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Coronavirus Isn’t a Pandemic
The world is in a full state of panic about the spread and incidence of COVID-19. The latest worldwide tallies, as of 12 p.m. ET March 16, 2020, are:
The most dramatic news of the day has been the sudden spike in the number of Italian cases, totaling 24,747 with 1,809 deaths, which may grow to exceed the 3,099 in China.
Overlooked is the good news coming out of China, where the latest report shows 16 new cases and 14 new deaths, suggesting that the number of deaths in the currently unresolved group will be lower than the 5.3 percent conversion rate in the cases resolved to date. In my view, we will see a similar decline in Italy, for reasons that I shall outline in the remainder of this article.
From this available data, it seems more probable than not that the total number of cases worldwide will peak out at well under 1 million, with the total number of deaths at under 50,000 (up about eightfold). In the United States, if the total death toll increases at about the same rate, the current 67 deaths should translate into about 500 deaths at the end. Of course, every life lost is a tragedy—and the potential loss of 50,000 lives worldwide would be appalling—but those deaths stemming from the coronavirus are not more tragic than others, so that the same social calculus applies here that should apply in other cases.
These are deeply contrarian estimates. In dealing with any future prediction it is necessary to develop some model. Right now, the overwhelming consensus, based upon the most recent reports, is that the rate of infection will continue to increase so that the most severe interventions are needed to control what will under the worst of circumstances turn into a high rate of death. This pessimistic view is well captured in an op-ed by Nicholas Kristof and Stuart Thompson, who offer this graph to stress the importance and the immediacy of the looming crisis.
The model here projects a slow takeoff, a sharp rise, and an equally dramatic decline, with a huge cumulative total of deaths. The authors allow that if moderate precautions are taken, these totals might be reduced by about half. The key assumption of this model is a replication rate of 2.3, whereby each person who is infected then infects two others, seemingly without end. But the model does not specify the periodicity of the replication rate or allow it to vary with any downward changes in viral toxicity or human behavioral responses that delay interaction. Nor does the model recognize that if the most vulnerable people are hit first, subsequent iterations will be slower because the remaining pool of individuals is more resistant to infection. And finally, the model explicitly ignores the possibility that the totals will decline as the weather gets warmer.
The writer Tomas Pueyo has struck a similar chord with his viral post “Coronavirus: Why You Must Act Now.” That article contains graph after graph indicating an exponential expansion of cases in the last several days, and then claims that these infections will translate themselves into a similar number of deaths down the line unless radical countermeasures are taken.
Much of the current analysis does not explain how and why rates of infection and death will spike, so I think that it is important to offer a dissenting voice. In what follows, I look first at the trends in the American data, and then, building on my conclusions there, I construct a theoretical framework to evaluate the evolution of the coronavirus in other places.
Based on the data, I believe that the current dire models radically overestimate the ultimate death toll. There are three reasons for this.
First, they underestimate the rate of adaptive responses, which should slow down the replication rate. Second, the models seem to assume that the vulnerability of infection for the older population—from 70 upward—gives some clue as to the rate of spread over the general population, when it does not. Third, the models rest on a tacit but questionable assumption that the strength of the virus will remain constant throughout this period, when in fact its potency should be expected to decline over time, in part because of temperature increases.
As of March 16, the data from the United States falls short of justifying the draconian measures that are now being implemented. As of two days ago, 39 states have declared states of emergency, and they have been joined at the federal level with President Trump’s recent declaration to the same effect. These declarations are meant to endow governments with the power to impose quarantines and travel bans, close schools, restrict public gatherings, shut down major sporting events, stop public meetings, and close restaurants and bars. Private institutions are imposing similar restrictions. The one-two punch of public and private restrictions has caused a huge jolt to the economy.
