Trump’s Promise of Only 100,000 Deaths Assumes We Ignore Him

Court transcribers like Peter Baker and Mike Allen were very impressed with what they deemed a very somber new Donald Trump in yesterday’s COVID rally. At it, Trump warned that we’re going to have a hard two weeks ahead of us (and then, over an hour later, admitted in an offhand comment it might actually be three). He warned there were going to be a lot of deaths — then stepped aside so someone not up for election could explain that means upwards of 100,000 deaths. And so, Trump implored while promising everything would get better in two weeks (or maybe three), we need to follow White House 30 Days to Slow the Spread guidelines to ensure we can limit deaths to 100,000.

There are a couple of major problems with that.

First, those guidelines ask for 30 days, but Trump is just asking for two more weeks (or three, if you manage to watch over an hour of this stuff).

Then, as Dr. Deborah Birx noted repeatedly, that 100,000 best case scenario is based off the IHME projections. But the IMHE projections are based off adopting a more stringent level of social distancing than White House 30 Days to Slow the Spread guidelines — basically, stay at home orders — and they assume those orders will remain in place until the end of May, not April.

To be fair, starting before the time Trump was pushing to reopen the economy, a bunch of governors (most of them Democrats, including people like Jay Inslee, whom Trump has repeatedly attacked) decided to impose more stringent requirements than Trump was recommending. As of yesterday, 29 Governors had stay-at-home measures in place to match the IMHE projections. Republican die-hards Doug Ducey of Arizona and Greg Abbott of Texas even capitulated yesterday and imposed state-wide orders (though on second review Abbott’s is just a non-essential business closure).

But even as this presser was going on, Trump’s closest ally among the governors, Ron DeSantis, was digging in, claiming that the White House task force had never suggested to him that they should impose a stay-at-home.

“I’m in contact with (the White House task force) and I’ve said, are you recommending this?” DeSantis said. “The task force has not recommended that to me. If they do, obviously that would be something that carries a lot of weight with me. If any of those task force folks tell me that we should do X, Y or Z, of course we’re going to consider it. But nobody has said that to me thus far.”

Trump was even asked about this. In a presser where Trump and Birx suggested that New York had been really late in adopting social distancing (that’s not true: Andrew Cuomo imposed an order more stringent than Trump’s current guidelines on March 18, just two days after Trump first called for social distancing, and imposed a full stay-at-home on March 20, effective March 22, which was among the earliest full state shut-downs), Trump and Mike Pence also had nice things to say about DeSantis, with Georgia’s Brian Kemp, the last of the major state governors not have one.

Reporter: I wanted to ask you about individual states issuing stay at home or what do you think, for instance, in Florida, Ron DeSantis has resisted urges to issue one of those, but he said moments ago that if you and the rest of the task force recommended one, that would weigh on him heavily. What sort of circumstances need to be in place for you to make that call and say this is something you should consider?

Trump: Different kind of a state, also great Governor, knows exactly what he’s doing, has a very strong view on it, and we have spoken to Ron. Mike, you want to just to tell him a little bit about that.

Pence: Well, let me echo our appreciation for Governor DeSantis’ leadership in Florida. He’s been taking decisive steps from early on and working closely with our team at the federal level. But let me be very clear on this. The recommendation of our health experts was to take the 15 days to slow the spread, and have the President extend that to 30 days for every American. Now, that being said, we recognize that when you’re dealing with a health crisis in the country, it is locally executed by healthcare workers, but it’s state managed. And so we continue to flow information to state governors. We continue to hear about the data that they’re analyzing and consult with them. But at the President’s direction, the White House Coronavirus Task Force will continue to take the posture that we will defer to state and local health authorities on any measures that they deem appropriate. But for the next 30 days, this is what we believe every American and every state should be doing at a minimum to slow the spread.

Trump: So, unless we see something obviously wrong, we’re going to let these governors good. Now, it’s obviously wrong, I mean, people can make things, they can make a decision that we think is so far out that it’s wrong, we will stop that. But in the case of DeSantis, there’s two thoughts to it, and two very good thoughts to it, and he’s been doing a great job in every respect, so we’ll see what happens. But we only would exercise if we thought somebody was very obviously wrong.

Aside from some rural states and Georgia, just about the only entity in the country not telling DeSantis to shut his state full of especially vulnerable seniors down is the President.

