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The Brooklyn Rail

APRIL 2020

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APRIL 2020 Issue
Field Notes

Fear is more powerful than facts

Thomas Paine wrote in American Crisis, “To argue with a man who has renounced the use and authority of reason, and whose philosophy consists in holding humanity in contempt, is like administering medicine to the dead.” These words, penned in 1778, are like a preview of the global disposition to the threat posed by COVID-19. Scientific reasoning can be and has been used in an attempt to assure a frightened public that a virus-laden doomsday is probably not going to claim 2-3% of the world’s population. In this same piece of writing Paine also said, “Tis surprising to see how rapidly a panic will sometimes run through a country.” At this point, I am not certain that COVID-19 is causing actual panic, aside from the mass snatchings of toilet paper supplies and the seriously overblown reactions of the media, which are not helping. However, relaying productive information and discussion about the virus, rather than misinformation, or combating disease politicization on all ends by engaging with critical discussion on COVID-19 becomes an exercise in what Paine described as “endeavoring to convert an atheist by scripture.”

What is happening with the virus—aside from a pandemic—is a deft manipulation of limited facts and words via an endless parade of media talking heads, non-expert government officials, and self-anointed armchair public health experts on social media. These folks, along with many others, are co-creating a crisis beyond the virus itself. Why? Because in the absence of factual data we rely on predictive models to inform our visions of a safe future. These models tend to use worse-case scenarios to project a sense of societal safety when in fact, we have little control over the course into the future. What we can control is how we react.

The very few existing studies illuminate whom the virus kills and why, in a limited way. Generally, it is the very old and infirm, or the very infirm, with some exceptions. Yes, the young also get sick and this is not a good thing. But aside from these knowns, a lack of empirical insight is hugely problematic. John P.A. Ioannidis from Stanford University addresses this issue. He argues, “The most valuable piece of information for answering those questions would be to know the current prevalence of the infection in a random sample of a population and to repeat this exercise at regular time intervals to estimate the incidence of new infections. Sadly, that’s information we don’t have.”1 This is not all that we are missing. Even the CDC complained on March 18 that data on crucial variables of interest are missing, including outcomes such as, “hospitalizations, ICU admissions, and death” and were left out of “9%-53% of cases, which likely resulted in an underestimation of these outcomes.”2 But we do have the very basic statistics of infection and death rates, although these are also not exact due to lack of testing and mis- and underdiagnoses, and the issue of large numbers of asymptomatic individuals.

I use these statistics3 to provide some insight. Currently there are over 400,000 documented cases world-wide of COVID-19, with almost 20,000 deaths. This is bound to change, of course. Of these, most have occurred in China with a bit over 81,000 infected out of their 1.8 billion people. The country’s population is massive, thus the risk of catching the virus is statistically thin. To be precise: risk, or what is called ‘cumulative incidence’ in epidemiology, means the number of new cases of a disease over a period of time divided over the number of people free of the disease at the beginning of the period of time. Thus, if one considers the total number of cases of COVID-19 in China to this date as ‘new cases’ and people at risk as the total population, the risk of contracting the virus since cases have been recorded is about .00044, or .04%. Keep in mind, though, this is over the period of time and it is assumed that the denominator are people free of the disease, when it is highly likely there are people who were not. The point here, is that risk of contracting the virus in China over the period of the outbreak is very low, and probably much smaller considering large populations of untested individuals. The same calculations can be applied to every country currently experiencing a COVID-19 outbreak. In Italy, for example, risk of contracting the virus is .0011, or .11%. This is since cases have been recorded up until the time of this writing and is probably lower due to the number of those undiagnosed.

Much has been said among public health officials and in media about COVID-19’s “deadly” case fatality rate (CFR) of 2-3.4%. This would mean that if everyone in the entire world were infected with COVID-19, at worst-case scenario, two percent of the population would be wiped out, or 3.5% if the actual CFR were the latter. A CFR of even 2% would be relatively high for a pandemic-level disease. A CFR (also called case fatality ratio or, morbidly, the “death rate”4) as an indicator of virulence is “the proportion of persons with a particular condition who die from that condition. The denominator is the number of persons with the condition; the numerator is the number of cause-specific deaths among those persons.”5 Even though the CFR can be estimated given the numbers of people who have died among those diagnosed, an accurate case fatality rate, or the chance that a person will die of a particular disease, cannot really be known until an outbreak is over, because only at that point can we estimate how many people have had the disease. In fact, it is thought by many disease scientists that the actual CFR of COVID-19 is much lower than 2-3.4%. This is because of lack of testing leading to large numbers of undiagnosed, misdiagnosed, or asymptomatic people. The crude CFR is obtained through simply dividing the number of deaths by the current documented cases.

