by Sarah Dillingham (April 2020)
Bad Premonition, Kasimir Malevich, 1928
March has been a difficult month for optimists. It began on a tenuous note, as ominous signs of a worldwide Covid-19 pandemic began to take shape and the stock market dipped in late February. But as news and opinion, consistently lacking nuance, pivoted from early coverage downplaying the significance of the novel coronavirus to broadcasting catastrophic predictions—and stock markets inevitably plummeted in response—two competing narratives have emerged which attempt to navigate and organize a tsunami of conflicting, ever-changing information.
The predominant position, amplified by repetition and an iterative sense of urgency across governments and private institutions, is that people across the globe must hunker down in quarantine for an indefinite period of weeks or months, until the monstrous threat of global pandemic is contained. Popular among proponents of this view is the complimentary idea that the severity of the pandemic is President Trump’s fault, and was largely within his control to contain. Excessive concern over the economic impacts of such sweeping action constitutes greed.
As recently as a week ago, before Covid-19 case rates in the U.S. began to visibly surge in earnest but following a cascade of state-declared economic shutdowns and shelter in place orders, economists began to sound alarms at the runaway economic impacts. “What is happening is a shock to the American economy more sudden and severe than anyone alive has ever experienced,” Annie Lowry warned in the Atlantic. Certainly the graveness of these warnings is not hyperbole; all of the stock market gains of the Trump presidency have been lost in a single month amid record-high unemployment claims. The potential severity of this impact inspired a competing narrative: a growing number of specialists, including two Stanford University professors of medicine, began to openly pose the question: Is the Coronavirus as deadly as they say? Does it warrant these extreme and potentially devastating policies of containment?
Humanity has seen pandemic events before, but never in an era so completely saturated by such a dizzying degree of novelty and constant waves of data, from which we must continually separate wheat from chaff. Predictably, the Covid-19 narrative one accepts as valid seems to track fairly consistently with political orientation, much like the cultural Rorschach tests of 2019 which now pale in comparison. But the dual perspectives and concerns raised about the Covid-19 pandemic are not mutually exclusive, and can be reconciled in a cohesive interpretation of our current predicament. While the full impact of Covid-19 is far from clear, arguments that the virus is milder or equivalent to seasonal flu appear to be overly optimistic. Nonetheless, we cannot simply freeze human activity in place indefinitely; and attempting to do so will exact greater human consequences than a pandemic virus. Thankfully containment of Covid-19 is possible without either shutting down the economy or blithely conducting business as usual.
Is Covid-19 a deadly pandemic or equivalent to seasonal flu?
It is neither outlandishly unscientific nor irresponsible to pose this question. As the first accounts began to emerge of a novel upper respiratory illness crippling Wuhan province, China, information was sporadic and inconsistent. The World Health Organization (WHO) tweeted in January that “Chinese authorities have found no clear evidence of human transmission,” a claim which disintegrated under nominal scrutiny. (WHO data has been so unreliable that on March 24th, researchers at Oxford University publicly announced they would stop using it.) As information leaked out—despite the Chinese government’s considerable efforts to suppress it—that a novel human coronavirus was infecting hundreds or thousands of Chinese patients, a reputable bioweapons expert posited that the virus might be a lab-engineered byproduct of a bioweapons program. The proximity of the epicenter of the outbreak to the Wuhan Institute of Virology, China’s only pathogen-4 level facility, naturally invited speculation. Scientists have since concurred that the subsequently-released full genome sequence of the SARS-Cov 2 virus disproves that theorypossibility remains that a wild strain could have leaked from a research lab, either accidentally through human infection, or through the illegal sale of lab animals in the nearby seafood market.
The exact evolution of the SARS-Cov 2 virus and details of its initial transmission into the human population can’t be unequivocally proven or disproven so soon after discovery, although scientists agree that the virus probably originated in bats and may have made the jump to human hosts via pangolins. Whatever the case, we know that in a population of 7 billion people living in close proximity, in which viruses are manipulated and studied by labs in many countries, pandemic events are always possible and likely inevitable over the course of time; we must be prepared for them.
In such a rapidly evolving landscape fraught with unreliable data, how can we gauge the impact Covid-19 is likely to have in the U.S., separate from media distortions in either direction? Numerous skeptical analyses have been published in recent weeks comparing Covid-19 to seasonal flu, as assumptions and sweeping decisions are made based on rapidly evolving data published in studies awaiting peer review. For instance, the R0 (R naught), a measure of the number of others a patient infects, is estimated to range anywhere from 2.2 to 6.6 for Covid-19. (Seasonal flu has an R0 of about 1.4-1.6, while Measles, the most contagious known virus, has a value of 12-18.) Preliminary data from China suggested a reported case fatality rate of 3.8% with the total population-wide infection fatality rate (IFR) is closer to 0.5%, compared to a case fatality rate of 0.1% for seasonal flu. A more recent New England Journal of Medicine report published March 26th states that the case fatality rate “may be considerably less than 1% . . . more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.”
