Still no need to panic, but need to be cautious

Re-reading my previous blog post, I feel that my emphasis was wrong. While there are no incorrect facts, the takeaway message now seems wrong. I did not sufficiently emphasize that the peak of infections can easily overwhelm hospitals. Currently, a doctor friend told me St Louis University hospital has only 10 vacant beds out of 65 ICU beds. There are only1888 ICU beds in the entire state of Missouri (population about 6.1 million). The number is low because of cost-cutting, especially since 2008, because having empty beds is “wasteful.” But reducing the number of beds so they are mostly being used reduces our capacity to deal with crises. As a doctor friend put it, “Hospitals in the US are already always running at 110 percent.” The additional serious cases of COVID-19, even if they are only 1 of 100 who get sick, can still easily be too many for the hospital to cope, and doctors will have to decide who gets the ventilator and who dies.

Three articles this past week, a piece in Medium by TomasPueyo, an article on Vox, and an article in the NY Times byNicholas Kristof and Stuart Thompson, make the point that the problem is not treating the disease itself, but is going to be treating the sick at the peak of the epidemic when hospitals are overwhelmed. I highly recommend these articles. The Times article also has a table that shows that the peak of the epidemic is likely to be in July, which means Americans' current “social distancing” is going to have massive economic effects.

It seems everyone I speak to has seen the Tomas Pueyo article, and I see now that it has been viewed 35 million times in 6 days. It gives me hope that ideas can, in fact, sometimes change people's ideas and behavior!

In the US, everything changed this week. Universities started closing on Tuesday, March 10, and the NBA suspended the season the next day. That was when everyone knew it was really serious. I don’t know all the factors that have gone into closing universities, but I’m told a major issue is uncertainty over a university's liability if they stayed open and someone got sick and died. It is easier to close. This is disturbing, because it is not clear what foreign students are supposed to do, and the extra travel this causes is precisely what we don’t want if we’re trying to prevent the spread of disease. I would have thought isolating the campus from outside visitors would have been more effective, in public health terms. But, I’m not aware of all the considerations. And I’m grateful I did not have to make these difficult decisions.

One thing I did not anticipate in my earlier blog was that Americans would take no precautions at all. I did not realize how unscathed the US was from SARS. Many friends who lived through SARS in Asia have commented on how blithely Americans have been taking the epidemic. I have not been panicking, but I have certainly been washing my hands a lot and avoiding crowds. I open doors with my back (to avoid touching the door with my hands), and push elevator buttons with my knuckle--all skills learned during SARS in Hong Kong. But a combination of lack of focus, and the fiasco with the US insisting on developing its own test for the COVID-19 virus and flubbing it, has led to serious problems. As late as yesterday, March 15, we’ve been reading reports in our local paper and on social media (see for example here) of people displaying coronavirus symptoms but not being tested because they do not meet some criterion. They perhaps came from Toronto, but not Italy, so are not eligible for the test. The problem is that from a public health point of view, we need to test everyone with symptoms so we can contact others who might have been infected. And there does not seem to be much contact tracing here in the US.

Taiwan is getting some attention for its success in limiting the epidemic, though it would be getting a lot more attention if it were part of the WHO. An article in the Journal of the American Medical Associationonline notes first, how early authorities moved to test visitors and suspected cases. 

On December 31, 2019, when the World Health Organization was notified of pneumonia of unknown cause in Wuhan, China, Taiwanese officials began to board planes and assess passengers on direct flights from Wuhan for fever and pneumonia symptoms before passengers could deplane. As early as January 5, 2020, notification was expanded to include any individual who had traveled to Wuhan in the past 14 days and had a fever or symptoms of upper respiratory tract infection at the point of entry; suspected cases were screened for 26 viruses including SARS and Middle East respiratory syndrome (MERS). Passengers displaying symptoms of fever and coughing were quarantined at home and assessed whether medical attention at a hospital was necessary.

China only began to take action by classing COVID-19 as a notifiable disease on Jan. 20, and shutting down Wuhan on Jan. 23.

