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We Have Met the Enemy and He Is Us
This year in the USA we’ve had around 35 million cases of influenza with around 35,000 deaths, for a fatality rate of 0.1%. That’s a pretty typical year, although a couple of years ago we lost 80,000 people one flu season. That was considered to be a bad year, but it barely made the papers. After all, it’s influenza. It happens.
Meanwhile, we’ve had a grand total of 282 deaths from COVID-19 so far and not only has this made the papers, we’ve essentially shut down our society and our economy. This has struck me as odd from the beginning. I’ve had the feeling that I simply must be missing something. So I’ve spent the last few weeks reading all the data I could find on this topic from the World Health Organization, the CDC, and various other data sources. Today I read an outstanding article from Aaron Ginn. I know a lot more about COVID-19 now, but I’m still confused.
Let’s consider three countries and their experiences with COVID-19:
- Italy has 778 cases per million population, with a fatality rate of 8.5%.
- South Korea has 172 cases per million population, with a fatality rate of 0.1%.
- The United States has 67 cases per million population, with a fatality rate of 0.1%.
Italy has essentially locked down its entire country. South Korea has done very little in terms of public policy but has encouraged common-sense personal hygiene practices, like hand washing. The United States is somewhere in between. So suppose you’re a politician and you’re trying to explain the benefit of draconian government actions in response to this virus. How would you present your argument, based on those numbers?
The best controlled study group we have available for this disease is The Diamond Princess. From an infectious disease standpoint, this was close to a worst-case scenario. During its two-week “quarantine,” it turned into essentially a floating petri dish. It had 3,711 people on board, including staff and passengers. It started out with ten COVID-19 cases. Two weeks later, it had 705 cases, and seven of them died. What a fiasco.
But let’s stop and think about that for a moment. First of all, with 705 cases and 7 deaths, that means a fatality rate of 1%. And remember that this is an extremely elderly population, away from their homes, under living conditions that were far from ideal, in a closed environment that was absolutely flooded with the COVID-19 virus. Health care facilities were woefully inadequate. The average age on the Diamond Princess was 58, and 33% of the passengers were over 70. All seven of the deaths were in those over 70.
There were no children on board, to skew the numbers toward the more mild form of COVID-19 that children get. Only old people. Old people who are traveling, tired, away from home, and spending two weeks sitting in their tiny cabins in a floating petri dish being flooded with the COVID-19 virus. And of those 3,711 people, there were 7 deaths.
So of the 3,711 (mostly elderly) people trapped in that worst-case scenario, 0.2% of them died.
Surely we can do much, much better than that 0.2% fatality rate here.
The American population is much younger and healthier than the Diamond Princess passengers, we are not cooped up in a floating petri dish for weeks at a time, we have good health care facilities, and we can respond to problems much more quickly and intelligently than they did.
Plus, huge segments of our population are not seriously threatened by COVID-19. Children, for example.
An article in JAMA from February pointed out that of the 45,000 cases of COVID-19 in China at the time, only 2% were in children, and there were no deaths in children under 10. So far this flu season, we’ve lost 136 children to influenza. But COVID-19 does not seem to threaten kids. On March 8, the Korean Centers for Disease Control and Prevention reported that South Korea had 6,300 cases of COVID-19, but no deaths in anyone under 30.
The World Health Organization has been studying COVID-19 all over the world for months now, and reports: “Even when we looked at households, we did not find a single example of a child bringing the infection into the household and transmitting to the parents. It was the other way around. And the children tend to have a mild disease.”
So children do not seem to act as a vector to give this disease to older family members. And if older family members give the disease to children in the home, children get only a mild form of the disease.
So why are we closing schools? Not due to data or evidence, that’s for sure. “Just to be safe.” Or “out of an abundance of caution – it’s all about the children.”
Ok, but these actions are not without consequences. Much of the hoarding and other unhelpful behaviors we’re seeing right now are not due to fear of the COVID-19 virus, but rather due to fear of ever-increasing government crack-downs on personal liberties.
As Mr. Ginn states, “Infection isn’t our primary risk at this point.”
I’ve spent an enormous amount of time reading, and trying to figure out why we’re responding this way to this virus. I now know a lot more about COVID-19, but I still don’t understand our response.
As I mentioned in a previous post, I think a big part of the problem is that we, as a society, have lost the ability to consider risk-benefit ratios with any semblance of reason or logic. The herd mentality and panic-mongering on social media don’t help. The conventional media earns a living on advertising dollars, so they endlessly repeat the scariest scenarios they can think of, to attract viewers. Politicians, of course, want to exaggerate every problem so they can portray themselves as our indispensable saviors.
