Just when it looked like we’d turned a corner, COVID has returned with a vengeance – or so it seems. Most of the recent media attention has focused on rising infection rates in Florida, Texas, Arizona, and California. Three of those four (FL TX, CA) top the list of most populous states, so their raw case numbers should be no surprise. The fourth most populous state is New York, which second only to New Jersey, leads not just the US but the entire world in accumulated per capita infections and mortality.
What's going on?
According to the New York Times, new cases are on the rise in 38 states and the Virgin Islands. They are mostly steady in 11 states and Guam, including the hardest hit states of NY, NJ, MA, and CT. Cases are declining in only 3: NH, ME, and VT. (All are based on recent seven-day averages, so are sensitive to daily fluctuation and can be misleading). These “record” case counts should be taken with a grain of salt. Testing was so scarce in the early stages we have no idea what the actual counts should have been in March and April. Increasing hospital admissions confirm that the disease is truly on the upswing in a few populous regions, though probably not as dramatically as the simple case counts might suggest.
In the context of the present resurgence, this is a good time to assess where things stand and how our previous calls have stood up. A number of the following points have already been made on this site, but are re-introduced both for new readers and as a reminder to others.
New York mostly failed to flatten the curve. It saw a massive spike in infections and deaths, followed by a continuous decline to now very low levels. New cases, hospitalizations, and deaths in New York City have dropped to almost nothing. This follows the pattern seen in the worst-affected nations, including Belgium, United Kingdom, Sweden, Italy, Spain, and France. NJ flattened it only slightly. Both NY and NJ suffered per-capita fatality rates double that of Belgium and triple that of Sweden. Here we see the infection curve for New York:
Some states did flatten the curve, seeing moderate infection rates spread out of many weeks. (IL, IN, MD). Most of them now have steadily declining fatality rates. Illinois, for example:
Many states totally squashed the curve. Instead of spreading out the cases over time, their shutdowns had the unfortunate consequence of merely pushing the curve, hence the crisis, forward in time. Until quite recently, FL, TX, AZ, and CA had infection rates far, far below the national averages. Presently, their per capita fatality rates remain less than 1/2 the national average, and around 1/10 the death rates of NY and NJ. This was predicted by Kissler, et al, from the Harvard Department of Epidemiology, whose recent paper in Science warned:
"Strong, temporary social distancing can lead to especially large resurgences"
"Under all scenarios, there was a resurgence of infection when the simulated social distancing measures were lifted. However, longer and more stringent temporary social distancing did not always correlate with greater reductions in pandemic peak size."
Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period, Science, 22 May 2020: Vol. 368, Issue 6493, pp. 860-868
The virus is incredibly infectious and easily spread by asymptomatic victims. A recently discovered variant that has become dominant is even more infectious, though not more deadly. (The original, less infectious strain that circulated through Asia may partially account for their early success in suppression). There was, and is, zero possibility of containment. From the very outset, Harvard epidemiologist Mark Lipsitch predicted that 40 to 70 percent of the global population would be infected [possibly much lower; read on]. Masks and social distancing can slow the spread. In so doing, they accomplish the original purpose of “flattening the curve”: to prevent hospitals from being overwhelmed. Unfortunately, many got the message that through such efforts we could stop the pandemic in its tracks. That became impossible about six months ago. The overwhelming percentage of cases are now known to be mild or asymptomatic, something we have been reporting from the outset.
The infection fatality rate is confirmed at a mean value of around 0.4%, or about four times worse than the common flu. This is in the range initially predicted by internationally renowned researcher John Ioannidis in mid-March. By May 4, the evidence had become sufficiently compelling that we made that call on this blog. This is now the official position of the CDC. [Note: On July 13, 2020 this was revised upward to 0.65%] The local death rate may be higher (Bergamo, Italy) or lower (Singapore) depending upon the age distribution of its victims.
