OPINION: How do we place COVID-19 in its proper context?OR Tambo Airport (Photo Department of Health)

OPINION: How do we place COVID-19 in its proper context?

Comment & Analysis

The world-wide number of confirmed infections with the COVID-19 virus this weekend crossed the 100 000 mark. Deaths will soon exceed 4 000. While there have been multiple attempts to model how much higher these numbers might go over the next year or so, the reality is that right now we are still working with very limited information, many variables,  and accordingly we can’t predict with all that much certainty how things might turn out.

How then should we think about COVID-19. Between the untenable positions of indifference at the one end of the spectrum, and panic at the other, where exactly should we place COVID-19?

There are of course a number of ways to approach this question – among others, by comparing with other diseases, by trying to assess the potential human and economic cost, and by thinking about the window of opportunity we do or do not have to change how things will play out.

 Comparing with more familiar diseases

Though it only takes you so far, one way to contextualise COVID-19 it is to compare the available COVID-19 numbers to those of other more familiar diseases. According to the World Health Organization (WHO), tuberculosis (TB) killed an estimated 1.5 million people world-wide last year. COVID-19 has so far claimed around 3 500 lives in two months (a period in which in the region of 250 000 people would have died of TB). As yet then, it is not claiming remotely as many lives as TB.

The WHO estimates between 290 000 and 650 000 people die of influenza per year (over two months this works out to around 48 000 to 108 000). This is also far higher than the current levels of COVID-19 deaths.

The absolute number of deaths is the most concrete number to look at, but comes with the important snag that we know a lot less about how many people will die of COVID-19 in future than what we do about familiar diseases like TB and influenza. It is for example quite plausible that over the next two months more than 10 000 people will die of COVID-19 – or alternatively we can’t completely discount the possibility that fewer than 3 000 people will die in this period.

For this reason, it is also worth looking at measures of how well the virus spreads and how deadly it is. Here things can get complicated quite quickly though, since there are many factors that impact the speed at which a virus spreads and building models to anticipate potential spread are by their very nature filled with assumptions that may or may not turn out to be correct.

While any prediction of the future course of COVID-19 is uncertain, the numbers can also create a different kind of uncertainty when they are quoted out of context or interpreted wrongly. There has, for example, appeared to be some confusion over how deadly COVID-19 is. Some of this confusion is down to whether you calculate the death rate in people who have been diagnosed, or the death rate in people who have been diagnosed plus your estimate of the number of undiagnosed people (the latter obviously resulting in lower death rates).

One message here is that to keep things in perspective one should be careful to consider the numbers in context. In South Korea, where they have been testing people very aggressively, they have by Saturday reported 7 041  cases and 46 deaths – suggesting a death rate of under 1%. By contrast, in the United States, where testing has been much slower, over 500 infections and 21 deaths have been reported – suggesting a death rate above 3%. The difference in death rates here is not because the virus is more deadly in the US, but rather because the US has so far been testing mostly just the sickest people.

Another complication to consider when trying to anticipate the possible future course of COVID-19 is that epidemics tend not to be linear.  This impacts the deductions we can make from estimates of how easily the virus spreads and how deadly it is. The outbreak in Italy, for example, was highly unpredictable. As of now, it remains hard to predict which other countries or regions will end up having similarly large or worse epidemics. We simply do not know what will happen in South Africa when winter comes or if we start seeing significant levels of local transmission.

Unknown versus familiar

One way in which COVID-19 is clearly different from influenza and TB is that it is new to us. Since we tend to fear the unknown more than the familiar, and since us humans are generally bad at understanding risk, it is not surprising that COVID-19 is dominating the headlines.

The newness is however about more than just human psychology. Because it is still new, it is much harder for us to predict the future of the COVID-19 epidemic than it is to predict the future of the TB epidemic. These very real uncertainties are broadly linked to two types of uncertainties –  scientific uncertainty (partially discussed above) and uncertainties regarding how people and their governments will respond to COVID-19.

