Our efforts to “flatten the curve” of the Covid-19 epidemic are onerous.
Children aren’t allowed to go to school. We’re forcing small retailers out of business. People aren’t hugging when they greet.
Some people think these sacrifices are worthwhile, though, if they reduce the number of people who die from Covid-19.
Unfortunately, the effort to “flatten the curve” can cause more people to die of Covid-19 — including more of our elders — than if we’d carried on with life as usual.
Antibodies are like the memory of your immune system. After you’ve been infected with a particular virus, your body can destroy further copies of that virus.
This memory doesn’t last forever. Your body will “forget” how to fight off the coronavirus that causes the common cold within a year.
If we carried on with life as usual, the coronavirus that causes Covid-19 would probably make its rounds through the population of the United States within a few months. After that, there would be no new people to infect, and so the virus would disappear.
If, however, we practice social distancing and slow the rate of transmission – the same number of infections spaced over eighteen months instead of eighteen weeks – your immune system has a chance “forget” how to fight off the virus while this virus is still circulating in the population. By slowing the rate of transmission, you give yourself the opportunity to contract the infection twice.
If we slow the rate of transmission enough, this coronavirus will survive indefinitely. Then people will continue to die of Covid-19 forever.
Even if you are currently at risk — elderly or immunocompromised — you should still fear this possibility. Will you be less at risk when this virus hits your hometown again in another year?
When a virus infects a cell, it uses that cell’s replicative machinery to make more copies of itself. A virus can’t reproduce on its own – it can only co-opt its host’s cells into making more copies for it.
Each time the host makes a new copy, it must replicate the entire genome of the virus. Our cells are pretty good at copying genomes – every time the cells of our own bodies divide, they produce a new copy of our 3-billion-base-pair genome, and the copies usually have only a handful of mistakes.
Of course, a handful of mistakes compounded over time can be deadly. That’s what cancer is – your cells didn’t copy your DNA perfectly, and so you wound up with slightly mutated DNA, and this mutated DNA instructs cells to form a tumor that kills you.
The same accumulation of errors can change a virus. In the 1918 influenza epidemic, huge numbers of people died because the virus mutated to become more deadly.
The longer we allow the Covid-19 outbreak to go on – the more we strive to “flatten the curve” – the more mutations will accrue in its genome.
Consider a city in which ten people live, one of whom has the virus. If they throw a party, the other nine will be infected all at once – they will all come down with the Nth generation of the virus, whatever the current sick person is shedding. If, however, they practice social distancing and get sick one at a time, each passing the infection to the next, the last person in the chain will be infected with viral generation N+9. It could be very different, and more dangerous, than the initial virus.
Mutation doesn’t always make a virus more dangerous. It’s entirely random. It was bad luck that a mutation in 1918 made that strain of influenza more deadly.
But the risk is real. It’s a risk we aggravate if we “flatten the curve.” Right now, very few young healthy people will be hurt by Covid-19, but no one can know what monstrosity we’ll produce if we allow this virus to cycle through enough generations.
Inconveniently for us, Covid-19 is caused by an RNA virus. Our cellular machinary is pretty good at making copies of DNA – every round of cell division makes a few mistakes, but not so many. Our cellular machinary is worse at making accurate copies of RNA. A virus with an RNA genome will mutate faster.
People are worried that, without drastic efforts to slow the rate of transmission of Covid-19, the influx of new cases would overwhelm our hospitals. We might run out of ventilators and be forced to triage, providing heroic medical interventions only to those people most likely to survive. Some number of elderly patients with a low chance of survival would not receive care.
Is this bad?
Most medical doctors have signed “do not resuscitate” orders. I have, too. Most medical doctors, who have seen over and over again what it’s like when elderly patients with a low chance of survival receive heroic medical interventions, don’t want it for themselves. They would rather die in peace.
