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Evidence over hysteria — COVID-19

Aaron Ginn
Mar 20 · 34 min read
After watching the outbreak of COVID-19 for the past two months,
I’ve followed the pace of the infection, its severity, and how our world
is tackling the virus. While we should be concerned and diligent, the
situation has dramatically elevated to a mob-like fear spreading faster
than COVID-19 itself. When 13% of Americans believe they are
currently infected with COVID-19 (mathematically impossible), full-
on panic is blocking our ability to think clearly and determine how to
deploy our resources to stop this virus. Over three-fourths of
Americans are scared of what we are doing to our society through law
and hysteria, not of infection or spreading COVID-19 to those most
vulnerable.

The following article is a systematic overview of COVID-19 driven by

data from medical professionals and academic articles that will help
you understand what is going on (sources include CDC, WHO, NIH,
NHS, University of Oxford, John Hopkins, Stanford, Harvard, NEJM,
JAMA, and several others). I’m quite experienced at understanding
virality, how things grow, and data. In my vocation, I’m most known
for popularizing the “growth hacking movement” in Silicon Valley
that specializes in driving rapid and viral adoption of technology
products. Data is data. Our focus here isn’t treatments but numbers.
You don’t need a special degree to understand what the data says and
doesn’t say. Numbers are universal.

I hope you walk away with a more informed perspective on how you
can help and Wght back against the hysteria that is driving our country
into a dark place. You can help us focus our scarce resources on those
who are most vulnerable, who need our help.

Note: The following graphs and numbers are as of mid-March

2020. Things are moving quickly, so I update this article twice a
day. Most graphs are as of March 20th, 2020. Follow me on
Twitter if you would like to see the updated graphics and articles.

Best,

Aaron Ginn

Table of Contents
1. Total cases are the wrong metric

2. Time lapsing new cases gives us perspective

3. On a per-capita basis, we shouldn’t be panicking

4. COVID-19 is spreading

5. Watch the Bell Curve

6. A low probability of catching COVID-19

7. Common transmission modes

8. COVID-19 is likely to burn o_ in the summer

9. Children and Teens aren’t at risk

10. Strong, but unknown viral e_ect

11. What about asymptomatic spread?

12. 93% of people who think they are positive aren’t

13. 1% of cases will be severe

14. Declining fatality rate

15. So what should we do?

16. Start with basic hygiene

17. More data

18. Open schools

19. Open up public spaces

20. Support business and productivity

21. People fear what the government will do, not infection

22. Expand medical capacity

23. Don’t let them forget it and vote

. . .

Total cases are the wrong metric

A critical question to ask yourself when you Wrst look at a data set is,
“What is our metric for success?”.
Let’s start at the top. How is it possible that more than 20% of
Americans believe they will catch COVID-19? Here’s how. Vanity
metrics — a single data point with no context. Wouldn’t this picture
scare you?

Look at all of those large red scary circles!

These images come from the now infamous John Hopkins COVID-19
tracking map. What started as a data transparency e_ort has now
molded into an unintentional tool for hysteria and panic.

An important question to ask yourself is what do these bubbles

actually mean? Each bubble represents the total number of COVID-19
cases per country. The situation looks serious, yet we know that this
virus is over four months old, so how many of these cases are active?

Immediately, we now see that just under half of those terrifying red
bubbles aren’t relevant or actionable. The total number of cases isn’t
illustrative for what we should do now. This is a single vanity data
point with no context; it isn’t information or knowledge. To know how
to respond, we need more numbers to tell a story and to paint the full
picture. As a metaphor, the daily revenue of a business doesn’t tell you
a whole lot about proWtability, capital structure, or overhead. The
same goes for the total number of cases. The data isn’t actionable. We
need to look at ratios and percentages to tell us what to do next —
conversion rate, growth rate, and severity.

Time lapsing new cases gives us perspective

Breaking down each country by the date of the Wrst infection helps us
track the growth and impact of the virus. We can see how total cases
are growing against a consistent time scale.

Here are new cases time lapsed by country and date of Wrst 100 total
cases.
Here is a better picture of US conWrmed case daily growth.

The United States is tracking with European nations with doubling

cases every three days or so. As we measure and test more Americans,
this will continue to grow. Our time-lapse growth is lower than China,
but not as good as South Korea, Japan, Singapore, or Taiwan. All are
considered models of how to beat COVID-19. The United States is
performing average, not great, compared to the other modern
countries by this metric.

Still, there is a massive blindspot with this type of graph. None of

these charts are weighted on a per-capita basis. It treats every country
as a single entity, as we will see this fails to tell us what is going on in
several aspects.

On a per-capita basis, we shouldn’t be

panicking
Every country has a di_erent population size which skews aggregate
and cumulative case comparisons. By controlling for population, you
can properly weigh the number of cases in the context of the local
population size. Viruses don’t acknowledge our human borders. The
US population is 5.5X greater than Italy, 6X larger than South Korea,
and 25% the size of China. Comparing the US total number of cases in
absolute terms is rather silly.