The irony here is that even though self-help measures like avoiding crowded spaces make abundant sense, the massive public controls do not. In light of the available raw data, public officials have gone overboard. To begin with, the word pandemic should not be lightly used. Recall that the Spanish influenza pandemic, fully worthy of the name, resulted in perhaps as many as a half-billion infections and between 50 and 100 million deaths, worldwide, of which some 675,000 were Americans, many coming back from Europe in the aftermath of the First World War. The World Health Organization recently declared coronavirus a pandemic at a time when the death count was at 4,000, presently being just over 6,500. It will surely rise no matter what precautions are taken going forward, but what is critical is some estimate of the rate.
By way of comparison, the toll from the flu in the United States since October ran as follows: between 36 to 51 million infections, between 370 thousand to 670 thousand flu hospitalizations, and between 22 thousand to 55 thousand flu deaths. That works out to between roughly between 230,000 to 320,000 new infections per day, and between 140 to 350 deaths per day for an overall mortality rate of between 0.044 percent to 0.152 percent.
As we think about the mortality rate of COVID-19, there are some important pieces of data to consider. The chart below documents the most current numbers reported by the New York Times (as of March 16) for the four hardest-hit states:
Note that Washington state, with 676 reported cases and 42 deaths, has a mortality rate of 6.21 percent, which can be traced to a nursing facility in Kirkland, WA. While only contributing 57 cases, it was the source of 27 of the reported deaths, almost two-thirds of the fatalities. (We should expect, as has been the case, that the mortality rate in Washington will decline as the newer cases will not come exclusively from that high-risk population.) The next three states have 1,577 diagnosed cases and 11 deaths for a mortality rate of 0.69 percent, a number which has trended lower over the last few days. Unlike the deadly exposures in Kirkland, the exposures in New York state produced many documented illnesses, but only two deaths even after two weeks of exposure. And while it is easy to miss latent cases, it is harder to miss any virus-related death. Given that the incubation period is about two weeks, the pool of cases before March 1 should be small.
Many of the dire media accounts do not mention evolution. After the initial outburst in Kirkland, the target population was fitter. It is instructive therefore to look at the total number of cases, which spiked from 70 cases on March 5 to 672 cases on March 15. But those figures do not presage an increase into the thousands of daily cases that would be needed to reach the totals of the flu season. The current numbers are about 3 percent of the rate of new flu cases in the 2019-2020 virus season. Even if there is some undercounting, it is highly unlikely, given the relatively short (two-week) incubation period, that the number of current cases will more than double or triple. It is also unlikely that most of the increase in reported cases (as opposed to deaths) will be in the population over age 70. More importantly, these numbers, as reported by the Centers for Disease Control, do not give any indication of heightened severity.
What, then, does all of this portend for the future of COVID-19 in the United States? Good news is more likely than bad, notwithstanding the models that predict otherwise. The deaths in Washington have risen only slowly, even as the number of infections mount. The New York cases have been identified for long enough that they should have produced more deaths if the coronavirus was as dangerous as is commonly believed.
But why might the dire predictions be wrong? Consider the New York Times graphic below, which catalogs the daily totals of new coronavirus cases:
The theoretical answer to the question of how deadly the virus will turn out lies in part in a strong analytical relationship between the rate of spread and the strength of the virus. Start with the simple assumption that there is some variance in the rate of seriousness of any virus, just as there is in any trait for any species. In the formative stage of any disease, people are typically unaware of the danger. Hence, they take either minimal or no precautions to protect themselves from the virus. In those settings, the virus—which in this instance travels through droplets of moisture from sneezing and bodily contact—will reach its next victim before it kills its host. Hence the powerful viruses will remain dominant only so long as the rate of propagation is rapid. But once people are aware of the disease, they will start to make powerful adaptive responses, including washing their hands and keeping their distance from people known or likely to be carrying the infection. Various institutional measures, both private and public, have also slowed down the transmission rate.
At some tipping point, the most virulent viruses will be more likely to kill their hosts before the virus can spread. In contrast, the milder versions of the virus will wreak less damage to their host and thus will survive over the longer time span needed to spread from one person to another. Hence the rate of transmission will trend downward, as will the severity of the virus. It is a form of natural selection.
