Coronavirus Special Coverage

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Think it’s time to sacrifice lives to reopen the economy? You’re wrong about COVID-19’s fatality rate

There’s a growing chorus of calls to immediately re-open the economy, all of them based on a variant of the following argument: the economic devastation caused by the lockdowns is far worse than the damage caused by the virus’s sub-1 percent fatality rate. Here’s an example from investor Michael J. Burry, made famous by his prescient call on the 2008 housing crisis as chronicled in the book and movie “The Big Short”:

https://twitter.com/michaeljburry/status/1241963119133331456

Some versions of this argument are outright mercenary, premised as they are on the claim that a few hundred thousand deaths of the elderly and vulnerable are a small price to pay for a thriving economy. Others appeal to altruism by first pointing out that economic downturns are a cause of increased deaths by themselves (true), and then arguing that there will probably be more deaths from the economic damage than from the virus itself.

But whatever form this argument takes, it is always wrong for the same reason: it’s based on a wildly incorrect understanding of COVID-19’s case fatality rate (CFR).

The argument that we can and should risk the lives of roughly 0.2% of the population to save the economy belies COVID-19’s CFR in two critical, dangerous ways.

First, the fatality rate swings wildly based on the properties of the country that the virus hits. Specifically, it goes up and down with the average health and makeup of the country’s population (old, young, smoker, obese, health, etc.) and on the capacity of the country’s healthcare system to treat a massive, sudden spike in respiratory illnesses.

Second, the early optimistic suggestions by many experts and press outlets that the coronavirus’s CFR would surely settle at below one percent (0.5% was a popular guesstimate) once all the mild and asymptomatic cases were discovered and accounted for have turned out to be wrong. There is absolutely no record of a representative patient cohort anywhere in the world that has run its course and has a CFR of less than 1%.

CFR estimation is very complex, as we discussed all the way back in early February, so let’s walk through in more detail the problems with the “sub-one-percent CFR” claims that are driving so much of the current push to re-open the economy before the lockdowns have had a chance to work.

About 1.3% is the lowest that a COVID-19 CFR gets in a typical population

We have now had the opportunity to follow a number of individual outbreaks with through a complete cycle — from the initial infections, through the discovery and documentation of most of the cases, to the final resolution (recovery or death) of the infected — and CFR numbers below 1% are scarcely to be seen.

South Korea has had perhaps the world’s best testing program in the main ramp-up phase of a now-contained local epidemic, and its crude CFR has settled at around 1.9%.  Germany has been another noted performer, and its crude CFR is also about 1.9%. The Diamond Princess cohort had about 100% ascertainment (almost everyone on the ship got tested, including many asymptomatic people) and ideal care (every case was treated as a high priority in a first-world hospital with ample capacity), and also had a CFR of about 1.7%.

So we’re just not seeing the hoped-for settling of the CFR below one percent, and it’s looking more likely that we never will. Note that this pattern of a rising CFR (vs. the expected drop) was also true of SARS-CoV-2’s predecessor, SARS. The 2003 SARS outbreak started with CFR estimates of about two percent and actually went up to 11 percent by the time the outbreak had run its course.

An overwhelmed healthcare system can put CFR in the high single digits

Even more sobering is the news from places where the virus has not yet infected a significant percentage of the population but has nonetheless overwhelmed the healthcare system (what we call a “Level 4” scenario in our framework).

Italy continues to run at a crude CFR of over 10%, Spain and the UK and the Netherlands are at about 10%, France is around 9%, and Iran, New York City, and Seattle are all around 6% and 7%.  These numbers are certainly inflated by continuing ascertainment problems to some extent, but are nevertheless almost certainly higher than we have seen in areas where hospital capacity is adequate.

It’s clear that Level 4 clusters elsewhere in the world are following the pattern of Hubei province compared to the rest of China, and experiencing higher CFRs than areas which prevent their outbreaks from overwhelming hospitals and thus going above Level 3.

