What is the baseline for a proper response to a new virus outbreak like COVID-19? The most recent virus pandemic we can compare it to is the Swine flu outbreak in 2009. The way we are responding to COVID-19 right now in this country is vastly different from what we did in 2009.
We know that the epidemiology of these two viruses is different. However, in the early stages of the Swine flu pandemic, there were the same general set of unknowns that we presently have with COVID-19. In the face of those unknowns in 2009, the government and the media chose a far more measured and lighter touch approach than what is transpiring right now. Most significantly, the media, politicians, the CDC, and other experts, did not incite a national panic. Why not?
One of the explanations for the Swine flu response back in 2009 was that the virus spread was inevitable. It therefore made no sense to disrupt society by restricting international travel and closing down schools, stores, bars, restaurants, and sports leagues. No “large gathering” events were canceled and there was no such thing as “social distancing” instituted. To be fair, there were some preventative measures and actions taken by the government for Swine flu1. However, they were nothing more than window dressing in comparison to what is happening now with COVID-19. Swine flu spread at what was probably very close to its natural rate of infection unimpeded by any of the nationwide countermeasures we are employing right now. The result within the U.S. was 61 million people becoming infected and between 12,000 and 18,000 deaths. In the midst of accumulating these massive numbers there was a notable lack of public panic, in contrast to now. We are being told now that it is essential to “flatten” the upward curve of infection for COVID-19. Why was there no similar effort to flatten the curve for Swine flu? Did we just throw in the towel in 2009 and decide to hope for the best?
There is an argument that the smaller case fatality rate2 of Swine flu makes it not as deadly a disease as COVID-19. But those holding that view now have hindsight knowledge that didn’t exist in the early stages of the Swine flu pandemic. At this moment in time we don’t know the true fatality rate of COVID-19 in this country. If anything, the latest numbers for the U.S. from the CDC indicate the case fatality rate is dropping3. And while the numerator in this rate calculation is well known (# of deaths), the denominator only includes confirmed cases of infection. It does not include any estimate of the number of infected people who are not (and will not be) tested because they present with only mild to moderate symptoms. This presentation is typical of a large percentage of those infected with COVID-19. That means the actual case fatality rate is likely lower, probably much lower.
There is also a big inconsistency in the recommendation that everyone practice “social distancing” to combat COVID-19. The theory goes that before you become symptomatic, you could unwittingly infect another person, a senior citizen for example, who has a much greater risk of serious illness or death than you do. Well, how is COVID-19 any different at all as regards the elderly from the more common influenza virus? Because we have so much data over so many years about the influenza virus, a known fact is that 85% of all deaths from influenza are seniors. That means that while we are anticipating a high death rate among older people from COVID-19 (based on initial numbers), we know an average of 200 seniors per day are dying from influenza during a typical flu season. That’s a total of ~36,000 senior deaths each flu season4. Up until a couple weeks ago, this fact was not important enough to government health officials to warrant extraordinary influenza social distancing measures of the kind now being employed for COVID-19.
In addition to the hoped for minimization of COVID-19 deaths among seniors during this nationwide practice of social distancing, self-isolation (and in some instances) quarantine, we strongly suspect the number of senior deaths due to influenza will also drop during this period compared to previous years due to these measures. If this does occur, and the influenza death rate among seniors does go down, we have to ask another difficult question. What makes the lives of each of those ~36,000 seniors who die each year from influenza less important than the potential number of seniors who will die from COVID-19? We have yet to hear a peep out of any infectious disease expert or politician on this point.
Finally, there is the most difficult question to answer – is the collective investment in all the countermeasures being taken to combat COVID-19 worth the cost? And we don’t just mean financial cost. Obviously, if this virus is much more deadly than is currently apparent, and tens of millions of lives are saved in the U.S. because of all the restrictive things we’re doing right now, it will have been well worth the sacrifices we’re making. That would be true even if the country spirals into an economic depression. But what if the number lives lost to COVID-19 is closer to the total lost from Swine flu (12,000 – 17,000)? We know that many of us would instinctively say that if we have a chance to save 12,000 lives we should do it at any cost. But if we are to be brutally honest with ourselves, the fact is that as a society we have decided against taking extraordinary action to save a similar number of lives in other situations. For example, if federal and state governments greatly restricted people from driving cars for one year, we would save the lives of roughly 40,000 people in the U.S. who die annually in car accidents. Our government and its citizens have made the decision to keep driving and accept these fatalities. Consciously or unconsciously, we have decided that the consequences of not being able to drive cars are worse than losing 40,000 lives each year.
