Corona Perspective: Taking A Look At The Big Picture

Fear and misinformation run rampant: Here’s a constructive guide to thinking about the future

A thank you to Itamar Medved for the edits and the insightful conversations.

Markets are collapsing. Fear spreads. Everyone looks to everyone else for answers. This article is about trying to understand the big picture. This article won’t give you answers, but it will help you think clearly about the issues. I hope that my thought process gives you a framework with which to formulate your opinions and preparations better.

These articles will cover several angles, including the potential economic impact of such a pandemic. With this first article, I focused on understanding what we can about the trajectory of the virus. On this, all else rests. The social, political, and economic impact ultimately depends on the length and severity of the virus. Therefore, we begin here.

The Spanish Flu: A framework for understanding the Coronavirus

COVID-19 is the first truly global pandemic we’ve seen since the 1918 Spanish Flu, a disease that killed an estimated 25–100 million people (the population in 1918 was a quarter of what it is today). There’s much we can learn from the Spanish Flu as we look to understand the trajectory of COVID-19.

Many suggest that it was WWI that was responsible for the enormous death toll of the Spanish Flu. However, while the terrible conditions in the trenches and the massive troop movements certainly created the ideal conditions for the start of the pandemic, it cannot be used to explain the rapidity with which the virus spread far beyond the trenches, and the loss of life it incurred upon the world. Instead, it was likely the same factors that have made COVID-19 so infectious and deadly: an extremely contagious pathogen, overwhelmed medical systems, global quarantine, and severe economic downturn.

Throughout the following sections, you’ll see the Spanish Flu referenced. I will analyze those similar characteristics that might guide COVID-19 towards a similar trajectory and those aspects of our modern reality that might change its course.

What course will the virus take?

Deaths per thousand for the Spanish Flu
Deaths per thousand for the Spanish Flu — Wikipedia Commons

The Spanish Flu came in 3 waves, although the second was by far the most deadly. The first began in January 1917 and spread rapidly beginning in March. In August, the virus mutated and unleashed a far more deadly second wave upon the world. In February and March of 1919, the virus spread again in a third wave.

I think that whether COVID-19 arrives in multiple waves depends on two factors:

  1. The totally unpredictable factor of a mutation. The virus mutates frequently. Most mutations have minimal effect on any observable element of the virus. Whether it mutates into a form more (or less), deadly is very unpredictable. The question of immunity is also frequently brought up. What if another wave struck after the virus mutated? Would those who were first infected get infected again? The answer is that it depends. While data is limited on the Spanish Flu, it appears that those infected by the second wave were generally immune to the third wave. Those infected in the first wave were not so lucky.
  2. The global response and the world’s willingness to maintain quarantine until 100% containment. I think one of the reasons the Spanish Flu had three successive waves was because, although the world implemented travel restrictions and quarantines, the war limited the effectiveness of those measures. Troops were still living in close and horrendous conditions. Supply ships were still traveling. Although the war ended in November of 1918, troops were still being transported and diplomatic parties were on the move, leaving ample opportunity for transmission. Thus, I think that the world will need to remain in lockdown (or at least ready for re-lockdown) to prevent the spread of additional waves.

Bottom Line

Mutations are nearly impossible to predict. However, I’m skeptical of the world’s capacity to stomach prolonged closures and quarantines and the resulting economic downturn. I would imagine that they will reopen things at the earliest opportunity, leaving the potential open for the spread of additional waves. I would imagine that the timeline will align similar to that of the Spanish Flu with each outbreak lasting between 2–4 months.

Death Rates: How Lethal Will the Coronavirus Be?

The Spanish Flu was unusual in that its lethality graph formed a ‘W.’

Deaths per 100,000 according to age group
Deaths per 100,000 according to age group — Wiki Commons

Expectedly, the mortality rate was highest among the young and old (generally the most vulnerable population groups). But unusually, the third most vulnerable group was among 25–35 year-olds. This is commonly attributed to cases of Cytokine Release Syndrome (CRS)which is basically an overreaction of the immune system. Because young adults have such a strong immune system, it was not the virus but rather the strength at which their immune systems fought the virus, that actually killed them.