Rank ordering based on the total number of cases shows that the US
on a per-capita basis is signiWcantly lower than the top six nations by
case volume. On a 1 million citizen per-capita basis, the US moves to
above mid-pack of all countries and rising, with similar case volume
as Singapore (385 cases), Cyprus (75 cases), and United
Kingdom(3,983 cases). This is data as of March 20th, 2020.
Here is a visualization of a similar per-capita analysis.

But total cases even on a per-capita basis will always be a losing

metric. The denominator (total population) is more or less Wxed. We
aren’t having babies at the pace of viral growth. Per-capita won’t
explain how fast the virus is moving and if it is truly “exponential”.

COVID-19 is spreading, but probably not

accelerating
Growth rates are tricky to track over time. Smaller numbers are easier
to move than larger numbers. As an example, GDP growth of 3% for
the US means billions of dollars while 3% for Bermuda means
millions. Generally, growth rates decline over time, but the nominal
increase may still be signiWcant. This holds true of daily conWrmed
case increases. Daily growth rates declined over time across all
countries regardless of particular policy solutions, such as
shutting the borders or social distancing.
The daily growth data across the world is a little noisy. Weighing daily
growth of conWrmed cases by a relative daily growth factor cleans up
the picture, more than 1 is increasing and below 1 is declining. For all
of March, the world has hovered around 1.1. This translates to an
average daily growth rate of 10%, with ups and downs on a daily
basis. This isn’t great, but it is good news as COVID-19 most likely isn’t
increasing in virality. The growth rate of the growth rate is
approximately 10%; however, the data is quite noisy. With
inconsistent country-to-country reporting and what qualiWes as a
conWrmed case, the more likely explanation is that we are increasing
our measurement, but the virus hasn’t increased in viral capability.
Recommended containment and prevention strategies are still quite
e_ective at stopping the spread.
Cases globally are increasing (it is a virus after all!), but beware of
believing metrics designed to intentionally scare like “cases doubling”.
These are typically small numbers over small numbers and sliced on a
per-country basis. Globally, COVID-19’s growth rate is rather steady.
Remember, viruses ignore our national boundaries.

Viruses though don’t grow inWnitely forever and forever. As with most
things in nature, viruses follow a common pattern — a bell curve.

Watch the Bell Curve

As COVID-19 spreads and declines (which it will decline despite what
the media tells you), every country will follow a similar pattern. The
following is a more detailed graph of S. Korea’s successful defeat of
COVID-19 compared also to China with thousands of more cases and
deaths. It is a bell curve:
Here is a more detailed graph of S. Korea graphed against the total
number of cases.
Here is a graph from Italy showing a bell curve in symptom onset and
number of cases, which may point to the beginning of the end for Italy
—

JAMA — https://jamanetwork.com/journals/jama/pages/coronavirus-alert

Bell curves are the dominant trait of outbreaks. A virus doesn’t grow
linearly or exponentially forever (if assuming reasonable assumptions
about time). It accelerates, plateaus, and then declines. Whether via
environmental factors or our own e_orts, viruses accelerate and
quickly decline. This fact of nature is represented in Farr’s law. CDC’s
recommendation of “bend the curve” or “natten the curve” renects
this natural reality.

It is important to note that in both scenarios, the total number of

COVID-19 cases will be similar. The primary di_erence is the length
of time. “Flattening the curve”’s focus is to minimize a shock to the
healthcare system which can increase fatalities due to capacity
constraints, as seen in Italy and Wuhan, China. In the long-term, it
isn’t pure “infection prevention”, rather it prioritizes lower healthcare
utilization. Unfortunately, “nattening the curve” doesn’t include other
downsides and costs of execution.

Predictive models out of Imperial College of London predicts millions

of infections if nothing is done, but follows a bell curve pattern.

Both the CDC and WHO are optimizing for healthcare utilization,
while ignoring the economic shock to our system. Both organizations
assume you are going to get infected, eventually, and it won’t be that
bad.

A low probability of catching COVID-19

The World Health Organization (“WHO”) released a study on how
China responded to COVID-19. Currently, this study is one of the most
exhaustive pieces published on how the virus spreads.

The results of their research show that COVID-19 doesn’t spread as

easily as we Wrst thought or the media had us believe (remember
people abandoned their dogs out of fear of getting infected).
According to their report if you come in contact with someone
who tests positive for COVID-19 you have a 1–5% chance of
catching it as well. The variability is large because the infection is
based on the type of contact and how long.

The majority of viral infections come from prolonged exposures in

conWned spaces with other infected individuals. Person-to-person and
surface contact is by far the most common cause. From the WHO
report, “When a cluster of several infected people occurred in China,
it was most often (78–85%) caused by an infection within the family
by droplets and other carriers of infection in close contact with an
infected person.

From the CDC’s study on transmission in China and Princess Cruise

outbreak -

A growing body of evidence indicates

that COVID-19 transmission is
facilitated in con@ned settings; for
example, a large cluster (634 con@rmed
 cases) of COVID-19 secondary
infections occurred aboard a cruise ship
in Japan, representing about one @fth of
the persons aboard who were tested for
the virus. This @nding indicates the high
transmissibility of COVID-19 in
enclosed spaces
Dr. Paul Auwaerter, the Clinical Director for the Division of Infectious
Diseases at Johns Hopkins University School of Medicine echoes this
Wnding,

“If you have a COVID-19 patient in your

household, your risk of developing the
infection is about 10%….If you were
casually exposed to the virus in the
workplace (e.g., you were not locked up
in conference room for six hours with
someone who was infected [like a
 hospital]), your chance of infection is
about 0.5%”
According to Dr. Auwaerter, these transmission rates are very similar
to the seasonal nu.

