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Putting the COVID-19 pandemic in perspective (Number 2)
See a list of all of my articles related to COVID-19

This is the second in a series of reflections aimed at putting what we know about the COVID-19 pandemic in perspective. The first, "Ode to Joy," posted April 9, looked at examples of the human spirit rising to the challenges of the pandemic.

It's hard to wrap our heads around big numbers. During the COVID-19 pandemic, the news bombards us with them . People infected. Deaths. Unemployed. Record-breaking relief packages.

At the beginning, we heard very distressing projections, most of which were based on "worst-case" scenarios. Many in the media did not understand these numbers in ways that would have provided a context for the public to understand what was going on, and what might lie ahead.

Would this be like the devastating Spanish flu of a century ago that produced such staggering numbers and went on for two years? Would we, in fact, see millions of deaths in America, and tens of millions around the world?

With mixed messages coming from governments around the world, we began to hear about the need to respect the science, the numbers, "the math" as New York Governor Mario Cuomo likes to say. As the pandemic progressed and more data became available, mitigation efforts were employed, and I sensed a shift from a Chicken Little "the sky is falling" hysteria based on those worst-case numbers, to a less extreme but equally hyped reliance on benchmarks or milestones. The numbers were lower, but frightening nonetheless.

EARLY PROJECTIONS: MODELS AND WORST-CASE SCENARIOS

Computer models used for weather and climate change are often derided as unreliable, leaving the public skeptical of the value of models. As the coronavirus began to spread beyond China in January and before WHO (World Health Organization) declared a global pandemic on March 11, 2020 there was early forecasting based on worst-case scenarios from various models.

Some models purposely look at worst-case outcomes in order to assess the range of possibilities which, when taken together with other models, can help determine appropriate responses.. To say that extreme models are wrong misunderstands the role of modeling. For viruses, in particular, models can be used to project results with and without mitigation, leading to vastly different scenarios.

To use only the worst-case scenarios abuses public understanding—in the process showing how little some journalists understand science and the use of numbers. It is similar to using as news a press release describing one study to suggest a breakthrough in an area, instead of waiting for a summary of multiple peer-reviewed studies (the essence of scientific method). .

Because of what is known about the spread of viruses and the social networking of populations, the models used in virus research have high degrees of reliability. They are looking at the past to better assess the current threat. (Even worst-case models may reflect terrible experiences in the past, such as the 1919 Spanish Flu).

For a good explanation of modeling pandemics, check out a podcast my brother referred me to, called "Going Up and Down the Curve," from On the Media. Even before this podcast was posted in April, the term "flattening the curve" was becoming common around the world.

We started posting articles about the coronavirus on SeniorLifestyle in late February. On March 14, I wrote about "Flattening the Curve," which shows the impact that mitigation could have on spreading out the impact on the healthcare system of a viral outbreak. The most serious forms of mitigation, which many of us have gone through by now, promised to prevent a huge spike in infections by extending the number of cases over a longer time, flattening the curve and making the response more manageable.

In addition, serious mitigation efforts could also lead to a substantial reduction in the total number of infections. Early, worst-case projections of a million or more deaths in America began to scale back to 100- to 200-thousand as effective mitigation efforts were promoted by the CDC and governments at the federal, state and local levels. Since we passed the 90-thousand mark in the past week, it may appear that this lower window was too optimistic, but barring a catastrophic spike in the fall, it does appear that it will be much closer to reality than worst-case scenarios that look more like 1919.

When I started investigating the impact of COVID-19 in DuPage County, Illinois, where I live, there was an early worst-case projection that indicated an infection rate of 23% with no mitigation—roughly 212-thousand people out of a population of 922-thousand could become infected. That rate of infection approximates the Spanish flu epidemic a century ago, where it is estimated that 500-million people (25% of the global population at the time) were infected over two years and 50-100 million died. Using today's population, that would translate to nearly 2-billion people infected globally and 100-million deaths (at 5% of those infected—the 1919 epidemic killed 10% or more of those infected).

We're only a matter of months into the COVID-19 pandemic, and every death represents a tragedy, but...yes there is a "but." The evidence at this point indicates that stay-at-home, lock-downs, social-distancing, and other mitigation efforts are having a profound effect.

As of May 18, DuPage County IL has reported 6,033 confirmed cases (0.6 % of the population), with 302 deaths (5% of confirmed cases). The percentage of deaths has been going down. Deaths have been declining even as more people are being tested. The dashboard for our county shows that those testing positive is trending down and has been below 20% most of the past two weeks (getting close to one of the CDC guidelines for safely "reopening").

On the global level, confirmed coronavirus cases by May 18 had reached nearly 4.9-million (0.06% of the world population), with 320-thousand deaths (6.5% of confirmed cases). 1.9-million who tested positive have recovered. Of the 2.7-million active cases, 98% are mild, 2% serious or critical.

