Our current news is, of course, dominated by the pandemic, and much of it comes at us numerically.
Each day brings headlines about record numbers of cases, and hospital occupancy. Such news is grave and grim, and made all the more so by comparing the quantitative thresholds of the day for cases and casualties alike to precedent, and proclaiming that things are worse now than ever.
We are simultaneously receiving hopeful, and at times even giddy news, about the imminent relief of vaccination. Here, too, numbers prevail, as the discourse turns quickly to the units of vaccine that can be produced and distributed, how quickly, and to whom.
Perhaps, amidst this daily assault of calculus on your beleaguered attention, you missed another quantitative update that made a bit less noise for offering neither sadness nor euphoria: the CDC recently reported that total cases of COVID19 to date in the United States are 8 times higher than the official tally (currently, as I write this, at about 14.5 million).
However unprepossessing this news seemed to be amidst all the rest, this number is vital to making sense of all the others.
Well, consider that the terrible mortality toll of COVID in the United States, now at over 280,000 deaths, is roughly 2% of the total reported cases. That is an extremely alarming infection fatality rate, roughly 20 times that of influenza. If, however, the actual number of infections is nearly an order of magnitude higher, then the infection fatality rate is an order of magnitude lower. An infection fatality rate of roughly 0.2% still makes COVID twice as lethal as influenza- but that’s much better than 20.
The CDC numbers, based on scientific modeling, also make sense. Global data have long suggested a high end for the COVID infection fatality rate of about 0.3%. While the relatively poor cardiometabolic health of the American population could conceivably elevate that somewhat, an American death rate almost an order of magnitude higher than in other industrialized countries around the world is not plausible. The 0.2% figure makes far more sense than 2%, and thank goodness.
My methods were rather cruder and simpler than the CDC’s when I reached this same conclusion over two and half months ago. I calculated that case counts in the U.S. must be ten times higher than reported, landing in much the same ballpark as CDC. Further, we know that a sizable portion of the general population has native resistance to SARS-CoV-2 derived from prior infection with common cold coronaviruses. That portion, generally thought to be at least 50% of us, means that there may be as many of us exposed but not infected as have been infected.
When I published my simple calculations, the official case count in the U.S. was only half of what it is now. With about 7 million cases reported, I inferred that we actually had experienced (as of mid-September) at least 70 million infections. If again as many had been exposed without infection, that meant 140million of us had “encountered” SARS-CoV-2.
On that basis, and on the basis of the timeline for the COVID wave to surge, crest, and dissipate in New York City and surrounding areas of the Northeast, I made the hopeful- and now clearly wrong- projection that the pandemic might wind down by or about October 1. Here we are, two months later, with the gravest daily tolls of the pandemic to date. What went wrong?
Assuming the CDC is correct now, and I was more or less correct those two and half months ago, the numbers we both generated indicate that while many, many more of us have already made it through COVID19 infections than officially acknowledged, a great many of us have not. If 100 million or more Americans have confronted SARS-CoV-2, roughly 200 million have not.
Had those 200 million heeded the lessons garnered from the 100 million- including the duress in New York City during the surge- and the lessons bequeathed by other hard-hit populations around the world, notably in Northern Italy, we might indeed be out of the darkness by now.
My hope, naïve in retrospect, was that we were learning as we plodded through the pandemic, and would apply those lessons in real time. The most critical lesson, fairly clear from the start of all this, was that while this virus is not very dangerous for young, healthy people- it is highly dangerous to the elderly and infirm. The crucial application of that lesson was to practice respect for those risk differentials- on our own behalf, and on behalf of others- and make sure that the high risk who had avoided the virus thus far continued to do so until the “all clear” sounds.
Instead, the formerly unexposed seem to have been caught up in a wave of divisive politics, pandemic fatigue, and rebellion against the crude indifference of one-size-fits-all mandates, and forayed back to the world en masse, without regard for risk differentials. This may be compounded by the seasonal turn, with more exposures happening indoors than out, as we have long been warned. Exposure dose matters, and viral exposure doses are apt to be much higher with indoor congregations- perhaps, even in some cases, higher enough to induce infection in those with partial native immunity.
So here we are. Something like half the country is already through their encounters with SARS-CoV-2. Much, perhaps even most, of the other half, is going through theirs now, all at the same time. That’s why the current numbers are so grim.
But there is a meaningful glimmer of hope amidst the gloom.
