• Zuzanna Fiminska

COVID-19: Numbers are like alpacas

Updated: Jul 9, 2020

Disclaimer: I have been involved with the novel coronavirus-related research since the early cases reported in Wuhan. Eyes-deep in the data, for the longest time, I was oblivious to what was going on in the press, bewildered by people's sudden interest in my job.

Since then, I've been a grassroots teacher of epidemiology, answering questions from friends, family, and people in masks, queuing for the supermarket. This piece is an extension of these impromptu talks.

This piece is for people who want to think through this crisis and take lessons in anticipation of future prosperity and calamity. It looks at us as individuals in a complex system of global interdependence, and it inevitably succumbs to sweeping statements and cognitive shortcuts to accommodate this format. This piece makes no pretence to “the truth.” As I write it, I strive to see the world as a whole.

This piece attempts to make us think about the current pandemic in a broader context. It does not feature interviews with COVID-19 survivors or people whose loved one is currently receiving treatment at an intensive care unit. It does not report details of COVID-19-related autopsies. It does not make references to historic disease outbreaks that ravaged Europe before modern healthcare. If you need any of this, you're at the wrong place.

Dress rehearsal

The novel coronavirus, with its associated disease abbreviated to COVID-19 (a term hereafter used for all things novel coronavirus), brought the world to a halt, leaving many of us for the first time in our lives in countries with closed borders.

Like a dress rehearsal, this pandemic is showing us where years of political wishful thinking around climate, migration, and health have left us susceptible to swift destruction on Mother Nature’s whim.

As a person who spent the last weeks of 2019 telling everybody that, after two years of uncertainty (a personal crisis, job and address changes, a twelve-hour horizon), come April 2020, my life would be mine again, I felt slapped.

Then I thought about the pillars of democratic societies that we, the people, and we, the citizens, need to strengthen to ensure they support the upcoming crisis.

Keep calm: Disasters are coming

Things to worry about are the slow-to-emerge trends that change the way the sun rises, the very phenomenon that our civilization was built around when we chose where to settle and what to eat.

These changes might not have been as in-our-face as an infectious disease that overwhelms Western healthcare systems and takes down even the richest countries, though this is one of them and more of them are coming. A bunker stocked with non-perishables will not help.

Let’s stop getting distracted by shiny objects, sharing gossip as fact and electing leaders based on talent show criteria.

What we have is an issue that can’t be solved by issuance of visas, one that doesn’t have a spokesperson whose facial features can be used in character assassination, and an issue that will not disappear when a consultant says it has.

Luckily, we also have an issue that is relatively benign. It will move on. Life will resume. We can decide how resilient this life will be.

ballet dancers project neighbours

To create this new world, we're going to need dancers' strength, flexibility, balance, and ability to partner

Health BEFORE wealth

“I’m not worried about getting it. I’m worried about what it’s going to do to the economy,” is a line a variation of which I have heard (and said) plenty of times in the past several weeks.

And while it might be true that the long-term consequences of large-scale social disruption will claim lives and livelihoods of more people than the virus itself, no one is invincible. Life is a prerequisite for livelihood.

Like playground bullies, pathogens take down anyone they can. Maybe not me, maybe not you, maybe not even our friends, our colleagues, or our parents, but several people in this transmission chain die daily. Worries about the economy are sound. But worries about infection should be greater.

Without health, there is no economy

A truth hard to swallow for a culture that lives from the neck up, wears exhaustion as a badge of honour, shows up at work with a fever, and equates human value with ability to generate and accumulate wealth, leaving sick pay for the “weak.”

Health is fundamental. It’s true that the wealthier we are, the more likely we are to be healthy. But once ill, money has a poor conversion rate to health despite widely spread fantasies about private hospitals and private insurers that bestow dignity and vitality. Health is for all, not just for the wealthy.

Health results from clean air, clean running water, healthy diet, movement, limited screen time, close relationships, protection from toxins – the boring stuff whose public relations budget is much lower than that of a sugary cereal or pills to make us thin and happy – alongside good hygiene, reliable sanitation, and sick-leave when muscle ache and shortness of breath require bed rest.

Medical progress sits on top of these elements.

environmental causes of deaths project neighbours

Source: Public health, environmental, and social determinants of health by WHO

The chain of neglect is hard to counteract with ventilators alone. The health choices we make every day – not just the choices we make while in confinement – determine our individual and collective immunity. Medical miracles can prolong and support it. They cannot create or replace it.

