“Be Safe” is the official mantra of our age, and has been for quite some time now. No wonder we're anxious. While 21^st century America emerged as the safest time and place in human history, we came to perceive our pampered vantage point as a reality against which the most trivial of threats seemed terrifying. The terrorist attacks of 2001 briefly shattered our illusion, but that didn’t last long. A new generation arose for whom 9/11 was just history.

Now we face a new threat. A global pandemic called COVID-19 has once again disturbed our reverie. This should not be! We must be safe! Government and science will save us! On a recent interview, a former director of the CDC used the word “safe” fifteen times in the course of a 10 minute interview.

There's just one wee little problem......

The world is not a safe place.

The world was never a safe place.

In Part 1 of this series, “COVID-19: Was the bark worse than the bite?” we noted early indications that the disease was far less deadly than initially predicted. Contrary to earlier and more dire forecasts, it was becoming clear that the true average fatality rate was coming in at under 1%. On April 9 we speculated that the US was at or near peak infection. The death curve for New York indeed peaked on that precise date, but other states were still catching up. Based on a rolling 3-day average, the US death curve peaked 9 days later, on April 18.

In Part III of this series, “Covidistan, Coronacita, and Carnivals” we saw how COVID infection fatality rates could vary dramatically between different populations, depending simply on which age group bore the brunt of the illness.

As the pandemic approaches its fifth month, and America begins slowly to emerge from isolation and economic shutdown, there is much we have learned. What do we know now that we didn’t know, or could only guess, at the beginning of March?

What have we learned?

#1. While COVID-19 is much worse than the seasonal flu, it is not nearly as deadly as initially believed.

It is now firmly established that most infections are mild or asymptomatic, never come to medical attention, and are not reflected in the daily statistics. We’ve already mentioned that in prior posts. The evidence continues to mount.

In Eagle County, CO recent antibody testing indicated that 11.5% of the population had been infected by mid-May, with only eight recorded deaths. According to Chris Lindley, the medical director of Vail Health, this meant that 6,300 people in the county have had COVID. Yet only 570 cases were officially recorded and only eight deaths. This meant that over 90% of cases were minimally or asymptomatic, and the true infection fatality rate was less than 0.15%. (8 out of 6300).

Now, the extremely low fatality rate in Eagle County is not The Ultimate Final Number. Breaking news, folks: there isn’t one. Death rates vary widely, depending various factors, but especially the age of the population that is infected. At the very lowest end, Singapore (as of May 24) has recorded only 23 deaths out of 31,616 infections, for a case fatality rate of 0.07%. Their population fatality rate is, to date, 4 in one million. What we do have is a range – and that range is well below 1% (as correctly called by John Ioannidis in mid-March to the consternation of many doomsayers).

At the upper end of the range, the most severely affected region of Bergamo, Italy may have experienced a population fatality rate of 0.57%, or 5700 per million. Almost all of that was attributed to excess mortality in the extreme elderly.

#2. COVID-19 will not be contained or cured.

As of this writing there have been 5.5 million cases of COVID-19 reported worldwide. There is no longer any possibility of containment. Many still speak as though we could halt its spread if we identified every person who was infected, traced all their contacts, and quarantined everyone for two weeks (like they nearly succeeded doing in Taiwan or South Korea). That is wildly unrealistic; it is simply not going to happen. This has been known for some time, though few seemed to notice. On February 24, The Atlantic announced “You’re Likely to Get the Coronavirus”. It quoted Harvard epidemiologist Marc Lipsitch saying “I think the likely outcome is that it will ultimately not be containable.” The article explained:

“Lipsitch predicts that within the coming year, some 40 to 70 percent of people around the world will be infected with the virus that causes COVID-19. But, he clarifies emphatically, this does not mean that all will have severe illnesses. “It’s likely that many will have mild disease, or may be asymptomatic.”

Social distancing only slows the progression. The more who abide by the restrictions, the more slowly it will spread, but whether we have 100% compliance or only 95% makes almost no practical difference. Those who are most fearful of catching the illness can very effectively self-isolate but can never reduce the chance to zero.