One key question is how rapidly this change will take place. There are two factors to consider. One is the age of the exposed population, and the other is the rate of change in the virulence of the virus as the rate of transmission slows, which should continue apace. By way of comparison, the virulent AIDS virus that killed wantonly in the 1980s crested and declined in the 1990s when it gave way to a milder form of virus years later once the condition was recognized and the bathhouses were closed down. Part of the decline was no doubt due to better medicines, but part of it was due to this standard effect for diseases. Given that the coronavirus can spread through droplets and contact, the consequences of selection should manifest themselves more quickly than they did for AIDS.
It is instructive to see how this analysis fares by taking into account the Korean data, which is more complete than the American data. South Korea has been dealing with the coronavirus since January 20. Since that time, the Korean government has administered a total of 261,335 tests to its citizens. In press releases updated every day, the Korean CDC is reporting (as of March 15) 8,162 total infections against 75 deaths for an overall mortality rate of 0.92 percent. But as shown in the table below, the age-disparity in outcome is striking:
Clearly, the impact on elderly and immunocompromised individuals is severe, with nearly 90% of total deaths coming from individuals 60 and over. But these data do not call for shutting down all public and private facilities given the extraordinarily low rates of death in the population under 50. The adaptive responses should reduce the exposures in the high-risk groups, given the tendency for the coronavirus to weaken over time. My own guess is that the percentage of deaths will decline in Korea for the same reasons that they are expected to decline in the United States. It is highly unlikely that there will ever be a repetition of the explosive situation in Wuhan, where air quality is poorer and smoking rates are higher.
So what then should be done?
The first point is to target interventions where needed, toward high-risk populations, including older people and other people with health conditions that render them more susceptible to disease. But the current organized panic in the United States does not seem justified on the best reading of the data. In dealing with this point, it is critical to note that the rapid decline in the incidence of new cases and death in China suggests that cases in Italy will not continue to rise exponentially over the next several weeks. Moreover, it is unlikely that the healthcare system in the United States will be compromised in the same fashion as the Italian healthcare system in the wake of its quick viral spread. The amount of voluntary and forced separation in the United States has gotten very extensive very quickly, which should influence rates of infection sooner rather than later.
Perhaps my analysis is all wrong, even deeply flawed. But the stakes are too high to continue on the current course without reexamining the data and the erroneous models that are predicting doom.
© 2020 by the Board of Trustees of Leland Stanford Junior University.
Published in Healthcare
The irony is that Mr. Epstein does, it is called the police power. A doctrine of common law giving the government the power to enact and enforce legal measures for public health and safety. It is the power that allows the government to issue curfews, martial law, and quarantines. Among other powers that all recognize can and have been abused when implemented without just cause.
You’re assuming the extrapolation will continue – but the underlying premise is that more people are being tested, not that the virus itself is expanding into the population at those rates.
It can’t be both things at once. The underlying population of infected already existed; they just got identified through a test. That they got tested does not mean that the jump in the count of infected informs the rate of extrapolation. That would only be true if you had ongoing testing both prior to and during the spread of the virus, at a significant percentage of the population, at all age demographics.
We don’t have that. But I think we’re overreacting. I’m hoping I’m right, for everyone’s health and well-being.
No one disagrees with sensible – it’s the differing definitions of sensible that’s causing the problems.
The Fed blew another bubble and this is the wrong moment for it to implode.
This is why the LP is never going to amount to anything. Someone needs to come up with a new political strategy.
“Public goods” only. (Public health is a public good.) Central banks can’t help the economy. Why is there such a thing as an unfunded liability?
If we figure that out, that is enough.
Anecdata: A former co-worker of mine, 71 years old, died of the flu in February.
He is the only person I can think of in my entire life (I’m 58) who has died from the flu.
A friend of mine died in January of 2019 of the flu. His wife was in a coma from the flu for two weeks, and barely recovered. I’m like you, it was the first time I heard of the flu being so serious.
