Battling Coronavirus Covid19 in Mind, Body and World

March 5th, 2020, New Delhi

Don't panic! Every one of my social groups was telling me, and then they said it again, and again. Every second message was about how I need to wash my hands and not panic. It was the 4th of March yesterday morning and everyone I cared to read on WhatsApp was forwarding messages throughout the day on not panicking. 

But I don't see any panic, I thought. To the contrary people seemed to be a bit too relaxed about it. My cousin was [planning a party, my neighbourhood was arguing about whether a water tanker should be called for Holi, my kids were asking me where we will travel after their exams, people were merrily shaking hands. I had a roundtable discussion at a new-age conference place (AntiSocial at Hauz Khas Village, Delhi); a group of youth were busy greeting each other with a hug at the entrance. And at that roundtable people were trying to not shake hands but too embarrassed about it, eventually giving in to the social norm. I must admit I tried to as well but failed. While Namaste comes very naturally at home, outside the home I need to touch the other person's hand. Why I don’t know, what I do know is there is no panic. And all those posts were pointless, in fact, should we not be taking this more seriously than we are?

 A friend’s forwarded post effectively argued that there was no need to get so worked up about Coronavirus Covid19 virus and the real mortality rate was closer to 1 per cent and not 2. Which got me thinking, how can they say that? And so started a journey since yesterday evening into Coronavirus Covid19 mortality rates and what I can do about it.

 Meanwhile, a niggling irritation in the throat had become worse, I decided to go home and take steam, have my standard ginger-turmeric tea, and sleep it away. This is a standard problem I have and it occurs in November and February, typically when the seasons change. Sadly Dr Mathur was no longer alive, or I would have called him and he would have taken the decision for me. He spoke little, a habit formed after years of keeping a tobacco laced paan in his mouth. He would listen carefully and give me two-word advice, which would be ‘do nothing’, ‘take rest’, or ‘take LCZPlus’. The last being a combination of paracetamol and an anti-allergic. He had known me since I was 6 and I am 53 now, he was the last of the no-nonsense medical professionals whom my whole family would trust blindly.

 As a researcher who grew up in an old-fashioned way, the first step is to visualize the data. I searched the net and found two graphs on the Coronavirus Covid infection. The coronavirus or Covid19 infection has taken over the global mind space as it spreads rapidly across countries and continents.

Source: ECDC.EUROPA.EU

Essentially the blue represents Chinese cases of Covid19 (henceforth Coronavirus) and the brown (or is it orange) those outside China. Leave that long blue bar aside as an anomaly due to changed practices by Chinese authorities. The data is clear, Covid19 infections took off in China and following some extreme containment measures which perhaps only China and North Korea can do, it now appears to be under control. Great going China, but now it is taking off in the world very rapidly. 

Can any other country contain it like China? Perhaps North Korea can, could Russia? I can’t think of any other. They have been sealing homes, locked down a complete city, evacuated suspected patients, even forcibly carried them away. That has been efficiency at its ruthless best if the videos are to be believed. So let us look at the other countries, another graph shows what’s happening in countries excluding China. See figure below. The same exponential curve found in the early days in China is now showing up globally. EXCEPT and this is important, no other country can control it like China can. In other words, it will expand at a global level. The timelines may differ in different countries, but it will expand.

Source: WHO

It’s the night of the 4th of March and the throat infection was getting worse. I added LCZPLus to my standard regime of steam and ginger-turmeric tea. Meanwhile, my mother and wife suggested a homoeopathic medicine, which I quietly consumed, more to keep them happy and off my back. What should I do? Could it be a coronavirus infection? Could I die? I am ok with dying but I have kids taking board exams, busy wife, and a frail mother downstairs, I don’t want to spread it to them.  Am I acting like a hypochondriac? Is this what the WhatsApp messages meant by ‘panic’? I haven’t travelled, don’t have a dry cough, breathing problems, do Yoga regularly, haven’t met many people from China, Italy or Iran or for that matter any other country lately. But I do need to be careful right? Should I not get a test done? But where? Thankfully I have other doctor friends, one had forwarded a WhatsApp message with a government’s emergency number. But I am not sure of calling them. Will they come home with their white clothes on? Imagine! I would rather do this quietly. So no number calling, let me go myself I thought. And so asked another doctor friend, Ram Manohar Lohia Hospital is the only place she said. This was far away, the other side of Delhi, and let’s face it, I am low probability. Let me wait and see how this goes I thought. Yes, I am confused. I do quite miss Dr Mathur with his two-word response. Thankfully got another message that or 18 other diagnostic centres had just been announced in Delhi for the diagnostics.