According to the IHME projections (and assuming those aren’t hopelessly optimistic because of a known lag of test results in places like California), we might still make that 100,000 projection if DeSantis imposes a true lockdown within seven days. But he says he’ll only do that if President Trump gives him political cover to do so.

Effectively, then, the allegedly sober President yesterday said we might only have 100,000 deaths if people ignore him and one of his closest political allies, Ron DeSantis.

Update: DeSantis is announcing a stay-at-home order within the hour.

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118 replies
  1. Yogarhythms says:

    Ew,
    Thank you for suggesting ignoring President Trump. President Trump is leading the fight against Covid 19 the way a Santa Cruz Banana slug leads in the mountains. Standing tall among the dead leaves rotting the forest floor slime. Real leadership investigates the crisis from different perspectives. Seeking alternative viewpoints. Testing as many people possible as soon as possible creating a battle foundation. Without a foundation your drifting and the journey is exciting and life threatening. Ask any healthcare workers in hospitals treating Covid 19 patients about life threatening bedside patient care without PPE?

    • ducktree says:

      And note that the VP’s milking stool was missing the most critical leg for the task: (1) executed by the health care workers, (2) managed by the states and (3) SUPPORTED by the Federal government (the missing leg). But in this case, as usual, the third leg is MIA.

    • P J Evans says:

      Banana slugs are at least ecologically useful. (Also impressive as heck, when all you’ve seen is garden slugs.)

  2. P J Evans says:

    Being in California, I’ve been ignoring Trmp’s pronouncements on the virus since he started babbling about it. I already figured it would be late May, at best, before we get any relaxation of stay-home rules – and that might be temporary.

  3. Kelly Canfield says:

    This chart is total cases and total deaths for the US,
    data from covidtracking.com/api/ updated yesterday 3/31 at ~2:00 Mountain

    My prediction is that if this model holds, today before or by midnight, we will cross the 5,000 deaths line. If that holds true and tomorrows number is ~7,400, then I think we are looking at 20,000+ deaths Monday

    4/1 – 5,000 +/- 2%
    4/2 – 7,400 +/- 2%
    4/3 – 11,000 +/- 2%
    4/4 – 14,800 +/- 3%
    4/5 – 19,500 +/- 3%

    http://kellycanfield.net/K_COVID_Forecast_04.01.2020.1032.jpg

    • Rayne says:

      Cases only represent people who’ve been tested. Deaths are the only sure measure and they can be coded incorrectly as something other than COVID-19-related.

    • Kelly Canfield says:

      Oops, made a big error; I had the model set for 7 forecast days, and drew them as 5 days; bad

      Updated forecast

      4/1 – 5,000 +/- 2%
      4/2 – 6,500 +/- 2%
      4/3 – 8,100 +/- 2%
      4/4 – 10,800 +/- 3%
      4/5 – 14,000 +/- 3%
      4/6 – 18,000 +/- 3%
      4/7 – 24,000 +/- 3%

      • Kelly Canfield says:

        Also, I think that since deaths are absolute, they “trump” any other observed numbers.

        If mortality is truly 1%, you can calculate cases backwards

        • earlofhuntingdon says:

          That 1% is a big if. It seems to be the big question, upon which is dependent much policy. So is the transmission rate.

        • Fishmanxxx says:

          The only countries presently close to 1% mortality rate appear to be Germany and Canada, and those will likely increase with time. Today Germany had a jump in fatalities. If the mortality rate is deaths over infections the US rate is 2% presently, with a likely increase to 4% or more depending if the availability of ICU beds and ventilators don’t crash. Based on 100,000 lost souls, and calculating backwards that means 2.5M cases!
          The UK rate is roughly 8%, Spain at 9%.

        • John Paul Jones says:

          Canada isn’t doing nearly enough testing, hasn’t done a huge amount of testing, and the last time I looked, BC’s guidelines for who should get tested amounted to pretty much almost dead. So numbers are going to jump, both of hospitalizations and deaths. BC has a lock-down order, and so far, the majority of deaths have been in long-term care facilities.

        • fishmanxxx says:

          In the spirit of maintaining accurate posting I would encourage readers to visit https://ourworldindata.org/covid-testing where the per capital testing is provided. It’s not the « Huge » numbers that count, it’s the per capital testing and Germany, Canada and South Korea are way ahead of the US. Huge is a word too often used by the unstable idiot in charge!

