COVID-19, the Aversion of Aging Science, and the Psychology of Fear
About a week ago, I mused to myself whether anybody gets the irony that we are shutting down the world to protect, predominantly, those above 70 or 80 years old, yet whenever scientists or advocates discuss getting to the cause of aging itself to ameliorate the majority of non-communicable diseases, the vast majority of people become offended based on the assertion that death from age-related causes is “natural”. If it really were the reasoning that aging and death are natural, then by that logic, communicable diseases, such as those caused by viruses and the current COVID-19 pandemic, are natural as well. What differentiates the two? Why do we do anything and everything possible to give the oldest and most physically vulnerable amongst us another few years, or less, but scoff at the notion we could give everyone, including ourselves, an extra 10, 20, or even potentially many more GOOD years?
Many arguments have been circulated as to the importance of acting now. Flattening the curve is the popular philosophy in many nations, and massive closures and restrictions are being put upon the population in order to do so. This mantra is repeated endlessly and mindlessly. In Vancouver, Canada where I live, we hear it non-stop, on the news, by our politicians, the top doctors, and from shaming on social media. Many cities have moved forward and shut down parks in fear of overcrowding, yet the most crowded places continue to be grocery stores. Shutting down parks feels like utter insanity, with an argument from a trio of Harvard Professors, one of which is an epidemiologist, that the benefits of keeping parks open outweigh the risk of infection even in hard hit areas. Logically, shopping in person should be banned with delivery services instituted in its place, far before shutting down parks where people can walk trail systems alone or with their household, not coming into contact with anything others have touched.
In British Columbia (BC), the province I live in where parks are being shut down, we have seen declines in new cases and death for weeks on end. Despite this, the mantra continues to be shouted out, social distance. Now is not the time to let off the gas, they say, but the time to double down. What is this based off? In BC we have done no large-scale randomized testing to determine how many currently have the virus. For that matter, no country has done this. Some have tested more than others, but none have instituted a proper randomization process. It is too early to start handing out immunity passports as the tests aren’t 100% accurate yet, but the low level of inaccuracy does not stop us from getting a relative idea on how many have developed antibodies in order to make better policy decisions. Thankfully, I just heard on the news that researchers at the University of Southern California (USD) are doing exactly this, testing to determine the extent of how widely the virus has spread within Los Angeles county, and how close to immunity we are. If 30% or more of the population has already had it, for instance, we could safely allow it to continue to spread with minimal loss of life. I am not saying that 30% in BC is an accurate guess or even my own guess. One town in Germany determined 14% of its residents have had the virus via antibody testing, with an infection fatality rate (IFR) of 0.37%.
The sweeping closures and actions to stop the spread of the novel coronavirus have been done so without any sound statistical evidence. The fear is based on a combination of two factors: the observed case fatality rate (CFR), and how contagious the virus is (each person is expected to give it to ~2.5 others). The CFR is incredibly concerning if you look at it at face value. At the time of this writing (April 12th), Italy has a CFR of 12.7%, and the UK, France, Spain, Belgium, and The Netherlands all have CFRs above 10%. These are first world countries with modern healthcare systems, painting a grim picture for other nations. Again, this is if the CFRs are accurate.
The CFR becomes dramatically less concerning when looking at countries that have tested significantly more or began testing much earlier. For instance, South Korea has not tested much more per capita as of today than other countries, the difference being they conducted the testing in the early days. Their CFR sits at 2% and most of their cases are recovered. Every day that goes by without testing, the numbers skew to look worse. Inevitably, more of the very sick will be tested, as they are the ones being admitted to hospitals. The numbers get even better (but still very concerning) when looking at Iceland, who has tested 10% of their total population. Iceland’s CFR is 0.5% and over half of their population has recovered.
Iceland determined that roughly 50% of cases were asymptomatic, and the vast majority of symptomatic cases presented as very mild cold-like symptoms. New data out of China, as reported in the British Medical Journal (BMJ), suggest that 4/5ths of cases are asymptomatic. If accurate, that would bring the IFR down to 0.2% based on Iceland’s numbers. To clarify, the CFR is the death rate based on confirmed cases, whereas the IFR is the death rate based on how many were infected, which we could find out through antibody testing, or estimation after enough about the spread is known. From the BMJ news article:
“Tom Jefferson, an epidemiologist and honorary research fellow at the Centre for Evidence-Based Medicine at the University of Oxford, said the findings were ‘very, very important.’ He told The BMJ, ‘The sample is small, and more data will become available. Also, it’s not clear exactly how these cases were identified. But let’s just say they are generalisable. And even if they are 10% out, then this suggests the virus is everywhere. If—and I stress, if—the results are representative, then we have to ask, ‘What the hell are we locking down for?’”
