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.

How Instacart works : The Complete revenue and business model

Instacart is an on-demand grocery delivery platform facilitating doorstep deliveries of groceries and other home essentials in major cities of USA. The technology driven business model of Instacart boosts of delivering groceries to customers in as little as 1 hour, making it one of the most promising and futuristic company of USA which is based on sharing economy model.

This grocery delivery startup has become so famous in the on-demand sector that a lot of budding entrepreneurs are interested to learn more about Instacart business model and understand its overall working in order to develop the next big thing in the sharing economy. This post from Juggernaut will show you how Instacart works and makes money along with some interesting facts and figures about this $2 billion valuation company.

Founders, Funding received, Facts and Timeline

Instacart was founded in year 2012. It is one of the most recent technology developments which has shaken the world by its business model. Being considered as a leader in on-demand economy, Instacart has received massive funding to expand its grocery delivery operations all across USA. Here are few facts about Instacart:

Founded by: Apoorva Mehta (CEO / Founder) and Max Mullen (Co-Founder)

Funding received: $275 million (Till the mid of year 2015)

Company Valuation: $2 Billion. (As per Jan 2015)

Revenue: $100 million (As of Jan 2015).

Headquarters: San Francisco, California, USA.

The amount of funding received by Instacart clearly shows the trust of investors in this start-up and its projected future. To understand what makes Instacart a promising company, let me quickly take you through the salient features and the value propositions of Instacart. Thereafter, we’ll move on to understand Instacart’s core working and its customer segments.

Salient Features of Instacart:
Available in major areas of the USA including SF Bay Area, San Jose, NYC, Brooklyn, Washington DC, Philadelphia, Boston, Chicago, Austin, Seattle and Los Angeles.
A collection of over 300,000 items from several stores such as Whole Foods, Safeway or Costco enabling customers to place orders from their favourite store or to mix items from different stores into one order.
Crowdsourced Marketplace model with users being connected to personal shoppers who shop for ordered items and deliver them to the customers.

Value Proposition:
Tie-ups with existing supermarkets
Willing part time workers and their cars
Vast inventory
Extremely quick delivery
No warehouses
No shiny delivery trucks

Instacart’s 3 Customer Segments Explained:

Users:

They have an app from where they can order groceries by choosing one or more stores.
They can even order from a desktop or laptop using a web based interface.
Users pay online for their order and can tip their shopper in advance during check out.
Option to shop from any of the available stores in their area. An order can even be placed by combining items from different stores.
Users can schedule orders for a specific day and time.

Shoppers:
Shoppers receive orders on their smartphones.
Shoppers are stationed near the stores in order to save time.
They pick up the ordered items manually and deliver it to the customer.
Apart from the per hour pay, shoppers often get a tip from customers.

Stores:
Instacart has tie-ups with major superstores in various cities.
These stores have been able to increase their revenue through online sales via Instacart.
Instacart Business Model Canvas [Image: changes done] The 4 step model about How Instacart Works:
A customer places his order for groceries and pays online to instacart.
A personal shopper receives the order and starts collecting items as mentioned in the order.
Shopper pays the bill through Instacart’s prepaid debit card which is accepted at the store.
The shopper then goes to deliver the groceries to the customer as per the address mentioned in the order.
Any tip paid in cash at the time of delivery directly goes to the shopper and the tip paid to shopper during checkout gets accumulated in his Instacart account and is paid at the end of the week along with the salary.

Instacart revenue model – How it makes money?
Delivery Fee
Every order processed by Instacart which is above the value of $35 attracts a standard delivery fee of $3.99 for a scheduled or 2 hour delivery and $5.99 for a 1 hour delivery.

Orders under $35 value are charged at $7.99 for a scheduled or 2 hour delivery and $9.99 for a 1 hour delivery.

Membership Fee (Instacart Express)
Instacart offers an annual membership by the name ‘Instacart Express’ priced at $99. Users having this membership can get free delivery of groceries for full 1 year with few terms and conditions.
Mark up prices (15%+ more)
Some stores selling their products on Instacart offer the same prices as their in-store prices but few stores listed on Instacart have a mark-up of 15%+more from their in-store prices. The revenue from these mark-up prices goes to Instacart which helps them pay the shoppers.

How Instacart finds customers?