There really is no one who is motivated to present a more reasoned perspective. No one.
Plus, people naturally love bad news and are skeptical of good news. A patient can come to me with a headache, I can do a complete history and physical, complete with labs and X-rays, and then finally tell the patient, “You’re fine. Go home and take some aspirin.” And they’ll respond, “Are you sure? I think something’s really wrong…”
Or I can have the exact same patient come in, with the exact same headache, and I can just walk in the door and holler from across the room, “You’ve got brain cancer. You’re gonna die.” And the patient will respond, “I knew it. I just knew it.” They don’t even question me. Because people love bad news.
So, in summary, I think we have a serious problem here, which has no clear solution. A very, very serious problem.
And it’s not COVID-19.
It’s us.
Note: I thank Aaron Ginn for his outstanding article. Please read the whole thing. Some of my writing above was based on (or in a couple of cases, shamelessly plagiarized from) his work. He covers a lot of topics that I skipped, he does a good job citing his sources, and he explains his logic clearly. It’s very long, and I was afraid that most would not read it, so I compiled the above summary. But please read Mr. Ginn’s article. It’s worth your time.
Published in General
Hospitals in New York are already getting pounded by COVID-19. Their ICUs are full, and it looks to me like we’re still in the early stages of this epidemic. The velocity of spread of the bug has not even begun to come down, at least according to the gross, aggregated figures we are seeing, which may be misleading because of how much testing is being done, etc. Regardless, running out of ICU beds seems like a pretty concrete data point.
The epidemiology of seasonality of viruses doesn’t lend much support to the idea that summer will end this epidemic. I saw some numbers suggesting that COVID-19 does not spread well above 56 degrees F. Hopefully that will be a factor, but it’s warm in Brazil, and it’s spreading there.
I had the same reaction as @mendel to the article when reading it when still available on Medium. It’s a pastiche of accurate info (all of which I was already familiar with), accepting favorable hypotheses as fact (declaring it “very likely” that higher temperatures will help – a hypothesis but that is all it is at this point), cherry picking the most favorable interpretation of any data, and outright inaccuracies; for instance, stating that all of the Diamond Princess passengers were tested so we know the infection rate. In fact 2/3 of the passengers refused to be tested, fearing that if they were positive they’d be quarantined when all they wanted to do was to return home. They were allowed to return without testing.
I am not arguing in favor of lockdowns, but the data analysis in Ginn’s article is seriously flawed.
False Binary. There is, of course, a third option: the CDC is a large hierarchical bureaucracy, and like all bureaucracies, it is riddled with sycophants, inefficiency, and infighting. The behavior that would most protect this bureaucracy in a time of crisis is to support the worst case scenario because that is the stance that least threatens the bureaucracy. No one will blame them for overreacting, but the blame from underacting would be a critical blow to the organization. So the CDC is simply behaving in a manner consistent with its own survival, not that unlike the microorganism they study every day.
Also, the unusually high percentage of people from Wuhan China specifically who live and work in northern Italy’s fashion and textile industries.
https://www.ecnmy.org/engage/prato-chinese-stuff-look-around/
https://www.forbes.com/sites/douglasbulloch/2017/02/16/textile-wars-will-made-in-italy-replace-made-in-china
https://www.newyorker.com/magazine/2018/04/16/the-chinese-workers-who-assemble-designer-bags-in-tuscany
https://www.altnewsmedia.net/news/corona-virus-exclusive-why-italy/
On the other hand, this article claims that virtually zero of the Chinese workers in northern Italy have tested positive for coronavirus. Of course, that doesn’t rule out all the Italian and Chinese businesspeople who fly to and from Wuhan regularly.
https://www.bccourier.com/why-the-corona-virus-hits-italy-so-hard/
Considering the Director-General’s incredibly close ties to the ChiComs, there are some who say we shouldn’t put too much trust in the World Health Organization’s numbers either.
https://www.newsweek.com/who-praises-china-country-that-deserves-gratitude-respect-some-question-coronavirus-1484716
https://www.nytimes.com/2017/05/23/health/tedros-world-health-organization-director-general.html
https://www.sgtreport.com/2020/02/who-is-whos-tedros-adhanom/
https://addisstandard.com/letter-editor-dr-tedros-adhanom-not-lead-world-health-organization/
https://www.nationalreview.com/2017/06/world-health-organization-corrupt-wasteful/
(Edited to erase the claim about Chinese media bragging. That video is actually from Taiwanese television. Mea culpa!)
