Today’s guest post is courtesy of Rachel H. DeMeester, MPH, a public health expert and Latter-day Saint living in the Seattle area.
Living in Washington state and being a public health professional, Covid-19 is on my mind almost constantly, but really, there are few places it hasn’t touched. Public health’s greatest challenge is giving recommendations that don’t induce panic but also aren’t ignored. That clearly has failed so far as people hoard toilet paper (irrational) and masks (ineffective since healthcare workers need them) and in many cases ignore pleas to spread out. Do we know everything we need to know about the virus? No. Do we know enough to act? Absolutely. No matter how independent we feel we are, we all have some level of social contact and therefore a personal stake and responsibility in Covid-19. Those who believe in God receive an extra reminder that we are all God’s children and are expected to care for each other as such. We should be concerned—not panicked—enough to act.
If I had thirty seconds to describe the Covid-19 situation, I would say:
- The main goal is to slow down its spread to avoid overwhelming our medical system beyond capacity and to reduce its impact on people. This requires doing things differently than we are used to.
- There are no steps yet that will perfectly balance economic impact, loss of life, healthcare capacity, and individual freedom at the same time. We should try anyway.
- Recommendations may change rapidly. Critical thinking is important, but most of us aren’t sitting at home studying the virus or modeling how the disease spreads. It would be wise to listen to those who do.
What’s different about this pandemic? It’s not the first one the world has ever encountered.
Maybe the disease isn’t so different, but the world’s incredible interconnectedness exacerbates a pandemic. As in prior pandemics, we have no existing immunity to slow the virus down; that will change slowly as people recover and a vaccine is developed. Features of the virus itself combined with a highly mobile society make the speed of transmission concerning.
- The novel coronavirus can be transmitted before people have noticeable symptoms.
- After you get it, you might not show symptoms for up to five days (the “incubation period”). Think about how many people you normally interact with in a work week!
- The virus can live on surfaces for a few hours or up to nine days. To compare, common cold and flu viruses typically remain infectious for less than 24 hours—and we still suggest hand washing and disinfecting.
- The virus may or may not be seasonal. While it’s too soon to say, we do know it can still spread in hot, humid environments, so delaying action in the hopes that warmer weather will save us would be under-reacting.
Fast transmission affects more people and could strain the healthcare system past capacity, decreasing recovery rates. Even if we personally aren’t at high risk, do we care about the risk to our friends and neighbors?
Why panic when HIV/flu/car accidents have killed way more people? Why don’t we do something about that?
I relate to the skeptics, but first, there are interventions to try to address those issues. (Level of funding is a different story.) Second, we aren’t sure yet how bad Covid-19 is going to be, but almost certainly worse than the seasonal flu that we’re used to. Third, any previous lack of action is a bad justification for continuing lack of action.
What’s the big deal? The recovery rate looks pretty good to me.
The recovery rate is fairly high, but it may not stay that way. Currently, recovery is high overall but not for certain populations (elderly or certain conditions), and more interestingly, not everywhere. Recovery will decline if healthcare systems become overwhelmed by continued exponential spread of Covid-19.
- Healthcare capacity affects outcomes. My favorite analogy compares this to what would happen if a family got sick; if everyone gets sick at the same time, especially the parents, it’s much harder to deal with than if one person at a time gets sick. That is why “flattening the curve”—or slowing down transmission—is important. The US has 95,000 ICU beds (the kind needed for severe Covid-19), many of which are occupied already. About 20% of Covid-19 cases are sick enough to require hospital care. We need masks, hand sanitizer, and healthy staff to provide care. Washington state has already had to receive federal shipments of masks to keep up with demand. The WA department of health is also issuing emergency licenses to healthcare providers from other states to help us out.
- Fatality rates vary widely between countries. Italy’s current fatality rate is 8.3% and seems to be rising. Germany’s is 0.2%. Ours is 1.4%. (Check out this map by the World Health Organization.) There are many possible explanations, including population age, population density, testing availability, level of coordinated response, and social customs, but one thing is certain: we are not guaranteed a low fatality rate without effort.
