The Dogs that are not barking: Thoughts on the Coronavirus

When the Coronavirus first came on to the public stage, I was in the “so what, the flu is worse” group of people. I think I am still more skeptical then current consensus promulgated by the great and good.

Given all that has happened since then, it would be fair for people to wonder why. After all, it is a well known human phenomenon that people tend to double down on their initial beliefs and have trouble adjusting to new information. But it is also a fact that people had a natural tendency to go along with the herd. It is far better (from an emotional point of view) to be wrong along with everyone else then to be wrong in your own particular way.

So is my current level of skepticism a result of being wedded to my previous views? Or is the fact that the great and good view this more seriously just a reflection of the pressure to join in with the herd of humanity as it bolts in a random direction?

I have to admit that I would have never predicted that a disaster such as the Lombardy region of Italy is dealing with right now would have happened based on my initial understanding of the virus. On the other hand, I never would have believed that countries would have as much success controlling the spread of it as some countries supposedly have (I thought like the flu it would be pretty much unstoppable but not all that deadly). The obvious take away is that I don’t have a crystal ball anymore then anyone else does.

But even after admitting my failures of foresight, I still can’t help feeling that media is giving people a very skewed idea of the risks. They are ignoring or not putting into to context a lot of things that are going on and focusing on the most sensational things out there. This type of focusing on the sensational things is what cause people to way overestimate the dangers of shark attacks and way underestimate the dangers posed by white tailed deer (who kill far more people then sharks).

I think of the things that media is missing as being the “dogs that don’t bark” after that Sherlock Holmes story “Silver Blaze” in which Holmes notes the importance of the dog that people did not hear. The following will be some facts and figures that you might not have been exposed to if all you have been reading is mainstream media accounts.

Dog That Did Not Bark #1: Death Rates

I have seen a lot of media reports throwing around scary high death rates. A 3% rate is a common figure and certainly certain places in Italy and China have seen some pretty high death rates. If these death rates hold true for the world at large, millions and millions of people are going to die. But this focus on the scary places has hidden the fact that in the vast majority of places Covid has not been all that bad. Let us take China as an example…..

The death rate in Wuhan was 5.8%. The death rate in the rest of China is .7%. That is quite the difference. If you break it down further and exclude the entire province that the city of Wuhan is located in, the death rate is .16%. South Korea is also showing a death rate of around .7%.

Let us take Diamond Princess. This cruse ship is the nearest thing we have to a controlled experiment as to what happens when you introduce coronavirus into a trapped population that skews to the elderly side. Total number of people on the ship that came down with the virus was 696 people. Total dead was 7 for a death rate that was just a little over 1%. That is bad, but not anywhere near 3% bad. More to the point, there was 3,711 people on the ship. You would think that all of them were exposed to the virus but less than a third of them even came down with the virus at all. Death rate on the ship as a whole was only .19%.

Now .19% is pretty bad death rate if it would be applied to an entire nation. If America were just like this cruse ship, there would be roughly 60 million people dead. But presumably the cruse ship is a worst case scenario as it represents a vulnerable population trapped in an enclosed space with the virus.So why has the death rate been so much higher in other places that are not floating petri dishes (and it is worth noting that outbreaks of various type on curse ships are fairly common)?

One answer is that everyone on the ship was tested, but not everyone out in the rest of the world has been tested. So many mild cases have been missed in the real world that make the death rate seem higher then it is. Another common answer is that once the medical system gets overwhelmed, the death rate starts going up.

But I suspect that there is more going on then just lack of testing and overwhelmed hospitals. Most countries have done a bad job of testing but few have the problems that Lombardy has. Furthermore, Italian reported death rates were quite high before their health care system started to be overwhelmed. In an American context, 60% of current US deaths from COVID come from one nursing home in Washington state. These deaths did not come about because the US health care system was overwhelmed, but because the virus got into a vulnerable population and ran rampant.

So what is causing some areas to be hot spots and other areas to see little in the way of deaths?