Air-based transmission or untraceable community spread is very

unlikely. According to WHO’s COVID-19 lead Maria Van Kerkhove,
true community based spreading is very rare. The data from China
shows that community-based spread was only a very small handful of
cases. “This virus is not circulating in the community, even in the
highest incidence areas across China,” Van Kerkhove said.

“Transmission by @ne aerosols in the air

over long distances is not one of the main
causes of spread. Most of the 2,055
infected hospital workers were either
infected at home or in the early phase of
the outbreak in Wuhan when hospital
safeguards were not raised yet,” she said.
True community spread involves transmission where people get
infected in public spaces and there is no way to trace back the source
of infection. WHO believes that is not what the Chinese data shows. If
community spread was super common, it wouldn’t be possible to
reduce the new cases through “social distancing”.

“We have never seen before a respiratory pathogen that’s capable of

community transmission but at the same time which can also be
contained with the right measures. If this was an in<uenza epidemic, we
would have expected to see widespread community transmission across
the globe by now and e@orts to slow it down or contain it would not be
feasible,” said Tedros Adhanom, Director-General of WHO.

An author of a working paper from the Department of Ecology and

Evolutionary Biology at Princeton University said, “The current
scientiWc consensus is that most transmission via respiratory
secretions happens in the form of large respiratory droplets … rather
than small aerosols. Droplets, fortunately, are heavy enough that they
don’t travel very far and instead fall from the air after traveling only a
few feet.”

The media was put into a frenzy when the above authors released
their study on COVID-19’s ability to survive in the air. The study did
Wnd the virus could survive in the air for a couple of hours; however,
this study was designed as academic exercise rather than a real-world
test. This study put COVID-19 into a spray bottle to “mist” it into the
air. I don’t know anyone who coughs in mist form and it is unclear if
the viral load was large enough to infect another individual. As one
doctor, who wants to remain anonymous, told me, “Corona doesn’t
have wings”.

To summarize, China, Singapore, and South Korea’s containment

e_orts worked because community-based and airborne transmission
aren’t common. The most common form of transmission is person-to-
person or surface-based.

Common transmission surfaces

COVID-19’s ability to live for a long period of time is limited on most
surfaces and it is quite easy to kill with typical household cleaners,
just like the normal nu.

COVID-19 can be detected on copper after 4 hours and 24 hours

on cardboard.

COVID-19 survived best on plastic and stainless steel, remaining

viable for up to 72 hours

COVID-19 is very vulnerable to UV light and heat.

Presence doesn’t mean infectious. The viral concentration falls

signiWcantly over time. The virus showed a half-life of about 0.8 hours
on copper, 3.46 hours on cardboard, 5.6 hours on steel and 6.8 hours
on plastic.

According to Dylan Morris, one of the authors, “We do not know how
much virus is actually needed to infect a human being with high
probability, nor how easily the virus is transferred from the cardboard
to one’s hand when touching a package”
According to Dr. Auwaerter, “It’s thought that this virus can survive
on surfaces such as hands, hard surfaces, and fabrics. Preliminary
data indicates up to 72 hours on hard surfaces like steel and plastic,
and up to 12 hours on fabric.”

COVID-19 will likely “burn oG” in the summer

Due to COVID-19’s sensitivity to UV light and heat (just like the
normal innuenza virus), it is very likely that it will “burn o_” as
humidity increases and temperatures rise.

Released on March 10th, one study mapped COVID-19 virality

capability by high temperature and high humidity. It found that both
signiWcantly reduced the ability of the virus to spread from person-to-
person. From the study,

“This result is consistent with the fact

that the high temperature and high
humidity signi@cantly reduce the
transmission of inZuenza. It indicates
that the arrival of summer and rainy
season in the northern hemisphere can
e\ectively reduce the transmission of the
 COVID-19.”
The University of Maryland mapped severe COVID-19 outbreaks with
local weather patterns around the world, from the US to China. They
found that the virus thrives in a certain temperature and humidity
channel. “The researchers found that all cities experiencing
signiWcant outbreaks of COVID-19 have very similar winter climates
with an average temperature of 41 to 52 degrees Fahrenheit, an
average humidity level of 47% to 79% with a narrow east-west
distribution along the same 30–50 N” latitude”, said the University of
Maryland.

“Based on what we have documented so

far, it appears that the virus has a harder
time spreading between people in
warmer, tropical climates,” said study
leader Mohammad Sajadi, MD,
Associate Professor of Medicine in the
UMSOM, physician-scientist at the
Institute of Human Virology and a
member of GVN.
In the image below, the zone at risk for a signiWcant community
spread in the near-term includes land areas within the green bands.

