What Is Our COVID Endgame?

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One of the problems with the current pandemic has been that there is no clear and unified U.S. public health goal. Meaning, are we trying to protect the healthcare system, eliminate all deaths, or protect the economy? So let’s dive in today and cut through the media hysteria to try to figure out what makes the most sense.

Media Hysteria

Most in the media continue to fan the flames of mass panic in their never-ending quest to sell eyeballs to advertisers. The lack of an overarching public health goal is what has allowed them to keep us all whipped into a froth. So how can we deescalate the madness? Come up with a single unified game plan that everyone can buy into.

We can break down our options into a few categories:

  1. Maximize Public Protection-Allow no deaths or as few deaths as possible, regardless of what happens to the economy.
  2. Balanced Protection-Allow some deaths and protect the economy as much as feasible. Hence, our only goal should be to avoid any overload of our health-care system.
  3. Maximize Economic Protection-Allow whatever deaths will happen and maximally protect the economy.

The media seems to be headed toward number 1, which is why it freaks out at the notion that the number of cases may be rising in parts of the country. So let’s review these options and try to make sense of them. Before we do, we need to cover two topics: lethality and Non-COVOD deaths.

Lethality

As I have shown previously, the real COVID-19  infection fatality rate (the number of people who will die if they catch COVID-19) is somewhere less than 1 in 200 and more likely as low as 1 in 2,000. That’s FAR LOWER than the media had reported early on. Hence, this is a bad bug with a fatality rate of 2-4X flu, but it’s NOT the stone-cold killer that most Americans believe it to be.

Non-COVID Deaths

The problem we have in figuring out the perfect pandemic calculus is that the reaction of the general public to our response will kill lots of people. For example, people are foregoing routine healthcare that keeps them alive. In mid-May, a JAMA article estimated that nearly 23 million Americans aged 50-75 were past due for their colonoscopy screenings (1). Adult primary care visits were down by 49%!  The American Academy of Family physicians reported that we could lose 150,000 people due to the shut down because of deaths like suicide, alcoholism, or drug abuse (2).

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Our Public Health Options

Maximize Public Protection

This is of course an admirable goal. However, there are some serious practical issues with this approach. Let’s dig in.

First, in this category, applying massive resources early in the pandemic is key. However, no U.S. administration has EVER allocated this level of resources to controlling a pandemic. Let’s review.

This early pandemic approach only works with HUGE dedicated resources and a willing population who is heavily policed. For example, Taiwan, which now has a huge pandemic response team (Central Epidemic Command Center (CECC)) down to the regional levels within cities, was burnt twice by SARS viruses coming out of China before it got it’s act together in time for COVID-19 (3).  For example, Taiwan has an entire pandemic war room, armies of workers dedicated to contact tracing, pandemic ward captains in large cities, a military that was used early in the pandemic to manufacture PPE, and imposed jail time for those citizens who didn’t play by the rules (4).

Without a massive early response like Taiwan, we’re left with only a late “catch-up” response which is like forever chasing our pandemic tail. Hence, the only response we could muster was to shut down our society and shelter in place. The problem is that this has caused devastating economic consequences.

What the four graphs above demonstrate is clear economic suicide. Basically, large sectors of the economy have been pulverized by the shutdowns and have yet to fully recover. You may be in a sector that didn’t initially get hit hard, but when 1 in 5 Americans are not able to work over the next year, whatever sector you’re in eventually be hit by the drop in economic activity. Hence, continuing to maximize public protection by continuing the shutdowns until we see very little virus activity or find an effective vaccine is not realistic.

Balanced Protection

This is balancing protecting the public with protecting the economy. The focus here is really on protecting the healthcare system from overload. Hence, no more shutdowns unless there is a credible threat to healthcare resources and hospitals being swamped. More people will die in this scenario, but the economy will limp along and recover more quickly, only suffering locally from small regional shutdowns.

The advantage here is obvious. We don’t destroy the economy. This disadvantage is also obvious. It’s likely that a few hundred thousand Americans will perish with this plan, perhaps more.

However, it’s critical to keep those deaths in perspective. First, shutdowns only push the peak of the disease down the road, they don’t change total deaths. The only way that total deaths are reduced is if we shut down for 1-2 years while we get a vaccine developed. A shut down of that length is just not economically possible.

In addition, it needs to be noted that hundreds of thousands of deaths due to a respiratory virus is in keeping with other pandemics that the US has suffered without shutdowns. For example, the 1957-1958 H2N2 influenza pandemic scaled to today’s population caused more than 250K US deaths. 

Maximize Economic Protection

In this plan, we maximize protecting the economy and let the pandemic rip along. Who has done it this way? Look no further than Sweden.

Sweden has been the pandemic bad boy country, deciding to forego the shutdown approach. It’s been heavily criticized in the media, but despite that criticism, it actually hasn’t fared badly. Let’s dive deep into this idea.