We must remember, however, that until a vaccine is developed, along with successful treatments, we are not out of the woods. The risk of spikes and resurgence remains high, but we now know that mitigation can act as a valve. The debate spreading around the world now is how to balance severe restrictions (from safer-at-home to full lock-downs) with "opening up"while observing workable mitigation (face masks, social distance, hygiene).

There is a sense now that failure to open up soon will exacerbate damage done by severe shut-downs: increased mental health issues, depression, suicides, unemployment, business closures, financial ruin, disruptions to the wide spectrum of normal health care put on hold, etc. We might beat this virus to death, but at what cost?

Just as the time we are in is unprecedented, so those who attempt to bring us news, explain things, and provide some measure of hope find themselves in uncharted waters. COVID-19 is a story that is all-encompassing and seemingly without end. How do we as consumers of news figure out what is going on, who to believe. . . and specifically for the point of this reflection, how to interpret the numbers?

FROM MODELS TO MILESTONES

As we go through life, we mark and celebrate various personal and family milestones—birthdays, anniversaries, graduations, promotions, moving, births and deaths. History and our own experience are marked by significant events: the moon landing, polio vaccine, sports victories on the positive side, natural disaster, war, economic collapse and disease on the negative side.

Milestones need context

The term milestone refers to literal stone markers along ancient roads that marked off miles. We still use them today, though most are not stone, but metal signs. For example, when driving on an Interstate highway, there are mile markers along the shoulder of the road.  You pass one that indicates "54," but what does that mean?  If you know you have to get off at exit 172, you can quickly calculate that you have 118 miles to go  If the numbers are going down, you know how far it is to the state line, but unless you know how long the highway is, seeing numbers going up is not much help in getting a sense of where you are. We can, therefore, derive greater meaning if we understand the context.

Let's look at two of the milestones used by various media outlets during the COVID-19 pandemic and how a sense of context leads to greater understanding.

Milestone 1 (with two markers): The U.S. surpasses Italy—first in cases, then in deaths

On March 26, the U.S. surpassed Italy as the country with the most reported COVID-19 infections in the world. That was a dramatic moment, but notice the language used by just one news source, USA Today (emphasis mine):

The U.S. surged past China and Italy to become the planet's most infected nation Thursday, a stark milestone in the coronavirus era - and a reminder of its deadly, culture-changing effects on American life.

While the pandemic has lead even the oldest among us into a time unlike any other, that paragraph is chock full of breathless drama. The two paragraphs that follow begin to provide some perspective, but not enough. We are basically being fed raw numbers.

The Johns Hopkins University dash board showed the U.S. with 85,840 COVID-19 infections as of 11 p.m., ET, moving past Italy (80,589) and China (81,782). More than 1,296 people have died in the U.S. [6,153 in Italy according to US News].

Part of the reason for the nation's top ranking is cause and effect: The U.S. has drastically ramped up its testing protocols in order to identify infected people and those who may be carriers of the virus. As testing has increased, so has the number of confirmed cases.

By April 11, the U.S. surpassed Italy in COVID-related deaths, with 19,700 (Italy had 19,468). An ABC-30 report (Fresno CA) made the following comparison: "Over the past week, the number of new deaths each day has been about three times higher on average in the U.S. than in Italy. Deaths have risen more than 9,000 for the week in the U.S. compared with fewer than 3,000 in Italy." Does that statement really provide us with any meaningful information?

Here's the context to put the US-Italy numbers in perspective. The most consistent source of statistics I could find on a daily basis is the Situation reports issued by WHO.

• Size. The U.S. is the third largest country in the world, with 331-million people. That is 4.5 times the size of Italy, ranked number 23, with 60-million people. While raw numbers say something, they don't describe the differences in the level of cumulative infections as a percentage of population or the rate of death as a percentage of cases. .
• When the U.S. passed Italy in reported cases of the virus on March 26:
  • U. S. cases represented 0.025 percent of the population, or 25 cases for every 100,000 people.
  • Italy's level was 0.13% or 130 per 100,000, four times greater than the U.S.
  • U.S. deaths (1,296) accounted for 1.5% of reported cases, compared to 7.6% for Italy. Because Italy was weeks ahead of the U.S. in the spread of the virus, the U.S. mortality rate is low at this point; Italy's is higher, but will keep climbing.
• When the U.S. passed Italy in reported deaths on April 11:
  • The U.S. death rate was 3.8% (18,516 deaths out of 492,881 reported cases). The infection level at this point rose to 0.14% or 140 per 100,000, about where Italy was on March 26.
  • In Italy, the death rate was 12.9% (19,470 deaths out of 152,271 reported cases)—7.5 times higher than the U.S. at that point in time.
• As of May 18, the comparison looks like this:
  • The U.S. death rate is 6.1% (87,180 deaths out of 1,432,265 reported cases). The cumulative infection level stands at 0.46% or 460 per 100,000.
  • In Italy, the death rate stands at 14.1% (31,908 deaths out of 225,435 cases). The cumulative infection level in Italy is 0.38%, or 380 per 100,000.
  • Worldwide, there are now 4.6 million reported cases, or 0.05% of the world population—50 per 100,000. The death rate stands at 6.5% from nearly 300-thousand deaths.
  • Thus, the U.S. has surpassed Italy in both total number of infections and the level of infection as a proportion of population. Italy's death rate is more than double that of the U.S. and the world.

