The COVID-19 coronavirus pandemic is a global health and economic crisis unlike anything in living memory. Although we’re “all in it together,” as the saying goes, the issues in play have caused an incredible amount of division. Since the middle of March, I’ve encountered more confirmation bias than I’ve ever seen in my life. An array of opinions ranging from conspiracy theory-fueled skepticism to an almost fanatical dogmatism make finding and articulating a balanced position an extremely precarious task. Social media discussions — which are the only discussions most people are having during a time of mandatory social distancing — have become virtual minefields. The fact that nobody has enough information on this virus — including the medical community — has certainly not tempered our appetite for (often highly-contentious) debate.

In a way, this is all understandable. There is a great deal at stake, and a lot of justifiable fear. Which is why discarding popular narratives, keeping goalposts fixed, and challenging assumptions should be a part of any reasonable approach to understanding the topic.

The facts, and only the facts — however hard it may be at times to find them — are going to tell us what we’re really up against.

Despite concerns that some deaths are falsely being attributed to COVID (and a fair share of fake news helping to amplify that theory), we know from past pandemics that the reported numbers are likely to be lower than reality. In fact, there are already some indicators that this is happening. But to look at a recent a historical example, the 2009-2010 H1N1 pandemic is demonstrative of how this might play out. Though the original global death toll for that outbreak was believed to be fewer than 20,000 people, researchers who went back and studied case records ended up revising the estimate to over ten times that amount. Why? Because epidemiological data isn’t as clean and clear as we’d like it to be:

As the end of the swine-flu pandemic was announced in 2010, the World Health Organization (WHO) reported the death toll was about 18,500, but the organization warned that the figure reflected only the minority of cases that were confirmed by lab testing.

 

“This modest number has caused many to wonder what all the excitement was about, and some to question whether the pandemic response was excessive,” the researchers who worked on the new study said.

 

For the study, the team obtained weekly virology data from WHO to identify periods when the flu was active, and then combined this information with weekly death rates from respiratory illnesses during 2005 and 2009 in 21 countries, accounting for about 35 percent of the world’s population. They then extrapolated those results to the rest of the countries in the world.

 

The results suggest that between 123,000 and 203,000 pandemic influenza respiratory deaths occurred globally from April through December 2009.

 

The researchers took into account only deaths caused by respiratory diseases. However, people can die from bacterial infections that happen after they’ve been weakened by the flu. The H1N1 virus can also kill by worsening existing health problems, such as heart disease. The researchers found that when the H1N1 deaths due to causes other than respiratory disease are included, the 2009 pandemic toll might be as high as 400,000 people.

A lot of people scoffed when President Trump said in March that 100,000 deaths in the United States was an optimistic number – indicative that the government had done “a very good job.” Even he went back and lowered that estimate to 60-70,000. The problem is that as of this writing, we’re already at a total of 69,011 US deaths, causing the president to revise the estimate again, bringing it back up to at least 100K yesterday. In fact, with a partial re-opening of the economy and some relaxation in social distancing practices, we’re statistically on track to hit that number by the end of this month.

While it seems clear that we have managed to “flatten the curve” — the phrase used to describe how social distancing and other restrictions can stop a rapid spike in the number of infections — the case numbers and their related deaths continue to increase. The lowest number of US deaths we’ve seen in the past 7 days was yesterday, May 3rd, with 1,154 reported. The highest was April 28, with 2,470. We haven’t had fewer than a thousand COVID-related deaths per day since March 30th. And the number of daily deaths may actually be headed up, not down:

As President Trump presses for states to reopen their economies, his administration is privately projecting a steady rise in the number of cases and deaths from coronavirus over the next several weeks, reaching about 3,000 daily deaths on June 1, according to an internal document obtained by The New York Times, nearly double from the current level of about 1,750.

 

The projections, based on modeling by the Centers for Disease Control and Prevention and pulled together in chart form by the Federal Emergency Management Agency, forecast about 200,000 new cases each day by the end of the month, up from about 25,000 cases now.

 

The numbers underscore a sobering reality: While the United States has been hunkered down for the past seven weeks, not much has changed. And the reopening to the economy will make matters worse.

There are things we know now that we only suspected weeks ago. The fact that all the major intelligence agencies believe that the virus leaked from a Wuhan bioweapons lab, for starters. With indications that China may have spread the virus intentionally, there are now escalating cold war tensions — up to and including whispers of armed conflict — between the US and China.

