We don’t stop everything for flu, why for Covid-19??
As we pass the first few weeks of increasing quarantine and economic inactivity, the novelty of not leaving your apartment is wearing off and likely being replaced by financial anxiety as the economy continues to contract in response to contagion prevention. Millions have already lost their jobs and the whole world is feeling the pinch.
A lot of people have been asking “if Seasonal flu kills up to 500,000+ every year, and this coronavirus pandemic so far has killed ‘only’ 30,000, why does everything have to come to a screeching halt, and for how long? We didn’t even do this for SARS; why for Covid-19??”
First, putting aside the problem with the phrase “has killed ‘only’ 30,000” (especially if you’re one of those unlucky families), influenza and Covid-19 and SARS may share outward similarities but are also very, very different. There are real reasons why our response has to be so drastically different than it is for flu. We’ll focus just on seasonal flu here (SARS is a totally different animal, which is why SARS was essentially eradicated globally by less drastic measures than this).
An estimated 35 MILLION Americans were infected last flu season, and about 500,000 were hospitalized. Approximately 35,000 died in the US alone, and it was considered a mild flu season. With more than 10% of the U.S. population affected by the flu most years, these are stunning numbers. But nothing closes down and people don’t stay home.
So why does Covid-19 need a response that is causing so much disruption? Will this ‘cure’ ultimately be worse than the disease? Hopefully this helps answer this question:
Covid-19, plain and simple, just kills way more people that get infected than people who get infected by flu.
There’s debate over the exact mortality rate (how many people who get infected end up dying), but for seasonal flu it’s known to be about 0.1% and for Covid-19 most agree that it is somewhere between 2–4% on average. This means that of ALL cases, serious or not, about 1 in 1,000 people infected by seasonal flu will die. But about 2–4 out of every 100 people infected by Covid-19 will die. That’s a big, big difference for something that spreads a bit more easily than seasonal flu. I much prefer 1 in 1000 odds compared to 1 in 25–50 chance of dying!
There’s a difference between the burden of people dying from a disease and from getting very, very sick from it.
Most compelling for the media is focusing on the death toll, but the real burden is not from the number of deaths, but the number of people who get so sick they need to be hospitalized (or worse, put in an ICU and isolated and put on a ventilator). We probably can’t stop lots of people from getting infected, but we CAN stop everyone from getting sick AT THE SAME TIME and overwhelming our (already overwhelmed)health systems. What we are doing now is not to contain it but to soften the blow (‘mitigation’): to ‘flatten the curve’ so that people who do get sick don’t all get sick at the same time.
After all, there are also still people who get cancer and heart attacks and car accidents and all of the other things that people need the hospital for. Not so good if every emergency room and intensive care unit is occupied by people in respiratory failure from Covid-19. So far this flu season, about 1% of all flu-infected people in the United States have developed symptoms severe enough to be hospitalized: about 61 hospitalizations per 100,000 people, or a 0.061% chance of getting hospitalized if you have flu.
However, In a study of Covid-19 even in the early stages (between Jan 1 and Feb 11), 13.8% were severe enough to need hospital care, and 4.7% critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure) according to the researchers. A more recent U.S. study in the CDC journal Morbidity and Mortality Weekly found that a whopping 12% of sick were hospitalized. That means you are about 200 times more likely to be hospitalized by Covid-19 than by flu. That’s a big burden on the health services; best to spread it out as much as we can (a 30 year mortgage is usually preferable to a 15 year mortgage for the same reason!)
Covid-19 spreads MUCH more rapidly than flu, for several reasons.
You may have seen something about Covid-19’s ‘R0’, called the ‘Basic Reproduction Rate.’ All bugs have one; this just means how many people each infected person is likely to directly infect. Covid-19 sufferers probably infect about 2-3 other people. That’s a reproduction rate up to TWICE that of flu, which typically infects 1.3 new people for each patient.
Worse, a LOT more people infected with Covid-19 show little or no symptoms compared to flu. This is called “silent infection.” We get sick all the time and never know it because our body is constantly hurling back invaders — that’s why people with compromised immune systems like AIDS suddenly start getting sick all the time, with all the things we constantly get INFECTED but not SICK with — and if you don’t know you’re sick, it’s a lot easier to spread it around. When people with the flu are most infectious, they mostly lie in bed and stay home feeling pretty rough. But with Covid-19, up to 80% of infected people don’t feel sick at all, but are still infectious for a pretty long period. Add to that the very high viral shedding of Covid-19 in your upper airways (where’s it’s easier to disperse them in breathing and coughing and sneezing than lower down in your lungs like flu), and you get a bug with real extension ability. In fact, even though is true that you are probably much MORE contagious if you are sicker, the sheer volume of ‘silently infected’ people walking around feeling fine means that these patients are likely the biggest cause of spread.
