Two months ago, I wrote about my concern that COVID-19 would become a much bigger problem than most people thought. Since then, it has. The public’s perspective has shifted accordingly. We now have a couple more months of data as well. I believe that it is now a much smaller problem than most people think. I am more concerned about the consequences of continuing the measures we have implemented to combat it thus far. I fear that those consequences will create much larger problems than most people think. For that reason, I would like to share my current perspective on the problem presented by COVID-19. I will begin by turning the clock back a century.
This has not killed like the Spanish Flu.
A little over 100 years ago, The Spanish Flu decimated humanity. It killed approximately 50 million people in about two years. That was around 2.8% of the global population at the time.
To date, COVID-19 has killed approximately 200,000 people in about 2 months. Extrapolating that average death rate over the course of two years would result in 2.4 million deaths worldwide. That would come out to 0.03% of the global population.
In other words, if the average death rate to date is maintained from now through the end of February 2022, we would reflect on the Spanish Flu as having killed 90 times as many people as COVID-19 as a percentage of the global population in their respective times.
At this rate, COVID-19 is not killing like the Spanish Flu did. In fact, it is not even remotely close.
Is it possible that COVID-19 could have thus far killed at a much higher and potentially comparable rate in the absence of the actions that most of the world has taken to date in an effort to mitigate it? Sure. I think it is reasonable to suggest that could have been possible. How likely would that have been? I am not sure. I do not believe anyone could be. My intention is not to speculate on what could have been. It is to consider what has been, to put that in perspective, and to take a closer look at the problem. Once we understand the problem, we can better propose a solution.
This has killed more like car accidents or the seasonal flu.
The reality of COVID-19 thus far has been nothing like the Spanish Flu in terms of the death rate. It has been more like car accidents or the seasonal flu in that regard. So far this year, COVID-19 has killed half as many people globally as road traffic accidents (437,822) and 33% more people than the seasonal flu (157,813). I am not suggesting that this is anything like the flu, and it is obviously nothing like car accidents, but it is comparable to both in terms of the number of people it has killed this year. It is important to put the number of COVID-19 deaths in perspective. It allows us to observe how little attention we pay to comparable killers and contrast that against how much we are sacrificing to prevent incremental deaths from COVID-19.
Side note: please resist the urge to discredit this analysis by using the easy out that I must be dumb or ignorant because I am comparing this to the flu. I am only comparing it in terms of the total number of deaths so far this year, and as such, the average rate at which it has killed. I am well aware that the basic reproduction number (R0), which can be thought of as the expected number of cases directly generated by one case, seems to be significantly higher without intervention (social distancing and alike). I am also aware that the case fatality rate (CFR), or the percentage of cases that result in death, also seems to be significantly higher, though our ability to accurately estimate it has been compromised by a global lack of testing. For a bit of color on that lack of testing, it is worth noting that the 10 countries with the most COVID-19 deaths (excluding China due to lack of numbers) have administered between 1 and 29 tests for every 1,000 citizens (the US figure is 17). A disproportionate number of these tests go to severe cases versus mild ones and people who are asymptomatic. Since severe cases have the highest death rate, we know that the rate suggested by dividing total deaths over total confirmed cases is overstated to some degree. The problem is that we have very little idea about exactly how overstated it is.
It is time to shift from panic mode to manage mode.
We now know that what we have done to mitigate the spread of the virus has worked. Most hospitals seem to have cooled from their recent peaks. We flattened the curve to the point where it did not overwhelm our hospital systems in the US like it did in Italy. Our response in panic mode likely saved us from that type of scenario and from many more COVID-19 deaths as a result. That said, the consequences of what we have done and continue to do could lead to other deaths and a lot of suffering. The time has come for us to switch from panic mode to manage mode.
We can afford to open things up in a sensible manner. We can monitor the rate of people entering hospitals with COVID-19. We can manage this evolving crisis one day at a time. If we need to shut certain areas down again, we can. I believe we can do it better too. Either way, we need to start turning the lights on again.
I am disappointed to see places like San Francisco extending the stay at home order for another month. Their leadership seems to be operating with an impractical objective of getting COVID deaths as low as possible. That is a fine objective in panic mode when the issue seems exponential and out of control, but that is no longer the case. Unlike several weeks ago, we have now established measures by which we can mitigate this virus. We have established some semblance of control. It is no longer the same blind threat that it once was. This virus will not be entirely extinguishable without impenetrable borders and perfect adherence to quarantined isolation inside of those borders. That is not a feasible approach in the US. For what it is worth, I would be fine to do that myself, but I suspect most people would not. Since the approach is not feasible, neither is the objective.