#3. The nation’s healthcare capacity was never stressed.

As the United States entered national lockdown, we joined in unison to the chorus of “Flatten the Curve”. Amidst a barrage of panicked reporting from Italy it seemed inevitable that short of drastic action, our future scenario was one of overwhelmed hospitals choosing who would live or die. If only we could at least slow the virus’s progression a bit, there might be an open bed in the ICU when your number was called.

The flood never came. Even in hard-hit New York City, at the peak of infection in mid-April, hospital and ICU occupancy remained below 90%. Was that because of the lockdown? Even that would be arguable, given that the case curve for New York from March 15 forward wasn’t remotely flat. Meanwhile, throughout the rest of the United States empty hospitals were facing bankruptcy and healthcare providers faced mass layoffs, furloughs, work reductions, and pay cuts. This was a strange pandemic, indeed.

#4. In hindsight, is difficult to prove that the sacrifices justified the benefits (and it is totally fair to ask).

In early March, there was much we did not know about COVID. All we had was the data from China, and that formed the basis for early models. The unfolding events in Italy pushed policymakers to the brink. We were going to shut down the world’s economy to slow or stop a disease without even knowing the true danger. We were between Scylla and Charybdis – if we waited for more data, it could be too late. It was fair to argue we couldn’t afford to wait for data, though the responses could have been more measured. Shutting down the nation’s healthcare system, banning outdoor activities, returning ill patients to nursing homes were foreseeable errors. (Admittedly, the nation’s healthcare providers were in a tight spot over a nationwide shortage of personal protective gear).

With almost three months of learning behind us, “flattening the curve” seems like a dubious justification for the drastic measures that were imposed. That’s not just because the healthcare system had plenty of capacity. It’s also because there is little evidence they even worked. As of today, eight US states (NY, NJ, CT, MA, LA, RI, MI, PA) and the District of Columbia have witnessed per capita COVID death rates higher than Sweden, which never locked down. Collectively, those eight states and DC account for approximately 2/3 of total US COVID fatalities.

#5. The surest path to a falling infection rate is to start with a really high one.

Federal guidelines currently recommend that States should see 14 days of steadily declining cases before loosening restrictions. Some have been criticized for opening up while their infection rates aren’t dropping. But that’s a moot point, if those rates were low to start with. Infections in New York and New Jersey have been declining rapidly – but only after they attained per capita mortality levels much higher than Spain and Italy. Wyoming peaked at 26 confirmed infections on April 22 and reported 25 new cases on May 24. Statewide, it has recorded 12 deaths since the beginning of the pandemic. Mathematically, it is incredibly difficult to achieve a sustained reduction from such a low baseline. Wisely, Wyoming began reopening on May 1.

#6. We’re only beginning to comprehend the consequences of the global shutdown.

On April 30, the New York Times reported that because of the COVID-induced world economic shutdown “a half billion people could slip into destitution by the end of the year.” Reversing the extraordinary progress of the last three decades, we may soon again witness starvation on a massive scale.

Other consequences yet to be reckoned include:

• Long-term damage to America’s healthcare system as hospitals go bankrupt and healthcare providers face permanent job loss.
• Increased mortality rates from non-COVID causes
• Mass unemployment. The Wall Street Journal reported “it probably will take years for the economy to fully replace the millions of jobs lost in March and April.”
• Deterioration of mental health, as the Washington Post reported: “the coronavirus pandemic is pushing America into a mental health crisis”.

Unknowns

There are many things we still don’t know and won’t for some time.

When will a vaccine become available?

In a recent broadcast, Dr. Francis Collins, head of the National Institutes of health, mentioned that a vaccine had never been developed and brought to market in less than three to four years. Now, there are some ways of speeding up the process, for instance, by having the manufacturing capability already in place. But there is no guarantee that a vaccine will be developed, that it will work, and that it will be safe. (I'm no anti-vaxxer, but I think I'd prefer to see how the first million fare before I roll up my sleeve.) Every other day seems to bring a new report of progress in the vaccine arena. On the in-between days, there is often a new setback.

How many have to be infected for herd immunity?

