Last week I was searching the Internet for some COVID-19 statistic or other, and I came across a new CDC website. The site featured some numbers the federal government is using to model the spread of the epidemic. One in particular caught my eye: 0.4 percent, the “current best estimate” of the disease’s “case fatality rate.” The document also said that 35 percent of infections are asymptomatic, which suggests the infection fatality rate is just 0.26 percent.
These numbers struck me as low for several reasons. For one thing, the virus has already killed 0.2 percent of all New Yorkers, and obviously a much higher percentage of those who’ve actually been infected in the city. For another, if we’ve had 100,000 deaths nationwide and a CFR of 0.4 percent, that means we’ve had 25 million symptomatic cases; including cases without symptoms, more than 10 percent of the entire country has been infected, which seems out of sync with what we’re hearing from serology tests. Individual studies and reviews of the evidence tend to put the infection fatality rate somewhere around 0.5 to 1 percent, though there’s at least one dissenting review that puts it lower (while managing not to include any studies finding a fatality rate above 0.5 percent, of which there are plenty).
I put out a tweet expressing my confusion, and things spiraled quickly, as they often do on social media. A follower alerted the prominent biologist Carl Bergstrom, who wrote a thread criticizing the CDC’s numbers. The next morning he was featured in a CNN story about the issue. There have been many media reports since, with the narrative predictably varying from “Heroic Scientific Experts Hammer Corrupt CDC for Fake Low Fatality Rate” to “CDC Finally Admits COVID Is Basically Harmless.” (I exaggerate, but only a little.)
I don’t have a scorching hot take on the number. But I do want to know where it comes from, which is not clear from the site itself. It says the information is based on data about a month old and names the source “Preliminary COVID-19 estimates, CDC,” which I have not been able to locate (if indeed it refers to a specific document at all).
I have contacted the CDC several times in the past week to no avail. Both the Center for Public Integrity and BuzzFeed similarly report that they sought comment and received no reply.
If the fatality rate of this thing is 0.26 percent, that is fantastic news. If the CDC has evidence this is the case, it should share it with the rest of us.
Nonetheless, there is a fairly large gap between what the WHO recommended in 2019 and what governments actually did in 2020.
Consider their 2019 recommendations:
Hand hygiene
Hand hygiene is recommended as part of general hygiene and infection prevention, including during periods of seasonal or pandemic influenza. Although RCTs have not found that hand hygiene is effective in reducing transmission of laboratory-confirmed influenza specifically, mechanistic studies have shown that hand hygiene can remove influenza virus from the hands, and hand hygiene has been shown to reduce the risk of respiratory infections in general.
Respiratory etiquette
Respiratory etiquette is recommended at all times during influenza epidemics and pandemics. Although there is no evidence that this is effective in reducing influenza transmission, there is mechanistic plausibility for the potential effectiveness of this measure.
Face masks
Face masks worn by asymptomatic people are conditionally recommended in severe epidemics or pandemics, to reduce transmission in the community. Disposable, surgical masks are recommended to be worn at all times by symptomatic individuals when in contact with other individuals. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure.
Surface cleaning
Surface and object cleaning measures with safe cleaning products are recommended as a public health intervention in all settings in order to reduce influenza transmission. Although there is no evidence that this is effective in reducing transmission, there is mechanistic plausibility for the potential effectiveness of this measure…. The effectiveness of different cleaning products in preventing influenza transmission – in terms of cleaning frequency, cleaning dosage, cleaning time point, and cleaning targeted surface and object material – remains unknown.
In the middle of that earlier decade, the free market economist, Wilhelm Röpke (1899-1966), who had been forced to leave his native Germany due to Hitler’s rise to power in 1933 and into exile at first for several years to university teaching in Turkey before finally settling in Geneva, Switzerland, published an English translation of his work, Crises and Cycles (1936).
