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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
Thank you for allowing us to return to our lives, both leniently, cautiously, and conscientiously. That’s the rational approach to controlling the lives of millions.
Thank you, for your service.
I think we all know why onions are hot commodities:
I’d say the same thing for someone who suggests that exponential growth is inevitable.
See how that works? Suggesting that deceit is OK from people with power over our lives is something that historically hasn’t worked out well.
I don’t know where or how you work. I have an online company. My partners and suppliers are hogtied at best. Children at home means parents are not at work, and are severely hampered. Hotels and airlines are at existential risk. So is Boeing and Airbus.
What we are doing right now is crushing the economy.
Then instead of shutting down all schools, community buildings and organizations, many companies, firing millions of employees…. we should openly encourage the use of these agents.
You are incorrect, BTW, that physicians in the US do not do much off label prescribing. It is VERY common.
Up to 79 percent of hospital medications and 56 percent of office-based drugs are used “off-label” in pediatrics.
Is anyone arguing that it is not? I must have missed those posts saying things with the economy are A-OK.
The people in power may well be overracting today, but if they underreact, they will get it then too as people die.
I am civilian who works on an Air Force Base. The base is closed to non-mission essential work (although this happened last night) and I am teleworking. However, I have been out and about in my town and things are open, grocery stores are full, no lines for gasoline, stores restocked. School is out, but it is just a continuation of spring break.
I had been on leave (my mom’s funeral) since last Wednesday until Sunday night, when I stopped by the office to get my laptop to telework.
Telework procedures have been in place for me since May of 2019, when I requested it for COOP (Continuity of Operations) purposes. One of the reasons I gave to the leadership was “COOP in the event of Pandemic”.
Base went into non-mission essential lockdown last night.
Economies bounce.
Yup. Or if they’re able (as my rheumatologist is) they can adjust a diagnosis to get to the drug. Many forms of inflammatory arthritis have similar symptoms, so if a new biologic is approved for psoriatic arthritis and the doctor thinks it will help, she can modify a diagnosis to PsA from RA.
Spoken like someone who is paid by the government. In the pure private sector, we cannot be so equanimous.
I have spent this morning calling all my people and tightening their belts for them. They will suffer. And entirely unnecessarily – we should let this bug spread through the population (excepting truly at-risk people) quickly.
People are hurting, and will hurt for MONTHS simply because some geniuses in government decided that doctors and nurses should not be overworked for a period.
The panic buying and the tensions and fights breaking out aren’t restricted to fringe groups but are rather widespread in virtually every community. The stories, videos and reports of hoarding and fighting for toilet paper and other items is being documented everywhere in the country. So, if you could define what you mean by “PART” of the country, that would be welcome.
I understand you are angry and upset. You are 100% sure you are right. That was still uncalled for way to talk to Instugator. You are dismissive of him.
You say we should let the bug spread fast. Fine. The UK is doing that, and we will see the wisdom of it. Based on some of my sources, especially around the risk of reinfection (which by the way these types of viruses can do in cats, I am told), poses some issues with that.
You are not in power, so you don’t get to make the call, or face the consequenses of being wrong.
Please show me that decision tree, because I don’t think it exists.
It isn’t about the shift work of doctors and nurses. It is about the availability of ventilators or other critical equipment for people in respiratory distress.
You break the vectors to slow the spread in order to not overwhelm the critical care beds at once.
Right-on, Brutha!
I agree. There is NO DECISION TREE. There is just panic. Nobody is making a coherent argument for the quarantine.
If it was, then we would use the drugs that avoid the respiratory distress.
Is there ANY PRICE worth making sure nobody is short a ventilator?
Right now hospitals are empty, twiddling their thumbs. All the electives are cancelled. Nobody in the US is whelmed, let alone overwhelmed.
