Support The Bulwark and subscribe today.
  Join Now

Stop Undermining Health Policy with Misinformation

Let’s agree that we don’t know enough—but we do know a lot.
Stop Undermining Health Policy with Misinformation

Over the past few weeks, Americans have watched, read, and heard much about the novel coronavirus and how policymakers should fight it. President Donald Trump and New York Governor Andrew Cuomo both give widely-viewed daily press conferences. Terms like “social distancing” and “case-fatality rate” have escaped from medical journals into our daily vocabulary. The challenge in this explosion of health policy commentary and analysis is that some arguments have failed to ground themselves in the data.

For instance, in the Wall Street Journal Stanford professors Eran Bendavid and Jay Bhattacharya argued that the COVID-19 fatality rate is closer to 0.01 percent—which would make it one-tenth that of the flu mortality rate (0.1 percent) and far less than the WHO estimates of 2 percent to 4 percent.

We wish this were true.

None of this is to say that some contrarian theories don’t contain grains of truth. Bendavid and Bhattacharya are correct in pointing out that testing more mild or asymptomatic cases would indeed push down fatality rates.

But it’s a long way from a 2 percent fatality rate to 0.01 percent.

We don’t know everything about this virus yet, but the lack of perfect knowledge does not mean that we have no understanding whatsoever. So let’s make one thing on which we have at least the beginnings of a handle clear: COVID-19 is far more deadly than the flu.

We propose the following thought experiment for the theory that so many asymptomatic people are untested as to make the fatality rate 0.01 percent.

Imagine an extreme scenario where all 60.4 million Italians were infected with the virus, giving a hypothetical prevalence of 100 percent.

Even then, the April 5 total of 15,887 Italian deaths—a number that climbs by hundreds daily—results in a mortality rate greater than 0.01 percent. The total number of infected Italians—even though it is almost certainly higher than the number of positive COVID-19 tests—is, just as certainly, not 100 percent. And the number of deaths—which is growing daily—may be even higher than what has officially been ascribed to the disease. Translation: The real mortality rate is much much higher than 0.01 percent.

Or consider the cruise ship the Diamond Princess. Its population of passengers was older, but also wealthier, than average. Every passenger onboard was tested. Of the 3,711 tests, 712 were positive and they have resulted in 11 deaths (so far). Which, at least for this one sample, implies a mortality rate of 1.5 percent.

Consider also the case of South Korea, where extensive testing of mild and asymptomatic patients has resulted in a case fatality rate of 1.8 percent—well over one hundred times greater than the 0.01 percent proposed by Bendavid and Bhattacharya.

In Italy, there is already the beginnings of an attempt to document how undercounted the COVID-19 death toll has been. At some point, we will have to do the same in the United States.

From a clinical standpoint, hospitals lose patients with pneumonia and acute respiratory distress syndrome—two of the most dangerous diagnoses associated with COVID-19—every day without an infectious agent necessarily being assigned. This is especially so when testing is scarce and/or the hospital is overwhelmed. People also die of these symptoms at home or in nursing homes, infected but never tested. These COVID-19 fatalities are never counted.

In order to get a more accurate sense of the fatality rate, we will need to learn more about both the number of undiagnosed infections and the number of unassigned deaths.

But the preponderance of available evidence suggests that a death rate of 0.01 percent is not plausible.

In a time of pandemic, there should be a healthy public discussion of the available data and its implications. No one is served by happy talk any better than they are served by hysteria.

But the discussion should be a responsible one and the wilder claims and hypotheses do not add any value. Rather, they subtract it.

We are in an ongoing medical crisis. We are at an early stage of imposing restrictions in an effort to suppress the spread of an epidemic. It is exactly at this time that we should be aggressive because in only a few weeks time we will know (1) if we have turned the tide in the New York metro area and (2) if other hot spots have erupted.

By then, we will also have greater testing ability and more data, and thus the ability to take more focused actions.

In the long run, we are likely to find that the coronavirus and its impact on our healthcare system were, if anything, more deadly than an epidemiologist’s mortality rate calculations would suggest.

In New York and Seattle, hospitals are straining to provide ICU beds and ventilators. Doctors and nurses are re-using N-95 respirator masks. Students in their final year of medical school and retired doctors are being called in to help. Elective surgeries, including for early stage cancers, are forced to be delayed. This reduced overall quality of care harms not only COVID-19 patients, but also the healthcare workers who care for them—and other patients who find their care postponed.

The immense suffering in New York and Seattle has given the rest of us an early warning. Let’s make sure we learn from it.

Pranam Dey, Edieal Pinker, and Howard Forman

Pranam Dey (@DeyPranam) is a medical student at Yale School of Medicine. Edieal Pinker is a professor of Operations Research at the Yale School of Management where he also serves as deputy dean. Howard Forman (@thehowie) is a professor of radiology, economics, public health and management at Yale University.