In the new introduction that Röpke wrote for this English-language edition, he told the reader that it is easy to fall into the belief that all is lost, that one is living through an epoch change in the social order and the economic system, and that liberal society and its accompanying market economy is at their end in the face of the rising tide of collectivist central planning and the government command and control that was visible all around.
What was essential, Röpke argued, is to not lose historical perspective. Yes, such turning points in human society have happened in the past and the events of the present may forebode the coming of another such epoch change. But it is just as possible that it is not such a time, and that when the existing crisis and trends have run their course for a period of time, much of the liberal society and its market economy may be left standing in place, surviving the collectivist challenge and continuing its interrupted path toward liberty and prosperity after a period of intellectual and policy recovery. Or as Wilhelm Röpke expressed it in 1936:
“There is another danger of which both author and reader must beware: that of viewing the matter in the wrong perspective; that is to say, attaching too much importance to the events of the moment and consequently failing to see things in their historical perspective.
“Let us not be too hasty in expressing the opinion that Providence is doing us a special favor by allowing us to witness (or even to be instrumental in introducing) a new epoch of world history . . . Only people devoid of historical sense could so quickly forget that it is a mere matter of fifteen years since the [First] World War brought greater suffering to humanity than the present world crisis has done.
The experiences of health care workers in New York City during the COVID-19 pandemic has put into stark relief the kind of care that will benefit all Americans, moving forward. It is not too soon to incorporate the insights gained at the pandemic epicenter to improve patient care in lasting ways.
First, the pandemic has demonstrated that telemedicine is here to stay in a big way and that it should be incorporated across health care, more broadly.
As New York grappled with the worst of the crisis, video visits were an invaluable tool for outpatients who needed to consult with a primary care doctor or specialist. The crisis demonstrated that many symptoms and treatments can be assessed remotely, while critical care physicians used mobile devices to observe and help manage ICU patients in other hospitals that were short-staffed.
Medicare and many health insurance companies responded to the state of emergency by temporarily extending coverage for video visits with physicians. These measures should be made permanent, especially as the nation lurches towards something vaguely resembling normalcy.
Telemedicine can play a central role in providing continuity of care while also steering patients clear of possible virus exposure. It can make our health care system more efficient by streamlining office visits and redirecting physician expertise to areas of pressing need. It can allow greater access to care for underserved metropolitan communities and help address the gaping health disparities exposed by the virus. This last point is supported by encouraging research showing that telemedicine improves access to care and reduces health disparities among rural communities.
Americans are vigorously debating the merits of continuing to lock down the U.S. economy to prevent the spread of COVID-19. A single statistic may hold the key to resolving this debate: the astounding share of deaths occurring in nursing homes and assisted living facilities.
Nursing homes and assisted living facilities: The #1 COVID problem
2.1 million Americans, representing 0.62% of the U.S. population, reside in nursing homes and assisted living facilities. (Nursing homes are residences for seniors needing help with activities of daily living, such as taking a shower or getting dressed, who also require 24/7 medical supervision; assisted living facilities are designed for seniors who need help with activities of daily living, but don’t require full-time on-site medical supervision.)
According to an analysis that Gregg Girvan and I conducted for the Foundation for Research on Equal Opportunity, as of May 22, in the 41 states that currently report such figures, an astounding 42% of all COVID-19 deaths have taken place in nursing homes and assisted living facilities.
(Among states reporting their death totals, 42% of COVID deaths have taken place in long-term care facilities; we also estimate the share as 42% for the full U.S. population, based on incorporating the demographics of the non-reporting states.)
Let that sink in: 42% of all COVID-19 deaths are taking place in facilities that house 0.62% of the U.S. population.
And 42% could be an undercount. States like New York exclude from their nursing home death tallies those who die in a hospital, even if they were originally infected in an assisted living facility. Outside of New York, more than half of all deaths from COVID-19 are of residents in long-term care facilities.