The consensus so far has been that "herd immunity" would only be attained when 60-70% of a populace became infected. This seemed to be the case for Bergamo. But there are suggestions that herd immunity might be achievable at significantly lower infection rates.

In one pre-publication study, a multinational team of researchers examined the role of individual susceptibility in the rate of spread. While this should be regarded as no more than a tantalizing hypothesis, the authors explain how herd immunity could be achievable with an infection rate as low as 20%:

“A crucial caveat in exporting these calculations to immunization by natural infection is that natural infection does not occur at random. Individuals who are more susceptible or more exposed are more prone to be infected and become immune, which lowers the threshold. In our model, the herd immunity threshold declines sharply when coefficients of variation increase from 0 to 2 and remains below 20% for more variable populations.”

Are there overlooked factors that make the disease less deadly?

Though it has been widely accepted that no one has immunity to the novel coronavirus, that is not necessarily the case. Other coronaviruses cause the common cold, and there is now some experimental evidence that previous exposure to these may confer at least partial immunity to COVID.

It has been known for decades that one side benefit of vaccines is that they can prime the immune system against other potential invaders. The BCG vaccine is used worldwide (though not in the US or most western European states) to enhance resistance against tuberculosis. There have been early indications that the BCG vaccine offers partial protection against COVID, and may account for the low infection and death rates in certain nations.

Predictions:

What is the chance of a mass deployable vaccine in 12 months?

Because it’s never been done before and the technical obstacles seem forbidding, I would not count on a vaccine within the next twelve months. On the other hand, the resources being mobilized toward this effort are unprecedented. Odds of success within 12 months: 50:50.

Is a cure on the horizon?

While there has been much excitement over the relatively modest benefits of Remdesevir, the odds of a highly effective treatment are remote. Viral diseases have been notoriously difficult to cure with medication, and it is very difficult to improve upon a survival rate that is already well over 99%.

How many Americans will eventually die from COVID?

By now we have good and reliable on the risk of death from infection as a function of age and predisposing conditions. The risk for anyone under 20 is nearly zero and for those over 70 it is quite high. The overall death rate for a population depends on whether it is more like Coronacita or Covidistan, Singapore or Bergamo.

Most COVID deaths occur among the elderly, who were already at risk of dying. The case fatality rate of COVID for those over 80 is somewhere between 13 and 20%. The infection fatality rate may be half that or lower. By comparison, the likelihood of a random male over the age of 84 dying in any given year in the US is 15%. There is clear and compelling evidence that COVID has caused an abrupt spike in weekly mortality rates in those areas where it struck the hardest. Still, those spikes could be averaged downward by lower mortality rates in the ensuing months. Or, they may remain elevated due to deferred elective medical care and missed diagnoses. There are many variables involved, and much we cannot yet measure.

The greatest uncertainty involves how many will ultimately become infected. The state of New York leads the US, and in fact the world, in per capita infections that so far generated a population fatality rate of 1500/million (0.15%). If the entire US saw the same infection and death rate as NY, that would total almost 500,000 deaths nationwide (400,000 additional deaths above the current tally). There seems to be little chance of that happening. The US death curve is flattening significantly. We presently stand at about 100,000 deaths but the average daily death rate has dropped by more than half from its peak and continues to decline. Barring another New York-style outbreak in a major metropolitan area, we should end the year below 200,000.

What about a second wave?

The famous “second wave” depends on a number of assumptions that may not hold. It also depends on intense suppression of the first wave, something we have not witnessed. In fact, it was defined as a potential hazard of flattening the curve too much. The present trends suggest neither complete eradication nor a second mass wave, but a continued slow burn with occasional spikes in densely populated regions or should mass gatherings resume.

Prescriptions

Public and private strategies can be categorized along a continuum, from continued lockdown in an effort to completely eliminate the virus, all the way to total indifference and allowing the disease to run its course. Let’s consider five possible responses to the COVID threat. They are not mutually exclusive.

#1. Containment: round up the herd and put ‘em back in the barn

As opposed to merely “flattening the curve”, the idea of containment was that if we could identify and quarantine every infected person, the virus could be stopped dead. Many seem to have thought that could be attainable. If that was ever the goal, the lockdown failed. In New York, while businesses were shut down, the subways were kept open and became a major avenue of spread.

