Coronavirus: facts & reflection

London, 31 March 2020—

The coronavirus outbreak has now reached Europe and the U.S. at a large scale. For many of you who will read these lines, you are being confined at home and if so, you are likely into your 2nd, 3rd or 4th week already. What was something far away in China just 3 months ago has now taken a much more tangible form. Yet a form that is invisible, for you can’t see a virus; what you can see however are the consequences on our lives, and they are far reaching… How did we come to this madness?

In this article I propose to examine the facts about this virus and the spread of diseases in general, analyse the human reactions, question the measures taken by some governments and reflect upon what is truly taking place right now.

The public health situation so far

It’s always good practice to put things into perspective and go over the facts, again. We are overwhelmed by information day after day—some of that information being grossly exaggerated, taken out of context or distorted—but patterns only really emerge when you stand back a little.

The origins

COVID-19, a disease caused by a new type of coronavirus appeared in China around December 2019. First reported in the city of Wuhan, it has now spread across the globe. At the time of writing, it is reported it has already killed nearly 40,000 persons worldwide. COVID-19 spreads rapidly from person to person and its death rate is thought to be between 0.5–5% depending on the source you listen to. That’s a tenfold difference in the estimates. And it matters. A LOT.

The maths of death rate

Let’s start with a key indicator used by epidemiologists that you will probably have heard of by now: the death rate.

Death Rate (%) = number of deaths / number of cases.

In other words: the probability of dying for someone who was infected by the virus. A more scientific designation is case fatality rate (CFR).

Note—this should not be called a mortality rate because technically a mortality rate is the number of deaths for an entire population (regardless of tested or not for a disease). However mortality rate is often mentioned in lieu of death rate…

That notion of death rate is critical to understand if the coronavirus can be tagged as ‘dangerous’. That’s because there are established benchmarks against which it can be compared.

THE BENCHMARKS

• The seasonal flu has a death rate of around 0.1%.
• In 2002–2004 the severe acute respiratory syndrome (SARS) infected around 7,000 people and killed almost 500; the death rate was around 7%.
• In 2009, the H1N1 flu pandemic caused over 284,000 deaths; the death rate was estimated to 0.02%.
• Ebola has death rates of about 50%. That means half of the people infected die.

Note—the 1918 influenza has killed tens of millions of people worldwide (the world population was then around 1.8 billion). But the numbers are uncertain and cannot be used for a fair comparison, although many comparisons have already been circulated between COVID-19 & the 1918 flu.

The issue with data uncertainty

The problem with the death rate is that while it’s a key measure of how dangerous a disease is, it’s also very hard to estimate. The key uncertainty is on the number of cases i.e. the people who got infected—that’s because we only find what we search for… People need to get tested to enter the statistics.

Let’s say there are 500 confirmed deaths over 10,000 people who tested positive for COVID-19 (or any disease for that matter). That’s a death rate of 0.05%. But now let’s assume that the real number of cases was 25,000. Why such a difference? Typically: because a lot of people had mild symptoms or no symptoms at all and therefore never got diagnosed nor tested; because of the lack of testing equipment and staff to perform them. That’s now a new death rate of 0.02%, less than half of the original one.

BACK TO COVID-19

Experts agree that when there is an outbreak of a new disease, there is likely an over-estimation of the death rate during the first couple of months. Indeed, the current estimates are biased by a deficit of testing and by the lag time between onset of the illness and death. The numbers for COVID-19 are collected day after day and cannot show the full picture until the data is properly validated. That means later, in several months.

So don’t be surprised to hear large fluctuations in the reported numbers. To illustrate that, we could quote the World Health Organization (WHO) saying on 5th March that the death rate of COVID-19 was revised to 3.4% compared to earlier figures of about 2%. It’s the same WHO that declared COVID-19 a pandemic on March 11th.

Now, to add to the confusion, fresh news published on 31st March now say that some researchers revised the death rate estimate to 0.66% (source). Yet another number for the death rate… Why does it matter so much? Because when projected onto large populations, that makes the death toll much higher or much lower.