South Korea provides an interesting example relevant to the argument for why case fatality rates are not reliable as ways to predict the virulence of a pathogen in the midst of an outbreak, so that COVID-19 might not be as deadly as it seems. This is something that has been said before yet is drowned in histrionic doomsday media coverage and disease containment actions that position COVID-19 as a plague of biblical proportions. South Korea has some of the highest number of COVID-19 infections in Asia outside of China. Since the virus appeared in early February, over 9000 people have officially contracted COVID-19, with well under 150 deaths. The country thus has a low CFR, which can probably be attributed to aggressive testing efforts. One reason why CFRs tend to be high until an outbreak is over is mis-or underdiagnoses of a disease. Accurate identification of a cause of infection makes the denominator of the fraction bigger—thereby making the calculation smaller, to put it in the simplest of terms. The more people diagnosed with a disease, the better. Korea has some of the highest rates of COVID-19 testing in the world. Therefore, officials are able to get a more accurate picture of who actually is infected with the virus when assertive screening efforts are enacted.6 There are other interesting clues rough case fatality rates by country can provide us about who COVID-19 likes to kill—or not. Germany currently has a good number of cases at diagnosis, a relatively high number of cases, and a low number of deaths. Who has died as a result of the virus in Germany? Again, most are over 75 but I could not, at this point, find much information. I also could not find data about German testing practices and data. It is unclear at this time as to why Germany has such a small CFR. However, isn’t it at the very least worth exploring and talking about?

What is being talked about, however, is Italy and even Spain, as portents for what is to come for the United States. Currently, the very rough CFR rate for the US is 1.29. Italy has more cases than the US, but its CFR is leaps and bounds higher at 9.85%. Spain, which, for now, is under the States in diagnosed infected, is catching up with Italy, with a CFR of 7.04%. Yikes! Seems pretty scary and leads us to think that we are all on a path not unlike Gwyneth Paltrow’s role in the movie Contagion as patient zero for a pandemic originating from a deadly chicken dinner she ate as a guest in China. Will we be like Spain and Italy? No. Don’t start burning your $75 Paltrow vagina-scented candles for your doomsday party yet, folks. There is a reason for this difference, and it is linked to the ‘graying of Europe.’ Southern Europe was home to a recent gigantic wave of older Europeans who migrated south. A recent article in an academic journal, the Gerontologist, reported in 2012 that Spain’s population of 65 and older was 8,221,047.7 These numbers are similar for Italy, and to a lesser extent for France. This is one of the reasons why Italy and Spain have really high death rates, compounded with issues such as high smoking and population densities.

The sociocultural considerations of infectious disease risk are vastly neglected in predominant discourses about the pandemic. I cannot underscore the importance of the following statement, so let me bold and italicize it for you, sociocultural factors are incredibly important in considering which areas are at risk for outbreaks and thus higher clusters of morbidity and mortality related to COVID-19. In the United States, for example, the initial outbreak occurred in Washington State at an elder-care facility. Why? Because we shove our elders into group settings with a bunch of other infirm old people. So it was easy for the virus to circulate and kill a bunch of old people. Another example: While the current epicenter of outbreaks is New York – which makes sense given its density and global flows of people, New Orleans is probably most at-risk for a high mortality explosion, albeit on a smaller scale than southern Europe. First, because of high rates of COVID infections due to the recent Mardi Gras and the descent upon the city of millions of party-time revelers. That is simple epidemiology. Second, and equally important is a set of unique sociocultural factors. New Orleans is city shaped by a history of systemic racism – it is a poor city, has an abysmal healthcare system, pretty bad health indicators, and very vulnerable residents.

The collection of actions and headlines focused on COVID-19 have not sought to engage directly with the true vulnerabilities regarding age and co-morbidities exposed by the virus. Rather, they are obsessive discourses of panic, death, and uncertainty that open their arms to a viral apocalypse. The unfortunately named coronavirus is crisis business-as-usual but in hyper fashion. That the United States Ebola situation of 2014 foreshadowed what is now happening is no surprise to me, as I have been studying the former for the past six years. Ebola never actually materialized as a crisis, because in the US that virus was really hard to catch, unless people vomited into each other’s mouths. Nonetheless, it evoked a fear similar to the one on view in the current situation. In this vein, all the words spent gasping over volatile global markets, lockdowns, and quarantines, prioritize a future of isolation, stuck in our houses, drowning in stockpiles of toilet paper – ‘together, yet alone’ as encapsulated in yet another noxious slogan in an attempt to unite our pain. Unprecedented actions have been undertaken in an attempt to control the movement of the virus. They will not work that well. COVID-19 is already here. It has been for some time. We are all going to die, yes, but most of us more youthful Americans, probably not from the coronavirus.