Infectious disease exists

For several years, the West has been under a shared illusion that infectious disease is no more, and very little has been done to create healthcare systems agile enough to accommodate sudden spikes in need for care.

At the same time, very little has been done to ensure populations’ continued protection from disease.

Vaccines are essential

Anti-vaccine sentiments have been active in the West in the past several years, leading to outbreaks of diseases conventionally considered non-existent.

To put this in perspective: We’re being confined against a disease that kills slightly more than 1% of the people it infects, by current estimates. Many people will get infected. One per cent of many people is still a lot of people; yet, remember, nearly everyone will recover from this brutal cold, likely, without long-term health consequences.

Our confinement slows down the spread of disease, protecting hospitals from getting overwhelmed, so they can provide care to anyone who needs it, increasing chances of recovery even among the most vulnerable, while smart people figure out a vaccine.

This is an important point, as the disease will not stop spreading until after a large proportion of the population has become immune.

Meanwhile, a highly infectious disease that kills 15% of affected people and leaves 1 in 4 survivors with neurological damage, measles, has reached epidemic proportions in Europe in the past 4 years, with over 10,000 cases reported last year alone.

Source: European Centre for Disease Control and Prevention

Measles affects children, adolescents, and adults, and can be safely prevented with a vaccine, uptake of which has been declining in Europe and the United States, resulting in outbreaks of a disease previously largely eliminated.

Yes, the numbers are low compared to the ones being reported for COVID-19. Yes, the spread of the disease is slower, more contained, and there are fewer gaps in our knowledge about measles than there are about the COVID-19, creating less urgency to our response.

But outbreaks of measles are not outbreaks of novel infections that “no one could have predicted.” They are outbreaks of our neglect. And so, no confinement, no measles virus graphic spinning on prime time news, and no FIFA multi-million donation to treat and prevent it. In fact, we refuse vaccinations and choose to be at risk.

Infectious disease is often seen as a problem restricted to poor countries, when in fact, the proliferation of infections is associated with increased urbanization, houses not fit for habitation, wars, civil turmoil, cutting down trees, and increased air travel, to name a few, all of which are “right here” and none of which can be dismissed as “out there.” Ask anyone who’s ever rented property in Britain.

Think about it in the context of Europe’s negligence regarding prevention and its complacency regarding use of treatments, such as overprescribing of antibiotics.

No, really, think about it

Think a little bit more, because we suck at responding to outbreaks.

Our collective neglect around infectious disease goes beyond anyone’s individual decisions and extends to world leadership that has not prepared a political or logistical response to a pandemic that science said was coming.

This failed response involves creating hospitals optimized to the point of grotesque, running at maximum capacity at all times, without a stockpile of essential supplies, perhaps efficient but certainly not agile enough to respond to a sudden spike in need.

It also involves a lack of emergency response teams, including well-equipped medical staff, field epidemiologists, statisticians, and lab scientists.

We have the know-how

Until a couple of weeks ago, this short TED talk by Bill Gates was a treat for geeks, where he shared what he had learnt about preparedness from the Ebola outbreak. Now it’s the top-watched TED talk of all time. (A COVID-specific follow-up is now available.)

My hope is that this inoculates us against the circulating claims that no one saw this coming, that there was no way to prepare, and that we’re in uncharted territory. Things are only ever new in form, rarely (if ever) in content.

These lessons can still be learnt.

Systems can be put in place to protect us from future threats robust to passport control. This will not happen by itself.

I don’t know exactly how this will happen, but I know that having our citizens’ rights curtailed without a comprehensive explanation of the metrics that will be used to decide when this curtailment should end will have something to do with it.

Evidence and decisions

As far as I know, the evidence-base for the presently made decisions is not available to the public, and neither is any local or Europe-wide monitoring system to track progress toward reinstating our freedom of movement and right to assemble.

Indeed, decisions are being made without oversight or accountability. Without clear metrics upon which restrictions are being implemented, there are no clear criteria for assessing the success of these decisions, let alone to hold any person or institution responsible for lapses of judgement.

Meanwhile, we're being looked after by politicians who seem flabbergasted by the requirements of their jobs, followed by journalists who rarely ask the right questions, of the right people, at the right time, let alone effectively differentiate smokescreen answers from evidence-based statements.

I am hard-pressed for a media outlet that has the citizens’ interest at the heart of its broadcasting, consistently replacing actual reporting with fear-mongering, and misleadingly calling it “the whole truth, the whole time” (COVID-19 is not the Spanish flu).