Another excellent example of keeping a logical perspective on these numbers is how the annual number of deaths from the influenza virus is reported. The CDC provides a range of influenza deaths, never an exact number. Last year that range was reported as 25,000 – 61,000. That’s a pretty big range. John P.A. Ioannidis, a professor of medicine, epidemiology, and statistics at Stanford University described the possibility of 10,000 deaths from COVID-19 this way – This sounds like a huge number, but it is buried within the noise of the estimate of deaths from ‘influenza-like illness.’ If we had not known about a new virus out there, and had not checked individuals with PCR tests, the number of total deaths due to ‘influenza-like illness’ would not seem unusual this year. At most, we might have casually noted that flu this season seems to be a bit worse than average. Think about that for a minute. 10,000 or more additional people in the U.S. could die of a sickness resembling the flu and those deaths would easily fall within the statistical range of influenza-caused deaths. No panic, no shutdowns, no social distancing. Even with ~30,000 more deaths than usual from influenza in 2017, we didn’t do anything different and just chalked it up to a particularly bad flu season.
Also, the extreme preventative measures we are now taking are not just targeted at reducing deaths. In the under-65 age group, which includes the vast majority of the U.S. workforce, the case fatality rate for COVID-19 (so far) is much lower. It is equivalent to influenza in this age group and, unlike influenza, deaths are virtually non-existent for children. For people younger than 65, our current extreme precautions are primarily to avoid a recoverable sickness. This brings up a separate question of value for what we are sacrificing. We all get sick from time to time. Our employers are set up to expect this, which is why there are such things as sick time off or some flexibility to deal with sickness built-in to most jobs. We also regularly accept the fact that a germ or virus of unknown origin (at least to us non-scientists) can make its way through a workplace, town, state, or other larger area. How many times have you heard the phrase “there’s somethin’ going around”? We each have our own ways of dealing with this, and it never results in a national panic.
Let’s say COVID-19 does not cause anywhere near the predicted number of fatalities and hospitalizations. Our government leaders and the media will of course tell us that the only thing that saved us from total catastrophe was their massive bold action to shut everything down. What’s going to happen later this year if there is a resurgence of COVID-19 (as predicted in the models)? Are we going to go through this all over again and cause another economic meltdown just as we are recovering (hopefully) from this present one? At some point, measured logic must begin to be the basis for our decisions rather than acting against a worst-case scenario each time. We are fast on the pathway to destroying a lot of small businesses in this country, not to mention what just a few weeks ago were the bright futures of millions of young people getting ready to leave school and enter the workforce.
We sincerely hope COVID-19 does not turn out to be as destructive as the experts predict. And if it is, we hope the countermeasures being undertaken work to diminish the harm. We also seriously hope that our disease experts, government leaders, and news media think long and hard about weighing the devastating societal and economic effects of a national panic against our capacity to endure a certain level of sickness and loss of life due to a new virus. We are taking an extremely big risk with the country in our response to COVID-19 that we deliberately did not take with the Swine flu and other epidemics/pandemics.
1Specifically, daycare centers in close proximity to the outbreaks were closed as well as some elementary schools. But there were no across-the-board nationwide closings. Quite differently from COVID-19, Swine flu attacked the under-65 group more than seniors, and the likelihood of severe illness and fatality was worst for children. Practicing social distancing would arguably have been of greater value for Swine flu than COVID-19 since the main age group affected by Swine flu was the country’s primary workforce (adults under 65). This also raises the messy question of which group, children or seniors, command the use of extraordinary national countermeasures if they are specifically attacked by a virus. In 2009 when Swine flu targeted children, we did not go pedal-to-the-metal with the kind of preventative measures we are doing now with COVID-19 (which is primarily attacking seniors).