That effort for individuals is mostly “social distancing.” We also desperately need to do more testing and “contact tracing,” as in South Korea where they are actively finding people who have been exposed, testing them, and containing the disease. In the US, we’re still only testing people that self-report and meet a list of criteria.
If you’re still on the fence about social distancing, watch this fascinating simulation. The level and duration of social distancing may not be the same in every community or country, but in the US all fifty states have confirmed cases, so be prepared.
Since everything is canceled, let’s get together for a playdate/homeschool co-op/etc.
When my kids’ preschool was canceled last week, I left chatting with a friend about getting together to make sure we didn’t lose our sanity. I have changed my opinion as cases continue to rise. In order for the virus to really slow down, pushing the limits of recommended group size doesn’t make sense. I don’t want to be alone for weeks, but my spouse works with the elderly; if we can prevent the virus from coming through our house, we can keep them served and safe. If rates start dropping here, I’ll reassess. Dr. Darria Long Gillespie (American College of Emergency Physicians spokesperson) suggests asking oneself: “How many people will be there? How close will you be to all of those people? How well ventilated is the space or how much people can move around?”
So if everyone stays home for two weeks will this go away?
Theoretically, sure. But since one host can infect multiple people, it would have to be 100% to stop the virus. That’s pretty unlikely. Even if everyone stayed home, the 14-day incubation period is an estimate; there’s a possibility that 14 days might not be long enough. The best bet IS to take some space, paying attention to your area’s risk of transmission.
If this goes on too long, won’t the economic effects cause worse health effects than the disease?
I don’t know how long we have before the societal cost of social distancing outweighs the benefit. Food insecurity, medical bankruptcy, domestic violence, and mental illness are already widespread and likely to get worse. For individuals living in compromised situations, actual harm due to social distancing may already outweigh potential harm; we need more information. Food and money are easily shared without contact, but I urge us to consider anyone in our network who may need a “buddy home” at which to spend time. I think this small increased risk of transmission is worth keeping people safe in their homes. (See domestic violence and suicide resources at the end of this page.)
How long will this last? A recent model from the Imperial College London predicts several months followed by a second peak later in the year unless containment measures continue until a vaccine is available in 12-18 months (summary and full report). That’s scary. But they also modeled an “on/off” method of social distancing and school closures. In it, Covid-19 cases would be closely monitored and social distancing/school closures implemented only when ICU cases pass a certain (manageable) threshold. This would result in the more disruptive measures being “on” about 2/3rds of the time, with some respite in between. That might be a nightmare to coordinate at even a state level, but it could help mitigate the impact to other health and financial outcomes.
(Graph from Page 12)
Stay compassionate.
A final note about equity during this pandemic. Most of my professional life has been spent targeting vulnerable populations and working to reduce disparities in the health care system. There are going to be differences in people’s ability to distance. Someone with a well-paying desk job is going to have a different experience than someone who must physically show up to work either by function or by risk of not being able to pay their rent. When someone orders groceries, someone delivers them. When grandma gets sick, someone cares for her and cleans the hospital. In all of this, let us be gracious and not use someone else’s extenuating circumstances to justify any unwillingness on our part to act responsibly. Instead, let’s support each other from a distance however we can. Buy gift cards. Send a text. Lists of ideas are all over the internet to remind us that social distancing doesn’t mean shutting down all communication and regard for those around us.
Obviously, I wish the Covid-19 pandemic weren’t happening. But since it is, I hope we succeed in slowing its spread and emerge with greater curiosity for the role we play in each other’s wellbeing. We could learn so much.
National Domestic Violence Hotline allows you to speak confidentially with trained advocates online or by the phone, which they recommend for those who think their online activity is being monitored by their abuser (800-799-7233). They can help survivors develop a plan to achieve safety for themselves and their children.
Suicide Lifeline: If you or someone you know may be struggling with suicidal thoughts you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) any time of day or night or chat online.
By Common Consent, a Mormon Blog 
It’s been interesting to watch the spread. Domo has a pretty good tracker built – https://www.domo.com/coronavirus-tracking
Thanks Rachel. And it always good to have locals at BCC.
