In April, I wrote several essays and articles about our collective response to Covid-19.
I was worried – and am still worried, honestly – that we weren’t making the best choices.
It’s hard not to feel cynical about the reasons why we’ve failed. For instance, our president seems more concerned about minimizing the visibility of disaster than addressing the disaster itself. We didn’t respond until this virus had spread for months, and even now our response has become politicized.
Also, the best plans now would include a stratified response based on risk factor. Much more than seasonal influenza, the risk of serious complications from Covid-19 increases with age. Because we didn’t act until the virus was widespread, eighty-year-olds should be receiving very different recommendations from forty- and fifty-year-olds.
Our national response is being led by an eighty-year-old physician, though, and he might be biased against imposing exceptional burdens on members of his own generation (even when their lives are at stake) and may be less sensitive to the harms that his recommendations have caused younger people.
I’m aware that this sounds prejudiced against older folks. That’s not my intent.
I care about saving lives.
Indeed, throughout April, I was arguing that our limited Covid-19 PCR testing capacity shouldn’t be used at hospitals. These tests were providing useful epidemiological data, but in most cases the results weren’t relevant for treatment. The best therapies for Covid-19 are supportive care – anti-inflammatories, inhalers, rest – delivered as early as possible, before a patient has begun to struggle for breath and further damage their lungs. Medical doctors provided this same care whether a Covid-19 test came back positive or negative.
(Or, they should have. Many patients were simply sent home and told to come back if they felt short of breath. Because they didn’t receive treatment early enough, some of these patients then died.)
Instead, our limited testing capacity should have been used at nursing homes. We should have been testing everyone before they went through the doors of a nursing home, because people in nursing homes are the most vulnerable to this virus.
I realize that it’s an imposition to make people get tested before going in, either for care or to work – even with real-time reverse-transcription PCR, you have to wait about two hours to see the results. But the inconvenience seems worthwhile, because it would save lives.
From March 25 until May 10 – at the same time that I was arguing that our limited Covid-19 tests be used at nursing homes instead of hospitals – the state of New York had a policy stating that nursing homes were prohibited from testing people for Covid-19.
I really dislike the phrase “asymptomatic transmission” – it’s both confusing and inaccurate, because viral shedding is itself a symptom – but we knew early on that Covid-19 could be spread by people who felt fine. That’s why we should have been using PCR tests before letting people into nursing homes.
But in New York, nursing homes were “prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.”
Not only do nursing homes have the highest concentration of vulnerable people, they also have far fewer resources than hospitals with which to keep people safe. Nursing home budgets are smaller. Hallways are narrower. Air circulation is worse. The workers lack protective gear and training in sterile procedure. Nursing home workers are horrendously underpaid.
The low wages of nursing home workers aren’t just unethical, they’re dangerous. A recent study found that higher pay for nursing home workers led to significantly better health outcomes for residents.
This study’s result as described in the New York Times – “if every county increased its minimum wage by 10 percent, there could be 15,000 fewer deaths in nursing homes each year” – is obviously false. But even though the math doesn’t work out, raising the minimum wage is the right thing to do.
If we raised the minimum wage, we probably would have a few years in which fewer people died in nursing homes. But then we’d see just as many deaths.
Humans can’t live forever. With our current quality of care, maybe nursing home residents die at an average age of 85. If we raise the minimum wage, we’ll get better care, and then nursing home residents might die at an average age of 87. After two years, we’d reach a new equilibrium and the death rate would be unchanged from before.
But the raw number here – how many people die each year – isn’t our biggest concern. We want people to be happy, and an increase in the minimum wage would improve lives: both nursing home residents and workers. Which I’m sure that study’s lead author, economist Kristina Ruffini, also believes. The only problem is that things like “happiness” or “quality of life” are hard to quantify.
Especially when you’re dealing with an opposition party that argues that collective action can never improve the world, you have to focus on quantifiable data. Happiness is squishy. A death is unassailable.
Indeed, that’s partly why we’ve gotten our response to Covid-19 wrong. Some things are harder to measure than others. It’s easy to track the number of deaths caused by Covid-19. (Or at least, it should be – our president is still understating the numbers.)
It’s much harder to track the lives lost to fear, to domestic violence, and to despair (no link for this one – suddenly Fox News cares about “deaths of despair,” only because they dislike the shutdown even more than they dislike poor people). It’s hard to put a number on the value of 60 million young people’s education.
But we can’t discount the parts of our lives that are hard to measure – often, they’re the most important.
2: “We know that the current shutdown is either delaying or preventing deaths due to Covid-19.”
To date, the data suggests that the virus has only reached saturation inside a few closed environments, such as prisons. In Italy, both the timecourse of mortality and the results of antibody studies suggest that infections were still rising at the time of their lockdown.
Among the passengers of the Diamond Princess cruise ship, deaths peaked 21 days after infections peaked – if the virus had already reached saturation in Italy, we’d expect to see deaths peak sooner than 21 days after the lockdown began. They did not.
So, again, this much is clear: worldwide, there was a significant new cause of death. When we look at mortality data, we see the curves suddenly rise in many locations. Some researchers, such as John Ioannidis, have speculated that Covid-19 causes death primarily in people with low life expectancy, in which case we would expect to see these mortality curves drop to lower-than-average levels after the epidemic ends. But even then, it’s unprecedented to see a number of deaths that would usually occur over the course of a year all within a matter of weeks.
Covid-19 is killing people, and the shutdown is either delaying or preventing people’s death from Covid-19.
For the shutdown to actually prevent death, one of the following needs to happen:
1.) We create a vaccine, allowing our population to reach 70% immunity without as many people contracting the illness.
2.) We take action to change which segment of the population is exposed to the virus, allowing us to reach 70% immunity without as many at-risk people being exposed.
See #3 and #4, below.
3: “Ending this epidemic with a vaccine would be ideal.”
Vaccination is great science. Both my spouse and I love teaching about vaccines, in part because teaching the history of vaccine use is a good component of anti-racist science class.
