A Letter from Italy to Friends and Family back home in America

Hi everyone,

I’m wrote this to answer a bunch of questions that we have been getting in order to clarify some misconceptions about the virus and to share some real concerns.

“Why aren’t you guys coming home? Isn’t it worse in Italy? What if you get locked down?”

Italy was one of the first places that the virus was detected outside of China. Italy initiated a large-scale testing campaign in an attempt to control the spread of the disease. To date, over 35,000 tests have been conducted. As a result, Italy has surfaced many more cases of the disease than in other countries where tests are only being performed on sick people after they’ve been admitted to the hospital. Currently over 5000 Italians have tested positive.

The cases are currently centered in the Lombardy area but we expect them to spread everywhere. We are currently making plans for a possible lockdown, including building up a store of nonperishable food and medical supplies. This is something I advise everyone to do. I will explain why as this email continues.

As to the question “isn’t it worse in Italy” the answer is yes and no. Italy is experiencing an unusually high case fatality rate — over 4%. Experts believe this is because the disease is particularly more deadly to the elderly and infirm, and Italy has the world’s 3rd oldest population.

So in short, Italy appears to have more cases than other countries in part because of an aggressive testing regime, and it appears to be more fatal in Italy because of the relative age of the typical victim.

“It’s not so bad, just like a bad flu. Some people don’t even get symptoms.”

While it’s true that some people experience only mild symptoms, in fact the fatality rate of coronavirus appears to be many times more dangerous than the flu. It is a bad bug, and you do not want to catch it. It particularly affects the elderly, people with respiratory illnesses, and people with compromised immune systems.

Ironically, the fact that young, healthy people can be asymptomatic or have mild systems is contributing to the spread of the disease, because these people continue to mingle in the general population.

People see graphs like this which compare Covid-19 to MERS, or SARS, and Ebola, and assume the impact of Covid-19 will be much less. After all, the case fatality rate is much lower. This is the wrong conclusion because Covid-19 is much more contagious than these other diseases. As a result Covid-19 has already killed more people than MERS, SARS, and Ebola combined and it’s going to get worse. A lot worse.

“The rate of new cases seems to be leveling off”

Graphs of new cases are misleading. Consider this one. A reader might assume that the disease is already hitting some sort of plateau as of late February.

There are two problems with the data that we have.

Problem One: The first problem is that China is, statistically speaking, the 800-lb gorilla in the data, and it’s skewing all the data. China may be controlling its outbreak (or it may be controlling the news) but even assuming we’re getting the truth out of China, and they’ve stemmed the exponential growth of the disease, you have to understand how they’ve gone about it. China has put an estimated 50 million people under effective house arrest: a complete lockdown. Only medical workers and food delivery personnel are allowed to be in the streets. So by controlling the disease’s spread, China is skewing the international data.

When you look at the disease outside of China, the numbers show that the disease continues to spread at an exponential rate. Here in Italy, and in other places where significant testing is being done, we are seeing the numbers of new cases continuing to rise by something like 20% to 30% every day. This is expected, by every epidemiologist that I can find, to continue until the disease saturates into the population, or unless draconian, possibly unsustainable quarantine measures are enacted, like the ones we see in China, and which are now being considered in Italy.

Problem Two: The second problem is that data collection is simply awful. The best data we have so far comes from South Korea, where testing has been even more aggressive than Italy. In South Korea, citizens can get tested on demand at kiosks (mass testing). In Italy, pandemic officials attempted to seek out and test everyone connected to a confirmed case (proactive testing). In other places, unfortunately, the only people getting tested are those who are already so sick they’ve sought hospitalization (reactive testing). The effect of this patchwork testing is that the data from different countries cannot be safely compared. If you only test the gravely ill, you end up wildly underestimating the number of infected people, and overestimating the case fatality rate.

The best data so far comes from South Korea, where over 150,000 test have been performed. They have surfaced over 7000 cases to date, with only 50 dead so far, for a case fatality rate of 0.7%. That’s good news. But South Korea’s 65-and-up population (~10%) is 1/2 that of Italy’s (~20%) and 30% lower than the USAs (~14%) so we must expect the fatality rates to be higher in the USA and Italy.

“But there are still so few cases where I live.”

This gets back to the problem above. If testing is only being performed on the very ill, then the number of infected people is wildly underestimated. In the USA, only about 1500 tests have been performed so far. By comparison, Italy is testing almost twice that many people every day. It is critical to understand that the numbers coming out of the USA are highly inaccurate and the number of infected people is almost certainly much higher than official reports suggest.