The UK population is 66 million. Let’s say 5% of people become infected by the coronavirus, that’s 3.3 million:

• with a death rate of 0.66% that means that we can expect around 22,000 casualties.
• with a death rate of 2% that means that we can expect around 66,000 casualties. That’s 44,000 more people than in the first scenario.
• with a death rate of 3.4% that means that we can expect around 112,000 casualties. That’s now 90,000 more people than in the first scenario!

One thing is for sure: the death rate given will continue to fluctuate and we will know a more precise estimate—but never its real value unfortunately, as with all diseases—only a lot later. Now in the meantime, lots of decisions have been made based on these numbers and worst-case scenario type of projections. Keep that in mind, because we will get back to it later.

VARIATION OF DEATH RATE WITH AGE

Now another important point is that the death rate, while given as a single number, shows in fact huge variations among the population based on their age. Here’s the current global death rate per age bracket for COVID-19.

Age	Death Rate (all cases)
80+ years old	14.8%
70-79 years old	8.0%
60-69 years old	3.6%
50-59 years old	1.3%
40-49 years old	0.4%
30-39 years old	0.2%
20-29 years old	0.2%
10-19 years old	0.2%
0-9 years old	no fatalities

Source: www.worldometers.info/coronavirus/ on 31st March 2020

It’s important to look at this table carefully, because these numbers tell a story that is hardly being depicted in the news. Because details do matter. So you may hear or read the following:

“COVID-19 does not only kill elderly people, it can kill anyone, even young people.”

Is this statement true? YES. Now is this statement also hiding an important fact? SURE! What is not being said is—for example—that if you are in your sixties, you are 18 times more likely to die from the disease than if you are in your thirties. Is that relevant? Hugely. But that’s a detail… ah but who has time for details these days?! We like it when facts are simplified enough so we can process them. But it pays to look beyond the surface.

Also bear this in mind: this does not tell you anything about the general health condition of casualties before they got infected. It may be common sense, but in times of stress we precisely tend to lose common sense: the persons at risk (i.e. aged, with fragile health, with chronic conditions) are more likely to catch any type of disease whatsoever. This simple observation actually has a huge implication on its own too: the coronavirus statistics may well ‘absorb’ some of the deaths that would have probably occurred over the coming months. Because the persons at risk will succumb to the coronavirus as it spreads rapidly, whereas they may have caught the seasonal flu during the next winter for example and die from it anyway. We will never know for sure, and I am not an epidemiologist, but that seems like an obvious corollary. When we get the seasonal flu numbers for 2019/20 and 2020/21 we can verify that supposition (means we can expect the number of deaths to be record low).

Now there are some countries that have been impacted more than others by this COVID-19 outbreak. Italy has sadly the record number of deaths per country in the entire world so far. Spain is just behind. Now is this totally a surprise? When you know that Italy has more than 20% of its population aged over 65 years old, you can understand why that particular country is severely affected. In fact, Italy has the most ageing population in all Europe. Sure, the age profile of the population does not explain everything, but it’s a major factor.

Now let’s look at the actual number of casualties.

The death toll

The virus propagation numbers can be seen in the table below. As of 31st March 803,000 infections and 39,000 deaths have been reported globally.

Country	Infected patients	Deaths	Death rate
USA	164,435	3,175	1.93%
Italy	101,739	11,591	11.39%
Spain	94,417	8,189	8.67%
China	81,518	3,305	4.05%
Germany	67,051	682	1.02%
Iran	44,605	2,898	6.50%
France	44,550	3,024	6.79%
UK	22,141	1,408	6.36%
Switzerland	16,176	373	2.31%
Belgium	12,775	705	5.52%
Netherlands	12,595	1,039	8.25%
Turkey	10,827	168	1.55%

Source: www.worldometers.info/coronavirus/ on 31st March 2020

I computed the death rate in the last column to show one more time that it varies, this time based on the location factor. The global death rate is 4.8% so far.

Let’s be clear, 4.8% is a high death rate. But with all the caveats given above, this is not a surprise. We can expect the real death rate to be much lower than that (likely under the 1% mark). Plus, the problem is compounded because each new country facing the epidemic is now having to deal with healthcare and testing en masse. And for the first few weeks/months their own estimate of the death rate will be over-inflated and unreliable…

I hope I have convinced you at this stage that the death rate is a complex number that is subject to the influence of multiple variables, each hard to determine. It should not be taken in isolation and if trying to make comparison, it should be used with caution.