But these numbers are at best preliminary, and conflict wildly with case fatality rates reported by countries with more open data-sharing policies. Throughout the past several months, international Covid-19 statistics and case mortality rates have varied wildly even among neighboring countries with similar demographics. The novel characteristics of the virus, especially its long latency period of 5-11 days and high rate of asymptomatic infection, make it very difficult to track across nations which have wildly differing rates of accuracy and coverage of population-wide testing. Data from South Korea, whose response is widely considered be among the most effective and transparent, currently reflects a 1.6% case mortality rate. By contrast, Italy and Spain, the hardest-hit countries in Europe, currently report staggering fatality rates of 11.7% and 8.8%, respectively, which may reflect sporadic and incomplete testing inflating mortality statistics as well as the abysmal reality of triaging patients in decaying and overburdened health care systems.
Which sources are to be believed? Whose experience and which dataset accurately predicts the immediate future of other countries in Europe and North America? Dr. John Ioannidis of Stanford University argues persuasively that it’s unwise to take such radical and potentially damaging economic steps without more accurate data. It’s certainly true that experts and policy makers are flying blind, and must weigh the potential impacts of containment with potential deaths from other causes if a crashing economy makes basic health care unavailable to millions of Americans.
Ioannidis presents the Diamond Princess Cruise ship, quarantined in February, as the most reliable infected population from which to glean an accurate picture of transmissibility and virulence, although he corrects for the fact that Covid-19 deaths occur primarily in patients over 70 and cruise populations are disproportionately elderly. When his article went to print on March 17th, that population of 3,711 passengers had 700 infected passengers and 7 deaths—a case fatality rate of 1%, which he projected down to 0.125% based on US population statistics. Today there are 712 infected and 10 deaths with 15 still critically ill, reflecting a 1.4% case fatality rate which, using Ioannidis’ assumptions, adjusts to 0.175%, or close to twice the estimated case mortality rate of seasonal flu. Ioannidis concedes that applying this small and contained example to our broad population is highly speculative, and suggests a range of case mortality anywhere between 0.05% and 1%.
These case mortality rates would generate vastly divergent impacts, when we consider the consequences of a novel virus striking a population with no immunity to the virus experiencing all of the cases within a number of weeks rather than distributed throughout the flu season. Skeptics cite CDC estimates of up to 61,000 deaths per year from flu and “flu-like illness” which have never inspired widespread panic or draconian containment measures, even during the 2009-2010 H1N1 pandemic which caused an estimated 60.8 million infections, over 274,000 hospitalizations, and over 12,000 deaths. However these hospitalizations didn’t all occur simultaneously. The American Hospital Association estimates there are 924,107 staffed hospital beds in the U.S. of which approximately 107,000 are ICU beds. There were an estimated 44 million infections and 808,000 hospitalizations in the U.S. during the 12-month 2017-2018 flu season, the most severe over the past decade. If those infections occurred simultaneously over the course of even 8-10 weeks, demand for beds would quickly exceed capacity. CDC Wonder data reflect that during January 2018, the peak month of that season, the total number of combined flu and pneumonia deaths was 12,164, the maximum number of flu-like illness deaths in a single month over the past decade.
How does Covid-19 compare to seasonal flu, based on the data we have? It’s incredibly difficult to calculate the reported case rate accurately, given the woefully sporadic and inaccurate testing in the U.S. Unfortunately the Centers for Disease Control (CDC) insisted on developing its own test and centralized processing, rather than relying on the highly accurate and efficient German test approved by the WHO, delaying testing roll out for weeks. However the U.S. is hardly the only country to lack the political will or infrastructure to roll out timely and efficient testing; save for a few outliers, the majority of the international community seems to have followed a policy Quillette’s Ben Hunt terms “don’t test, don’t tell”—testing too few citizens too infrequently to get an accurate picture of their population-wide case rate. With differing protocols and widely divergent rates of transparency across the international community, case fatality rate becomes a wholly unreliable and confusing metric to gauge the future.
Mortality statistics offer a more accurate picture. While approximately 80% of Covid-19 cases are mild in healthy subjects under 70, the 20% of cases which progress to serious disease are punctuated by a distinctive characteristic: interstitial pneumonia which causes an appearance of “ground-glass opacity” easily identified on a scan. Patients who die of Covid-19 are likely to be correctly diagnosed.