Developing vaccines often takes a long time. I’ve read predictions of a year or two; my father, an infectious disease doctor, epidemiologist, research physician who runs vaccine trials, and co-developer of Merck’s HPV vaccine, guesses that it will take about five years.
And then, for the vaccine to end this epidemic, enough people will need to choose to be vaccinated that we reach approximately 70% immunity.
The reason it’s worthwhile to compare Covid-19 to seasonal influenza is that a vaccine will only end the epidemic if enough people choose to get it. Many people’s personal risk from Covid-19 is lower than their risk from seasonal influenza. Will those people choose to be vaccinated?
Obviously, I would be thrilled if the answer were “yes.” I’d love to live in a nation where people’s sense of altruism and civic duty compelled them to get vaccinated. My family is up-to-date on all of ours.
But many privileged families in the United States have elected to be freeloaders, declining the (well tested, quite safe) measles vaccine with the expectation that other people’s immunity will keep them safe. And, despite the well-documented dangers of influenza, only 40% of our population gets each year’s influenza vaccine.
A vaccine with low efficacy will still offer better protection when more people get it. If a higher percentage of our population were vaccinated against influenza, then influenza transmission would drop, and so each person’s immunity, whether high or low, would be less likely to be challenged.
The influenza vaccine saves lives. In Italy, where fewer people choose to get vaccinated against influenza (about 15% compared to our 40% of the population), the death rate from influenza is higher. Although it’s worth noting that this comparison is complicated by the fact that our health care system is so bad, with poor people especially having limited access to health care. In the United States, people between the ages of 18 and 49 comprise a higher proportion of influenza deaths than anywhere in Europe. Either our obesity epidemic or limited access to health care is probably to blame; possibly a combination of both.
In summary, for this plan to help us save lives, we will need to develop an effective vaccine, and then people will have to get it.
I am quite confident that we can eventually develop a vaccine against Covid-19. The virus includes a proofreading enzyme, so it should mutate more slowly than most RNA viruses. We don’t know how long it will take, but we can do it.
I am unfortunately pessimistic that people will choose to get the vaccine. And, unfortunately, when a low-risk person chooses to forgo vaccination, they’re not just putting themselves in harm’s way, they are endangering others. Most vaccines elicit a weaker immune response in elderly or immunocompromised recipients – exactly the group most at risk from Covid-19 – which is why we spend so much time harping about herd immunity.
4: “Ending the shutdown while requesting that at-risk people continue to self-isolate would save lives.“
This plan has major downsides, too. Because we didn’t take action soon enough, every plan we have now is bad.
Low-risk people can still die of Covid-19. Even if they don’t die, Covid-19 can cause permanent health effects. Covid-19 reduces your ability to get oxygen to your body and brain. Even a “mild” case can leave your breathing labored for weeks – you’re not getting enough oxygen. Your muscles will ache. Your thoughts will be sluggish.
With a more severe case, people can be looking at heart damage. Renal failure. It would be cruel to look at all these long-term consequences and blithely call them “recovery.”
If our health care system were better, we’d treat people sooner. The earlier you intervene, helping to boost people’s oxygen levels, the better outcome you’ll have. There’s a great editorial from medical doctor Richard Levitan recommending that people monitor their health with a pulse oximeter during this epidemic.
If you notice your oxygen levels declining, get help right away. Early intervention can prevent organ damage. And you’ll be helping everyone else, too – the sooner you intervene, the less medical care you will need.
Because medical debt can derail lives, many people in this country delay treatment as long as possible, hoping that their problems will go away naturally. That’s why people are often so sick when they show up at the ER. I imagine that this is yet another reason – alongside air pollution, food deserts, sleep loss, and persistent stress exacerbated by racism – that poor communities have had such a high proportion of people with severe cases of Covid-19.
And I imagine – although we don’t yet have enough data to know – that financial insecurity caused by the shutdown is making this worse. It’s a rotten situation: you have a segment of population that has to continue working during the shutdown, which means they now have the highest likelihood to be exposed to the virus, and they’re now under more financial strain, which might increase the chance that they’ll delay treatment.
We know that early treatment saves lives, and not everyone is sufficiently privileged to access that.
All this sounds awful. And it is. But, if we took action to shift exposure away from high risk groups, the likelihood that any individual suffers severe consequences is lower.
And there is another caveat with this plan – some people may be at high risk of complications for Covid-19 and not even realize it. In the United States, a lot of people either have type 2 diabetes or are pre-diabetic and don’t yet realize. These people have elevated risk. Both smoking and airpollution elevate risk, but people don’t always know which airborn pollutants they’ve been exposed to. (Which, again, is why it’s particularly awful that our administration is weakening air quality standards during this epidemic.)
Even if we recommended continued self-isolation for only those people who know themselves to have high risk from Covid-19, though, we would be saving lives. The more we can protect people in this group from being exposed to the virus – not just now, but ever – the more lives we will save.
We won’t be able to do this perfectly. It’ll be a logistical nightmare trying to do it at all. People at high risk from Covid-19 needs goods and services just like everybody else. We might have to give daily Covid-19 PCR tests to anyone visiting their homes, like doctors, dentists, and even delivery workers.
At that point, the false negative rate from Covid-19 PCR tests becomes a much bigger problem – currently, these false negatives reduce the quality of our data (but who cares?) and delay treatment (which can be deadly). A false negative that causes inadvertent exposure could cost lives.
Some people will be unable to work, either because they or a close relative has high risk of Covid-19. Some children will be unable to go to school. We will need a plan to help these people.
We will have to work very hard to keep people safe even after the shutdown ends for some.
But, again, if everyone does the same thing, then the demographics of people infected with Covid-19 will reflect our population demographics. We can save lives by skewing the demographics of the subset of our population that is exposed to Covid-19 to include more low-risk individuals, which will require that we stratify our recommendations by risk (at least as well as we can assess it).
5: “Why is it urgent to end the shutdown soon?“
1.) By delaying Covid-19 deaths, we run to risk of causing more total people to die of Covid-19.
2.) The shutdown itself is causing harm.
See #6 and #7, below.
