Winter is Coming, America
By: Jesse Pines M.D.
Tags: Game of Thrones, Coronavirus, Risk, Masks, Pandemic

Winter is Coming, America

Time to Hunker Down (and Wear a Mask)

This is my first Medium post. The reason I’m writing this is that the COVID-19 pandemic is at a critical inflection point. Cases are rising, everywhere. November 27 marked the first time there were nearly 200,000 documented cases of the virus; on November 25 there were 2,181 deaths. The concern is not only the staggering incidence of illness and death but the shape of the curve.

My friends, Winter is Coming. Game of Thrones fans know what this means. For non-fans, it means an ominous force that intends to harm us slowly marches closer.

So, what then? You say, “I’m tired of all the sacrifices”. It has been 8½ months, staying away from friends and restaurants and large gatherings. Yet right now it’s time to rethink risk. We are entering what will be the worst winter in years, from the perspective of infections and death. Here are four useful resources that help me think about risk. When I say “risk”, I mean risk of contracting COVID-19.

First: it’s important to understand whether specific activities are safe, less safe, or unsafe. Most know these risks well. Nevertheless, I walk around and see many people I consider highly intelligent engaging in unsafe interactions. Gathering in small or even large groups, face-to-face, talking for long periods without masks, sometimes outside. The virus is airborne. Yes, it is less likely to blow away in a crowded restaurant. But there is no magic about being “outside” that universally prevents transmission. Wear a mask, and make sure it covers your mouth AND nose. Here is a good CDC resource about specific activities.

Second: risk is cumulative. That means consistent, continuous exposure to small risks adds up big risk. The converse is also true, the greater number of precautions you take, the less likely you are to get it or spread it to your community. This is the “Swiss Cheese” model: adding multiple imperfect interventions on top of one another, each being a piece of cheese with holes in it, the less likely COVID-19 will slip through, and more successful the outcome will be. For example, adding masks to social distancing to disinfecting to hand washing — each imperfect in reducing transmission — dramatically reduces spread. Here is an explanation with a good picture of the “Swiss Cheese”.

Third, the risks of getting COVID-19 are local. Yes, cases are going up everywhere, but different communities harbor different risks. Many websites have data on infections, case positivity rates, deaths, hospitalizations, all easily searchable regionally. Here are a few ones I use: Bing’s COVID-19 website and the IHME website at University of Washington.

Here’s how I use that information and please note these are ballpark estimates. On November 27, in Fairfax County (near my home), there were 499 new cases. Given “ascertainment bias”, this ~500 cases likely represents 20% to 25% of the actual COVID-19 cases. So, let’s say there were ~2,000–2,500 cases in Fairfax yesterday. The county has a population of about 1.114 million people. The virus lasts on average 10 days. At this moment, roughly 20,000–25,000 people in Fairfax, VA have COVID-19 in various stages, or 1.8–2.2% of the population. Given a 40% asymptomatic rate, that means that a little less than 1 in 100 people in Fairfax County are walking around without realizing they have COVID-19. Perhaps they might be standing behind you in the grocery store with their mask covering their mouth but not nose. Or maybe they are sitting three tables over from you, dining with their family, laughing and talking loudly, a fountain of virus.

If you attend a gathering, large or small, someone there may be asymptomatic or even mildly symptomatic (i.e. the sniffles) and contagious. Here is an interactive tool of county-level risks of someone having COVID-19. The clear message: if your local risk exceeds the risk you are comfortable taking, change your behavior and reduce your risk. That means hunker down (and wear a mask), wash your hands, etc.

Fourth, when you think about risk, don’t just think about yourself. Indeed, there is a roughly 2% mortality rate for the virus. This means that if you get it, you’ll have a 98% chance of survival. Of course, this risk is dramatically better if you’re young and healthy. But it’s worse if you’re old or chronically ill. For many, the odds are in your favor. Yet if you get it, you will probably spread it.

The risk is not just about you.

The risk is that the healthcare system will be overwhelmed this winter. Remembering back to March and April, the purpose of the early quarantine was to “flatten the curve”, so hospitals wouldn’t be overrun. As November ends, hospitals are filling up. ICUs are reaching or have reached capacity in many parts of the country. North Dakota hospitals reached 100% capacity on November 11th.

Overrun hospitals mean that doctors, perhaps in your local hospital, may need to make decisions about which people get scarce resources, such as ventilators or ICU beds. As a doctor myself, I have never seen true rationing. Rationing means that some who could have been saved or treated will be allowed to die or get less than “standard care”. The IHME site gives good estimates of state level bed capacity.

Sorry to be a Debbie Downer, but I thought it important to speak up because of where we are and what may happen. To end on a positive note, all these risks will hopefully be dramatically lower, or relatively so, six months from now. COVID-19 vaccines are clearly effective, and they are only months away.

Be safe.

Jesse Pines, M.D.