My personal hypothesis is that transmission rates correlate to the severity of infection. In my hypothesis, populations with high percentages of vulnerable people will have a greater transmission rates because more people will have bad infections. This in turn will lead more healthier people to get the virus then would otherwise be the case. My personal hypothesis is that any area with a median age that is less then 40 will also see sub-1% death rates from the virus. I suspect that in most areas with a sub-40 median age, the majority of the people will not even come down with Covid even in the absence of effective controls.

The sub-40 median might seem arbitrary, but what it means is that majority of your population is still under 40 years old. Picking that figure is just a guess, but it does seem that the effects of Covid start to really show up once you go past 40 and really take off once you go past 60. So I suspect that areas that have a population where the majority of people are going to be over 40 years old are going to see more transmission and a greater spread of Covid then areas with more young people who might act as a break in the chain. This logic is dependent on the idea that the severity of the infection drives the rate of transmission. This idea is in no way proven but seems consistent with the available data.

If my hypothesis is in any way correct, the US will see hot spots in localized areas that are pretty bad but the nation as a whole will not see that a death rate from those suffering from Covid that is over 1%. Even though this death rate will be higher then the flu over all I don’t think it will be that bad as I suspect that most of the nation will not even come down with Covid symptoms. I would guess that total number of Covid deaths this year will be less than the US lost from the flu last year in terms of total numbers (I am comparing last year flue deaths to this year Covid deaths because I think Covid will kill a lot of vulnerable people this year before flu gets a chance).

My reason for thinking this is that the US is just under the 40 year median. However, there are parts of the country that are considerable older and those areas may very will be hit hard (New England and some of the rust belt areas are my top pics for US hot spots). Some rural farming areas may be hit hard as well but it remains to be seen how bad transmission rates will be in rural areas as this is something we don’t have a lot of data on yet.

The obvious counter to this hypothesis is Iran. They have quite a young population and seem to be doing quite badly. This could be used to invalidate my hypothesis. However, I am not ready to accept that just yet. I suspect the major reason Iran is having issues is the city of Qom. This is has a large population of Shia scholars whose average age I suspect is over 40. Lots of pilgrims (millions) come to this city so if a hot spot developed in this city it would be a good place to spread the virus.

Furthermore, if you go by the official figures, Iran is not doing all that badly in terms of deaths. Granted, nobody believes the official figures but I think that lack of trust leads people to imagine the worst when that may not be warranted. I personally suspect that the closed caste of elderly Islamic scholars that rule Iran is being hit hard but it remains to be seen how badly Iran as a whole is really doing.

Regardless of whether my hypothesis is correct (and I make no claim to have special insight in this area, it is just my current speculation) you should always remember that news reports are focusing on the worst hit areas and that can give you a skewed perspective on what is normal.

Dog That Did Not Bark #2: Young People Not Showing Symptoms

If you read a lot of media reports, you will come across the fact that young people tend not to die from the virus. Mostly that reporting is accompanied by arguments showing that young people can too get sick from it and they can be carriers even if they are not badly ill themselves. The goal is to make sure young people take virus seriously and don’t spread it around. The problem is that this effort to make sure that young people take this seriously is obscuring one of the biggest mystery’s surrounding this virus. This mystery is the question of why so few children get Covid at all.

For example, if you look at the death rates from China, you will see that children between the ages of 10-19 have a death rate of .2% (this includes Wuhan). This is actually a fairly high death rate and higher then what the flu produces in most adults. But it greatly overstates the risk to young people because it is a calculation of death rate vs the number of children showing symptoms. The problem with this approach is that it seems that very few children (even in hard hit areas) show any symptoms of having the virus at all. And nobody under 10 has been known to die from this virus anywhere in the world.

One of the frustrating things about current reporting is that nobody is talking percentages of various age groups that come down with symptoms at any give hot spot. As we discussed earlier, on the Diamond Princess 2/3 of the people never even came down with symptoms. The constant focus on death rates of people who show symptoms obscures the question of how hard it is to come down with symptoms at all an any given age cohort. All we have to go on are statements like this….

“In general, relatively few cases are seen among children.”

Or this…..

“In fact, through mid-January, zero children in Wuhan, the epicenter of the outbreak, had contracted Covid-19. It’s not clear whether that’s because children do not show signs of illness even if infected.”