6: “Why might more people die of Covid-19 just because we are slowing the spread of the virus?“
[EDIT: I wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!]
This is due to the interplay between duration of immunity and duration of the epidemic. At one point in time, seasonal influenza was a novel zoogenic disease. Human behavior allowed the influenza virus to become a perpetual burden on our species. No one wants for humans to still be dying of Covid-19 in ten or twenty years. (Luckily, because the virus that causes Covid-19 seems to mutate more slowly than influenza, it should be easier to design a single vaccine that protects people.)
In the Harvard model, we can see that there are many scenarios in which a single, finite shutdown leads to more deaths from Covid-19 than if we’d done nothing. Note the scenarios for which the colored cumulative incidence curves (shown on the right) exceed the black line representing how many critical cases we’d have if we had done nothing.
Furthermore, their model does not account for people’s immunity potentially waning over time. Currently, we do not know how long people’s immunity to Covid-19 will last. We won’t know whether people’s immunity will last at least a year until a year from now. There’s no way to test this preemptively.
If we could all go into stasis and simply not move for about a month, there’d be no new cases of Covid-19, and this virus would be gone forever. But people still need to eat during the shutdown. Many people are still working. So the virus is still spreading, and we have simply slowed the rate of transmission.
This seems good, because we’re slowing the rate at which people enter the hospital, but it’s actually bad if we’re increasing the number of people who will eventually enter the hospital.
Based on our research with other coronaviruses, we expect that re-infection will cause a person to experience symptoms less severe than their first case of Covid-19. But a re-infected person can still spread the disease to others. And we don’t know what will happen if a person’s risk factors – such as age, smoking status, diabetes status, etc. – have increased in the time since their last infection.
7: “How is the shutdown causing harm?“
If you turn on Fox News, I imagine you’d hear people talking about the damage we’re doing to our economy. They might discuss stock market numbers.
Who gives a shit? In my opinion, you’d have to be pretty callous to think that maintaining the Nasdaq bubble is more important than saving lives.
In this report, they estimate that the shutdown we’ve had so far will cause hundreds of thousands of children to die, many from malnutrition and the other health impacts of poverty. The longer the shutdown continues, the more children will die.
That’s a worldwide number, and most of those children live outside the United States. But I’d like to think that their lives matter, too.
The report also discusses the lifelong harm that will be inflicted on children from five months (or more!) of school closure. Drop-outs, teen pregnancy, drug abuse, recruitment of child soldiers, and the myriad health consequences of low educational attainment.
I live in a wealthy college town, but even here there is a significant population of students who don’t have internet access. Students with special needs aren’t getting the services they deserve. Food insecurity is worse.
You’re lucky that privacy protections prevent me from sharing a story about what can happen to poor kids when all the dentists’ offices are closed. I felt ashamed that this was the best my country had to offer.
As the shutdown continues, domestic violence is rising. We can assume that child abuse is rising, also, but we won’t know until later, when we finally have a chance to save children from it. In the past, levels of child abuse have been correlated with the amount of time that children spend in the presence of their abusers (usually close family), and reporting tends to happen during tense in-person conversations at school.
The shutdown has probably made our drug epidemic worse (and this was already killing about 70,000 people per year in the U.S.). When people are in recovery, one of the best strategies to stay sober is to spend a lot of time working, out of the house, and meeting with a supportive group in communal space. Luckily, many of the people I know who are in recovery have been categorized as essential workers.
A neighbor recently sent me a cartoon suggesting that the biggest harm caused by the shutdown is boredom. (I’m going to include it, below, but don’t worry: I won’t spend too much time rattling sabers with a straw man.) And, for privileged families like mine, it is. We’re safe, we’re healthy, we get to eat. My kids are still learning – we live in a house full of computers and books.
But many of the 75 million children in the United States don’t live in homes like mine, with the privilege we have. Many of our 50 million primary and secondary school students are not still learning academically during the shutdown.
Whether the shutdown is preventing or merely delaying the deaths of people at risk of serious complications from Covid-19, we have to remember that the benefit comes at a cost. What we’ve done already will negatively impact children for the rest of their lives. And the longer this goes on, the more we’re hurting them.
8: “What about the rate at which people get sick? Isn’t the shutdown worthwhile, despite the risks described above, if it keeps our hospitals from being overwhelmed?“
In writing this, I struggled with how best to organize the various responses. I hope it doesn’t seem too ingenuous to address this near the end, because slowing the rate of infection so that our hospitals don’t get overwhelmed is the BEST motivation for the shutdown. More than the hope that a delay will yield a new vaccine, or new therapies to treat severe cases, or even new diagnostics to catch people before they develop severe symptoms, we don’t want to overwhelm our hospitals.
If our physicians have to triage care, more people will die.
And I care a lot about what this epidemic will be like for our physicians. My father is a 67-year-old infectious disease doctor who just finished another week of clinical service treating Covid-19 patients at the low-income hospital in Indianapolis. My brother-in-law is an ER surgeon in Minneapolis. These cities have not yet had anything like the influx of severe cases in New York City – for demographic and environmental reasons, it’s possible they never will. But they might.
Based on the case fatality rate measured elsewhere, I’d estimate that only 10% of the population in Minneapolis has already been infected with Covid-19, so the epidemic may have a long way yet to go.
If we ended the shutdown today for everyone, with no recommendation that at-risk groups continue to isolate and no new measures to protect them, we would see a spike in severe cases.
If we ended the shutdown for low-risk groups, and did a better job of monitoring people’s health to catch Covid-19 at early, more-easily-treatable stages (through either PCR testing or oxygen levels), we can avoid overwhelming hospitals.
And the shutdown itself is contributing toward chaos at hospitals. Despite being on the front lines of this epidemic, ER doctors in Minneapolis have received a 30% pay cut. I imagine my brother-in-law is not the only physician who could no longer afford day care for his children after the pay cut. (Because so many people are delaying care out of fear of Covid-19, hospitals are running out of money.) Precisely when we should be doing everything in our power to make physicians’ lives easier, we’re making things more stressful.
