

Klausner, who is also a medical director of a US testing and vaccine distribution company, says he initiated conversations about offering a fingerprick antibody screen for people with suspected exposure before vaccination, so that doses could be used more judiciously. But “everyone concluded it was just too complicated.”

“It’s a lot easier to put a shot in their arm,” says Sommer. “To do a PCR test or to do an antibody test and then to process it and then to get the information to them and then to let them think about it—it’s a lot easier to just give them the damn vaccine.” In public health, “the primary objective is to protect as many people as you can,” he says. “It’s called collective insurance, and I think it’s irresponsible from a public health perspective to let people pick and choose what they want to do.”

But Klausner, Gandhi, and others raise the question of fairness for the millions of Americans who already have records of positive covid test results—the basis for “recovered” status in Europe—and equity for those at risk who are waiting to get their first dose (an argument being raised anew as US officials announce boosters while the virus spreads in countries lacking vaccine supply). For people who did not have a confirmed positive result but suspected previous infection, reliable antibody tests have been accessible “at least since April,” according to Klausner, though in May, the FDA announced that “antibody tests should not be used to evaluate a person’s level of immunity or protection from covid-19 at any time.”26

Unlike Europe, the US doesn’t have a national certificate or vaccination requirement, so defenders of natural immunity have simply advocated for more targeted recommendations and screening availability—and that mandates allow for exemptions. Logistics aside, a recognition of existing immunity would have fundamentally changed the target vaccination calculations and would also affect the calculations on boosters. “As we continued to put effort into vaccination and set targets, it became apparent to me that people were forgetting that herd immunity is formed by both natural immunity and vaccine immunity,” says Klausner.

Gandhi thinks logistics is only part of the story. “There’s a very clear message out there that ‘OK, well natural infection does cause immunity but it’s still better to get vaccinated,’ and that message is not based on data,” says Gandhi. “There’s something political going on around that.”

Politics of natural immunity

Early in the pandemic, the question of natural immunity was on the mind of Ezekiel Emanuel, a bioethicist at the University of Pennsylvania and senior fellow at the liberal think tank Center for American Progress, who later became a covid adviser to President Biden. He emailed Fauci before dawn on 4 March 2020. Within a few hours, Fauci wrote back: “you would assume that their [sic] would be substantial immunity post infection.”27

That was before natural immunity started to be promoted by Republic politicians. In May 2020, Kentucky senator and physician Rand Paul asserted that since he already had the virus, he didn’t need to wear a mask. He has been the most vocal since, arguing that his immunity exempted him from vaccination. Wisconsin senator Ron Johnson and Kentucky representative Thomas Massie have also spoken out. And then there was President Trump, who tweeted last October that his recovery from covid-19 rendered him “immune” (which Twitter labelled “misleading and potentially harmful information”).

Another polarising factor may have been the Great Barrington declaration of October 2020, which argued for a less restrictive pandemic strategy that would help build herd immunity through natural infections in people at minimal risk.28 The John Snow memorandum, written in response (with signatories including Rochelle Walensky, who went on to head the CDC), stated “there is no evidence for lasting protective immunity to SARS-CoV-2 following natural infection.”29 That statement has a footnote to a study of people who had recovered from covid-19, showing that blood antibody levels wane over time.

More recently, the CDC made headlines with an observational study aiming to characterise the protection a vaccine might give to people with past infections. Comparing 246 Kentuckians who had subsequent reinfections with 492 controls who had not, the CDC concluded that those who were unvaccinated had more than twice the odds of reinfection.30 The study notes the limitation that the vaccinated are “possibly less likely to get tested. Therefore, the association of reinfection and lack of vaccination might be overestimated.” In announcing the study, Walensky stated: “If you have had covid-19 before, please still get vaccinated.”31

“If you listen to the language of our public health officials, they talk about the vaccinated and the unvaccinated,” Makary tells The BMJ. “If we want to be scientific, we should talk about the immune and the non-immune.” There’s a significant portion of the population, Makary says, who are saying, “‘Hey, wait, I’ve had [covid].’ And they’ve been blown off and dismissed.”

Different risk-benefit analysis?

For Frieden, vaccinating people who have already had covid-19 is, ultimately, the most responsible policy right now. “There’s no doubt that natural infection does provide significant immunity for many people, but we’re operating in an environment of imperfect information, and in that environment the precautionary principle applies—better safe than sorry.”

“In public health you are always dealing with some level of unknown,” says Sommer. “But the bottom line is you want to save lives, and you have to do what the present evidence, as weak as it is, suggests is the strongest defence with the least amount of harm.”

But others are less certain.

“If natural immunity is strongly protective, as the evidence to date suggests it is, then vaccinating people who have had covid-19 would seem to offer nothing or very little to benefit, logically leaving only harms—both the harms we already know about as well as those still unknown,” says Christine Stabell Benn, vaccinologist and professor in global health at the University of Southern Denmark. The CDC has acknowledged the small but serious risks of heart inflammation and blood clots after vaccination, especially in younger people. The real risk in vaccinating people who have had covid-19 “is of doing more harm than good,” she says.

A large study in the UK32 and another that surveyed people internationally33 found that people with a history of SARS-CoV-2 infection experienced greater rates of side effects after vaccination. Among 2000 people who completed an online survey after vaccination, those with a history of covid-19 were 56% more likely to experience a severe side effect that required hospital care.33

Patrick Whelan, of UCLA, says the “sky high” antibodies after vaccination in people who were previously infected may have contributed to these systemic side effects. “Most people who were previously ill with covid-19 have antibodies against the spike protein. If they are subsequently vaccinated, those antibodies and the products of the vaccine can form what are called immune complexes,” he explains, which may get deposited in places like the joints, meninges, and even kidneys, creating symptoms.

Other studies suggest that a two dose regimen may be counterproductive.34 One found that in people with past infections, the first dose boosted T cells and antibodies but that the second dose seemed to indicate an “exhaustion,” and in some cases even a deletion, of T cells.34 “I’m not here to say that it’s harmful,” says Bertoletti, who coauthored the study, “but at the moment all the data are telling us that it doesn’t make any sense to give a second vaccination dose in the very short term to someone who was already infected. Their immune response is already very high.”