We don’t yet know how high the CFR can go in a worst-case scenario

Right now, all the verifiable CFR numbers from higher-ascertainment cohorts that have run their courses, even in the hardest hit areas, are significantly below the 11% CFR of SARS.

The ones that approximate the CFR of SARS, like Spain and Italy, probably still have a significant number of mild or asymptomatic cases yet to be uncovered (these would cause the fatality rate to drop). However, we’ve never seen a cluster of COVID-19 run completely unchecked through a double-digit percentage of a population, and we don’t know what would happen if the vast majority of those patients couldn’t get even rudimentary medical care.

We can guess at this, however, by looking at the distribution of symptoms.

In high-ascertainment cohorts like South Korea and the Diamond Princess, the percentage of serious cases by various definitions and criteria ranging from those requiring hospitalization to those requiring intubation seems to vary between about 5% and 20%.

Unless the majority of those who were “serious” by the loosest definitions would outright die without expert care, even a Level 5 COVID-19 outbreak, while it might approach the CFR SARS attained in the harder-hit locations, would not exceed it.

COVID-19’s death toll is bigger than just COVID-19 deaths

Another important thing to remember is that once an epidemic overwhelms the healthcare system, deaths from all other causes go through the roof as well.

Heart attacks, car crashes, construction accidents, kitchen injuries, strokes, and every other form of non-COVID-19 emergency doesn’t get the attention it would ordinarily get, and frail, elderly, and sick people—as well as sufferers of chronic diseases like cancer, dementia, and heart failure—simply don’t get the care they need on a regular basis.

In Hubei province, estimates are that the excess mortality during the crisis was about 15 times the number of officially acknowledged COVID-19 deaths, and while some portion of these were unacknowledged COVID-19 deaths, as we reported at the time, many others were surely not.

Excess mortality numbers from Italy have come in at about 5-6 times the explicit COVID-19 death toll, and Italy is unlikely to be lying about COVID-19 statistics in a major way.  New York has also seen a similar spike in all-causes mortality.

But because the excess mortality effect stems from medical neglect and social shutdown, it may not increase that much if the virus spreads through a large chunk of the population.  This is what was observed in the 1918 flu pandemic.

Even some experts still aren’t being sober about COVID-19’s fatality rate

But a lot of people aren’t assimilating the above information. We often see them seriously understate how deadly COVID-19 is and, more importantly, can be if we relax the mitigation measures that are working to flatten the curve in places like Seattle, Italy, and New York.

By far the most galling recent example of undue CFR optimism was an analysis Dr. Birx presented at the White House on Tuesday.

Billed as a “worst-case” scenario for the USA and widely circulated since, it predicted 2.2 million deaths in the USA in the event of a nationwide Big Burn (i.e. where we end the lockdowns and just let the virus burn through the population, or if whatever measures we adopted in the long run were a complete failure). This number was arrived at by multiplying together the population of the United States, a notional 67% infection rate, and a CFR of 1%.

But attaining a CFR better than the best-managed outbreaks, where the healthcare system remained intact the whole time, in a nationwide Big Burn is probably not even a realistic possibility, and definitely not a worst case.

Any analysis which wants to be a worst-case or even typical representation of uncontrolled spread needs to use CFR numbers derived from or projected for those situations, not the rosiest numbers from countries that have kept the virus under control and given a hospital bed and ventilator to everyone who needs one.  It’s astonishing that scientists, let alone such prominent ones, are operating this way.

Conclusion: we can’t just reopen everything & let the virus rage

If we re-open our economy too early and we get an uncontrolled outbreak, we may very well see a fatality rate that creeps up towards the high single digits and kills millions. In such a scenario, the economy would likely collapse as people just stopped showing up for work. And in such a disorderly economic collapse scenario, parts of our critical infrastructure may collapse, as well.

We already have closures of meat processing plants that will soon impact our food supply, so if millions are dying will people risk their lives by showing up for work at our food processing and distribution centers? Will there still be supermarket workers to unload trucks and stock shelves?

Would the workers at power plants and municipal water facilities keep showing up, or would they stay home out of fear or to care for sick family members?

