Monday 23 March 2020

COVID-19: Let It Be

Miguel Opazo, Pest, 2017
Posted by Thomas Scarborough and Martin Cohen
Jeffrey Kluger, the editor at large for TIME magazine, observed last week, ‘There’s nothing quite like the behavior of panicky humans.’  He was writing in the context of the COVID-19 pandemic.
Is the panic -- or should we say, alarm -- justified?

The initial response to the disease, although stumbling and slow in some respects, was by and large the correct one: get a fix on the disease.  What are we dealing with?  What is its character?  The next steps, then, were textbook containment and mitigation.  Since then, of course, the pandemic has developed other dimensions, though not as a direct result of the disease. Rich Lesser, the CEO of a global management consultancy, wrote in Fortune magazine last week, ‘It started as a health crisis, within days became a real economic crisis, and is now on a swift path to becoming a massive fiscal challenge.’

There would seem to be two assumptions in the early -- and continuing -- response to the pandemic: under no circumstances sickness, yet if there is, complete control.  All over the world, we find language which reveals an ‘uncompromising’, ‘relentless’, and ‘aggressive’ approach -- an ideal plan which is not to make any concessions to the disease.  And always, in the statistics, one finds a column marked ‘deaths’, to which all control would seem to defer.  The aim is zero deaths, zero deaths, zero deaths.  In fact the biggest opprobrium for any government in the midst of the pandemic is the death rate.

The COVID-19 pandemic has two important features: the seriousness of the pandemic, and the character of the disease.

About the seriousness of the pandemic, mortality stood last week at about 3% -- if one calculates the ratio of total confirmed cases to deaths.  Yet for a number of reasons, this is quite uncertain.  For example, various academic papers have estimated that more than 80% of cases are undetected.  This reduces 3% to 0.6%.  Some place mortality far lower -- the Centre for Evidence-Based Medicine placed it at 0.14% last week.  The World Health Organization calculated that in China, the 'real' mortality rate for ‪COVID-19‬ was 0.7% of reported cases, where only 5% of cases were reported. That's a 0.035% death rate.

While various kinds of ‘experts’, media, and ‘modellers’ have been plugging in figures as high as 10% for ‪Corona virus‬ fatalities, one professor of public health, John Ionnidis of Stanford University, suggests ‘reasonable estimates for the case fatality ratio in the general U.S. population vary from 0.05% to 1%’.  Compare the lower figure.  He explains his reasoning, too, saying that the one situation where an entire, closed population was tested was the Diamond Princess cruise ship and its unfortunate, quarantined passengers.
‘The case fatality rate there was 1.0%, but this was a largely elderly population, in which the death rate from Covid-19 is much higher…’  
Writing for Stat magazine, he adds,
‘Projecting the Diamond Princess mortality rate onto the age structure of the U.S. population, the death rate among people infected with Covid-19 would be 0.125%.’
If we assume that the ‘case fatality rate’ among individuals infected by the virus is 0.3%, and 1% of the U.S. population gets infected, this would translate to about 10,000 deaths. This sounds a huge number, but is within normal flu toll.

Even the one thing everyone agrees -- that we have to flatten the curve to spread out the load of cases (and avoid overburdening health services) -- Ionnidis casts doubt on.  Spreading the infections out over a longer period of time is better?  Not necessarily.  It ‘may make things worse: Instead of being overwhelmed during a short, acute phase, the health system will remain overwhelmed for a more protracted period.’  For Ionnidis, the policy response, not the virus, is the perturbing part, as ‘with lockdowns of months, if not years, life largely stops, short-term and long-term consequences are entirely unknown, and billions not just millions, of lives may be eventually at stake.’

The point is that fatalities, although they are tragic and traumatic in every case, are comparatively small, although, the numbers sound alarming given the large population which may be affected.