As of right now reported cases as a function of latitude, about one-

third of the world’s population is below 22.5°N yet has not
experienced meaningfully high levels of infections.
About 95% of all infections in a latitude band encompassing 55% of
the world’s population, which includes a large portion of America.

Infections as a function of temperature and humidity: 90% still in the

blue zone
Children and Teens aren’t at risk
It’s already well established that the young aren’t particularly
vulnerable. In fact, there isn’t a single death reported below the age of
10 in the world and most children who test positive don’t show
symptoms. As well, infection rates are lower for individuals below the
age of 19, which is similar to SARS and MERS (COVID-19’s sister
viruses).

According to the WHO’s COVID-19 mission in China, only 8.1% of

cases were 20-somethings, 1.2% were teens, and 0.9% were 9 or
younger. As of the study date February 20th, 78% of the cases
reported were ages 30 to 69. The WHO hypothesizes this is for a
biological reason and isn’t related to lifestyle or exposure.

“Even when we looked at households, we

 did not @nd a single example of a child
bringing the infection into the
household and transmitting to the
parents. It was the other way around.
And the children tend to have a mild
disease,” said Van Kerkhove.
According to a WSJ article, children have a near-zero chance of
becoming ill. They are more likely to get normal nu than COVID-19.

A World Health Organization report on China concluded that

cases of Covid-19 in children were “relatively rare and mild.”
Among cases in people under age 19, only 2.5% developed severe
disease while 0.2% developed critical disease. Among nearly
6,300 Covid-19 cases reported by the Korea Centers for Disease
Control & Prevention on March 8, there were no reported deaths
in anyone under 30. Only 0.7% of infections were in children
under 9 and 4.6% of cases were in those ages 10 to 19 years old

Only 2% of the patients in a review of nearly 45,000 conWrmed

Covid-19 cases in China were children, and there were no
reported deaths in children under 10, according to a study
published in JAMA last month. (In contrast, there have been 136
pediatric deaths from innuenza in the U.S. this nu season.)
 About 8% of cases were in people in their 20s. Those 10 to 19
years old accounted for 1% of cases and those under 10 also
accounted for only 1%.

However even if children and teens are not su_ering severe symptoms
themselves, they may “shed” large amounts of virus and may do so for
many days, says James Campbell, a professor of pediatrics at the
University of Maryland School of Medicine.

Children had a virus in their secretions for six to 22 days or an average

of 12 days. “Shedding virus doesn’t always mean you’re able to
transmit the virus”, he notes. It is still important to consider that
prolonged shedding of high viral loads from children is still a risky
combination within the home since the majority of transmission
occurs within a home-like conWned environment.

A strong, but unknown viral eGect

While the true viral capacity is unknown at this moment, it is
theorized that COVID-19 is more than the seasonal nu but less than
other viruses. The average number of people to which a single
infected person will transmit the virus, or Ro, range from as low as 1.5
to a high of 3.0
Newer analysis suggests that this viral rate is declining. According to
Nobel Laureate and biophysicist Michael Levitt, the infection rate is
declining -

“Every coronavirus patient in China

infected on average 2.2 people a day —
spelling exponential growth that can
only lead to disaster. But then it started
dropping, and the number of new daily
infections is now close to zero.” He
compared it to interest rates again: “even
if the interest rate keeps dropping, you
still make money. The sum you invested
does not lessen, it just grows more
slowly. When discussing diseases, it
 frightens people a lot because they keep
hearing about new cases every day. But
the fact that the infection rate is slowing
down means the end of the pandemic is
near.”

What about asymptomatic spread?

The majority of cases see symptoms within a few days, not two weeks
as originally believed.
On true asymptomatic spread, the data is still unclear but increasingly
unlikely. Two studies point to a low infection rate from pre-
symptomatic and asymptomatic individuals. One study said 10% of
infections come from people who don’t show symptoms yet. Another
WHO study reported 1.2% of conWrmed cases were truly
asymptomatic. Several studies conWrming asymptotic spread have
ended up disproven. It is important to note there is a di_erence
between “never showing symptoms” and “pre-symptomatic” and the
media is promoting an unproven narrative. Almost all people end up
in the latter camp within Wve days, almost never the former. It is very
unlikely for individuals with COVID-19 to never show symptoms.
WHO and CDC claim that asymptomatic spread isn’t a concern and
quite rare.

Iceland is leading the globe in testing its entire population of

~300,000 for asymptomatic spread, not just those that show
symptoms. They randomly tested 1,800 citizens who don’t show
symptoms and, as far as they knew, were not exposed to positive
individuals. Of this sample, only 19 tested positive for COVID-19, or
1.1% of the sample.

Obviously, this type of viral spread is the most concerning; however

based on the level of media attention and the global size of positive
infections, it seems more probable we keep looking for a COVID-19
viral trait that doesn’t exist.
Another way of looking at virality and asymptotic spread is the
number of night attendants, airport sta_, or pilots that have tested
positive for COVID-19. Out of the thousands of nights since November
2019, only a handful of airport and airline sta_ have tested positive
(such as AA pilot, some BA sta_, and several TSA employees).