Despite the extensive global spread of the virus, the previously infected population “hasn’t been studied well as a group,” says Whelan. Memoli says he is also unaware of any studies examining the specific risks of vaccination for that group. Still, the US public health messaging has been firm and consistent: everyone should get a full vaccine dose.

“When the vaccine was rolled out the goal should have been to focus on people at risk, and that should still be the focus,” says Memoli. Such risk stratification may have complicated logistics, but it would also require more nuanced messaging. “A lot of public health people have this notion that if the public is told that there’s even the slightest bit of uncertainty about a vaccine, then they won’t get it,” he says. For Memoli, this reflects a bygone paternalism. “I always think it’s much better to be very clear and honest about what we do and don’t know, what the risks and benefits are, and allow people to make decisions for themselves.”

Decline in child nutrition levels during covid

Alarming Decline in Child Nutrition Levels in India The COVID pandemic has understandably grabbed most of the Government’s attention, becoming the single largest health focus in the country currently, but as India moves ahead to deal with this challenge, it would do well to simultaneously focus on the health of its most precious human resource, its children.

 By Qrius Unsplash (representation purposes only)

 Anupma Mehta 

 The year 2020 has become synonymous with COVID the world over but for India, it signifies another health risk calling out for attention. The State and district level findings of the fifth round of the National Family Health Survey (NFHS-5), conducted in 2019-20, and released recently, raise serious concern about the status of childhood nutrition in the country. The NFHS, a large-scale survey conducted throughout India in four earlier rounds in 1992–93, 1998–99, 2005–06, and 2015–16, provides State and national level information on various health indicators, including fertility, nutrition, infant and child mortality, reproductive health, prevalence of anaemia, and utilisation and quality of family planning services. NFHS-5 covered 6.1 lakh sample households to provide estimates for 707 districts, with data for its first phase encompassing 22 States and Union Territories.

 One of the most promising results in NFHS-5 is the successful use of contraception to control the Total Fertility Rate (TFR), which has declined to touch the replacement rate in almost all States and UTs. The survey, however, red flags the issue of child malnutrition, with the Government hard put to explain the worsening nutrition status among the country’s children vis-à-vis the previous NFHS. This is especially worrisome as most other indicators of child health like optimal vaccination rates, reduction in under-5 and infant mortality, and rise in institutional deliveries, exhibit promising trends.

 Deterioration in Childhood Health Parameters 

 Another piece of data that stands out like a sore thumb in NFHS-5 is that the prevalence of anaemia has multiplied in nearly 70 per cent of the States, across different age groups. The survey indicates that in 18 States, at least one in every three pregnant women is anaemic despite a substantial increase in the consumption of iron and folic acid tablets. Most global studies demonstrate that maternal anaemia is one of the key causes of foetal as well as childhood malnutrition. It is also well known that the failure to initiate timely breastfeeding after delivery and to sustain it through the first six months of an infant’s life subsequently leads to undernutrition. NFHS-5 found that only ten of the surveyed States showed an improvement in the rates of early initiation of breastfeeding, and even more alarmingly, only one-fourth of the infants in all States were reportedly receiving adequate nutrition through breastfeeding. So, how can a nation that aspires to become a $5 trillion economy within the next few years ensure that its children are healthy and well-fed? The answer lies in tackling three indicators of undernutrition among a nation’s child population—stunting (low height for age); wasting (low weight for height); and being underweight (low weight for age). Children with these anthropometric failures are also more likely to suffer from severe diarrhoea and acute respiratory infection than their healthier counterparts.

 While addressing these three parameters is imperative for ensuring adequate child nutrition, some of the NFHS-5 results are counter-intuitive and necessitate out-of-the-box thinking to find viable solutions. For instance, Goa, the State with the highest per capita income in the country, reported an increase in stunting to 25.8 per cent in the current survey from 20.1 per cent in NFHS-4. And Kerala, the most literate State, which also enjoys the tag of being a welfare State, showed a rise in stunting from 19.7 per cent to 23.4 per cent during the corresponding period. Other developed States like Gujarat and Maharashtra also recorded similar trends. In sharp contrast, Bihar, widely believed to be less advanced than its peers, has proved to be an outlier, with an impressive performance in bringing down the incidence of stunting from 48.3 per cent in NFHS-4 to 42.9 per cent in the current NFHS. Albeit NFHS-4 had recorded 62 million stunted children in India, accounting for 40 per cent of the global share of stunting. But there was still room for some satisfaction, as between the two previous NFHS rounds in 2005-06 and 2015-16, the country had managed to lower its share of stunted children by nearly 10 percentage points. These gains have apparently been frittered away in the last five years with current figures clearly showing that children born between 2014 and 2019 are more malnourished than the previous generation.

These findings call for a deeper dive into the reasons for the widespread and rising prevalence of malnutrition across the country. Key IHDS Findings The NFHS figures are largely corroborated by data from the India Human Development Survey (IHDS), carried out by the National Council of Applied Economic Research (NCAER) in collaboration with the University of Maryland, USA, in two phases, in 2004-05 and 2011-12, respectively. The IHDS is a nationally representative multi-topic survey administered to over 41,000 households in 1503 villages and 971 urban neighbourhoods across the country in the first wave, with a re-contact rate of 82 per cent in the second wave. The IHDS dataset is not only the largest source of panel data for children in India, but also the only single source for anthropometric data, dietary intake, and household income and expenditure. A comprehensive analysis of IHDS data in conjunction with the successive NFHS findings suggests that poor nutrition adversely affects the physical and cognitive development of children, and consequently their productivity and progress in later life. It is also worth exploring whether apart from anthropometric factors, other causalities like maternal autonomy, female literacy, financial status, and social background play a role in mitigating or aggravating child undernutrition in households. For instance, a well-educated mother, who enjoys some autonomy in her home, would ensure better care and nutrition for her children whereas a Below the Poverty Line (BPL) household is unlikely to generate sufficient resources for providing a healthy diet to its children. The IHDS also offers evidence that open defecation and poor hand hygiene are two of the leading factors responsible for stunting among children. An assessment of IHDS data shows that the incidence of children being underweight and stunted in households with acceptable hygiene levels, even if they were in the low income category, were much lower, at 25.3 per cent and 35.2 per cent, respectively, as compared to the much higher corresponding figures of 29.2 per cent and 38.8 per cent, respectively, in households with similar income levels but poorer hygiene standards. Further, IHDS-II found that 26 per cent of the married women surveyed were living in families wherein men ate first, clearly indicating that women are more likely to be under-nourished than their male counterparts. This also makes them susceptible to nutritional deficiencies like anaemia, which have a cascading effect on the health of the children they nurture, especially during pregnancy and lactation.

