Not everyone who dies of the pandemic will die of COVID-19

It may seem compassionate, or chic, to denounce putting dollars before lives. But it’s worse than nonsense. Lives depend on ‘the economy’

By John Robson, NATIONAL POST

The Canadian government has been criticized for lack of transparency on COVID-19. But since politicians’ reflexive secrecy often hides embarrassing ignorance not inconvenient knowledge, here’s what we and they need to make intelligent choices.

First, à la Donald Rumsfeld, we must realize what we don’t know. We’ve all seen those colourful charts about whether we’re flattening the curve, and apparently not really because the number of “cases” keeps rising fast. But actually they show “identified cases” which, absent widespread random testing, tell us something about serious cases but nothing about total numbers so nothing about the trend. If the pandemic spread silently for months we may already have “flattened the curve” of total cases even as hospitalizations continue to rise.

We also know less than we think about how deadly SARS-CoV-2 is because of the crucial distinction between two terms we should all be familiar with, case fatality rate (CFR) and infection fatality rate (IFR). As the BBC recently explained, CFR means “the proportion of people who die who have tested positive for the disease,” while IFR means “the proportion of people who die after having the infection overall.” Since in a crisis doctors focus on testing those with serious symptoms, CFR exaggerates lethality.

Health-care workers test patients in a COVID-19 drive thru assessment centre at a hospital in Mississauga, Ont., on March 30. Nathan Denette/The Canadian Press

So does a common error the BBC fell into. It said CFR “describes how many people doctors can be sure are killed by the infection.” Not even close. The number of people who die after testing positive for diabetes tells you nothing about how many people doctors are sure were killed by it. Many die from cancer, accidents, infection or multiple comorbid causes.

So CFR is too high because someone with terminal cancer and chronic emphysema who dies with COVID-19 certainly didn’t die of it alone even if it hastened their death. But it’s also too low because if an accident victim bleeds to death because the ER is overwhelmed by pandemic cases, they died of COVID-19 without getting it. (And because doctors rushing to save the sick won’t test everyone who dies.)

Another problem with CFR, and even IFR, is they don’t reveal who it’s killing. But just as there’s a reason for labels telling pregnant women not to drink, sometimes you quarantine retirement residences not an entire society.

It’s not just illness that kills people. The actuarial data tell us poverty, despair and loneliness kill too.

John Robson<
>

Do these soft numbers mean we know nothing? No. We have one number that’s both hard and informative: “excess deaths.” Every death may be a tragedy, except those bringing release from intolerable suffering. But every death is also inevitable and while individual ones are largely unpredictable, actuaries know the aggregate numbers with eerie accuracy.

Statistics Canada’s table 13-10-0708-01 doesn’t just list annual deaths. It says 10 per cent happen in January and under eight per cent in June and July. Nationally it’s around 300,000 a year, and in Ontario around 110,000. One way or another, about 25,000 people a month would normally shuffle off the Canadian coil, 820 a day, and in Ontario those numbers would be 9,100 and 300. If significantly more die this month, it shows the impact of the pandemic. So when officials project between 200 to 6,000 pandemic deaths in Ontario by April 30, you see that the former would be unfortunate, the latter catastrophic.

But there’s more to this “excess death” measure, something painful we must face. It’s not just illness that kills people. The actuarial data tell us poverty, despair and loneliness kill too. We don’t know how any individual person will deal with these hardships. But they will take a predictable, cruel aggregate toll.

Masked GlobalMedic volunteers set up a “infrastructure tent” in a parking lot at Brampton Civic Hospital in Brampton, Ont., on April 4. Ernest Doroszuk/Toronto Sun/Postmedia

I know the mantra “if it saves one life.” But every life matters. So in deciding what to do we must weigh not only excess deaths from the pandemic, but also excess deaths from the lockdown.

Both depend on how we behave. And it’s tricky because they move in opposite directions. But both are very real. Shutting down the economy will prevent deaths from COVID-19, but it isn’t free. Far from it.

If we don’t start restarting some economic activity soon, within weeks, we will see massive consequences. Municipalities and even provinces will become insolvent, businesses will fold never to reopen, supply chains will break even for groceries and hospitals. And people will die.

It doesn’t matter that not one death certificate will mention the quarantine. The excess deaths from cardiovascular disease, cancer, diabetes, substance abuse, suicide, etc., will be just as tragic, and as directly caused by lost jobs, bankruptcies and broken dreams, as the pandemic deaths from respiratory failure. And they will mount and mount. That curve is not flattening.

When Prime Minister Justin Trudeau blithely foretells “several weeks, perhaps several months” of lockdown, he may not grasp the consequences. But Canada being a democracy, we should. It may seem compassionate, or chic, to denounce putting dollars before lives. But it’s worse than nonsense. Lives depend on “the economy.” It’s where food comes from, and medicine, and hope.

So people will die from the lockdown too. More and more of them. And every life matters.