The data increasingly suggests that the Swedish approach (prohibit large gatherings, no closures or lockdown) has been equally effective with far less social and economic disruption. Swedish COVID fatalities have declined precipitously since a mid-April peak. (Their death rate could have and should have been much lower, but for a policy of malign neglect toward the elderly having nothing to do with the decision not to shut down). As of today, the per capita fatality rate in Sweden remains lower than nine US states and the District of Columbia – all of which locked down.
"Herd immunity" may kick in at much lower levels than popular wisdom asserts, and is by far the best explanation for the dramatically declining rates of the nations and states listed in #1. The widely circulated estimate that herd immunity requires a 60-70% infection rate is based on a simple formula with simplistic assumptions. The weakest of these assumptions is that all people are equally susceptible. Now, there are four widely circulating coronaviruses that cause the common cold. A series of reports in the last two months have reported evidence for pre-existing T-cell immunity to the SARS-Cov-2 virus in unexposed individuals, linked to at least two of the more benign coronaviruses. The implication is that a large proportion of the population already has partial immunity that would never show up on antibody tests. One international team of researchers, including representatives of Oxford and the NIH, projects that herd immunity could occur at levels as low as 20% after taking into account variations in individual susceptibility.
A vaccine is not inevitable. Every report, commentator, and column that speaks of a vaccine in terms of "when" or "until" is either naïve or disingenuous. Dr. Francis Collins, head of the NIH, stated in an interview that a vaccine has never been developed in less than three years. After forty years, there is still no vaccine against HIV, and that is clearly not from lack of trying.
It would be inaccurate to declare our containment measures (masks, social distancing) are futile. It is mathematically possible that fewer will get sick or die because of these, yet the long-term net reductions may be minimal. It also wouldn't be fair to trivialize the benefit of dying six months later rather than now. Risk is an unavoidable fact of human existence. We'd save many more lives by the abolition of cigarettes, mandatory flu vaccines, confiscating all firearms, and raising the driving age to 21 - but there's no popular support for such measures.
Much criticism has been targeted toward young people going to the beach and having parties rather than conforming to rigid social distancing, yet there is little evidence for any long-term benefit. I have tremendous sympathy for young people forever missing out on once-in-a-lifetime opportunities like high school graduation, or in the case of my own son, live stage performances with summer theater. We are all paying a price, but the young and poor are paying the most. Every policymaker must be called to answer one simple, overriding question: what is the endgame, here?
“Be Safe” is the official mantra of our age, and has been for quite some time now. No wonder we're anxious. While 21st 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 onemillion. 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.
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”.
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.
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.
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.’
If you find this helpful, please spread the word by sharing it via email and social media! And don't forget to subscribe (top right box). This is going to be it for COVID and us, but we have many interesting topics to explore in the months ahead!
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 90th 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.”
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.
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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For several weeks now, the Spaniel and I have been poring over charts, analyzing the data, and perusing commentary from multiple reliable sources (and occasional not-so-reliable ones) in order to provide you, our esteemed fan base, with trustworthy evidence-based guidance for what the future brings. Discretion is often the better part of valor, and those who strike first usually miss. We thought about issuing our predictions weeks ago. We were wise not to.
In mid-March, there was cause for optimism that COVID was “no worse than the flu”. Well, that rather depends on which flu one has in mind. The 1918 Spanish flu was devastating. Indeed, le Spaniel et moi were hopeful that COVID would follow a more benign course, comparable to a severe seasonal flu. One early indicator would be Italy. Annual flu deaths in Italy run about 8,000. By March 26, the total COVID deaths in Italy crossed that threshold and continued to rise. They are now slowly approaching 30,000. Could Italy be near the peak? Four times 8,000 would be 32,000. Interestingly, one writer inferred from an early German antibody screen that the fatality rate would be about four times deadlier than the seasonal flu.
COVID also differs from the flu in two key respects. First, it is much more contagious. It is transmitted more easily between persons, leading to a much more rapid spread. This was reflected in the speedy dissemination through nations and around the globe, with exponential growth rates in both infections and fatalities. The second difference has been the degree to which COVID can be transmitted by asymptomatic carriers.