Outside of medical and hospital sta_, these individuals are in greatest

contact with infected persons in conWned spaces. Despite having no
protective gear and most likely these people were asymptomatic,
airline and airport sta_ aren’t likely to catch COVID-19 compared to
the rest of the population. Those employed in the travel sector are
infected at a lower rate than the general population or healthcare
workers.

“We still believe, looking at the data, that

the force of infection here, the major
driver, is people who are symptomatic,
unwell, and transmitting to others along
the human-to-human route,” Dr. Mike
Ryan of WHO Emergencies Program.
If the symptoms are so close to other less fatal coronaviruses, what is
the positivity rate of those tested?
93% of people who think they are positive
aren’t
Looking at the success in S. Korea and Singapore, the important tool
in our war chest is measurement. If we are concerned about the
general non-infected population, what is the probability those who
show symptoms actually test positive? What is the chance that the
cough from your neighbor is COVID-19? This “conversion rate” will
show whether or not you have a cold (another coronavirus) or are
heading into isolation for two weeks. Global data shows that ~95% of
people who are tested aren’t positive. The positivity rate varies by
country.

UK: 7,132 concluded tests, of which 13 positive (0.2% positivity

rate).

UK: 48,492 tests, of which 1,950 (4.0% positivity rate)

Italy: 9,462 tests, of which 470 positive (at least 5.0% positivity
rate).

Italy: 3,300 tests, of which 99 positive (3.0% positivity rate)

Iceland: 3,787 tests, of which 218 positive (5.7% positive rate)

France: 762 tests, of which 17 positive, 179 awaiting results (at

least 2.2% positivity rate).

Austria: 321 tests, of which 2 positive, awaiting results: unknown

(at least 0.6% positivity rate).
 South Korea: 66,652 tests with 1766 positives 25,568 awaiting
results (4.3% positivity rate).

United States: 445 concluded tests, of which 14 positive (3.1%

positivity rate).

In the US, drive-thru testing facilities are being deployed around the
nation. Gov. Cuomo of NY released initial data from their drive-thru
testing. Out of the 600~ that was tested in a single day, ~7% were
positive. Tested individuals actively show symptoms and present a
doctor’s note. This result is similar to public tracking on US
nationwide positivity rate.

University of Oxford’s Our World in Data attempts to track public

reporting on individuals tested vs positive cases of COVID-19. For the
US, it estimates 14.25% of those tested are positive.
Last week, the US was signiWcantly behind in testing, near the bottom
of all countries worldwide. As of March 20th, a week later, the US is
much closer to other G8 and European countries, but there is a long
way to go.
Based on the initial results and the results from other countries, the
total number of positive COVID-19 cases will increase as testing
increases, but the fatality rate will continue to fall and the severity
case mix will fall.

In general, the size of the US population infected with COVID-19 will be

much smaller than originally estimated as most symptomatic
individuals aren’t positive. 93% — 99% have other conditions.
Globally, the US has a long way to go to catch up in testing. As testing
expands, the total number of cases will increase, but the mild to
severe case ratio will decline dramatically.

1% of cases will be severe

Looking at the whole funnel from top to bottom, ~1% of everyone who
is tested for COVID-19 with the US will have a severe case that will
require a hospital visit or long-term admission.

Globally, 80–85% of all cases are mild. These will not require a
hospital visit and home-based treatment/ no treatment is e_ective.
As of mid-March, the US has a signiWcantly lower case severity rate
than other countries. Our current severe caseload is similar to South
Korea. This data has been spotty in the past; however, lower severity
is renected in the US COVID-19 fatality rates (addressed later).

Early reports from CDC, suggest that 12% of COVID-19 cases need some
form of hospitalization, which is lower than the projected severity rate of
20%, with 80% being mild cases.

For context, this year’s nu season has led to at least 17 million medical
visits and 370,000 hospitalizations (0.1%) out of 30–50 million
infections. Recalling that only comparing aggregate total cases isn’t
helpful, breaking down active cases on a per-capita basis paints a
di_erent picture on severity. This is data as of March 20th, 2020.
Declining fatality rate
As the US continues to expand testing, the case fatality rate will
decline over the next few weeks. There is little doubt that serious and
fatal cases of COVID-19 are being properly recorded. What is unclear
is the total size of mild cases. WHO originally estimated a case fatality
rate of 4% at the beginning of the outbreak but revised estimates
downward 2.3% — 3% for all age groups. CDC estimates 0.5% — 3%,
however stresses that closer to 1% is more probable. Dr. Paul
Auwaerter estimated 0.5% — 2%, leaning towards the lower end. A
paper released on March 19th analyzed a wider data set from China
and lowered the fatality rate to 1.4%. This won’t be clear for the US
until we see the broader population that is positive but with mild
cases. With little doubt, the fatality rate and severity rate will decline
as more people are tested and more mild cases are counted.

Higher fatality rates in China, Iran, and Italy are more likely
associated with a sudden shock to the healthcare system unable to
address demands and doesn’t accurately renect viral fatality rates. As
COVID-19 spread throughout China, the fatality rate drastically fell
outside of Hubei. This was attributed to the outbreak slowing
spreading to several provinces with low infection rates.