The geopolitical ramifications only complicate an already precarious public policy response. Opportunistic government officials have, to varying degrees, taken tyranny for a test drive, using the pandemic as pretext. Reports of ludicrous policies, videos of law enforcement harassing or arresting people for trying to hold together some semblance of normal life, and a growing fear that basic rights will be permanently revoked are all fueling the debate over how to properly deal with a threat that would have caused massive damage if we didn’t react, but arguably more because we did.

Neither the economic consequences, the ramifications for civil liberties, nor the public health consequences can be dealt with independently of each other. Each plays a major role in evaluating the efficacy and consequences of the response.

One of the most chilling and prescient evaluations of what we would be facing came via a series of tweets from computational/system biologist and “pandemic response modeler” Francois Balloux. They were published on March 14th — a day when the United States had only 2,664 known cases of the virus and just 10 deaths. “After having spent considerable time thinking how to mitigate and manage this pandemic,” Balloux wrote, “and analysing the available data. I failed to identify the best course of action. Even worse, I’m not sure there is such a thing as an acceptable solution to the problem we are facing.”

He went on to say that

The covid-19 pandemic is not just an epidemiological problem. It is a ‘Global Health’ problem, that can only be tackled with an integrated and global approach. For example, there is no such thing as a choice between managing the pandemic vs. protecting the economy.

Health and the economy are closely linked. The correlation between per-capita GDP and health (life expectancy) is essentially perfect. If the covid-19 pandemic leads to a global economy collapse, many more lives will be lost than covid-19 would ever be able to claim.

Just today, I saw that he’s still writing about the challenges of finding the correct balance in our response:

#COVID19 is a complex optimisation problem with many unknowns. Paradoxically maybe, the two high-risk strategies in terms of years of life lost are to ‘let the epidemic loose’ and to ‘suppress it’. Intermediate mitigation strategies are actually more prudent (i.e. bet hedging).

This is a virus we don’t properly understand. I’m not a doctor, obviously, but I can tell by reading — and reading between the lines — that the medical community remains perplexed about the full scope of this virus and its effects, to say nothing of identifying an effective course of treatment. We don’t know if there will be a second wave in the fall, but there’s reason to expect one – and it may very well be worse.  Reports that the virus isn’t mutating much are a positive sign, despite concerns, for the possibility of both immunity and vaccine effectiveness. According to studies in Britain, people are developing antibodies to the virus, although they still don’t know if that’s enough to stop reinfection. There are indications that hundreds of tests indicating reinfections in South Korea had to do with testing errors, which is another sign of hope. Even if a workable vaccine is created, however, there is an increasingly fearful and untrusting portion of the public, many of whom are already wary of vaccines, that isn’t exactly eager to inject a government solution.

There’s so much to consider, and no easy, clear path forward.

We are, as a society, being faced with decisions that can only be prudently made with the benefit of hindsight. There is so much that is unknown about the outcome of various courses of action, but to fail to make those choices now means that we will almost certainly make them too late. As jobs are lost and businesses are closed, we recognize that we have to do something to stop our decline before it’s too late. But we also have no choice but to accept that doing so won’t drop the number of infection cases and deaths, and will very likely bring them up even further.

The Wharton School of Business at the University of Pennsylvania has created a web-based data modeling tool that projects both economic outcomes and public health outcomes under several different approaches. Of course, projections aren’t perfect, but they help give us a picture of what we’re up against. In this case, the modeling is showing us a best-case scenario of 116,523 US deaths by the end of June if we maintain the restrictions in place as of April 30th and current social distancing.

The worst case scenario, if we open everything and relax distancing procedures? Roughly 900,000 US deaths in that same period of time.

The tool’s prediction for today’s US death total, by the way, was 63,302 deaths — approximately 6,000 short of the actual total for the day so far.

The application also projects changes in GDP based on the same set of assumptions. In the restrictive, best case (in terms of public health) scenario, it models a 11.6% drop in GDP by the end of June. If we open everything and embrace a far higher death toll, that number drops to an 8.1% loss. We’re going to take a hit no matter what we do, so the question remains one of proportionality.

For those treating this like a binary issue, I suggest that that’s the wrong way to look at it. It’s not EITHER you support public health measures OR you care about the economic devastation and civil liberties. It has to be both. How well we walk the tightrope between them will determine a great deal about our future.

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