Up here in the Great White North, the opposition Conservatives actually agreed with the Trudeaupian government to suspend Parliament, citing the need for social distancing. The Trudeaupians are operating during this crisis without any appreciable opposition.
And yet, the medical systems in South Korea, Singapore, and Hong Kong did not crash. The Italian experience is not the only case study for decision-makers to study.
New York City is not America. New York City has phenomenally high population density. Measures to fight COVID-19 that are appropriate for New York City are not necessarily appropriate for the country as a whole.
It’s back up at ZeroHedge.
https://www.zerohedge.com/health/covid-19-evidence-over-hysteria
Are there any differences between the Italian region of Lombardy and other jurisdictions that could account for that region’s unusually high number of deaths from COVID-19? Why must we use Lombardy as the baseline for how this disease propagates when there are other jurisdictions that have not suffered the same extreme events that Lombardy has?
That is a news story. In the time of the Trump administration. They are not neutral arbiters of truth.
I try to go to official press releases. – Yes, I know, but then again I pay attention (somewhat) to news reports that specifically contradict the official press release.
Singapore went aggressive early. Based on their experience with SARS.
The word “aggressive” covers a lot of ground.
Spelled it out in another thread, I’ll look for it.
Here is an article from the Financial Times. Note, Singapore has 3 main points of entry – the Airport, the Causeway, and the Cruise ship terminal.
Politicians should use the following talking point: “My government could have beaten COVID-19 if only we’d been more aggressive earlier like South Korea and Singapore, but since my government didn’t do that I’m going to have to suspend democracy indefinitely and anybody who disagrees is a crazy person.”
Of course, they won’t do that. Instead, they repeat uplifting slogans about “unity” and “solidarity”.
Here’s a CDC report about what Singapore did. They didn’t shut down schools and businesses, but I suppose they didn’t have to because they got on it early.
That is still on the table if it breaks containment.
Read the report. One thing I didn’t see mentioned is that businesses had their own plans in place to deal with results form contact tracing. They divided their workforce up into teams, with each team having different business hours and strict non-interaction with other teams. If a contact trace resulted in a team member being quarantined, the entire team that person was on went home as well.
I think the best guess at the moment is simply that’s where the epidemic in Italy first gained momentum, and the lockdown was imposed before it could reach a similar magnitude anywhere else in the country.
I wouldn’t call it a baseline.
The difficulty I see is that there is such a jumble of statistics – many of questionable quality (due to differences in testing rates) or difficult to interpret (because of things like lag times between infection and testing, or testing and death) that make it incredibly difficult to quantify all of the statistics people want to know, like case fatality rate, susceptibility among the population, reproduction rate, and so forth.
That’s why I think it’s helpful to at least look at a clear test case with one relatively reliable figure (deaths). And in the end, one of the things we’re really worried about is not the long-term death rate, but whether the virus can cause such a spike in medical treatment as to overwhelm our system.
Lombardy is large enough (10 mil.) to have some statistical power, and its geographical size, climate, density, genetics, etc., are close enough to a few US states to be representative enough. Plus, the curves from other hot spots that are slightly behind Lombardy have very similar trajectories, suggesting it’s not an outlier.
And the answer from Lombardy sure seems to be: yes, the virus is capable of overwhelming a medical system.
Does this mean a similar situation would automatically happen somewhere in the US or Canada? Of course not. But it shows that the virus is capable of being something much different than the common flu.
Let me try to reword my last comment in a simpler manner:
In a situation like this, there’s a big difference between Could, Can, and Will.
When the danger starts, everybody talks about what the virus Could do, but nobody knows what the virus Will actually do. In that situation, it’s very helpful to be aware of what the virus Can do, i.e. what it is actually capable of. And in this case, it’s capable of something we’ve never witnessed in the past century.
Now, just because the virus Can wipe out a flu season’s worth of patients in 2 weeks doesn’t mean it Will everywhere else or even anywhere else. But it’s still a much more solid data point than every single other discussion of coronavirus focussing on what the virus Could do – all of which (on both sides) is little more than pure speculation.
