A Washington Post contributor asks this morning, “Is this the morning that Trump panics about COVID-19?” The article points out that, since moving into the White House, Donald Trump has minimized every crisis—whether it’s a hurricane, a wildfire, or a looming war—because he doesn’t want people to associate anything bad that happens with his time in office. And this may be a mercy. After all, the last thing people dealing with an emergency need on top of everything else is a reminder that their lives depend on Donald Trump.
But with COVID-19, many, many lives depend on Trump. This is a hurricane that is likely to strike everywhere across the nation. We can see it coming. We don’t know whether it’s going to fade to a tropical storm, or roar in as a Category 5. But that it’s going to hit is almost inevitable. Almost. The world is teetering at a tipping point.
Today’s the day that I’m going to do what I’ve held off doing from the start—look at the possible range of effects from an unchecked global COVID-19 pandemic. I’ve held off because until the last few days, I’ve thought the odds were against such a pandemic occurring—and honestly, I still lean toward there being no such event. The window may be closing, but it’s not shut. Avoiding disaster still seems possible.
However, at this point it seems dishonest not to look at why this virus presents a threat unlike that of a bad flu season, unlike that of even something as awful as Ebola. Going back to Feb. 11, Hong Kong’s leading public health epidemiologist, Gabriel Leung, warned that what was visible of the coronavirus epidemic was the “tip of the iceberg.” In an attempt to determine the size of the titanic impact ahead, Dr. Leung estimated that potentially 60% to 80% of the world population would be infected with the the virus behind what’s now called COVID-19.
Three days later, Harvard School of Public Health epidemiologist Marc Lipsitch made a similar estimate. “I think it is likely we will see a global pandemic. If a pandemic happens, 40% to 70% of people world-wide are likely to be infected in the coming year.”
On Friday, World Health Organization Director General Tedros Adhanom Ghebreyesus said of the possibility of preventing a pandemic, “The window of opportunity is still there, but the window of opportunity is narrowing.” U.K. epidemiologist Paul Hunter followed up with, “The tipping point after which our ability to prevent a global pandemic ends seems a lot closer after the past 24 hours.”
On the same day, Johns Hopkins Center for Health Security epidemiologist Jennifer Nuzzo was more blunt in her assessment: “I think we should assume that this virus is very soon going to be spreading in communities here, if it isn’t already, and despite aggressive actions, we should be putting more efforts to mitigate impacts. That means protecting people who are most likely to develop severe illness and die.”
So what does all this really mean? What follows is a back-of-the envelope analysis of “How bad could COVID-19 really be?" It's going to be long. It's going to be grim. If you don’t want to take that ride, please check out now. It’s a lovely, globally warmed winter day in much of the United States. Plus, there are puppies. Go and find them. But if you're sticking around, here we go.
To begin, this is not a time to panic. Because it's never a good time to panic. However, it is a time to consider what it will mean if there is actually an unchecked global pandemic of novel coronavirus. Think of this as a time to plan more seriously.
Again and again, experts (as well as "experts") have reminded us that the flu already infects millions of Americans each year, causing 10,000-60,000 deaths, and that the flu is a more immediate threat for Americans. This is absolutely true, for a very narrow definition of “immediate.” Get your flu shot. Of course get your flu shot. What are you, a Trump follower? Get your flu shot! But recognize that the massive number of flu cases each year is already constrained because many people do get their flu shots, and there is also a reservoir of residual immunity.
For COVID-19 there is currently no vaccine. There is also absolutely zero immunity out there among the population. That is why estimates of an unchecked epidemic range from 40% to 80% of people becoming infected by the virus. That's an order of magnitude greater than infections from the flu. That number is going to make all the difference.
In the case of the flu, the Centers for Disease Control indicate that 9.3 million to 45 million Americans are infected each year, resulting in 140,000 to 810,000 hospitalizations. So about 1%-2% of flu cases are sufficiently severe to require hospitalization. Those millions of cases result in between 12,000 and 61,000 deaths each year. Put it together and that's a case fatality rate (CFR) of 0.13% overall, or 8% for hospitalized cases.
How that compares to COVID-19 still requires some guessing. Right now the overall case fatality rate works out to 3.3%, not the 2% that gets repeated endlessly in the media. There are good reasons to believe it will settle around 3.5% (I’ve done the math … which I will go into on another day). But is that comparable to the CFR for hospitalized cases of flu? Overall cases? The answer is likely neither.
Experience on the unwilling human Petri dish known as the Diamond Princess cruise ship indicates that half the cases on board had few to no symptoms. That may be true everywhere. Of course, some of those cases are still being caught by healthcare workers trying to track down the sources of infections. Any number for how the number of cases corresponds to the total base of infections requires an estimate, so … we still need a new number.
Dr. Marc Lipsitch, the guy who was up there with the 40%-to-70% infection rate number, provided an estimate that the number of actual cases of COVID is likely 10 times what is being caught. So let’s take that. Scary as the thought that actual infections out there in the world are already close to 800,000 may be, that cuts the overall case fatality rate to 0.35%, which seems a lot better—until we look at what that really means.
In the United States alone, an unchecked COVID-19 epidemic would be expected to infect 130 million to 260 million people. Based on the experience in China and around the world, 20% of confirmed cases have been critical or serious. That’s 26 million to 52 million. Cut that by 10, and it’s still 2.6 million to 5.2 million hospital beds. Except there are fewer than 1 million hospital beds available in the United States. So that's daunting.