The mutations of pandemics generally follow a different process than normal viruses. Under normal circumstances, weaker virus mutations generally win out over more deadly mutations. This is because patients experiencing extremely severe symptoms go to the hospital where they can be quarantined from the general population. It is the people with moderate symptoms who might still go to work or school and will be infecting others. But with a pandemic virus, the opposite is generally true. As more and more people get sick and health systems begin collapsing, hospitals become the most dangerous places to be. Those with moderate symptoms quarantine themselves, thus stopping the spread of those strains. Those with severe symptoms go to the hospitals, which — already overloaded — become epicenters for contagion.

Fortunately, while data is still limited, it seems that the coronavirus has a very different mortality-age spread than the Spanish Flu.

See this summary of a report by the CDC:

“This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55–64 years, <1% among persons aged 20–54 years, and no fatalities among persons aged ≤19 years.”

Thus, it seems that the coronavirus is not triggering CRS in younger patients. Additionally, two modern drugs not present during the Spanish Flu outbreak should help lower the death rate. Steroids help address CRS today, and antibiotics help treat the post-virus lung infections that proved so deadly in 1918. This represents a more positive outlook than in 1918.

On the other hand, the Spanish Flu demonstrates how dangerous the results are of an overwhelmed healthcare system. America will likely hit this critical point soon. As the Washington Post reported, America has 2.8 hospital beds per 1,000 people in comparison to South Korea (12 per 1000) and Italy (3.2 per 1000). I think we will see a spike in the death rate as the health systems become overwhelmed. Non-associated deaths will also rise as people with heart attacks or other health problems struggle to receive health care.

Bottom Line

Initial reports seem to signal that COVID-19 will not be as lethal as the Spanish Flu, at least in terms of the death rate per population. However, older patients will still be extremely vulnerable to the disease. How much the system is overwhelmed depends mainly on how well people respond to the quarantine measures.

What are the potential positive outcomes:

I try to think about what news we might wake up to that would promise a far better scenario than the current. I can imagine three possibilities:

  1. “We have a vaccine.”
  2. “It’s not actually as deadly as we first thought.”
  3. “We’ve contained the virus.”

“We develop a vaccine”

Eventually, we’ll have a vaccine. The question is how long until we do. This is a very different situation than the conditions that led to the rapid development of the vaccine that likely saved America from a pandemic in 1957. Unlike then, the COVID-19 is a novel virus that essentially requires creating a vaccine from scratch.

Wired posted an excellent article on this. Below I will summarize the process vaccines must pass before they can be given to the public. However, we must also account for the increased urgency, the increased resources (the CDC isn’t doing anything else right now), and the potential for regulators to skip several of the traditional steps.

Here’s what Wired had to say about the timeline:

“On Tuesday, National Institute of Allergy and Infectious Diseases director Anthony Fauci told US Senators, “It will take at least a year and a half to have a vaccine we can use.” That might seem like an eternity for public health officials staring down a probable pandemic. But if true, it would actually set a record. Most vaccines take between five and 15 years to come to market.”

I think, based on the reality of the timeline, that we’re closer than that to a vaccine.

Traditional vaccine timeline:

  1. Discovery Stage: Identify the protein sequence and test the vaccine on animals. (At times, this takes years. With new sequencing equipment this can take a matter of weeks).
  2. Phase 1 Clinical Trial: Testing for drug safety on a few dozen (non-infected) volunteers. (Takes about 3 months)
  3. Phase 2 Clinical Trial: Testing of several hundred people from COVID-19 infected areas. This tests the efficacy of the vaccine (6–8 months).
  4. Phase 3 Clinical Trial: Repeat the Phase 2 experiment on multiple thousands of people (6–8 months).
  5. FDA Review and Approval: (Several Weeks). Let’s assume that FDA speeds this one up…

Here’s what Wired had to say:

“If you’ve been doing the math, this means that, since vaccine candidates started being developed in January, a version approved for public use won’t be available until the end of summer 2021, at the earliest. And that’s if nothing goes wrong. “Constricting the whole timeline of going from concept to a product that can be distributed into a year or two is really a herculean endeavor.”

I actually think we’ll move much faster, given the urgency of the matter at hand, the number of teams working on it, the available resources, the willingness of people to participate in tests, and the corners that will likely be cut to get this to market quicker.