I want to stress that even a 0.2% IFR is significantly higher than that of the seasonal flu, which ranges from 0.001 to 0.01%, meaning that the novel coronavirus is, at the most optimistic estimates of IFR, 20 to 200x more deadly than the flu during most seasons, and is more contagious. The flu does have a very wide range in IFR. In real-world data from the USA, particularly deadly years of the flu see around 60,000 deaths. 2017-2018 was estimated at 61,000 deaths across 45 million cases. That’s an IFR of 0.136%. Given this particularly deadly year, if we estimate that the IFR of COVID-19 will be 50% higher, bringing it to the 0.2%, and the total amount of cases (if left unchecked) would be quintupled, 450,000 people would die from COVID-19 in the USA over the next year. This sounds like a staggering number, but in fact is lower than the annual death rates from cancer and heart disease, individually. Many will be quick to point out the burden to the healthcare system, and that this is additive not “instead of”, which I agree with and have pointed out in previous articles, and I will address this shortly.
The real reason for the overwhelming response to this pandemic is two-fold. First, it isn’t part of the plan and we fear what isn’t part of the plan. It is rare I quote movies or pop culture, but in this case, it is entirely fitting.
“Nobody panics when things go "according to plan." Even if the plan is horrifying! If, tomorrow, I tell the press that, like, a gang banger will get shot, or a truckload of soldiers will be blown up, nobody panics, because it's all "part of the plan". But when I say that one little old mayor will die, well then everyone loses their minds.”
-The Joker from The Dark Knight
Aging is part of the plan. We’ve accepted that we grow old and die. It’s a horrifying plan if I must say. What could be more terrifying than resigning to slowly deteriorate, both physically and mentally, losing everything that makes us “us” in the process? It is such a terrifying notion that we most certainly have evolved to deal with what would otherwise be panic inciting fear at even thinking about the prospect. We’ve rationalized that it is natural, distorted the process to be beautiful. We’ve done this because throughout history we have had no other option. When some audacious group of scientists declare that they can ameliorate the effects of aging, or even work towards halting or reversing it, many become angered to the core. The notion that we can do something about it makes many think about it. Thinking about it is uncomfortable, and as a species, we tend to react poorly to things that make us uncomfortable.
The same is true for the various lifestyle-induced non-communicable diseases, such as heart disease and diabetes. We all know it is a risk, but we live our lives in the moment anyway. We’ve evolved to believe, at some level, that we will live forever. Why else would we behave as we do? To quote Sam Harris, “you’ll spend most of your life tacitly presuming you will live forever”. I encourage everyone to take two and a half minutes to watch this short clip of Harris speaking on the subject:
Aging, age-related diseases, and lifestyle-related diseases are not today’s problems. They are problems we can ignore because thinking about them is uncomfortable and painful. As Harris says in the video above
“Part of us always knows that we’re just a doctor’s visit away, or a phone call away from being starkly reminded with the fact of our own mortality, or of those closest to us. Now, I’m sure many of you in this room have experienced this in some form. You must know how uncanny it is to suddenly be thrown out of the normal course of your life and just be given the full-time job of not dying or caring for someone who is.”
During this pandemic, with the media coverage and daily press conferences, we have all been thrown into this situation. We are all living in this surreal state where death is on our minds to one degree or another. Not dying from COVID-19 or not allowing friends and family we believe to be at risk to die is on our minds. This fear, this disruption to the “plan” in which we craft our thoughts and reality around, is motivating us all. Aversion to this fear causes some to deny any risk, and others to not only miscalculate the risk as more than what it is but ignore the risks created by our hasty responses based off insufficient data. Confronting our own mortality is terrifying. When it is not immediate, such as with aging or lifestyle diseases, we have a choice to ignore it. The pandemic, media coverage surrounding it, and massive alterations to our lifestyles, is not affording us this luxury. This is applicable to not only us as individuals, but our policymakers as well.