We could end the shutdown without even needing to evoke the horrible trolley-problem-esque calculations of triage. Arguments could be made that even if it led to triage it might be worthwhile to end the shutdown – the increase in mortality would be the percentage of triaged cases that could have survived if they’d been treated, and we as a nation might decide that this number was acceptable to prevent the harms described above – but with a careful plan, we need not come to that.
9: “Don’t the antibody tests have a lot of false positives?“
False positives are a big problem when a signal is small. I happen to like a lot of John Ioannidis’s work – I think his paper “Why Most Published Research Findings Are False” is an important contribution to the literature – but I agree that the Santa Clara study isn’t particularly convincing.
When I read the Santa Clara paper, I nodded and thought “That sounds about right,” but I knew my reaction was most likely confirmation bias at work.
Which is why, in the essay, I mostly discussed antibody studies that found high percentages of the population had been infected with Covid-19, like the study in Germany and the study in the Italian town of Robbio. In these studies, the signal was sufficiently high that false positives aren’t as worrisome.
In Santa Clara, when they reported a 2% infection rate, the real number might’ve been as low as zero. When researchers in Germany reported a 15% infection rate, the real number might’ve been anywhere in the range of 13% to 17% – or perhaps double that, if the particular chips they used had a false negative rate similar to the chips manufactured by Premier Biotech in Minneapolis.
I’m aware that German response to Covid-19 has been far superior to our bungled effort in the United States, but an antibody tests is just a basic ELISA. We’ve been doing these for years.
Luckily for us, we should soon have data from good antibody studies here in the United States. And I think it’s perfectly reasonable to want to see the results of those. I’m not a sociopath – I haven’t gone out and joined the gun-toting protesters.
But we’ll have this data in a matter of weeks, so that’s the time frame we should be talking about here. Not months. Not years. And I’ll be shocked if these antibody studies don’t show widespread past infection and recovery from Covid-19.
10: “What about the political ramifications of ending the shutdown?“
I am, by nature, an extremely cautious person. And I have a really dire fear.
I’m inclined to believe that ending the shutdown is the right thing to do. I’ve tried to explain why. I’ve tried to explain what I think would be the best way to do it.
But also, I’m a scientist. You’re not allowed to be a scientist unless you’re willing to be proven wrong.
So, yes. I might be wrong. New data might indicate that writing this essay was a horrible mistake.
Still, please bear with me for a moment. If ending the shutdown soon turns out to be the correct thing to do, and if only horrible right-wing fanatics have been saying that we should end the shutdown soon, won’t that help our current president get re-elected?
There is a very high probability that his re-election would cause even more deaths than Covid-19.
Failing to address climate change could kill billions. Immigration controls against migrants fleeing war zones could kill millions. Weakened EPA protections could kill hundreds of thousands. Reduced access to health care could kill tens of thousands.
And, yes, there are horrible developments that neither major political party in the United States has talked about, like the risk that our antibiotics stop working, but I think it’s difficult to argue that one political party isn’t more dangerous than the other, here.
I feel pretty confident about all the scientific data I’ve discussed above. Not as confident as I’d like, which would require more data, but pretty confident.
I feel extremely confident that we need to avoid a situation in which the far right takes ownership of an idea that turns out to have been correct. And it’ll be dumb luck, just a bad coincidence. The only “data” they’re looking at are stock market numbers, or maybe the revenue at Trump-owned hotels.
EDIT: I also wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!
First, some background: in case you haven’t noticed, most of the United States is operating under a half-assed lockdown. In theory, there are stay-at-home orders, but many people, such as grocery store clerks, janitors, health care workers, construction workers, restaurant chefs, delivery drivers, etc., are still going to work as normal. However, schools have been closed, and most people are trying to stand at least six feet away from strangers.
We’re doing this out of fear that Covid-19 is an extremely dangerous new viral disease. Our initial data suggested that as many as 10% of people infected with Covid-19 would die.
That’s terrifying! We would be looking at tens of millions of deaths in the United States alone! A virus like this will spread until a majority of people have immunity to it – a ballpark estimate is that 70% of the population needs immunity before the epidemic stops. And our early data suggested that one in ten would die.
My family was scared. We washed our hands compulsively. We changed into clean clothes as soon as we came into the house. The kids didn’t leave our home for a week. My spouse went to the grocery store and bought hundreds of dollars of canned beans and cleaning supplies.
And, to make matters worse, our president was on the news saying that Covid-19 was no big deal. His nonchalance made me freak out more. Our ass-hat-in-chief has been wrong about basically everything, in my opinion. His environmental policies are basically designed to make more people die. If he claimed we had nothing to worry about, then Covid-19 was probably more deadly than I expected.
Five weeks have passed, and we now have much more data. It seems that Covid-19 is much less dangerous than we initially feared. For someone my age (37), Covid-19 is less dangerous than seasonal influenza.
Last year, seasonal influenza killed several thousand people between the ages of 18 and 49 in the United States – most likely 2,500 people, but perhaps as many as 5,800. People in this age demographic account for about 10% of total flu deaths in the United States, year after year.
Seasonal influenza also killed several hundred children last year – perhaps over a thousand.
There’s a vaccine against influenza, but most people don’t bother.
Seasonal influenza is more dangerous than Covid-19 for people between the ages of 18 and 49, but only 35% of them chose to be vaccinated in the most recently reported year (2018). And because the vaccination rate is so low, our society doesn’t have herd immunity. By choosing not to get the influenza vaccine, these people are endangering themselves and others.
Some people hope that the Covid-19 epidemic will end once a vaccine is released. I am extremely skeptical. The biggest problem, to my mind, isn’t that years might pass before there’s a vaccine. I just can’t imagine that a sufficient percentage of our population would choose to get a Covid-19 vaccine when most people’s personal risk is lower than their risk from influenza.
When I teach classes in jail, dudes often tell me about which vaccines they think are too dangerous for their kids to get. I launch into a tirade about how safe most vaccines are, and how deadly the diseases they prevent.
Seriously, get your kids vaccinated. You don’t want to watch your child die of measles.
