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May 1st, 2020
“There are lies, damn lies, and COVID-19 statistics”
Johan Norberg
The term quarantine comes from a venetian word meaning “forty days” which was the number of days in which ships and people had to be isolated before being admitted to the Republic of Venice in Medieval times in order to be sure that they were not infected by deadly infectious diseases, such as the Plague, Cholera, Syphilis, or Yellow Fever.
In Bolivia we are nearing our forty days of “reverse quarantine” (keeping the healthy people locked up, in order to prevent them from getting infected by an external threat).
This reverse quarantine has bought us some time to get to understand the novel SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Corona Virus No. 2), and the COVID-19 disease it is causing. Initial data out of China and Italy was so scary that it was worth the high costs to buy us some time to formulate a strategy on how to deal with the threat, and prepare the population and the health system to manage it as well as possible. We have very little data from Bolivia, but since this is a global pandemic, we can learn a lot from other countries, despite extremely flawed data.
A few basic things have become clear:
- The SARS-CoV-2 virus has infected people in pretty much every country and territory on the planet, so suppression and eradication of the virus is unfortunately no longer a realistic option (1);
- Many people who catch the virus have no symptoms, which is why this virus has managed to spread so easily across the globe (2).
- There is no previous immunity, nor any treatment available (3), so the virus will not go away until we have achieved herd immunity, either through vaccination, or by 60-70 percent of the population having been infected (4);
- Although many potential vaccines have been developed in record time, they have to be tested for safety and efficacy, which means that vaccines at a global scale will not be available for at least another 12 months. By the time a safe and effective vaccine becomes available for billions of people, it may not be needed any more (5);
- The Infection Fatality Rate (IFR) is likely to be somewhere between 0.1% and 10%, depending on the health of the population, the age composition of the population, the quality of the health care system, the policies enacted to confront the problem, and possibly the type of the virus that dominates, because there seem to be different strains circulating already (6). It is clear that men are more likely to die than women, older people are far more likely to die than younger people, and people with underlying health problems, especially hypertension, obesity and diabetes, are more likely to die (7).
Given these facts, it is clear that we are facing some difficult decisions. Short of simultaneously locking up everybody on the planet for many months, there is no way we can prevent that millions of people will die from COVID-19. In the absolute best case scenario (IFR like the common flu at 0.1% and 60% of the world population getting infected), we will see 4.2 million people die from this disease, and we should consider ourselves very lucky if that is the number we converge towards over the next 24 months. More likely, there will be at least 5 times more deaths than that, meaning at least 20 million people will die. So far, only about a quarter of a million have died, so the world is still in the very early stages of the pandemic (98% still to come).
How are we doing in Bolivia?
In Bolivia, we have barely started the process, because we locked down early and thoroughly. To date we have only 62 confirmed COVID-19 deaths, out of a minimum of 7,000 and a maximum of 800,000 to be expected. That is a frustratingly large range, and it is difficult to make wise decisions until we narrow down the likely path of this epidemic. The whole point of locking down is to obtain more information and figure out which end of the range is most likely, and thus which kind of policies are appropriate to get us through this pandemic.
In a normal year, about 24,100 people die from all causes in Bolivia. In the absolute best case scenario, this virus would kill off 6,600 old and frail people who would have died from other causes this year anyway, thus implying no excess mortality. Unfortunately, we already know that this best case scenario will not play out, because among the first to die of COVID-19 in Bolivia were a pregnant nurse, and several otherwise healthy people below 70 years of age.
How bad is it going to be?
We have waited for 40 days in order to rule out the worst case scenario, which would be a 10% IFR. The original data coming out of Wuhan suggested that 20% of infected people would need hospital care in order to survive, and that almost 4.9% of infected people died anyway. Also, of more than 1 million closed cases to date worldwide, 18% have died (8). However, recent antibody tests carried out in California (9), Germany (10), Denmark (11), and the Netherlands (12) suggest that many people have been infected without any symptoms, which means that the true number of infections is several times higher than the confirmed cases, implying that the IFRs are much lower than the official Case Fatality Rates (CFR = Deaths/Confirmed Cases) suggest.
In the USA, the New York State recently carried out random anti-body testing on 3,000 individuals to figure out how many people had really been infected, and they found that 13.9% of the population, or about 2.7 million people in the state, had already been infected at a time when “only” 19,453 COVID-19 deaths had been registered. This suggests an IFR in New York state of around 0.72%, or a little bit higher, since some of these infected people are still critically ill and more will unfortunately die (13).