There is no right choice for our leaders. No matter what they do or do not do, it is going to be wrong in hindsight.
I’d heard of it being serious. Just never personally experienced it.
I know a 40 year-old mother who died of the flu last month.
Dr. Robert is right. We’re undergoing the most extreme, dangerous and costly reaction to a flu in anybody’s history, and we’re imposing the greatest disruptions on the least threatened, and the most threatened such as folks as old as me, can easily self isolate as most don’t have to go to work. It’s a political stampede and we’d better start saying so. Avoiding crowds for most of us is easy, although with the panic it’s hard to avoid them in groceries stores. Businesses could find ways to help employees who can’t get to work except on buses and subways, or make exceptions. These stupid decisions are the kinds made when bureaucrats take charge, who still get paid even if they’re staying at home. Top down bureaucracy is at best mindless and they’re using this exaggerated crisis to double down, weakening those who matter and strengthening those who have been taking control without adding measurable benefits for over a hundred years. Let’s be clear, this isn’t a coordinated strategy, or didn’t start out that way, it’s just what people do, respond in ways that are self interested and most bureaucrats can’t know what’s in the general interest. Unlike private business, what is self interested and what is public interest are different.
Because no one in public service can be trusted, ever. They are all interested only in increasing their personal power at the expense of all others. It cannot be that a single person has the best interests of the community at heart. It is all about power and getting more. For every person in government. /sarcasm
I wonder that people like you don’t call for them all the be pulled from their homes and shot with this point of view.
I do so love how people decrying the panic also have their own form of limbic system reaction.
Everybody’s trying his best to figure out how this will go. The good news is, three weeks into “we’re three weeks from Italy”, we’ll have some resolution. That’ll be April 1.
The potential for April Fools/Coronavirus memes is staggering.
I do think by then we will really know where we stand.
The the recriminations can really get rolling.
Eaxctly! If the 500 number holds up, it will be significantly less than the deaths from the 2009-10 Swine Flu. Back then, things kept humming along – sports, conventions, elections, you name it. Here in Aiken, SC, it was decided to cancel our Spring Steeplechase, an equestrian event that’s draws a crowd the size of our town.
I still maintain there is a political aspect driving coverage of this outbreak unlike others in the past. It’s difficult to argue in favor of it being an overhyped event when others counter with “better safe than sorry”. However. “better safe than sorry” doesn’t seem to come into play when dealing with other risky aspects of life like driving a car, working a construction job, or answering your wife when she asks, “Does this dress make me look fat?”
In another post, I commented that answering my wife’s question truthfully puts me at a greater risk of dying than the coronavirus . . .
We already have enough information to stop the insanity.
Quarantine the at-risk. Treat them with known treatments that have been shown to work.
The rest of society can get back to work and school.
We have to take a pet for a periodic heart exam this week, and have been instructed to wait in the car until someone comes out to pick him up. If that person isn’t wearing a hazmat suit, I may just laugh at them.
On the other hand three weeks from being Italy is true if we do nothing. A straight line projection from our current situation. Like looking over the devastation of Pearl Harbor and thinking “My God, in three weeks they will attack the fleet at San Diego.”
The purposes of the isolation orders, closing restaurants, schools, etc. is to limit viral spread limiting its spread for two or three weeks will have significant impact on the course of the disease. Like putting a fire out before it gets too big for your hose.
I think on April 1st there won’t be many Italians making saucy memes about COVIDD-19, and if in the US we are we should consider ourselves fortunate that we can be so decadent. Of course if we as a society were capable of such introspection we wouldn’t be making the memes to begin with…
Huh?
Who is “doing nothing”?
Even the skeptics (and I am clearly among them) wants us to pursue careful hygiene and quarantine for those at risk. Have Chloroquine on hand in quantity at all hospitals, and consider making it available OTC since it works in tablet form.
These steps alone will do wonders for serious illness and death.
It’s just a continuation of the political battles of the past 3 years. Everyone is out to score points at the expense of the other side, the other side is vastly overreacting, and the public gets infected with hysteria rather than with any actual illness.