In whichever country, there are two ways that people are diagnosed. The high-risk groups are those who have directly come in contact with known infected patients and if the government mechanism is efficient, they will be contacted and tested. The low-risk group are those for whom there is no evidence of contact with an infected person, these people need to self-report and get evaluated. In the early days, it is the high-risk group who dominate, but as a communicable disease spreads beyond a few isolated cases it is the low-risk people such as myself who dominate. The mechanism for evaluating or diagnosing needs to be very accessible, a single hospital for a city the size of Delhi is quite a lousy way of controlling an about-to-be pandemic. 

The data though early, is fairly clear on this. Between the time a person gets infected and the first symptom shows up (called dyspnoea or breathing troubles) is about 5 days on the average and if the public health mechanism is good you get hospitalized in about 7 days on the average. In other words, 7 days between infection and being quarantined. For those 7 days for about 3-5 days, we are probably also spreading the ailment. Contrast with flu which is only 2 days. In other words, people will spread it unknowingly until symptoms become strong enough, and they will do this for a few days. 

While we are at it let us also look at mortality or death numbers. Between the time we get diagnosed and death it is another 7 days on the average, earlier for older more susceptible people, and later for younger and less susceptible people. So after having read some research literature (of course on the average, and estimated in China but also by WHO and the US’s CDC), my likely numbers relevant are as below:

Day 0: Come into contact and infected

Day 5: Symptoms show up

Day 7: Symptoms become stronger, hospitalization

Day 14: Death for susceptible

Day 17: Release from the hospital for recovered

Where do I get these numbers from? I have only had a few hours to work on this, but the internet does reveal much. There are of course very few studies, and the most quoted one is by Wang et. al. published in JAMA, but there are also those published elsewhere.

·        Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China - Wang et. al, JAMA, Feb. 7, 2020

·        Novel Coronavirus(2019-nCoV)Situation Report-7 - World Health Organization (WHO), January 27, 2020

·        China's National Health Commission news conference on coronavirus - Al Jazeera. January 26, 2020

·        Symptoms of Novel Coronavirus (2019-nCoV) - CDC

Where was I seven days back? Yes, I don’t have breathing troubles or a dry cough, but the mind is difficult to control. I remember now, I was at a meditation centre. Wait a minute! I just recall I did meet a European woman there. I don’t recall shaking her hands, but then someone else may have and that person could have shaken mine. Should I call up the meditation centre and ask if she is still there and how she is doing? Or how everyone else is doing, she could have passed on to others too. Coming back, to where we started from, is this panic, or is it being careful. Frankly, I don’t know, but it would be good if someone were to tell me what’s panic and what’s being careful. If a better testing method was there, I would have definitely gotten myself tested by now, but going to Ram Manohar Lohia Hospital, where all suspects would be going, I would be crazy to go there. And so decision taken, I put my family at lesser risk by staying at home than by going to a common diagnostic centre. If I get breathing troubles and join the moderate risk category, then I will go to RML Hospital. There is life after Dr Mathur after all!

So now we get to the most important questions of all:

A.     What is my chance of being infected?

B.     If infected, what is my chance of dying?

The medical literature is very poor at answering the first one and indeed there are many things that affect our chances, habits, underlying health, type of infection, how it spreads etc. What we do know is that it appears to spread very fast in the early phases when people don’t take care, but the spread can slow down dramatically when people take care. China took extreme care and locked down a whole city and even its people, but I don’t think that is possible elsewhere. Also what we don’t know is, whether warm weather slows its spread as apparently happened with SARS. When we don’t know somethings, best to leave it to be.

The second question on the chance of dying or mortality rate is easier. Currently, the WHO is releasing figures based on number died divided by number infected. And that was thought to be about 2 per cent initially but the latest WHO released figure is 3.4 per cent. I think using their methods it will increase further as time goes by. But there are many weaknesses with the current method.

Why mortality may be higher than reported

First, there is a lag between infection and diagnosis and also between diagnosis and fatality (7 days discussed above). So a better estimate would be Mortality cases today divided by Diagnosed cases 7 days earlier.