We humans are really, really bad at estimating exponential growth. Like, really bad. We see 100 cases two weeks ago, then today it’s 400 some-odd cases, and we think, meh, in a month maybe it’ll hit 1,000 cases. By summer, maybe 10,000.

That’s not how this works.

The way it works is that we’re seeing a doubling of cases roughly every 6 days.

So if you have 400 cases today, then in a month you can estimate 13,000 cases. And a month after that, 400,000 cases. A month after that, June 8, the number hits 13M. I built a spreadsheet so you can see for yourself.

Now this is a very crude estimate that doesn’t take into account the science of epidemiology — the effects of quarantine, lockdown, saturation in the population, and a host of other factors. But trust me when I tell you: everyone is almost surely underestimating the rate at which this thing will suddenly get out of control. That’s the thing about exponential growth: it looks gradual, until suddenly it’s not.

“If this thing is truly as contagious as people say, then there’s nothing to do but go on business-as-usual, and ride it out. After all, I’m healthy, so I’ll be OK if I get sick.”

This is probably the biggest problem that I’m seeing because it misses the systemic problem that’s going to really hurt every nation when the virus reaches saturation in the population, and that’s the effect of overloading the healthcare system.

Folks, the simple, hard truth is that there isn’t a healthcare system in the world that’s going to be able to handle what’s coming. Italy just announced an emergency call-up asking for 5000 doctors to come out of retirement — in part to cope with the fact that already 100 doctors are infected with the disease and are out of commission. Plans are underway to expand the number of ICU beds. Emergency shelters are going up in the red zones. They’re even discussing the disturbing possibility of triage — people over a certain age will simply be denied access, to ensure there’s room for those who are more likely to survive. And Italy has one of the world’s best healthcare systems — — particularly in the wealthy Lombardy region. And unfortunately, we’re still in the early stages.

I STRONGLY encourage everyone to read this thread that describes the problem in more detail.

This really is a question of when, not if.

Therefore everyone — everyone — has an ethical obligation to limit the spread of this disease to create as much breathing room for a healthcare system that is going to buckle under the inevitable load. It doesn’t matter if you might survive. The problem is that by contracting the disease and carrying on business-as-usual, you will increase / accelerate the rate of infection in the population. Once hospitals are saturated, then the fatality rate can only increase.

“When summer comes this problem will take care of itself”

The good news is that other coronaviruses do seem to spread less easily in the heat. The bad news is that in places which are currently hot (ie Singapore, Australia) we aren’t seeing a lot of slowdown. While I am hopeful that there could be some improvement in the rate of new cases due to the heat, at this point there is simply no evidence to support my hope; and past that, we’re still very likely to overwhelm the healthcare system anyway. This article does a good job of explaining the facts.

“People in charge said it was under control. What the hell do you know?”

These are grim facts, and they are not all-inclusive. Maybe there will be some good news we don’t know about. But this is the truth as best I can tell. Everyone needs to understand the facts as they exist today. Today, there is no silver bullet. No vaccine, and no underlying immunity in the population. While a vaccine is possible, best-guess estimates are that we are 12–18 months away.

And this brings me to my last issue, which is that some politicians in the government are outright lying about this situation, and declaring it “under control.” My friends, not only is the disease not “under control” it is arguably not even controllable.

This isn’t about red side vs blue side, or the personality of certain individuals in charge, or politics in any way (I’m highly nonpartisan myself). This is about RIGHT and WRONG. It’s one thing to lie about tax returns, or how many people were at an inauguration, or any number of things which don’t matter in the grand scheme. But to lie now about what’s happening, when America faces a true epidemic, is simply unconscionable.

These lies are permitting the disease to spread most rapidly NOW, at the very time that strong, swift, clear communication and action could tap the brakes just enough to allow the nation’s healthcare system to gird its loins for what is to come. Instead I see people still getting on cruise ships, still going to sporting events, partying like it’s 1999, and still arguing that they can’t afford to miss a day of work.

This is the estimate that the American Hospital Association sent out to its members. It is chilling. It’s from a month ago, and so far, it lines up closely with our experiences in Italy. The numbers are a little better than what was originally estimated — the R0 (the basic reproduction rate) is closer 2.2, not 2.5, and that does make the other numbers a little lower. But still totally unfathomable.