 Half-hearted Solutions With the persistence of the problem, several solutions have been explored and proposed at the policy levels, but how far have they worked? Two of the most prominent measures for facilitating better nutrition and health for households included the passage of the historic National Food Security Act (NFSA) by the Government in 2013, and strengthening of the Integrated Child Development Services (ICDS). The NFSA, believed to be one of the largest safety net programmes in the world, legislated the availability of 5 kg of cereals per person per month at prices ranging from Re 1 to Rs 3 per kg to about 67 per cent of India’s population. The ICDS is a Centrally-sponsored scheme aiming at holistic development of children below 6 years of age, pregnant women, and lactating mothers by providing them a consolidated package of health and education services. A sub-programme, the Supplementary Nutrition Programme (SNP), is also administered under the ICDS. What then accounts for worsening child health in the country despite the implementation of these measures? One explanation is that economic challenges caused by mounting unemployment and rising food inflation during the period 2014–19 have led to declining household incomes, compromised dietary intakes, and consequently deteriorating child health outcomes. It is also posited that notwithstanding the policy announcement of ramping up the ICDS, in reality, it suffers from many gaps such as degenerating infrastructure, insufficient human resources including ASHA and Anganwadi workers, and declining budgetary allocations—one study by the Accountability Initiative has claimed that the SNP component of the ICDS received only 44 per cent of the requisite funds in 2019-20. All these factors have ostensibly aggravated food insecurity among indigent households, with child nutrition becoming the biggest casualty in this situation. The COVID pandemic has understandably grabbed most of the Government’s attention, becoming the single largest health focus in the country currently, but as India moves ahead to deal with this challenge, it would do well to simultaneously focus on the health of its most precious human resource, its children

. Anupma Mehta is Editor at the National Council of Applied Economic Research. Views expressed in this article are personal.

Say the Liberals Win, Then What

An article form The Atlantic by Elaine Godfrey

If Democrats manage to hold the House of Representatives and win back the Senate and the White House in November, the party will have full control of the federal government for the first time in 11 years. Police reform, climate change, and health care are all on their agenda. But before newly empowered Democrats get to any of that, they will very likely pass a relief package to address the coronavirus pandemic and the associated economic crisis. Then, they will aim to fundamentally change how voting and government work in the United States by expanding voting rights, reducing the influence of money in politics, strengthening ethics rules, and maybe even ending the Senate filibuster—reforms they hope will make America’s democracy work better and the rest of their agenda easier to carry out.

“If there is any political capital to be spent, the concerns over democracy reform take a front seat to everything in the agenda,” a senior aide to a progressive senator told me (the aide requested anonymity because he wasn’t authorized to speak on the record). It “would mean so much just in terms of building long-term power,” a senior aide to a progressive House Democrat added.

By starting with these reforms, Democrats are taking a risk: They’ll likely have only a short window of time in the majority to accomplish their most pressing agenda items. Prioritizing one item could mean sacrificing another—and failing to deliver on key issues.

But the Democratic lawmakers, staffers, and activists that I spoke with view government and voting reform as a kind of precursor to accomplishing any of their other policy goals. “The first attention will be to the economic implosion, but there are a group of [other] issues on people’s minds,” Senator Jeff Merkley of Oregon told me. “We are at that moment where we have to succeed now in restoring the integrity of the American vision.” Democrats have given these process changes, which they call “democracy reform,” top billing on their legislative docket before. The For the People Act, more commonly known as H.R. 1, was the first piece of legislation the Democratic-controlled House passed in 2019. It contained a grab bag of reforms: establishing automatic voter registration for all Americans, making Election Day a national holiday, ending partisan gerrymandering, requiring presidents to disclose their tax returns, and creating a public-financing system for federal campaigns. These reforms would make it easier for most Americans to vote. They’d also, Democrats hope, make it easier for Democrats to win elections.

The Democrats’ plan is informed by experience. The last time Democrats controlled both the White House and Congress, they—under the leadership of President Barack Obama—attempted, at least at first, to foster a good working relationship with Republicans. Yet, after weeks of negotiations, the 2009 stimulus bill received only three GOP votes in the Senate. Not a single Republican voted to pass the Affordable Care Act, after a year of negotiations and floor debate—despite the fact that the legislation was modeled, in part, on a Republican template, and GOP amendments had been accepted to the bill. Obama had hoped to reach a “grand bargain” with Republicans but instead became acquainted with what his aides came to call “the party of no.” Many Democrats believe those times offer a lesson: They need to fix the structural issues that have long given Republicans political power disproportionate to the number of votes the party wins.

Republicans, naturally, are deeply resistant to many of the proposals included in H.R. 1. They argue that the provisions amount to extreme government overreach, and that expanding voting access through mechanisms such as automatic registration will open America’s elections system up to voter fraud. Not a single Republican voted to support H.R. 1 in the House last year, and Senate Majority Leader Mitch McConnell has blocked it from coming to a vote on the Senate floor. “They’re trying to clothe this power grab with cliches about ‘restoring democracy’ … but their proposal is simply a naked attempt to change the rules of American politics to benefit one party,” he wrote in a Washington Post column.

With McConnell and House Republicans opposed to most of their priorities, Democrats will have to structure their agenda carefully—and move quickly. Some Democrats would prefer to take advantage of the increased appetite for health-care reform to pass Medicare for All or a public option in the first weeks of a Joe Biden presidency. Others see climate-change legislation as the first priority. But voting-rights expansion and campaign-finance reforms would likely be simpler and faster to pass, given that the framework already exists in H.R. 1, the Democrats I spoke with said. And everyone agreed that both health care and climate change could be addressed—at least to some extent—in an initial coronavirus-response package; Biden’s “Build Back Better” economic-recovery proposal already promises investment in clean energy sources.