“New York City’s multitentacled subway system was a major disseminator – if not the principal transmission vehicle – of coronavirus infection during the initial takeoff of the massive epidemic that became evident throughout the city during March 2020.”

Jeffrey Harris, National Bureau of Economic Research.

By early May, two-thirds of New Yorkers hospitalized for COVID were infected at home, while under “lockdown”. New York and New Jersey authorities ordered nursing homes to readmit infected COVID patients from local hospitals, leading to higher nursing home infection rates and fatalities. They quarantined the least vulnerable while exposing the most vulnerable.

An astonishing number of analysts, commentators, and possibly most of the public still seem to think and talk as if containment were our ultimate strategy.

#2. Control: pay me now or pay me later

The driving concept behind flattening the curve was to spread infections out over time so the hospitals were not overwhelmed. If any lives were saved, it would be those of heart attack patients, trauma victims, or critical COVID patients who might be denied care for lack of resources. It wasn’t about keeping you from getting it; it was about keeping everyone from getting it at once.

All fifty states are beginning to re-open to some degree. With the curve already squashed flat, the rationale for proceeding slowly is murky at best. Confident talk of "saving lives" is hopeful but unrealistic. The virus will continue to spread no matter what we do. Of all possible interventions, the prohibition of large mass gatherings is most likely to be beneficial. There was a very strong connection between the largest COVID outbreaks and large group events, as seen in New Orleans following Mardi Gras.

With no possibility of containment, no chance of a cure, and a vaccine a long way off, all our best efforts at social distancing serve only to postpone infection, not prevent it. Yet, there is one thing we can do to minimize the loss of life: protect those at greatest risk.

#3. Cocooning: protecting the most vulnerable

Those most likely to die from COVID are people over 65, or those with underlying conditions such as obesity, diabetes, and hypertension. Many of these have the ability to self-isolate until we are closer to herd immunity. We now have sufficient testing capacity to ensure that retirement communities and nursing homes should be able to identify and quarantine infected residents and staff. For at-risk persons who choose to go out and about, we know enough about how the disease is spread that it should not be so terribly challenging to avoid getting infected.

#4. Coming to terms with reality.

America, and much of the world, is now emerging from a dramatic experiment in induced economic coma. We may have saved lives, more probably just prolonged them a bit, but at tremendous cost.

All the talk of “saving lives no matter the cost” is brazen demagoguery. It’s not lives versus the economy. It’s lives versus lives. No one yet knows how many more will die of suicide, or heart attacks, or starvation because of the shock to the global economy.

The economic consequences have already been devastating and are likely to get worse. We need to reopen for business as soon as possible, but it’s not that simple. If governments lifted all restrictions tomorrow, many people would continue to self-isolate out of prudence or fear. That may be the best solution for all concerned – allowing individuals to make their own choices.

We have always allowed people to take risks. The CDC estimates that cigarette smoking continues to cost 480,000 lives per year. It would be simple to ban cigarettes. But they employ many people, and we let consumers assume the risk. We allow teenagers and the elderly to drive, even though getting them off the roads could save many lives.

#5. Courage - a neglected virtue

If this is the Age of Anxiety, then it is an age where Believers can testify through their thoughts, speech, and actions to something better. In the Bible, God commands his people to “fear not” at least one hundred different times. (But not 365!) How many times must a command be issued before disobedience qualifies as a sin? Then fear is also a sin. Now, some may object that fear is just an emotion, and we aren’t responsible for our emotions - but they would be wrong. Throughout Scripture, emotions, sin, and obedience are densely intertwined.

If you are a Christ-follower in this age of COVID, "fear not" applies to you. Just remember that we are accountable only for our own attitudes. This does not constitute a license to judge others still trapped in fear; they deserve our love and compassion.

COVID-19 is a disease to be taken seriously, but this isn’t the Black Death. Many of you will get it, and never know it. Many others will get it and know it, but nearly all will recover just fine. For some of you, or ones you love, it may be the pathway home, where a greater glory awaits. But that has always been true.