The New York Times – which, alongside the New York Review of Books, is my favorite news outlet, even though it’s been full of fear-mongering about Covid-19 – printed a quote from Giacomo Grasselli, who coordinates intensive care units throughout Lombardy, Italy. Grasselli is working at the front-lines of the Italian Covid-19 outbreak.
“My father is 84 and I love him very much,” but it would be irresponsible, he said, to make him go through the invasive procedures of an I.C.U.
In the United States, we spent over three trillion dollars on medical care in 2016. A huge fraction of this spending is used for minuscule extensions of life. A third of all Americans have surgery during their last month of life. We often spend more on interventions that extend the life of wealthy patients by a month than we do on all the pre-natal, preventative, and acute care that other people receive, ever.
What’s been missing, in the United States, is a conversation about what constitutes a good life. What needs to happen for people to be able to face death with the thought that their lives have been enough?
Covid-19 has killed thousands of people who were privileged to live to extremely old age. In the United States, the worst outbreak will be in New York City – a city that is so expensive to live in that it harbors huge concentrations of wealthy elderly people.
In the United States, the life expectancy is 78 years. Of course, there are major inequalities. If you are wealthy, you might live longer than that. If you are poor, you’ll probably die younger. My spouse’s parents both died in their 60s.
Covid-19 has a high mortality rate for people who have already exceeded this life expectancy. For people under retirement age, Covid-19 is less dangerous than seasonal flu.
In the United States, life expectancy has been falling. This decline is primarily due to an epidemic of “deaths of despair”: Drug addiction. Suicide.
In the United States, around 40,000 to 50,000 people die of suicide each year. Around 60,000 people die of drug overdose. Around 70,000 people die from alcohol abuse.
Each year, the epidemic of “deaths of despair” kill somewhere between 100,000 and 200,000 people.
Our efforts to “flatten the curve” will probably increase the number of people who die from deaths of despair.
Small towns across the United states have been gutted by the internet. People used to visit local retailers, which could employ local salespeople. Then we switched to buying things on Amazon, giving Jeff Bezos our money instead.
Now, local retailers are being forced to close due to fears about Covid-19. People have to buy things online. But local retailers still have expenses. They still have to pay rent. The owners still have to eat. Many small retailers will run out of money and never open again after the Covid-19 epidemic is over.
As if our small towns needed yet more punishment.
In general, people will experience more financial woes because of our response to Covid-19. Businesses are closed. Work has slowed. The stock market has tanked.
And financial instability increases the risk of deaths of despair. That’s a major reason why there’s been such a dramatic rise in deaths of despair among young people.
Thankfully, our efforts to “flatten the curve” aren’t guaranteed to make this coronavirus mutate. Our efforts aren’t guaranteed to make this virus a permanent parasite on the human race.
We might cause these calamities, but we don’t know for sure.
Indeed, we know very little about this illness. We do know that tens of thousands of elderly people have died. But we don’t know whether ten thousand died out of a hundred thousand who were infected, or a million, or tens of millions.
Our perception of the disease would be very different in each of those scenarios. But we do not, and can not, know. We have no retrospective testing, and we have never tested a random sample of the population to investigate viral prevalence.
The best we can do is estimate from small data sets, the way Stanford epidemiologist John Ioannidis has done. Ioannidis is very clear about his methodology, so if you happen to disagree with any of his assumptions, you can re-work the math yourself.
He concludes that our response is a horrific over-reaction.
The people recommending these policies – social distancing, school closure, stay-at-home orders, or total lockdown – aren’t doing so out of malice. They’re making the decisions they feel to be best. But no policy is neutral, obviously.
These policies prioritize the short-term needs of wealthy people who have exceeded their expected lifespans, at the expense of everyone under retirement age. In particular, these policies do not value the needs of children.
Many of our country’s policies prioritize the desires of wealthy older people over the needs of children, though “Flatten the curve” is just another example.
In many places, we are probably attempting to “flatten the curve” after the epidemic has already run its course.
More likely than not, I already had Covid-19. In early January, a co-worker of my children’s best friends’ parent left China, stayed briefly with her daughter in Seattle, then returned to Bloomington.
