MUSINGS: COVID-19 - "Abundance of Caution" | "Abundance of Fear"

As discussed a few days ago, there is remarkable fear out there with COVID-19. Last night, as I was checking out the news, I clicked on Drudge Report to see what's going on in this world and got that screen above.

Wow. What a time we live in. I suspect if we checked Drudge on September 11, 2001, the top part of the screen with numerous headlines would have all been about the same topic as well!

Unfortunately, parts of Europe are not faring as well as others. Italy and Spain particularly. As of this afternoon, the death toll in Spain sits at 1,093 vs. Italy at an unfortunate 4,032. As per previous discussions, age is an important variable; the population in Spain of 65+ sits as 17.1% vs. Italy at at >20%; I suspect this alone will make a huge difference in terms of mortality in a population where there is broad spread and especially strained medical care. France with about 12,500 cases and 450 deaths seems to have an intermediate death toll so far compared to the other nations in Europe.

Notice the variation among the countries. Germany's numbers are impressive with 68 deaths and about 20,000 total known cases. As I discussed last time, I don't think the total number of known infected is that important at this point given that pandemic spread and community transmissions are widespread; given enough time, vast percentages of the population will be infected. Note that Germany has quite an older population as well with >20% 65+ like Italy. Clearly they're doing something right when it comes to limiting spread and improving care for those infected. When the crisis is over, I'm sure there will be thousands of articles published on public health policy in "shutting down" the virus at an early stage and health care system advantages/disadvantages. Also, I'm sure we'll be seeing all kinds of interesting comparisons in the academic literature comparing how well the Asian countries have fared (esp. Japan, S. Korea) thus far compared to Europe and N. America.

Let's talk about the fear out there...

First, let me say that I am in no way trying to downplay the seriousness of what is happening. Obviously the effects of this virus needs to be mitigated. Follow the recommendations of the Public Health officials locally.

Having said this, I wonder whether news site headlines and images like the one above with people in biohazard suits pulling a guy on a stretcher also in a biohazard suit is clearly too dramatic and potentially doing harm to the cause... What's the point? Is it to impress upon people the seriousness of the situation? If it is, what's the message exactly? That even if you're protected, still be careful because COVID-19 "spreads in shadows" like the news item at the bottom? Let's stay calm folks, YOU'RE NOT (in all likelihood) GOING TO DIE from this!!!

Remember, just like everything else we consume in the media, make sure to read the news with some emotional detachment while maintaining perspective so as not to be overwhelmed by fearful headlines clearly designed to stoke anxiety (and website "hits"). Remember that on many news sites like this one, they're collecting items from numerous sources which may or may not reflect the situation locally for you; a good example is the "testing chaos" article where the Wall Street Journal reporter jumps between states and gives examples of inconsistencies but we're not given a clear perspective by the end of the article. What's the point of an article like this except to instill fear and doubt? Unless you live in those states, towns or cities, in those particular areas, this is not useful is it? Remember that the purpose of testing will change over time.

In the early phases of an outbreak, it's good to have testing available to catch as many cases as possible to start containment and halt spread. This early model of "massive free testing and treatment" was what worked in South Korea along with rigorous contact tracing to limit spread. Alas, here in North America, we are beyond that point now as we are already in a sustained community transmission phase where it's fair to say that tens of thousands plus people are now walking around already having been infected but unaware (remember that for many, the disease is mild or asymptomatic - around 20% for these studies had no symptoms).

With a disease that has no specific treatment (ie. unlike say HIV or Hepatitis C), nor immunization (like the seasonal flu), nor prophylactic drug available (eg. valacyclovir to prevent recurrence of herpes), testing availability at this point is not limitless and should be reasonably rationed to those who might spread the disease to the vulnerable (ie. health care staff), for confirmation of symptoms especially if needing hospitalization, special situations like investigation of an outbreak or within nursing care facilities where residents cannot self-quarantine. This is why Canada's prime minister Justin Trudeau has not been tested (last I heard) because his wife is known positive. So long as he is asymptomatic, self isolation is the treatment already regardless whether a test comes back positive or not.