It may seem that indicating that numbers are far less than they could be is too detached and unfeeling. To those in Milan and New York City, the health care situation has been horrific. We must recognize that, but also recognize that if COVID-19 was spreading at rates comparable to the Spanish Flu of 1919, with a quarter of the world's population infected over two years, the situation today would be truly apocalyptic.

We need both empathy and perspective. Empathy is not dependent on the numbers, perspective is gained in understanding the numbers.

Milestone 2: U.S. deaths exceed those of the Vietnam War

Another prominent milestone was watching as the U.S. approached deaths on a scale that would soon surpass the number of Americans killed in the Vietnam War. We are familiar with the memorial in Washington D.C. that identifies 58,318 Americans, whose names are engraved in the stone of that simple, somber memorial.

In the 1960s America entered as a major player in a war that had been going on since 1954. By 1975, upwards of 4-million civilian and military lives had been lost. .

The Vietnam milestone for Americans deaths was reached on April 28. (National Geographic has a good visual comparing this to the major wars in which Americans fought). So, another number. What does it mean? That depends. Did you live through that war and have experiences related to it? Did you have a loved one killed or wounded? Have you been to the memorial and taken in the scope of that many names stretched out in front of you?

COVID-19 and the global response to it has been so sweeping in its impact that it will require viewing it through multiple lenses over many years. For now let's focus on a comparison with other causes of death (remembering that we are now well past the Vietnam War milestone of 58,000+, surpassing 90,000 in the last few days.)

According to the CDC, the 10 leading causes of death in 2017 (the latest year available) were as follows. COVID death milestones are shown in red. Even if the final toll by the end of 2020 is well below worst-case projections, it is striking how rapid the rise in deaths has been since early March. The good news is that new deaths each day have begun to decline, barring a second wave in the fall.

COVID-19 death "milestones" against the 10 leading causes of death in America (2017)

1. Heart disease: 647,457
2. Cancer: 599,108
3. Accidents (unintentional injuries): 169,936
4. Chronic lower respiratory diseases: 160,201
5. Stroke (cerebrovascular diseases): 146,383
6. Alzheimer's disease: 121,404
• COVID-19 deaths as of May 18, 2020: 91,985
  latest number as of this writing
  The CDC 's latest forecast, the National Ensemble Forecast "suggests that the number of cumulative deaths are likely to exceed 100,000 by June 1st." We will certainly surpass that number. The forecast is extended only four weeks at a time. If a downturn in deaths becomes reality, as expected, how will the final number at year's end compare to the 200,000 upper end of the window that gained currency in April? If deaths were to continue at the present rate—about 10,000 per week, the total by year's end would be around 372,000. .
7. Diabetes: 83,564
• COVID-19 deaths as of April 28, 2020: 58,365
  not only surpassed Vietnam, but flu and pneumonia in 2017
8. Influenza and pneumonia; 55,672
9. Nephritis, nephritic syndrome, and nephrosis: 50,633
10. Intentional self-harm (suicide): 47,173
• COVID-19 deaths as of April 11, 2020: 18,516
  date US surpassed Italy in deaths
• COVID-19 deaths as of March 28, 2020: 1,296
  date US surpassed Italy in reported cases (85,840)

IF YOU HAD BEEN BORN IN 1900

The following is based on a narrative suggesting what a person born in 1900 would have witnessed in the 20th century. It's been making the rounds on the Internet and the few sources I've found so far simply say it came from a friend. Be that as it may, it provides an interesting framework to help put the COVID-19 pandemic in perspective. I have broken down the narrative into chart form, to which I have added more detailed data, including US and World population at each milestone. (US population estimates are available for each year since 1900, world population by decade until 1950 when annual estimates from the UN are available).

Maybe we don't have it that bad. It’s a mess out there now. Hard to discern between what’s a real threat and what is just simple panic and hysteria. For a small amount of perspective at this moment, imagine you were born in 1900.

This article was originally posted on Stu's InfoMatters blog.