So if we reopen too early, and the virus spins out of control in a way that no country has yet let it do, then we risk a breakdown of the critical parts of our society and economy that keep people fed and the lights on.

Of course, if we reopen too late, we also risk a similar collapse, as massive unemployment leaves people without the ability to buy whatever groceries make it to the shelves. Surging unemployment rolls and widespread precarity — even straight-up hunger for many families with maxed out credit cards and no cash cushion — could bring about a massive loss of social cohesion that sours into violence and chaos.

So we cannot just re-open and let the virus rage, nor can we stay closed indefinitely. Both those paths lead to chaos and collapse. Our only choice is to come up with a way to thread the needle between doing too much and too little. We’ve already covered one proposed plan for that and will cover more as they’re published in the coming weeks.


  • 11 Comments

    • Mar Tam

      Well-written and a good corrective. This is not quite the point of this article, but it is very frustrating to see people like Burry put forth evidence supposedly showing how our collective response has been “too much” when much of their evidence is actually incorporating elements of our response.

      That said, I wonder if politicking from people like Cuomo has played into these “ultra-skeptics” hands… e.g., it does seem that Cuomo was wrong when he decided to pick a fight with Trump by saying NY needed 30,000 ventilators, right? (Not that he was wrong about the feds’ lackluster response or NY needing more ventilators, of course.)

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    • Brett Ferrell

      I really nice sounding article that, I think, still misses the point.  The fatality rate isn’t actually important.  We won’t realistically have a vaccine in less than a year, and not everyone will take it when we have it.  And Americans, and the economy, are not going to cower in place for a year.

      So what’s really important is not overwhelming the health care system so those that might die can get the best care we can offer them – the so-called “curve flattening”.  In Ohio we have been running essential businesses and carry-outs and grocery stores for nearly 3 weeks, and we’re over the peak and trending down on new cases – which have been steady between 350 and 425 for 8 days and trending lower.  We have over 12k hospital beds and 1/2 our ICU capacity is empty, so those that need supportive care can easily get it.  The state hasn’t ‘officially’ admitted it yet, but even they had to adjust them “social distancing” model down by 500% yesterday.

      This ‘story’ you tell belies the idea that we can’t have an economy and care for the ill.  We’ve shown we can.  This virus may or may not be more deadly than the flu, but like the flu we have shown we can work and care for people.  People who want to hide at home, or take the eventual vaccine, fine, but let’s get the economy moving because we can totally do it.  Folks who claim otherwise are either ignoring the data or have another agenda.

      Ohio’s modeling good or bad?

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      • Valkyrie612 Brett Ferrell

        In situations where you are facing an invisible, deadly foe as is SARS-CoV-2, and you know precious little about the enemy, or how it kills, much less how to get ahead of its infection rate, it is wise to prepare for the worst possible outcome. If you are government, and your primary responsibility is to provide for the safety and welfare of the people, it is wise to prepare for the worst possible outcome. If you are a family member, and want to protect your loved ones from the ravages of the disease COVID-19, and death, then you must prepare for the worst possible outcome. To do anything less is not only irresponsible, it is reckless endangerment. To put it bluntly, doing anything less is Darwinian in its stupidity, not only in survival of individuals, but also the survival of economies worldwide; for, you cannot have an economy without a healthy workforce with the confidence they will not die or inadvertently kill someone else if they show up to work.

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      • Brett Ferrell Valkyrie612

        This is just silly, you act like this is the plague.  97% of everyone who gets Covid survives.  The seriously ill are getting the care they need. You’re going to kill far more with the economic damage you do than the virus ever does.  And the American government’s primary responsibility is to “protect and defend the Constitution” – so much so it’s in the Oath of Office.  We have the inalienable right to assemble (First Amendment).  So clearly they’re breaching their highest responsibility.

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      • That was true a month ago, it is not any more.  To continue to say this is simply ignorant.  The Ohio data shows it’s not true, as do these front line doctors.

        https://vimeo.com/399733860

        https://www.dailystar.co.uk/news/world-news/scientist-germanys-wuhan-claims-coronavirus-21805392

        But when Prof Streeck examined the home of one infected family, he found the house did not have “any live virus on any surface”, contradicting the belief that coronavirus can live on various surfaces for days.