By January 2021, America will likely still be experiencing the twin public-health and economic crises brought on by the coronavirus pandemic, and voters will likely have gone through a drawn-out and chaotic November election. Appetite for political reform will be high, Democrats argue. “Over four years, we’ve learned of weaknesses in our democracy,” Neera Tanden, the president of the Center for American Progress, a Washington-based liberal think tank, told me. “To move a progressive agenda, we need to restore faith in government.”

Another reason that many Democrats would like to prioritize H.R. 1: It’s one of the few issues that unites nearly all factions of the party, so it’s politically feasible. Every single House Democrat voted in favor of the bill. “There’s gonna be an element of, how can you show progressives that you’re in it to win it and willing to go big? There are some things on democracy reform that will really send that message and really do that,” said one aide to a centrist senator, who was not authorized to speak on the record. “Leadership knows that is an issue that would make the left very happy and allow the moderates to deliver on what they’ve promised,” Lanae Erickson, a senior president at the think-tank Third Way, told me.

Democrats believe their reform agenda could be a political winner. “Ending the culture of corruption in Washington” was the top issue for 75 percent of voters in swing districts in 2018, according to a poll from Greenberg Quinlan Rosner Research. That year, 72 percent of candidates on the House Democrats’ list of highly competitive races rejected donations from corporate political action committees, a pledge that became a litmus test during the campaign. That was up from just 6 percent in 2016, according to End Citizens United, a political action committee working to pass campaign-finance reform.

Before they can pass their “democracy reform,” though, Democrats have to decide exactly what that entails. Most progressives interpret the phrase to include not only expanding voting rights, but also establishing D.C. statehood and abolishing the Electoral College, two proposals that are still controversial among rank-and-file members. Public support for both ideas is mixed: More than 60 percent of U.S. adults oppose D.C. statehood, according to a recent Gallup poll, while a majority of Americans support amending the Constitution so the presidential candidate who wins the popular vote wins the election.

But far and away the most serious threat to the effectiveness of a Biden presidency and a Democratic House and Senate is the filibuster, the Senate rule that requires 60 senators, instead of a simple majority of 51, to move forward on most legislation. Even if Democrats win the Senate in November, they very likely won’t have 60 votes, meaning that Republicans could still block legislation from being debated. Progressives have long wanted to abolish the supermajority voting threshold, but the idea has begun to gain traction among other Democrats, too, in recent weeks. Perhaps, some Democrats argue, the filibuster is a natural place to launch their democracy-reform initiative: They can put forward a slew of policies strengthening ethics guidelines and expanding voting rights—including a bill that would restore the Voting Rights Act of 1965—and dare Republicans to vote against it. (The VRA had strong bipartisan support until the mid-2000s.) “It’s a pretty easy argument to make,” the aide to the centrist senator told me. “Democrats would be happy to be like, Look at these fuckin’ guys! They still want to make it difficult for people of color to vote!”

Progressives are enthusiastic about that plan. “If I had to guess how it’s going to happen, it’s going to be, If we can’t pass the VRA, we’re going to get rid of the filibuster,” Adam Green, the co-founder of the Progressive Change Campaign Committee, told me. “Starting with H.R. 1 is a good idea,” Representative Ro Khanna of California told me. “The filibuster could come right next.”

Then again, Democrats might not have any of these options in January. Trump could win the election; Republicans could hold the Senate or even win control of the House. The Democrats could sweep, but have something else at top of mind. Or, some of my Hill sources suggested, Biden may want to start off his first term by pursuing legislation that is more amenable to Republicans, though none of the aides I spoke with could identify what that unifying project might be. When asked about Biden’s own legislative priorities, a campaign spokesperson responded that his No. 1 goal will be “repairing and rebuilding from the economic ruin and public-health crisis caused by Donald Trump’s utter failure to fulfill his basic duty as president: protect America.”

Even if they win full control, though, Democrats won’t have a lot of time. As my colleague Ronald Brownstein noted recently, “the last four times a president—of either party—went into a midterm with unified control, voters have revoked it. … No party has controlled all the levers of government for more than four consecutive years since 1968.” And a President Biden and an incoming Democratic Congress will be facing a mountain of tasks. There will almost certainly be early battles over government funding and coronavirus-response packages.

If Democrats find themselves in the majority again for the first time in more than a decade, though, they are determined not to squander the opportunity. In his July eulogy for Representative John Lewis, Obama implored lawmakers to quickly make changes that protect and expand the right to vote—not for partisan advantage, he insisted, but in an effort to form a more perfect union. Republicans remain skeptical. But Democrats were listening.

The much needed fiscal policy during covid 19 lockdown in india

There are multiple measures implemented by the government to stimulate the economy in the covid 19 induced pause in the economic activity. The question is whether they are effective and is there a magic pill which could resolve all the issues

All stimulus should have the desired effect on increased spending and resultant surge in economic activity. Unlike a developed economy, India cannot afford to provide unemployment packages like PPP (paycheck protection programme) as their tax collections are abysmally low. Indias tax to GDP ratio is c.10% as compared to US-24% UK- 34%. Also a significant majority of the labor force is outside of the payroll system in India which is evidenced by the low personnel registered for employee security schemes like EPF,NPS etc. It means that it is virtually impossible for India to have a payroll based stimulus as it would basically ignore most of the labor force.The fact that India dont have an universal health care system compounds the impact in case of surge of covid 19 cases. Thereby it is prudent for the government to have a strict lock-down to prevent a pandemic and the medical resources of State and Central Governments being overwhelmed. It provides the government a breather and focus their initiative in mitigating the constraints imposed on the economy by such strict lockdown measures.

FISCAL MULTIPLIER

Any macroeconomic study is incomplete without analysis of the desired fiscal multiplier effect of a stimulus package. It is defined by the marginal propensity to consume ("MPC") of the beneficiaries of the scheme. If the government has limited resources as is the case for India with lower tolerance for increased fiscal deficit, they should look for a package which could act like a adrenaline shot to the comatose economy.

The poor families usually tend to have the highest MPC as they usually spend most of their revenues on sustenance. It is the same essential goods and services which are allowed to operate in the lockdown. Thereby it would be an accurate assessment that any stimulus directed toward the families of the Public distribution system (PDS) i.e ration card holders below a certain level of income should have the desired impact of increased economic activity. Grocery stores also employ labor with a higher MPC thereby leading to the compounding effect of the stimulus i.e the fiscal multiplier.