What is the Sweden approach? Tell everyone to social distance, but keep bars, restaurants, businesses, and schools open. How could that work out? Well, as shown above, comparing deaths per day in Sweden vs. the US is interesting. Both have similar drops in death rates over the past few months, but we shut down everything and they did not.

How about deaths per million inhabitants?  Just looking at today’s data, Sweden had 4.8 deaths per million and we had 2.45. However, that may not be a fair comparison, as for several days last week, Sweden reported 0 deaths per million. On Jun 18th their rate was a little more than 1 per million. Hence, the difficulty of direct comparison is that since they only have 10 million people to our 330 million, there are days that they have very few or zero deaths, whereas our lowest death toll per day (reported last week) was 267.

So why would Sweden’s data be similar to ours? Surely our shutdowns have saved lives? As I have noted before, this argues that some other external factor is reducing the COVID-19 death rate as we go into summer, other than the US shelter in place orders.

How did Sweden fare economically with its approach? Looking at the graphs above, Sweden’s GDP growth was down and stagnant, but the US fell off an economic cliff (7,8). That’s just the 1st quarter as most economists believe that the 2nd quarter, which will be reported soon, will be a MUCH bigger disaster. For example, the GDPNow tracker at the Atlanta Federal Reserve is currently stating that the average 2nd quarter U.S. GDP forecast is currently clocking in at -35%! (5) When was the last time we saw anything close to this level of decline in GDP? The great depression saw worldwide GDP fall by only 15% (6). In the great recession of 2008, the GDP declined only a paltry 1%.

What Makes the Most Sense?

As I have shown above, you could make a real argument that Sweden’s approach was no worse than our approach. However, I’ve always been a fan of the middle of the road approach rather than the extreme. Hence, to protect our economy and also as many people as possible, I’ll argue that avoiding healthcare system overload should be our ONLY concern. Meaning, we don’t focus on if cases are up or down, only if the models show that our healthcare system may get swamped. If that looks to be the case, then we act to impose regional shutdowns.

The same would also hold true with the total number of deaths. Given that past influenza pandemics in the US have seen deaths in the range of several hundred thousand US dead when scaled to today’s population, any number of total deaths in that range is what we will expect. We will obviously continue to test various treatments and improvements in therapy for severe COVID-19, so total deaths will likely be less as therapies improve. In addition, we would continue to maximally protect our elderly and those who are at high risk for severe disease. We would also continue social distancing and aggressively sourcing a vaccine.

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The Media

If the public health game plan that makes the most sense is a balance between protecting people and the economy, then the media needs to get behind this plan. That means no more hysterical news stories about cases rising here or there!  No more “Panic Porn” as Bill Mayer has coined the term:

The upshot? Let’s stop the COVID hysteria. This is a disease that is not nearly as lethal as many media pundits guessed. We can’t continue to keep society shutdown and people away from hospitals because we have made them too paranoid to venture outside. We also need to start pressuring the media to end the Panic Porn. That means unsubscribing from your favorite media outlet that is participating in or fomenting mass hysteria.

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References:

(1) Issaka R, Somsouk M. Colorectal Cancer Screening and Prevention in the COVID-19 Era. Jama Health Forum. https://jamanetwork.com/channels/health-forum/fullarticle/2766137 Accessed 6/23/20.

(2) The Well Being Trust and the Robert Grahm Center (American Academy of Family Physicians). PROJECTED
DEATHS OF DESPAIR from COVID-19. https://wellbeingtrust.org/wp-content/uploads/2020/05/WBT_Deaths-of-Despair_COVID-19-FINAL-FINAL.pdf Accessed 5/8/20.

(3) Schwartz J, Yen MY. Toward a collaborative model of pandemic preparedness and response: Taiwan’s changing approach to pandemics. J Microbiol Immunol Infect. 2017;50(2):125-132. doi:10.1016/j.jmii.2016.08.010.

(4) The Wall Street Journal. Coronavirus Quarantine Breakers and Evaders Face Fines, Jail Terms. https://www.wsj.com/articles/asian-countries-wield-fines-jail-terms-to-stop-coronavirus-quarantine-violations-11582824849 Accessed 6/23/20.

(5) Federal Reserve Bank of Atlanta. GDPNow. Estimate for 2020: Q2. https://www.frbatlanta.org/-/media/documents/cqer/researchcq/gdpnow/RealGDPTrackingSlides.pdf Accessed 6/23/20.

(6) Wikipedia. Great Depression. https://en.wikipedia.org/wiki/Great_Depression Accessed 6/22/20.

(7) Trading Economics. Sweden GDP Growth Rate. https://tradingeconomics.com/sweden/gdp-growth Accessed 6/23/20.

(8) Trading Economics. United States GDP Growth Rate. https://tradingeconomics.com/united-states/gdp-growth Accessed 6/23/20.

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