How does Covid-19 mortality compare to population-wide seasonal flu mortality in the U.S.? In the 2017-2018 flu season, average monthly mortality was about 5,000 deaths, or 1,175 per week. The weekly average mortality per million citizens was 4 deaths per million. (This was a severe season, double the following year in mortality.) As mentioned above, the peak mortality occurred in January with approximately 12,000 deaths or 3,000 per week across the country. Comparative Covid-19 statistics change by the hour, as does the forecast for what Americans can expect in the coming weeks. As of Tuesday, March 31, Covid-19 mortality in the U.S. is 10 deaths per million, over double that of the average weekly mortality rate during the worst flu season in a decade. Of 3,431 total deaths, 2,651 (77%) occurred within the past week. There’s no indication that this week represents the peak incidence or mortality rate; cases and mortality are exploding exponentially in New York, New Jersey, Washington State, Michigan, and Louisiana. New York is the current epicenter of the U.S. epidemic, with their 1,550 deaths accounting for 45% of all U.S. Covid-19 mortality. By contrast, according to CDC Wonder data, New York mortality has consistently averaged about 8.5% of all U.S. flu and pneumonia deaths over the past decade, which means we have yet to see what the rest of the country will look like when and if Covid-19 takes hold in other states. During the peak flu month of January 2018, New York reported 706 flu and pneumonia deaths, compared to the 1,550 Covid-19 deaths since the first reported death on March 14th. These statistics, along with countless anecdotal accounts of overwhelmed medical staff and hospital systems, indicate that Covid-19 may strike the U.S. with at least twice the prevalence and virulence of the most severe flu season in several decades. Efforts to scale up capacity of ICU beds with respirators and contain the spread of the virus among latent carriers are warranted.
Did the U.S. Respond Appropriately? Is Mass Quarantine Necessary?
Unquestionably, the slow and incompetent CDC response led by career bureaucrats hobbled national containment efforts during the most critically important early weeks of the outbreak. Ironically, the decision which earned President Trump the most criticism and perhaps saved the most lives was closing the border to China in January. Since that time, leaders around the world have struggled to keep up with current information and make decisions which protect the economy from the catastrophic effects of either freefall from instability, or collapse under burgeoning and fragile healthcare systems treating a sick population. Architects of the widely promoted Imperial College epidemiological model have had to walk back their most dire predictions which informed policies implemented throughout Europe and the U.S. While it made sense to try and freeze contagion in place once the potential scope of the pandemic came into view, it’s equally rational to plan a cessation of mass quarantine once protective social distancing measures are implemented. After 14 days, those infected today will have shown symptoms and will be able to self-quarantine.
Suggestions to wait out the pandemic under quarantine until a vaccine can be developed are unrealistic and dangerous, both biologically and economically. The Federal Reserve estimated, before the emergence of Covid-19, that 38% of American families have less than $400 in reserve for unexpected emergencies. Unemployment claims have skyrocketed in recent weeks, with a record 3.3 million people filing claims during the week of March 21st. Furthermore, experts including NIAID Director Dr. Anthony Fauci have warned that rolling out an inadequately tested and experimental vaccine could be ineffective and dangerous. An experimental coronavirus vaccine was fast-tracked to approval for human trials this year without animal testing, despite ominous outcomes in animal trials of a previous coronavirus vaccine which was tested in mice. The results indicated that recipients could become more susceptible to pulmonary damage and pneumonia upon exposure to multiple strains of coronavirus. Study authors urged caution in developing coronavirus vaccines.
Luckily, waiting for a vaccine may not be necessary. On Sunday, President Trump announced an extension of social distancing guidelines until April 30th. This policy, in combination with proven effective treatments such as prophylactic and therapeutic Vitamin C, hydroxychloroquine particularly in combination with Zinc and azithromycin, should provide the foundation under which state and federal lockdowns can be safely eased in compliance with measures to “flatten the curve.” Perhaps the most damaging misinformation propagated by public health officials and the press has been the idea that masks provide inadequate protection against infection. While it’s true that medical-grade masks in particular should be distributed to healthcare providers first, trying to dissuade hoarding with false information was poor strategy which must be reversed once production and distribution is ramped up. Face masks, when worn by everyone, are a safe and effective way to prevent transmission of virus among infected people who don’t yet have symptoms, and prevent people from touching their mucous membranes while out and about. If everyone wears masks while interacting with the public and practices rigorous social distancing, transmission could be curbed exponentially. There’s no question that the Covid-19 pandemic presents a real and unprecedented challenge to the world’s population, and that an unprecedented response to contain the virus is necessary. With use of masks, social distancing, and proper handwashing, Americans can be back to work and out and about, engaging in meaningful activity and adjusting to the new Covid-19 era normal.
As we emerge from lockdown into the new Covid-19 normal, there’s opportunity to look to the silver linings amid our challenges. We’ve had a glimpse over the past weeks of what an even greater catastrophe might look like, and so we have a tremendous opportunity to prepare and adjust accordingly. The vast majority of us, if we are infected with Covid-19, will recover from the virus especially with access to proper therapeutics, including OTC prophylactic Vitamin C. Economic recovery may be within reach. And we’ve had the chance under quarantine to rediscover what’s real and important: biological reality has made a comeback. Social justice mobs have given way to quarantine memes. And a citizenry which was divided in a remarkably divisive political climate just a few weeks ago is pulling together to endure this crisis and dig our way out of it, together.
Sarah Dillingham writes on matters of health and wellness and is mom to a rambunctious boy in the D.C. suburbs.
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