John P.A. Ioannidis is professor of medicine, of epidemiology and

population health, of biomedical data science, and of statistics at
Stanford University and co-director of Stanford’s Meta-Research
Innovation Center recently wrote about fatality rates and how our
current instrumentation is leading to faulty policy solutions:

“The one situation where an entire, closed population was tested was the
Diamond Princess cruise ship and its quarantine passengers. The case
fatality rate there was 1.0%, but this was a largely elderly population, in
which the death rate from Covid-19 is much higher.

Projecting the Diamond Princess mortality rate onto the age structure of
the U.S. population, the death rate among people infected with Covid-19
would be 0.125%. But since this estimate is based on extremely thin data
— there were just seven deaths among the 700 infected passengers and
crew — the real death rate could stretch from ^ve times lower (0.025%)
to ^ve times higher (0.625%). It is also possible that some of the
passengers who were infected might die later, and that tourists may have
di@erent frequencies of chronic diseases — a risk factor for worse
outcomes with SARS-CoV-2 infection — than the general population.
Adding these extra sources of uncertainty…”

“Reasonable estimates for the case

fatality ratio in the general U.S.
population vary from 0.05% to 1%.”
Looking at the US fatality, the fatality rate is drastically declining as
the number of cases increases, halving every four or Wve days. The
fatality rate will eventually level o_ and plateau as the US case-mix
becomes apparent.

4.06% March 8 (22 deaths of 541 cases)

3.69% March 9 (26 of 704)

3.01% March 10 (30 of 994)

2.95% March 11 (38 of 1,295)

2.52% March 12 (42 of 1,695)

2.27% March 13 (49 of 2,247)

1.93% March 14 (57 of 2,954)

1.84% March 15 (68 of 3,680)

1.90% March 16 (86 of 4,503)

1.76% March 17 (109 of 6,196)

1.66% March 18 (150 of 9,003)

1.51% March 19th (208 of 13,789)

1.32% March 20th (256 of 19,383)

Source: Worldometers.info

Mapped against other countries, our fatality rate and case-mix are
following a similar pattern to South Korea which is a good sign, a
supposed model of how to manage COVID-19.
Here are deaths weighted by the total number of cases as of March
20th, 2020. Ranked by the total number of cases, our death rate is
closer to South Korea’s than Spain’s or Italy’s.

The initial higher fatality rate for the US is trending much lower than
originally estimated. A study of about half deaths within the US (154
of 264), almost all Wt a similar demographic proWle as the other global
~11,000 fatalities.
Another analysis by Nature, comparing the fatality rate (since revised
down) and infectious rate of COVID-19 to other illnesses. COVID-19 is
now within range of its less potent sister coronaviruses.
As the global health community continues to gather and report data,
the claim that “COVID-19 isn’t just like the nu” (though still severe) is
looking less credible as fatality rates continue to decline and
measuring of mild cases increases.

It is important to consider case-mix when looking at fatality rates. The

fatality rate is signiWcantly higher for patients with an underlying
condition.
The fatality rates by underling condition mimics the rise in the
average fatality rate with those with underlying conditions who get
the seasonal nu.

Pneumonia and innuenza: 1.53% — 1.93%

Chronic lower respiratory disease: 1.48% — 1.93%

All respiratory causes: 3.04% — 4.14%

Heart disease: 3.21% — 4.4%

Cancer: 0.68% — 1.05%

Diabetes: 0.26% — 0.39%

For all underlying conditions: 10.17% — 13.67%.

Comparing case-mix across countries with a wide range of fatality

(China and Italy) and those with low fatality rates (S. Korea) reveals a
stark di_erence in age; therefore, underlying conditions also vary
signiWcantly across countries. These two factors contribute the most
to a country’s fatality rate.

Source: Goldman Sachs

Divided by most at risk and low risk, Italy had signiWcantly more cases
of high at-risk patients than Germany or Korea
Source: https://medium.com/@andreasbackhausab/coronavirus-why-its-so-deadly-
in-italy-c4200a15a7bf

Based on an initial CDC study of 2,449 COVID-19 cases (almost half

of current US cases have missing demographic data), the United
States case-mix looks more like S. Korea and Germany rather than
China or Italy. Approximately 69% of COVID-19 cases are in the lower
at-risk population of under 65, while 31% are older than 65 and in
the higher-risk population. This suggests the US will experience a
declining fatality rate; however, the US has over 100 million adults
with underlying and chronic illnesses that will negatively impact our
fatality rate.
An older population skew within the infected population explains
most of the disparity in fatality rates between high and low countries.
According to a study of the fatalities of COVID-19 cases in Italy, 99%
of all deaths had an underlying pathology. Only 0.8% had no
underlying condition.
Most of those infected in Italy were over the age of 60, but the median
age of a fatality was 80. All of Italy’s fatality under the age of 40 were
males with serious pre-existing medical conditions.

This doesn’t factor in a wide variance in healthcare capacity, such as

hospital beds per 1,000 citizens which could a_ect health outcomes;
however, this doesn’t seem to be highly correlated with fatality rates
at this moment.

S. Korea — 11.5
 Germany — 8.3

China — 4.2

Italy — 3.4

United States — 2.9

Singapore — 2.4

So what should we do?