The U.S. has a much older population and is especially vulnerable.
Almost all infectious diseases like this generally affect three groups the most: the very young, the very old, and people at any age whose immune systems are compromised in some way. Some viruses target younger people — the 1918 pandemic appears to have really hit younger people hard — but not so much Covid-19. Ironically this is a disease probably likely to land more heavily on more developed nations that have extensive movement of people, lots of big crowded cities, but most importantly much older populations. Probably a main reason Italy has been hit so hard is because Italy has the most elderly population in Europe (over 23% older than age 65) and this bug does really like older people.
The U.S. also has an older population with a lot of baby boomers now in their 70s. The problem with lots of older people getting very sick, as any hospitalist knows, is that they are challenging to care for well — they are a lot more likely to have other conditions like diabetes or high blood pressure or heart disease and so on. It is hard enough taking care of a young healthy person struck down by flu, imagine how much harder it is when it’s all geriatric patients with multiple existing medical problems and greater frailty? So the burden of Covid-19 on health services is disproportionately greater because older people getting very sick are already more complicated to care for. There’s about 76 million baby boomers in the US now, about aged 60–75, a big pool of potential prey for Covid-19. If they all got sick at the same time, along with all of the other coexisting health problems that many of them have in their 70s, that too could terribly overwhelm the healthcare system rapidly. Look how overwhelmed the healthcare system has been so far even with very few cases.
Flu has been with us a long, long time, but Covid-19 is a ‘novel’ virus.
‘Novel’ means it’s a new type we’ve never experienced before. There have been at least 14 influenza pandemics in the last 500 years, on average about 40 years apart, and likely many more since ancient times. By now, most of the flu strains of the past that were a lot worse have died out with the people they killed. When a new disease appears (flu mutates very easily so we have to do this continuously) there’s a period of mutual adjustment (usually over hundreds of years): the people who are genetically most susceptible die out and the most deadly strains of the disease die out too.
Look at it from the flu’s point of view: it doesn’t help the disease to kill you…if you die you can’t pass the disease on anymore — the ideal is that we become infected but not so sick we can’t continue to spread it. Syphilis is a good example.
When it first arrived from the New World back to Europe in the 15th century (most likely with Columbus’ returning ships), everyone in Europe was so vulnerable that there were huge syphilis plagues killing thousands. As Jared Diamond describes it, “[W]hen syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people’s faces, and led to death within a few months.” Now of course syphilis can take years to manifest such severe symptoms. Most of the really vulnerable people died out long ago and most of the really bad syphilis strains died out long ago too.
Because Covid-19 is totally new, that means there are many among us who will have a very strong genetic vulnerability to it compared to flu. This is probably why some younger and healthier people inexplicably are dying from it. Even seasonal flu still takes some young and healthy folks each year because it mutates into different enough forms that a new vaccine is needed every year, and some people are just unluckily vulnerable.
With a novel virus like Covid-19, we have absolutely no real idea how it will behave for sure…novel viruses are predictably unpredictable. First we thought it targeted older people almost exclusively, then it started taking younger people including otherwise healthy folks who dropped dead or had to be ventilated during a rapid deterioration even after days of relatively mild symptoms. So it’s better to be feel our way forward as carefully as we can.
COVID-19 is totally new so nobody has any acquired immunity to it.
We bask in the fiery glow of flu every year and we have huge numbers of people vaccinated globally and it still kills up to 500,000+ each year. Think about that — with half the US population vaccinated for flu, and so many people exposed to it the previous year and gaining a little immunity to help next year, up to half a million people can still be expected to die worldwide. Since Covid-19 is a novel, or a new virus, nobody has really any acquired immunity to it. So especially because we don’t really know what the true mortality rate and death rate will be until after this is all blown over, we have to treat it as though a LOT of people could be especially vulnerable to it. We’re still learning what it can do, too — at first we thought ‘it only targets older folks’ but now we know that even though it hits older folks hardest, it can infect and kill people of a wide range of other ages. An analysis of 45,000 confirmed cases in China showed that the vast majority of deaths were indeed among the elderly (14.8% mortality among over folks in their 80’s) but other clinical data shows that up to 40 percent of serious cases occur in folks under under 50.
“It’s true that if you’re older you’re at greater risk, but serious cases can also happen in relatively young people with no prior conditions,” said French deputy health minister Jerome Salomon.
Covid-19, like all RNA viruses, mutates pretty easily and more infected people mean more opportunities to mutate.
Another thing you’ve surely heard is speculation about Covid-19 mutating into something worse. Outside of what you may have heard in Zombie apocalypse movies, here’s what you need to know about mutation and Covid-19.
