The media are filled with news about the covid-19 pandemic that is spreading across the globe, and leaving millions infected and nearly three hundred thousand dead in its wake.
There is no end in sight. In an effort to save lives, governments throughout the world have enacted a variety of measures that have had a profound effect on the economies of their countries and on the daily lives of their citizens. This is doubly true for the United States, which leads the world in covid infections and deaths. In the absence of an effective treatment or vaccine for the virus, the only measures that have been proposed have been social distancing, wearing masks, and thorough hand washing.
Because of the profound economic disruption that social distancing has caused in the United States and in other countries, not to speak of the personal hardships endured by its citizens, other approaches to dealing with the pandemic have been proposed that would seek to mitigate the economic hardship while allegedly saving lives.
In a situation like this, where literally millions of lives are affected by government policies that deal with the pandemic, it is critically important to deal with the medical and epidemiologic facts in as objective a way as possible rather than be influenced by political or ideological biases. And although there is much that we do not yet know about this utterly devastating virus and its epidemiology, there is enough information both from the current pandemic and from the last major global pandemic of the 1918 Spanish flu so that fact-based proposals can be made and misinformation rebutted.
Question: Does social distancing save lives?
Answer: Most definitely yes. Probably the most important lesson to be learned from the 1918 Spanish flu pandemic, which took approximately 30 to 40 million lives across the globe and 675,000 deaths in the United States, was the efficacy of social distancing. Philadelphia conducted business as usual and was overwhelmed by the epidemic, suffering one of the nation’s highest death rates. Seattle quarantined a nearby army camp where the flu was present, and the city was placed in lockdown that continued for two months. When the restrictions were eased, the disease returned. Seattle suffered one of the lowest death rates on the West Coast and had substantially fewer deaths than Philadelphia. In general, the stricter the isolation policies, the lower the mortality rate.
Nancy Bristow, professor of history at the University of Puget Sound and the author of a book on the 1918 pandemic, writes: “early, sustained, and layered imposition of interventions such as social distancing worked in 1918, slowing the pandemic’s pace and lowering death rates.” Never has George Santayana’s aphorism been more relevant. He said: “Those who cannot remember the past are condemned to repeat it.”
It is no coincidence that Orthodox communities in Boro Park and Williamsburg in Brooklyn and Bnei Brak in Israel suffered disproportionate numbers of covid infections and deaths compared to surrounding communities. In large part this has been due to the crowded conditions in which those people live and the reluctance, at least at first, to call off community religious celebrations and prayers.
It is to the great and lasting credit of the Rabbinic Council of Bergen County that it cancelled community religious activities very early, at the advice of health officials. The early imposition by the RCBC of social distancing — often to harsh criticism by those who felt it was an overreaction — unequivocally saved lives and saved many people from becoming ill with this virus.
In short, social distancing works, and it is one of the most powerful weapons against this scourge. The real question is not whether it and an associated economic lockdown work, but how to target these measures appropriately and balance the substantial economic harms they inflict while trying to save the most lives.
Question: Is the Swedish model of a minimalist approach to social distancing one that the United States should emulate?
Answer: No. While many people favorably cite the Swedish model of far more loose social distancing with the goal of establishing “herd immunity” and minimizing social unrest, they often omit the correlative fact that it leads to significantly more deaths than in surrounding countries with stricter social distancing.
Consider the following: Sweden’s population is roughly double that of Norway’s and Denmark’s, which have strict social distancing. With a population only double that of Norway and Denmark, Sweden has 14.7 times the number of deaths from covid than Norway, and 6 times the number of deaths as Denmark. As if to mitigate this damning statistic, proponents of the Swedish model stress that 40 percent of the deaths in Sweden are among patients older than 80, implying that allowing the virus to cull the elderly justifies the economic benefit. Furthermore, Swedish economists feel that it is unclear whether Sweden’s economy ultimately will benefit from the looser lockdown.
Lest it be assumed that covid spares the young, data in the United States show a different picture. Early CDC data showed that nearly 40 percent of patients who were hospitalized in the United States were under 55, and 20 percent were between 20 and 44.
