Sunday, December 27, 2020

Pandemic Year in Review

The first year of the COVID-19 pandemic is coming to an end.  I have posted a few substantive reflections about this pandemic over the past 8 months.  And I have already started in earnest on a multi-year interdisciplinary research project on the issue of “pandemic justice”.

Here I will offer a few lengthy reflections on insights outside the mainstream frameworks and talking points.  My usual disclaimer follows- this pandemic is a very serious public health problem, but not among the most pressing public health predicaments facing us today nor over the past century.

The World Health Organization estimates that the death toll from COVID 19 in the year 2020 is approximately 1.7 million, which means it is equal to the number of annual deaths from diabetes.  However diabetes is much more lethal for the young than COVID-19, as 50% of diabetes deaths are among people age < 70 compared to less than 20% of COVID-19 deaths.  I don’t recall hearing any media news item about diabetes this year, and sadly there has been no government announcements about new preventative measures or emergency therapeutics in development to tackle this public health predicament. 

OK, some will complain this isn’t a fair comparison because COVID-19 is an infectious disease and diabetes is not.  Because it is an infectious disease it has the potential to cause significantly higher rates of mortality, overwhelm healthcare resources, etc.  I don’t actually think this fact undermines my point- nor do I think it is a compelling response to the people currently living with diabetes concerning the priority we currently place on diabetes research vs Covid-19 research.  Nonetheless I will move on to consider this rejoinder because it is important to address.

At this moment in time (late Dec. 2020) the top media headlines are focusing on (i) the rapid growth of positive infection numbers, (ii) a new (dubbed “UK”) variant of the virus, (iii) the approval and distribution of vaccines and (iv) the growing mortality toll from the virus (which I just noted, now equals the annual death toll from diabetes).

What I want to emphasize in this post are what I think are the significant stories about this pandemic that are not currently dominating media headlines, but will prove to lasting and significant stories in 2-3 years time, once better data is in and there has been time to digest what actually took place in the year 2020.

Firstly, we still do not know what the infection mortality rate of the virus is.  Back in March 2020 infection fatality ratios of 3.4% were being thrown around which would (if they were accurate) have made the virus extremely lethal and likely to kill millions of people in just a few months.  However these estimates proved to be cavalier and, most importantly, mistaken.  Initial estimates focused simply on the case fatality ratio, which is the percentage of people who die from a confirmed case of a virus.  But such a measure is very problematic when trying to determine the actual lethality of a virus because the only data it considers are confirmed cases of the virus.  If the only confirmed cases are people suffering severe symptoms on the virus this will inflate the estimated fatality ratio.  What makes things challenging in determining the infection fatality ratio of COVID-19 is that (i) anywhere from 20% to 80% of people with the virus have no symptoms at all (asymptomatic), and (ii) that it is much more lethal for older persons (age 60 and above).  When the dust settles, in 2-3 years time, we should have a sense of how many life years the virus has cost different countries.  There have been some early estimates on this front, but I think they are premature (they were published before the first year of the pandemic was even over) because of the second complication which I will address now.

All year long the media, politicians and public health experts and advisors have been referring confidently to the number of deaths caused by COVID-19.  I think this will prove to be an issue of significant revision.  Before 2020 we didn’t even know COVID-19 existed as a virus, let alone it being listed as the cause of death on any person’s death certificate.  And like influenza deaths, we should expect there to be a range of estimated COVID-19 deaths vs a precise number of such deaths.  There are clearly cases were it makes sense to say someone died from COVID-19.  For example, if there was a 55 year old who was otherwise healthy and contracted the virus and died that is a easy case of a COVID-19 death.  But that will be an atypical case.  In most cases the virus was a contributing factor.  For example, imagine the case of an 87 year old chemotherapy patient dying from stage 4 lung cancer who contracts COVID-19 and this accelerates (by a few months) when they die.  Do we say that COVID-19 killed them?  And then there will be cases of persons who died from some other cause but who also tested positive for COVID-19.  Is the patient in a nursing home who dies of a heart attack who was also isolated for COVID-19 considered a COVID-19 death?  There has been so much ambiguity around these cases, and politicians and public health advisors have been loose and opportunistic when invoking the (in my opinion premature) data.

