COVID-19: A best-case scenario

Opinion: When it comes to COVID-19, we need to prepare for the worst. But there are also reasons for optimism, writes the Faculty of Medical and Health Sciences' Robert Bartholomew.

COVID-19 has the world on edge. Without question, there have been widespread instances of public over-reaction, from panic buying of surgical masks and canned goods to the hoarding of toilet paper, and the rampant spread of wild rumors and conspiracy theories based on the flimsiest of evidence.

In this time of crisis, we need to trust our health authorities and politicians. Their advice on social distancing is essential to slowing the spread. But understand, they have taken a worst-case scenario approach. One U.S. Government report even suggests that we may be in crisis mode for 12 to 18 months as we stave off wave after wave of COVID-19 outbreaks. But amid the apocalyptic scenarios, the situation may not be as dire.

The central issue in understanding the outbreak is figuring out the mortality rate. In Germany, it is exceptionally low—0.3 percent at the time of this writing, while Italy is around 8 percent. This is a massive disparity. There hasn’t been sufficient testing to accurately gauge the mortality rate because we don’t have enough tests to know how many people have been infected. As testing ramps up, the mortality rates may fall, as 4 out of every 5 people are spreading the virus without even knowing they have it—their symptoms are mild or they have none.

There is credible evidence that the mortality rate is significantly lower than what has been reported. A study published on March 19 in Nature Medicine found that the death rate in Wuhan was 1.4 percent. Early in the outbreak, the World Health Organization placed the figure at 5.8 percent. One early study even had the rate at 12 percent.  

There are several reasons why the new study of Wuhan patients is significant: It did not include people who were asymptomatic.

Other factors will further influence mortality rates:

Poor healthcare

Comparing China to other Western countries is not a straightforward exercise because it has an inferior healthcare system and significantly higher rates of people dying of secondary infections compared to the West.

The smoking epidemic

China has the largest population of smokers in the world—over 40 percent of adult Chinese males smoke, while the rate is under 3 percent for adult females. Smoking elevates your risk for numerous health problems, and pre-existing conditions play a big part in the mortality rate for COVID-19. One Chinese study of 78 patients who were suffering from Coronavirus-related pneumonia found that the likelihood of the disease progressing was 14 times higher in those with a history of smoking.

Breathing polluted air

China also has a huge air pollution problem. Recently, it was so bad in Wuhan that protests broke out. Many people in China have lung problems when compared to the West, and hence, compromised health.

What about Italy?

While the images from Italy are alarming, 92 percent of deaths are in the north, which has some of the most polluted air in Europe. Before the outbreak, a leading environmental scientist described air pollution in the region as “frightening” and “alarming”. It may be no coincidence that the three areas hit particularly hard at this time, in China, Italy, and Iran—have some of the worst air pollution on the planet. Residents in Hubei Province where Wuhan is, and in the city of Tehran, often breathe in the equivalent of a pack of cigarettes a day.

Another factor affecting the mortality rate in Italy involves health reporting protocols. Professor Walter Ricciardi, an advisor to the Italian Health Ministry, observes that the high death rates there may reflect the way that deaths are recorded. “The way in which we code deaths in our country is very generous in the sense that all the people who die... with the coronavirus are deemed to be dying of the coronavirus,” he has said. “On re-evaluation by the National Institute of Health, only 12 percent of death certificates have shown a direct causality from coronavirus, while 88 percent of patients who have died have at least one pre-morbidity—many had two or three”. Pre-morbidity refers to having serious health issues prior to the onset of a disease.  

The spread of infection could also be much higher in Italy because of the custom of kissing people on their cheeks when meeting. Italy also has one of the oldest populations in the world, with the country's average age of death from Coronavirus at 81. Yet another factor contributing to the situation in Italy is the prominence of the country's anti-vaccination movement, as elderly Italians who have been fighting off the flu would also be at greater risk of dying of COVID-19. In one recent study of 83,000 elderly residents in Northern Italy, just 50 percent had been vaccinated for flu.  

The key to understanding the impact from this epidemic hinges on the mortality rate. No one knows what it is, but there is significant evidence that it will be lower than has been forecast. That is reason for optimism.

Robert Bartholomew is an Honorary Academic in the Department of Psychological Medicine within the University of Auckland's School of Medicine. He specialises in social panics, popular delusions and mass suggestion.

This article reflects the opinion of the author and not necessarily the views of the University of Auckland.

Used with permission from Psychology Today, COVID-19: A Best-Case Scenario, 24 March 2020.

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