How We Should Think About the Odds of Dying From Covid-19
As government officials consider relaxing the lockdown of the national economy, there remains concern among many in the population that the risks of dying from Covid-19 are too high and that government decisions authorizing a return to work are premature. Putting aside the trauma and associated pain and suffering from contracting the virus, the central concern is whether people would likely lose their lives by returning to work, going to a restaurant, or even visiting the hair salon or gym. At the same time, the economic costs of the lockdown are imposing catastrophic and long-term damage to the national economy.
The current situation, as Governor Cuomo has pointed out, is “not sustainable.” We cannot eliminate all deaths from this disease, but as we try to restore economic growth, it is time to evaluate what strategies, at the margin, are likely to provide the biggest payoffs in reducing individual risk. Of course, collective behavior (increasing or decreasing the rate of transmission of the virus) can also alter the number of fatalities. This is the primary reason that public-health policy has focused on enforcing social isolation. But extreme social isolation is costly.
CDC collects an enormous amount of data and will continue to be in a central position to publish and inform the public on the risk of dying from Covid-19. Most of us recognize that we cannot fully eliminate the risk of becoming infected, but what strategies are likely to have the highest yield in lowering our risk of infection, and who among us is most at risk? Individual risk of death will shift down as we learn more about the disease and become better informed on what measures are most effective for reducing transmission and what therapies work best for the infected.
How risky is it to go back to work?
There is a lot of discussion about the case fatality rate, i.e., what the chances are of dying if we become infected. But since we have little good data on the probability of becoming infected, we are not in a position to make an informed judgment on joint risk, which is the chance of getting infected and dying. We do, however, have a fairly accurate estimate of deaths from Covid-19. Data on deaths in Italy and New York confirm that for the population under 50 years of age, the risk of death is close to zero and rises after that through all older age cohorts. I am well aware of heart-wrenching stories of younger men and women dying from Covid-19; but so far, they account for a very small number of those who die from the disease.
Here is what we know from death data from New York and Italy: 70%–80% of Covid-19 deaths occur among those over 70. We also know that the risk of death rises with so-called comorbidities—diabetes, obesity, high blood pressure, impaired immunity, and so on. Two other groups are especially vulnerable: health-care providers (which should now be given a separate status category under occupational health risk); and those living in nursing homes. For New York and New Jersey, 20%–40% of the deaths are occurring in nursing homes.
How can CDC help us understand the death risk from Covid-19?
* The 2017 crude death rate, according to CDC, for the entire U.S. population (325 million) was 8.65 per thousand (yielding a probability of dying in any one year of 0.87%). This is calculated from a total of 2,813,000 deaths from all causes. Most epidemiological models are now showing 60,000–70,000 deaths for Covid-19 by August. Even if total Covid-19 deaths were to rise to 120,000 for the entire year, the crude death rate for the entire population would rise to only 0.9%.
* Taking U.S. resident population data and the actual death rate for older cohorts, the pre-Covid-19 crude death rates calculate out as follows for older males (men face a substantially higher risk than women): (i) 65–74 years: 17 per thousand, which yields an annual probability of death of 1.7%; (ii) 75–84 years: 42 per thousand, which yields an annual probability of death of 4.2%; (iii) 85+ years: 150 per thousand, which yields an annual probability of death of 15%.
It is not surprising that the older we get, the higher the chance of dying. Let’s look at some worst-case outcomes, starting with the 75–84 age cohort (a crude death rate of 42 per thousand). I have no idea where we will be by year-end, but let’s start with a somewhat worst-case estimate of 120,000 and then allocate half (60,000) of the entire Covid-19 deaths to the 75–84 age cohort. We are also assuming that these deaths are a net increase, i.e., they are not deaths that would have occurred anyway a few days or months later. For the 75–84 age cohort, the annual probability of dying would rise from 4.2% to 4.7%. If we were to allocate as many as 100,000 deaths to this cohort, it would raise the annual probability of dying to 4.9%. This death rate is an average from those who are healthy as well as those with extensive medical vulnerabilities. The death rate would fall to near the base risk rate if we excluded deaths in nursing homes, those with comorbidities, and health-care workers. Nursing homes are especially problematical: in New Jersey, the state’s roughly 400 facilities all have at least one positive coronavirus case. About 1,700 deaths have occurred at these facilities, or about 40% of the death toll for New Jersey. So for healthy males in this age category who are not residing in a nursing home or engaged as a health-care worker, the base risk number likely moves by very little above 4.2%.
What should CDC and other government agencies do to place the risk in perspective? Many of us are now under extreme isolation measures, following government edicts. Most of us have refrained from engaging in any social activities and traditional commercial transactions, and even if restrictions are relaxed, concern over the risk will make revival of the national economy difficult. Cable news and media sensationalism have generated a perceived risk that is largely unwarranted. For the population under 65, the crude death rate, even with Covid-19, has not substantially altered the risk of dying. A commonsense approach would suggest placing additional resources and focus on the most vulnerable (strict isolation and more care for those with comorbidities) and ramping up development of therapies to treat the illness. We need to directly address the occupational risk for health-care workers (e.g., more protection, shorter shifts, and more compensation). More important, we need to do these things not just to improve prospects for survivability of the nation’s residents but to promote confidence that it is “safe” to return to normal routines.
It is essential to convey to the public the true nature of the risk. CDC should publish risk estimates for age groups, including the joint chance of getting infected and dying. Give the public hard data on the joint risk of contracting and dying from the virus. Once the public understands that the risk is low, that modest measures can reduce the base level of risk, and that many normal activities of day-to-day life remain well within their personal risk tolerance, the public and a large segment of the workforce (most of whom have extremely low probabilities of dying from the coronavirus) more likely will head back to work. This would likely yield most of the benefits of the current lockdown and keep us from permanently damaging the national economy.
What about the potential to overwhelm the availability of hospital services? Clearly, it is a risk. But one benefit of a prosperous and growing economy, if we can restore it, is that we will have the resources and wealth to quickly expand medical services, including those available from the armed forces and, at the same time, to undertake a crash program for therapies and vaccines.