Past the outright lies, which must be called out, the government has also fumbled the ball terribly in terms of testing. The USA has tested only a tiny fraction of the population, and therefore the true number of infected Americans is surely far higher than what is being reported. Again, Italy is currently testing more people every day than have been tested so far in the USA.

People are carrying on like there’s still all the time in the world to take preventive action, when the time to act boldly is NOW.

“This will cause a panic.”

It’s my opinion that panic may be inevitable, but the longer the American people are kept in the dark, the worse the panic, and its consequences.

“Stop it you’re scaring me.”

No. I’m trying to get your attention. I’m not scary. This disease is scary.

My deepest hope is that 90 days from now, I will be apologizing to everyone on this list for overreacting. But I don’t think I will be.

It is quickly becoming clear that there is no hope of “containment” of this disease to affected areas. The only containment that is possible must happen at the individual level.

It is every person’s ethical responsibility to slow the transmission of this disease to the greatest extent possible, with the goal of softening the inevitable, crushing blow that is coming to our nation’s hospitals.

I think it’s also advisable for people to contact their representatives, and express their outrage at the conduct of people in charge that are downplaying the coming danger.

“Fine. So what am I supposed to do?”

First off, do not let fear overtake you. Most of us will get exposed to this disease, but will not catch it. That’s great news!

Secondly, do not expose others. If you think you might be sick with any sort of fever or cough, you have a duty to self-isolate.

Third, observe strict hygiene practices. You know these already. Wash your hands after all contact with unknown objects. Use an alcohol-based hand sanitizer. Avoid touching your face. Avoid contact with anyone who appears even remotely sick. Observe the six-foot rule from other people as far as possible. Avoid all non-essential public gatherings. Stay home as much as possible. Work from home if possible. Keep your work environment sanitized. Be extra-careful in bathrooms (evidence shows that fecal matter can contain live viruses, and toilets can “sneeze” the virus about). Cover your face to protect against droplet contamination.

This last one bears some discussion. We’re seeing warnings from the government NOT to wear masks. This is despite evidence that wearing a mask provides benefit against droplet contamination and infection and despite contradictory information on the FDA website.

I think the educated guess is that the government is concerned about a run on masks depleting them from the places they are needed most: in hospitals. This is a valid concern. But “don’t wear masks” sends the wrong message, because some people think it means “masks just don’t work.”

The right message is that barrier prevention is somewhat effective but don’t hoard surgical masks. Instead, consider a makeshift mask, a scarf, or a bandana mask. No, I’m not crazy. While definitely falling into the “better than nothing” category, studies do suggest that these sorts of barriers can provide some protection against droplet exposure to the face, and in the event that you are sick (and maybe don’t know it) can reduce (but not eliminate) the area impacted by your sneeze or cough. Remember: our primary goal must be not only to keep ourselves well, but those around us too.

That said, current information suggests that the primary source of infection is close contact with an infected person; past that, by touching a contaminated surface, then touching the face. So the most important ways to avoid infection, based on what we know, are to avoid infected people if you are uninfected, avoid infecting others if you yourself are infected, and keep your hands clean.

Lastly, some basic preparation is probably in order. Do not make a run on the stores. But it would probably be advisable to lay back a small supply of emergency survival staple supplies in case of supply chain disorders. Beans and rice. Pasta. Canned goods. Toilet paper. Essential medicines — your necessary prescriptions, especially fever reducers, cough suppressants, and expectorants. As someone with chronic bronchitis, I advise on buying medicines with separate ingredients, not “one shot does it all” drugs that probably include ingredients that you don’t need.

If everyone will start laying back “just a little extra” now, then we can avoid possible panic-buying in the event of a shortage later. This is what we’re doing. Worst case scenario, I don’t need to buy beans or pasta for a while.

Conclusion

Look, I’m as worried as you are. I’ve been watching the situation unfold here in Italy, and it is concerning. If you aren’t worried then you are not paying attention.

Our ancestors lived through worse, however. And they had less. I think we’re heading into some hard times. It’s going to be frightening. I have been frightened. It is critical to think clearly and not be overwhelmed by what is coming. The best way to handle the fear of the unknown is to (A) eliminate unknowns by gathering facts then (B) facing those facts with action.

Taking steps to make yourself ready, and making some lifestyle changes now that will help in the coming months, are concrete actions you can take that will move you away from fear and toward a solution.

I have endeavored as much as possible to provide helpful facts without disseminating any false information. If you discover any issues with the accuracy of the content of this post, please comment below, and I will update as needed.