I have just lost a friend.
Fernando González worked the night shift as the doorman in my apartment building. I often came home late from work, and when I passed through the lobby we would greet each other. This Thursday, he died of COVID-19.
He was not the first person near me to die from it. A few weeks earlier, the brother of a cleaner in our lab, a nurse, also died of COVID-19. He will not be the last.
In New York City, about 2% of the population has already tested positive. That figure comes despite a testing system that, at its daily peak, was only doing around 25,000 tests statewide. Yesterday, when testing rose slightly to more than 30,000, the city immediately produced a new record for daily confirmed cases. Put plainly, testing is still insufficient: the number of positives rises with the number of tests. Because the early testing criteria were so strict, many patients may have recovered before they were ever tested.
Medical resources, at least in one sense, have become enough, because hospitals are only taking severe cases. Mild cases have no specific treatment and are not being centrally admitted. In effect, this is herd immunity by another name: mild cases continue to spread the virus. That is also why, after two weeks of lockdown in New York — roughly one incubation cycle — the numbers still did not come down. Later measures such as promoting masks and raising fines were already somewhat late.
But then how should we explain the continuing decline in severe hospital admissions?
More than 80% of those in New York City who progress to severe disease have underlying conditions, and most of them are elderly. People aged 65 and above make up 14.1% of the city’s population, about 1.176 million people. Among confirmed COVID-19 deaths, 7,868 were over 65, accounting for roughly 80% of the total. In addition, there are about 5,000 deaths not confirmed by testing but marked as COVID-19 deaths in New York City, which the state government does not include in its count. By proportion, that would put the number of elderly deaths at around 12,000.
What does that mean? About 1% of New York City’s elderly population has already died of COVID-19, not to mention how many have been infected. If one accepts the claim that the fatality rate is only a few per thousand, then by that logic all of the city’s elderly would already have been infected, because the denominator is fixed. I know this is a rough and imperfect extrapolation, but it illustrates the point. The so-called passing of the epidemic peak may simply mean that the people most likely to die — the elderly, those with underlying disease, and those without enough immune resilience — have already died. In the absence of a specific drug or a vaccine, this is not hard to imagine.
If you think carefully about the strategy of “flattening the curve,” it is not really a prevention strategy. It is a delay strategy. It allows susceptible groups to be infected gradually, without overwhelming medical resources, and in the process transmission is supposed to be interrupted. But people will naturally die during that process. Hospital admission standards and testing standards have both remained high. What we are seeing now as a decline in admissions is likely a decline in the proportion of severe cases. Testing standards may later be relaxed, but hospital admission standards will probably remain strict.
We may only have passed the peak of deaths. Where the peak of infections is, I do not know, because testing has remained inadequate. It may still be ahead. The good news is that testing capacity is improving. Large numbers are not what should scare us; not knowing is what should scare us. Testing and isolation should be effective. But if the underlying strategy is ultimately herd immunity, then testing and isolation are still only part of a delaying strategy.
What about a specific treatment? Hydroxychloroquine came first, then remdesivir. Both have performed poorly in clinical trials. As for the idea of injecting disinfectant, whoever wants to believe that can go ahead. For a disease with a single-digit fatality rate, it is very difficult to distinguish the effect of a drug from spontaneous recovery. Recovery by itself is the most common regression phenomenon. If a few small-sample recoveries are enough to convince you that a treatment works, then science has been developing in vain all these years.
Many deaths are not caused by pneumonia itself, but by complications. That makes the effectiveness of an antiviral drug even harder to demonstrate. Trials require high-quality, suitable patients. Even though so many people have been infected, the number of severe patients who meet the criteria is actually not that large.
Then surely vaccines should be reliable? Only partly.
Both SARS and MERS involved the possibility of antibody-dependent enhancement, or ADE. In simple terms, if you develop antibodies to a coronavirus, and later encounter a mutated version of that virus, those antibodies may help the mutated virus enter the system and worsen the disease rapidly. There have already been scattered reports of this possibility. If ADE is widespread, then even a vaccine could expand the susceptible population.
Of course, there is no need for ordinary people to worry about every technical detail. Vaccine design has several possible paths that can avoid ADE, but they require extensive testing, and that takes time. If ADE does become a serious issue, then the so-called herd immunity path is useless and may produce a much worse second wave.
We still lack imagination when it comes to this virus.
If there are long-term positive carriers — and Wuhan has already reported such cases — people who feel fine themselves but can still transmit the virus, should they be isolated for life? That immediately becomes an ethical problem. The main symptoms of COVID-19 are respiratory, but could the virus persist long-term, become a chronic condition, or damage other physiological systems, only to cause illness when the host’s immunity weakens? If so, the long-running increase in average human life expectancy may stop here. It has been less than half a year since this virus appeared. We cannot answer these questions yet.
I do not want to create anxiety. But many of the negative scenarios once dismissed as pessimistic are becoming reality one after another. Contingency plans have to be designed; otherwise the disappointment later will be even greater. Life before 2020 and life after 2020 will not be the same. The old way of living is not coming back, and we will have to get used to a new one. Long-distance travel may no longer be easy. Routine antibody testing may become part of daily life. Masks may be worn for a long time. Consumption habits and religious practices that once seemed natural may all have to change.
Conspiracy theories are pure internal consumption. No government and no ideology could have known in advance that this virus would have so many hidden properties. Blaming one another has no value for disease prevention. It is only a contemptible method of self-preservation by leaders. Ignoring facts while telling stories and stirring up opinion will not produce anything positive. It will only bring hatred, division, and perhaps even war.
If you want to understand the facts, read academic papers. If you want to vent your emotions, unplug the internet and go chop meat for dumplings. If you want confirmation for your opinions, first convince yourself thoroughly, instead of choosing a position and then looking for evidence.
I have just lost a friend. I am very sad.