Of course, New York is one of the richest places on the planet, so their IFR may not be relevant for Bolivia. Data from Peru is probably more relevant here, and fortunately Peru has somehow managed to carry out more than 300,000 tests, while Bolivia has only done around 6,000. In Peru, more than 37,000 people have been confirmed to have the virus, but only 2.8% of confirmed cases have died so far (8). However, Peru, like all other countries, has limited testing capacity, so in reality there will be many more infected, and thus the IFR will be a lot lower.
With the still very incomplete information available at the moment, I estimate that we will end up with an IFR of around 1% for Bolivia (meaning anywhere between 0.3% and 2%, given the still high uncertainty). If 60% of 11.6 million people get infected, and 1% of those die, we would end up with about 70 thousand COVID-19 deaths in Bolivia. The number could be lower if a vaccine becomes available before we reach herd immunity through infection, but I consider that unlikely (5). The good news is that more than 11 million Bolivians will not die from COVID-19.
Proportionate interventions
We are facing an undeniably difficult situation, like all other countries. What we definitely have to make sure is not to make things even worse than they have to be. 70,000 dead people is bad. But these people dying alone, shunned and isolated in designated COVID hospitals, without family, friends and funerals, seems much worse. If at the same time even more people are losing their livelihoods, their investments and their dreams due to quarantine, that would be awful. If children start dying from hunger because their parents are not allowed to work (14), it would be a full-blown disaster. If we lose our basic human rights and freedoms, and we cannot see and hug our loved ones for years (15), that is simply an unbearable thought.
Thus, we have to make sure our interventions are well thought through and based on the best evidence possible. We are lucky that our country got infected relatively late (first confirmed case on the 10th of March, 2020), and we managed to keep numbers low for the first couple of months through strict quarantine measures, which means we got the gift of time to enable us to learn from good and bad experiences in other countries, and from all the new scientific research that is coming out to help us understand our options better.
Flattening the curve is clearly necessary
I am not suggesting that we should flatten the curve so that our health care system does not get overwhelmed, because it got overwhelmed by the very first patient (16). But I do suggest we flatten the curve enough to make sure that we can physically, mentally and socially handle every diseased person in a dignified manner. If we do not spread our expected 70,000 deaths out as evenly as possible over at least a year, we will experience the horrors of dead bodies piling up in the streets, like we are seeing in Guayaquil in Ecuador (17). If we could spread our expected 70,000 deaths perfectly evenly over the next 12 months, we would have around 1,350 COVID-19 deaths per week. Hopefully some of these would have died from other causes anyway, but it is clear that we have to be prepared to increase our funeral capacity, because Bolivia is used to handle only about 1,300 deaths per week from all causes.
What does successful management of a global pandemic look like?
Ideally, we should have nipped this epidemic in the bud, like we managed to do with the first SARS outbreak in 2003, the MERS outbreak in 2012, the Ebola outbreak in 2014, and hopefully most future similar outbreaks. However, this time the world screwed up big time, and with millions of people being infected all over the globe, eradication is just not realistic anymore. A few rich island nations may be able to test, trace and isolate cases and keep it under control until a vaccine is available, but for most of the world’s countries, including Bolivia, that is just not a realistic aspiration.
My criteria for success are much less ambitious: If less than 0.6% of the population die from COVID-19 within the next 12 months, and if the unfortunate 0.6% die with loved-ones holding their hands, and family members and close friends get the opportunity to pay their respects and process their losses, and if the economy contracts less than 5% (a setback of less than 2 years), then I would consider that a successful management of an unescapable pandemic with no known cures available.
How do we successfully manage this epidemic?
The key is avoiding huge and unmanageable spikes in deaths. That will require carefully calibrated social distancing measures.
Some “easy” social distancing measures should be implemented by everybody at all times until this pandemic is over:
- No kissing, hugging and handshaking, but try to be kind to everybody anyway;
- No unnecessary gatherings of a lot of people, meaning no sports events, no concerts, no carnivals, no festivals, no graduation events, and no religious gatherings; but try to have fun in new creative ways;
- Maintain a 2-metre distance from strangers, interact with as few different people as possible, and wear a mask if you have to be close to them;
- Avoid touching surfaces that a lot of other people touches, and wash your hands thoroughly after touching a potentially infected surface;
- Work and study from home as much as possible, and limit interactions to as few different people as possible.
- When work from home is not possible, implement flexible working hours and staggered work schedules to reduce peak occupancy in public transportation systems and work places.
