Coronavirus: Do We Need to Do More or Less?

Reality Check:

One week ago globally there were 156,653 coronavirus cases and 5,833 deaths. Today there are 300,227 cases and 12,948 deaths — a total mortality rate of 4.3%. In the last week, global case numbers increased by 192% and the death numbers increased by 222%.

One week ago in the U.S., there were 2,943 cases and 57 deaths. Today there are 24,137 cases and 288 deaths. In the last week, the U.S. case numbers increased by 820% and the death numbers increased by 500%.

I take pride in the Weekend Reader covering a breadth of topics, from sports to politics to technology, parenting, health, etc. But like many of you, though I’m still reading from a wide variety of sources, I’m reading very narrowly about this disease and its impact on our health, our economy and our society.

Today I have several good and important pieces to share. The core question: Are we doing enough to fight coronavirus or is the remedy we’re prescribing worse than the disease?

Articles:

1. This is How We Beat the Coronavirus — The Atlantic
2. Bill Gates’s greatest fear: viral influenza (from 2015) — Vox and TED
3. The Best-Case Outcome for the Coronavirus, and the Worst — Nicholas Kristoff in the NYTimes
4. Evidence Over Hysteria — Covid-19 — Aaron Ginn in Six Four Six Nine
5. Is Our Fight Against Coronavirus Worse Than The Disease? — David Katz in the NYTimes
6. Coronavirus: The Hammer and the Dance — Thomas Pueyo

Read widely. Read wisely.

Max

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Recommended Readings

1. This is How We Beat the Coronavirus
The Atlantic (12 minutes)

A professor of Global Health at Harvard and a professor of pediatrics at the University of Indiana, argue that we need to engage in suppression not just mitigation of the coronavirus.

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Let’s start with the bad news. The Imperial College response team’s report looked at the impact of measures we might take to flatten the curve, or reduce the rate at which people are becoming sick with COVID-19. If we do nothing and just let the virus run its course, the team predicts, we could see three times as many deaths as we see from cardiovascular disease each year. Further, it estimated that infections would peak in mid-June. We could expect to see about 55,000 deaths, in just one day.

Why does the Imperial College team predict this for the West when things seem to be improving in Asia? Because we are taking different approaches. Asian countries have engaged in suppression; we are only engaging in mitigation.
Suppression refers to a campaign to reduce the infectivity of a pandemic, what experts call R0 (R-naught), to less than one. Unchecked, the R0 of COVID-19 is between 2 and 3, meaning that every infected person infects, on average, two to three others. An R0 less than 1 indicates that each infected person results in fewer than one new infection. When this happens, the outbreak will slowly grind to a halt…

…Because we failed to set up a testing infrastructure, we can’t check that many people. At the moment, we can’t even test everyone who is sick. Therefore, we’re attempting mitigation — accepting that the epidemic will advance but trying to reduce R0 as much as possible.

2. Bill Gate’s Nightmare Scenario: Viral Influenza
Interview with Vox in 2015 (3 minutes)

Recorded in 2015. Gates describes how we are unprepared with a global viral disease like coronavirus.

3. The Best-Case Outcome for the Coronavirus, and the Worst
Nicholas Kristoff in the New York Times (8 minutes)

Solid, concise exploration of the tail end outcomes on either side of Coronavirus, from best case to worst.

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Here’s the grimmest version of life a year from now: More than two million Americans have died from the new coronavirus, almost all mourned without funerals. Countless others have died because hospitals are too overwhelmed to deal adequately with heart attacks, asthma and diabetic crises. The economy has cratered into a depression, for fiscal and monetary policy are ineffective when people fear going out, businesses are closed and tens of millions of people are unemployed. A vaccine still seems far off, immunity among those who have recovered proves fleeting and the coronavirus has joined the seasonal flu as a recurring peril.

Yet here’s an alternative scenario for March 2021: Life largely returned to normal by the late summer of 2020, and the economy has rebounded strongly. The United States used a sharp, short shock in the spring of 2020 to break the cycle of transmission; warm weather then reduced new infections and provided a summer respite for the Northern Hemisphere. By the second wave in the fall, mutations had attenuated the coronavirus, many people were immune and drugs were shown effective in treating it and even in reducing infection. Thousands of Americans died, mostly octogenarians and nonagenarians and some with respiratory conditions, but by February 2021, vaccinations were introduced worldwide and the virus was conquered.

4. Evidence Over Hysteria — Covid-19
Aaron Ginn in Six Four Six Nine (32 minutes)

Aaron is a friend and is a wonderful analytical thinker as you will see in this article. He argues that the media is overplaying the severity of coronavirus and that governments are making freedom-stealing policies based on mimetic cover-your-butt instincts rather than on evidence.

