We are, no doubt, all comparably eager to consign this blighted interval - of coronavirus contagion, social upheaval, recrimination and fear - to the history books.
One day, this will all just be a reference in a tale told to grandchildren, an episode stripped of its visceral impacts and neatly archived.
Before living through COVID19, though well-schooled in the great flu pandemic of 1918, I never paused to wonder what it felt like to be a family caught up in it, waiting for fate to play out that century ago. Textbooks on epidemiology and public health preserve the facts, but are very antiseptic to feeling and the human experience. Now I know.
One day, this will be sanitized accordingly, too, and how welcome that view from here.
I contend the transition from this dark blight of contagion can be accelerated by a suffusion of light. It waits not at the end of a tunnel, but at the top of a pyramid. The pyramid in question is made of data, and we need to build it.
The pyramid we need looks like the below, and is responsive to our urgent needs for illumination.
We talk about the virulence, or severity, of SARS-CoV-2 infection, but the blunt reality is- we don’t know. We certainly know that some cases are severe, that some cases are lethal. But we just don’t know the denominator: how many people in the United States (or world) have been infected? The overall severity of this infection derives from the ratio of severe cases to total, and we simply can’t know that without knowing the total.
We talk about the case fatality rate, but that, too, is unknowable without the denominator. That figure is the ratio of deaths from a given cause- coronavirus infection in this case- to the total number exposed. We don’t know the total number exposed.
A pyramid constructed of the data highlighted above would answer all of our most pressing questions. Who is at risk of severe infection, and who is not? Can we safely achieve herd immunity by loosening interdictions in phases, based on risk stratification? How much of this contagion has been asymptomatic? Is it infection, or haphazard interdiction, that is hurting more people?
To be clear, the construction of this pyramid does not require vast resources. We don’t need millions of test kits. We simply need to do representative, random sampling in a critical mass of us- as the CDC does routinely- and then extrapolate. This is not perfect, it’s just very, very good- and monumentally better than the dense fog of ignorance from which policy proposals are emanating now.
We are not limited to only extreme and dire choices: expose everyone to the risk of infection for the sake of normalcy, or abandon all hope of life as we knew it for the sake of one-size-fits-all interdiction.
With the guidance of data, we can determine who can encounter this pathogen at very low risk, and who must be kept away from it. A data-informed pivot to vertical interdiction remains possible. We still have the opportunity to protect the vulnerable; resume living, learning, and work in phases; make our safest possible way to herd immunity; achieve the “all clear” that lets grandparents hug their grandchildren once more; minimize the total harms of infection and societal collapse alike; resurrect life much as we knew and loved it, before all this.
Or at least, we might have that opportunity. To know for sure, we need to rise above the fog down here and get to the light. To know for sure, we need to build, and climb, a pyramid of data. We can; we should.
As I’ve hastened to note before, the numbers used in that construction cannot substitute for, and should never obscure, the experiences of individual patients and families. If you are a family who has lost a loved one to this scourge, I doubt you care all that much what the accurate case fatality rate is. You only care about the hole the pandemic punched into your lives, and rightly so. My heartfelt condolences to you.
I truly understand this challenging juxtaposition, of the one and the many. I write this under some time pressure: I leave tomorrow for a deployment of several days to a New York City hospital as a volunteer physician. I am doing that because while I think striving to exert a beneficial influence on public policy is important, it is not more important than rendering care to a person in acute need. Writing about policy today, departing to a hospital tomorrow, makes me reflect, as I have across the span of my career, on how clinical medicine and public health are both greater and lesser than the other. For impact at scale, public health – both its practice, and contributions to salutary policy decisions -is the greater. But for immediacy, intimacy, and the indelible impressions of human interaction- nothing rivals the privilege of clinical care.
We all must strive to bridge that divide. The seemingly sanitized, dispassionate, anonymizing statistics of public health veil the stories of real people, real families, real feeling. We can honor that, while still allowing for the value intrinsic to those numbers, what they reveal about patterns. Only by knowing the patterns of this pandemic- from denominator through numerator, from the base of the pyramid to its peak- can we know the path to total harm minimization.
If there is a light after COVID19, it’s not at the end of a tunnel. It’s at the top of a pyramid. The pyramid is made of data. If we climb that pyramid, we have the best possible opportunity to get up, over, and beyond this- and lay it to rest as a historical episode of singular challenge and memorable cost.
The pyramid will be useful for that purpose, too. After all, these structures are, famously, tombs. Let us use the data we need to make policy aimed at total harm minimization as the place we bury the dark days of COVID19. First, good data. Then, good understanding. Then, good policy. And then, good riddance.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health.
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