These simple measures substantially reduce infection rates, but they may not be enough. Even tougher measures may be necessary in certain locations if infections spike for some reason.
Monitoring of outbreaks
In order to know when tougher measures are necessary, we need extremely good monitoring of the epidemic. Ideally, we would have massive testing capacity like Iceland or South Korea, but Bolivia has the lowest testing capacity in South America at less than 1 in a thousand people (18), and we have to be realistic about what is actually feasible.
There are two alternative options that could provide us with valuable information in real time about how the pandemic is evolving:
- A daily symptom tracker app on our phones, which could alert authorities to a local outbreak, and help individuals get the help they need. A simple such app exists in the UK, and much more elaborate apps are used in many places in Asia (19). It is trickier in Bolivia, as it requires high levels of trust in the government, and the population would need to perceive concrete benefits of using the app. For example, it could be linked to a generous donation of free phone minutes and Internet access, telemedicine consultations, free medicine delivery, and more. Such an app would be technically relatively easy to develop, but it would require serious thoughts on how to get a large share of the population to trust and use the app daily.
- A less demanding option is to monitor weekly deaths from all causes at a sub-national (ideally municipal) level, so as to alert us if any region is beginning to spike, and would therefore need to implement stricter social distancing measures and receive more support from the central government. EuroMOMO would be a good model for this (20).
Both of these options would be much less expensive and damaging than shutting down the entire country for many months. A traffic light system could be designed to clearly communicate the current levels of restrictions in different parts of the country. Indeed, this should be part of the app mentioned above.
Sustainable transition towards a new Bolivia
Whatever systems we do implement, we have to make sure they can be sustained over time, because this is going to take at least a year to get through, and the world will look different on the other side. Families and firms will have to adapt to these new circumstances, and the government needs to support them through this transition. At the very least, the government has to make sure nobody starves to death (people should be able to request help through the app if they have urgent needs, and the government needs to develop the infrastructure needed to respond). The government also has to accelerate investments in absolutely crucial infrastructure, such as water, sanitation, electricity and Internet. In order to facilitate a more agile transition and response to the rapidly changing market conditions, now is a good time to eliminate the very strong rigidities in the Bolivian labor market, because many of the changes we will see are not going to be transitory. It would also be a good idea to make it much easier to close companies that have become unsustainable, so that people can spend their time and money on starting up new businesses, instead of spending months or years going through all the ridiculously difficult procedures to close a company.
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Footnotes:
(1) Bolivia, as well as several other female-led countries, such as Taiwan, Hong Kong, New Zealand, Iceland, Norway, Finland and Germany, potentially could suppress and eliminate the virus, but that doesn’t help us much in this globalized world, if there are major male-led countries around us that fail to do that (e.g. United States, United Kingdom and Brazil).
(2) For example, 408 residents at a homeless shelter in New York was tested for the virus, and 36% of them was found to have the virus, but 87.7% of the people who had the virus, did not have any symptoms (https://jamanetwork.com/journals/jama/fullarticle/2765378?guestAccessKey=a5d28066-8f72-4633-a291-90b472754093&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=042720).
(3) Countries around the globe have been scrambling to buy mechanical ventilators, but it is not a treatment, it only provides life-support while the body’s own immune system battles the virus. A recent study of outcomes in 12 New York hospitals show that the vast majority of COVID-19 patients on ventilators die. Indeed, of those aged 65+, 97.2% of COVID-19 patients with an outcome by the end of the study, had died. For patients aged 18-65, 76.4% had died. See: Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775 ( https://jamanetwork.com/journals/jama/fullarticle/2765184)
(4) Some people are questioning whether we will even be able to achieve herd immunity, as some people who had previously been diagnosed and then cleared, have caught the virus a second time within a few months (https://www.reuters.com/article/us-health-coronavirus-who/who-says-looking-into-reports-of-some-covid-patients-testing-positive-again-idUSKCN21T0F1?il=0). See also this note about Corona virus immunity research at Columbia University: https://www.technologyreview.com/2020/04/27/1000569/how-long-are-people-immune-to-covid-19/?fbclid=IwAR3fkGPtqipyy_eieEBWaWOTeDnsdxkcb8BMpkYOXlaBW10OYaPs0CmUFVk.