Putting things into perspective

Now a natural question would also be: “How does COVID-19 compare to the seasonal flu (influenza)?” Let’s take a look at the official numbers for the UK as a comparison basis.

Season	Deaths	Average Deaths per day
2014/15	28,330	77
2015/16	11,875	32
2016/17	18,009	49
2017/18	26,408	71

Source: Public Health England

I’ve computed the average death toll per day in the last column. We see there are large variations from one year to the other. Yet it’s quite common, in average, for a few dozen people to die every day of the flu. In fact the real numbers per day are likely higher because the seasonal flu epidemic is concentrated during winter, whereas I smoothed that out over the full year.

In the entire world, the World Health Organization reports each year 290,000 to 650,000 deaths linked to the seasonal flu (you will notice the large uncertainty!). That’s a death rate of around 0.1%.

Now that’s where it gets interesting. Do you remember last winter that the daily death toll of flu was announced on the news, day after day, country per country? Surely not. Did you feel anxious because you could catch the flu and die from it? Most likely not. Yet that was a lot of people who departed… But here’s the trick: it happens every year at the same season so it’s kind of normalised. It’s part of the background. We have a tendency to pick up only on what’s new and unusual.

So are we seeing a pattern here? Is there something profoundly disturbing in the way we are managing this pandemic? Are the measures taken proportionate to the real threat? But what if there was also something that made us feel terribly anxious about this entire crisis?

Our relationship to death

Maybe the unfolding of the current crisis also reflects our difficult relationship to death. In the western world, we are terrified by the idea of death, disease and physical diminishment whereas other cultures accept(ed) that it was a natural process.

Now I am not saying that death is good. I am just saying that it happens. DEATH IS PART OF LIFE. Maybe we forgot, but people die every day, just like babies are born every day. It’s part of the process of life. Whether we keep that fact conveniently out of our awareness—or not—is for us to decide.

Now you may wonder, what do people die of? And how many of them? That will help us form a better picture still on what’s at play with COVID-19.

HOW MANY PEOPLE DIE EACH YEAR IN THE UK

Year	Number of deaths (male)	Number of deaths (female)	Number of deaths (all)	Mortality Rate
2010	270,945	290,721	561,666	0.85%
2011	267,491	284,741	552,232	0.84%
2012	273,347	295,677	569,024	0.86%
2013	279,171	297,287	576,458	0.87%
2014	278,455	291,886	570,341	0.86%
2015	292,707	310,075	602,782	0.91%
2016	293,001	304,205	597,206	0.90%
2017	298,843	308,329	607,172	0.92%
2018	304,373	311,641	616,014	0.93%

Source: www.ons.gov.uk

What does this table show us? That at large, in the general population of a country such as the UK (with 66 million inhabitants), on average each year nearly 1% of the population dies. At the same time, each year, babies are born. For example in the UK in 2016 while nearly 600,000 people died, there were 775,000 births (source: Office for National Statistics).

WHAT PEOPLE ARE DYING FROM

I retrieved the breakdown of deaths by cause from the Office for National Statistics for 2016, England and males only. I then extrapolated in the last two columns the results for the whole of the UK, males only still, so the numbers are not exact (because of Wales, Scotland and Northern Ireland not being included in the original breakdown data), but their order of magnitude certainly is.

Rank & Cause	Male deaths (%)	Number of male deaths	Average male deaths per day
1- Heart disease	13.60%	39,848	109
2- Dementia and Alzheimer’s disease	8.30%	24,319	67
3- Lung cancer	6.50%	19,045	52
4- Chronic lower respiratory diseases	6.10%	17,873	49
5- Stroke	5.40%	15,822	43
6- Influenza and pneumonia	4.80%	14,064	39
7- Prostate cancer	4.10%	12,013	33
8- Colorectal and anal cancer	3.10%	9,083	25
9- Leukaemia and lymphomas	2.60%	7,618	21
10- Cirrhosis and other diseases of liver	2.00%	5,860	16

Source: www.gov.uk

This reads for example as: in the UK, in 2016, every single day, the average number of males who died from heart disease alone was in the region of 100. That’s a lot of people, isn’t it?! Well you can roughly double it because the numbers are quite similar for women.