It's becoming time to assume that SARS-CoV-2 is widespread and eventually is going to affect most of us before the availability of a vaccine. This is in essence the point in the article about how in California "56% will be infected". What the headline here missed is that they're talking about "over 8-week period" which is the scary part if true. It suggests that the California governor believes the current health policy of "shelter-in-place" started in San Francisco would fail and potentially overload the health care system with cases over the next 8 weeks! Hopefully this is not the scenario that plays out...

What would be "good" is to achieve that "flattening of the curve" where instead of 8 weeks, the infection rate is slowed and even if 50% of the population is to be affected, this is over something like 3+ months so the health care system does not become overwhelmed. Ideally, long enough until an efficacious vaccine is available to prevent further mortality and morbidity. Remember, as more people are affected, "herd immunity" builds up and viral transmissions slow. The initial "hit" is the most painful since the population is naive to the illness. With subsequent waves, hopefully the illness transmission drops and severity will ebb.

If we look at those article headlines, we see the other major anxiety of the day - the economy. Jobs. Financial stress.

I suspect it's going to be VERY important in a couple of weeks once the initial "tsunami" hits North America that we start focusing attention on the wisest way to re-open up. Remember, without at least some semblance of a functioning economy for extended periods of time (say >1 month), we're looking at huge pain ahead. Central governments backstopping bankruptcies, financial injections to stabilize currencies and debt obligations, subsidizing salaries, delaying tax collection, etc... will come with consequences down the road as all this needs to be unwound eventually. Nothing is truly free even if it comes from the government. The US has a GDP of almost $20T/year, and Canada $1.7T; with these kinds of numbers, even if we're asking central governments to backstop 50% for a month, that's $0.83T in the US and $71B in Canada worth of aid. This money is not "stimulus" proper, just temporary funding to keep the lights on and a roof over the business or the individual... And if businesses cannot restart at a reasonable pace, there will be permanent losses beyond the situation now.

In a world where savings are tight, the younger folks have less secure jobs, many working in "gig" arrangements, and good jobs with good benefits and pensions have been dwindling, this economic shutdown with be painful. No decent amount of government "relief" will be able to repay the productivity lost if this is prolonged for "months" as some have even suggested.

That ultimately appears to be the terrible dilemma governments will need to face... At what point after the initial COVID-19 wave would it be good to open up economic activity in a paced fashion that allows the young and healthy to resume economic productivity?

The earlier this is done, the more it will benefit the young and healthy. They will likely pick up more shifts if needed, take on more responsibilities, perhaps advance up the corporate ladder to take over positions once held by older folks nearing retirement, or those with chronic health conditions who need to remain in longer isolation until herd immunity is built. I suppose this can be seen as a form of enforced "succession" in some companies, or early retirement for those nearing the time. Let's not forget that something like 80% of seniors have their savings locked up in illiquid assets like their homes and RRSP/401Ks in stocks which IMO will never recover to the peaks of late February at this point - remarkable how things change! As such, many who were expecting to retire comfortably will need to reevaluate their expectations if we end up trapped in a perpetual deflationary spiral. Regardless of what risks might need to be taken to open up, the key here is that the health care system must be able to handle a steady stream of sick, but hopefully younger and more resilient individuals while those at high risk of death remains in self-isolation longer.

To take a safer trajectory and open up the economy later will benefit the older and those with chronic medical conditions. Obviously, if one keeps everyone in isolation until a highly efficacious drug is found or if new cases dwindle near zero, this will be best for those most at risk with hopefully minimum mortality. The cost of course will be to the otherwise young and healthy, as well as massive costs to the public purse if this freezing of activity persists for months. This is why on a grand scale, we must get a handle on mortality and morbidity risks and rates (basically the main point of my previous post). Absolute risk reduction is likely impossible if it means prolonged closures like this and I suspect that a prolonged shutdown will result in countless unexpected harms down the road for those who are not going to die from COVID-19 (already warnings about mental health impacts). Lives lived in perpetual fear rarely brings with it satisfaction, much less rewards.