A few days later, she came down with a high fever and a bad cough. She went in for a flu test, but tested negative. The doctors sent her home.
A week later, my children’s best friends’ parent – the sick woman’s co-worker – came down with a high fever and a bad cough. His children were sick enough that they stayed home from school for a day. He was sick enough that he missed a week of work.
A week later, on February 10th, my children and I got sick. We had a high fever and a bad cough. The kids felt better the next day. I felt wretched for an entire week. I am an endurance runner with strong lungs – still, I needed puffs of my spouse’s Albuterol inhaler four times a day. I took naproxen but still had a hallucinatory fever. I wouldn’t wish that illness on anyone. For the next two weeks, I was vigilant about washing my hands and tried to minimize my contact with other people.
Over the next month, many other people in town came down with a cough and fever. It would typically last a week, then they’d feel better.
But it was pretty scary for some people. I’d felt wrecked. Another friend of mine — 55 years old, cigarette smoker, & former methamphetamine addict — felt like he could barely breathe. The doctor said that if his oxygen flow had been any lower, she would’ve kept him at the hospital.
He wasn’t tested for Covid-19. There were still no tests available. And after a horrible week, he felt better.
And then, on March 12th – after the epidemic had probably run its course in our town – our schools closed. The university students left for spring break, and the remaining populace of our small town began to practice social distancing.
And yet, in mid-March, the first case of Covid-19 was diagnosed here. This patient could not trace the social connections that would have led back to a known Covid-19 outbreak. As should be expected by that late stage of an epidemic.
All around the country, reported Covid-19 cases are exponentially rising. But that doesn’t mean that Covid-19 infections are exponentially rising. It only means that access to Covid-19 testing has risen.
When the epidemic likely spread through my town, it went undetected – no Covid-19 tests were available in the United States, and there’s no way to test whether someone was infected in the past. The reported numbers of Covid-19 cases are guaranteed to be lower than the true number of people infected, because you can only be counted as a Covid-19 if you feel sick enough to visit a doctor, and then somehow manage to get access to the test.
The test will only register positive during the acute phase of the illness. There is no possible way to test whether someone who isn’t currently shedding virus has been infected.
A useful way to consider this epidemic is to imagine what would happen if the Covid-19 PCR test wasn’t invented.
People would still get Covid-19. We would take no extraordinary protective measures, because we wouldn’t realize what they were sick with.
This is like what happened at the beginning of the HIV crisis in the United States. Medical doctors called the disease GRD, or “gay-related disease,” and it was terrifying. Healthy young people suddenly wasted away.
If we lacked a PCR test to accurately diagnose Covid-19, though, we wouldn’t call it “age-related disease.” We would call it “seasonal flu.” This year, about 30,000 people will die of seasonal flu, including many healthy young people. This year, my nephew almost died of the flu. He couldn’t breathe. He needed invasive ventilation to survive.
If we did nothing to staunch the Covid-19 outbreak, somewhere between 15,000 and 30,000 people probably would die from it. Combined with the 30,000 deaths actually caused by influenza, we would think that between 45,000 and 60,000 people had died from seasonal flu. No more than a dozen or so of the additional deaths would have been healthy young people.
That’s many more deaths! But nothing exceptional. In 2017, 60,000 people died of seasonal flu.
In 2017, we still let children go to school. I’m not sure I read any news articles about seasonal flu in 2017. And in the following years – after huge numbers of people died! – about half our population didn’t bother to get a flu vaccine.
Influenza is a more dangerous illness, and it’s preventable. But our country’s vaccination rate is too low to confer herd immunity. Even if you are young and healthy, a bad case of the flu can kill you. Even if you are young and healthy, your vaccination protects others.
Social distancing would protect people from the flu, also. Every flu season, we could stay six feet away from each other for a few weeks, and then we’d vanquish the flu. But social distancing comes at a tremendous cost, as we’re now learning.
Or we could get the vaccine. But we, as a people, don’t.