70% of COVID-19 deaths in Ohio, 69% in Pennsylvania
Prior to last week, Ohio reported that 41% of COVID deaths were taking place in long-term care facilities. But updated disclosures last Friday, taking deaths prior to April 15 into account, upped that share to 70%.
In Minnesota, 81% of all COVID-19 deaths are of nursing home and residential care home residents. The region from the eastern seaboard from Virginia to New Hampshire has been especially hard-hit.
Nearly one-tenth of all New Jersey long-term care residents have died from COVID-19
Another way to cut the data is to look at nursing home and assisted living facility deaths as a share of the population that lives in those facilities. On that basis, three states stand out in the negative direction: New Jersey, Massachusetts, and Connecticut.
In Massachusetts and Connecticut, COVID deaths per 10,000 nursing home and assisted living facility residents were 703 and 827, respectively. In New Jersey, nearly 10 percent of all long-term care facility residents—954 in 10,000—have died from the novel coronavirus.
The tragedy is that it didn’t have to be this way. On March 17, as the pandemic was just beginning to accelerate, Stanford epidemiologist John Ioannidis warned that “even some so-called mild or common-cold-type coronaviruses have been known for decades [to] have case fatality rates as high as 8% when they infect people in nursing homes.” Ioannidis was ignored.
New York, New Jersey, Michigan forced nursing homes to accept infected patients
Instead, states like New York, New Jersey, and Michigan actually ordered nursing homes to accept patients with active COVID-19 infections who were being discharged from hospitals.
The most charitable interpretation of these orders is that they were designed to ensure that states would not overcrowd their ICUs. But well after hospitalizations peaked, governors like New York’s Andrew Cuomo were doubling down on their mandates.
As recently as April 23, Cuomo declared that nursing homes “don’t have a right to object” to accepting elderly patients with active COVID infections. “That is the rule and that is the regulation and they have to comply with that.” Only on May 10—after the deaths of nearly 3,000 New York residents of nursing homes and assisted living facilities—did Cuomo stand down and partially rescind his order.
Cuomo’s change of heart came too late for Maria Porteus. Her father, Carlos Gallegos, died of COVID-19 in a Long Island nursing home in April that adhered to Cuomo’s mandate. “It’s a slap in the face,” she said, “because he’s not taking responsibility for what happened to my father and so many others.”
Why Florida has performed better with vulnerable seniors
Contrast the decisions by governors like Cuomo with those of Florida Gov. Ron DeSantis. In Florida, all nursing home workers were required to be screened for COVID-19 symptoms before entering a facility. On March 15, before most states had locked down, DeSantis signed an executive order that banned nursing home visitations from friends and family, and also banned hospitals from discharging SARS-CoV-2-infected patients into long-term care facilities.
“Every day on these calls [with hospitals], I would hear the same comments and questions around, ‘We need to get these individuals returned back to the nursing home,’” said Mary Mayhew, who runs Florida’s Agency for Healthcare Administration. “We drew a hard line early on. I said repeatedly to the hospital, to the CEOs, to the discharge planners, to the chief medical officers, ‘I understand that for 20 years it’s been ingrained, especially through Medicare reimbursement policy, to get individuals in and out. That is not our focus today. I’m not going to send anyone back to a nursing home who has the slightest risk of being positive.’ What we said constantly is let’s not have two cases become 20 or five become 50. If you don’t manage this individual as you return them back, you will have far more being transferred back to the hospital.”
Florida also prioritized long-term care facilities for personal protective equipment, or PPE, with the understanding that it was just as important, if not more so, to protect workers at nursing homes and assisted living facilities. “If I can send PPE to the nursing homes, and they can prevent an outbreak there, that’s going to do more to lower the burden on hospitals than me just sending them another 500,000 N95 masks,” said DeSantis.
Learning from Florida’s example
While it is too late for thousands of nursing home residents who have already died, there is still time to protect the millions who remain, by learning from Florida’s example.
