‘This Is an Impending Catastrophe’
This is an overreaction.
That was my first thought upon receiving an email from my son’s college earlier this week informing me that he had to leave campus within five days due to the threat of Covid-19, or coronavirus. All of his college classes are being moved online, and all students are to leave their dorms for the duration of the school year. His long-anticipated freshman year in college will now be completed in his bedroom — upstairs in my house.
Is this really necessary?
Exasperated, I called my older brother. Why, I asked, are we doing all this for a flu? And why close schools that are full of young people, who reportedly only suffer mild symptoms from coronavirus?
My brother was not impressed with my take on the pandemic. He proceeded to walk me through the issues and matter-of-factly school me in the cold calculus of exponential disease spread and its consequences.
I admit that my brother knows a little more than me about such things. Steve Goodman, MD, MHS, PhD, is an associate dean at the Stanford School of Medicine, where he is Professor of Epidemiology and Population Health, and Medicine.
As I listened intently to my brother’s explanation, I thought about how others, including my similarly skeptical friends, would benefit from hearing this. Steve graciously agreed to continue our conversation on the Vermont Conversation, a public affairs radio show that I host. Less than 12 hours after this episode of the Vermont Conversation aired on March 11, 2020 on WDEV/Radio Vermont, it became the most shared podcast in the eight-year history of the show.
The following is adapted from our discussion on the radio.
Elemental: Just in the last day, I’ve had several conversations with intelligent people who echoed what I said to you: Closing schools is an overreaction. How do you respond to that?
Steve Goodman: Well, this is the luxury of having lived in a society that has not faced something like this in almost a century. We’ve already seen what’s happened in China, Korea, Italy, and now all over Europe. This is about exponential growth. If you wait to make a move until it’s clear that there’s something to worry about, it’s too late. If one is wondering whether one needs to take extreme measures, that’s exactly when you take extreme measures.
So with very few cases here in the U.S., I’m not surprised that folks who have not studied the numbers are wondering whether these measures are really needed.
Let’s look at China, where there were initially two cities that took action. Wuhan started taking what we would consider to be extreme measures when they had about 500 cases and 23 deaths, which is comparatively nothing in a city of 11 million. Their epidemic got totally out of control and the world is now dealing with the consequences of that.
Another city, Guangzhou, started making its moves when there were just seven cases and no deaths. The peak of the Guangzhou epidemic was less than 1% of the Wuhan outbreak. Once you’re in an epidemic, once you notice what’s going on, you are already in an exponential growth situation and you’ve lost control of the epidemic.
We have a completely virgin population in the U.S. The number of infections is likely doubling every six days. And there’s an invisible reservoir that we’re not seeing because of the lack of testing and because the symptoms are mild in many people.
If one is wondering whether one needs to take extreme measures, that’s exactly when you take extreme measures.
How is coronavirus different from the conventional flu?
That’s a great question. It’s a flu in the sense that it’s highly contagious. Some of the symptoms are quite similar, such as fever, cough, and respiratory distress. But there are two huge differences with the flu. The glaring one is the case fatality rate. The case fatality rate for the flu is estimated to be about 1 in 1000, or about 0.1%. The case fatality rate for coronavirus is unclear because of the lack of testing, but it is probably around 3% for those who are seriously ill, and somewhere closer to 1% for the general population — which is still 10 times the fatality rate of the flu.
So right away, 10 times as many people infected with coronavirus will die compared to those who get the flu.
Then you have the issue of who gets sick. The number of people in the United States who can get the flu is actually limited. We already have about 15 million cases of the flu in the U.S. this year, which represents about 5% of the total population. But we have flu shots and we have years and years of partial immunity built up over exposure to the flu. So not everybody in the country is susceptible to the flu.
Right now, 100% of this country is susceptible to the coronavirus. So we have a virus that’s probably in the range of 10 times as a fatal and potentially a population that is 20 times bigger in terms of susceptibility. That could mean over a million deaths from Covid-19 in the U.S.