The Current Plan
One of the big issues with the current plan is there is no uniformity across countries, or in North America anyway, across the various provinces and states. The USA has been hit significantly harder than Canada. The US projections also have the economy getting back on track within a few months, whereas in Canada the prediction is a year or more. None of these projections can really be accurate, given we have no good data on how many have had the virus and currently have it. On top of what I have already discussed regarding incorrect data, and throwing a confounding variable into the simple projections I calculated, the death rate may be significantly under-reported, due to people dying at home and not being tested post-mortem. One article I read earlier this week that is now buried in Google as I could not find it after 15 minutes of searching, suggested that a reasonable estimate would be 40% of deaths are not reported. Additionally, there are significant amounts of false negatives in testing, however, this would affect both the total count and total death count. The deviance from real numbers, on top of other corrections, could be quite significant:
“Our infectious disease experts think that about 30% of patients we believe have COVID are testing negative”
-Thomas Huth, the health network’s vice president of medical affairs
If the plan is to flatten the curve until enough of the population has had it that we wouldn’t see our medical system overwhelmed, we can’t predict this timeline without proper data, which we have none of. If we simply extrapolate IFR to what it may be (0.2%), the USA has potentially had 11 million cases to date, and an additional 30% bringing it over 14 million when accounting for estimates on false positives. At 4% of the US population, this is very far from herd immunity levels. However, if some very basic corrections are made for how far along the cases are based on how many have recovered, and correct for where Iceland is and correct the US IFR to be in line with the previously mentioned European nations in the 10% range, that would indicate 35 million Americans have already had the virus. This figure is roughly in line with what the one German town found, although there would certainly be a wide range depending on the area, i.e. New York could be several times this, but some small towns in states with few cases may be 1% or less. With a doubling every 20 days to account for the aggressive social distancing measures, this indicates the worst is yet to come and cases will be winding to a halt by the end of May. This is very different than current models, which are changing every day leading to outright denial and dismissal from many, and simply indicates how variable the trajectory may be depending on what stage of it we are in.
If Canada has quelled the surge, or at the very least Western Canada has, and plans to enact strict social distancing for the next year, this actually means that we cannot remove the measures until a vaccine is available. If the US peaks in the coming months, as do many European countries, but Canada remains relatively unscathed, that means the Canadian population is still vulnerable. Opening international travel would pose the risk of beginning all over again. Is Canada prepared to self-isolate the country, with the accompanying disastrous effects on the economy, for the next 18 months? At what point do we just bite the bullet and allow for more spread, so that this depression will not negatively impact Canadians for years, if not decades? If we “win” relative to other countries in curbing the spread, we may be winning a battle while losing the war, with the Canadian dollar, economy, and quality of life plunging relative to our neighbors and trading partners. To quote Christopher Nolan’s Dark Knight trilogy, in words but not context, one more time
“Victory has defeated you”
-Bane, The Dark Knight Rises
The various plans with COVID-19 are terrible for a few reasons and based on acutely applied logic on the situation in question, ignoring the ramifications of protocol applications on the wider range of society, including total deaths. First off, in the US, if we correct the 450k estimated deaths I suggested, to account for unreported deaths due to lack of testing and false negatives at a rate of 40%, this brings us to 600,000 deaths, which is on par with cancer and heart disease. Of course, as mentioned, this is additive in a short time frame and will lead to massive healthcare burdens in the short term. This is a serious concern, one worth considering.
To account for the surge and health care burden, one which may never come in Canada, we have shut down all non-life-threatening procedures in our hospitals and clinics. In BC, our hospitals are largely empty with just over 100 hospitalizations and less than 60 deaths to date, most of which have been in long-term care homes for the elderly. All procedures have been canceled, as thousands wait for surgeries, they, often desperately, need to get back to their daily lives and become active, healthy and fit. Every day that the procedures are halted increases the wait times, and further burdens the system once the restrictions are lifted, by at least a factor of two. Our system may never be burdened by COVID-19 directly, but it certainly will be once it ends.
This brings us to the question of what will be the death tolls of COVID-19, compared to the death toll of our actions to stop the spread? Economic hardship will certainly increase crime, which will increase incarceration rates, and indirectly increase deaths. Economic hardship will also negatively impact health, with those with less financial resources less likely to eat healthily and stay fit by significant margins. This will shorten countless people’s lives, possibly millions, and burden our healthcare system as well, not today, but years and decades from now. The panic and wide-ranging isolations will see a rise in mental health issues and associated deaths. These are not being considered enough, mostly because they are abstract concepts difficult to properly project, and are future issues, not today’s issues. We overwhelmingly have a proclivity of passing the burden on to the future, whether it be our future selves or future generations, even if the burden increases exponentially. Anything but deal with it now, to deal with it ourselves. Many have stated the cure is worse than the disease, and this may be true even in total death rates when accounting for both direct and indirect deaths. We are scrambling to give the elderly (predominantly, but not solely. Many younger individuals are dying, just much less frequently statistically speaking) another year or two of life now but condemning many more to lose several years later. This is an intangible, and as such inconsequential, consideration for most of us.