        The virus was not found on door knobs or animal fur either.

        We know it’s not a smear infection that is transmitted by touching objects, but that close dancing and exuberant celebrations have led to infections.”

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      • Jon StokesStaff Brett Ferrell

        One problem I have with the blog post you link is that it uses the word “actual” a whole lot, instead of “confirmed”. We have no idea what the “actual” case count in Ohio is at the moment. None. We only know how many cases have been confirmed from whatever testing we’ve done.

        So the blog post, as written, is incorrect… or at the very least misleading. It doesn’t acknowledge any limitations on the testing, and seems to presume that ascertainment is 100% (it is definitely not).

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      • Well, we know a few things about the testing.  It is possible (even certain) that there are people infected that haven’t been tested.  But even the governor says “we’ve tested the only the very sickest”.  So, a couple of things.   First, there is a good error rate on the positive tests, and the ‘rapid’ tests are notoriously unreliable (see below).  But, we’ll set that aside for now.

        Ohio has tested over 55,000 people, all of whom got a doctor’s order because they thought they had Covid-19.   Only 9% of them are testing positive – consistently, in every update.   Sure, in a state of 11 million people that’s a small sample, but many the balance don’t show meaningful symptoms so it really doesn’t matter.  And we’ve been locked down for over 2 weeks, so it will be very hard for lots of new cases to crop up (at least in significant numbers), so it seems clear to me we will soon know the true number of those that will get meaningfully ill.  And that’s what we peaked New Cases days ago.  Some will continue to trickle in, particularly from the prisons, but the general spread has been stopped.

        Next, those that get it and recover are actually good for society.  The virus is only a problem if folks are getting seriously ill.  If we test the other 10 million and find out we’ve all already gotten over it, then it is just like the flu (in it’s mortality rate) and is no biggie, and we don’t worry so much about a vaccine.  If we find they didn’t have it, we still win – it’s not as contagious as they said, and we know (through PPE and distancing) how to avoid transmitting it.

        My point is, I don’t know why people get wrapped around the axle about how critical testing is.  I don’t have an issue with testing, but it’s really only important in guide treatment of the seriously ill (we know what’s wrong with them) or triage when the system is overwhelmed (prioritization).  A vaccine is still a LONG way off, so I don’t think it’s reasonable to believe we’re going to shutdown the economy and distance to the current degree for a year.  If we don’t, it’s a pretty good bet we’re all going to get infected.  So, we (as everyone here admitted up front) just need to keep the hospitals from getting overwhelmed.  Today Ohio has over 14,000 empty hospital beds. https://twitter.com/GovMikeDeWine/status/1246500712630104066?s=20

        So, what do we care about?  Our current distancing is keeping the seriously ill well below the manageable level for the health care system to treat everybody who needs treatment.  Full stop.  And we’re doing that with lots of “essential” business now, so we can just extend that model so we don’t make a health crisis a total economic collapse or depression.

         

        PCR – https://arstechnica.com/science/2020/02/how-does-one-test-for-coronavirus-anyway/

        “one problem is that PCR is so sensitive that it can also amplify small errors—primers sticking to a distantly related sequence, a distantly related coronavirus in the sample, or even contamination from the previous sample.”

        Rapid tests – https://news.abs-cbn.com/news/04/01/20/different-kinds-of-coronavirus-test-kits-used-in-the-philippines

        “The FDA also said that the rapid test kits cannot be used for mass testing and will need confirmatory PCR testing. “

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    • TraceContributor

      Great article. I believe you are spot on that we still just don’t know. And that we must be careful not to assume that because what we’re doing now is working (sort of), so we can start preparing to go back to normal because “it’s not as big of deal as we thought”.

      Especially in our community, we need to keep the worst case scenario in mind and be prepared for that. The continued normalcy bias (especially politicized) of telling people that things will “likely get back to normal soon” is dangerous.

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