Deaths in Italy keep getting cited. Does Italy count Covid-19 deaths the same way other countries do? A columnist at TownHall.com asserts that Italy may be counting every death by a person who has Covid-19 as a Covid-19 death, regardless of whether the virus was actually the cause of death. TowhHall.com is not necessarily a reliable news source, but maybe the question raised is still valid. I know from data keeping at work that statistics can be significantly different if different input data criteria are used.
It seems like the “only 20% infection rate” on the ship must take into account the isolation/quarantine that occurred. 20% might seem very low if none of that had happened. But it did happen, and if one might normally expect a much lower than 20% rate in those conditions, then having it turn out to be 20% still, would seem to be alarming.
Also, if a significant number of people left the ship without even being tested, that dings the numbers too.
Well to start with, 50 million is about 1/6th of the whole US population.
But you just said (wrote) that out of those 50 million “cases” of flu, “only” 600,000 required hospitalization. And that would be over a period of several months, which could mean that maybe 100,000 people or possibly far less were hospitalized, at any given time. So it doesn’t mean that it might take 51 million COVID-19 cases to “swamp” the US healthcare system Just a little over 100,000 at once, could do it.
I looked at ICU census rates a couple of days ago. There are 95K ICU beds in the US. According to a study in 2005, the vacancy rate on those beds was about 32% or about 30K beds nationwide.
Problem is, those beds are distributed over the entire country – a pretty big place. So, like what is happening in NY today you don’t really need that many excess cases to overwhelm a particular locality.
I guess that is why one of the USN hospital ships is heading to NYC Harbor, bringing about 1K extra beds with it.
It may be “unfair” or something, but if someone dies from, say, COPD that they might have otherwise recovered from, because the additional COVID weakened their immune system or just the pile-on was too much… Yes, I would say COVID caused their death, not the COPD.
But it’s certainly possible to lie with statistics, if someone wants to. China is likely the worst offender in that regard. If, as I’ve read elsewhere, they were only counting “COVID deaths” as those who died after being hospitalized and testing positive, while thousands may have died without reaching a hospital OR being tested; then yes, the China deaths – both total number and rate – are much higher than they admit.
Most did leave without being tested. I misunderstood this early on and took some comfort in what seemed to be a 20% infection rate under favorable circumstances for spreading and given the old cohort. Supposedly returning passengers, at least to the U.S., were under quarantine for two weeks but I can’t find out if this was home quarantine or something stricter, and can’t find anything on the crew. If anyone knows of a followup study on the passengers and crew after release it would be good to know.
Yes, the 100k figure of hospitalizations swamping the system – like the 51 million total flu cases (which seems to be actually a projection anyway, not a solid number) and 600,000 hospitalizations – was overall for the US, with most not requiring ICU. And maybe 30% of those 100,000 wouldn’t require ICU either, but it wouldn’t take very many in any particular area, to cause big problems.
Clearly there was a variety of options available to them for calculating “infection rates” and so forth. Did they always use the maximum number of people who had been on the ship from the start, even after some were allowed to leave? That would seem likely to artificially lower the rates, especially if people left the ship without being tested. And that could be someone’s intent. You would think the cruise line officials especially, would be looking for the lowest number they could claim.
If even after vigorous number-juggling, the lowest figure they could claim was 20%, that could be a big problem.
Thanks @drbastiat and @mendel.
It seems to me as if there is a combination of enormous uncertainty in which scenarios play out under various courses of action, insufficient data and the time to prevent worst-case results is much shorter than the time to understand enough to craft a better response.
Catastrophic death tolls cannot yet be ruled out.
Most of the “data” comes from exceedingly unreliable sources. I don’t believe that we can trust anything about the data from China or Iran – they are likely much worse than reported. The variance of data from places with more reliable data (Korea vs.Italy & Spain) is consistent with huge variations in virulence and deadliness and how that applies to what will happen in the US is quite unclear.
If we wait until we understand better which scenario will play out here to react, it seems plausible that our health care system could be overtaxed – vastly increasing the # of dead from the disease itself and from other causes which we have run out of various resources to treat.
Therefore, the drastic distancing we are exercising now to buy us more time to understand how the disease will manifest itself here seems prudent. I assume that we are using the time well to understand and decide upon better long term approaches. Surely our country can bear such a cost for the weeks time scale.
Perhaps. But it appears that the Italian, Spanish and French versions of how the virus impacts patients than other parts of the world. S Korea has a LOT fewer patients in the “serious” category than any of the a fore mentioned countries(the overall patient to serious patient ratios are very different). So what gives?
Much younger demographic and quickly slowing growth avoided healthcare system overload.