As for the character of the disease, it has some well-defined features.  It is now certain that it is far more dangerous to those who are more advanced in years, from about age 60, certainly from age 70.  It is far more dangerous for those with pre-morbidities, or compromised health, or concurrent infections, among other things.  This makes the picture far more varied than the simplest scenario of containment and mitigation.  Also, methods of containment and mitigation themselves are very varied, and may be greatly helped with fairly simple -- and far from extreme -- measures.

Given this brief survey, and assuming that it is broadly true -- what would the philosophers have said?

The Delphic maxim proclaimed, ‘Nothing to excess,’ while Aristotelian philosophers emphasised the Golden Mean -- the middle way between extremes of excess and deficiency.  Socrates said, ‘Choose the mean, and avoid the extremes on either side, as far as possible.’  In short, they sought a general holism.  With this in mind, they might well have cautioned us against a reductionist response to the crisis, and to take all factors into account and to balance them.  Protect the elderly, defend the vulnerable, comfort the distressed, yet for the rest, accept the tragic inevitability of illness and death among us, maintain the life and pulse of society -- and let it go.  Let it be.

A more holistic view suggests, too, that we should think, not only of the present pandemic, but of the past and the future.  As with all pandemics, there is a bigger picture.  Where have we come from, that this has happened to us now?  Where are we going to, as we shape the society of the future?  And what if it had been worse?  Pandemics are always embedded in background conditions.  One needs to consider economic and financial systems, urban planning, health care, lifestyle choices, communications -- in fact, the entire order of the day.

Above all, it is a reductionist response which drives us to the totalising ambition of no illness, and certainly, zero deaths -- and in the midst of this, the suppressed premise of our age: preserve life at all costs.  Less than a hundred years ago, religious congregations all over the world would pray for healing through God’s angel of death, if he should so will.  That prayer has now been expunged.  Death is not a constant companion today, as it sometimes was in the past, but an enemy to be defeated at all costs.  If only one knew what one were hoping to save.  It would seem that not many do -- and that in itself may be a large part of the panic, the alarm.  There has to be a way of living that triumphs over stalking death.

It remains to be seen whether ‘the behaviour of panicky humans’ can be sustained today.   At the moment, we are all locked into a more or less unified response to the pandemic, by the decisions of governments the world over -- and they in turn are judged by their peers.  


Keith said...

A timely and trenchant discussion, Thomas and Martin.

It’s humbling that something measured in nanometres — billionths of a metre — can so capably, efficiently, and unflinchingly bring, even temporarily, much of human civilization to its knees: politically, sociologically, economically, culturally. If there’s any time to clear one’s throat of self-exceptionalism or species hubris, now is that time.

As I see it, the ‘let it be’ notion — allowing the virus to run its course — is the crux of what’s ungainly called the ‘herd immunity’ argument. That is, to allow exposure in order for the bulk of the world’s population to build antibodies and immunity, knowing there’ll be a large (acceptable?) body count by the close of the coronavirus chapter. (The ethics of that strategy is a separate conversation.)

To my mind, and more prosaically, just one among many disquieting alarms regarding the coronavirus pandemic is that the soaring number of patients seriously ill from the disease is rapidly stressing the capacity of hospitals to treat everyone equally. Life-and-death decisions are already being made in some quarters around the world.

Decisions are increasingly inevitable as to whom to save, given the critical shortage of essential equipment like ventilators. Some people have dubbed these decisions by medical personnel as “Sophie’s choice.” However, maybe that metaphor isn’t fully right; Sophie’s (painful) choice is between two equally deserving alternatives as to whom to save.

Perhaps a better term than Sophie’s choice is “generational culling,” where younger patients are disproportionately favored over older patients in allocating the scarce resources of overextended medical facilities — all else being roughly equal, of course. “Triage” is merely a polite way of saying the same thing, if that makes one feel better.

The choice comes down to the odds of members of each generational group surviving — a decidedly utilitarian decision focused on known (at least, presumed) consequences of withholding resources. Or, to paraphrase English philosopher Jeremy Bentham’s famous maxim, our ostensibly seeking the greatest good for the greatest number.