The ^rst rule of medicine is to do no harm.

Local governments and politicians are innicting massive harm and

disruption with little evidence to support their draconian edicts.
Every local government is in a mimetic race to one-up each other in
authoritarian city ordinances to show us who has more “abundance of
caution”. Politicians are competing, not on more evidence or more
COVID-19 cures but more caution. As unemployment rises and
families feel unbearably burdened already, they feel pressure to “Wx”
the situation they created with even more radical and “creative”
policy solutions. This only creates more problems and an even larger
snowball e_ect. The Wrst place to start is to stop killing the patient and
focus on what works.

David L. Katz MD & MPH, the founding director Yale University’s Yale-
Grisn Prevention Research Center and the past-president of the
American College of Lifestyle Medicine, writes for NY Times,
 First, the medical system is being
overwhelmed by those in the lower-risk
group seeking its resources, limiting its
capacity to direct them to those at
greatest need. Second, health
professionals are burdened not just with
work demands, but also with family
demands as schools, colleges and
businesses are shuttered. Third, sending
everyone home to huddle together
increases mingling across generations
that will expose the most vulnerable.

Start with basic hygiene

The most e_ective means to reduce spread is basic hygiene. Most
American’s don’t wash their hands enough and aren’t aware of how to
actually wash your hands. Masks aren’t particularly e_ective if you
touch your eyes with infected hands. Ask businesses and public places
to freely distribute disinfectant wipes and hand sanitizer to the
customers and patrons. If you get sick or feel sick, stay home. These
are basic rules for preventing illness that doesn’t require trillions of
dollars.

More data
The best examples of defeating COVID-19 requires lots of data. We are
very behind in measuring our population and the impact of the virus
but this has turned a corner the last few days. The swift change in
direction should be applauded. Private companies are quickly
developing and deploying tests, much faster than CDC could ever
imagine. The inclusion of private businesses in developing solutions is
creative and admirable. Data will calm nerves and allow us to utilize
more evidence in our strategy. Once we have proper measurement
implemented (the ability to test hundreds every day in a given metro),
let’s add even more data into that funnel — reopen public life.

Taiwan is held up as a model for its approach. They embraced both

data, tracking, free movement of people, evidence-based prevention,
and focused their energy on those most vulnerable — preexisting
conditions and those over the age of 65. Here are some of the steps
they took:

QR code scanning and online reporting of each person’s travel

history

Health symptoms were used to classify traveler infectious risks

based on night origin and travel history in the past 14 days

People with low risk were sent a health declaration border pass
 via SMS to their phones for faster immigration clearance

Those with higher risk were quarantined at home and tracked

through their mobile phone to ensure that they remained there
during the incubation period

Taiwan also proactively seeks out patients with severe respiratory

symptoms (based on information from a national health
database) to see who had tested negative for innuenza so that
they could be retested for COVID-19

Open schools
Closing schools is counterproductive. The economic cost for closing
schools in the U.S. for four weeks could cost between $10 and $47
billion dollars (0.1–0.3% of GDP) and lead to a reduction of 6% to
19% in key health care personnel.
CDC’s guidance on closing schools speciWcally for COVID-19 -

Available modeling data indicate that early, short to medium closures do

not impact the epi curve of COVID-19 or available health care measures
(e.g., hospitalizations). There may be some impact of much longer
closures (8 weeks, 20 weeks) further into community spread, but that
modeling also shows that other mitigation e@orts (e.g., handwashing,
home isolation) have more impact on both spread of disease and health
care measures. In other countries, those places who closed school (e.g.,
Hong Kong) have not had more success in reducing spread than those
that did not (e.g., Singapore).

Based on transmission evidence children are more likely to catch

COVID-19 in the home than at school. As well, they are more likely to
expose older vulnerable adults as multi-generational homes are more
common. As well, the school provides a single point of testing a large
population for a possible infection in the home to prevent community
spread.

Open up public spaces

With such little evidence of proliWc community spread and our
guiding healthcare institutions reporting the same results, shuttering
the local economy is a distraction and arbitrary with limited accretive
gain outside of greatly annoying millions and bankrupting hundreds
of businesses. The data is overwhelming at this point that community-
based spread and airborne transmission is not a threat. We don’t have
signiWcant examples of spreading through restaurants or gyms. When
you consider the environment COVID-19 prefers, isolating every
family in their home is a perfect situation for infection and
transmission among other family members. Evidence from South
Korea and Singapore shows that it is completely possible and
preferred to continue on with life while making accommodations that
are data-driven, such as social distancing and regular temperature
checks.

Support business and productivity

The data shows that the overwhelming majority of the working
population will not be personally impacted, both individually or their
children. This is an unnecessary burden that is distracting resources
and energy away from those who need it the most. By preventing
Americans from being productive and specializing at what they do
best (their vocation), we are pulling resources towards unproductive
tasks and damaging the economy. We will need money for this Wght.