Footage of people losing their mind in Wuhan, images of empty shelves in shops across the region, interviews with people, wearing masks and gloves, repeating ad nauseam the number of deaths in isolation from the number of cases, none of this is helpful. And building a narrative around numbers without context is confabulation.

Numbers and alpacas come in packs

pack of alpacas project neighbours

Alpacas live in packs and need company of at least one other alpaca. On her own, an alpaca fails to thrive and may die. A statistic is like an alpaca in that it needs at least another one of its kind; without it, it's meaningless

As we head into post-crisis culture change, this is the thing I want us all to learn from this outbreak and this piece: Numbers are like alpacas.

Here is how we herd the pack

Any number, such as the number of disease-related deaths, is only ever meaningful in the company of the following context:

  1. Is this a final number or are we still counting?

  2. Out of how many? Is this a final number of are we still counting?

  3. How many people who could have died, in fact died?

  4. How do these outcomes compare to equivalent outcomes in other contemporary diseases?

In case of COVID-19, we’re still counting, but what we do already know is that roughly 30% of infected people in Europe require hospitalization; roughly 5% of infected people require intensive care treatment; roughly 1% of infected people are likely to die (based on data from the European Centre for Disease Control and Prevention).

This is how COVID-19 estimates look in the context of world's present leading causes of death.

As the media feast on comparisons with the Spanish flu and the plague, here is a much more appropriate broader albeit grassroots perspective, capturing the world’s leading causes of death, based on COVID-19 estimates available on 31 March 2020 and WHO's latest available estimates of the top 10 global causes of death (Image credit: Charles Opondo)

To match the average daily death rate associated with heart disease, COVID's current average daily death rate would have to increase by a factor of six. In other words, six times as many people would have to die of it every day, for COVID-19 to become the world's leading cause of death.

As patients with COVID-19 follow a very distinct disease progression which requires special management, it is unlikely that these deaths be mistaken for another cause. Nevertheless, even if we inflated the numbers by 3% to satisfy the worry about potential under-reporting, the relative position of COVID-19 in the graph would remain unchanged.

This matters. First, putting things in context protects our collective sanity. Second, it shows that while we might be obsessing over one problem, other problems are lurking. Third, hopefully, it helps us become self-reliant in assessment of claims that have anything but our best interest at heart.

Perhaps this is also one way of ensuring that citizens are able to keep their governments and press accountable. Ask specific questions during the next political campaign. Distinguish reporting and analysis from hearsay and gossip. Break the chain of transmission of disease and confabulation.

It gets worse before it gets better

In the coming weeks, we will see the number of COVID-19 cases and associated deaths continue to grow, as the case-fatality ratio converges towards its 'true' value, meaning the proportion of infected people who die will decline.

At this point in the epidemic, it is unlikely that any Western country will follow the tragic case of Italy that saw the perfect storm of a highly infectious pathogen, in a population with a large proportion of older adults, and an overwhelmed healthcare system at a relative start of the outbreak, where guidance we’re now obsessed with was yet to be proposed.

With populations in confinement, provided we take precautions seriously, the epidemic’s spread is likely to slow down enough to keep our healthcare systems safe, minimizing the number of deaths. But recommendations regarding physical distancing are likely to continue for several months, although governments are likely to propose two-week extensions of the present measures, creating more fear and uncertainty.

This is going to take a while

But the world is a whole and it’s still spinning. Just as I am still dealing with the fallout of crises I dealt with before the pandemic, Greece is in the throes of tragedy (economy, migration, disease, take your pick). Refugees are still being kept on European shores (and have restricted access to medical care). Brexit is here. The war in Syria continues. Yemen is on a brink of yet another acute disaster, to name but a few things that are not grabbing the current headlines. The world is still spinning. And we’re spinning with it.

We will throw up. But once we’ve washed our hands and brushed our teeth, we will get to breathe cleaner air and things might change.

I have a deep belief in our collective capacity for culture change and I know that there are some people, somewhere in the world, taking this time to learn and reflect, seeing for the first time the world as a whole. Once you see the connections between phenomena that the mainstream has siloed (health, destruction of nature, walls along borders, exploitative employment), these connections are like the face on the surface of the Moon: you can't unsee them.

Then you see the beauty of what's at stake. Once you do, you fall in love. And we protect what we fall in love with.

Zuzanna Fiminska is a writer and epidemiologist, and the author of this piece.

Charles Opondo shared thoughts and figures included in this piece and reviewed it for statistical accuracy.