One of the more curious aspects to this pandemic we have learned is the surprising frequency of asymptomatic infections. This is a double-edged sword. On the one side, it means the disease is not as lethal as raw numbers might suggest. On the other side, it means that containment is much more difficult.
After several months of study, we are closing in on answers to some of the most critical questions.
What is the real mortality rate?
Many casual observers have focused on the case fatality rate (CFR) a simple – and simplistic – ratio of recorded deaths to recorded cases. This results in a wide range of estimates, from 0.09% (Singapore) to 15.7% (Belgium). This number is wildly misleading for a host of reasons, but especially because most recorded cases and even more deaths were among the elderly. In Singapore, almost all of the cases have been among young migrant workers living in dormitories, among whom the fatality rate is exceedingly low. One thing that we knew early on was that the fatality rate was highly age-dependent, from nearly zero among those under 20 to 15% or higher among the most elderly:
It is important to emphasize that the CFR's in the chart above are considering only diagnosed, symptomatic infections, who were more likely to be severely ill or hospitalized. Much more relevant is the infection fatality rate (IFR). This is the actual chance of someone dying from infection with the virus. This number allows us to predict the risk for an individual who is infected, but also can predict the impact on a large population. Even among diagnosed cases, the IFR varies wildly with age and is extremely low among those younger than 40. However, to get an accurate IFR, we need to know how many have actually been infected, so…
How many have been infected?
Officially, there are now over 3.6 million cases worldwide (May 4) and over 1.2 million in the US alone. This number is almost certainly low due to limited test availability, false negative test results, and - especially - the very high rate of asymptomatic infections.
We knew from the outset that many infections were asymptomatic. This is important for several reasons. First, the disease is not as lethal on a percentage basis if there is a significantly large cohort that gets infected without falling ill. Second, the disease is extremely difficult to contain if it can be transmitted by apparently healthy people. Third, it raises the tantalizing prospect that so-called “herd immunity” could some sooner than many expect. "Herd immunity" is a poor choice of words, since we cannot yet prove that recovering from the disease actually confers immunity. Nonetheless, every epidemic eventually burns out or we’d have gone extinct eons ago.
The first clues of asymptomatic infection came from studies in China and the cruise ship Diamond Princess, resulting in estimates of 25-50%. That would mean for every 100 known infections, there were 33 to 100 unknown ones.
Later studies using a variety of methods pointed to even higher rates. In late March, a multinational team of researchers applied mathematical modeling to internet usage to trace the spread of COVID in China. Its spread could only be explained if 86% of the early cases were “undocumented” – meaning, unsuspected and undiagnosed. The best explanation would be that that were minimally or asymptomatic. If true, there might be 7 asymptomatic infections for every symptomatic one.
This was mirrored by a second study in early April that used a completely different approach. In a letter to the New England Journal of Medicine, some New York obstetricians reported on the testing of 215 consecutive inpatients tested for coronavirus. Thirty-three tested positive; only four (12%) were symptomatic. Asymptomatics outnumbered symptomatics again, by seven to one.
By late April, several sites were reporting initial results of random antibody testing that could indicate how many had been infected. While there have been legitimate concerns about both the accuracy of the tests and the methodology of the studies, they again point to many asymptomatic infections. On the day the results were released (April 23), Governor Cuomo surmised that as many as 2.7 million New Yorkers had already been infected. That was over 10 times the number of confirmed cases on that date – and antibodies are a lagging indicator. It takes up to two weeks for the antibodies to become detectable. The actual ratio of asymptomatic to symptomatic could be even higher.