“Fear not, for I am with you; Be not dismayed, for I am your God. I will strengthen you, Yes, I will help you, I will uphold you with My righteous right hand.’

Isaiah 41:10 NKJV

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The Myers Briggs inventory can tell you wonderful things you already know about yourself. I’m an INTJ. One thing about us INTJ’s is that we march to the beat of a different drummer. If everyone else goes right, we go left and that’s OK. Now, this combination of independence and social indifference is a mixed bag. It was never my genetic destiny to be homecoming king or a contestant on The Bachelorette. On the other hand, when an epidemic is sweeping the country, steering clear of the herd can be excellent for your health. We can come back for a visit when it’s over. [“You're so right. Nerds don't herd.” – the Spaniel] Speaking of herds….

Epidemic modeling is a carnival game

So what’s all this talk about herd immunity, anyway? Doesn’t that demand a laissez-faire approach leading to millions of needless deaths? Isn’t that what Boris Johnson was for before he was against it? Isn’t that what the crazy Swedes are trying to accomplish by doing nothing? (Which isn’t, by the way remotely true).

Well, “herd immunity” is more theory than reality when it comes to the present pandemic. COVID is so new, we still don’t know for certain that recovering from it makes you immune. But even without actual long-term immunity, every epidemic eventually burns out.

How does that work? Let me try and explain. Imagine that game at the fair where you’re throwing darts at balloons on a wall, but you’re a really bad aim. Or blindfolded. At the beginning there’s lots of balloons and they’re all close together. It’s pretty easy to hit one by dumb luck. The more that pop, though, the harder it gets to hit one that isn’t popped.

Now, make it a million balloons and you have a really good arm. Same game. But you’re still only popping one at a time, and the growth rate remains linear.

This could take forever, so let’s pick up the pace. Every time you pop a balloon you gain a teammate (the dead balloon gets reincarnated). The more you pop, the more throwers you get, but they’re all still blindfolded. Now, pops can grow exponentially. To add an element of suspense, every tenth balloon that got popped sails to Avalon and is not reincarnated as a dart thrower.

Just one more rule and we’re there. You only get 7 throws before you’re out of the game (you get bored easily). Eventually, there just aren’t enough blind dart throwers to randomly hit the remaining balloons. All retired dart throwers are immune (theoretically). But the remaining balloons aren't immune. They’re just lucky. If this were an epidemic instead of a dart game, your best strategy is to be the balloon that never gets popped. Your second-best strategy is to be popped and then get reincarnated as a thrower.

That’s how an epidemic runs its course. After enough people have been infected and recover, the number who are actively infected and the number who were never infected are low enough that they seldom cross paths. How many are enough? For something incredibly infectious, like measles, it doesn’t stop until 98% have been infected. With COVID nobody knows, so the experts assume somewhere between 60 and 80%.

Covidistan and Coronacita – opposite approaches to herd immunity

Early in the COVID outbreak, two small European nation-states – call them Covidistan and Coronacita - decided to shoot for herd immunity and skip the induced economic coma shtick. They were mirror images of one other, with some very odd demographics (to keep our math simple). The birth and death rates were exactly constant year by year, and everyone died of natural causes the day after their 90^th birthday (totally hung over following a truly smashing send-off). Both nations had a population of exactly 900,000, with exactly 100,000 people at each decade of life. Both nations decided to let the disease run its course, while protecting the most important. Herd immunity would be achieved when exactly 2/3 of the population had been infected and recovered.

Covidistan is very child-centric so it decided to lock up its children, in fact everyone under 30, in protective quarantine with plentiful pizza and burgers, game consoles, and unlimited free streaming. Coronavirus swept the remainder of population, infecting everyone over the age of 30. Unfortunately for the victims, they were the ones at greatest risk. In the end, Covidistan lost 11,570 people or 1.3% of its population. * [based on the age-adjusted COVID-19 mortality of Spain and allowing for an asymptomatic infection rate of 50%]

Coronacita, on the other hand, was a well-entrenched gerontocracy. The old people felt they’d paid their dues. “Let the young-uns bear the brunt of the illness” said they. Everyone over 60 was quartered in a luxurious seaside resort sipping mai-tais and playing extreme shuffleboard. The rest were left to face the virus while continuing with work and school. When the disease had run its course, COVID killed only 520 Coronacitans, or 0.06% of the population.