Taiwan’s quick and effective reaction was possible because they have highly centralized immigration records and a National Health Insurance Administration (AKA "universal healthcare"), and were able to link the two databases. Though 850,000 Taiwanese live and work in China, and many came back to Taiwan for the Lunar New Year on Jan. 25, the health authorities could identify who had traveled from China within the previous 14 days and could contact them for testing. Taiwan’s household registration system also allows authorities to locate residents; the US has no such system. In Taiwan, and Hong Kong, they have the data and the will to trace contacts; this does not seem to be the case in the US. In Hong Kong and Taiwan, they also monitor people by tracking their cell phone, something that will probably not be politically possible in the US. But I had assumed tracking contacts of people who come down with COVID-19 would be standard procedure in the US, as it was in Asia for SARS in 2003, and is currently the case in Asia. But as I mentioned, they are not even testing many of the people who show coronavirus-like symptoms, let alone tracing contacts. The first case in Missouri was a student who took the train from Chicago on March 4, and came down with symptoms on March 6th. They did disinfect the entire train.

Many people are expecting the epidemic to end with warmer weather, as happens with the flu season. Unfortunately, the fact that there are coronavirus cases in Singapore, which is on the equator, and that the Spanish Flu actually first emerged in June-July of 1918, make this unlikely. (The seasonality of the flu is actually an interesting scientific puzzle.)

Frozen food section at Trader Joe's 

 The panic in the US really hit on Thursday March 12, when there were runs on supermarkets. The panic buying of toilet paper has been widely reported, and my local supermarket had empty shelves; even paper dinner napkins were all gone. Especially surprising was the fact that all the white vinegar was gone! Back in January 2003, Hong Kong newspapers carried stories that mocked Guangzhou people for clearing stores of vinegar, because “superstitious” people were boiling vinegar to prevent what later was known as SARS. Just two months later, there was also a run on vinegar in Hong Kong, as the illness spread to the region. So it is a bit surprising that I see vinegar also gone from my local supermarket.

Paper products at local supermarket

But there are notable differences in cultural ideas of how to quarantine. In Hong Kong, people were encouraged to keep windows open at home, and go out in country parks to get fresh air. (Many people do not realize that Hong Kong is actually 70% country parks and nature reserves.) In California, starting tomorrow, people are required to stay in their homes. It seems to me that it is very safe to go outside as long as there are no crowds, but that is not the advice we are being given in St Louis. We are expected to stay indoors; in Hong Kong, fresh air was believed to be healthy.

The most notable difference in how COVID10 is dealt with is with masks. In Hong Kong, everyone is expected to wear a mask when outside. In the US and Singapore, one is only to wear a mask if ill. The argument is that a surgical mask does not help much in preventing catching the virus. (Here is a brief and insightful anthropological analysis of the different beliefs surrounding masks.) Of course, most people operate on the “better safe than sorry” principle, so would wear masks if they could. But they have been unavailable in St Louis since late January. And now we learn from the NY Times and Wired that there are people who have been buying up masks and hand sanitizers since January, to sell them on eBay and Amazon at a steep markup. This should be the topic of a future (economic anthropology) blog posting, but for now, I'll just say that it adds to the chaos and distrust.

My 90-year mother-in-law lives near Seattle in a retirement home. When asked how she was doing, with all this worry about coronavirus, she said that she has seen so many things in her life, this does not scare her that much. After all, she lived through the Japanese occupation of Hong Kong during WWII, the Cold War and "Red Scare." Yes, this is serious. But with organization and care, societies can get through this.

The Coronavirus Panic

I have been interested in “risk” for my research on pesticides, and as part of my work on magic and the supernatural. I therefore look at the world response to the new coronavirus that emerged in Wuhan with a slightly different perspective. While I understand the fear of a novel illness (having lived through SARS in Hong Kong), I also see that a lot of the fear is unnecessary and irrational, if understandable.

Every year, influenza kills thousands of people in the US and around the world, and people accept that as somehow normal. Pneumonia is the 2nd leading cause of death in HK (8032 people in 2017, causing 17.5% of deaths). And the death-rate from pneumonia shoots up for people over 74. In the US, 55,672 people died of influenza and pneumonia in 2017. The press regularly mentions large numbers of infected and dead (14,300 and 305 as I write) which seem like large numbers, but in comparison to the overall population of China is small. For the US, the NY Times reports: 

For perspective: The flu kills roughly 35,000 Americans every year. This season, it has already sickened an estimated 15 million Americans and killed 8,200, according to C.D.C. estimates.

• Influenza kills more Americans every year than any other virus, Dr. Peter Hotez, a professor at Baylor College of Medicine, told Liz Sabo at Kaiser Health News. But the flu is rarely paid such attention, and fewer than half of adults get a vaccine.

• “When we think about the relative danger of this new coronavirus and influenza, there’s just no comparison,” Dr. William Schaffner, a professor at Vanderbilt University Medical Center, told Ms. Sabo. “Coronavirus will be a blip on the horizon in comparison.”