Take the age-adjusted case fatality rates from the prior illustration and apply them to the US population. If no cases were asymptomatic and everyone fell obviously ill – an impossible 100% - we would expect an overall IFR of 1.15% and a staggering 3.8 million deaths. But if seven out of eight are asymptomatic, the IFR drops to 0.14% causing 474,000 deaths, still assuming 100% get infected. A more realistic assumption would be an infection rate of around 60%, bringing the total mortality down to about 284,000. That’s with no effective treatment and no public precautions. We’re now a quarter of the way there nationally. The state-wide death rate in NY is closing in on 0.14%. It could end up exceeding that but appears quite unlikely to go much higher.
What has been the disease trajectory in the US and other countries?
The European states that were hit earliest and hardest showed a rapid rise in cases that peaked in a few weeks but then steadily declined. This was most notable in Spain, Netherlands, and Italy, where the nationwide death rates reached around 500 per million. France and Belgium followed similar trajectories shortly afterwards.
Because of this, most expected the US to follow a similar path. We appeared to hit a peak of 34,517 cases on April 4 and that record stood for 20 days, with slowly declining numbers. However, daily deaths hit a new high of 2683 on April 21 and on April 24 new cases rebounded with a new daily record of 38,598:
Why did the US not behave like Europe? Perhaps because the United States is more like 50 individual countries, with profound local disparities. When cases in the US were rising rapidly, most of those were concentrated in the regions around New York City, Detroit, and New Orleans. These regions actually did follow the expected trajectory. However, as cases began to fall in these areas, they began to rise in others. As a result, total US cases and deaths have remained virtually flat for three weeks.
A second compelling fact to consider is that the death rates in Europe only began to show marked declines after per capita mortality hit a certain level. The per capita mortality in the US remains less than 1/3 that of Belgium, less than ½ that of Spain, Italy, and the UK, and almost ½ that of France. Yet on a local level, the statewide mortality of New York (0.13%) is higher than any European state. After hitting such a high level, the daily death rate in New York City has been dropping even faster:
There has been surprisingly little correlation between public containment strategies and the local course of the epidemic. In Illinois - among the first to issue a stay-at-home decree (March 21) - cases are increasing at an increasing rate.
In Florida, one of the last (April 3) to issue a state-wide decree, new cases have trended downward for a month:
Most cities and states never saw the surge in patients that had been expected. While personal protective equipment has been in short supply – truly a serious problem – there was never a ventilator shortage. The one metropolitan area that saw huge volumes of patients over a very short period of time – New York City - never came close to exhausting the reserve capacity that had been mobilized.
In summary, we have learned that COVID is highly infectious, and moderately lethal with an infection fatality rate that may be about four times worse than the common flu, or a little higher. All signs point to a very high rate of asymptomatic infections. The upside to that is that it remains much less deadly than predicted initially. The downside is that makes it much more difficult to track and contain.
In our next installment, what does all this signify for the future and what’s the endgame? Some of the nation’s most experienced analysts are beginning to reach a consensus on this. Stay tuned, sign up for our notifications (top right) and we’ll take a look in the coming weeks. In the meantime, go take your dog for another walk.
As COVID deaths were skyrocketing in the Lombardy region of northern Italy, overwhelming local hospitals, Samaritan’s Purse (SP) - the Christian relief ministry headed by Franklin Graham - airlifted an emergency field hospital to Cremona, Italy. Staffed with both SP workers and emergency medical volunteers, the 14-tent 68-patient field hospital arrived on March 17 and began taking patients by March 20. It has been in continuous operation since.
America was to be next. On April 1 in New York’s Central Park, Samaritan’s Purse erected and ran an emergency field hospital to care for overflow patients from Mt. Sinai hospital. Volunteer physicians, nurses, and ancillary personnel stepped forward, risking their lives to care for victims of a rampant epidemic. By April 17, SP had admitted and cared for more than 130 patients. Courage in the face of danger is just another day’s work for SP, who heroically helped shepherd Liberia through the 2014-2015 Ebola outbreak.
Meanwhile, an obscure independent Louisiana pastor defiantly held Easter Sunday services attended - he claimed - by 1,220 churchgoers (though the true number was probably much lower) putting hundreds of lives at risk of illness and death.
