Current CoVid-19 deaths for North America West Coast jurisdictions to March 28, 2020 per the nCoVid2019 Dashboard, and projected most likely (95% confidence intervals: +/- 50%) total deaths to the end of this wave of the pandemic for each jurisdiction per U of Washington IHME projections as at March 24, 2020. Interpolations of this data for Canadian jurisdictions are mine. Click on image for larger version.

Caveat: I am not an expert in this subject, and these are only my wild informed guesses, subject to drastic future change and possibly great retroactive embarrassment. But I thought I’d try to summarize how it looks to me at this pivotal point, based on my experience and research.

The most important things to keep in mind right now IMO:

1. CoVid-19 deaths in North America are going to skyrocket by an order of magnitude over the first two weeks of April. That doesn’t mean the disease is out of control; in fact the rate of infection and death is already starting to decelerate and will likely continue to do so per the charts above.
2. While high and tragic, the projected death rates are astonishingly low for such a pandemic. This is due to (a) relatively rapid implementation of social distancing (“flattening the curve”), which has likely reduces death rates by a factor of 10-20x, [here’s why: thanks to Tree Bressen for the link]; (b) learning from the Chinese early hospitalizations about timing of use of invasive ventilators in serious cases, which may well halve the death rate here; and (c) our good luck — this strain seems to have a relatively short and fragile life before it dies unless it finds new hosts, and a relatively low morbidity rate.
3. If the American president relaxes social distancing, isolation and travel restrictions before the summer, all bets are off: Death rates from 1-2 orders of magnitude higher could then be entirely possible unless he is quickly removed from power and saner governance is put in place. (Same is true for other dangerous populist national leaders.)
4. There may well be more waves of this virus, perhaps with wildly different human vulnerability profiles and morbidity rates. The first wave of a pandemic is not always the worst.

LEARNING FROM PAST PANDEMICS

When I worked 12 years ago with the Ministry of Health with a special group hired to learn the lessons of SARS so there would be no repetition of the mistakes made then, we studied the epidemiology not only of SARS (CoV-1) but of various bird flus (H5N1, H7N9), swine flus (H1N1), and the 1918 pandemic (“Spanish flu”, also an H1N1). 

What was so remarkable about this work is that most of what we would ideally like to know/learn about these diseases we could not learn, for a number of reasons — mostly about how incredibly little we really understand viruses and how they proliferate, but also because the history is still unclear. You would think, for example, that by now we would know where the 1918 pandemic arose, but we remain utterly clueless, with at least 3 major theories, all of them somewhat suspect.        

We also can’t yet agree on how many died from the 1918 virus, with estimates varying by more than an order of magnitude. 

Nevertheless, there is much to learn from that pandemic, and I’d commend this New Yorker video to you — an interview with John Barry, a writer who’s spent much of his life studying it.

 Some things that we did learn, that now seem to have become lost in the shuffle:

1. Flu pandemics come in waves. The severest wave in 1918 was the second, not the first. And it wasn’t (so much) because people got complacent and eased restrictions when the first wave abated; it was because viruses can mutate incredibly quickly, and the second wave arose from a much, much more virulent strain.
2. Unlike most flu viruses, including the first 1918 wave virus, the second wave 1918 mutation struck almost entirely young people. It did this by inciting what is called a cytokine storm in the bodies of its victims. It wasn’t the virus or any side effects of the virus (like pneumonia) that killed the second wave victims, it was the victims’ own immune systems. So those with autoimmune disorders (hyperactive immune systems) were devastated, while those with suppressed immune systems were almost entirely spared (fewer than 1% of second wave victims were over 65). 
3. There were several waves of the 1918 virus after the second one, but a peculiar paradox made them much milder: The second mutation essentially ran short of available hosts, and had to mutate to survive. The second mutation was simply too potent for its own good, and essentially eradicated itself by mutating into a much milder form. 

MODELS OF WHAT TO DO NEXT TIME

The economic impact of this virus, due to our unpreparedness for it, will be staggering. There is a significant risk of a long and deep economic depression (more on that in a future article). But this didn’t have to be.

Some jurisdictions have been largely spared both the health and economic costs of this virus, notably Taiwan. Lessons from their experience and preparedness:

1. A process must be in place to enable rapid and repeat testing of every citizen, to quickly isolate the disease. The cost of being ready with swabs, masks, sanitizers, protective shields and test equipment pales in comparison with nationwide economic shutdowns, and such shutdowns are needed onlybecause we have no idea who has the virus now. It is very likely that actual positive cases (if we had the tools to test for them) would be about an order of magnitude (10x) the current “official” figures, which have resulted from testing only those who already exhibit strong symptoms.
2. In Taiwan, spreading fake news, hoarding, price-gouging and other actions that exploit and inflame the situation are indictable offences and considered shameful, not shrewd, behaviours. There, businesses and schools and restaurants are re-opened and life is nearly normal, and there’s been very little effect on the national economy.
3. The town of Vo, in Italy, had the luxury of having the equipment and political will to test and retest every one of its 3,300 residents and isolate those who tested positive, even if asymptomatic. Their experience is a model for every community in the world to follow, if we’re willing to learn from it.