Note—these top 10 causes of death account for more than 56% of all males death. For context there were also:

• 1,770 reported road deaths for the year ending June 2018. That’s an average of nearly 5 persons each day.
• 6,507 suicides in 2018. That’s an average of nearly 18 persons each day.

So maybe we had just forgotten some basic truth: people die. EVERY SINGLE DAY. In the UK in 2016 over 1,600 persons (male & female) have died every day on average. Maybe we just feel uncomfortable thinking about it? And provided it does not happen around us, we are just oblivious of it.

I rest my case. The point of this morbid exercise was just to share the numbers and put the death toll of COVID-19 into a larger perspective: people die every day in every country in the world—yet we are surprisingly obsessed by the COVID-19 deaths. For some people it seems that by each single death announced on the news every day, they are one step closer to death. And that feeling is irrational. But this is a free will universe, so you can feel this way if you choose to.

THE POWER OF YOUR ATTENTION

It is the fact of focusing our attention on COVID-19, fuelled by media overdose, that has an amplification effect. We become specifically preoccupied with this epidemic, oblivious of what else is going on in this highly complex and dynamic world. We filter all the rest. Then one day we start to feel the panic, we get anxious and feel powerless because we feel this has become a large scale catastrophe. A sense of looming doom pervades us. We feel trapped. This brings to the surface all sorts of negative feelings that we had repressed deep within us for too long, and that waited this kind of occasion to burst out. A general sense of insecurity starts to settle in the background of our lives… These are dark thoughts and dark emotions.

Fortunately, none of this is ineluctable. We should remember that we have control over our thoughts. That thoughts are fleeting by nature. That whatever we place our attention on, we give it energy; or fuel it if you prefer. That the news and facts are neutral in nature, it is how we react to them that has consequences on our lives. That what matters overall to remain healthy is to keep balanced and positive. That we will get through this crisis, all together. That the world is not going to end.

The public health dilemma

So far, and looked in proper context, the rational analysis is that COVID-19 is not very virulent. Now where it gets more complicated is that it seems however that it propagates rapidly (scientists call that factor the basic reproduction number). Which means essentially that a large chunk of population could get exposed to it in a matter of weeks.

So what to think of that? My view is that realistically most people are not in danger. I mean we can become obsessed with the coronavirus, but before we even knew about it, there were already countless diseases out there. And what to say of car accidents and other injuries? Sure, living is a risky business.

Now, if you are over 60 years, if you have a fragile health overall, then you are more at risk. But just like for any other disease! Have we forgotten that being healthy is important? That we need to take care of our body to go through life? That once our body gets weak, we are prone to catch all sorts of infections? Maybe once more we have lost common sense. The people at risk today with COVID-19 are the people at risk every day. It’s no news.

So our most fragile people need to be protected from this wave of viral infection. And this is why in the early days of the epidemic reaching a country, some governments asked the more fragile people to self-isolate. Then they asked everybody to confine at home… Why?

The need to flatten the curve

The real challenge for countries is to cope with the number of patients to treat for COVID-19. If there is a rapid increase in the number of cases, then a major issue will be the saturation of public health infrastructure. This is summarised in the chart below.

If the number of cases goes over our healthcare system capacity, then we jeopardise not only these COVID-19 patients, but the entire healthcare system! We should not forget that hospitals treat patients daily for all sorts of conditions. A heart attack or appendicitis are always urgencies, a virus much less often so. If A&E are inundated daily with hundreds of patients who have COVID-19 symptoms, then this is putting extra pressure on the healthcare system. For many countries who are already stretched in staff and fundings, this is bad news.

If you anticipate a surge in the number of cases, then a sensible thing to do is to flatten the curve. In other words, you delay the infection spread and smooth out the curve over time. How do you do that? You impose isolation measures on the population to slow down the spread of the disease. It avoids the collapse of your public health infrastructure under the extra volume of patients. In simple terms: you’re buying time. Hoping that a vaccine will surface (unlikely to be soon, as it usually take months or years). Hoping that the madness will wane. The key information here is: the total number of cases (and likely deaths) may not change much between the 2 scenarios (without protective measure -and- with protective measures). You merely deferred the problem. And the big problem is: this virus is new and your general population is not immune yet—at least not at a level that will provide herd immunity.