CONSTRAINTS

Will the families be allowed to spend primarily on the essential goods - what if they have a outstanding loan and rental payments

The Government did announce a moratorium on rental collections but it needs to be strictly implemented and extended till the lock-down restrictions are eased. A prolonged moratorium is required on both rental and loan repayments (inc. interest) as it defeats the purpose of any benefit package if most of it used to pay a landlord or loan shark who doesnt have the desired MPC/fiscal multiplier effect.

If only essential goods and services are available then people with higher income usually tend to save as there are basically limited avenues to spend other than food during the lockdown

Thereby any benefits directly provided to individuals or families should be directed towards increased propensity to buy groceries and eliminate any redirection to leverage or rental costs.

FIRMS

The above direct stimulus to individuals through PDS or bank accounts can help to sustain the poorer section of society who are the hardest hit for a few months but what about firms. The actual engine of production for the economy, what is the impact of strict lockdown measures on them

There are three key factors which needs to be considered

a) Low margin industry - High fixed cost

b) High inventory

c) Largest employment - direct and indirect

First we need to accept that the government cannot allow a large number of firms to go bankrupt due to the govt lockdown as it would create a comatose climate which would be far more difficult to recover than the covid 19 pandemic. Thereby the Government should drive the initiative to hit the above three factors.

Any industry with high fixed cost ratio would be crippled and are most likely to go bankrupt. Even-though they can prevent working capital issues by reducing inventory or even laying off temporary staff but they cannot avoid the fixed costs like borrowing, property,plant and equipment maintenance and depreciation.

Firms carrying large unsold inventory either in the form of raw materials or finished goods would find it difficult to restart operations as the carrying cost of inventory would significantly impair their cash flows.

Large employers primarily in the manufacturing sector would require the most support as they would be the most likely to lay off permanent staff and reduce their purchase orders which would in turn precipitate a vicious cycle of supplier side unemployment who are primarily in the medium and small sector

FISCAL MEASURES

The government needs to announce a funding mechanism where the RBI directly invests in firms based on the above factors. A designated bank needs to be created under the supervision of RBI which is government funded. This "Covid 19 Bank" should extend long dated instruments carrying a reasonable coupon rate with contingent convertible and a mandatory redemption feature after 5 years. This would be the much need capital infusion required for the indian industry.

The current blanket announcement of 20 lakh crore loans targetting small and medium sector through an already struggling banking sector would only add to the ever increasing NPA issues. It is difficult for a listed banking institution to carry such higher risk on their balance sheet even if it is guaranteed by the RBI/Govt due to the higher capital costs associated with the same and its resultant impact on capital ratios.

Thereby this stimulus needs to be extended by the government directly through its segregated "covid 19 bank" rather than putting the onus on the banking sector. also there is no point in targetting small and medium enterprises as evidenced in the manufacturing sector they are usually engaged in the supplier or distribution side of large enterprises. If the orders from large enterprises dry up then there is no point of any stimulus. It is imperative that we target firms based on the above three key factors and target them for covid 19 financing instruments.

Usually financing for Large industries would help them to maintain their purchase orders and also meet the sale orders when demand picks up post easing of lockdown which brings us to the next important point ...... timing.

TIMING

The above fiscal measures shouldnt be implemented at the same time. Cause there is an inherent synergy between lockdown, stimulus and increased demand. In the initial phase of intense lockdown where only essential goods and services are allowed to operate, the focus should be on the fiscal multiplier stimulus like direct money transfer to high MPC families through the PDS and banking infrastructures with strict implementation of rent and loan moratorium which needs to be extended till the end of lockdown.

During the next phase of the lockdown when the restrictions are eased for industries to operate with minimal or reduced capacity, the first tranche of funding through the Covid 19 bank needs to be extended to firms based on the above three key factors. It is important that the funding is extended in a staggered manner which is coinciding with the gradual easing of the lockdown. There is no point in a giving a bulk amount to an enterprise with no vision on when they will have the opportunity to restart their operations.

This staggered cash flow funding which is in effect a capital instrument would provide the much needed breathing space for the industry to meet the increased demand on the projected consumption post lockdown.

In case there is extended lock-down due to non flattening of the covid 19 spread then the above industry fiscal stimulus needs to be on hold.

To reiterate i believe the following key features are required to restart the Indian economy

a) Immediate and regular stimulus to PDS families during lockdown.

b) Strict implementation of Rent and Loan payment holidays during lockdown

c) A Separate Covid 19 bank created with govt funding under the supervision of RBI

d) Staggered funding timed with the easing of lockdown of long dated instruments with contingent convertible and mandatory redemption feature after 5 years

e) Targeted funding to firms based on the three key factors

Uber results for Q1 2020

Revenue of $3.5 billion, growing 14% year-over-year or 16% on a constant currency basis

Rides Adjusted EBITDA of $581 million

SAN FRANCISCO--(BUSINESS WIRE)-- Uber Technologies, Inc. (NYSE: UBER) today announced financial results for the quarter ended March 31, 2020.

Financial Highlights for First Quarter 2020

Gross Bookings grew to $15.8 billion, up 8% year-over-year, or 10% on a constant currency basis, with Rides declining 3% and Eats growing 54% year-over-year, respectively, on a constant currency basis.
Revenue growth of 14% year-over-year, or 16% on a constant currency basis.
Adjusted Net Revenue (“ANR”) growth year-over-year of 18%, or 19% on a constant currency basis. Adjusted Net Revenue and segment Adjusted Net Revenue excludes the impact of COVID-19 response initiatives.
Net loss attributable to Uber Technologies, Inc. of $2.9 billion, which includes $277 million in stock-based compensation expense and pre-tax impairment write-downs of $2.1 billion. Net loss attributable to Uber Technologies, Inc. excluding the impairment write-downs, net of the tax benefit would have been $1.1 billion.
Rides Adjusted EBITDA delivered $581 million in profit, up $389 million year-over-year, and down $161 million quarter-over-quarter, and 23.5% margin as a percentage of ANR.
Eats Adjusted EBITDA of $(313) million, down $4 million year-over-year and up $148 million quarter-over-quarter.
Adjusted EBITDA of $(612) million, up $257 million year-over-year, and up $3 million quarter-over-quarter. Adjusted EBITDA excludes the impact of COVID-19 response initiatives.
Unrestricted cash, cash equivalents and short-term investments were $9.0 billion.
COVID-19 response initiatives impact on GAAP revenue of $19 million and impact on GAAP cost of revenue of $5 million. (details and reconciliation below)

“While our Rides business has been hit hard by the ongoing pandemic, we have taken quick action to preserve the strength of our balance sheet, focus additional resources on Uber Eats, and prepare us for any recovery scenario,” said Dara Khosrowshahi, CEO. “Along with the surge in food delivery, we are encouraged by the early signs we are seeing in markets that are beginning to open back up. Our global footprint and highly variable cost structure remain an important advantage, as our expectation is that the Rides recovery will vary by city and country.”