There is also the issue of excess deaths.  Did the year 2020 actually have significant and unprecedented numbers more people dying than in your typical non-pandemic year?  And if so, how many of those deaths can be attributed to the virus itself vs our response to the virus?  Lockdowns have caused unemployment, isolation leads to more addictions and suicides, people afraid to go to hospitals don’t seek out medical assistance after a heart attack or stroke, cancelled medical procedures mean cancers go undetected and important surgeries are delayed etc.  If we look at the country that took the most lax policy (among the developed countries) with respect to the lockdowns and face masks- Sweden- in 2019 approximately 88, 882 people died, with cardiovascular disease accounting for nearly 1/3 of those deaths.  As 2020 ends, the number of total deaths for lax Sweden are not yet posted.  But there is approximately 8200 COVID deaths, which would be 10% increase in deaths.  I suspect that percentage will actually be significantly lower, because the majority of deaths in the first six months from COVID-19 represented people who would have died this year from non-COVID-19 causes.  This means that the country with the most lax lockdown measures will likely be only a few % increase in total deaths (if that) and the vast majority of those deaths will be among persons over age 70.  This doesn't mean it is trivial death toll, nor is it the calamity we often hear in news stories about Sweden.  

Another profound insight that the media has completely ignored today is the fact that the countries hit hardest by the virus in terms of per capita mortality are among the world’s most affluent and developed (not poorest) countries.  The 4 highest COVID-19 deaths per 100 000 people countries are Italy, Spain, the UK and USA.  On the face of it this is baffling.  What could possibly explain this fact?  The USA and UK have over 100 COVID-19 deaths per 100 000 people, and yet India and Indonesia have 1/10th those rates?  Doesn’t wealth and better healthcare translate into better protection from infectious disease mortality?  There is no simple answer to this question.  What more wealth and better healthcare can buy is success in helping aging populations better manage multi-morbidity (thus delaying death but keeping people alive into ages that are very susceptible to COVID-19 mortality).  

My hunch, and that is all it is at this point, is that age (coupled with ability to manage co-morbidity so the elderly survive beyond age 80) explains a least a non-trivial part of this differential.  Biology trumps even capitalism! The median age of the USA is 38 (though with a 41% obesity rate among adults age 20 and older, it is de facto much higher), the UK age 40, whereas India has a median age of only 27 and Indonesia 30.  And the richer countries can afford(!) to pay for the medicines and treatments needed to keep more people alive into the advanced ages where they are most at risk of COVID-19 mortality.  Other factors that probably explain part of it are the number of COVID-19 cases identified and deaths classified as being caused by COVID-19.

In my worldview, this pandemic is just the tip of the iceberg of a much bigger issue facing humanity this century- the predicament of global aging.  The world’s aging populations are more susceptible to COVID-19 mortality, and (even more significantly) to the chronic diseases of late life like cancer, heart disease, stroke and dementia. 

In 2019 I published this article titled “Aging,Geroscience and Freedom”.  In that paper I argue that senescence (biological aging) is one of the greatest threats to human freedom in the 21st century.  My central target in the piece was the chronic diseases of late life, like cancer, heart disease and dementia, which limit both the negative and positive liberty of people all over the world.  But this year the pandemic has revealed how global aging can also bring significant threats to the freedom of both young and old alike via state interventions that treat millions of persons not as individual persons, but as contagion that should be contained indefinitely.  This has lead to months and months of strict lockdowns, the cancellation of in-person learning for children and university/college students, massive unemployment, and the enforcement of social distancing and wearing face masks.  All these measures have been undertaken by most developed countries to try to mitigate/contain a virus that is mostly lethal for a low percentage of persons over age 70. 