In a more tragic case, blues musician and itinerant preacher Landon Spradlin died from COVID only weeks after dismissing it as “mass hysteria” and driving to New Orleans to preach the gospel during Mardi Gras. He fell gravely ill on the drive back home to Virginia. How could someone be so tragically wrong? The usual simplistic answers don’t really address the core issue. It wasn’t “science denial” – even excellent scientists can be fatally mistaken. It wasn’t his politics – when it comes to respecting the nationwide social distancing guidelines, there is scarcely any difference between Democrats and Republicans. It wasn’t the fault of Donald Trump, as one left-lurching acquaintance of Spradlin’s uncharitably alleged. Nor was it misinformation from the mainstream news media, although it could have been. In the runup to America’s COVID pandemic, many governments and institutions dropped the ball.
Intellectual pride and its consequences
The sad story of Leonard Spradlin points to a naïve yet ultimately fatal certainty: not in God, not in Scripture, neither in religious authorities nor in any public institution, but in himself. In that regard, he is us. The universal affliction of pride inclines everyone of us toward overconfidence in our own opinions. But no matter how sincerely and fervently we nurture a belief, our beliefs do not bind God. God’s opinions are not contingent upon our own. Just because we think it, doesn’t make it true.
Crises such as this can bring out both the best and worst in human behavior. Recent headlines have proclaimed:
We’ve previously seen how human credulity cuts across culture, ideology, intelligence, and education. Most of these "coronaspiracies" are completely secular in nature. The professing Christians highlighted here are extreme outliers even within conservative and Evangelical circles, but they crave the attention. Many within the media are more than happy to provide that attention. It confirms their own biases and helps to foster the false narrative that most Christians are anti-scientific bigots.
Spradlin hurt only himself and those he loved. Many secular actors have descended into criminality. In recent weeks, over fifty cell phone towers have been vandalized across the United Kingdom by fanatics consumed with the bizarre belief that 5G towers are causing COVID. I have read some of the circulating polemics on this issue, which I will not dignify by linking here. The clever admixture of fact with fable can seem quite persuasive to someone with no particular scientific expertise. They press the hearer with a barrage of claims in rapid succession, a tactic that has been dubbed the “Gish gallop” after the debating strategies of the late young-earth proponent Duane Gish. Typically, all of the claims are either false sources or misrepresentation of legitimate sources, but the time and research required to thoroughly refute each one can be truly daunting. They might even throw in a few true claims to enhance the illusion of plausibility. An average person could never afford the time or effort to fact-check the sources, and usually lacks the skill to do it.
Christians are neither more nor less vulnerable to such manipulation, though probably more inclined to some fringe beliefs while less inclined toward others. A disturbing number of Christians have fallen for anti-vaccination myths, risking not only their lives but the lives of innocent children. Almost always this is wedded to the conceit that there is some great conspiracy of government, physicians, and “Big Pharma” to suppress evidence and thrust an allegedly dangerous product upon an unsuspecting populace. Anti-vaxxers seem impervious to the fact that leading authorities such as Focus on the Family and the Christian Medical and Dental Associations have taken great care to defend vaccinations and debunk false claims. Anti-vaccination and other conspiracy myths utilize the same persuasive appeal of ancient gnosticism - a chance to elevate one's own self-importance through the possession of "special" knowledge. Recently on National Review, Andrew Stuttaford (an atheist) expressed it perfectly:
The draw of a conspiracy theory to its followers is reinforced by the perception it gives them that they are in the know. They reckon that they have discovered what the “sheeple” could not, endowing them with a sense of superiority that is as enjoyable as it is undeserved, a fact that hucksters of all stripes have turned to their financial, political, or other advantage over the generations: Sign up with me and I’ll tell you what’s really going on.