At this rate, we will spend more money on “shelter-in-place” than if we

completely rebuilt our acute care and emergency capacity.
 Source: https://www.macrobond.com/posts/blog-central-banks-go-big-covi-19-
market-crash-crisis/

Americans won’t have the freedom to go help those who get sick,
volunteer their time at a hospital, or give generously to a charity.
Instead, big government came barrelling in like a bull in a china shop
claiming they could solve COVID-19. The same government that
continued to not test incoming passengers from Europe and who
couldn’t manufacture enough test kits with two months' notice.

Let Americans be free to be a part of the solution, calling us to a

higher civic duty to help those most in need and protect the
vulnerable. Not sitting in isolation like losers.

People fear what the government will do, not an infection

Rampant hoarding and a volatile stock market aren’t being driven by
COVID-19. An overwhelming majority of American’s don’t believe
they will be infected. Rather, hoarding behavior strongly
demonstrates an irrational hysteria, from purchasing infective
household masks to buying toilet paper in the troves. This fear is
being driven by government action, fearing what the government will
do next. In South Korea, most citizens didn’t fear infection but the
government and public shaming. By presenting a consistent and clear
plan that is targeted and speciWc to those who need the most help will
reduce the volatility and hysteria. A sign the logic behind these
government actions aren’t widely accepted, nor believed as rational
by the American people is the existence itself of the volatility and
hysteria. Over three-fourths of Americans are scared not of COVID-19
but what it is doing to our society.

In CDC’s worst-case scenario, CDC expects more than 150–200

million infections within the US. This estimate is hundreds of times
bigger than China’s infection rate (30% of our population compared
to 0.006% in China). Does that really sound plausible to you? China
has a sub-par healthcare system, attempted to suppress the news
about COVID-19 early on, a lack of transparency, an authoritarian
government, and millions of Chinese traveling for the Lunar Festival
at the height of the outbreak. In the US, we have a signiWcant lead
time, several therapies proving successful, transparency, a top tier
healthcare system, a democratic government, and media providing
ample accountability.

Infection isn’t our primary risk at this point.

Expand medical capacity

COVID-19 is a signiWcant medical threat that needs to be tackled by
both Wnding a cure and limiting spread; however, some would argue
that a country’s authoritarian response to COVID-19 helped stop the
spread. Probably not. In South Korea and Taiwan, I can go to the gym
and eat at a restaurant which is more than I can say about San
Francisco and New York, despite a signiWcantly lower caseload on a
per-capita basis.

None of the countries the global health authorities admire for their
approach issued “shelter-in-place” orders, rather they used data,
measurement,and promoted common sense self-hygiene.

Does stopping air travel have a greater impact than closing all
restaurants? Does closing schools reduce the infection rate by 10%?
Not one policymaker has o_ered evidence of any of these approaches.
Typically, the argument given is “out of an abundance of caution”. I
didn’t know there was such a law. Let’s be frank, these acts are
emotionally driven by fear, not evidence-based thinking in the process
of destroying people’s lives overnight. While all of these decisions are
made by elites isolated in their castles of power and ego, the shock is
utterly devastating Main Street.

A friend who runs a gym will run out of cash in two weeks. A friend
who is a pastor let go of half of his sta_ as donations fell by 60%. A
waitress at my favorite breakfast place told me her family will have no
income in a few days as they force the closure of restaurants. While
political elites twiddle their thumbs with models and projections
based on faulty assumptions, people’s lives are being destroyed with
Marxian vigor. The best compromise elites can come up with is
$2,000.

Does it make more sense for us to pay a tax to expand medical capacity
quickly or pay the cost to our whole nation of a recession? Take the
example of closing schools which will easily cost our economy $50
billion. For that single unanimous totalitarian act, we could have built
50 hospitals with 500+ beds per hospital.

Eliminate arcane certiWcate of need and expand acute medical

capacity to support possible higher healthcare utilization this season.

Don’t let them forget it and vote

These days are precarious as Governors noat the idea of martial law
for not following “social distancing”, yet violating those same rules in
their press conferences. Remember this tone is for a virus that has
impacted 0.004% of our population. Imagine if this was a truly
existential threat to our Republic.

The COVID-19 hysteria is pushing aside our protections as individual

citizens and permanently harming our free, tolerant, open civil
society. Data is data. Facts are facts. We should be focused on
resolving COVID-19 with continued testing, measuring, and be
vigilant about protecting those with underlying conditions and the
elderly from exposure. We are blessed in one way, there is an election
in November. Never forget what happened and vote.

. . .
You may ask yourself. Who is this guy? Who is this author? I’m a
nobody. That is also the point. The average American feels utterly
powerless right now. I’m an individual American who sees his
community and loved ones being decimated without given a choice,
without empathy, and while the media cheers on with high ratings.

When this is all over, look for massive conWrmation bias and pyrrhic
celebration by elites. There will be vain cheering in the halls of power
as Main Street sits in pieces. Expect no apology, that would be
political suicide. Rather, expect to be given a Jedi mind trick of “I’m
the government and I helped.”

The health of the State will be even stronger with more Americans
dependent on welfare, another trillion stimulus Wlled with pork for
powerful friends, and a bailout for companies that charged us $200
change fees for nearly a decade. Washington DC will be Wne. New
York will still have all of the money in the world. Our communities
will be left with nothing but a shadow of the longest bull market in
the history of our country.

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