Read this and then re-read the OP.
https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/
I build models for a living. If I tried to persuade clients to take drastic actions based on such low quality data I should be laughed out of the profession.
PaulM–do you do a lot of modeling in situations where waiting for better data would mean thousands of deaths?
Kristine,
First, yes. I model risk among other things.
Second, did you read the article I posted? In it the author, with a lot more credentials than the author of the OP, points out that some of the decisions we are currently making could ultimately result in more deaths than we might otherwise realize.
Kristine,
First, yes. I model risk among other things.
Second, did you read the article I linked. The author, with a longer list of credentials that the author of the OP, points out that some of the measures we are taking could ultimately prove to have cost more lives than doing nothing.
Paul M – lots of people with heavy credentials have weighed in on this. The questions brought up in the comments to the article are valid and missed by the author. While it’s too early to get organized measures of much in the US, the Diamond Princess, South Korea, and Italy can all be used for statistical measures. With the high transmission rate, even with a mortality rate as low as 1%, 60 million people is too many to cede to inaction.
Most importantly, as has been mentioned somewhere before, better to have done too much than too little.
Here is a reply to the article Paul M cites, from one of the author’s equally qualified colleagues, and published at the same site: “We know enough now to act decisively against Covid-19. Social distancing is a good place to start”
https://www.statnews.com/2020/03/18/we-know-enough-now-to-act-decisively-against-covid-19/
If 99 out of 100 experts say A, and one contrarian says B, and hundreds of thousands of extra people will die if B is wrong, just go with A.
C. Keen,
I read that article too. Very thin on analysis. And Dr. Ioannidis is not a lone wolf. Take a look at that entire journal. Overall, those who actually make a living with data analytics are delivering the same general message: We are blindly taking action without knowing if the action we are taking will have positive impact all the while ignoring the known costs. We are behaving irresponsibly in order for a certain professional set to save face.
Paul M: That article is atrocious; the author bases most of his counter arguments on a sloppy back of the envelope calculation from a single cruise ship, willfully ignoring the data available from worldwide sources with considerably higher N values. It’s an irresponsible piece, and you either read the links in this article or you’re exaggerating your ability to model risk if you think it presents a compelling case.
For considerably better information, I’d recommend checking out McKinsey’s projections for how different approaches will turn out: https://www.mckinsey.com/business-functions/risk/our-insights/covid-19-implications-for-business
Kristen,
YTD, how many more Italians over the age of 70 have died this year than last year? And is that an overall higher morality rate?
Specifically, fewer than 50k medical-surgical ICU beds, and fewer than 100k general ICU beds: https://www.aha.org/statistics/fast-facts-us-hospitals
Ah, I overlinked. Here is my comment so it can escape moderation purgatory, piece meal:
PaulM, are you under the impression that the answers to either of those questions absolves the author of your piece of using tiny numbers to make a completely ludicrous case? There is absolutely no reputable epidemiologist projecting that 10,000 deaths is a reasonable estimate for US deaths.
This is partially because the author fails to acknowledge the situation in many other countries, including the fact that in the US, nearly 40% of those in the ICU (our national ICU capacity is less than 50,000 beds, most of which are already full) are those under 60. (https://www.nytimes.com/2020/03/18/health/coronavirus-young-people.html?fbclid=IwAR0DHLPNJ_LLRbmtSSL4OY_XJFMbTtOwTPbLnMJkVP_D613HodaMtppfVPU)
Doctors in Italy have been directed to give ventilators and other life-saving medical care to “those patients with the highest chance of therapeutic success”, and more bluntly states: “It may become necessary to establish an age limit for access to intensive care.” (https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/?fbclid=IwAR2oNEAA53h7MYcE6ionJ3UIoicQQ3vVWiaK75lrAqLNnJssmmFok4DLtQo)
So since you were asking the question, it might be useful to note that such measures have absolutely resulted in a considerably higher rate of death in seniors than is normal. The morgues in Italy are so full that they’re putting bodies in churches. (https://www.reuters.com/article/us-health-coronavirus-rites-insight/there-are-no-funerals-death-in-quarantine-leaves-nowhere-to-grieve-idUSKBN2161ZM)
Feel free to read the McKinsey projection, or any of the following, for considerably better data analysis. Where did you earn your qualifications? You should send a complaint.