"Corona conspiracies", April 13, 2020
Suspicion of the media and government can be totally rational if a consistent standard of skepticism is applied across the board. One should not believe everything that is reported, simply because it is reported. But it is a much greater error to abandon all skepticism toward less reputable, even more ideologically partisan sources.
Bringing out the best
Times such as this call for courage, hope, selflessness, and humility.
The courageous doctors, nurses, and technicians of Samaritan’s purse reflect the image of Christ, who willingly set aside heaven’s glory to fully know and experience the most profound suffering and agony.
Through trust in God’s saving grace and final sovereignty, we can enjoy a confident hope that this, too, shall pass and that glory awaits on the other side of death’s door.
We demonstrate our selflessness by accepting burdensome restrictions, by respecting social distancing, by wearing masks (if they help), by reaching out to those in greater need than ourselves, and patiently enduring the economic hardship in order that many more lives may be spared.
Lastly, and most importantly, let's stay humble. Accept how much we don’t know, then act accordingly. Only health experts are experts in health. Humility may save your life.
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Less than four weeks ago I was looking forward to a week in Colorado for some late-season skiing and to check up on our summer home, about to be vacated by six Latin American ski-season guests. [Lacking a Real-ID, the Spaniel wasn’t going to be able to make this trip]. Within a few days, the COVID really hit the fan. On March 16, I flew from Atlanta to Vail on a Boeing 757 with three passengers on board. The service was amazing.
Suddenly, our nation was in panic, its people hunkered down, the economy in free fall. The ski resorts closed for the season, public assemblies were banned, meetings were cancelled, restaurants restricted to take-out service - all soon followed by state-wide “stay-at-home” orders. (Bizarrely, as of this writing eight US states have decreed that marijuana dispensaries are an “essential business” and have permitted them to stay open. Because, you know, this is a perfect time to be dropping our inhibitions).
Predictions are hard, especially about the future.
Cynics commonly remark that financial experts have predicted thirty of the last three recessions. One might also say thirty of the last three pandemics have been similarly predicted. There is an observable tendency to overpredict disaster that is deeply rooted in human personality and yet not exactly irrational. People are risk-averse and instinctively choose minimizing loss over maximizing gain across a variety of situations. When an unknown number of lives are at stake, it is perfectly reasonable to err on the side of caution. Medical people in particular possess a mindset oriented toward doing “whatever it takes” to save a life (within the realm of possibility). That is probably what you hope for when your number comes up.
In rapid succession we went from a mysterious new virus showing up in Wuhan in December, to a deadly epidemic in China in January, to global spread in February, to economic shutdown in March. The only data we had were the numbers from China, coupled with a concern that, if allowed to proceed unchecked, hundreds of millions might die.
The Number Games
Just how many could die from COVID? Everything depended on the numbers, particularly the mortality rate. Would COVID be just another flu-type pandemic, with an average mortality rate of 0.1% and an estimated 650,000 annual deaths worldwide? We don’t shut down the global economy for the flu. The initial numbers for COVID looked much worse. As recently as February 24, Chinese health officials and the WHO were estimating a mortality rate of 3-4%. By early March, terrifying reports from Italy described an exponential rise in cases, overwhelmed hospital systems, and overflowing morgues. This didn’t look anything like flu, which fells an estimated 8,000 Italians each year over a period of many months. It was probably the situation in Italy more than any other factor that galvanized America into action.
On March 16, the Imperial College COVID-19 Response Team predicted that without active suppression, the US should expect deaths approaching 2.2 million or more. To avoid a similar fate, we had to “flatten the curve”. It might never keep you from catching it, but at least when you did there might be room in the hospital.
Just one day later, internationally renowned researcher John Ioannidis of Stanford says “hold on, there.” Is this a once-in-a-century pandemic? Or a “once-in-a-century fiasco”? Ioannidis was concerned that - based on current data - the mortality rate might be much lower, on par with a bad flu outbreak. While death rates among the elderly were quite high, death rates among the young were very low. Ioannidis suspected the overall fatality rate might lie between 0.05 and 1.0%. At the upper range, it would still be ten times deadlier than the flu. He speculated that the death toll could even be as low as 10,000. Drastic measures might be truly necessary, but we needed better data to know for sure.