His data is helpful to read but I disagree with his interpretations of it and fear his recommendations may be dangerous in facilitating spread. But you should read and judge for yourself. We’ll all think better for reading clear arguments.

Note, since I originally wrote this, Aaron’s piece was taken down from Medium and Twitter

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As the US continues to expand testing, the case fatality rate will decline over the next few weeks. There is little doubt that serious and fatal cases of COVID-19 are being properly recorded. What is unclear is the total size of mild cases. WHO originally estimated a case fatality rate of 4% at the beginning of the outbreak but revised estimates downward 2.3% — 3% for all age groups. CDC estimates 0.5% — 3%, however stresses that closer to 1% is more probable. Dr. Paul Auwaerter estimated 0.5% — 2%, leaning towards the lower end. A paper released on March 19th analyzed a wider data set from China and lowered the fatality rate to 1.4%. This won’t be clear for the US until we see the broader population that is positive but with mild cases. With little doubt, the fatality rate and severity rate will decline as more people are tested and more mild cases are counted.

5. Is Our Fight Against Coronavirus Worse Than The Disease?
David Katz in The New York Times (7 minutes)

Katz is the founding director of the Yale-Griffin Prevention Research Center. He argues that if we are “at war” with the Coronavirus, we can be more surgical in our strikes rather than carpet bombing and all the collateral damage that entails. He advocates for protecting the most at-risk (the elderly) and allowing the rest of us to develop “herd immunity.”

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The clustering of complications and death from Covid-19 among the elderly and chronically ill, but not children (there have been only very rare deaths in children), suggests that we could achieve the crucial goals of social distancing — saving lives and not overwhelming our medical system — by preferentially protecting the medically frail and those over age 60, and in particular those over 70 and 80, from exposure.

Why does this matter?

I am deeply concerned that the social, economic and public health consequences of this near total meltdown of normal life — schools and businesses closed, gatherings banned — will be long lasting and calamitous, possibly graver than the direct toll of the virus itself. The stock market will bounce back in time, but many businesses never will. The unemployment, impoverishment and despair likely to result will be public health scourges of the first order.

5. Coronavirus: The Hammer and the Dance
Tomas Pueyo (28 minutes)

SUMMARY
Pueyo’s pieces have been read by tens of millions in the past couple weeks. This one is a must-read. Here’s his own summary:

Strong coronavirus measures today should only last a few weeks, there shouldn’t be a big peak of infections afterwards, and it can all be done for a reasonable cost to society, saving millions of lives along the way. If we don’t take these measures, tens of millions will be infected, many will die, along with anybody else that requires intensive care, because the healthcare system will have collapsed.

When you’re done reading the article, this is what you’ll take away:

• Our healthcare system is already collapsing.
• Countries have two options: either they fight it hard now, or they will suffer a massive epidemic.
• If they choose the epidemic, hundreds of thousands will die. In some countries, millions.
• And that might not even eliminate further waves of infections.
• If we fight hard now, we will curb the deaths.
• We will relieve our healthcare system.
• We will prepare better.
• We will learn.
• The world has never learned as fast about anything, ever.
• And we need it, because we know so little about this virus.
• All of this will achieve something critical: Buy Us Time.

If we choose to fight hard, the fight will be sudden, then gradual. We will be locked in for weeks, not months. Then, we will get more and more freedoms back. It might not be back to normal immediately. But it will be close, and eventually back to normal. And we can do all that while considering the rest of the economy too.

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So why is the fatality rate close to 4%?

If 5% of your cases require intensive care and you can’t provide it, most of those people die. As simple as that.

…What happens if all your healthcare system is collapsed by coronavirus patients? Others also die from other ailments.

What happens if you have a heart attack but the ambulance takes 50 minutes to come instead of 8 (too many coronavirus cases) and once you arrive, there’s no ICU and no doctor available? You die.

There are 4 million admissions to the ICU in the US every year, and 500k (~13%) of them die. Without ICU beds, that share would likely go much closer to 80%. Even if only 50% died, in a year-long epidemic you go from 500k deaths a year to 2M, so you’re adding 1.5M deaths, just with collateral damage….

…When you hear: “We’re going to do some mitigation” what you should really hear is: “We will knowingly overwhelm the healthcare system, driving the fatality rate up by a factor of 10x at least.”

Postscript

First, I want to say thank you to all the nurses, doctors and health care workers on the front lines around the country and around the world who are putting themselves in harm’s way to care for the sick. You are heroes. Even when you are exhausted. Even when you don’t feel like it. I speak for millions when I say we appreciate you and admire you more than we can say.

