Risk and Sensibility
The Denver Post ran an opinion piece posing a useful question: how did we do in evaluating risk of COVID-19? Answers are all over the map, but so many are so breathtakingly stupid as to make the value of the piece pretty minimal (“Hey, the mortality rate was only 1.4%, so not so bad!” “My restaurant didn’t have a case, so restaurants were safe!”). The tone of the op-ed leans towards “hey, we panicked, this wasn’t such a big threat after all.” Having the cojones to put that in print after over half a million Americans perished in under a year–easily the number three cause of death in 2020, and when you toss in the excess mortality since the start of the pandemic, you are up to ~650,000 deaths either directly or indirectly caused by the pandemic. The age-adjusted death rate increased by nearly 16% in 2020. COVID-19 was the number three killer in the U.S. Sure, your odds of dying if you were between 25 and 34 only increased by about 4%, making COVID about the #6 killer in that age range, but for 44-55 year olds, the odds of dying went up by 11% or so, making COVID the number 4 killer and close enough to “unintentional injury” that it could well be #3. And then none of this considers the long term impacts of having had COVID-19–of the more than two million Americans who have spent time in the hospital, something like a half million or more are seeing long-term effects from COVID-19, effects that are often pretty debilitating.
A way of looking at this is years of life lost to the disease–in essence, if you die at 25 and were expected to live to 85, that is 60 years lost, but if you die at 80 it is only 5 years lost. A paper in Nature tackles this and makes comparisons with traffic deaths, seasonal influenza, and heart disease. In the U.S., COVID-19 has been seven times the losses from influenza, about 2.3 times the loss due to transport (mainly auto accidents) and maybe about 0.4 times the loss due to heart disease. This is with a pretty conservative estimate of COVID’s impacts, and it is worth keeping in mind that we tried very hard to limit COVID-19 but not so much many of these other causes of death. Additionally, this study found that about 20% of the loss of years of life in the U.S. was suffered by those under 55.
So were we overreacting to a disease that did cause more loss of life that auto accidents (by more than a factor of two)? Certainly had we done nothing the toll would have been far, far worse (millions dead), so the question maybe should be, what were the really effective steps, and what was theater that did little? in other words, a better question is, how well did we do in balancing the risks posed by different activities for dying of COVID-19?
There are two aspects of the disease that really matter: it is transmitted dominantly as an airborne virus, and most infections come from a small fraction (10-20%) of those infected. It can hang in the air for some time and travel a fair distance from a source. We’ve pretty much known all this from sometime in April of 2020. So what were some of the stupid moves?
Arguably the UK’s opening of pubs while discouraging people from meeting outdoors was wrong-headed; California pretty much did the same with opening retail stores while discouraging outdoor meetings. Closing beaches was a popular trick a year ago that probably had little or no real impact on cases–in fact, it might have created more cases if folks moved indoors. On the COVID theater side, disinfecting everything in sight may have made people feel safer (hmm, smells of Lysol…), but fomites were kind of ruled out for the most part by last summer, which didn’t really stop the wiping down of everything. And of course the WHO and CDC pronouncements against masks early on was seriously misguided, mistaking what they wanted people to do (don’t buy masks needed for health care workers!) for what they were saying (incorrectly!) was the science (masks won’t help you!). And we shouldn’t forget universities pretending they could reopen without having an impact on surrounding communities. And frankly a lot of governmental leaders were too slow to react (New York being a prime example).
On the flip side, what have been some of the most effective interventions? Almost without a doubt, masks have been highly effective even if imperfect. Closing bars and indoor restaurants also has had a major impact (every study GG has seen on this has placed bars and restaurants at the top of the list of businesses increasing COVID cases). In fact, of all the government interventions, this was really the main one to actually affect the disease. Closing or limiting indoor church services was nearly as effective. Large indoor venues also seemed iffy, though typically the air volumes and air flow might have been enough to make these safer than they might seem, but eating and cheering are both pushing infections into the air. Basically, if you were indoors and had a mask off and were loud, you were in a bad spot.
And what were the missed opportunities? Well, frankly, the most dangerous place was to be home with someone who had COVID; the number of stories of entire families falling ill with multiple mortalities was saddening. Had there been a more holistic means of isolating ill people, either within their homes or, if not possible, in some other place, could have spared a lot of deep anguish from shattered families. The other huge missed opportunity was in the spring of 2020 as cases were finally rapidly declining due to lockdowns, a national effort to stay the course long enough to bring case numbers well below what contact tracers could deal with might have spared the nation most of the deaths as well as minimized the impact on businesses. At that point Congress had actually acted and there was money that could have kept businesses (and renters) afloat to really push cases to a very low level, from which things could improve. Taiwan, South Korea, Australia and New Zealand were all able to demonstrate this approach successfully.
Looking back in Colorado, we saw a pretty sensible response. After “Stay at Home” we went to “Safer at Home” and then “Safer at Home in the Great Outdoors” (which, technically, we never really left). Bars were closed for most of the pandemic, and indoor restaurant seating was either banned for quite awhile or highly limited. Going outdoors, while originally restricted in the Stay at Home level, was essentially encouraged once we hit “Safer at Home in the Great Outdoors.” Restrictions were more localized and formalized over the summer into the state’s COVID dial. We didn’t have the free-for-all like Florida or South Dakota, nor the slamming the brake and then the accelerator actions seen in California.
The absolute level of risk people would accept varies tremendously, so that isn’t the useful question, and indeed the responses in the op-ed illustrated that perfectly. Were we balancing equal levels of risk into the choices of what was open and what was closed? Somewhat, with many exceptions, and it did seem to improve with time. While many choices don’t impact others too much (sure, go running with scissors or dancing with bears, it’s your life), COVID was an unusual case, where my low sensation of risk could make yours go sky high. Indeed, this was evident in college towns where students, unafraid of consequences, had parties and fell ill, leading to huge spikes in cases that then migrated out to the community at large. We’re on the verge of seeing the same thing happen with vaccinations: if we don’t get enough people vaccinated (kind of looking to be in the 80-90% range), then this disease will probably bounce around, endemic to the population and never fully go away, threatening some with death or lengthy illness while others dismiss the threat as personally insignificant. We’re also probably seeing yet another mistake in the risk/reward category: suspending vaccinations for a negative outcome that is in the one to a million range is riskier than accepting that relatively low level of risk.
So whether the response matched the absolute level of risk is unclear, but a lot of the relative risk eventually got decently sorted.
P.S.-The suspension of the Janssen and AstraZeneca vaccines is another illustration of the poor grasp of risk out there. The odds of dying from the blood clot complication is about one in a million. To get that risk driving a car in the U.S., you’d travel about a hundred miles–something most Americans wouldn’t even give a second thought to. The odds of dying from COVID? Well, for a 20-49 year old (which is where the risk of the blood clots seems most severe), the odds are on the order of one in 5,000 if you get COVID…equivalent to driving 20,000 miles, or 200 times more than of getting the blood clot. Given penetration of the disease to double digit percentages of the population and the risks to others created by continuing to have unvaccinated people out there, it seems that administration of the vaccines should not have been suspended. (At most, restricting use somewhat might make sense).