I think within a month we will have candidates available for testing in Phase 1. I assume Phase 1 will need to play out normally, within about a 3 month period. Skipping this could be extremely dangerous. That means, in an ideal situation, in about 4 months we could have a drug that shows theoretical efficacy and is demonstrated to be safe (albeit on a small scale). However, I do think that we could potentially run some of these stages in conjuncture. It’s possible to plan Phase 1 testing to demonstrate both safety and efficacy. Researchers could target select people in extremely vulnerable population groups and run Phase 1 results to glean statistically significant data. At that point, I think that it might be possible to squeeze the clinical testing into 3–4 months and satisfy most regulators given the danger of these times.

Next, we would need to mass-produce the vaccine. For a reference as to how fast we could produce a vaccine, it’s estimated that if Moderna (a biotech company in Boston) devoted 100% of its efforts to COVID-19 it could create 100 million vaccines in a year. Considering that Moderna is not even top-10 in size among biotech companies, with enormous outsourcing to other companies, we could see billions of vaccines within the first year.

Bottom Line

Given this analysis, I think that in the best-case scenario, we’re looking at a vaccine on the market by about the 5-month mark. It will likely be another 6 months before we see a substantial, global distribution of the vaccine to the world. Likely, the West will receive such a vaccine first. However, other variables exist. Perhaps the virus mutates, rendering the vaccine ineffective? Perhaps initial trials fail and force teams to start over? All of these could prolong the time it might take.

“The virus is not actually as deadly as predicted”

People hope that the disease will go the route of the 2009 Swine Flu (H1N1) scare.

The ADN summarizes this hope well:

H1N1 turned out to be much milder than initially feared, causing little more than runny noses and coughs in most people. And H1N1 is now so commonplace, it’s simply seen as a part of the seasonal flus that come and go every year among the global population. Early estimates on the fatality rate for H1N1 were much higher than the roughly 0.01 to 0.03% it turned out to be.”

The theory is that even today, many people may be infected but not symptomatic. Thus, the current death rate only accounts for those who are symptomatic and is thus, greatly exaggerated. The logic is that if we tested more people, the death rate would drop significantly.

If this is true, it means that, right now, COVID-19 is building herd immunity (when a high-enough subset of the population gains immunity) while remaining relatively harmless. If this is true, COVID-19 would likely enter the history books as just another virus (such as H1N1). This blog promotes this idea, citing data from the Diamond Princess cruise ship:

of the…“3,711 people on board, about 700 had the virus when tested, 400 of these were asymptomatic, 300 became sick, 7 died. But, how many of the 3,711 had recovered before they were tested? One of the problems is that the current tests for COVID-19 only tell us if someone is currently hosting the virus. The vast majority of people tested so far have been negative; is that because they never had the infection or is it because they had already successfully recovered? If 3,000 on the Diamond Princess recovered before testing, the mortality rate was 0.2%. That is high, but it is much better than the mortality rate of those we know caught the virus.”

Here’s what concerns me. South Korea has done an enormous amount of testing. This is largely credited with slowing down the transmission of the virus and allowing South Korea to contain the virus. S.K. has tested 295,000 people and found 8,565 people who have tested positive.

This data seems to me to demonstrate that herd immunity is not being rapidly approached. Most people tested in South Korea did not have the virus. They were not infected and asymptomatic; they simply did not have it. It’s certainly possible that many of these people already recovered from the disease and were simply being tested too late. However, given the effectivity of South Korea’s response and the fact that they likely tested those experiencing symptoms, I doubt that most of those 287,000 non-infected people had simply “recovered.” Additionally, it appears that South Korea is still experiencing outbreaks, and it’s feared that the virus may again begin spreading quickly.

I think South Korea’s death rate gives us a best-case outlook for the West. Currently, South Korea has experienced a death rate of 8.2% for people aged 80+, a 4.8% rate for people 70–79, and a 1.44% rate for those 60–69. Unfortunately, I think the lack of testing and the lack of hospital infrastructure in Europe and America will result in a much more harmful scenario (as currently being witnessed in Italy).

Bottom Line

I don’t see this scenario happening. I don’t think we have a situation where many people are infected and entirely asymptomatic, as demonstrated by both China and Korea’s data.