The question is why is this so? Anyone who has seen a group of kids passing around the cold virus knows that there is nothing special preventing those under 10 years old from coming down with virus. So why does the COVID seem so different?

The answer to this question is likely to make a lot of difference to how COVID turns out. But nobody is really talking about it. Whatever the answer, it likely explains why large numbers of adults don’t seem to show symptoms even after being exposed to the virus.

I personally wonder if it does not have something to do with vitamin D levels as this is known to greatly decrease with age. This study speculates that vitamin D levels had something to with the Spanish Influenza death rates so it not like this idea is not on the radar.

Again, I have no special insight and I don’t really think it a can be boiled down to just vitamin D levels. But I do think it is important to remember that deaths rates of people who come down with Covid are only part of the story. The other part of the story is the question of how many people are susceptible to coming down with Covid even when exposed.

Dog That Did Not Bark #3: Why no large outbreak in Africa?

Nobody in the developed world really cares about Sub-Saharan Africa. Few people know that massive numbers of Chinese workers are scattered all throughout Sub-Saharan Africa working on various projects. Those who do know these things and care about Sub-Saharan Africa would think that Sub-Saharan Africa would be at least as far along as Italy in terms of the virus outbreak. But so far, it seems to be a non-issue in Sub-Saharan Africa.

Is this because Africa has so many other health issues and general poor governance that Covid is going undetected in the noise? Is it because of the lack of a large concentrated vulnerable populations? Luck of the draw?

In general, most tropical countries seem to be doing pretty well so far but that may just because many of them lack exposure to large numbers of Chinese. The reason I focus on Africa is that much of Sub-Saharan Africa has had a lot of exposure to China so that does not seem like it would be the case for them.

However, it could be that hot humid weather reduces transmission rates of the virus. This is certainly true for the flu so one could hope that the same thing is true for Covid. If it is, that is good news for North America and Europe as they head into summer.

Again, Iran is one of the biggest arguments against this hope. But if I am right that Qom is the main cause of Iranian Covid problems, then it should be remembered that Qom is not tropical. Average day time temp for Qom in February is in the low 40s. Average for March is low 50s. On top of that, the Middle East as a whole has been fairly cold this year.

It is to early to answer this question, but the question of how temp effects transmission will make a big difference in terms of how many third world countries will suffer serious effects.

What Difference Does It Make?

It is important to keep in mind that everything has its costs. Past epidemics have shown that taking decisive early action can limit the number of deaths. But “flatting the curve” can also drag out the epidemic and extend the economic pain. The number of lives saved might not be all that much different either way. It is easy to say the people’s lives is more important then money, but for many people on the bottom of the economic ladder, the difference between life and money is not all that clear.

Even seemingly obvious things like shutting down visiting rights to nursing homes can have serious costs. This certainly seems like a sensible thing to do (and I would probably do the same thing if I was a nursing home administrator). But it is likely to raise the death rate of those in the nursing homes even if it succeeds in keeping COVID out. I know people who visit their parents in the nursing homes every day to ensure that they eat. Others just check on them to ensure quality of care is being maintained and to show they care. In the absence of any visits, how many will decided they don’t want to eat from depression or the lack of nursing home staff to effectively follow up? Most likely it will be less then Covid would kill but it certainly not be zero.

We accept hundreds of thousands of deaths from flu every year as just being the price of doing business. What is the magic number that makes it so that we should sharply curtail economic activity so as to prevent deaths to the vulnerable? In the end, when things are not as bad as many fear, will that be seen as proof that we overacted or proof that swift actions saved the day?

My own answer to these questions is that it is good to stress test the system every so often. I think it is good to force people to face the potential problems that come with supply chain disruption. I think it is good for people to face the fact that pandemics can and will occur. So even though I expect that total US Covid deaths this year will be less then total flu deaths last year (comparing last year flu deaths to this year’s Covid deaths because I expect that Covid deaths will cut down on flu deaths this year as Covid eliminates people who would have died from the flu before the flu gets a chance to take them) I still think it is a good idea to treat this seriously.

But I expect that the current hysteria will get so out of hand that the net result will be that in the future people will be even less willing to take things seriously when it might be more important to do so.

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