First, every state that has mandated that nursing homes accept actively infected COVID-19 patients should immediately rescind and reverse that mandate.
Second, as Florida has done, we must restrict visits to nursing homes by family and friends for at least the next several months, with the possible exception of those who can prove that they are not actively infected with the novel coronavirus.
Third, we must prioritize nursing homes and assisted living facilities for personal protective equipment, at an at least equal level of priority as hospitals and other first responders.
Fourth, we must test all nursing home workers and residents for active infections, using RT-PCR tests and other FDA-authorized methods of detection.
Fifth, we must strive wherever possible to ensure that nursing home staff are working at a single facility; it is likely that staff working at multiple facilities are helping to spread the infection. Infected nursing home workers and residents should be quarantined at an off-campus facility. States could contract with now-empty hotels to assist with this process.
Sixth, the seven states that thus far have refused to report COVID nursing home deaths—Hawaii, New Mexico, North Dakota, South Dakota, Missouri, Michigan, and Vermont—need to start reporting their death tolls in long-term care facilities. The federal government has instituted such a requirement for nursing home deaths occurring after May 5, but as Ohio teaches us, it is also important to get the data from the previous several months.
Michigan, in particular, has had a significant outbreak of COVID-19, and Gov. Gretchen Whitmer recently extended the state’s economic lockdown through June 12. Transparency into fatalities at long-term care centers in Michigan is essential for assessing the wisdom of her policy.
The optimistic take: Those outside of nursing homes are at lower risk
There is one silver lining—or perhaps bronze lining—to the COVID long-term care tragedy. The fact that nearly half of all COVID-19 deaths have occurred in long-term care facilities means that the 99.4 percent of the country that doesn’t live in those places is roughly half as likely to die of the disease than we previously thought.
Many European countries have struggled with the same nursing home problems that we have. But based on the mounting evidence that serious illness from COVID-19 is concentrated in the elderly, Switzerland and Germany have reopened their primary and secondary schools. Sweden, for the most part, never closed them to begin with. Germany has kept most of its factories in operation, and Sweden’s restaurants remain open. All of these countries have stable-to-declining rates of hospitalization and death from COVID-19.
The results in these countries should give us increased confidence that measured steps to reopen the economy can work here.
State governments bear much more of the responsibility for the depth of the COVID-19 pandemic than many Americans appreciate. But that also means that states have the opportunity to learn from their own mistakes and do the right thing: by protecting vulnerable seniors, and letting millions of Americans get back to work.
This acceleration is fueled by international regulators, companies, academic researchers, hospitals, and others collaborating to break down silos between medical research and patient care. They are creating an adaptive research network that can harness the latest findings from patients treated in frontline settings and use that experience to help select and test the most promising new therapies and vaccines in clinical trials.
Three major tools in this effort are modernized regulatory science, digital medicine technologies, and adaptive clinical trial designs. Together, these approaches can dramatically shorten the time and cost needed to generate the essential safety and effectiveness data that regulators need to review and approve new medicines and diagnostics.
The first tool, modernized regulatory science, is being adopted by regulators around the world. In the U.S. over the last few months, the Food and Drug Administration has released in record time vital new guidance for drug developers. This guidance, which normally takes the FDA years to issue and update, contains critical features for conducting clinical trials and good clinical practice for investigational drugs.
The FDA has also launched the Coronavirus Treatment Acceleration Program, an expedited program for drug development. It can generate significant efficiencies by coordinating senior agency staff and expertise from multiple drug review divisions to give sponsors rapid advice on how best to test and develop promising new therapies.
Digital medicine technologies represent a second vital tool. Digital tools are helping advance medical research when many patients can’t go to a physician’s office or hospital for even routine assessments. For instance, telemedicine visits using tablets and smartphones make it possible to remotely monitor patients, reducing the risk of patients and physicians’ being exposed to coronavirus in health care settings while also reserving scarce personal protective equipment for higher-risk settings.
