How Bad Is It?

  • Updated April 2, 2020

I am asked this question every day. It’s one of the hardest to answer. That’s partly because it depends on how bad you think it is. If you believe that coronavirus is a plot to get the President, that the media has overhyped things, and that this will go away, then I will tell you that you are wrong, and it’s very much worse than you think. If, on the other hand, you think this is the zombie apocalypse, that the world is going to end, and there is nothing we can do, then I will tell you that you are wrong, and things are not as bad as you think.

So, where exactly in between these two extremes are we?

Making projections is risky because things are changing so fast. There is still too much we don’t know about the basic facts of this epidemic. But, the field of epidemiology is working very hard; we are increasingly seeing the smartest people in the world beginning to estimate where we are and what is going to happen using a variety of fancy statistical models. But the truth is we still don’t know, and this has led to confusion and distrust about what we do. Read this outstanding article from FiveThirtyEight about why predicting the COVID-19 epidemic is so hard.

Starting the week of March 9th, the global COVID-19 pandemic arrived in the public consciousness of Americans. We are no longer living in a world where COVID-19 can be contained as was the case with SARS in 2003. The epidemic cycle of sustained community transmission has ignited across the globe. Events are now happening at break-neck speed. Today’s reality would have been unthinkable to many a week ago. It will be like that for some time. Our perceptions and actions are, and have been, lagging behind the epidemic. With that said, here are some specific things I think we know:

  1. This is really happening. COVID-19 is a global pandemic that has spread rapidly to all nations across the globe. The window of opportunity to contain the outbreak is now closed. The time for false optimism is over. It’s time for individuals, communities, families and the world to get busy fighting this.
  2. There is a lot that we can do. Don’t listen to people who say it’s hopeless. As individuals, communities, and societies, there are many things we can and must do. If we do the right things, it will make a big difference. The main goal must be to slow the spread of the disease (or flatten the curve) to allow our health care system to keep up with the needs and to reduce death and suffering.
  3. Life has changed. Schools are closed, sporting events are canceled, gatherings are discouraged, at least 38 states are under stay-at-home orders, non-essential businesses are shuttered, unemployment claims have skyrocketed, store shelves are sparse, churches are dark, the stock market is in disorder. People are fearful, stressed and worried. We must deal with the fact that life will, for a time, not go on as before. Expect disruption to continue and possibly to increase in the coming weeks. Also, know that we will recover. In the meantime, it’s going to be a bumpy ride. Buckle up!
  4. This will last 18 months to two years (and then will be here to stay). COVID-19 is a new disease caused by a new virus called SARS-CoV-2. This is not like the ordinary seasonal flu because it is a brand new pathogen that jumped from animals to people in the fall of 2019. Like SARS and MERS before, this version of the coronavirus will be a hazard for humans from now on. Because it’s new, the first time it works it’s way around the globe, the impact will be severe. Based on previous outbreaks of novel virus, this first chapter in the COVID-19 story is likely going to last a full year. Some people think that warm weather will curb the outbreak, but while we may see a slowing of the epidemic as summer approaches, the current wave is likely to be the first of several periods of waning and resurgence. It is prudent to assume the disruptions associated with this pandemic will be with us for at least six months to two years.
  5. Welcome to a world of multiplication (instead of addition). One of the biggest challenges is that we are not used to situations where change is happening on an exponential scale. That sounds technical, but it means that instead of change happening through addition (1 + 2 + 3 + 4 = 10), in epidemics, change happens through multiplication (1 x 2 x 3 x 4 = 24). Take a look at the epidemic curves published by me or any other epidemiologist. The change over time curves upward (not a straight line). That’s exponential growth. And, it applies not just to cases but to the way supplies of toilet paper run out, how rumors and misinformation spreads, and how fear can turn the sentiments of a crowd in very dark directions. Because we keep thinking in terms of addition, our perceptions of what’s happening are too slow to catch up. What we think of as today is already last week to the virus.
  6. This is much worse than seasonal flu. Some Americans have been slow to respond because we have grown accustomed to tens of thousands of flu-related deaths per year and we hardly seem to notice. Don’t get me started! But we now know that this virus is much worse than flu. How much worse? It’s not possible to say with certainty. That’s because we don’t yet have a good idea of what the case fatality rate (CFR) actually is. And we don’t know what the prevelance of infection is now or will be later. But, based on what we do know, it looks like the CFR will be between 5x and 30x greater than the seasonal flu. That rate is about 0.1% (or 1 death per 1,000 cases) for the flu, which sounds low, and it is because of vaccination and immunity to past years of the flu. We don’t have either immunity or a vaccine for this disease. A vaccine for COVID-19 is likely still a year away.
  7. The COVID-19 epidemic is going to take many American lives. The plain fact of the matter is that thousands of Americans will lose their lives to COVID-19 over the next year and a half. The virus causes no symptoms or only mild symptoms in the vast majority of people who become infected (about 70-80%). Ironically, this is precisely the reason this virus is so “successful” and hard to stop. For the people who experience more severe illness, the virus can cause severe damage to the lungs, the heart and the immune system. Patients can develop life-threatening inability to breath due to fluid buildup in the lungs. The technical term for this is acute respiratory distress syndrome (ARDS) and it is a very deadly situation, which can come on in COVID-19 patients very quickly and is usually fatal if untreated. Many patients require a ventilator machine to take over breathing for them to prevent death. Those machines are, and will increasingly be in short supply.
    What’s the bottom line? The White House estimates between 100,000 and 240,000 deaths in the U.S. by the end of the year. This is an optimistic forecast. At this moment, the average predicted number of total deaths is about 263,000 with a high-end estimate of 1.7 million deaths (based on a consensus survey of experts conducted by FiveThirtyEight). At this time, any estimate must be assumed to be subject to change and potentially wrong in either direction.

Updated 3/13/20.

*Revised, 3/18/20 at 4:30 pm

2 thoughts on “How Bad Is It?

  1. I am reading this post on Dec 8, nearly towards the end of 2020. The # covid deaths in the US so far is ~ 265K. This is remarkably close to the expected deaths predicted by 538 back in March – which was 283K.


    1. Sure but keep in mind our ascertainment rate is 60-70% which means 265K is a substantial undercount. We will be at half a million on or just after the new year. US deaths in 1918-19 were about 550K but over 2 years.


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