“It resembles a small monster that hides three metal bars behind its back”
When we finally got hold of the seroprevalence results in mid-April 2020 and found that the death rate from the novel coronavirus at the level of the whole population cannot be a few per cent, as it seemed initially, but in most circumstances less than 1%, did that mean that we could abandon quarantine measures and ignore COVID-19, much like we neglect the flu?
Epidemiologists would be the happiest of all if they were able to say that this is the case and declare the end of the great danger to public health. However, many things during this pandemic were much more complicated than usual in regard to public communication on most other topics.
As such, I will explain why the conclusion on the infection-fatality rate (IFR) being confirmed in a range of 0.5–1.0% following the first seroprevalence studies still didn’t make things much simpler. Namely, unlike more or less all other diseases that health systems encounter, this virus also had a “fourth dimension” — time — which caused problems that we aren’t really used to in medicine.
In medicine, we encounter situations of there being too many patients in relation to available capacities, mainly when a traumatology clinic needs to suddenly take care of injured people coming in after a large train or bus collision. Another example is in war surgery when several surgeons need to take care of a sudden large number of wounded people in an unforeseen tragedy out on the battlefield. But beyond that, too many patients at a time isn’t something doctors often have much of a reason to think about.
So, let’s suppose that this relatively low “death rate” with the spread of a new coronavirus is somewhere between 0.5% and 1.0%, and is indeed the only danger associated with it. Then we could compare the new coronavirus to a monster that is slowly approaching us from a distance, but we see more and more clear that this monster is physically small in stature, i.e. it reaches our navel at its tallest. So, we start to relax, because whatever it is, we’ll knock something that small to the ground and easily overcome it.
However, we’re only looking at it from the front, and we’re not paying attention to the fact that this monster is keeping its hands behind its back. There, in a dimension we can’t see, it is hiding three metal bars. When it finally stands in front of us, if we let it out of our sight for a moment and relax, it will hit us over the head using all of its strength and with an incredible force with one of those three hidden bars.
The first problem that the new coronavirus causes us from this, the fourth dimension, in addition to the death rate itself, is its very rapid spread. If we allow it to spread freely among the population, it can theoretically infect hundreds of thousands of people in several weeks, stemming from just one single infected person. Even with a low “death rate,” we will soon have to deal with thousands of seriously ill people in hospitals because of it. All those who don’t receive care will then simply suffocate to death.
At the same time, they would die alone in hospitals, because their family shouldn’t be permitted to be in the wards full of those who are infected. The conditions of burial of all the deceased would also be extremely limited and quite different from the custom. I believe this is not a fate that anyone would want for an older member of their family, if it can be avoided at all. But that’s only the first problem. The first metal bar that can quickly hit our head.
Another problem is that the new coronavirus is two-faced. When it spreads among the community, it acts relatively harmlessly, giving the majority of sufferers mild to moderate symptoms and a fairly low death rate. But when it manages to get in among a vulnerable population, such as those hospital wards, rehabilitation centres or retirement homes, then it spreads among them at a very high rate because they are particularly susceptible to it.
As a result, its “spread rate coefficient” increases, but this is a minor problem in these situations. The bigger problem is that then, its “death rate” increases by at least ten or twenty times, and among such subgroups of residents, it can kill up to every tenth infected person, or even more, depending on how old and sick they are. In many countries of the European Union, a very large share in the total number of deaths was due to severe epidemics having taken place in retirement homes. That is its second metal bar that can quickly hit our head.
The third metal bar held in the hands of this little monster, i.e. the third major problem to which we have no answer, are the indirect effects of the virus on the healthcare system, causing mortality from all other diseases to increase. Namely, if the virus was allowed to spread freely, hospitals would immediately be full of infected people - both patients and doctors, nurses, but also people who are simply coming in for basic examinations or visits. A huge number of healthcare professionals would end up on sick leave themselves due to COVID-19, or in self-isolation so as not to spread the infection to their patients who are in serious and critical conditions.
In order to prevent hospital epidemics which come with a significantly higher “death rate”, as many patients as possible should be sent to be taken care of at home immediately. There would be a disruption of the functioning of the healthcare system at all possible levels, which would cause patients suffering from all other types of diseases to die much more frequently and much more rapidly. That is its third metal bar that can quickly hit our head.
These are three big problems to which there is little answer if the virus starts spreading freely among the population, having escaped all epidemiological surveillance through testing, tracing and isolating. If we lock down to stop its spread, we are harming our society at so many levels. But if we allow it to spread freely, these are the mechanisms through which it will soon punish us. This is why governments must take it as a serious problem and get their populations on board on how to solve it, because solutions are possible. Several Asian countries are demonstrating to the rest of the world throughout 2020 that they are managing to control it and keep both the death toll and the economic damage at the very minimum.
Declaration: Professor Igor Rudan, FRSE, is the President of the International Society of Global Health; co-Editor-in-Chief of the “Journal of Global Health”; Joint Director of the Centre for Global Health and the WHO Collaborating Centre at the University of Edinburgh, UK.
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