Now that’s an extreme number, and it may not be that high, but that’s why people are scared. Angela Merkel and some other European leaders have been saying that between 40% and 70% of their population is going to be infected. Whatever the peak, it’s likely to be higher than the 5% for the flu.
So coronavirus is different in those two ways: It kills a lot more people among those who get infected, and it’s going to infect a lot more people.
The official statistics (as of March 11, 2020) are that the total number of cases of coronavirus is just over 1,200, and about 37 people have died. Do these numbers bear any resemblance to what you think is actually going on?
The number of deaths is probably accurate. The number of cases is a joke.
We are testing almost nobody. The Koreans are testing around 10,000 people a day. The number of tests in the U.S. is just a few thousand over all the weeks and months that we’ve had this. So we have no idea how many people are actually infected. About 80% of people will have pretty mild symptoms, particularly the younger you are.
The criteria for being tested right now are that you have to be pretty sick. At Stanford right now, you cannot get tested if you’re not hospitalized or if you are not a candidate for hospitalization. That’s because too few tests are available. As more tests come online, they will broaden those criteria. Testing the sickest does nothing for people who want to know if they’re infected so they can protect all the people they’re in contact with.
Given that the epidemic is completely unchecked at the moment and is doubling every six days, the number of cases will multiply by about 1,000 in two months if nothing is done.
Let’s talk about testing. The World Health Organization cited what it called the inaction of governments to respond as one reason it was declaring this a pandemic. The New York Times reported a story about how the Centers for Disease Control ordered a Washington lab to stop testing for coronavirus. If this is an emergency, how can it be that the CDC is trying to shut down opportunities to test for this? And I understand that the CDC initially rolled out a botched coronavirus test.
The lack of testing and lack of urgency and not aligning all the elements of the country very early on reflects a lack of understanding at the top of what is coming. They failed to convert to an emergency pandemic mentality, which should be like being on a war footing. And the dismantling of the public health pandemic response apparatus within the National Security Council over the past two years has greatly contributed to this.
This is an impending catastrophe. We have a tsunami that is rolling in. The depth of the ocean at our feet at the beachhead is only a few inches right now, but it’s rolling in.
Fox Business Network host Trish Regan charged that “the coronavirus scare” is an effort to create massive hysteria to spark a market sell-off and hurt President Trump. She calls it the new impeachment. And Trump is saying this may all “miraculously” go away by April. What is your response to that and what are the real-life effects of that kind of messaging?
The shift from a sense of normality to a wartime footing — when a lot of the normal rules of life have to be changed — takes leadership. It takes somebody addressing the nation and saying this is what we face, this is what we need to do. And the lack of that from the country’s president makes it very difficult for people to accept the seriousness of what’s going on and decide on their own what their response to this epidemic will be.
This pandemic will require profoundly changing the way we live, for a little while at least. We can’t do that if we don’t have an atmosphere of collective commitment and sacrifice. It’s going to be a burden. It’s going to be very difficult. It’s difficult right now — and we’ve seen nothing compared to other countries.
What can we reasonably expect that public health measures can succeed in doing?
The meme-able phrase is to “flatten the curve.” We cannot stop this in the sense of preventing many, many thousands of people from getting sick and dying. But we can affect how many thousands and how fast that comes. “Flattening the curve” means spreading out the cases over a longer period of time and keeping the peak lower so our health care system can accommodate it.
This epidemic threatens to overwhelm our hospitals. At our current rate of infection, there will be more cases than we have ICU beds. If we can slow it down and spread it out, we can manage it and keep the fatality rate lower than it would be if we overwhelm the health care system. That’s the most we can hope for.
We began this conversation by asking whether closing schools is an overreaction. Hard to know. I’m much more worried about under-reaction. Because when the infection doubles every six days, the failure to act is much, much more serious than the inconvenience of overreacting.
I would love it if we look back in a month or two and say, “the worst did not happen.” Because if the worst does not happen, maybe that will be because we took the actions we’re taking now.
The coronavirus outbreak is rapidly evolving. To stay informed, check the U.S. Centers for Disease Control and Prevention and your local health department for updates. If you’re feeling emotionally overwhelmed, reach out to the Crisis Text Line.