      • stryx says:

        Let’s don’t forget that fatality isn’t the only outcome. A large fraction of cases will require hospitalization, which may include a lengthy stay (Ohio’s Dr. Acton has said 20 days may not be unusual.) Assuming the patient is released alive, they not only face diminished lung capacity and related painful respiratory impairment, but also an astronomical medical bill.

        Well, someone will face an astronomical medical bill even if the patient isn’t released alive.

        • stryx says:

          According to a slide Gov DeWine tweeted March 30th from the Ohio Dept of Health, 75% of current cases were not hospitalized, 16% were hospitalized but not in ICU, and 8% were in ICU.

  4. Peterr says:

    I like IHME and their numbers, but there are limits to the conclusions you can draw. For instance, they project no shortage of hospital beds in Kansas. In reality, however, the vast majority of those beds are in metro KC, Topeka, and Wichita, with smaller numbers elsewhere. If/when there is an outbreak of COVID-19 in western Kansas, all those empty beds in Topeka aren’t going to be much of a comfort.

    Similarly, counting across the state lines is a particular issue here, and I have to wonder how they are accounting for this in Missouri and Kansas. St. Louis hospital beds are the destination of many folks from southern Illinois whose problems outstrip their small-town local hospitals. This will add to the burden in St. Louis, but I don’t know if this is taken into account. Similarly, hospitals in metropolitan Kansas City draw folks from eastern Kansas, and they may come not simply to the hospitals on the Kansas side of the state line. This works in the other direction too, as there are Missouri folks who will end up at KU Med Center, which is on the Kansas side of the line.

    And Missouri is one of those states where Governor Mike Parson (R) has yet to issue a statewide Stay at Home order. He is up for reelection in November, likely running against the sole Democratic statewide officer, Auditor Nicole Galloway. She is sharp, and clearly has Parson worried. But Parson doesn’t want to anger the rural towns, so he alternates between pushing a conservative “This will be solved on an individual basis by freely chosen personal decisions, not by Big Government edicts” and also feeding into the “this is an urban problem” myth, despite the fact that COVID-19 cases are showing up more and more outside of KC and St. Louis.

    Oh, and rural areas put Missouri near or at the top of the list of states with the highest number of rural hospitals that have closed over the last several years — in part because of the failure of the GOP super-majorities in the state legislature to do anything to address it. “It’s individual choices. . . . It’s the free market at work . . .” is gonna end up killing a bunch of rural Missourians, along with a non-trivial number of poor urban folks.

      • Molly Pitcher says:

        The Governor of California arranged for the state to take over two hospitals, one North and one South and they have been cleaned, re-staffed and are up and running.

        The one in the North had threatened to close if it could not find a buyer back in February. Truly an appalling corporate decision in the face of a pending epidemic.

      • Pajaro says:

        These Vulture Capitalists don’t even wait for the wheezing, last-minute gasps of their prey to end they just start snipping flesh off with their beaks, as the prey is helpless.

    • Raven Eye says:

      Collecting information on hospitals is hugely problematic. Generally, the federal government gets that kind of information from the states and state-like entities, or ends up sorting by those entities. But as been noted, that does little to understand the distribution of health care resources.

      Dropping down to SMSAs, the information is mostly state and county (and counties are the local government “units of issue” that FEMA tends to deal with), but those rarely cross state lines because they are census-driven. The “all caps” titles in this map are the SMSAs:

      https://www2.census.gov/geo/maps/metroarea/us_wall/Sep2018/CBSA_WallMap_Sep2018.pdf?#

      It would probably be more illuminating to look at the heat maps for health care catchment areas, but those are inconsistent and usually generated by factors other than pandemic response. Perhaps ESRI as already done this — mapping intensive care and acute care beds across the country.

      • posaune says:

        Yes, ESRI has a dedicated COVID team for sharing & producing data mapping. They will share with local and state agencies. I can ask them about this.

    • Peterr says:

      Per IHME, Florida’s “peak hospital resource use” will hit on May 2, which is 31 days from today. To the extent that this order contains loopholes and/or folks don’t take it seriously across the state, that peak will hit sooner and be higher than they project.