HERD IMMUNITY (definition from Wikipedia)

Herd immunity is a form of indirect protection from infectious disease that occurs when a large percentage of a population has become immune to an infection, whether through previous infections or vaccination, thereby providing a measure of protection for individuals who are not immune.

The difficult decision

So how do we deal with this situation? Our governments have the power to make decisions that will influence the course of the crisis.

Now this becomes a psychological exercise. Assume you are a Prime Minister and you take counsel from doctors, scientists and subject-matter experts. You are given different views. But there are some simulations, some worst-case scenarios that predict that your citizens could be contaminated in the millions and die in the tens or even hundreds of thousands. Remember, that is very much linked to the death rate we talked about earlier. The uncertainty being large at the moment on that number, the estimates you get from scientists vary enormously. There is also the second variable called the basic reproduction number that defines the speed of propagation of the virus that is entered into the models. And for COVID-19 it is particularly high, which means you could get thousands of new cases within days…

So what do you do? Do you want to be remembered in history as the one who has let his population die in the thousands without taking the measures that ought to be taken… Even if they are unprecedented? Even if your economy will suffer tremendously and it will impact millions of people immediately? After all, human lives come first.

The lockdown option: a one-way ticket?

Based on scenarios with death rate alarmingly high and rapid spread of the virus leading to an incredible number of potential victims, governments reacted. Severe measures have been adopted by countries all throughout Europe (e.g. Italy, Spain, France, Germany) to face the threat of the coronavirus pandemic. They are unprecedented in peacetime.

People are being asked to practice social distancing and in many cases that also includes forced confinement at home with minimum time spent outdoor. Avoiding contact with other people will slow down the contamination. Well, it will. But now, it will also impact the entire society regardless of their health condition. You’re bringing entire economies to a halt.

So the lockdown was decided with the best interest of people at heart. But plenty of bad decisions are made with the best intentions in the world… Most of European countries have now locked down their citizens at home. What could have been dismissed as a totally ridicule story just a few months ago is now the daily life of tens of millions of people across Europe and the world.

In March, many European governments announced isolation and social distancing measures by chunks of 2 or 3 weeks at a time, renewable if need be. If the truth had been told, would they have faced revolt from the population? Because these measures will be extended for the foreseeable future. Yes, the bitter truth is that we’re in it for the long run. We’re most likely talking months, not weeks. It’s possible we will spend all of spring in this situation—at least in the UK. Some experts even talk about longer durations, from 6 to 9 months. The lockdown strategy is simple: we need to wait. Wait for an improvement of the public health situation. This is a passive approach. The measures announced will only get relaxed if things get better. There does not seem to be any other exit from lockdown…

So based on today’s data, we cannot predict how long we will be locked down for. It will depend on the evolution of the epidemic, country by country, day after day. The number of cases and deaths will be reported and analysed. Simulations will be updated. Experts will present their findings to the authorities. And governments will decide. And people will have to comply.

THE TROUBLING QUESTIONS

Sure we know that COVID-19 is not the seasonal flu, but it’s not Ebola neither! The survival of the human race is NOT at stake here. As we have seen earlier, the virus is not very virulent, but it spreads rapidly. That’s the dilemma. Many governments reacted strongly. However we should note that not all countries imposed a lockdown on their citizens. For example, Netherlands refused to do so and expect herd immunity to build up instead.

So the lockdown is not the only option. Yet it’s the one that has been selected widely. So here I just want to ask a few questions for the readers to wonder about:

• Could we say that many governments have taken extreme and disproportionate measures e.g. by adopting lockdown for the entire population? Was that the best decision they could have made in the general public interest?
• Are we sacrificing the post-pandemic future with our actions today, because we cannot cope with our fears? Are we damaging our economic prosperity and social well-being at large instead of asking only the most vulnerable people to isolate?
• Have we become so terrified with the idea of dying that it shuts down our logic and common sense?
• How long will entire populations tolerate to stay locked down for?
• Are we creating major unforeseen problems by locking down entire countries? Could the solution be worse than the original problem?
• Have we simply gone too far? And collectively overreacted? Were we driven by fear or reason?

