📊 Daily Data Brief:
New Cases outside China: 2,961 (+805)
New Cases in China: 150
Total Death: 3,408 (+121)
Serious or Critical Cases: 6,272 (-168)
The UK recorded its first death yesterday as did many other countries and US states. We have now over 100,000 reported cases. All media outlets have a live feeds, breaking news notifications are on the rise, and yet there is a huge cacophony and information overload whilst a lot remains unknown about COVID19. Two questions linger on: how worried should I be? what can I do? These questions are being asked in the “Age of distrust” where populism (and lies) are on the rise and leaders in some countries are more interested in spreading disinformation to advance their narrow interest than preparing the public with objective communication and leadership. It is a recipe for panic rather than decisive action. And yet we need the latter.
China’s authoritarianism which caused it to initially conceal the emerging outbreak with the current dire global consequences, was also its greatest strength in containing it subsequently. It is not our only option. As we are more knowledgeable about the outbreak from past epidemics, current findings from this outbreak and the effectiveness assessment of different policies in early affected countries provide valuable learning to inform future policy. The steps we now take will have profound impact on the ultimate severity of this novel coronavirus. Decision making can happen at different levels, and if higher authorities are failing us, we still have our individual freedom of action. Benjamin Franklin famously said: “Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety.”
As the famous saying goes: “Better safe than sorry”. Its French equivalent is: “Mieux vaut prévenir que guérir” (“an ounce of prevention is better than a pound of cure” is its less commonly used english version) is more relevant to the current situation. Let us use our freedom which our societies afford us to at least take now the individual decision which will enhance our safety. It is also key to continue to pressure authorities to accompany and support these actions.
❓ We are still dealing with a lot of unknowns about this novel coronavirus. 16 days ago in an excellent article, Julia Unwin from Vox had highlighted the two questions we need to answer to determine how severe this epidemic will be: “How easily does Covid-19 spread from person to person, and how severe is the virus?”. She focused on two measures with their estimate at the time to answer these: R0 (the basic reproduction number measuring how many person a sick person is likely to infect) and the Case Fatality Rate (CFR - the ratio between recorded deaths and contracted cases). She wrote at the time that we could only give estimates and these numbers would evolve as we get more data. For reference, R0 was estimated at between 2 and 3.11 (versus 1.3 for seasonal flu) and the CFR was then estimated to be at 2.3% (2.3 die for 100 who contract the virus; the Spanish Flu of 1918 which killed up to 100 million people had an estimated CFR of 2).
Julia wrote a follow-up article yesterday updating us on our current knowledge of the coronavirus’ CFR. I do not wish to focus on the absolute number, giving that it is a moving target with still imperfect data but everything points out that COVID19 is worse than the seasonal flu and potentially as bad or worse than the Spanish flu. I would just outline that data is imperfect for two reasons:
We do not know if all the positively test cases represent the actual contracted cases for the denominator (there has been a lot of debate about whether there were a lot of asymptomatic cases or mild cases - even though the WHO mission in China reported that there was no clear evidence that this was the case, which never got tested or whether in some countries (including the US!) limited testing ability deflated the number of contracted cases), and
A number of cases are still not closed in the sense that we do not know if the outcome will be ‘recovered’ or ‘death’.
Instead I would like to focus (throughout today’s newsletter in fact) about what we can and should do from what we have learnt as opposed to debate the numbers extensively. One of the best graphs to discuss this has been shared by The Oxford Trust.
You can see that until all the cases are resolved, we cannot estimate by country or globally what the CFR (nationally or globally). You can also notice that there is a huge variability per country in mortality rate (reported death to positively tested cases). South Korea is an outlier in the graph and is also the country which has ramped up its testing ability the most effectively having tested 140,000 of its citizens. It currently has a mortality rate of 0.6% compared to 3.4% globally. Greater testing ability is known to allow better surveillance and implement a better containment strategy. It is worth updating the South Korea numbers as of today for discussion purposes: 6,596 cases, 42 deaths (0.6%), 6,416 unresolved (97.3%) and 52 in critical conditions (0.8%). You can see that that the death numbers could obviously go up depending the death rate amongst unresolved cases and in particular the cases in critical conditions.
It is also worth noting that China’s mortality rate is one of the highest and that the mortality rate has varied per region. There is a good article from Nurith Aizennam in NPR looking at the variation of death rate in China across region and over different time periods. It is worth noting that if you exclude the Wubei region, Nurith reports that the mortality rate drops to 0.4% . As for date wise, the mortality rate peaked in China between January 1-10 at 16% to drop to 1% for the February 1-11 period. It is also worth noting that in the early stages of the outbreak, China did not implement any containment strategy preferring disinformation and censorship over precautionary measures. The Wubei health system was overwhelmed and sick patients were not properly taken care of driving proportion of death outcomes. Once China realised the severity of COVID19, as the West does now, it implemented a drastic containment strategy starting with a total lockdown of Wubei. This explain the variation across regions and time period in the data.