PREVENTING PANDEMICS IN THE FIRST PLACE

While the above models can dramatically mitigate the impact of pandemics when they first occur, it would be even better if we were to prevent them happening in the first place. When Dr Michael Gregor was working in epidemiology a decade ago, he published his findings on the history of human pandemics and their causes. He revealed that virus transmission to humans only became possible with the domestication of animals 10,000 years ago, and all known human viral infections (poxes etc) have their origin in domesticated animals or the consumption of bushmeat — without it there is no way for viruses to move from their endemic animal hosts to humans who have no immunity to them (hence leading to pandemics).

Two centuries ago pandemics became more prevalent again, commensurate with the intensification of “industrial” agriculture. Then with the development of vaccines, infectious diseases were almost eradicated from the planet by the 1970s, causing some health leaders to predict that such diseases would never again cause pandemics. 

But then suddenly there was a third huge upswing in novel infectious diseases, starting just 30 years ago.  This corresponded with the order-of-magnitude increase in CAFEs (factory farming) of both domesticated and “exotic” birds and mammals for human food. Pangolins may the source of SARS CoV-2 (the current coronavirus that is expressed as CoVid-19). 

There is nervous laughter around the room when Michael says, at the end of the 2009 presentation linked above, that “we could well face a situation in the near future where every American might have to shelter in place for as much as three months to prevent spread of a global lethal pandemic”. 

It is to be hoped that, along with all the other learnings from this current horrible outbreak, we take to heart that only by completely ending the three sources of the recent upsurge in pandemic risks — (1) disturbance of the last wild places on the planet that harbour viruses for which there is no natural human immunity, (2) the bushmeat trade including domestication of “exotic” species for food, and (3) factory farming — will there be any chance that situations like that we are currently facing will not become increasingly frequent and dangerous.

But I would be surprised if there’s even an acknowledgement of this cause, outside an increasingly censored and silenced scientific and medical community.

MORE INFO

• The charts at the top of this post came from IHME projections, and the underlying data is available here if you want to make your own or track the accuracy of them. They’re especially useful if you’re in a state that will likely face severe hospital bed, ICU or ventilator shortages and hence excess preventable deaths: New York, New Jersey, Connecticut, Michigan, Louisiana, Missouri, Nevada, Vermont and Massachusetts.
• The IHME used in its modelling information on other countries’ death rates after the number of deaths and infections reached a certain base level (“trajectories”). Our World in Data is maintaining excellent charts on trajectories. So is John Burn-Murdoch for the UK Financial Times.
• The data suggest that the mortality rate, on average, is converging on a rate of 1% of those infected. But the number of people testing positive (due to drastically limited testing stemming from unavailability of test kits and testing resources) is wildly underestimated (the actual number of those who would be testing positive if everyone had been tested is likely 8-20x the reported numbers). That means, if the projections pan out, that only 1.5-2.5% of North Americans would actually test positive at some point during the current wave, if the test were available. Without social distancing, it was estimated that 25-50% of the population would eventually contract the disease. This is the power of social distancing: It is almost certainly saving tens of millions of lives worldwide. It is these tens of millions of lives saved that we must weigh against the horrific economic cost of this pandemic, which is only beginning to emerge.

WHAT TO DO NOW

• Depends on your situation, of course. If you’re needed in the food, health care and other essential fields, thank you for continuing to do what you do. If you have things you can give away safely to people who would benefit from them, of course please do so. If you’re in financial peril as a result of the economic shutdown, the resources available to help differ in each jurisdiction.
• If you’re like most of us, the next few weeks especially will bring a lot of anxiety, and feelings of anger, being trapped, feeling shameful etc. These are all manifestations of grief (thanks to Maureen Nicholson for the link). There are many online resources on coping psychologically with this. Here’s one(thanks to John Graham for the link) that I find useful.
• Keep up the pressure to sustain social distancing on your government, if it’s dragging its heels or proposing to relax the rules. Here are the worst offenders globally. Likewise if your peers are flaunting the rules (the link above also has a tab on citizen behaviours, which largely parallels their governments’). Millions of lives are at stake.
• Limit your time on useless social media and other media that are mostly or entirely unsupported opinion, useless information and misinformation. If it’s not actionable, and doesn’t give you any sense of comfort that you’re doing the right things by being overcautious, and that it’s going to be OK, then there’s really no benefit in reading it.

And for the vast majority of us, it is going to be OK.

Next articles here will be on the economic fallout, which is likely to be longer and deeper than the health impact, but was overdue to happen anyway, and on why this horrible event may be a useful wake-up call that might get us started addressing some of the more profound and permanent challenges ahead.

Stay safe, everyone.