Word of Mouth Advertising
Internet Marketing
Free first delivery
Various offers

The process of Recruiting Shoppers:
Application are invited from individuals who want to earn money by shopping in their free time.
Applications are processed by the recruitment team and a face to face, one on one interview is scheduled.
Proper training is provided to selected individuals before they are ready to shop and deliver groceries.

Key Problems and Solutions:

Shopper Retention : As all shoppers work part time, it is difficult to retain them for a long time. To enhance the earnings of shoppers, Instacart added an option to pay tip to a shopper in the check-out section of the website.
Reduce Delivery time : Delivering groceries within 2 hours was a challenge for Instacart. To reduce the delivery time, Instacart places its shoppers outside the stores where it has tie-ups. Whenever a shopper receives an order, he is already at the store saving him 50% of the time.
Shopper Shortage : As Instacart shoppers work as freelancers with flexible schedules, it is difficult to manage the freelancers fleet and assign instant tasks to them. To deal with this problem, Instacart introduced a “busy pricing” policy by which it adds few dollars as delivery charges to a customer’s bill depending on how busy its shoppers are. A part of this additional price is also paid to the shoppers so that they can work as quick as they can.
Customer Trust : Customers lost their trust in Instacart when they came to know that the company is putting up its own pricing for products. These prices are marked up from the in-store prices. Instacart soon admitted to the marked up prices. However, few uses might have stopped using Instacart due to this, but majority are ready to pay the mark-up prices in order to get groceries at their door step.
Wrong item Delivery possibilities : Sometimes a shopper picks up the wrong item and delivers it. To handle all such issues, Instacart has a dedicated support team which can be reached over the phone or through email. Refund is processed if the personal shopper misses an item in the order list.
Out of stock items : Sometimes, Items in the shopping list go out of stock. In such cases, shoppers replace the non-available items with similar items that are available, which might not be wanted by the customer. To deal with this problem, Instacart allowed customers to add notes and they also added a “often out of stock” button on such items for the reference of customers.

The Future:

Grocery delivery business has a great future as more people want the most easy and convenient way to buy grocery items. Promising delivery within 2 hours, instacart has become a powerful solution in the US and with $275 million funding, it is ready to take on other cities in the USA as well as expand outside the country. Forbes has ranked Instacart at the Number 1 spot in the list of America’s most promising company.

So now you know how Instacart works. This amazing technology can be used to create a similar business model in the on-demand segment. If you are dreaming to make the next big thing in this world, then this is the time to take action.

Upload : Amazon series

Rolling Stone Review by Alan Sepinwall



Early in Amazon Prime Video’s new sci-fi comedy Upload, a character explains that her grandmother is in heaven. “Which one?” she’s asked.

The question makes sense within the context of the near future depicted in Upload, where tech companies can — for the right price — digitize human consciousness and grant customers a virtual afterlife of their choosing. There are computerized heavens modeled on the hills of Tuscany, the casinos of Las Vegas, the African veldt, and more, including Lake View — “the only digital afterlife modeled on the grand Victorian hotels of the United States and Canada” — where our hero, young coder Nathan (Robbie Amell) finds himself after dying in a self-driving car accident. .

But the question applies just as easily to the context in which Upload arrives. We are in the middle of Peak TV Afterlife, with lots of shows — many of them from people who used to work on Parks and Recreation with Upload creator Greg Daniels — set partially or entirely in versions of heaven where things aren’t working quite as they should. We only just said goodbye to The Good Place, and, even more recently, the finale to Devs discussed the idea of the recently deceased being given a new digital life. Amazon already dabbled in afterlife ennui with the short-lived Maya Rudolph/Fred Armisen vehicle Forever, and the first season of TBS’ Miracle Workers reimagined heaven as a corporate factory run by an incompetent CEO named God. The HBO miniseries Years and Years had one of its leads attempt to upload themselves to the Web before they died. And several Black Mirror episodes — including arguably the two most famous ones, “San Junipero” and “USS Callister” — involve characters gaining immortality through digital consciousness transfer..