And, seriously, dear reader – get a flu vaccine each year. Even if you’re too selfish to worry about the other people whom your mild case of influenza might kill, do it for yourself.
We already know how dangerous seasonal influenza is. But what about Covid-19?
To answer that, we need data. And one set of data is unmistakable – many people have died. Hospitals around the world have experienced an influx of patients with a common set of symptoms. They struggle to breathe; their bodies weaken from oxygen deprivation; their lungs accumulate liquid; they die.
For each of these patients saved, three others are consigned to an agonizing death in the hospital, intubated among the flashing lights, the ceaseless blips and bleeps. At home, they’d die in a day; in the hospital, their deaths will take three weeks.
And the sheer quantity of deaths sounds scary – especially for people who don’t realize how many tens of thousands die from influenza in the United States each year.
Indeed, when people die of Covid-19, it’s often because their lungs fail. Smoking is obviously a major risk factor for dying of Covid-19 – a significant portion of reported Covid-19 deaths could be considered cigarette deaths instead. Or as air pollution deaths – and yet, our current president is using this crisis as an opportunity to weaken EPA airquality regulations.
Air pollution is a huge problem for a lot of Black communities in the United States. Our racist housing policies have placed a lot of minority neighborhoods near heavily polluting factories. Now Covid-19 is turning what is already a lifelong struggle for breath into a death sentence.
I would enthusiastically support a shutdown motivated by the battle for clean air.
But if we want to know how scary this virus is, we need to know how many people were infected. If that many people died after everyone in the country had it, then Covid-19 would be less dangerous than influenza. If that many people died after only a hundred thousand had been infected, then this would be terrifying, and far more dangerous than influenza.
Initially, our data came from PCR testing.
These are good tests. Polymerase chain reaction is highly specific. If you want to amplify a certain genetic sequence, you can design short DNA primers that will bind only to that sequence. Put the whole mess in a thermocycler and you get a bunch of your target, as long as the gene is present in the test tube in the first place. If the gene isn’t there, you’ll get nothing.
PCR works great. Even our lovely but amnesiac lab tech never once screwed it up.
So, do the PCR test and you’ll know whether a certain gene is present in your test tube. Target a viral gene and you’ll know whether the virus is present in your test tube. Scoop out some nose glop from somebody to put into the test tube and you’ll know whether the virus is present in that nose glop.
The PCR test is a great test that measures whether someone is actively shedding virus. It answers, is there virus present in the nose glop?
This is not the same question as, has this person ever been infected with Covid-19?
It’s a similar question – most people infected with a coronavirus will have at least a brief period of viral shedding – but it’s a much more specific question. When a healthy person is infected with a coronavirus, the period of viral shedding can be as short as a single day.
A person can get infected with a coronavirus, and if you do the PCR test either before or after that single day, the PCR test will give a negative result. Nope, no viral RNA is in this nose glop!
And so we know that the PCR test will undercount the true number of infections.
When we look at the age demographics for Covid-19 infections as measured by PCR test, the undercount becomes glaringly obvious.
Friends, it is exceedingly unlikely that such a low percentage of children were exposed to this virus. Children are disgusting. I believe this is common knowledge. Parents of small children are pretty much always sick because children are so disgusting.
Seriously, my family has been doing the whole “social distancing” thing for over a month, and yet my nose is dripping while I type this.
Children are always touching everything, and then they rub their eyeballs or chew on their fingers. If you take them someplace, they grubble around on the floor. They pick up discarded tissues and ask, “What’s this?”
“That’s somebody’s gross kleenex, is what it is! Just, just drop it. I know it’s trash, I know we’re not supposed to leave trash on the ground, but just, just drop it, okay? Somebody will come throw it away later.”
The next day: “Dad, you said somebody would throw that kleenex away, but it’s still there!”
Bloody hell. Children are little monsters.
It seems fairly obvious that at least as high a percentage of children would be infected as any other age demographic.
But they’re not showing up from the PCR data. On the Diamond Princess cruise ship, the lockdown began on February 5th, but PCR testing didn’t begin until February 11th. Anyone who was infected but quickly recovered will be invisible to that PCR test. And even people who are actively shedding viral particles can feel totally well. People can get infected and recover without noticing a thing.
We see the same thing when we look at the PCR data from Italy. If we mistakenly assumed that the PCR data was measuring the number of infections, and not measuring the number of people who were given a PCR test while shedding viral particles, we’d conclude that elderly people went out and socialized widely, getting each other sick, and only occasionally infected their great-grandchildren at home.
Here in the United States, children are disgusting little monsters. I bet kids are disgusting in Italy, too. They’re disgusting all over the world.
A much more likely scenario is that children spread this virus at school. Many probably felt totally fine; some might’ve had a bad fever or the sniffles for a few days. But then they recovered.
When they got their great-grandparents sick – which can happen easily since so many Italian families live in multigenerational homes – elderly people began to die.
So we know that the PCR test is undercounting the true number of infections. Unless you’re testing every person, every day, regardless of whether or not they have symptoms, you’re going to undercount the number of infections.
In a moment, we can work through a way to get a more accurate count. But perhaps it’s worth mentioning that, for someone my age, Covid-19 would seem to be about as dangerous as influenza even if we assumed that the PCR data matched the true number of infections.
If you’re a healthy middle-aged or young person, you should not feel personally afraid.
That alone would not be an excuse to go out and start dancing in the street, though. Your actions might cause other people to die.
(NOTE & CORRECTION: After this post went up, my father recommended that I add something more about personal risk. No one has collected enough data on this yet, but he suspects that the next most important risk factor, after smoking and age, will be type 2 diabetes. And he reminded me that many people in their 30s & 40s in this country are diabetic or prediabetic and don’t even realize it yet. Everyone in this category probably has elevated risk of complications from Covid-19.)
After you’ve been infected with a virus, your body will start making antibodies. These protect you from being infected again.
Have you read Shel Silverstein’s Missing Piece book? Antibodies work kind of like that. They have a particular shape, and so they’ll glom onto a virus only if that virus has outcroppings that match the antibody’s shape. Then your body sees the antibodies hanging out on a virus like a GPS tracker and proceeds to destroy the virus.