Over the next 2-3 years I anticipate that ample empirical evidence will emerge that the prolonged lockdown measures taken to try to mitigate the spread of COVID-19 caused much more severe and lasting damage- loss of life years, mental health, educational deficits, economic prosperity, etc- than the virus itself could cause had we taken a more humane and targeted protection approach.  There never was anything like a cost-benefit analysis undertaken in response to COVID-19.  There wasn’t time.  Most governments adopted a precautionary principle and, as an initial response, I think that might not have been (significantly) objectionable as the initial response.  But after the first month of lockdown, when we knew much more about the virus (e.g. it was very contagious, asymptomatic for many people and not very lethal for those age < 70 without underlying co-morbidities) we should have opted for a focused protection strategy while expanding our healthcare capacity to care for the sick.  Instead most governments doubled down by asking the population to act like they were positive and contagious for a year +.  In my opinion this was an unethical experiment.  It had known harms, unproven benefits and was extremely costly.  I believe history will judge such measures to be among the worst public health decisions ever undertaken.  Not because such measures cannot be an appropriate response to certain infectious diseases, but they were inappropriate responses to take to this particular virus.  

I have the intellectual humility to recognize that my estimate could be mistaken.  And I know my view is (at this time) an outlier one.  But I believe that is so because most of the discussion and debate surrounding the pandemic has focused almost exclusively on the harms that are “on screen”- like the numbers of positive cases, hospitalizations and COVID-19 deaths.  But in the years to come there will be a steady stream of evidence from the demonstrable harms (currently “off screen”) caused by this massive social experiment.  These harms will include an increase in global poverty and unemployment, an increase in addictions, anxiety, and suicides, educational deficits, delays in other life saving vaccinations, delays in cancer detection and other health maladies that were pushed aside during the frantic year of fixation on one particular virus.   

There are so many important lessons to be learned from 2020.  We were unprepared for this pandemic, hopefully we won’t be for the next.  The prominence of social media, and the low quality of the media more generally, made responding sagely to this pandemic even more challenging.  It is much easier to invoke people’s fear and anxiety than it is to subdue those same emotions when public policy is driven by a need to placate those emotions vs follow the credible data.  This pandemic was a real test for how well democracies can handle an infectious disease pandemic, and I would score it a grade of D+.  Not quite a failing grade, but significant improvements are needed to avoid making these same mistakes again in the future.

I finish this lengthy reflection on the pandemic year of 2020 by emphasizing what, for me, is the most significant harm of our handling of this virus this year.  And that is this-- the kind of human beings our response to this virus has made us into.  The kind of human beings that phone the police on their neighbour if they believe they are floating the rules about social distancing or the number of people permitted in their house.  The kind of human beings that will voluntarily subject themselves and their children and friends to months and months of continuous isolation without critically questioning their justification.  The kind of human beings that will obsess about one particular health risk (COVID-19) and yet ignore risks that are much more likely to cause premature death (e.g. obesity or smoking) and mental health problems (prolonged social isolation). 

There are worst things than risking disease and death.  And that would be to create a culture, and become a people, were everything worth living for has been abandoned in favour of the one-dimensional obsession with placating our fears about one particular health risk.  Of course I want my children (and all children!) to live in a world with less infectious disease, but I also want them to live in a world with more human connection and play, less anxiety, more trust in public health, science and fellow human beings, less of an appetite for authoritarianism, higher quality of journalism, better education, and more love. 

The biggest mistake I think we can make is fighting for a future consumed by just one goal or value.  An environment devoid of the 1400+ infectious organisms that cause disease in humans would be great.  But it will never happen.  And like the chronic diseases that kill most human beings alive in the world today, we must find a way to sagely pursue the preventative and therapeutic aspirations of medicine, while also continuing to live full and meaningful lives that are worth living.  As we end the first year of this pandemic I think that aspiration has been lost. 

I finish this post with two apt quotations from authors I admire.  The first is from the Prussian philosopher Wilhelm von Humbolt (1767- 1835), the second passage from the British biologist and Nobel prize winner Peter Medawar (1915 –1987).

“As soon as one stops searching for knowledge, or if one imagines that it need not be creatively sought in the depths of the human spirit but can be assembled extensively by collecting and classifying facts, everything is irrevocably and forever lost”. Wilhelm von Humboldt from Humanist Without Portfolio

 “There is no quicker way for a scientist to bring discredit upon himself and on his profession than roundly to declare — particularly when no declaration of any kind is called for — that science knows or soon will know the answers to all questions worth asking, and that the questions that do not admit a scientific answer are in some way non-questions or pseudo-questions that only simpletons ask and only the gullible profess to be able to answer.”

― Peter Medawar, from Advice to a Young Scientist