Daniels is among the most gifted and influential comedy minds of the last 25 years of television, responsible for everything from classic Simpsons episodes like “Bart Sells His Soul” and “Homer Badman” to excellent shows he created or co-created, such as King of the Hill, the American Office, and Parks and Rec. But Upload has been in development for what seems like an epoch, going back to the HBO regime of Michael Lombardo (who hasn’t worked there since the Obama administration). So, through no real fault of his own, he can’t help but seem way behind the curve this time.

The show’s satiric portrait of a world in which the afterlife is just an app with pop-up ads and different subscription tiers plays like a longer, gentler Black Mirror story. Nathan’s dawning realization that his wealthy girlfriend Ingrid (Allegra Edwards) — who can video chat with him and even visit him in Lake View using virtual reality equipment — is a vapid monster with whom he will soon be doomed to spend eternity recalls the questions Forever asked about what happens when “’til death do us part” gets an unlimited extension. The bumbling artificial intelligence (Owen Daniels) that staffs Lake View is basically a creepier, much less helpful version of Janet from The Good Place. Nathan quickly grows frustrated to find this grinning A.I. around every corner; the sense of familiarity that Upload unwittingly evokes is just as omnipresent.

Upload has some sharp points to make about income inequality. Nathan can’t afford Lake View himself, and winds up prisoner to the whims of his sponsor Ingrid, while our frequent glimpses of the world he left behind suggest the have-nots have less than ever. (The One Percent can not only get into these digital heavens, but are the only people left who can afford real food, as opposed to the kind made in a 3D printer.) Its commentary about all the ways we’ve allowed corporations’ long tentacles to wrap themselves around our lives (or afterlives) is reminiscent of half of Black Mirror (get ready to be reminded of the one about the perils of being able to rate humans on a five-star scale), but that doesn’t make it any less pertinent to our own increasingly dysfunctional world.

Still, the déjà vu of it all makes the humor play softer than may have been intended. Where Upload is most successful is in depicting a star-crossed romance between Nathan and Nora (Andy Allo), the optimistic customer service rep for the company that runs Lake View. He’s technically involved with Ingrid, and Nora is forbidden from even befriending the “guests,” let alone dating one, yet their attraction is clear from the start. Their attempts to overcome the metaphysical distance between them is one of the few aspects of the show that feels completely current, and not borrowed from another recent series(*).

(*) Even smaller details inadvertently conjure thoughts of other shows. While Nathan is exploring the perks of Lake View, there’s a scene scored to Walter Murphy’s disco classic “A Fifth of Beethoven,” which is the theme song for FX on Hulu’s Mrs. America.

The chemistry between Amell and Allo is strong enough to push aside some sense of of overfamiliarity, and to cover for aspects of the show that don’t quite click. (An investigation into whether Nathan was murdered never really gets up to speed, and Ingrid is so cartoonishly awful that she throws the tone of everything else out of balance.) Once you get past the exposition-laden 45-minute premiere episode, the rest of it is a quick and mostly likable binge. And there are periodic moments of inspiration, be they comic (even in heaven, you can ask to speak to a manager) or something more divine.

Among the show’s running gags is that every corporation we know in 2020 has combined with at least one other, so that Nora and her colleagues are asked to encourage Lake View guests to try a new Nokia Taco Bell dish, while the scientists of Oscar Meyer Intel are hard at work trying to prove that the recently deceased can be downloaded back into clones of their old bodies. This itself is not a new joke — the final season of Parks and Rec, set in what was then the near future, did the same thing — but it seems fitting for a series that feels like an amalgamation of so many pre-existing ideas. Spend too much time in the afterlife — whichever version you prefer — and even the miraculous can get old.

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.

The Assistant - subtle movie of the year

The fact that it was directed by a documentary filmmaker like Kitty Green sets the tone for the movie. Just imagine a movie about predatory behavior at workplaces and they dont show the predator or the victims POV but rather the entire mundane life of an omnipresent employee of the firm It explores the tolerance of the public to the nefarious behavior of the wealthy and powerful and how it translates in to the decadence of society.I like how the movie literally walk-through the entire day of the assistant detailing the grind of chores and adhoc requests/tirades thrown at her. There is minimal dialogue in this movie and the director seems to prefer to let silence and facial expressions detail the mood and feelings of the protagonist. This demands an intricate performance fro the artist which Julia garner executed for this role. The minimal use of BGM and devoid of any flashy editing leads to a real life atmosphere throughout the movie.There is no explanation for the