So to make an antibody test, you take some stuff that looks like the outcroppings on the virus and you put it on a chip. Wash somebody’s blood over it, and if that blood contains antibodies that have the right shape to glom onto the virus, they’ll stick to the chip. All your other antibodies, the ones that recognize different viruses, will float away.
An antibody test is going to be worse than a PCR test. It’s easier to get a false positive result – antibodies are made of proteins, and they can unfold if you treat them roughly, and then they’ll stick to anything. Then you’ll think that somebody has the right antibodies, but they don’t. That’s bad.
You have to be much more careful when you’re doing an antibody test. I wouldn’t have asked our lab tech to do them for me.
An antibody test is also going to have false negatives. A viral particle is a big honking thing, and there are lots of places on its surface where an antibody might bind. If your antibodies recognize some aspect of the virus that’s different from what the test manufacturers included on their chip, your antibodies will float away. Even though they’d protect you from the actual virus if you happened to be exposed to it.
If you’re a cautious person, though – and I consider myself to be pretty cautious – you’d much rather have an antibody test with a bunch of false negatives than false positives. If you’re actually immune to Covid-19 but keep being cautious, well, so what? You’re safe either way. But if you think you’re immune when you’re not, then you might get sick. That’s bad.
Because antibody tests are designed to give more false negatives than false positives, you should know that it’d be really foolish to use them to track an infection. Like, if you’re testing people to see who is safe to work as a delivery person today, use the PCR test! The antibody test has a bunch of false negatives, and there’s a time lag between the onset of infection and when your body will start making antibodies.
If you use the antibody test on a bunch of people, though, you can tell how many were infected. And that’s useful information, too.
In the town of Robbio in Italy (pop. 6,000), the PCR test showed that only 23 people had been infected with Covid-19. But then the mayor implored everyone to get an antibody test, and 10% of people had actually been infected with – and had recovered from – Covid-19. Most of them couldn’t even recall having been sick.
I don’t know who made the tests used in Robbio – maybe they were a little better, maybe they were a little worse. Based on my experience, I wouldn’t be so surprised if the true infection rate with Covid-19 in that town was really just 10% – nor would I be surprised to hear that the chips had a high false-negative rate and that the infection rate was 20% or more.
If you calculate the fatality rate of Covid-19 in Italy by assuming that the PCR tests caught every infection, you’d get a terrifying 10%.
If you instead assume that many other towns had a similar infection rate to Robbio, you’ll instead calculate that the fatality rate was well under one percent.
Italy has higher risk than the United States due to age demographics, smoking rates, and multigenerational households – and even in Italy, the fatality rate was probably well under one percent.
When researchers in Germany randomly chose people to take a Covid-19 PCR test (many of whom had no symptoms), they found that 2% of the population was actively shedding virus – a much higher number of cases than they would have found if they tested only sick people. And when they randomly chose people to take an antibody test, they found that 15% had already recovered from the infection (again, many of whom had never felt sick). According to these numbers – which are expected to be an undercount, due to false negatives and the time lag before antibody production – they calculated a case fatality rate of 0.37%.
That would be about three-fold more dangerous than seasonal influenza.
In the United States, our bungling president gutted the CDC, leaving us without the expertise needed to address Covid-19 (or myriad other problems that might arise). During the first few months of this epidemic, very few people managed to get a PCR test. That’s why our data from the PCR tests is likely to be a dramatic undercount – indeed, when we finally started producing accurate tests, the apparent growth in Covid-19 caseload superimposed with the growth in test availability.
In the absence of good PCR data, we have to rely on antibody data to track infections after the fact. Which is why a town in Colorado with zero reported infections, as measured by PCR, had sufficiently widespread exposure that 2% of the population had already recovered from Covid-19.
Yes, there were problems with the Stanford study’s data collection – they displayed advertisements to a random selection of people, but then a self-selected subset responded. The pool of respondents were enriched for white women, but Santa Clara’s outbreak probably began among Asian-Americans. And we all know that random sampling doesn’t always give you an accurate depiction of the population at large – after all, random polling predicted that a competent president would be elected in 2016.
Now look at us.
It’s also likely that people with a poor understanding of the biology could misinterpret the result of the Stanford study. They found that PCR tests had undercounted the infection rate in Santa Clara county, at the time of this study, by 85-fold.
It would be absurd to assume that you could simply multiply all PCR results by 85 to determine the true infection rate, but some people did. And then pointed out the absurdity of their own bad math.
In places where more people are being tested by PCR, and they’re being tested more often, the PCR results will be closer to the true infection rate. If you gave everyone in the United States a PCR test, and did it every day, then the PCR data would be exactly equal to the true infection rate.
If we had data like that from the beginning, we wouldn’t have been scared. We would’ve known the true case fatality rate early on, and, also, at-risk people could’ve been treated as soon as they got infected. We’d be able to save many more lives.
10% is roughly the proportion of young people who die of seasonal influenza. But only 1% of Covid-19 deaths are people younger than 35. The news reports don’t always make clear how much the risk of Covid-19 is clustered in a small segment of the population.
This has serious implications for what we should do next. If we were dealing with a virus that was about three-fold more dangerous than seasonal influenza for everyone, we might just return to life as normal. (Indeed, we carried on as normal during the bad years when seasonal influenza killed 90,000 people instead of last year’s 30,000.)
Because the risk from Covid-19 is so concentrated, though, we can come up with a plan that will save a lot of lives.
Healthy people under retirement age should resume most parts of their lives as normal. Schools should re-open: for students, Covid-19 is much less dangerous than seasonal influenza. I think that people should still try to work from home when possible, because it’s the right thing to do to fight climate change.
At-risk people should continue to isolate themselves as much as possible.
This sounds crummy, but at-risk people would just continue to do the thing that everyone is doing currently. And the plan would save many lives because the epidemic would end in about 3 months, after the virus had spread to saturation among our nation’s low-risk cohort.