And even with the CFR cut to 0.35%, the overwhelming number of infections means that the next number requires a serious pause. Because it means that the number of deaths from COVID-19 in the United States alone would be (deep breath) 450,000 to 900,000.
This number is comparable to the 1918 flu epidemic, in which 500,000 to 675,000 died. That flu was far deadlier, but the population was two-thirds smaller then, so the total number infected was around 29 million. The same kind of numbers pop out when you look at the possibility of an unchecked COVID-19 pandemic around the world. Total deaths could be expected to be from 11 million to 25 million. Again, this is pretty similar to the 1918 numbers. And again, that's because the larger number of people infected overcomes the lower CFR.
And understand that this is taking a good projection, one that assumes we’re really missing nine cases out of 10 when calculating the current CFR. Because if we’re not, all those numbers above go up to values that are, frankly, unimaginable. Or at least to values I do not want to imagine. Numbers like 5 million deaths in the United States. A quarter of a billion worldwide. If we do not divide by 10, the case fatality rate for COVID-19 is twice that of the 1918 flu.
Now that I've cranked up the panic-o-meter to 12, let me dial it back several notches: This is not going to happen. It's simply not. Governments are moving to prevent the kind of unchecked pandemic that was seen in 1918. And they've gotten much better at this. Every effort is being made to slow the spread of the disease, to isolate outbreaks, and to prevent general exposure. Even in Wuhan, where the infection began, the case count appears to be less than 1% of the population. Actions can be extremely effective.
Go back to the Jan. 27 South China Morning Post and look at the predictions that were being made:
The team’s model predicted the number of infections in five mainland megacities – Beijing, Shanghai, Guangzhou, Shenzhen and Chongqing – would peak between late April and early May. At the height of the epidemic, as many as 150,000 new cases would be confirmed every day in Chongqing, because of its large population coupled with intense travel volume with Wuhan.
These kind of scenarios now seem extremely unlikely precisely because actions taken in Hubei have been successful at largely containing the wildfire of infection that had been burning through Wuhan, and other provinces have taken prompt—and sometimes brutal—action to nearly halt new cases in many parts of China. For a solid week now, the number of cases recovering in China has exceeded the number of new cases diagnosed. Rather than racing toward 150,000 new cases a day in a single city, the whole of China is below 500 cases a day. There are also multiple teams working on a vaccine, with some predictions that human trials may start in late spring.
That’s what makes the big chart bracing … but encouraging.
Day after day, the total number of cases of COVID-19 is being driven down. It’s hard to find fault with that.
Of course, the reason that every expert on the planet seems to be saying the phrase “tipping point” in the last 72 hours isn’t what’s happening in China. It’s this:
In the last two days, South Korea has displaced the Diamond Princess as the largest epicenter of disease outside China. At the same time, Italy has moved ahead of Japan. Both nations have seen growth that mimics the expansion of COVID during its original outbreak in Hubei. And while it’s still lurking off to the right, Iran represents a genuine unknown whose actual number of infections is likely to be hundreds, or even thousands, greater than this chart would indicate. Enough cases are turning up in enough places that the whole format of the chart is becoming unsupportable.
Those doomsday scenarios above? The ones with millions dead? They are extremely unlikely. The world may be tipping; it’s just not tipping that direction.
What is likely to happen is that concerns over the possibility of an outbreak will lead to the kind of local quarantines, shutdowns, and travel restrictions now being seen in Italy, South Korea, and China. This is likely in many nations, including the United States. At this point, it is very unlikely that this whole issue is just going to vanish smoothly without bringing disruption to your life—wherever you live. That doesn't mean catching COVID. It means that governments are going to take steps to prevent that. Some of which will suck.
These actions are likely to be the subject of political debate, and deservedly so. Making the right decisions in a situation like this means trusting science and having knowledgeable advisers, and neither of those things is exactly in vogue at the White House. Going way back to that “Is this the week that Trump panics?” article, expect actions that are both unnecessary and frustrating in addition to those that are genuinely helpful.
So hang in there. Watch the news. Wash your hands. Check out Ready.gov to make preparations that you really should be making in any case, and consider what it would mean for your family if you couldn't make that holiday trip across the country, or if the kids needed to be home from school unexpectedly for a few weeks. And don't hit me for saying this again, but Don't Panic.
When something like 9/11 happens, it divides the world into before and after. That doesn’t necessarily mean millions of people die. It doesn’t even mean someone you know gets sick. But everyone is affected: Everyone has their lives knocked off course, their thinking reset. Take a look around you … this is before. There’s still a chance that those terrorists—those extremely tiny, beta coronavirus terrorists—never board that plane. Still a chance that governments around the world stop this thing in its tracks. But if I’m being truthful, that chance is a small one.
And … that’s done.
Except for this last note: I'm not an epidemiologist. I am a writer and a part-time paleontologist with a special interest in cartilaginous fishes (Acipenseriformes for the win!). So don't listen to me. But do listen to the CDC, WHO, and your local health authorities. Also … wash your hands again.
World Health Organization 2019 Coronavirus information site.
World Health Organization 2019 Coronavirus Dashboard.
2019-nCoV Global Cases from Johns Hopkins.
BNO News 2019 Novel Coronavirus tracking site.
Worldometer / Wuhan Coronavirus Outbreak.
CDC Coronavirus-2019 (COVID-19) information site.