View at Medium.com
https://www.theatlantic.com/ideas/archive/2020/03/how-we-beat-coronavirus/608389/?utm_term=2020-03-19T18%3A42%3A19&utm_campaign=the-atlantic&utm_medium=social&utm_content=edit-promo&utm_source=facebook&fbclid=IwAR37YtFVEMWW00mFb2FQsea3Dt1nYekithoyF9MW9fav9aY13la4UWPrf3M
Thank you for this great summary. This comment thread is quite an interesting practical demo of your opening point that it’s hard to give the right amount of info that people will actually trust and act on! Makes me think too of the OT version of following the prophets. We’ve got a subset of people who can see a big problem coming with a little time to act. Like most OT examples, they’re *not* the heads of government or the heads of institutional religion, they’re community members with relevant experience or expertise. And we surely have far too many people, including heads of state, not listening. And we’re gonna be sorry. Yes, I am saying that activists, scientists, compassionate experts, community organizers are the real prophets today.
Stating unsubstantiated “facts” like: “About 20% of Covid-19 cases are sick enough to require hospital care.” is dangerous and makes people lose confidence.
jpv: the source is the following journal article, published in the Journal of the American Medical Association, from data on ~45k cases in China.
Here’s the journal article:
https://jamanetwork.com/journals/jama/fullarticle/2762130
Here’s the relevant paragraph: “Most cases were classified as mild (81%; ie, nonpneumonia and mild pneumonia). However, 14% were severe (ie, dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio 50% within 24 to 48 hours), and 5% were critical (ie, respiratory failure, septic shock, and/or multiple organ dysfunction or failure)”
[Yes, the above severe cases do require hospitalization.]
It’s been made into a widely shared infographic, found here: https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/
I just gotta lean towards PaulM. From April to April 2009-2010, 60.8 million people had swine flu. 12,469 deaths. IN AMERICA, friends. Please don’t go crazy and site infection rates of Corona or anything else about it, I understand it all. Just tell me this if you’re ticked off at me, do you really think we will exceed 12,000 deaths? 60 million Covid cases?? PLEASE, I don’t want anyone to die but why-o-why did nobody freak out over all those deaths then? Of course I know the reason…but please try to explain in a really convincing manner. With facts, not projections please, and addressing this, my main point: WHERE WAS YOUR CONCERN THEN.
thinkermama, Swine flu had a .02% fatality rate. The cases did not overwhelm the hospital system, they were able to be treated reasonably. Covid-19 appears to have a 1.6% fatality rate. Even in South Korea, which was able to treat all its cases within the hospital system, and which has extensive teasing able to pick up mild cases, appears to have a death rate around .7%. That is 35 times higher than the swine flu fatality rate. The number of people catching Covid-19 is still going up exponentially, so yes we will be seeing many many more than 12,469 deaths. When people cannot get regular medical care because the hospitals are packed with dying Covid-19 patients then deaths from other reasons is also going to climb.
To the OP: what are your thoughts on the drastically revised (downward) Imperial College model released yesterday?
https://www.dailywire.com/news/epidemiologist-behind-highly-cited-coronavirus-model-admits-he-was-wrong-drastically-revises-model
I am on the front line of this epidemic.
First problem: We don’t know as much as we think we know. We know how many people died in hospitals that were tested. We see it increasing . We know there are not limitless hospital resources. We are seeing them overwhelmed, several times now. But not everywhere.Yet?
We don’t know how many people died in hospitals who were not tested. Maybe they had mild covid-19 worsen their emphysema and then had a heart attack and died.
We definitely don’t know how many people are dying in the community of covid-19. Any number of scenarios could be another undetected covid-19 infection. The picture is not so cloudy to believe fewer young people are dying of it. We can compare it to other pandemics and make guesses. But the problem is that we didn’t test everyone in the previous epidemics either. We can’t test everyone every day. Confidence intervals are huge.