      • Rayne says:

        DeSantis deemed “attending religious services conducted in churches, synagogues and houses of worship” as “essential activities” — set the clock for 5-14 days from Sunday for a bunch of sick and dying fundamentalist Christians.

        • Rayne says:

          Well, I guess they’re going have a “witch test” — if the accused drowns, they’re innocent and if they float, kill them for a witch.

          So…if you get sick and die you weren’t Christian enough, you didn’t believe hard enough. But if you don’t go to their church you’re not Christian enough and must repent your sins.

          So medieval.

  5. Jenny says:

    The occupant of the WH is consistently inconsistent. I have one in my family. Best to ignore.

  6. Pete T says:

    DeSantis deferring the Trump instead of IHME epidemiologists

    “Ali Mokdad, a professor at the University of Washington’s Institute for Health Metrics and Evaluation, said he told Florida’s top health official Monday night that the governor should issue a blanket stay-at-home order mandating the closure of non-essential businesses and social isolation in order to control the spread of the virus. The institute’s model — which is updated daily as data changes — predicts that even if such an order is given, the state’s coronavirus outbreak is on pace to peak in early May in numbers that will overwhelm intensive care units and potentially lead to thousands of deaths by the summer.”

    https://www.miamiherald.com/news/coronavirus/article241637691.html

    • BobCon says:

      We will see DeSantis begging other states to provide hospital beds for Florida residents even though he is hassling New York residents at highway checkpoints right now.

      Still, I hope there is capacity somewhere to help them out. They shouldn’t suffer because their governor isn’t qualified to throw raw chickens in a gator farm.

      • harpie says:

        DeSantis is also not allowing a cruise ship with more than 1,400 passengers [and four deaths] to dock in Florida because:
        https://twitter.com/NBCNews/status/1245338645697040386

        “We cannot afford to have people who are not even Floridians dumped into South Florida using up those valuable resources,”

        This is what the usually even-tempered Representative Tom Malinowski [D-NJ-07] had to say to DeSantis:
        https://twitter.com/Malinowski/status/1245399735076257797
        1:16 PM · Apr 1, 2020

        I have a constituent onboard. He’s an American.

        BTW, we will continue to treat any sick Floridians in NJ with compassion, even if their governor is a jerk.

        • BobCon says:

          Shades of the ocean liner St. Louis in 1939, chased away from landing in Florida,

          It will probably be the case that some states lag far behind others in terms of recovery, and I would not be surprised if Florida is still hammered at a time when others are getting back in shape.

          In which case, I hope that the better off states are able to lend a hand.

          It’s gross how Trump is going to go to unfair lengths to help out DeSantis, who will probably end up squandering resources better used elsewhere. But if things are a lot better in, say, the Research Triangle area in six months while Tallahasee is seeing another rebound, I hope we are in a position to move people to where they can be helped.

      • Rayne says:

        Here’s the problem: Florida’s demographics versus that of other states means that they shouldn’t have any more help from other states. It has the fifth oldest average age at 42.2 years (Maine surprisingly has the oldest at 45.1). At that age and the likely co-morbidities which come with age, many Floridians couldn’t compete for ICU beds and ventilators in other younger states.

        Fuck DeSantis. He’s gotten the lion’s share of federal strategic reserve resources because he’s a GOP governor in a reddish state. He can make do.

        Thinking of my parents in Florida who are DNR. If they get COVID-19 at least they were smart enough to plan not to foist themselves on an overburdened health care system.

        EDIT: Just bugs the crap out of me that “only 1-2,400,000” American deaths are a “goal.”
        null

        • Raven Eye says:

          With that chart staring them in the face, I wonder if certain individuals are going to pop up again with their thoughts of just no bothering too much with the elderly.

          Odd though, how the pro-lifers (pro-lifers as in “every sperm is sacred”) seem to be omfortable with sending older folks off into that great darkness.

        • Rayne says:

          Yeah. All those conservatives who bitched about Democrats pushing them through death panels now seem entirely comfortable with elderly going into the Soylent Green factory.

        • BobCon says:

          The US Conference of Bishops fought Obamacare tooth and nail. They promote the “March for Life” every year, even with Trump’s participation, given their supposed deep opposition to his drive to hurt immigrants and cut services to the poor.

          But when the GOP pushes death for the infected, they can’t say a word.