I know these questions are controversial but I believe it’s healthy to ask them. All your answers will depend on your point of view on the events, and how cool-headed you are. Please do not judge whatever position each one of us can take. Is this situation unfortunate? Of course. Should we care for each other and support the community? Absolutely! Yet, having reservations about what’s going on does not mean being heartless or insensitive. We should not suspend our critical thinking in tough times, but quite the opposite.

The public panic

We live in a time of widespread fear and disinformation. And unfortunately internet and social medias are no exception. There were outbreaks in the years before, but never they resulted in such a widespread panic. What has changed? I cannot dismiss the fact that there may have been some kind of orchestration in the background by groups of people with certain agendas. If so, things will be revealed in due time. Nevertheless, it’s the reaction of people to the information broadcasted that is the source of many issues. Collectively, we have the power to control where we go as a species.

As some doctors have pointed out, “panic is more contagious than the virus itself”. Panic is a negative emotion, a subtle energy that can contaminate you. Listening to the news quoting all day long the latest death tolls will not help you at all! It will only increase your levels of anxiety. Anxiety leads to certains behaviours e.g. the stockpiling of food which at a large scale disrupts the entire society. I find it somehow relevant that when walking down the aisles of my local supermarkets, it’s mostly toilet paper that is out of stock. Because it’s linked to a very instinctive reaction induced by fear; remember the expression “shitting yourself”? Well, the relationship between fear and bowel control has long been observed… So people must be very afraid these days.

Mental health: the forgotten issue?

I think there is a collateral damage that may result from the confinement of people in their homes for extended durations. And I wonder if it has been carefully weighted, or even been considered at all.

Humans are social creatures. We need interactions for our balance. Connection with other people is a basic need. We now ask everyone to self isolate which means restrict their close interactions to the people in their households only. This is no small request. For one thing, the people who live far away from their family or lovers are now being separated. Next, many people are now stranded at home whereas they had life habits that made them spend precisely the minimum amount of time at home… Think about people having affairs, secret life arrangements, or simply the ones who are already in a difficult relationship with their partners/family and that will now get on each other’s nerves day in and day out. The coming weeks will for sure be interesting! Some people already predicted lots of births in 9 months. And it’s likely. But what about the divorces, the domestic violences, the separations and the extra stress to deal with? I am not saying that the coronavirus will create these issues. But it will reveal and amplify what was already there. The people going through these events will be distressed because everything will be condensed and accelerated.

Finally, people who already have a fragile mental health—and there is already a mental health epidemic in our modern western societies—are obviously even more exposed. We are talking about potentially millions of people who, as each week of confinement goes by, will find themselves sinking more into depression because of lack of physical contact with other humans. And when our mental health gets weaker, our body and our immune system get weaker. Not a very good prospect. An extreme outcome could even be suicide. That is not being widely reported at the moment, unless for prominent figures like this regional German finance minister (source). Again, time will tell.

There are certainly virtual meetings that can take place: phone call, video conferencing etc. While they are preventing us from total isolation, I am afraid they are no substitutes for real human interactions i.e. face-to-face.

Conclusion

I hope I could bring a new angle to your reflections on the coronavirus pandemic. As we are going through this crisis, I think we should keep in mind a few key questions. My top 3 would be:

• Have many governments over-reacted by imposing severe measures on their populations?
• How long can we stay in confinement and keep our sanity?
• Are we going to wake up one morning and wonder: “Oh dear, what have we done?”

This event is worldwide and triggers something in each of us. I am stunned by the variety of reactions from people around me. I feel like we’re entering a phase of intense change that will transform our societies profoundly and durably. There’s not going to be a resume button to push after hitting the pause button. We will have to bear the consequences of the collective actions we have taken during this crisis. Things that have been destroyed will take time to rebuild.

Yet I suspect this coronavirus crisis may just be the tip of the iceberg and there are other things happening in the background that the public is unaware of. There are other agendas that will become clearer later. Because for me, so far, this turn of events does not add up.

Anyway, what matters now is to take care of ourselves and I wish you and your loved ones the best on your paths. I am taking the bet that the confinement will last for many weeks to come… Let’s use this time wisely, shall we?

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