(5) See this article for a discussion of what it takes to develop, test, produce and distribute a new vaccine: https://unherd.com/2020/04/when-we-get-the-covid-19-vaccine/?tl_inbound=1&tl_groups[0]=18743&tl_period_type=3
(6) The Chinese scientist who originally proposed the lock down of Wuhan, Dr. Li Lanjuan, has carried out ultra-deep sequencing of the RNA in different samples, and says that the SARS-CoV-2 virus mutates faster than previously thought, and that some strains are more infectious and more lethal than others ( https://www.scmp.com/news/china/science/article/3080771/coronavirus-mutations-affect-deadliness-strains-chinese-study).
(7) Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775 ( https://jamanetwork.com/journals/jama/fullarticle/2765184)
(8) See https://www.worldometers.info/coronavirus/.
(9) Researchers at Stanford conducted antibody tests on 3,300 volunteers (a non-random sample obtained through facebook ads) in Santa Clara, California, and found that 1.5% of the sample tested positive for the antibodies, suggesting that the real number of COVID-19 infection was 50-85 times higher than the official numbers by April 1st, 2020 ( https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf). However, it should be noted that this was not a random sample. Volunteers who responded to the ad, might be people who had experienced COVID-19 symptoms, and were eager to find out if they have already had the virus.
(10) Researchers conducted anti-body tests on inhabitants of Gangelt, a German municipality near the border with the Netherlands, which was hard hit by covid-19 after a February carnival celebration. They found that 14% of the population had already been infected by late March (https://www.technologyreview.com/2020/04/09/999015/blood-tests-show-15-of-people-are-now-immune-to-covid-19-in-one-town-in-germany/).
(11) On 6-8 April 2020, Denmark tested 3,898 blood donations from asymptomatic people and found that 1.9% had COVID-19 antibodies (https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-ninth-update-23-april-2020.pdf).
(12) Between the 6th and the 12th of April 2020, the Netherlands tested 4,194 blood donations and found that 3.4% had COVID-19 antibodies (https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-ninth-update-23-april-2020.pdf).
(13) See Dr. John Campbell’s discussion of these results here: https://www.youtube.com/watch?v=ypsUIh41xUw
(14) Unfortunately this has already started happening in Bolivia. A 12-year-old girl in the municipality of Montero killed herself after being quarantined without food for several days with her mother and her 7 siblings (https://www.lostiempos.com/actualidad/pais/20200422/tragica-muerte-menor-enluta-familia-humilde-montero-piden-ayuda-entierro).
(15) While other countries help, or at least allow, their nationals to return home, Bolivia has closed its borders so tightly that many Bolivians have been stranded either at border crossings, or wherever they happened to be at the time of the lock down. Especially inhuman was the treatment of a group of Bolivians, including pregnant women and women with babies, who tried to get home from Chile late March (https://eldeber.com.bo/171695_bolivianos-en-la-frontera-con-chile-claman-por-volver-y-el-gobierno-les-responde-que-no). I was also horrified to read than an opposition mayor in Cochabamba was arrested in her home last week for playing loud music and drinking “chicha” (a fermented beverage made from corn) together with her closest family. Although she tested negative in the alcohol test made on the “scene of crime”, all eight people present were arrested, and the youngest child was sent to a center for homeless children ( https://erbol.com.bo/seguridad/alcaldesa-de-vinto-dice-que-s%C3%B3lo-%E2%80%9Cbrind%C3%B3%E2%80%9D-con-una-%E2%80%9Ctutuma-de-chicha%E2%80%9D).
(17) https://www.nytimes.com/2020/04/23/world/americas/ecuador-deaths-coronavirus.html?smid=tw-share
(18) See https://ourworldindata.org/coronavirus.
(19) Here is the symptom app used in the UK: https://covid.joinzoe.com/. Google and Apple are also working to develop a contact tracing app that can alert you if you have been near a confirmed COVID-19 infected person (https://www.theverge.com/2020/4/10/21216715/apple-google-coronavirus-covid-19-contact-tracing-app-details-use), but that would have to be used in conjunction with extensive testing and it requires a very disciplined population for people to self-isolate for two weeks, just because their phone indicates they have passed by an infected person, so it does not seem ideal for Bolivia.
(20) EuroMOMO is a European mortality monitoring activity, aiming to detect and measure excess deaths related to seasonal influenza, pandemics and other public health threats ( https://www.euromomo.eu/graphs-and-maps/)
* SDSN Bolivia.
The viewpoints expressed in the blog are the responsibility of the authors and do not necessarily reflect the position of their institutions. These posts are part of the project “Municipal Atlas of the SDGs in Bolivia” that is currently carried out by the Sustainable Development Solutions Network (SDSN) in Bolivia.