Second, a lot of the data are from China which is known to hide bad news, the classic case is SARS. Which initially was thought to have only 4 per cent mortality (See WHO Update on SARS: https://www.who.int/csr/sars/archive/2003_04_14/en/), it was much later that it was estimated at close to 10 per cent. And even in SARS, out of the 10 countries where people died, only China (6.6%) and Vietnam (7.9%) had mortality rates below 14 per cent! That is, mortality rates may be much higher than informationally challenged countries may report. This we can’t do much about, because Coronavirus has entered other countries only relatively recently and it will take a while for those number to stabilize. Currently, it seems that the mortality numbers will only rise moving forward. (See for SARS data: https://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome)

Why mortality rates may be lower than reported

In the initial phase, diagnosis is poor and only the most severe cases get diagnosed, so mortality rates are higher. As the public health system becomes more sensitive more people are diagnosed. However, people who have mild cases may never be caught by the system and if the case is mild it is not reported, and therefore is not diagnosed. If all mild cases were reported then figures could be much lower. I got a WhatsApp message that it may be 1.4 per cent and not 2! My argument is, we can never know mild cases as we are not testing everyone in the population, in fact in India we are not even testing all those who come in direct contact. We are only testing the severe cases since the testing infrastructure is also limited. So why bother about mild cases that appear and disappear without anyone knowing? In other words, think of all disease data as those with severe infection and those with severe infection who died. 

Estimating severe infections and mortality globally

My hypothesis is that global mortality rates will rise for some time to come as the share of China falls and that of other countries rises. Since other countries will not be able to hold it down as well as China did both mortality and morbidity can only rise, if other factors don’t come into play. What these ‘other factors’ can be? As summer approaches and the climate warms up, humanity embraces the namaste and is more careful, or if a miracle inoculation is found the likelihood of infections can fall. But all this will take time, for the next 2 months at least Coronavirus will rule the headlines.

And mortality rates? Consider the following graph that maps mortality rates as estimated conventionally and with a 7-day lag. The death rates as reflected in the graph - cumulative death rate, has been rising steadily and now stands at about 3.45 per cent as was also reported by the WHO. What is, however, important to know is that it has been steadily rising, and I suspect it will rise further as the share of non-China mortality increases.

The orange curve, however, provides a more revealing picture. Lagged mortality rates by 7 days have been much higher and I argue are more reflective of the real mortality rate than the WHO has been releasing. This has been falling due to China’s massive efforts on containment with ruthless efficiency. I do not believe any other country can go to the lengths China did. Given that global lagged mortality rates will once again rise, and some rise is already visible. The Lagged Death Rate has increased from 3.5 per cent on the 20th of February to 4 per cent on the 4th of March. To repeat, both the blue and orange curves above will continue their upwards trajectory for the next few days at least.

I don’t know how I can visualize what a 1 in 25 chance of death means, and how much different 4 per cent is from 3 per cent. The math may be apparent, but I don’t feel more scared when the likelihood of death rises from 3 to 4 per cent, or even higher. I suspect that’s true for most others. What is important for behaviour to change? Rationality or hierarchy? I chose not to go to work today, but then I am my own boss (when my wife is not around that is). It was my choice to not go to work, and of course that she had told me the same helped me make that decision! But it is difficult to translate such probabilities to rational decision-making, and most of us would rather have someone else do it for us. I just got to know that Holi celebrations were stopped in our neighbourhood because of Coronavirus threat, the fact that our PM and CM and President were not celebrating the festival got all neighbourhood societies in line. 

Finally, I would like to once again go back to the literature, who is at risk? The table above is taken from a paper published in the Chinese Journal of Epidemiology on February 7, 2020 (See The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) - China CCDC, February 17 2020) And it is so apparent that the death rates are concentrated among those who are above 50 and even more so above 70 years of age. In fact, for those below 40, it is almost like the flu in terms of mortality. Women also have a markedly lower propensity for fatality than men. Moreover, it is the males who are most at risk and those having other ailments.

Overall, therefore, we are facing a growing threat, a virus that selectively affects the old and the infirm the most. It will not go away even under the best of circumstances. What it will do is the following:

• Have better hygiene habits
• Make state take more responsibility for health
• Challenge our economic notions of dependency and growth
• Force us to think through notions of security and safety
• Leave no option to the government but to deliver

And what about my infection? I realize I don’t have that infection for now at least. My throat is sore but not coughing, don’t have a fever, have a lot of energy despite that I am lying on the bed since morning. So perhaps I should just send this off and sleep in peace!

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Death Rate = (number of deaths/number of cases) = probability of dying if infected by the virus (%)

Source: https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/