Not only is this a difficult proposition in terms of considering future risk, and intangible risk, with current risk and predicament, it is also a moral quandary. There is a famous thought experiment in which a train car is hurtling down a path. It is set to kill 4 people if you do nothing, but there is a lever in which you can pull to divert the train car. If you pull this lever, it will directly kill 2 people. Mathematically, and logically, most would agree that you must pull the lever. Saving 4 people is a net win of 2 people. When faced with this decision, many are incapable of pulling the lever, even hypothetically. To pull the lever is to act and directly cause the death of others. To do nothing is to allow the 4 deaths to happen on a previously determined course, mitigating much of the emotional distress and guilt associated with the loss of lives.
Our leaders, policymakers, and as a population, are currently running this thought experiment, slightly altered, in real-time. There is a key difference, making it even more difficult. Pulling the lever is directly saving lives. The car diverts, and we cannot immediately see how many lives it will kill on the other track. We could run an analysis to predict how many workers are expected to be on the track, but again, this is extra work to add significant guilt and indecision. Pulling the lever to save the tangible lives today is a much easier choice, one motivated strongly by emotion. Even if these models existed, who decides whether to pull the lever or not? Who amongst us has the strength to decide that saving x lives, in an intangible and abstract sense in the future, is more pressing than saving y lives, in a real and immediate sense, today?
Unfortunately, there likely is no good choice in this situation. People will die, no matter what. Poor decisions will be made, no matter what. All we can do is strive to collect better data and adjust our plans and positions as time goes on. One important thing we should all take away from this, but unfortunately most won’t, is if the elderly are worth saving from a current risk today, and I believe they are, they are worth saving from the ultimate risk, death from old age, both today and in the decades to come. Life is precious and maximizing the time we have is the ultimate goal. Hopefully, this pandemic will lead to us all reflecting on our own mortality, how our decisions affect our future health and life, and lead to more of us seeking resolutions to the biggest challenges to our existence that plague us year after year, not simply the new challenge that blind-sighted us today.
*Important update, written as an addendum
On April 17th a paper was published after measurements were taken from a random sampling of Santa Clara County, California on April 3rd and 4th. The data suggests that COVID-19 has circulated, widely asymptomatic, at a degree of 50-85x what the confirmed numbers show. When using the confirmed death counts as of April 17th, accounting for 2 weeks for more deaths to occur (more accurate than the death rate on April 4th), the projected infection fatality rate is 0.05-0.1%, 2-4x lower than my low estimate above. This puts it in line with many seasons of the flu and lower than particularly bad years (although still more infectious, and "in addition to"). If more data emerges that supports this, as well as considering the emerging data regarding a lack of severe cases/high death rates in southern hemisphere nations, or those below 20 latitude as a result of two potentials: Vitamin D deficiency in Acute Respiratory Distress Syndrome (90% of cases), and the potential that higher temperatures slow the spread, as we enter late spring, with this new information on more accurate infection fatality rate, we need to petition our leaders (both Politicians and health Authorities) to reassess policies based on the changing statistical evidence and understanding.
Further Addendum, afternoon April 17th:
After reviewing New York's fatality rate, a 0.05% IFR is impossible, and 0.1% is unlikely. A 0.2%, which I initially proposed, would indicate New York has had ~37.5% of the population contract the virus. This would put Spain at 22%, and Italy at 19%, numbers that are not unrealistic when considering one German town is at 14%. The study above that indicates 0.05-0.1% IFR is important, but clearly there are some confounding variables at play. This is a further indication of the immediate need for large scale randomized testing for antibodies.
An important consideration is that the IFR could vary widely between countries, and even regions of countries, based on multiple factors. For instance, it is possible Santa Clara's currently sits at 0.05-0.1%. This could be due to fewer hospital shortages in ICU beds and ventilators, as well as potentially effective experimental treatments being used. We do not know what works, but it is possible some of the anti-virals being used are effective. Areas that were hit earlier, and took longer to respond, could be seeing much higher IFRs, due to lack of treatment employed. We need more information on how widespread this has been in various areas, and we need clinical research to be expedited on each treatment method.