“Our ample liquidity provides us with substantial flexibility to navigate the current crisis, but we are being proactive and taking actions to emerge stronger and more focused as a company,” said Nelson Chai, CFO. “We have recently exited eight unprofitable Eats markets, significantly reduced the size of our customer support and recruiting teams, and merged our JUMP unit into Lime. Building on the steps we have already taken, we are continuing to look at all levers to ensure our core Rides and Eats businesses emerge from this crisis stronger than ever.”

First Quarter 2020 Financial and Operational Highlights

Operating Highlights for the First Quarter 2020

COVID-19 Initiatives

Launched programs to support drivers: We launched a program to support drivers or delivery people who are diagnosed with COVID‑19, or individually asked to self-isolate, providing up to 14 days of financial assistance while their Uber account is on hold. We also accelerated cross-dispatch from Rides to Eats, as well as surfaced other earning opportunities on and off the Uber platform via the Uber Work Hub. Providing cleaning supplies and PPE: We are working with manufacturers and distributors to provide drivers and delivery people with cleaning supplies and PPE including face coverings and disinfectants. We have distributed millions of pieces of PPE and are working to secure more supplies and are prioritizing active drivers in the cities with the greatest need.
10 million free rides and deliveries: We have committed to provide 10 million rides and meals to healthcare workers, seniors and people in need, free of charge, and have started offering those services around the world. For instance, we’ve begun providing $1 million in rides and food to healthcare workers in New York City, and up to 200,000 free rides for NHS staff in London.
Vulnerable populations: Working with partners, we are delivering medication to housebound patients and essential goods to those in need around the world. We have also partnered with domestic violence organizations in 35 cities to provide free rides to shelter and safe spaces, and free meals. We introduced a dedicated phone number for people without a smartphone to get assistance with ordering a meal.
Supporting restaurants: We waived new restaurant activation fees in a number of markets and have made it quicker and easier for restaurants around the world to join Eats. We also launched a global feature allowing eaters to provide direct support to restaurants, resulting in over $3 million in direct contributions.
Freight relief efforts: Over 10 thousand relief loads of critical goods booked on the shipper platform in the U.S. were hauled at cost. Platform

Uber Rewards gained traction: Uber rewards has grown to more than 31 million members, and is now live in France, our sixth country, in addition to the U.S., Brazil, Mexico, Australia, and New Zealand.
Uber for Business (“U4B”) grows customer relationships: U4B now has relationships with 46% of the Fortune 500 and continues to gain traction among governmental organizations, including the U.S. Federal government as of April 2020. U4B deals increasingly include both Rides and Eats following the launch of Eats within U4B earlier this year, in certain jurisdictions, including in Brazil, Canada, France, and the United Kingdom. Launched Uber Direct and Uber Connect: Uber Direct is a delivery platform for retail items; Uber Connect is a peer-to-peer package delivery service, for sending goods to family and friends. These offerings highlight the flexibility of the Uber platform, while also providing additional earnings opportunities to drivers and delivery people.

Rides

Driver app enhancements improve cross-dispatching: During the quarter, we made enhancements to the Uber Rides Driver App that make it easier for drivers to become Eats delivery people. Nearly 40% of U.S. and Canada Drivers active on the platform cross-dispatched to Eats in the month of April.
Uber for Health scales rapidly: Uber for Health has grown more than 200% YoY as we build out enhanced capabilities, including the ability to order rides to medical appointments and other health services over the phone. Other Segments
Eats added key new accounts: Signed partnerships with Chipotle (2,500 locations) in U.S. and Canada, along with Dunkin’ (4,000+ locations) and Shake Shack (150 locations).
Eats enabled grocery and convenience options: Uber Eats has enhanced the ability for grocery and convenience partners to sell a limited menu of everyday essentials via our restaurant platform. The offering is live with nearly 4,000 partners in 35 countries, including partnerships with Carrefour in France, Sysco in the U.S., and Shell in the UK.
Freight improved load bundle and multi-stop load product features: Added improvements to the Uber Freight application that are intended to improve match of available loads with available carriers.
Uber Transit continued expansion: Uber users now have access within the Rides app to the transit system of more than 15 cities, including two new cities that have also added ticketing capabilities within our app. To date, more than 2 million Uber Riders have used Transit. Uber Works expanded: Expanded from Chicago and Miami to its third market, Dallas. We are supporting COVID-19 response efforts through Uber Works Hub, reinforcing Uber’s role as platform for independent work opportunities, including for existing drivers and delivery people; and providing essential personnel for light industrial and grocery supply chain customers.
Next generation JUMP hardware deployed: Within New Mobility, our fifth generation of hardware, which includes shared swappable batteries between bikes and scooters, is being tested in an effort to increase durability and reduce operational costs. Recent Developments

Uber Eats: On Monday, consistent with our long-term strategy, we announced a change to the geographic footprint of Uber Eats operations affecting 8 markets. We will discontinue Uber Eats in the Czech Republic, Egypt, Honduras, Romania, Saudi Arabia, Uruguay and Ukraine, and will transfer Uber Eats operations to our Careem subsidiary in the United Arab Emirates. The discontinued and transferred markets represented 1% of Eats Gross Bookings and 4% of Eats Adjusted EBITDA losses in Q1 2020.
Headcount: On Wednesday, due to lower trip volumes and our current hiring freeze, we announced a reduction of our customer support and recruiting teams by approximately 3,700 full-time employee roles.
New Mobility: Today, we announced we are folding our JUMP e-bike and e-scooter business into Lime. Our customers will continue to have access to e-bikes and e-scooters in our apps. As part of the transaction, we made an additional convertible note investment of $85 million in Lime. The transferred business represents the vast majority of Gross Bookings, Adjusted Net Revenue and Segment Adjusted EBITDA loss for our Other Bets segment.