That is just not true, and putting things in all caps against the CoC won’t make it so.
https://www.nytimes.com/2020/03/11/science/coronavirus-curve-mitigation-infection.html
Now you may disagree with this, but you cannot say nobody is making a coherent argument for social distancing (we are not in an actual quarantie).
I saw that silly simplistic graphic. Summarized: we cause a Black Swan event crashing the economies worldwide in order to avoid overworked and overstressed hospitals for people who can and should be treated by approved drugs that have already been shown to work (but not by the FDA).
This is not a coherent argument. It is a single “good” prioritized ahead of everything else that matters.
We could do the same thing to end car accidents – just ban all cars. Equally short-sighted a “solution” to the problem.
Good graphic – shows the why very clearly. Had not seen it before.
Thanks
I also agree that is a good graphic. Here is an even better explanation on YouTube. You might skip the first 2 and 1/2 minutes of fluff to get to the heart of the matter.
I’ll be posting a video and link showing how wrong this all is. This line of thinking is simplistic and ignores the data we actually have.
It *was* from Vox.
I really do not know why people keep comparing this to the flu. The US just had 3000 cases and 44 deaths in 24 hrs. By early next week you are going to be on the lower number of daily deaths that Prof Epstein cited above (140), and going up. In other words, his predicted total of 500 will be surpassed in just a few days…
Well, the flu this year has gotten an average of one-quarter of a million new cases per day, and caused between 133 and 333 deaths per day for the last five and a half months running.
https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm
You don’t see the people who AREN’T mobbing the stores, who AREN’T getting into fights…
But they’re still panicking by believing that it’s going to kill millions and not pushing back against the irrational hysteria.
You do understand the definition of the word “virtually”, yes? I did not say nor even infer that it was happening all the time in every store in the country nor did I claim that fights were always breaking out everywhere. But the incidents of hoarding are far too many and have been occurring for going on 3 weeks now even before this was declared a pandemic and hoarding of what primarily? Toilet paper. Hoarding is sadly not restricted by a given geographic region, a specific demographic or a particular ideology. Too many otherwise responsible adults are acting like panicked fools. Not entirely sure what’s controversial about this.
You don’t see the people who aren’t getting into fights, and you don’t hear from the people who aren’t posting or whatever.
One term used to be “the silent majority.”
I have lots of lefty neighbors, I don’t even bother trying to point out when they’re certainly wrong about things, because the brutal truth is they simply aren’t smart enough to understand. I could talk myself hoarse making sense, work my fingers literally to the bone making charts etc, but it doesn’t matter. They’ll just believe Biden etc.
Stop putting words in my mouth, give it a rest and move on.
What words are those? I’ve just quoted your posts. Aren’t those your words? Which means you put them in your own mouth.
Try this: “You don’t see the people who aren’t getting into fights, and you don’t hear from the people who aren’t posting or whatever.” I never said this and that is deliberately misinterpreting what I’ve said. You can tell when someone is arguing in bad faith when they selectively edit what you’ve said or fabricate statements and then attribute them to you as you have done in the last few comments with me.
Let me make it easy for you. Widespread hoarding has occurred across the country – often of non-essential items like toilet paper. Fights have broken out across the country over the hoarding of toilet paper, meat, and other items. This is an accurate statement and it is indication or irrational panic over a widespread area.
There are very smart folks in our own and other foreign intelligence services who take note of human behavior on a micro and a mass scale and how people can be manipulated at every level of society – from the media, the scientific community, the military, and the general populace. Manipulating human behavior is how agents or military personnel can be turned, how a scientist can be compelled to share top secret information, how a rebellion can be generated to attempt to overthrow a regime. Much of this involves modeling and game theory and other tactical theories and uses tools like misinformation (or disinformation, if you prefer) and propaganda. The Russia collusion hoax is a classic disinformation campaign. These intelligence services study the effects of any given crisis to learn from them and to see what specific conditions can be created to replicate them if necessary. It’s not beyond the realm of possibility that the effects of current crisis are being studied quite closely.