2Case fatality, also called case fatality ratio: This is defined as the proportion of deaths due to a disease divided by the number of people diagnosed with the disease over a certain period of time, e.g deaths due to COVID-19 divided by the total number of COVID-19 cases for a certain period of time.
3 The fatality rate itself is not reported on the CDC website, but can be easily calculated at any time by dividing the two main numbers they do report (# of deaths / # of confirmed cases of infection). Here is the CDC webpage that reports those two numbers (which are updated daily): https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html.
4The 2017 flu season was particularly bad, with the number of deaths from influenza climbing to 80,000 (50% higher than normal). There was no panic, and no extraordinary counter measures taken. Despite the fact that this unusually heavy loss of life occurred just recently, most people probably aren’t even aware it happened.
4 Responses
Common sense dictates we let nature takes it’s course, as we have in the past. Having stated that, there are hidden benefits. The benefits are many and while economically costly, history may show that this pandemic is how the world learned to manage a much more catastrophic virus. The forcing of telemedicine into common practice (where it can be refined quickly) alone will reap huge healthcare benefits related to more immediate patient care and healthcare cost reductions. Global cooperation in areas of biotech research will create a global team framework for future more serious viruses and diseases. Another large benefit is how countries across the world learn to manage global economic hardships. Lastly, not related to the health and economic problems – families are forced together with quarantines that may help the family structure in many countries.
Johnny – I love the “brightside” attitude and agree that all the innovation and information sharing is (and will be) beneficial. However, those benefits are coming at such a tremendous cost, I question the value. To me, these are things we had the ability to know and learn well before now. I know that it often takes a real crisis to truly find and test the solutions that will work. But if the need for a good working strategy and plan of action is critical to have, there are ways to gain this knowledge without having to plunge the country (or the world) into an economic tailspin. The military does this all the time by war-gaming and simulating the battlefield and enemy. In the present context, we already have (and have had for some time) models of how viruses can spread. If, like the military, we regularly conducted “war-games” against various pandemic virus models, we would already have a lot of these solutions at hand. And we would have gotten them at a substantially lower cost.
I meant to respond sooner, but we’ve been holed up in the bunker with limited internet.
Seriously though, both articles are spot on. The current reaction is over the top and not sustainable for this pandemic or others that will follow. While my wife agrees, she’s also banned my use of the word “insane,” or any derivative, in conversations about COVID-19. Thank God for my thesaurus because the craziness continues.
There are no doubt things we can do (isolating those at high risk, be more intentional about self-isolation when sick, elbow bumps rather than handshakes, remote education, telemedicine, etc.) that can help to reduce impacts during future pandemics.
For this event, we are following the guidelines and honoring the directives of our leaders. We owe them that. With that said, in the future I do not want to see life as we know it completely upended unless we are dealing with something much graver in nature.
My understanding is that countries like South Korea, Denmark, and Sweden are taking a more measured approach and not shutting down their economies. News reports are that they are having success with this approach.
No doubt there will be a comprehensive event performance review and lessons learned conducted once we get beyond the heat of this crisis. Hopefully there will be response plans put in place at the federal, state, and local levels for future pandemics so that we don’t go into panic mode unnecessarily.
I didn’t think this was possible, but I have even more disgust and contempt for the mainstream media as well as for politicians like Pelosi and Schumer. The behavior is despicable!
And to top it all off, I had a colonoscopy last week, not an opportune time given the toilet paper shortage.
Stay healthy and safe!
Thanks Ray. Great comment! I feel the same disgust you do for Pelosi. She has not one spec of patriotism or respect for the people left in her. She is single mindedly focused on making Trump look bad no matter what it costs.
When you and I were young I was always a little jealous that you were a year older than me. I’m still jealous. I can’t believe that right at this moment, you get to go shopping for toilet paper at Walmart an hour earlier than I can (must be 60 yrs. old). I have to wait until my birthday in June for that to happen. The crisis will be over by then.