Andrew Porter said...

As with all threats to life, one lesson of the coronavirus is: Live while you can and live well. At least this viral threat, haha, is external.

docmartincohen said...

For me, there is an issue about the limits of human control. The common cold, for example kills a hundred thousand people a year. Perhaps that number could be reduced if everyone lived in a little box with food parcels (magically) appearing from time to time. The corona virus is not particularly 'new', it seems that is is closely related to other past winter viruses. We learned to cope with those.

There are many aspects to the issue, though, including the new ways in which (as Keith says) we can actually 'see' viruses, and the ways in which computer models claim to see the future.

Personally, I am struck by the way that the exact same advice on how best to respond 'to the threat' was offered in past virus episodes, like Swine Flu in 2009 - and by the same learned teams of academics. The US and UK governments are following the model produced by Neil Ferguson at Imperial College in London, a piece of computer wizardry, but it is only as good as the assumptions fed into it. This is the secret flaw of many a perfectly logical argument!

docmartincohen said...

Hi Andrew! Nice to see you popping in.

Thomas O. Scarborough said...

When dealing with unknowns, it seems justified that we act on unknowns, within reason. Yet there are certain questions we must ask, if we are to be scientific about it. For example, an Oxford laboratory reported yesterday that 'half of the population of the United Kingdom may have already been infected'. Now if I were a postgraduate student, and I said to my professor, 'Here's my research, Prof. A pity I didn't do the control group,' my academic aspirations could be ended then and there. Yet this is happening all around us with COVID-19.

There is something else. Mark Woolhouse, a professor of epidemiology, was quoted on the BBC last week, 'No country has an exit strategy.' His point is that they are locked into drastic measures that they cannot sustain for very long at all. Barring some vast and unexpected scenario, they have no way out. I think the way out will look something like this: 'Our response was good. No, not good, it was great! We protected our citizens to the hilt. We did the right thing. We triumphed! But now that we know XYZ, we shall scale back as follows ...'

Looking at The Conversation, which invited experts to suggest how this might change us, several said that our trust in Big Government will now be restored. Perhaps goverments' social scientists are studying this closely. It may give Big Government clues for controlling the masses at will, apart from what is seen already. In future, just pick off one of their deepest fears, and play on it. They are believing sheep, frightened sheep. And the testing we were told about, at least in my city, was mostly an illusion, judging by what I have seen behind the scenes.

At the time of writing this piece, I went down with rheumatic fever, which has a 4% mortality in my country (5% worldwide). People said, 'Thank God it's not COVID-19!' Yet my chances of death were, on the basis of the latest U.N. statistics on COVID-19 from China, about 100 times higher. (I appear to have recovered now).

Thomas O. Scarborough said...

A friend points out that the COVID-19 death rate is a subset of the total death rate. A critical question therefore is how the total death rate is affected.

Thomas O. Scarborough said...

I was in touch today (30 March) with the Lead Data Scientist at the World Data Lab in Vienna, Katharina Fenz. She writes, 'Unfortunately, you are right that the availability of reliable information regarding COVID-19 is still very limited. ... [not] enough information to draw reasonable conclusions."

Richard W. Symonds said...

"It may give Big Government clues for controlling the masses at will, apart from what is seen already. In future, just pick off one of their deepest fears, and play on it. They are believing sheep, frightened sheep. And the testing we were told about, at least in my city, was mostly an illusion, judging by what I have seen behind the scenes" - Thomas Scarborough

At risk of the accusation of conspiracy theorist, I would substitute 'Big Government' with 'Big Brother'. Although Orwell was no philosopher he was a superb political analyst. Reading again "The Theory and Practice of Oligarchical Collectivism" by Emmanuel Goldstein - the 'book-within-the-book' of Nineteen Eighty-Four - makes me shudder.

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