We don’t know if there is a dose effect. Can a good immune system keep up with a few invading viruses and limit the illness? Or does the virus usually outrun the immune system at the beginning so the initial dose is not important? We think maybe an over-reactive immune system might be damaging. (“cytokine storm”- cytokines are immune regulators)
We don’t know that the biological characteristics of the virus (we are guessing about) won’t change. Viruses can get more virulent during an epidemic or less. Or both in different places. They can come in waves with different features.We don’t know if this is ever going to go away. Vaccines hopefully will work, maybe, and not 100%. We don’t know how much herd immunity we will need to stop it, or if that even works with it.
Many of us living today are accustomed to finding out a zillion things before we make serious decisions. We are addicted to elaborate policies and procedures to control our risks and limit them. Our legal system thrives on parsing words and every decision. Guess what? Welcome back to the 19th century, where these approaches are not that useful, brought to you by covid-19.
One of the biggest logical fallacies out there is arguments based on credentials. Saying your expert is better than mine at this point is not logical. Both are guessing. The problem with listening to the wise ones who know is that they might not know. The other “elephant” in the room is that the one person with the most authority to gather information and recommend widespread coordinated action has mostly acted like a habitual ass. It is what it is and we must move on.
The other big problem is this is not some philosophical question we can debate for decades. We must act now, according to what we think is the best (and likely flawed) information we have. As far as what to do, I agree with pretty much most, if not all, of what Sister DeMeester says, being as good of a guess as we have of what to do at this point. But I also believe it will change.
——–
One area I do disagree with is the use of masks. These recommendations are based on a black and white logical flaw. (Even though the masks are described as N-95 or not 100% effective.)
To understand my argument consider 2 questions:
Why do surgeons wear masks? Why do pathologists wear masks?
The reasons are similar (and overlap a little) but not the same. The surgeon wears the mask to protect their patient from getting infected by the surgery. (Altruistic) The pathologist wears the mask to protect themselves from the nasty pathogens that explode after a body dies. (Selfish)
Let me elaborate on what is meant by more effective: If a person walks into church with 100 people and only one of them is infected but undetected, the mask has a small (but real) chance of protecting the wearer. If a person walks into an ER with 100 people seeking help and 75 of them are infected with symptoms, the mask has an enormous chance of protecting the wearer. We don’t have enough N-95 masks, so don’t horde them from the people in a dangerous situation who can make a bigger difference than you.
But that does not apply to DIY masks. Only your imagination limits them. Do they work? First, don’t let any mask give you a false sense of protection. Some doctors and nurses wearing the very best masks are going (already have?) to die in this epidemic. But far fewer than without the masks.There are a few studies that show some DIY masks provide some protection for you, in the same ways it protects the pathologist. But mostly in the way it protects the surgeon.
Wearing a less effective DIY mask will have a much larger benefit than nothing if you wear it for the reason a surgeon wears it. It works like social distancing. It is one more barrier the virus has to breech, as you cough it out on your neighbors. Obviously fabrics that are very “breatheable” will be like using a chain-link fence to exclude mosquitoes. But fabrics that partially restrict airflow will be better. Multiple layers of tightly woven cloth. And don’t forget leaks around the edge would make a plastic bag mask ineffective, (before you suffocate). And many of the DIY masks can be washed more easily.
I made a DIY mask out of 4 inches of duct tape on the upper edge over the nose, 2 shoestrings of 3 ft length and a 24 x 18 inch finely woven towel folded over the string such that I breath through three layers. I don’t use this at work (yet) but out in the community for rare errands, it is better than nothing. Depending on how bad this gets, if we run out of masks completely, this is my back-up plan for now.
I have allegorically reinterpreted a well-known scripture, by adjusting the meaning of the word “defile” to mean the shame of infecting someone with covid-19. Matt 15:11- Not that which goeth into the mouth defileth a man; but that which cometh out of the mouth, this defileth a man.
There is no shame dying of this infection. But there is shame of taking others out, by not doing the best you can to avoid infecting anyone else.
Back to work.