Now, I want to talk about the death rate. The U.S. coronavirus death rate is about 1.2% (288 out of 24,137 cases). The death rate in Italy is 9% (4,852 out of 53,578 cases). Why would the numbers be so different? Are U.S. cases more mild?

Some speculate that the Italians have an older more at-risk population than the U.S. — they have one of the oldest populations in the world with a median age of 46 years old, compared to 38 years old in the U.S. And nearly 99% of the Italians who have died had other illnesses. That may not be good news for America. Obesity is a complicating underlying factor for all kinds of diseases and America is in much worse shape on that score. Only 21% of Italians are obese, compared with 33% in the United States.

I think the bigger reason the death rate is so different is that Italy’s hospitals got overrun with cases. And when people in critical condition can’t get the medical treatment they need, they die.

I’ve read arguments that we don’t have that many cases in America. Only a small fraction of the population has the disease. But that is a naive focus on a snapshot in time. Wait one week, when our case rate has doubled and then doubled again, especially in places like New York City where they are facing a severe shortage of ventilators and hospital beds. My suspicion is that we will see the death rate rise faster than the infection rate once these local hotspots get overwhelmed.

I am a small business owner and I fear the implications of our businesses being shut down for a period of time. But I fear even more the risk that millions could die if we don’t act boldly enough. A “hammer” approach will buy us time, and that matters. As Pueyo writes,

We’re about to face the biggest wave of pressure on the healthcare system ever seen in history. We are completely unprepared, facing an enemy we don’t know. That is not a good position for war.

What if you were about to face your worst enemy, of which you knew very little, and you had two options: Either you run towards it, or you escape to buy yourself a bit of time to prepare. Which one would you choose?

As for the current government actions, I wish we would act big and decisively for a short period of time to hammer this disease into the earth, then relax restrictions once we’ve bought ourselves time to respond. It’s harder to plan when you don’t know if the government will let you keep working or not. I’d rather be told — everyone is taking off one month than to keep guessing. Better to pull the bandaid off quickly than slowly and painfully.

I like the idea of protecting the most vulnerable and allowing more of the younger healthy population to get a light and non-serious form of the disease and develop “herd immunity.” But I don’t know enough about the argument that the disease could mutate and make any immunity of the herd fruitless.

We need a hammer, an not one wrapped in velvet. Again, Pueyo writes:

The measures [China] took were pretty similar to the ones taken in Italy, Spain or France: isolations, quarantines, people had to stay at home unless there was an emergency or had to buy food, contact tracing, testing, more hospital beds, travel bans…

Details matter, however.

China’s measures were stronger. For example, people were limited to one person per household allowed to leave home every three days to buy food. Also, their enforcement was severe. It is likely that this severity stopped the epidemic faster.

In Italy, France and Spain, measures were not as drastic, and their implementation is not as tough. People still walk on the streets, many without masks.

Some people interpret this as “Democracies will never be able to replicate this reduction in cases”. That’s wrong.

For several weeks, South Korea had the worst epidemic outside of China. Now, it’s largely under control. And they did it without asking people to stay home. They achieved it mostly with very aggressive testing, contact tracing, and enforced quarantines and isolations.

If an outbreak like South Korea’s can be controlled in weeks and without mandated social distancing, Western countries, which are already applying a heavy Hammer with strict social distancing measures, can definitely control the outbreak within weeks. It’s a matter of discipline, execution, and how much the population abides by the rules.

The government should step in and support individuals and businesses affected by the Hammer. They have already begun this, though as my friend DJ says, I wish they would support the airline attendants (who are at risk of missing rent if they don’t have work) more than they support the airline investors (who can likely weather the losses that will come).

A friend asked me what I think of the U.S. government’s response to the crisis so far. I said that I have CNBC on all day and when Trump, Pence, Fauci and company appear every day (and I think it’s good that they appear every day rather than appear to be hiding) I usually feel encouraged (except when the president picks a petty fight with a reporter or has his deputies brag about what he’s done). I think those in Washington are taking this seriously now and doing a lot to mitigate the financial fallout.

But when I read about South Korea and Singapore’s response, I conclude that they have been able to stem the tide because they were more prepared and had tests ready so they could see ho was sick and isolate them and the people they had contact with. The U.S. government, sadly, was horribly underprepared and didn’t take the threat seriously early enough. Now we are in damage control mode and more painful remedies are required to make up for the prevention we failed to do months ago.

Read widely. Read wisely. Wash your hands.
Max