Webcast and conference call information A live audio webcast of our first quarter 2020 earnings release call will be available at https://investor.uber.com/, along with the earnings press release and slide presentation. The call begins on May 7, 2020 at 1:30 PM (PT) / 4:30 PM (ET). This press release, including the reconciliations of certain non-GAAP measures to their nearest comparable GAAP measures, is also available on that site.

We also provide announcements regarding our financial performance, including SEC filings, investor events, press and earnings releases, and blogs, on our investor relations website (https://investor.uber.com/).

About Uber

Our mission is to ignite opportunity by setting the world in motion.
We revolutionized personal mobility with ridesharing, and we are leveraging our platform to redefine the massive meal delivery and logistics industries.
We are a technology platform that uses a massive network, leading technology, operational excellence and product expertise to power movement from point A to point B. We develop and operate proprietary technology applications supporting a variety of offerings on our platform. We connect consumers with independent providers of ride services, restaurants and food delivery services, public transportation networks, e-bikes, e-scooters and other personal mobility options. We use this same network, technology, operational excellence and product expertise to connect shippers with carriers in the freight industry. We are also developing technologies that will provide autonomous driving vehicle solutions to consumers, networks of vertical take-off and landing vehicles and new solutions to solve everyday problems.

Forward-Looking Statements

This press release contains forward-looking statements regarding our future business expectations which involve risks and uncertainties. Actual results may differ materially from the results predicted, and reported results should not be considered as an indication of future performance. Forward-looking statements include all statements that are not historical facts and can be identified by terms such as “anticipate,” “believe,” “contemplate,” “continue,” “could,” “estimate,” “expect,” “hope,” “intend,” “may,” “might,” “objective,” “ongoing,” “plan,” “potential,” “predict,” “project,” “should,” “target,” “will,” or “would” or similar expressions and the negatives of those terms. Forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause our actual results, performance or achievements to be materially different from any future results, performance or achievements expressed or implied by the forward-looking statements. These risks, uncertainties and other factors relate to, among others: developments in the COVID-19 pandemic and the resulting impact on our business and operations, competition, managing our growth and corporate culture, financial performance, investments in new products or offerings, our ability to attract drivers, consumers and other partners to our platform, our brand and reputation and other legal and regulatory developments. For additional information on other potential risks and uncertainties that could cause actual results to differ from the results predicted, please see our Annual Report on Form 10-K for the year ended December 31, 2019 and subsequent Form 10-Qs or Form 8-Ks filed with the Securities and Exchange Commission. All information provided in this release and in the attachments is as of the date of this press release and any forward-looking statements contained herein are based on assumptions that we believe to be reasonable as of this date. Undue reliance should not be placed on the forward-looking statements in this press release, which are based on information available to us on the date hereof. We undertake no duty to update this information unless required by law.

Non-GAAP Financial Measures

To supplement our financial information, which is prepared and presented in accordance with generally accepted accounting principles in the United States of America (“GAAP”), we use the following non-GAAP financial measures: Adjusted Net Revenue; Rides Adjusted Net Revenue; Eats Adjusted Net Revenue; Adjusted EBITDA; Adjusted EBITDA margin as a percentage of ANR; and net loss attributable to Uber Technologies, Inc. excluding the impairment write-downs, net of the tax benefit, as well as, revenue and Adjusted Net Revenue growth in constant currency. The presentation of this financial information is not intended to be considered in isolation or as a substitute for, or superior to, the financial information prepared and presented in accordance with GAAP. We use these non-GAAP financial measures for financial and operational decision-making and as a means to evaluate period-to-period comparisons. We believe that these non-GAAP financial measures provide meaningful supplemental information regarding our performance by excluding certain items that may not be indicative of our recurring core business operating results.

We believe that both management and investors benefit from referring to these non-GAAP financial measures in assessing our performance and when planning, forecasting, and analyzing future periods. These non-GAAP financial measures also facilitate management’s internal comparisons to our historical performance. We believe these non-GAAP financial measures are useful to investors both because (1) they allow for greater transparency with respect to key metrics used by management in its financial and operational decision-making and (2) they are used by our institutional investors and the analyst community to help them analyze the health of our business.

There are a number of limitations related to the use of non-GAAP financial measures. In light of these limitations, we provide specific information regarding the GAAP amounts excluded from these non-GAAP financial measures and evaluating these non-GAAP financial measures together with their relevant financial measures in accordance with GAAP.

For more information on these non-GAAP financial measures, please see the sections titled “Key Terms for Our Key Metrics and Non-GAAP Financial Measures,” “Definitions of Non-GAAP Measures” and “Reconciliations of Non-GAAP Measures” included at the end of this release.

Why China has zero new covid 19 cases and the rest of the world doesnt

April 27, 2020

In this weekly round-up, Richard Lehman looks at a personal selection of articles of relevance to clinicians dealing with covid-19
The Kung Fu of Covid

One third of a year has passed since the start of the covid-19 pandemic, but there is little sense of shared global wisdom. The Chinese sage Kǒng Qiū (551-479 BCE) would be saddened. Among the many sayings attributed to him are: “All people are the same; only their habits differ.” China, with the largest population in the world, is the only one which has come close to eliminating covid-19 within its borders (with the possible exceptions of New Zealand and Iceland, as we go to press). Among 1.4 billion people, daily deaths are zero. Why then isn’t the rest of the world rushing to adopt the habits of China? Another maxim of Confucius/Kung Fu is “Learn avidly. Question repeatedly. Analyze carefully. Then put what you have learned into practice intelligently.”

Dialogue concerning the two world systems

“The man who asks a question is a fool for a minute, the man who does not ask is a fool for life.”