Their data are easy enough to understand. In each of these graphs, they show a blue box for how long social distancing would last, and then four colored lines to represent how many infections we’d see if we did no social distancing (black), medium quality social distancing (red), good social distancing (blue), or excellent social distancing (green).
So, from top to bottom, you’re looking at the graphs of what happens if we do a month of social distancing … or two months … or three, or four … or forever.
And you can see the outcomes in the panels on the right-hand side. The black line shows what would happen if we did nothing. Infections rise fast, then level off after the virus has reached saturation. There are two important features of this graph – the final height that it reaches, which is the total number of severe cases (and so a good proxy for the number of deaths), and the slope of the line, which is how fast the severe cases appear. A steeper hill means many people getting sick at the same time, which means hospitals might be overwhelmed.
So, okay. Looking at their graphs, we see that social distancing saves lives … if we do it forever. If you never leave your house again, you won’t die of Covid-19.
But if social distancing ends, it doesn’t help. The slopes are nearly as steep as if we’d done nothing, and the final height – the total number of people who die – is higher.
(Often, one of their curves will have a gentler slope than the others — usually the good-but-not-excellent social distancing seems best. So you’d have to pray that you were doing a precisely mediocre job of not infecting strangers. Do it a little better or a little worse and you cause people to die. This isn’t an artifact — it’s based on the density of uninfected people when social distancing ends — but let’s just say “mathematical models are wonky” and leave it at that.)
In a subsequent figure, the Harvard team tried to model what might happen if we occasionally resumed our lives for a month or so at a time, but then had another shutdown. This is the only scenario in which their model predicts that social distancing would be helpful.
Even in the extreme case that we mostly stayed in our homes for the better part of two years, social distancing would case more deaths from Covid-19 than if we had done nothing.
That’s not even accounting for all the people who would die from a greater risk of domestic violence, hunger, drug addiction, suicide, and sedentary behavior during the shutdown.
When our data was limited, the shutdown seemed reasonable. We wouldn’t be able to undo the damage we’d done by waiting.
Except, whoops, we waited anyway. We didn’t quarantine travelers in January. The shutdown didn’t begin March, when the epidemic was well underway in many places.
Now that we have more data, we should re-open schools, though. For most people, Covid-19 is no more dangerous than seasonal influenza. We already have enough data from antibody testing to be pretty confident about this, and even if we want to be extremely cautious, we should continue the shutdown for a matter of weeks while we conduct a few more antibody studies. Not months, and certainly not years.
At the same time, we need to do a better job of protecting at-risk people. This means providing health care for everyone. This means cleaning our air, staunching the pollution that plagues low-income neighborhoods. This might mean daily medical checkups and PCR tests for people who work closely with at-risk populations.
Our country will have to be different in the future, but mostly because we, as a people, have done such a shitty job of creating justice and liberty for all. We need to focus on addressing the inequities that we’ve let fester for generations. That’ll help far more than using a bandanna to cover up your smile.
I should preface these remarks by stating that my political views qualify as “extremely liberal” in the United States.
I’m a well-trained economist – I completed all but the residency requirement for a masters at Northwestern – but I don’t give two shits about the “damage we’re doing to our economy,” except insofar as financial insecurity causes psychological harm to people in poverty. Our economy should be slower, to combat climate change and inequality.
One of my big fears during this epidemic is that our current president will accidentally do something correctly and bolster his chances of reelection. The damage that his first term has already caused to our environment and our judiciary will take generations to undo – imagine the harm he could cause with two.
And yet, in arguing that our response to the Covid-19 epidemic is misguided, I seem to be in agreement with our nation’s far right.
As far as I can tell, the far right opposes the shutdown because they’re motivated by philosophies that increase inequality. Many of them adore Ayn Rand’s “Who will stop me?” breed of capitalism, as though they should be free to go outside and cough on whomever they want. They dislike the shutdown because they think our lives are less important than the stock market.
By way of contrast, I care about fairness. I care about the well-being of children. I care about our species’ future on this planet. It’s fine by me if the stock market tanks! But I’ve written previously about the lack of scientific justification for this shutdown, and I’m worried that this shutdown is, in and of itself, an unfair response.
Quarantine could have prevented this epidemic from spreading. If we had acted in December, this coronavirus could have been contained. But we did nothing until several months after the Covid-19 epidemic began in the United States.
Then schools were closed: first for two weeks, then a month, then the entire year.
Stay-at-home orders were issued: first for two weeks, then extended to a month. No data supports the efficacy of these orders – haphazard, partial attempts at social distancing, from which certain people, like my buddy doing construction for a new Amazon facility, have been exempted. And no metrics were announced that might trigger an end to the shutdown.
Currently, the stay-at-home orders last until the end of April. But, as we approach that date, what do people expect will be different? In the United States, we still can’t conduct enough PCR tests – and even these tests yield sketchy data, because they might have false negative rates as high as 30%, and they’re only effective during the brief window of time — perhaps as short as one week — before a healthy patient clears the virus and becomes invisible to testing.
Based on research with other coronaviruses, we expect that people will be immune to reinfection for about a year, but we don’t know how many will have detectable levels of antibody in their blood. As of this writing, there’s still no serum test.
The Italian government is considering the dystopian policy of drawing people’s blood to determine if they’ll be eligible for a permit to leave their homes. If you were worried about the injustice that the virus itself imposed on people who are elderly or immunocompromised, this is worse!
We know, clearly, that the shutdown has been causing grievous harm. Domestic violence is on the rise. This is particularly horrible for women and children in poverty, trapped in close quarters with abusers. The shutdown is creating conditions that increase the risk of drug addiction, suicide, and the murder of intimate partners.
We don’t know whether the shutdown is even helping us stop the Covid-19 epidemic. And we still don’t know whether Covid-19 is scary enough to merit this response. As of this writing, our data suggest that it isn’t.
Covid-19 is a rare breed, though: a communicable disease where increased wealth correlates with increased risk.
And so we’re taking extreme measures to benefit the most privileged generation to ever walk the face of this Earth, at the cost of great harm to vulnerable populations. This is why I feel dismayed.
