What We Worry About: It’s Not the Virus

“The term ‘triage’ normally means deciding who gets attention first.”  — Bill Dedman

Most people have no reason to worry about getting fatally ill from COVID-19.

Despite early estimates of fatality rates being about 2%, Sharon Begley reports in STAT News that a new paper puts the estimate closer to 1.4% overall: 0.5% for those aged 15 to 64, 2.7% for those aged over 64, near zero for those younger than 15.

For those in that age range of 15 to 64, a fatality rate of 0.5% may not seem so bad. After all, the fatality rate for seasonal flu is 0.1%. People worry about being out sick because of the flu, but honestly, how many people worry about dying from the flu?

So, what is the big deal? Why are we getting all worked up about COVID-19?

Fatality Rates vs. Fatalities

Most people don’t worry about dying from the seasonal flu. Yet the CDC estimates that for the eight flu seasons between 2010 and 2018,there was an average of about 38,000 flu fatalities per year, ranging from as low as 12,000 in the 2011-2012 flu season to 61,000 in the 2017-2018 flu season. During that same period, the average number of flu illnesses was about 28 million per year.

The average population of the United States during that period was around 320 million. That means that just under 10% of the population got the flu each year, and of those, just over 0.1% died from it.

The story with COVID-19 is different. First, no one has any immunity from this new virus because it is, well, new. While the fear that everyone will become infected is very conservative, a realistic assumption is that at least a quarter of the population will become infected. If a quarter of the population becomes infected with COVID-19 and 1.4% of those die from it, that means a little over 1 million fatalities from COVID-19 in the U.S.

But doesn’t that also mean that 319,000,000 people in the U.S. won’t die from COVID-19?

It’s Not the Fatalities

What is important to keep in mind is that for every flu fatality, there were 12 hospitalizations. If the same proportions hold (and who knows if they will), that means that for the more than 1 million COVID-19 fatalities, there will be another 13 million hospitalizations.

Thirteen million hospitalizations for which there is not enough capacity in our health care system.

There cannot be enough capacity. Capacity has a cost, and excess capacity has a cost that is hard to justify, especially when things are moving along normally. So, every leader in the health care industry, not just those with bottom-line responsibilities, has worked diligently to squeeze the excess capacity out of their organization. Because excess capacity is waste.

When there is not enough capacity, however, there is not enough capacity for all health care needs, not just for the needs of those suffering from COVID-19. Even if you are immune to COVID-19, you are not immune to automobile accidents, to emergency appendectomies, to heart disease, to cancer, to gunshot wounds, to all of the other things that put people in the hospital.

Triage

Every hospital emergency room has a triage nurse. Because the resources in an emergency room are finite, that nurse’s job is to evaluate incoming patients and determine which need immediate care and which can wait until there is a lull in demand. The expectation, however, is that there is sufficient overall capacity to handle the demand. There is no expectation that patients will be denied care.

When there is not enough capacity, triage reverts to its original meaning. During the Napoleonic Wars, Chief Army Surgeon D.J.Larrey of the French Army developed a method by which sick and wounded soldiers were sorted into three groups: those that would recover whether they received care or not, those that would not recover whether they received care or not, and finally those that would recover if they received care but would not recover if they did not. In times of limited medical resources—such as typically followed any battle in the Napoleonic Wars—only the last group received treatment.

We’ve already seen this in Italy during the current pandemic. “Doctors are deciding who lives and who dies.” No, they are being forced by lack of capacity to decide who they can help and who they cannot. And that decision does not just apply to those who are infected with COVID-19.

Because the ordinary things that can result in hospitalizations have not gone away just because of this pandemic, we all have an interest in seeing the system taxed as little as possible, whether we believe ourselves vulnerable to COVID-19 or not.

Just-In-Time Inventory

Eventually, this crisis will pass. We will be just as vulnerable to the next crisis, however, because the desire to wring out excess capacity—excess inventory—will still be there. A special report by Reuters following the massive earthquake and tsunami in Japan on March 11, 2011, reveals the soft underbelly of just-in-time inventory, of wringing out the excess capacity. The authors noted that “in a globalized economy where manufacturers have moved ever more toward lean inventories and ‘just-in-time’ production—keeping ultra-low quantities of parts on hand to avoid holding expensive stocks of parts—a speedy response [to the earthquake] was vital because a disruption to the global supply chain would spread quickly, shuttering plants employing legions of workers around the world”

Diana Tremblay, then GM’s Chief Global Manufacturing Officer, put it more bluntly.

“Years ago you had a lot of stock lying around. The big change is that there’s not all that inventory lying around anymore. It’s far better not to have all that inventory. But the opposite is true when you have supply chain disruptions. That’s the tradeoff.

“On balance, it’s still the right thing to do.”

There will be many lessons learned from this pandemic, but they will not include the need to build excess capacity into the health care system.

We Need to Keep the Healthcare System From Being Overwhelmed

If you have found yourself wondering if the response to the COVID-19 pandemic is overblown, please, set that aside. Sure, you only have a one in 200 probability of getting fatally sick if you are infected. But you need the health care system to have capacity for everything else as well. So, let’s do everything we can to slow the rate of infection down. Even being only mildly sick—the most likely result of an infection—still makes you a carrier, and the people you expose may not be as lucky as you.

Right now, the best advice we are getting is to wash hands frequently, avoid touching our faces, disinfect frequently-touched surfaces, and practice social distancing. Like most things in safety, it is not really about protecting ourselves, but protecting others.