My main point for this section is to say that containment strategy will affect greatly the R0 and CFR data and the severity of the pandemic, and that these are mainly ex-post data point which our individual and collective behaviour can greatly influence. In a very good editorial in Nature, “Coronavirus response: a focus on containment is still apt”, the author sides with the World Health Organisation (WHO) for not calling COVID19 a pandemic yet, leaving it as an option for now. Now is the time to apply pressure on government to understand the severity of the epidemic and put in place the measures to contain/slow its spread (Link)
❓ Max Fischer writes an article unambiguously titled “How Worried Should You Be About the Coronavirus?” focusing instead on the societal and economical consequences of the virus. It highlights the potential economic dislocation caused by the virus as well as the different in severity of impact and outcome depending on whether you are poor or well-off. It rightly notes that school closures, travel restrictions, supply chain disruption will have a large economic cost.
More needs to be written on this given that it is no longer whether the virus will have an economic cost but how big will it be. Is it better to urge and/or enforce drastic containment now to minimise ultimate cost rather than risk a more severe crisis by not communicating and pre-emptively acting given what we already know. Populist and authoritarian governments are always tempted in the beginning to please the people and hope for the best (for themselves). What is instead needed is effective communication, education and carefully/scientifically informed leadership. It is all the more important in free societies where authoritarian enforcement is rightly not the preferred route. We have now learned from China that drastic and decisive actions can successfully limit the severity of the outcome. As much as it was criminal for China to conceal the outbreak initially, it would be criminal now for countries with the current knowledge not to act decisively for the health of its citizens. (Link)
💪 Fortunately, in free and capitalist societies, individuals, regions and corporations have a key role to play in implementing the right decisions for themselves, citizens and their employees respectively. We have already seen the major tech companies urge their employees in Seattle to work from home.
As an article in the Pew Trust explains “States Have ‘Immense’ Powers to Fight Coronavirus” and the New York governor Andrew Cuomo has just seized such emergency powers to be allowed to take decisive action in his state to contain and mitigate the virus. And at country level, Italy as reported yesterday has also ordered schools to be closed across the country.
Nicholas Taleb tweeted a few days ago “If you must panic, panic now” quoting an excellent thread from Nicholas Christakis (Sterling Professor of Social & Natural Science at Yale). The thread explains with data from the Spanish Flu why it is better to order school closures (and by extension other containment measures) pre-emptively rather than reactively. Below is one of the tweet.
It is time for us to acknowledge that this virus will have economic cost, and rather than plan for the best, act early and decisively to minimise the severity of its outcome. Nicholas’ thread also demonstrated with data how, as we wait for a treatment, non-pharmaceutical measures can have a noticeable impact on the current epidemy’s outcome (Full thread here)
🤝 There is a very good article on trust in Five Thirty Eight by Maggie Koerth: “Politicians Are The Last People Americans Want Fighting Coronavirus”. A 2009 Pew Survey, pointed out that only 36% of Americans trusted their government, but 80% of them trusted the Center for Disease Control (CDC). It is therefore important that the CDC keeps its voice and is not muzzled by Mike Pence as was suggested earlier by the Task Force. Trust is a very important factor in effectively combating the crisis we are facing. As I have tried to outline above, whilst the World Health Organisation and individuals need to keep pressuring people in power to act, all levels of society needs to exercise their intelligence and freedom to act.
Dr Tedros (Director of WHO) issued a veiled threat yesterday to list the incompetent leaders if needed.
In the meantime, the press and the legislative should also continue to apply pressure on the executive where necessary as well. Here is Maggie’s article (Link)
💊 There is an interesting article reference in the link above detailing what happened during the 1976 swine flu pandemic, when too much political-motivated decision-making led to a vaccine fiasco. It reminds us that science needs to play a key role in informing decision-making so as not to repeat the mistake of Geral Ford at the time. This might have cost him his re-election (I know what the anti-Trump camp is thinking…). It seems that Trump is keen to see the emergence of a vaccine and sometimes communicates his wishful thinking unhelpfully and publicly. He should heed the lesson of Gerald Ford… (Link)
👶 Two interesting findings published recently as well, regarding children and pregnant women. It appears that vertical transmission (from mother to foetus) does not occur and that would be a relief.
There is also a study reported in Nature which is out about how susceptible to infection are children versus adults particularly. It appears unfortunately that children are as likely as adult to get infected further supporting the potential necessity to close schools as a containment strategy (Link and Link)
📊 A picture is worth a thousand words
Singapore remains the gold standard of government and communication in the time of an outbreak. It started with the highly praised communication from its leader posted on Facebook to this wonderful data dashboard publicly available for its resident to see and the rest of the world to emulate (Article and Dashboard link)
This is a data visualisation page by Joel Selanikio (MD) on COVID19 (Link)
This is the New York Times data and graph page on COVID19 with an update map of the US alone (Link)
🎬 One video and one link to Coronavirus videos