That governments can have significant impact on how epidemics unfold is worth stressing. In South Africa the HIV epidemic became much worse than it needed to be because of state-sponsored AIDS denialism and the delay in making antiretroviral medicines available to people living with HIV. On the other hand, an impressive WHO report published last week suggests that measures taken by China over the last two months has somewhat delayed the spread of COVID-19 to other countries and relatively successfully contained the outbreak inside China.

Either way, the potential harm from COVID-19 is certainly such that the cost may be much higher than it needs to be if governments don’t respond appropriately.

One complicating thing here is that even though the South African government is currently responding sensibly to the COVID-19 threat, years of government underinvestment and mismanagement has left our already stretched healthcare system ill-prepared for this new threat. Should we get a sudden increase in symptomatic COVID-19 cases in South Africa, it may well be that we simply do not have enough ICU beds and ventilators for all who need it. It is uncertain how well public and private sector resources will be shared and coordinated in such an eventuality.

Social and economic impact

This brings us to another critical bit of context. Apart from people getting sick and dying, COVID-19 is having significant social and economic effects on society. In various countries schools are being closed, football matches are being suspended, important conferences are being moved online, we may face an increase in medicine shortages, travel and tourism is reduced, and in general economic activity is being suppressed as governments try to slow down the transmission of the virus. This impact is real, and though not as serious as lives lost, is most definitely also serious.

Some might argue that the high social and economic costs are due to an over-reaction. Yet, while the value of some specific interventions might be debatable – and these are certainly debates we must have, it seems clear that doing nothing will be grossly irresponsible. The cancellation of large social gatherings in for example parts of Italy, the USA, France and China seems imminently sensible – even though such cancellations have significant social and economic cost. The WHO report on the Chinese response also provides compelling evidence that the highly disruptive measures taken in that country have been worth it.

How seriously then should we take the COVID-19 threat given all these uncertainties?

The first thing that should be clear is that there is no reason to panic. We are not in a Hollywood movie. The numbers make it quite clear that most people in South Africa are at a dramatically higher risk of a variety of other potential causes of death – not only TB and influenza, but also things like violent crime and motor vehicle accidents.

Panic also just doesn’t help. The things some are doing out of panic, such as bulk buying masks and hand sanitisers, are not of much use, and might actually be doing harm by depriving others who may have more need of these products. Some government decisions, like deciding not to take people from a cruise ship to more appropriate quarantine facilities are also counterproductive and smacks of panic.

But while there is no reason to panic, there is certainly reason to take the threat posed by COVID-19 very seriously.

What does it mean to take it seriously?

Firstly, it means we should expect our governments to take reasonable and scientifically sound measures to limit its spread and mitigate its impact. COVID-19 is serious enough that it requires political leaders to show real political will to implement a scientifically sound response as well as not allowing the response to become overly politicised.

Secondly, taking it seriously means doing certain responsible things at an individual level. Self-isolating when you have travelled to an affected area and are experiencing symptoms is the responsible thing to do. Washing your hands and making sure not to cough on people remains the decent way to go about things – just as it has always been because of diseases like influenza and TB. There is no need to think of these things as panic-induced measures – these can simply be precautions we take that are as natural and as every-day as putting on a seatbelt when you get into a car or not going to work when you have a bad case of the flu.

It might be that in time South Africa ends up having a substantial COVID-19 epidemic and that we are asked to reduce travel and meetings. This could be highly disruptive and harmful to the economy, so its impact should not be underestimated. That said, in South Africa we have faced severe droughts, continued load shedding, and many people still face the daily risk of rape and other forms of violence. If we get travel restrictions and social distancing, these will generally be things we can bear.

On the other hand, such a substantial epidemic may well push our already stretched public healthcare system beyond breaking point. It is not impossible that we will find ourselves in the unbearable situation where we do not have enough ICU beds for all who need them. In such a situation opening up ICU beds in private hospitals to public sector patients will help, but even so, we will struggle if the outbreak is large enough. This is why containment of the virus is so important at this early stage, and why taking sensible prevention measures at an individual level is critically important, even if you don’t think you are at much risk yourself.

One last thing – just as TB, influenza, traffic accidence and violence claim lives at present, the lives claimed by COVID-19 will be all too real for the families and friends of those who die – no matter how few or how many of them there are. Maybe this is ultimately the most important bit of perspective to keep in mind.