Despite this, I think that the death rate will remain relatively consistent at the 1–3% level. The rate will lower slightly as more people from low-risk demographics get sick. However, the rate will go up as the burden on the healthcare system compounds. I think these two factors will likely balance each other out. I am not expecting to see a headline announcing that this goes the way of H1N1. Things will continue to get worse.

“We successfully contain the virus”

This is the third possible “good news” outcome. Can we contain the virus?

The Spanish Flu shows how necessary quarantine measures are in containing viruses. Quarantine measures are less about containing and stopping the virus and more about “flattening the curve” so as not to overwhelm the healthcare system. Check out these great graphics put out by the Washington Post that visually demonstrate the importance of flattening the curve. This is confirmed by evidence from the Spanish Flu: American cities that effectively quarantined in 1918 were very effective at limiting the impact of the disease.

As the New York Times wrote:

“‘Assuming suppression fails, we must initiate aggressive mitigation, where communities try to lessen the impact of the disease. The crucial statistic from China is that the case fatality rate inside Wuhan is 5.8 percent but only 0.7 percent in other areas in China, an eightfold difference — explained by an overwhelmed health care system. That illustrates why flattening the curve matters; lessening stress on the health care system, especially the availability of intensive care beds, saves lives.’”

I am seriously skeptical that people today will follow quarantine measures. I think today’s population has a far more significant distrust of institutions than it did in 1918. I also think people today have a particular illusion of immortality against diseases that people in 1918 did not. For many years we have not been seriously confronted by deadly diseases, a luxury that people in 1918 did not have. Just look at the response of these “spring-breakers:”

Additionally, testing is essential in isolating individuals with the disease. This is because testing allows us to isolate sick individuals, preventing the spread of the disease, and more effectively flattening the curve.

Testing has been abysmal currently in the West. Just look at this chart outlining global testing rates. South Korea has conducted 4,099 tests per million people. For comparison, America has tested 26 per million people.

However, there is still reason for optimism. I wouldn’t expect the lack of testing to last long in America. Already, some of the burden of testing is being transferred to private companies.

Bottom Line

We are already seeing the difficulties that fragmented democratic states have at managing containment. Quarantining individuals is much easier when you care little about popular sentiment or constitutional rights. I genuinely think that it will take police and military enforcement to maintain a successful quarantine. Containment will only be possible with authoritarian measures. These measures may come, but things will need to deteriorate more before democratic countries authorize and condone them. This will result in a slow response which will likely mean that containment is not on the horizon.

What does this all mean?

Here’s the recap: I don’t think a vaccine will arrive soon enough to halt the virus this year. Best case scenario we see it by late summer. Even then, it’s unlikely it arrives in time to stop the current virus wave. However, it could potentially arrive to protect against future waves of the virus. I think that’s the realistic case in regards to a potential vaccine. For Wave #1, we’re on our own.

I do think we will fail at fully containing the virus in the West. I think the path of America will be more similar to Italy than to South Korea. That’s not to say that America won’t handle things better. America has had more time to prepare and has a far less dense population. They have a more robust economy and will likely have more resources at their hands in fighting the disease. However, America also has significantly fewer medical resources to fight this than South Korea or even Italy. This leads me to assume that the medical system will be overwhelmed, eventually leading to a death rate closer to Italy’s (8%) rather than South Korea (.8%).

I think it’s inevitable most countries enact strict quarantines and movement restrictions. Some have speculated that countries might simply allow the virus to spread uninhibited, accepting the death rate, and moving towards herd immunity, ultimately shortening the virus’ cycle (and perhaps the economic impact). However, I cannot see countries and governments simply admitting to their populations that they will stand aside while people die. Governments will institute quarantines. They will enforce those quarantines. They won’t knowingly condemn their citizens to die.

Practically, I can say confidently that this means that things are going to get worse for at least the next month. Your next month should be planned at home. Beyond that, I think that, barring a dramatic (and unexpected) shift, during the next six months, we will be subjected to extreme restrictions and quarantine. Even if the virus clears up in some areas, assuming that the virus is still circulating elsewhere, countries will be hesitant to open borders and resume air travel.

I will analyze the potential economic impacts in the following article. If you’re trying to get somewhere before it hits the fan, leave now or forever hold your peace.


FOLLOW me on Twitter: @noamlevenson

I love getting questions or suggestions, so comment away! I do my best to respond to all thoughtful comments.

I received no compensation for this article.

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