Question: What is the mortality rate of covid-19?
Answer: We don’t really know as yet. The mortality rate of an infectious disease — meaning its lethality — is the total number of deaths it causes divided by the total number of people infected with the pathogen. For seasonal influenza the mortality rate is probably less than 0.1 percent. We do not know the actual mortality rate of covid-19, but it is clearly significantly lower than original estimates based on data from China. That is because the number of people infected with the virus is far greater, probably by orders of magnitude, than the reported cases, given the fact that many people are minimally symptomatic when infected and do not report for testing. In the United States, such data is further compromised by the pathetically low number of covid tests that are available.
Accepting the fact that the covid mortality rate is almost certainly much lower than the 3 to 5 percent originally reported, it is extraordinarily contagious, much more so than ordinary influenza. So even assuming a much lower mortality rate that originally projected, the number of people infected now and likely to be infected in the future in the United States is so great that the absolute number of deaths are and will continue to be extremely high.
In my 52 years as a physician, I have never seen anything approaching the carnage of deaths that afflicted New York City in March and April of this year. Even in the worst days of the 1957 H2N2 flu epidemic, the AIDS epidemic, or the 2009 H1N1 flu epidemic, nothing approached the tidal wave of sick and dying patients that inundated New York City’s hospitals this spring. And there is a real possibility that a second or even a third wave of sick and dying patients will once again occur in NYC when the lockdown is relaxed, not to speak of the havoc it may wreak in the rest of the country.
Bottom line: no matter how low the true mortality rate of covid is, its extreme contagiousness and its lethality for an extremely large number of people make it the deadliest epidemic in the United States in the past century.
Question: What is to be done?
Answer: Most importantly, we as a society must face the true facts, both medical and economic. Unfortunately, social media thrives on lies and distortions; the greater the lies, the greater, it seems, the “viral” spread. Truth is less sensational than headline-grabbing falsehoods and fanciful tweets. But unless we emerge from a dream world of false cures, wrong data, and conspiratorial plots, we will end up dealing with this plague in a chaotic and irrational way that will kill both lives and the economy. We need rational, courageous, and informed leadership on a national, state, and local level that will recruit the best minds in all the relevant disciplines if we are to get through this with the least damage.
For the foreseeable future and until we get an effective vaccine and/or successful treatment for the covid virus, we must do the following: have states and localities continue social distancing until objective CDC safety guidelines are met that will allow relaxation in stages; greatly increase our ability to test and trace for the virus, especially among vulnerable populations, so as to quarantine those infected as well as their contacts for an appropriate period of time; vastly increase the supply of personal protective equipment to protect healthcare workers and others who care for people in hospitals, nursing homes, prisons and shelters; form a national covid taskforce consisting of the finest minds in the various disciplines impacted by the pandemic that will oversee the gradual, targeted, science-based opening up of our economy and schools, and coordinate on a national level the purchasing and distribution of resources needed to deal with the inevitable surges of disease in the coming months and possibly years. This taskforce should provide briefings to the U.S. public on a regular basis, free of political interference.
It is clear that despite reassurances from the president, it is overwhelmingly likely, based on experience with past epidemics and the best science available, that unless there is an effective vaccine or treatment for covid in the near future, the United States and the world are in for a long and difficult battle with the virus. Formulating rational policies that balance the real and profound economic harm of lockdowns and the goal of saving as many lives as possible is an excruciatingly difficult task. Anyone who proposes an easy fix is delusional. And we must keep in mind that most people would rather lose their jobs than lose their lives.
We all know that the principle of pikuach nefesh, the need to preserve a single life, overrides virtually every commandment in the Torah. The covid-19 pandemic is pikuach nefesh on a global scale unseen in more than a century. Thankfully we live in a country based on a Judeo-Christian ethic that emphasizes the sanctity of life. Hopefully this value will continue to be uppermost in the minds of policymakers as they proceed on the tortuous road of devising polices to protect the lives and the livelihoods of American citizens in the difficult months and perhaps years that lie ahead.