        • joejim says:

          The Seattle TImes reported today that it had come up with (an acknowledged undercount) of 95 WA State assisted living facilities that have confirmed “corona virus outbreaks,” a damn vague designation. The vast majority remain untested, both staff and workers. No standards that would enforce best distancing practices in these places, before or after identifying the presence of the virus, its all ad hoc.

          So one example of “a corona virus outbreak” is at my mother’s place. They ended all movements outside of rooms two weeks ago when the first worker got sick. They finally wrangled up test kits from a private lab ten days later and received results this morning, and an amazingly low 10% of about 140 staff and residents are positive, but this still means 14 people. Coyly, the management didn’t give a staff/resident breakdown, as it had in previous reports, I presume this is because a lot more staff are positive, who, in a sane universe, should have been tested two weeks ago, after the first one became sick. And they have never reported anything about the severity of the cases that exist, not even sure if there have been deaths. Its a big corporation, so Im sure they have their reasons.

          Its all frustratingly inconclusive and unspecific. I agree that as things stand, death stats will be the only fairly certain calculation, but even that won’t be completely accurate without testing, and not as useful a type of information as a lot of other data might have been.

        • Frank Probst says:

          Just looking at the map, I’m not sure where they’d go. Or how they’d get there. You’re pretty much looking at the Interstate Highways for transport. Atlanta is almost at (if not already over) capacity. Birmingham (Alabama) is too small. New Orleans is going to have its own problems. I don’t see much that handle a huge influx of patients until you get to North Carolina, Tennessee, or Texas, and those states will take patients from the cities above before they take patients from Florida.

  7. Ed Walker says:

    What’s galling about DeSantis’ recalcitrance is that people travel from FL to other places like Chicago. His holdout on the order means we are in isolation even longer while we wait for that part of the population and their contacts to get over the illness.

    I suppose I shouldn’t care as much as I do, because I’m something of a recluse, but the feeling of being cooped up is unpleasant, and I miss my social life and the shows, operas, concerts, movies, openings, museums, sports, walking on the beaches of Lake Michigan, and other delights of urban life.

  8. Wm. Boyce says:

    I heard this reporter on NPR this afternoon:
    https://www.theatlantic.com/health/archive/2020/04/coronavirus-pandemic-airborne-go-outside-masks/609235/

    He is the Atlantic’s science writer and wrote an article two years ago which predicted the scenario playing out now. Among many other things, he said that even the most pessimistic observers were surprised by the incompetence of the U.S. response to the pandemic. I guess he was being polite or circumspect, because with fucking morons like Trump and DeSantis, it’s no surprise, and it’s going to cost a lot of people their lives, and even more people their livelihoods.
    Things aren’t going to be the same for a much longer time than is being projected by the morons in the executive branch.

  9. punaise says:

    speaking of music:

    “The problem is all inside your dread”, she said to me
    “The answer is easy if you take it epidemiogically
    I’d like to help you in your struggle to find TP
    There must be thirty days to leave your glover”

    She said, “it’s really not my habit to intrude
    Furthermore, I hope my Purell won’t be lost, nor my mask come unglued
    But I’ll repeat myself at the risk of being crude
    There must be thirty days to leave your glover
    Thirty days to leave your glover”

    You just slip on the masks, Jax
    Take a new test, Bess
    You don’t need covid, Sid
    Just get yourself free
    Shelter in place, Stace
    And don’t touch your face much
    Just drop off the shield, Neil
    And work yourself from home

  10. Badger Robert says:

    Hard to believe the numbers that there be a domestic casualty toll, like the Vietnam War, within 60 days. But the math is simple.
    It won’t a lot Willie Johnsons and Joe Bob Wallace, fighting and dying. And it won’t be Vietnamese people dying in widespread bombing.
    The Vietnam War never shut down the economy for 6-8 weeks.
    I suppose, like the aftermath of the US Civil War, the people will never hold the leadership responsible, but find some outside force, immigrants, minorities and China to blame. That would be incredible, but bouts of self destructive faith based behavior have happened more than once among white European based populations.

    • Rayne says:

      In my first economics class back in the 1980s my prof explained war was an engine for the economy — we produced stuff and it never came back, he said.

      Uh-huh. That said, the 1960s saw unemployment fall to 3.4% by mid-1969.