As Elizabeth Rosenthal (a physician and NY Times journalistwho lived in Beijing through SARS) says, “Remember, by all indications SARS, which killed about 10 percent of those infected, was a deadlier virus than the new coronavirus circulating now. So keep things in perspective.” As you can see from the table below, influenza regularly kills between 0.2 and 0.4% of patients who see a doctor for the flu, and 7-13% of those who are hospitalized for the flu. It is estimated that 10% of those affected by the Spanish flu of 1918 died. The main reason for the fear today is that the coronavirus is new, so we don’t know everything about it. But much about it is already quite clear: the mortality rate appears to be at most 2-4%, and it spreads through heavy water droplets (i.e. sneezing and direct contact). This is not Ebola.

The media tend to emphasize the risk because fear attracts viewers. Readers are much more likely to forward and make viral an article that warns about the virus and emphasizes the danger. The NY Times had a photo essayentitled “China’s Battle with a Deadly Corona Virus” and “The Test a Deadly Coronavirus Outbreak Poses to China’s Leadership” but it was already clear on Jan. 21 that this virus is not as deadly as SARS or Ebola. And though we don’t know some things about the new coronavirus, we do know a lot, and it is misleading to call it “mysterious” (as Fox News did here). 

Lest I be considered distant and unaffected by the virus, let me add that my wife has a colleague in China whose father-in-law is among the dead, so I fully understand how serious and tragic influenza can be. But we need to take reasonable precautions and not panic. Often, panic causes more problems than the problem that sparked the fear. The point is, as Ian Johnsonputs it, “This outbreak is serious but not catastrophic.” (His essay on the government's Aksionismus or "actionism" is excellent, like most of his writing.)

There has been a run on masks, but as Rosenthal notes, masks are not that effective. They help in crowded places, but they have to be replaced frequently, because if they work and get viruses on them, they are contaminated. It is basic hygiene, like washing your hands frequently, and staying home if sick, that helps prevent the spread of viruses. There are many draconian measures undertaken in China that are pointless (like shutting gates to apartment complexes at night). Lest Americans think they are more “rational,” I hasten to point out that our local drug stores have sold out of masks. We tried to buy some for a friend who wanted to send them to Hong Kong, but even in St Louis, there has already been a run on masks!

Many of the bans being put in place are informed as much by xenophobia as by public health concerns. Particularly worrying are bans on all Chinese (like in Singapore), as if being Chinese was a marker of likely being ill. Stories that focus on Chinese eating wild animals have gone viral (pun unintended) but have nothing to do with the cause or spread of the disease (see the weird case of “bat soup”here). Jason Oliver Chang, Associate Professor of History and Asian American Studies at the University of Connecticut, has created a Googledoc with resources to teach about “Yellow Peril” to try to counteract these racist and xenophobic narratives that unfortunately fit into Trumpian anti-foreign sentiments.

It is natural to be cautious and afraid. I remember from the SARS outbreak in Hong Kong, and Emily Feng of NPR in Beijing said the same thing last week, you can know the chance of getting sick is small and not worry about yourself, but you worry more about transmitting it to others. You think, “What if I’m the person that spreads the disease to my workplace?”

Those of us who lived through SARS in Asia changed our habits, as Rosenthal notes. In addition to washing our hands more often, we push elevator buttons with our knuckles and not our fingertip, and we stay home if we are sick. I’m struck that many people with a cold or flu symptoms in the US do not quarantine themselves, but continue going to work and social events. And how many people who are worried about the coronavirus did not get their flu vaccine this year?

It is not that we don’t have to be vigilant. In fact, Laurie Garrett (Pulitzer-prize winning author of books on epidemics and public health) notes that the US is totally unprepared for an epidemic because: “In 2018, the Trump administration fired the government’s entire pandemic response chain of command, including the White House management infrastructure. In numerous phone calls and emails with key agencies across the U.S. government, the only consistent response I encountered was distressed confusion.” Not that is alarming.

Another thing is also clear: governments are under tremendous pressure to "do something" even if it is not necessary; no one wants to be blamed for not doing enough. And the weird thing is, if public health efforts succeed and there is no pandemic, or the virus burns out naturally before becoming a pandemic, both health and political officials will be accused of overreacting! It is not easy to make the calls right now. But we individually can at least avoid panicking.

PS: Here is a good NPR Morning Edition story from Monday Feb. 3rd that argues there is no need to panic.