We are not using the body of interdisciplinary science, including the social sciences and humanities, to understand how to deal with this virus in a meaningful way. Instead, we are left with a blanket of performative containment measures, half-baked suppositions masquerading as truth, and downright conspiracy theories. These are propagated by a band of keystone kops ranging from trigger-happy administrators and other higher ups canceling this and that, or by whichever new-found public health expert is expounding on their theories on the news or on social media, making the past two months an almost insufferable shitshow of 24/7 pandemic hysteria. This is after we spent the first part of the outbreak making fun of Chinese people for their “weird” eating habits. We then begin to fear the scratch in the back of our throats is a sign of doom to come. This social paranoia extends beyond bodies and our responses become insidious; the taking away of freedoms becomes excusable. At the same time, we are neglecting the protection of probable victims while performing disease containment, beyond posting on Facebook how “we should take this virus seriously because while it might not make me sick, it could make someone I care about sick.” Why didn’t you care about this when my friend’s 4-year old kid died from flu last year, Becky? You could have given it to him.

Political scientist Mark Neocleous argues, “It is often said that security is the gift of the state; perhaps we need to return that gift.” Our dual need for total security and for crisis is much stronger than our relationship with facts. We are in the grip of the power of fear. Again, Neocleous: “security and oppression are two sides of the same coin.” We are welcoming participants in our own sort of oppression. COVID-19 is just one more example of how we are, at times, much more horrific than this virus. I make this argument for two reasons.

First, we are complicit in an almost complete and very rapid willingness to forego liberty for the pretense of security. It has been breath taking to witness how quickly people are willing to forego the illusion of freedom (I do believe to a certain extent the idea of freedom is a gradation of illusion depending on your socio-economic-demographic place in the world) for safety from this virus. The measures enacted by no means guarantees safety from the virus, as much as they are a performance of it. Those who will truly suffer are the elderly and infirm; they are the ones left out of the rhetorics of ‘social distancing’ it is also they who cannot afford the luxury to take time off or simply just ‘work from home.’ Public health experts and policy makers have the power and resources to make scientifically sound and smart decisions about how to deal with this virus in a way that makes sense given what we know. But they will not. This is already certain. They have given into fear because it is much more powerful than the facts I have spouted here.

Second, we have elevated this virus to an existential threat to the neglect of what has killed us routinely. This is also more powerful than facts. While COVID-19 sends about 130 people to the grave a day, globally, cancer kills over 1600 people in the US a day alone. For heart disease, the number one cause of death for Americans, it is over 1700 people a day. Influenza, an oft made comparison to COVID-19 that has provoked the ire of many, particularly in light of recent asinine comments by Donald Trump, is actually a relevant comparison. Influenza is an infectious disease that is consistently the 8th killer of Americans every year for at least 50 decades. No, COVID-19 is not just like the flu, especially given how it will tax our already abysmal healthcare system in so called ‘hotspots’ like New York City. The novel coronavirus could have a higher CFR than flu, if the 2-3.4% or even more modest estimations stand. But we don’t know this. Influenza is caused by many different viruses, all with varying case fatality rates. The reason why I mention flu is not to suggest that it is worse than COVID-19, although the CDC estimates flu has killed 16,000 Americans as of the end of February 2020.8 I bring it up because, for the most part, we don’t give a crap about flu even though it kills a ton of us each year. The same goes for chronic disease. Also, suicide. And do not forget driving cars. Or our family members. They kill us too. Yet again, a virus rolls in from a foreign country and we turn our heads. We listen. Just like we did with Ebola, or SARS, or H1N1, or Zika... the list goes on… I mention flu for the cognitive dissonance of collective attention. Lives stolen, on ventilators, or you whose blood pulses with replicating virus either now, or in the future. You have our attention. The ghosts of the dead from neglected ailments probably needed it too.



Endnotes

  1. Ioannidis, JPA. A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data. STAT website. https://www.statnews.com/2020/03/17/a-fiasco-in-the-making-as-the-coronavirus-pandemic-takes-hold-we-are-making-decisions-without-reliable-data/ . Published March 17, 2020.
  2. Rabi, F., Mazhar, A, and Kasasbeh, G. et. al. “SARS-CoV-2 and Coronavirus Disease 2019: What We Know So Far” Pathogens:
  3. https://www.worldometers.info/coronavirus/
  4. To be clear, case fatality rates and mortality rates are not the same thing and are often conflated in the news and in social media posts by self-appointed experts. A mortality rate is “a measure of the frequency of occurrence of death in a defined population during a specified interval.”
  5. https://www.cdc.gov/csels/dsepd/ss1978/glossary.html
  6. https://www.worldometers.info/coronavirus/covid-19-testing/?fbclid=IwAR0s_CSGHiD9eWs7WuQXN8oktu5NbYMICnxfr4DXrUFdXS5zq9RE-ELL0uU
  7. Serrano, Juan P, Latorre, José M. Latorre and Gatz, Margaret. 2013. “Spain: Promoting the Welfare of Older Adults in the Context of Population Aging”. The Gerontologist Vol. 54, No. 5, 733–740 doi:10.1093/geront/gnu010
  8. https://www.cdc.gov/flu/weekly/index.htm?mod=article_inline

Contributor

Natalie Baker

NATALIE D. BAKER is an Assistant Professor of Security Studies at Sam Houston State University in Texas. She is at her best when she is deconstructing.

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The Brooklyn Rail

APRIL 2020

All Issues