The objective should not be to drive the number of infected as low as possible. It should be to manage the crisis as effectively as possible to limit the damage on all sides of the equation. We of course want to keep the number of COVID-19 deaths in check, but we also want to limit the unknown consequences of our actions in doing so. Determining the maximum average rate of COVID-19 deaths that should be considered “in check” is a difficult task. It is impossible to justify an exactly “right” number. There are far too many unknowns. Still, it seems to me that keeping the death rate under that of car accidents is too low a level to require on one side of the equation when the consequences on the other side are unknown and seem poised to potentially be more punishing in the long run and extremely difficult to resolve.
As it stands, we continue to risk these unknown consequences in exchange for incremental improvements against a single issue which has gained disproportionate attention. So far, we know unemployment has surged to the highest levels since The Great Depression and we know that food banks are seeing skyrocketing demand. We do not know all of the long-term impacts that the measures we have taken will have on suicide rates, domestic violence, poverty, starvation, homelessness, and more. We need to start mitigating the unknown and potentially brutal consequences of our unprecedented actions while sacrificing known consequences in the short-term at an acceptable level. We cannot afford to pretend every life saved from COVID-19 is invaluable when the fact of the matter is that there are many more lives lost every day by preventable problems that we can fix less consequentially but are simply not paying as much attention to.
This is a New York / New Jersey Problem.
Now that we put the problem in perspective, let us address its most obvious particulars. New York and New Jersey have 83 counties in total. A combination of New York City and only 6 of these counties has accounted for almost exactly one third of all US deaths from COVID-19 (32.93%). The combined population of New York City plus Nassau, Suffolk, Westchester, Bergen, Essex, and Hudson counties is 14.6 million people. That is 4.45% of the US population which is accounting for one-third of all deaths. That means 95.55% of the US population is accounting for the other two-thirds. In terms of deaths per capita, this has been 10x more deadly in New York City and the other 6 NY/NJ counties than it has been in the rest of the country. It has killed more than 1,200 people per 1,000,000 in these specific NY/NJ areas while killing only 120 people per 1,000,000 in the rest of the US. We should be treating it accordingly.
It is unwise for us to have a relatively uniform response nation-wide or even state-wide. Tennessee is not the same as New York. The other 70+ counties of New York and New Jersey are not the same as their much more severely infected neighbors. We need to see these differences more clearly.
This is an Older People / Comorbidities Problem.
The median age in New York State is 38.2 years old. That means about half of all people in New York are 39 and under while the other half is 40 and older. In New York thus far, less than 2% of all COVID deaths have been from the younger half while more than 98% have been from the older half. Let us leave aside for now the fact that the older half can and should be broken down further since a healthy 40, 50, or 60-year-old is almost incomparably less likely to die versus a 70-year-old diabetic. For starters, it is useful enough to establish the fact that one half of the population is dying at 49 times the rate of the other half.
From that starting point, we can take the large portion of healthy people from the older side and move them to the younger side. We can then take the small portion of young people with hypertension, diabetes, cancer or other comorbidities and move them to the older side. Once we separate the most at-risk population from the rest, I suspect we might end up with something like 90% of the population that is young and/or without comorbidity accounting for just 1% of all deaths. That would leave 10% of the population that is old and/or with comorbidity accounting for 99% of all deaths.
While these estimates are only speculative, I cannot imagine they are very far off. We need to drill down on the best data available, determine the most reasonable criteria by which we can separate the smaller most at-risk population from the rest, and treat these different populations accordingly.
COVID-19 has not killed like the Spanish flu. It has killed more like the seasonal flu or car accidents. The time has come to shift from panic mode to manage mode. We have to realize this has been a totally different problem for people who are older and/or have comorbidities than it has been for people who are younger and/or do not. In the US, we have to realize this has been a totally different problem in a few parts of New York and New Jersey than it has been in most of the rest of those states and most of the rest of the country.
In writing this, I relied on some numbers that I am assuming are mostly valid. I have linked to the sources for these numbers in the body of the text. I am also assuming that there are no significant long-term impacts for those who are infected but recover from COVID-19 as that could materially change my perspective on the matter. There are certain things I do not think should be re-opened such as offices that can operate remotely without significant consequence and schools that can do the same. We should continue using masks, gloves, washing our hands, not touching our faces, and being respectful and responsible in public. I personally will not be going out much in the beginning once restrictions are lifted, whenever that is. I am fortunate not to need to do so in order to maintain the satisfaction of my fundamental needs. I will continue to try to support people and small businesses without going out and potentially contributing to the spread unknowingly. My perspective as far as I know is not driven by any selfish desires to get “back to normal”. I stand by what I wrote previously. There is no going back. These are just my opinions. I have a number of thoughts regarding solutions that I look forward to hopefully sharing another day. If anyone has any respectful critiques of my perspective, I would genuinely enjoy getting to consider them. As always, please send any questions or comments to email@example.com or feel free to comment on Twitter @blogofjake. As always, my opinions are subject to change. This is where I stand today.