      • Badger Robert says:

        War may be an engine, but most likely it just reveals what capacity was already in existence. The virus is going to create a lot of empty stores and restr. but the productive capacity will go untouched.

  11. Badger Robert says:

    It probably goes on until, 1. There is a reliable antibody test that can give people certificates of immunity, like Germany is working on, or 2. There is a national vaccine campaign, as there was for polio.

  12. Rapier says:

    Take care of yourself and take care of others. Hygienically and every other way. In places where people do that as a matter of course and culture, especially on the hygiene part, is where the least worst outcomes will occur. That ain’t here. Still it can be for a majority if it is continuously said that mindfulness of others deserves our greatest respect. Not how much fucking money they have.

    6 or 8 weeks ago if Trump and the entire political world had just kept saying we have to help and take care of each other we would be many times better off. Where are the D’s in this by the way? Biden? Silent. Cripes. One of the biggest crisis in American history and he nor any D leader says anything. I mean WTF. The easiest message in the world and nobody can think to deliver it. All they think about is money and bitching about edicts from GOP politicians.

    Expecting edicts from conservative voices urging people to be mindful of others is a fools errand because they don’t believe in it. Nor do their fans so screw them. True 40% of Americans are with them. So it goes. 40% isn’t a winning political hand. And no matter what happens with politics, take care.

  13. observiter says:

    I do think the Administration knows exactly what they are doing.

    The power players leading Trump want “small” government. Get Americans to hate government. Strip of money, strip of regulatory power, get rid of excellent/efficient leaders, select bungling idiots as leaders.

    How telling. Mark Meadows is the new Chief of Staff.

    I don’t believe this group cares at all if people die, even if the afflicted work for the military.

    • PhoneInducedPinkEye says:

      I only sort of half believed this when I first commented it here, but I’m now convinced the admin is letting it rage across the country because it will hit urban areas harder, as far as total deaths, helping the gop in 2020.

      And racism ofc.

      • Wm. Boyce says:

        This administration doesn’t know what it’s doing. Sure they have ideas of what they’d LIKE to do, and they’ve caused lots of damage to the country and the structure of the government, but they are heedless of consequences, and have a real crisis on their hands for the first time.

  14. earlofhuntingdon says:

    This “administration” is critically understaffed in all agencies and at all levels, a result achieved by design, incompetence, and vindictiveness. Acting administrators predominate. Experience, teamwork, and management skills are inadequate.

    Trump has poured Roundup on the bureaucratic grapevine that makes government work in novel and extraordinary situations. He has exorcised expertise, he has squandered goodwill through his now twenty thousand odd lies. He has forced government to devolve, so that its competence matches his own, He achieved that with disappointing ease, an accomplishment that only neoliberals and Putin could admire.

    There will be no normal to go back to. Like the Brits post-Brexit – another self-inflicted, treasury-draining catastrophe – we’ll have to reinvent the wheel, while we fight the GOP and the neoliberals among the Democratic establishment. I’m going long on pitchfork futures, because they’ll be needed to dissuade the neoliberals from looting what comes after.

  15. orionATL says:

    together with trump firing or driving so many comptent professionals out at all levels of government, i wonder how much damage nitpiking budget reductions in medical preparedness huunying the covid-19 struggle were a consequence of making the numbers look good for the the 2017 corporate-pigs-at-the-trough republican tax bill.

    another example of the self-serving folly of the fact-checking tyrants of political speech.

    a tedious talmudic, legalistic approach to political speech completely misses the need to articulate in simple, broad terms an opponent’s bad-faith behavior damaging to the nation interest. exaggeration should not be treated as the great concern or the greater enemy here; it merely becomes to a reverse opposite- party talking point

    https://www.factcheck.org/2020/03/democrats-misleading-coronavirus-claims/

  16. orionATL says:

    voices from the near-past speaking of the pluperfect. this is good stuff:

    JAMA, vol. 298 no. 6 august 8, 2007

    …Original Contribution

    August 8, 2007

    “Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic”

    Howard Markel, MD, PhD; Harvey B. Lipman, PhD; J. Alexander Navarro, PhD; et alAlexandra Sloan, AB; Joseph R. Michalsen, BS; Alexandra Minna Stern, PhD; Martin S. Cetron, MD

    Author Affiliations Article Information

    JAMA. 2007;298(6):644-654. doi:10.1001/jama.298.6.644

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