Hopefully I can present some numbers simply enough to explain.
Many diseases are more likely to kill you if you’re poor.
Malaria kills between 400,000 and one million people every year. The vast majority are extremely poor, and many are children – the World Health Organization estimates that a child dies of malaria every thirty seconds.
Wealth protects against malaria in two ways. Wealthy people are less likely to live in parts of the world with a high prevalence of malaria (most of the deaths each year occur in Africa and India), and wealthy people can buy effective anti-malarial medications.
I took prophylactic Malarone when I visited Ecuador and India. Lo and behold, I did not get sick.
I believe Malarone costs about a dollar per day. I am very privileged.
HIV kills between 700,000 and one million people every year. Again, the vast majority are poor. HIV is primarily transmitted through intimate contact – exposure to blood, needle sharing, or sex – so this virus rarely spreads across social boundaries in stratified communities.
In the United States, HIV risk is concentrated among people living in our dying small towns, people without homes in inner cities, and people trapped inside the criminal justice system.
It seems that these people are all easy to ignore.
Wealth will protect you even if you do contract HIV. We’ve developed effective anti-retroviral therapies. If you (or your government) can pay for these pills, you can still have a long, full life while HIV positive. About 60% of the people dying of HIV happen to have been born in Africa, though, and cannot afford anti-retrovirals.
The second-highest cause of death among people in low-income countries is diarrhea. Diarrhea kills between one million and two million people each year, including about 500,000 children under five years old.
These deaths would be easy to treat and even easier to prevent.
Seriously, you can save these people’s lives with Gatorade! (Among medical doctors, this is known as “oral rehydration therapy.”) Or you could prevent them from getting sick in the first place by providing clean water to drink.
We could provide clean water to everyone – worldwide, every single person – for somewhere between ten billion and one hundred billion dollars. Which might sound like a lot of money, but that is only one percent of the amount we’re spending on the Covid-19 stimulus bill in the United States.
We could do it. We could save those millions of lives. But we’re choosing to let those people die.
Because, you see, wealthy people rarely die of diarrhea. Clean water is piped straight into our homes. And if we do get sick – I have, when I’ve traveled – we can afford a few bottles of Gatorade.
Instead, wealthy people die of heart disease. Stroke. Alzheimer’s. Cancer.
If you’re lucky enough to live past retirement age, your body will undergo immunosenescence. This is unfortunate but unavoidable. In old age, our immune systems stop protecting us from disease.
Age-related immunosenescence explains the high prevalence of cancer among elderly people. All of our bodies develop cancerous cells all the time. Usually, our immune systems kill these mutants before they have the chance to grow into tumors.
Age-related immunosenescence also explains why elderly people die from the adenoviruses and coronaviruses that cause common colds in children and pre-retirement-age adults. Somebody with a functional immune system will get the sniffles, but if these viruses are set loose in a nursing home, they can cause systemic organ failure and death.
I haven’t seen this data presented yet – due to HIPAA protections, it can’t easily be collected – but Covid-19, on average, seems to kill wealthier people than influenza.
But on a population level, wealth is correlated with increased risk.
Part of this wealth gap is due to age. Currently we don’t have enough data to know exactly where the risk curves for seasonal influenza and Covid-19 intersect, but it seems to be around retirement age. If you’re younger than retirement age, seasonal influenza is more deadly. If you’re older than retirement age, Covid-19 is more deadly.
And in the United States, if you’re older than retirement age, you’re more likely to be wealthy.
Because these people were receiving expensive medical care, they were able to survive despite their other diseases. Imagine what would have happened if these people had chanced to be born in low-income countries: they would already be dead.
This is a tragedy: all over the world, millions of people die from preventable causes, just because they had the bad luck of being born in a low-income country rather than a rich one.
We don’t have data on this yet, but it’s likely that Covid-19 will have a much smaller impact in Africa than in Europe or the United States.
When my father was doing rounds in a hospital in Malawi, his students would sometimes say, “We admitted an elderly patient with …” And then my father would go into the room. The patient would be 50 years old.
Covid-19 is particularly dangerous for people in their 80s and 90s. Great privilege has allowed so many people in Europe and the United States to live until they reached these high-risk ages.
Our efforts to “flatten the curve,” in addition to increasing many people’s risk of death (from domestic violence, suicide, and the lifelong health repercussions of even a few months of sedentary living), will save relatively few lives, even among our country’s at-risk population.
The benefit of this shutdown is simply the difference between how many people would die if we did nothing, compared to how many people will die if we “flatten the curve.”
Assuming that our efforts to flatten the curve succeed – and neglecting all the other risks of this strategy – we’ll be able to provide ventilation to everyone. But there will still be a lot of deaths. The shutdown will not have helped those people. The shutdown is only beneficial for the small number who would be treated in one scenario, would not be treated in another, and who actually benefit from the treatment.
Their lives matter, too. Many of us have a friend or relative whose life was cut short by this. But something that we have to accept is that we all die. Our world would be horrible if people could live forever. Due to immunosenescence, it becomes increasingly difficult to keep people alive after they reach their late 70s and 80s.
And the priorities of elderly people are different from mine. I care deeply about the well-being of children and our planet’s future. That’s why I write a column for our local newspaper discussing ways to ameliorate our personal contribution to climate change. That’s why my family lives the way we do.
These priorities may be quite different from what’s in the short-term best interests of an 80-year-old.
Schools are closed. Children are suffering. Domestic violence is on the rise. All to protect people who have experienced such exceptional privilege that they are now at high risk of dying from Covid-19.
Our national response to Covid-19 is being directed by a 79-year-old doctor. I haven’t gotten to vote in the presidential primary yet, but if I get to vote at all, I’ll be allowed to choose whomever I prefer from a selection of a 77-year-old white man or a 78-year-old white man. Then comes the presidential election, where there’ll be an additional 73-year-old white man to choose from.
It makes me wonder, what would our national response be like if we were facing a crisis as risky as Covid-19, but where elderly people were safe and children were most at risk?
And then I stop wondering. Because we are facing a crisis like that.