Most mutations actually hurt the virus. It’s very unlikely that Covid-19 will quickly change into a superbug worse than it is now (possible, but really unlikely). There’s one early study you might hear about from China isolating two strains, one that they thought was more aggressive, but most now believe that was not the case. What more mutation is likely to do, however, is change the part of the virus that diagnostic tests zeros in on. This means our tests stop working well and infected people could test negative. We’d be back to square one!
Mutation also increases the chance of antiviral medication resistance developing. If a drug wipes out all copies of the virus in a sick person’s body, the virus won’t have the chance to adapt. But if someone is infected and even a few copies of the bug have a mutation that helps them survive the drug, and the sick person spreads them to somebody else, then those resistant viruses could spread and our treatments won’t work as well either. That’s why we give several antiviral meds together, a ‘cocktail’ like we give for HIV and tuberculosis. It’s a lot harder for a bug to mutate resistance to multiple drugs at the same time, and even if some have mutated to resist one medicine, one of the other drugs in the cocktail does them in.
THAT’S why mutation is important and why it’s important to take measures to have fewer people infected — it’s not about Covid becoming a superbug; it’s about reducing the opportunities for Covid-19 to become resistant to our tests and our treatments. More infected = more chances for mutation = more resistance to our diagnosis or our medicines. We just want our tests and treatments to still work!
One reason ‘only’ 30,000 have died so far is that all these massive efforts are WORKING.
Just having people cover their mouths when coughing and washing their hands makes a massive difference in flu and other disease transmission; imagine what all the current measures are doing? Although it’s too soon to know for sure, the end of this year’s flu season may well have been facilitated by all the prevention measures we are taking for Covid-19. My prediction is that next year’s flu season will likely show less burden because people will be far more mindful and diligent about all the things we should be doing every flu season to avoid facilitating a pandemic.
Preventive medicine is pretty thankless. You prevent people from getting sick by putting them on medications that have side effects or are expensive or inconvenient, or you may recommend lifestyle changes that are life-saving but annoying. Over 20 years of this, perhaps your patient DOESN’T get a stroke or lose a foot to diabetes or develop cancer, but since it never happens, it’s hard for people to feel really grateful for the successful care.
This is one reason poor compliance with treatments to PREVENT disease is so common — plenty of people don’t stop smoking till they actually get emphysema, and by then of course it’s a bit late. Unless they truly believe they were at risk, then it’s as though you didn’t do anything except put them on a burdensome medication or make them change their lifestyle in inconvenient ways. But as you can see below, the bulk of the heavy lifting for your health maintenance comes from you, not your doctor:
So those are the key reasons why our response must be so drastic.
I of course can’t help but think much longer term…and when I see that although we are better prepared than we were for SARS, we are OBVIOUSLY not ready for a bug that is much worse than Covid-19…we weren’t even ready for Covid-19! I’m really looking at this like a full dress rehearsal against the day a much worse virus arises— hopefully that will be far in the future, but is inevitable someday (remember, pandemics have occurred about every 40 years over most of human history) and could literally be ANY MOMENT, like ‘the big one’ all of us in California know will one day come but we don’t think about often, just hoping it doesn’t come in our lifetimes. Of course, we still build our buildings to withstand the biggest quake we can, grumbling about the extra cost now, but when big quakes come we’re sure glad we prepared at all!
In 2018, the anniversary year of the 1918 Spanish flu pandemic, the WHO even warned that a flu pandemic could cost the US $60 billion or more, while pandemic preparedness would cost about $4.5 billion a year. That’s expensive insurance, but I can’t help but wish we’d all taken the WHO’s prophetic 2018 warning a bit more to heart. Preventive medicine, right? If it ain’t broke, who wants to spend money to fix it when we have pressing immediate problems every day? And yet here we are.
I think the real question is not why we must take such strict measures with this virus, but why most of us are not very diligent (including myself) about even the basic disease prevention methods we all know about during flu season every year? Right before Covid-19 I was in the grocery store and someone walking past me literally coughed hard right into my face (and didn’t even notice). A report from France’s health ministry says that only two in 10 people regularly wash their hands after using the bathroom.”And only 42 percent of people cover their mouth with an elbow or tissue when they cough or sneeze,” it added, not encouragingly. Yuck.
We don’t have to shut down our whole society every year but just doing the bare minimum of personal mindfulness would probably save tens of thousands of lives (or more) every year. I bet next flu season will be interesting to watch.
So thank goodness it’s a full dress rehearsal and not opening night or we’d be in a lot more trouble than we already are. Our task now becomes how to manage this necessary response to soften the downward economic and social shock as much as possible and set the conditions to bounce back after the restrictions on our society and economic activity are removed, and I feel like a lot of ingenuity is being applied to this challenge at every level, from individual all the way up to global. Of course to make the right tactical decisions now, we need to have a clear vision of what victory should actually look like and what long-term gains we might develop out of this experience (the answers might surprise you), but I’ll save that for another article.
Thanks for reading and hope this helps!