Galileo wrote a dialogue to show you could not believe contrary things at once: either the sun revolved around the earth, or the earth revolved around the sun. Unfortunately the Pope was office-bound to believe the first, and Galileo’s book made him look a fool. Mistake. The pope remained a fool for life, and Galileo remained under house arrest for life. Now, with covid-19, any containment policy either revolves around the value of individual life, or it revolves around the economy. It cannot do both at the same time. China exemplifies the first, and Britain exemplifies the second. On 12 March our chief medical officer, chief scientific officer, and our prime minister Boris Johnson declared in favour of “herd immunity”, and nothing that has happened since shows serious intent to prevent the cull which that implies. Britain has already lost ten times more people per head of population than China during the whole of its epidemic. If we had started by valuing the individual, this would not have happened. And our economy would be less ruined too. Maybe there is time to mend our ways in the second wave.

Controlled Avalanche

“Do not impose on others what you yourself do not desire.”
So let’s say you have embraced the idea of herd immunity, without waiting for a vaccine. That means allowing the infection to spread through the population. It will kill those it is going to kill, but in a “controlled avalanche” that will be spread out to allow some to return to normal economic activity and health provision. That sounds like a good British compromise, though in fact the following model comes from Israel. “Individuals whose probability of developing serious health conditions is low (i.e. 20-49 years old with no comorbidities) will be offered the option to be voluntarily exposed to the virus under controlled supervision, and will then be issued ‘immunity certificates’ if they are confirmed to have developed SARS-CoV-2 antibodies.” I can see that having some appeal, especially to altruistic health professionals who have already voluntarily exposed themselves to covid-19 risk through lack of protective equipment. What I can’t understand is how the modellers come to the conclusion that this “reduces the overall mortality by 43%, reduces the maximum number of people in need for ICUs by 62%, and decreases the time required for release of 50% of the low-risk population by more than 2 months.” How can any controlled infection strategy reduce the virulence and case-fatality rate of the infection itself?

Face value

“If you make a mistake and do not correct it, this is called a mistake.”

When you put on a mask in public, you lose a lot of face. You also stop a lot of droplets. But this is at the cost of adopting a habit that many people in English-speaking countries seem to find repellent. I think they lose more face by insisting on randomised controlled trial evidence than they ever would by just putting on a mask. No RCT is ever going to be as good for detecting harms as a natural experiment involving 2 billion people. No cluster randomised trial of sufficient scale is going to be able to adjust for confounders any better than an observational comparison. Every population observation we have favours masking. Then triangulate this with some simple, common sense physical experiments, such as this: “We found that most home fabrics substantially block droplets, even as a single layer. With two layers, blocking performance can reach that of surgical mask without significantly compromising breathability. Overall, our study suggests that most double-layered cloth face coverings may help reduce droplet transmission of respiratory infections.” I do wish that some EBM-loving friends would admit that some ideas that have face validity are in fact valid until proven otherwise. On faces, even.

Ventilator Mortality

“To know what you know and what you do not know, that is true knowledge.”
A month ago the question on everyone’s mind was how many very sick covid-19 patients would have to be turned away from ventilators. For some of us older people, there was also the question of whether it was worth going on to a ventilator at all. In fact it seems that very few ventilator rationing decisions have had to be made in the UK, and thanks to the brilliant work of ICNARC we know that the mortality of ventilated patients in the UK is 67%. This is based on a much larger sample than from any other country. A more pertinent question may be: which patients really need ventilation and which might do better with a non-invasive strategy? Since continuous positive airways pressure was first proposed as an alternative, surprisingly little seems to have appeared about it in the clinical literature. Meanwhile, high flow nasal cannulas are making an appearance. I hope someone sorts all this out before I arrive on an ICU.

Natural History
“No matter how busy you make think you are you must find time for reading, or surrender yourself to self-chosen ignorance.”

I may have been reading the wrong journals, but so far I’ve found little about the varied natural histories of the illness called covid-19. For sure, there have been plenty of symptom lists and time-course diagrams and so forth, but nothing that’s helped me understand the transition from what I’ve called benign covid into malignant covid. Now a very comprehensive review of the world literature has appeared in medRxiv.

This divides covid-19 into three stages: “the time of infection (Stage I), sometimes progressing to pulmonary involvement (Stage II, with or without hypoxemia) and less frequently to systemic inflammation (Stage III).” The hard-working authors go on to attempt to map therapy on to each stage. That is certainly the central challenge, though it seems hardly addressable in the present state of ignorance.

PM Question Time

“The essence of knowledge is, having it, to use it.”

Now let’s look at the few who die. Remember that modern medicine was not built on numbers but on observation: living patients reviewed on a daily basis, and then examined post mortem should they get unlucky. Autopsy just means seeing for yourself. I am baffled that medicine today should employ so many statisticians and so few gross pathologists. A new article tells us about the lung findings in 38 patients from Northern Italy. Terminal covid-19 is a systemic disease, but I guess it’s better to know about the lungs than about nothing. They are a mess, of course. “The features of the exudative and proliferative phases of Diffuse Alveolar Disease (DAD) were found: capillary congestion, necrosis of pneumocytes, hyaline membrane, interstitial oedema, pneumocyte hyperplasia and reactive atypia, platelet-fibrin thrombi.” There is lots about those thrombi in small arterial vessels, confirming that coagulopathy often dominates the end-stage of covid-19. In 4 patients, there were multiple small lung abscesses caused by bacterial infection.

Silver lining

“Success depends upon previous preparation, and without such preparation there is sure to be failure.” Two and a half millennia later, this Confucian saying reappeared on the lips of Louis Pasteur (1822-95) as “Fortune favours the prepared mind”. Pasteur’s experiments with yeast and cotton wool had prepared his mind to discover that infectious diseases were transmitted by filterable micro-organisms. Before long, other people discovered that certain infectious diseases, like smallpox, were spread by organisms that seemed to be invisible and pass through filters. Subsequently, with better filters and stronger microscopes, these viruses appeared in their full glory. The image of a blob covered in a mass of collar studs that you see everywhere is a triumph of cumulative science. Forget post-modernism. This represents knowledge that is certain and will never go away. Soon it will lead us to an effective vaccine. There is no reason to doubt that: the only question is when and which of the 115+ candidate vaccines it will be. And then it will all seem so straightforward. “Anyone can find the switch after the lights are on.”

No, Confucius did not really say that. There is no record that he invented the electric light in 500 BCE. Yet you can find it in a list of his sayings on Google.
Richard Lehman is professor of the Shared Understanding of Medicine at the University of Birmingham.