Despite what many people hoped, COVID-19 is clearly worse than the seasonal flu. But despite what other people feared, it does not seem to be nearly as lethal as the "Spanish flu" of 1918, which killed about 0.7 percent of the total U.S. population—equivalent to more than 2 million people today.
As we move from lockdowns to something more closely resembling normal life, the emerging evidence about the threat posed by COVID-19 should inform our judgment about which precautions make sense. The initial, ham-handed approach—which confined hundreds of millions of people to their homes except for government-approved purposes—should be replaced by more carefully targeted measures focused on protecting the people who face the highest risk.
According to the Centers for Disease Control and Prevention (CDC), the current "best estimate" of the death rate among Americans who develop COVID-19 symptoms is 0.4 percent. By that measure—the symptomatic case fatality rate (CFR)—COVID-19 is roughly four times as deadly as the seasonal flu but far less deadly than the Spanish flu.
More than 600 of the nation’s physicians sent a letter to President Trump this week calling the coronavirus shutdowns a “mass casualty incident” with “exponentially growing negative health consequences” to millions of non COVID patients.
“The downstream health effects...are being massively under-estimated and under-reported. This is an order of magnitude error," according to the letter initiated by Simone Gold, M.D., an emergency medicine specialist in Los Angeles.
“Suicide hotline phone calls have increased 600%,” the letter said. Other silent casualties: “150,000 Americans per month who would have had new cancer detected through routine screening.”
U.S. businesses continued to be slammed by the effects of the novel coronavirus epidemic into the middle of May, a Federal Reserve report showed on Wednesday, and few expected a swift recovery despite some signs of hope.
The sharp plunge in economic activity recounted in the U.S. central bank’s latest temperature check of business activity across its 12 districts shed light on the depth of the economic pain generated by the virus, which has led to an unprecedented downturn and a U.S. death toll approaching 100,000.
The Fed’s survey, known as the “Beige Book,” was conducted in April, when non-essential businesses were shut down in much of the country, through May 18, when some states had started to loosen restrictions.
“Economic activity declined in all districts – falling sharply in most,” the Fed said in its report. “Although many contacts expressed hope that overall activity would pick up as businesses reopened, the outlook remained highly uncertain and most contacts were pessimistic about the potential pace of recovery.”
The story goes on to say that the state’s dashboard “reflects anyone who died, that tested positive for COVID, irrespective of cause of death.” (Emphasis added.)
Basically, the state has been matching up the names of those who died this year with a database containing names of people who tested positive for COVID-19.
A review of the data by the Olympia-based Freedom Foundation found that of all the deaths attributed to the virus, 5% didn’t list COVID-19 as the cause of death on their death certificates. Another 13% involved people who had at one time tested positive for the disease, but the virus wasn’t “listed on death certificates as either causing or contributing to death.” Five of the state’s “coronavirus deaths” actually died from gunshot wounds.
In just four months, coronavirus has gone from takeoff to lockdown in the U.S. America’s first Wuhan virus case appeared on Jan. 21, and the first American died Feb. 12. California went into lockdown March 19, followed by New York the next day, and New Jersey on March 21.
Two months later, America is only now emerging from the lockdowns’ unprecedented social and economic cessation. The most restrictive — and longest-lasting — have occurred in blue states. The New York Times observed, “States in the Northeast and on the West Coast, as well as Democratic-led states in the Midwest, have moved the slowest toward reopening.”
The Wall Street Journal currently lists 21 states with “comprehensive, or some,” restrictions on business and travel. Of these, 17 had Democratic governors. Of the four that did not, three had Democrat-controlled legislatures (Maryland, Massachusetts, and New Hampshire). Only one of the “restricted” states, Ohio, had a Republican governor and Republican legislature.
The overall cessation has been harsh on nearly all of America — 38.5 million unemployed amid a precipitous plunge in economic activity — but it has been harshest on those with lowest earnings and least savings. In a word, it has been regressive.