Well folks... I think the next 2 weeks will be very telling here in North America. With all these precautions in place, hopefully the mortality rates do not turn out to be beyond expectations (low, and primarily confined to older and very old segments of the population). Furthermore, with the amount of time and foresight looking at the Asian response, let's see if central and regional governments can get their act together in a "good enough" fashion - I actually remain quite optimistic despite all the fear in the media as collected above.

Time to "hunker down" for the next 2-3 weeks - this will suck - but I think answers to the dilemma of balancing heath care and economic activity will become top-of-mind in the next month. I suspect the decisions made then will potentially having even more impact than COVID-19 itself for years to come.

Alas, my Spring Break "staycation" has been cut short to get back to the hospital in preparation for the "tsunami"/"hurricane" ahead. Today (Friday March 20, 2020), here in Vancouver it's actually eerily quiet as acute care is discharging all those that do not need to be in hospital. All elective surgeries cancelled. Our largest emergency department in the province this morning unusually almost empty. "Calm before the storm"? We'll see soon enough... And with any luck, it won't look as bad as what's happening in Italy, Spain, or France.

Stay safe. Stay cautious, but don't let caution's psychological "shadow" take over and be attacked by an abundance of fear and panic.

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Addendum - March 22, 2020

I got this message from a friend in Germany yesterday. Some interesting observations about the German coronavirus data (today, almost 25k cases positive, 93 deaths):


Hey Arch,

Been pleasantly surprised by your Corona-blogging. Very informative & well written!

With regards to the German numbers - apparently Italy does post-mortem testing while Germany does not. So some case might evade the statistics.

Secondly apparently there is widespread testing in German on the scale of about ≥1000 per day allowing for early detection and isolation. There is some confusion about the validity of this number so take it with a grain of salt.

Thirdly southern Europe has much more intergenerational living and hence more transmission pathways from young to old and vice versa. Such living arrangements are uncommon in Germany (see below though).

Lastly parts of the German population live in relatively low population density areas.

Part of the reason for this is the so called "Pendlerpauschale” or commuter tax relief of €0.30 per km. Lamented by the Greens for years this subsidy of the German automotive sector makes it more attractive to live on the countryside.

The Greens call it “Zersiedlungspauschale” - one of those intranslatable German composita - basically “Siedlung” is settlement, the prefix “Zer” is to spread out and pauschale is an allowance. Paying people to settle far apart is closest to the gist of it.

The situation is quite surreal really. My partner and I early on started to prep and are well stocked. Since last Saturday we are staying in and only go outside for some gymnastics in the park. As academics with no kids we are privileged to be able to work from home. Many colleagues have more challenging situations, espc. with younger children. So far we haven’t had any Covid-19 cases in our social contexts or at the universities but I don’t trust these numbers.

Berlin not yet has a lockdown but I am certain it will come soon. As I can observe and also hear from friends many people roaming outside and espec. I am seeing some of the Arab and Turkish migrant milieus not having visibly changed their behaviour - i.e. don’t adhere to the social distancing recommendations.

Since they often live in comparably small and intergenerationaly shared apartments we might see some espc. problematic dynamics here. I am not aware of any stats differentiating between “ethnicity” for Germany so we might not get any numbers validating or invalidating this hypothesis.

Politically Merkel so far has benefited, she is relatively weak on policy in normal times but an excellent crisis manager. Glad the far right which had a considerable surge the past month appears totally lost on this and I hope it stays this way. Economically the repercussions will be severe and I fear the worst for the European Union. It might not survive this storm.


Thanks for the note!

Good discussions about the complexity of this pandemic and how we do need to consider all aspects of the medical system including how numbers are generated for stats and societal variables including intergenerational living arrangements, cultural differences among immigrant populations, etc... Important to know because this is where public health policy will need to target the message to these populations. Here in Vancouver for example, the homeless and "Downtown Eastside" population are highly vulnerable and will need stronger measures such as testing and ensuring health care availability.

My friend could be right, repercussions may even affect the geopolitical level with considerations like the fate of the EU held together by very disparate states; some will be much more economically distressed than others with good reasons already!