Two nations, two different paths to herd immunity, but the infection fatality rate in Covidistan was twenty-two times higher. Certainly, that doesn’t correspond to anything in the real world, does it? Well, not precisely, but close. Coronacita is Singapore. The Bergamo district of Italy was Covidistan.

With over 23,000 documented cases to date, tiny Singapore is behind only China and India for the most cases among the nations of Southeast Asia. Yet, so far it has documented only 20 deaths. That’s a documented case fatality rate of 0.08% with a per capita death rate of 3 per million (0.0003%). How did they do it? Over 90 per cent of infections were among very young low-wage foreign workers, while the nation’s elderly heeded government advice to stay at home in response to direct pleas from Prime Minister Less Hsien Loong. No one is close to claiming Singapore has reached herd immunity, but the point is made.

“Fortunately, we have a much smaller proportion of elderly people than Italy or Spain,”

Paul Tambyah, President of the Asia Pacific Society of Clinical Microbiology and Infection

Bergamo, Italy was the epicenter of the COVID outbreak in the Lombardy region of northern Italy. In a yet unpublished report, researchers attempted to determine the actual impact of COVID in Italy by examining mortality data for 2020 compared to the preceding four years. By their calculations, the actual infection rate in Bergamo reached 67% (two-thirds) and they may have attained “herd immunity” (authors’ words). Overall fatalities were estimated at 6,171 (over twice the official number), or 0.57% of the total population.

To look at it another way, by May 6 Singapore had recorded 20,198 cases and only 20 deaths. When Italy crossed the 20,000-case threshold back on March 14, it had lost 1,441 citizens, seventy-two times as many. Now, Bergamo didn’t isolate its young people, but there wasn't much need. Italy has been “quarantining” its children for years – by not having them. Bergamo is one of the oldest communities in Italy, and Italy has the fifth highest median age in the world. According to the report, essentially 100% of the deaths in Bergamo were among people over 40.

Aiming for the side of the barn - and missing

In real life there’s a broad continuum between Covidistan and Coronacita, but our results are looking more like the former than the latter. By all accounts, the US has done a terrible job of protecting the most vulnerable. By late March, multiple societies had warned of the looming threat to nursing homes and called for immediate segregation of infected patients from the uninfected. Instead, the governments of New York and New Jersey enacted rules compelling facilities to take back their hospitalized COVID victims, whether they were recovered or not. (Louisiana did the opposite - banning their return until recovery was confirmed). It was like protecting your home with a 12-foot steel barrier armed with the latest military defense technology on the front (the economic shutdown) while the back was secured by a rotting wooden fence held together with string and duct tape (long-term care facility policies).

“The deadliest place for COVID-19 transmission remains in nursing homes, which now account for more than 26,000 deaths in the U.S…. That means that of the data available, nursing homes account for one-third of the nation’s fatalities from the ongoing viral outbreak.”

ABC News, May 11, 2020

The New York Times keeps a running count, and New York, New Jersey, Massachusetts, and Pennsylvania lead the nation in COVID deaths at long-term care facilities. In fifteen states, these facilities account for over half of all deaths, nearly 80% in West Virginia and Minnesota.

We should all remember that the coronavirus is highly infections, and that it’s incredibly difficult to contain a disease that is easily transmitted by asymptomatic carriers. Tragically, the nationwide economic shutdown conferred no real benefit to those who were at greatest risk, and in some instances state policies put them in still greater danger.

Even when you are old, I will take care of you, even when you have gray hair, I will carry you. I made you and I will support you; I will carry you and rescue you.

Isaiah 46:4, NET

As the pandemic continues, let us all be mindful of those most at risk and employ the utmost care to protect them. And next time you’re at Walmart passing an eighteen-year-old young man with no mask, give him wide berth and instead of griping about him, thank him for doing his part to build up immunity!

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