New York City and the Northeast, including my home state of Connecticut, are not currently experiencing excess demand on hospital, and in particular, ICU beds as happened last spring. Our case counts are high- but that is partly because we are testing so much more now than we did at the start of the pandemic. Our casualty counts appear not to be rising in tandem, because we suffered that toll already.
Having had our prior surge, we are apparently out the other side, and if not fully in the clear, at least much more so than the rest of the country. Where the pandemic is hitting hard for the first time, hospitals are at or near the limits of their tolerance. That experience is likely to replicate that of New York City, with a surge, crest, and fall. The timeline for that sequence is measured in weeks, not months. Things look dark in much of the country now, but this reasoning- and prior experience- suggest the dawn is not too far off.
There is, as well, a crucial lesson in the current numbers. Those at elevated risk for adverse COVID outcomes who have managed to shelter from exposure to date should not let that guard down now. Whether by means of prior infection, by means of vaccination, or most likely a combination of the two- the prospect of herd immunity is now clearly discernible. Garner your patience, and wait for it.
The matter of pandemic “waves” has often borne a veneer of mystery. How and why infections surged and subsided, seasonally or otherwise, has preoccupied experts and spawned diverse conjecture. Living through this pandemic, watching those waves in real time, they appear far less mysterious. SARS-CoV-2 has made no waves; it has just kept doing the same simple thing: infecting vulnerable hosts to which it gained access. We- in our decisions and actions, our restraint or rebellion- have determined who and how many of us would be exposed, when. We are making the waves.
We have suffered throughout the pandemic far more than necessary for want of effective governance. I mean that literally, with regard to the absence of clear, cogent guidance at the federal level. But I mean it figuratively as well. The infodemic has so distorted our understanding and so polarized our perspectives that we have failed to govern ourselves. We have renounced the governance of science, of sense, and of civility. We renounced the lessons of the first wave, and thus- suffer its repetition.
Famously, those who don’t learn from the follies of history are destined to repeat them. I really don’t ever want to go through this again, so I say: let’s learn from this harsh education. Here are some of the lessons that seem to me most salient:
1. SARS-CoV-2 is not, and never was, a one-size-fits-all threat. Accordingly, some of us are and were more likely to be hurt by the virus, while others are and were more at risk from our societal responses to the pandemic. A policy of total harm minimization always made sense, and still does, aiming to minimize the toll of infection, and interdiction, alike.
2. Public health policy is often stratified according to level of risk. That same basic sense can, and should, be applied in a pandemic.
3. There is no need to choose between respect for the virus, and respect for the social determinants of health; both can, and do, matter at the same time.
4. There is no need to choose between personal and communal/public responsibility for the protection of public health; both can, and do, matter at the same time. They are both situated within the common construct of hierarchical responsibility.
5. Practices can and do make sense (e.g., masking) before they make science. Science takes time. While waiting for the train hauling adequate data to catch up, we can and should follow the tracks of sense - invoking the precautionary principle. Do what is sensibly in the service of total harm minimization while waiting for confirmatory data to arrive.
6. We cannot know the true toll of the pandemic while still mired in it. Deaths from many causes occur every day in large populations; in the United States, roughly 8,000 people die daily of diverse causes, pandemic or no. How many deaths have been “of” COVID, versus “with” COVID will require time to know. In the interim, we are best served by considering both casualty counts and context, favoring best available data over drama, and giving the threat of COVID all respect demanded by the worst-case (i.e., all deaths “with” COVID are actually “of” COVID, and would not have occurred now otherwise) pandemic scenario. Such thinking will favor an excess of caution, preferable to a deficiency.
7. In this Internet Age, information goes “viral” even faster than any virus- and misinformation consistently goes viral faster than reliable information, since it can be designed for that very purpose- unconstrained by verity. Until or unless we devise cognitive vaccines against such “infodemics,” we are unlikely to handle the next pandemic any better than this one. Misinformation stokes our disparate passions, and divides the house; houses divided do not well withstand pandemics.
8. The common baggage of poor cardiometabolic health that prevails in America is a very weighty burden to carry through a pandemic. However great the ultimate pandemic toll proves to be, much of it in this country will relate to the confluence of chronic ill health and the acute threat of infection. COVID makes an acute case for chronic health- for a national commitment to health promotion- we ignore at our peril.
The sky is not falling, but the light of a new day is not rising just yet for us all, either. Let’s respect the precautions required by darkness, even while expecting that light. Be careful, and be patient a while longer. Among the many tales the pandemic numbers tell is this: we make the waves.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.