Needless to say, there’s quite a difference between 10,000 – fewer than a typical flu season – and 2.2 million. Well, that was three weeks ago. Most developed countries instituted strict social distancing and business closures. New COVID cases in Italy peaked on March 21 and have been declining since. Deaths in Italy peaked 6 days later – March 27 – and have since dropped by almost half. Spain followed a similar trajectory about one week later.
On March 29 Dr. Anthony Fauci predicted, on a somewhat more positive note, that US deaths could be limited to the range of 100,000 to 200,000 if restrictive policies were successfully implemented. At that time, the total US death count remained below 3,000. He was using projections from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.
In subsequent weeks, both deaths and total cases have fallen at the low end of projections. The total US death count was revised downward to 82,000 on April 5, then 60,000 (real-time projection on April 7). COVID remains primarily a threat to the elderly. Worldwide, 95% of deaths are in persons over 60 years of age. More than half are over 80. In New York, 83% of deaths have been in persons over 60, and 37% were over 80.
So what is the case fatality rate?
The case-fatality rate (CFR) is a simple ratio of deaths divided by the number of people who catch it. We have a pretty good grasp of the deaths. Some may go uncounted while others may be falsely counted, but we have to go with what we’ve got. The real problem is knowing the denominator – how many people have or have had the disease. It is universally acknowledged that many have been infected with the virus and have little or even no symptoms. We call those “subclinical infections”, and this is a known phenomenon for many infectious diseases. One of the most famous cases concerned the notorious “Typhoid Mary”, a cook and asymptomatic typhoid carrier who moved from household to household in the early 20th century infecting every family in her wake. There have been many reports of COVID transmission by asymptomatic carriers.
Untold others may have mild symptoms but either didn’t seek testing or couldn’t get it. The estimated proportions of undiagnosed cases have ranged from as low as 25% to as high as 94% worldwide. Meaning, for every 100 who get sick, there might be as few as 33 or as many as 1,600 who have been infected but are not reflected in the data. Anything approaching the high end of that range would mean a CFR far below 1.0%.
On March 30, a team of researchers publishing in Lancet calculated a CFR of 0.66% - near the middle of the range suggested by Ioannidis. (While the US total death count has already exceeded his lowest estimate of 10,000, that was assuming only 1% of the US population got infected, with a CFR of 0.3%. We may already be well past 1% of the population).
In any case, it is well-established that the case fatality rate is very high in the most elderly, but also extremely low in individuals under 40.
Where are we now?
Looking back three weeks at the wildly divergent projections of IHME and Ioannidis, we’ve seen a convergence of estimates and are probably at or very close to peak infection. The daily new cases in the US topped 34,000 on April 4 and have fluctuated within a narrow range since April 2. US deaths are currently just below 2,000 per day and the IHME projects we are at or near a peak.
The US health care system has not experienced the disastrous overload experienced in Italy. Many hospitals in New York City were swamped, but we were able to scale up very quickly. This revealed one pitfall behind some of the sunnier forecasts – even if the death rate were low, it could still be disastrous if the illness spread very quickly and everyone fell ill at once. And COVID certainly spreads quickly. By one recent analysis, it may be five times more infectious – and spread that much more quickly – than the common flu.
Fortunately, the worst predictions were unrealized. Much yet depends on what the next week or two bring us. No one is quite sure how or when the economy can resume. Only now has it been possible to undertake antibody testing, which may ultimately give a more accurate picture of the total scope of infection and reveal who may be immune and thus able to safely circulate in public. [The Spaniel wishes to remind you that you can't catch COVID from your dog, but cats are bad news].
In the next post, we’ll look at some important lessons to be learned, and how Christians should – and should not – respond to crisis.