You know, the risk of driving a car is orders of magnitude lower than the risk of dying from COVID-19 if contracted. Every year you have about 40K deaths in vehicular accidents. And you might be tempted to say that well, you only have about 100,000,000 drivers or so maybe 200,000,000 if we are being very generous. But your risk of injury or death behind the wheel is a risk you are exposed to every time you drive. How many people drive daily? Each time is like a contraction of COVID-19. So the number of drives that result in death is 40K every year but the total number of drives that occur is on the order of billions if not trillions (hundreds of millions every day). If 2% of all car trips everyday resulted in fatal crashes you would not see as much traffic as you do. It is because the mortality rate per trip is actually astronomically low that people feel safe enough to drive. Still even though it is so low, we take so many trips in cars that we still have 40K deaths a year.
I was thinking about this this morning when I got up. It stuck me that they are acting as though we don’t know the means of transmission, something like the plague was during the 1300s. We do know, and we do know how to stay safe. Being told to huddle in our homes and avoid going out except for emergencies is absurd. I’m a cyclist. I ride six days a week, covering about 200 miles during that time. At 75 is it keeping me strong and healthy, my BP and HR in very healthy zones. I read that is Spain the police are stopping cyclists, many of them professionals training for the grand tours, and forcing them to return home. That is totally absurd.
This is a nasty bug. There is certainly evidence of that. Stopping its progress is an admirable goal. However, creating and perpetuating superstitious fear in the population is unconscionable. All one has to do is to drive by Costco to see how effectively this stupidity is working on people terrified that they will be unable to get the essentials they need in the weeks ahead. Surely, there is some kind of reasonable approach to teaching the public awareness of how avoid the disease other than attempting to scare them to death.
While on my ride yesterday I saw a fair number of what appeared to be high school aged kids doing what kids their age do when on vacation. They were in groups of 8 to ten, certainly not doing homework. One group was out running track along the shoulder of a road I was riding. A second group of kids on motor bikes passed me heading through the farmlands that surround my town. Whatever the purpose was in closing schools statewide, it had little effect in the rural area I live in. Here the kids are going to get together no matter the rules set out by the government.
@Valiuth, your abuse of statistics is mind-blowing. I am in awe. The driving risk obviously must be understood annually (or even longer).
Here is simple math: THIS year, 40k Americans will die behind the wheel. 40k Americans will die of Flu. Thus far, Corona has killed many fewer than this, and thanks to known treatments, I am more sure than ever that I will win my wager with @Kozak: less than 40k Americans will die of Corona this year.
As my mother likes to say: an ex is a has been, a spert is a drip under pressure…
I agree. However, I believe there has been no end declared for the closures, and this is a problem. If people could say, “Two weeks? No big deal” and March Madness started later, things would be much more sane . . .
And trying to alleviate the fear by pointing out there were worse outbreaks in the past labels you an uncaring, coronavirus denier, and people wish you’d catch it . . .
Here’s hoping you are right and the experts are wrong. I am erring on the side of caution.
By the way, bicycling is fine. You need to maintain distance from people, not completely bunker down. Working outside is fine as long as you avoid masses of people.
He’s a lawyer and is among the brightest people commenting on current events that have legal bureaucratic angles. There are no such things as real experts, there are people who have more knowledge on specific matters than others, but such folks who have deep knowledge in one area often lack broader understandings. What I do is look at what experts and others have said on areas I know as well as most, and pay attention to those who get the things I know more right than others. In general I’ve found published folks we pay a lot of attention to when subjects are hot, are frequently way off base in such instances. It’s a crap shoot and the best thing to remember is that experts can give advice but shouldn’t have power act on it. Folks close to matters care more than remote experts no matter how brilliant, so democratic ground up almost always works much better than top down. Top down bureaucrats use experts that say what they want and in general central government folks are the worst because they all work in areas that they can’t know very well because they are so far from impossibly complex realities.