Search

Focusing on Cases Rather than Mortality in COVID-19 Creates Perverse Incentives

We should demand that our public officials focus on mortality rates. Doing so would force them to try to get a handle on the real extent of the disease.

Tying re-opening to case counts creates a variety of perverse incentives for elected officials. Specifically, focusing on case counts creates an incredibly strong incentive for public health and elected officials to decrease testing--the lower the testing, the fewer the positive tests.

It makes little sense to focus on case counts, when we know that this data is functionally meaningless throughout nearly the entire world. This is because only the very sickest are being tested. In my own state of Massachusetts, tests are reserved only for the at-risk. Anyone else must have a doctor’s order to get a test. Few localities now suffer from a lack of tests themselves, rather, they are seeing a shortage of the various materials they need to perform tests.

Our focus on tests stems from what must now be called a deeply misguided notion that we are going to STOP the virus. We are not stopping the virus. When we set out to “drop the hammer” on March 12th, we had 1581 confirmed coronavirus cases nationwide. We now have 1.8 million. That means that while we were “stopping the virus” the number of cases increased more than 1000-fold. Let’s assume that we were under-counting cases at the outset by a factor of 100. Let’s say that we are now only under-counting by a factor of 10—a conservative, but reasonable estimate based on the various antibody studies which have been done, all of which show that actual cases are being under-reported by a factor of 11 at the lowest, even in the most conservative interpretation of the data. So let’s say that when we really sounded the alarm and started to lockdown, we had 150,000 cases, and now, conservatively, we have 18 million. In that case, the number of cases has “only” grown by a factor of 100. Yay us?.... Doesn’t look like we’re stopping the virus to me.

Given that, it is imperative that we as citizens start holding our public officials accountable to other metrics. Case data is a false metric, given that we are testing a small subset of the people who have the disease, and using it to gauge the success of our public officials will only result in their testing fewer people. Contact tracing is equally meaningless when you are only capturing 5-20% of the people who actually have the disea

We need to start holding our public officials accountable to the observed mortality rate in our geographies. The change in behavior that this would effect in public officials could save literally hundreds of thousands of lives. This is because who gets COVID-19 makes a huge difference in terms of the likelihood of death.

The observed mortality rate, or case fatality rate, is calculated by dividing the total number of dead since the beginning of the pandemic, versus the number of total cases since the beginning of the pandemic.

Were we to shift our focus—and our ire—as citizens to the observed mortality rate, the changes we would observe in our political leaders and public health officials would be visible over night. Here are three ways that our approach to this pandemic would change overnight.

Given that, it is imperative that we as citizens start holding our public officials accountable to other metrics. Case data is a false metric, given that we are testing a small subset of the people who have the disease, and using it to gauge the success of our public officials will only result in their testing fewer people. Contact tracing is equally meaningless when you are only capturing 5-20% of the people who actually have the disease.


Given that, it is imperative that we as citizens start holding our public officials accountable to other metrics. Case data is a false metric, given that we are testing a small subset of the people who have the disease, and using it to gauge the success of our public officials will only result in their testing fewer people. Contact tracing is equally meaningless when you are only capturing 5-20% of the people who actually have the diseas

  1. PCR testing (the tests that looks for an active infection) would go through the roof. Public officials would be doing everything in their power to find and test every single person who had the disease. The result would be we might actually get a picture of where the disease was and really be able to slow it. We would be trying to understand how many asymptomatic cases there are—not downplay them.

  2. Public health officials would be tripping over themselves to do population-based antibody studies to understand exactly how many people had had the disease up until that point.

  3. Public health officials would be dumping that seroprevalanece and mortality data in its most granular form on scientists and demanding that they analyze it and help them understand exactly who is most likely to die. (Right now the opposite is happening, scientists are begging governments for dis-aggregated data). For example, what level of obesity is considered a co-morbidity? Is it just obese? Or is it morbidly obese? What degree, and what kind of hypertension? Is hypertension alone ever enough? Or is it only a predictor of death when coupled with diabetes or obesity? 98% of people who die from COVID have a co-morbidity. Half of those have 2. What are the most deadly combinations?

  4. Politicians would be putting in place targeted policies to protect the most at-risk—a stark contrast from now where the only groups who are truly protected by our public policy are those who can work from home (the upper middle-class), and children. Neither of which is at high risk of death for this disease.

  5. Politicians and public health officials would be trying to calm those groups with lower mortality rates—rather than inflaming their fears—encouraging them to go about their daily business, which would create an immunological shield for at-risk populations.

  6. Politicians would begin to look to other states--not just tiny all-white island countries--with the lowest mortality rates and try to understand what they were doing right, and how to emulate them. Likewise, they would look to those with the highest mortality rates and try to understand what they had done wrong, and how they could avoid following the same path.

In my home state, we see every day the perverse incentives that are created by our focus on cases, rather than mortality rate. Our Governor, Charlie Baker, has said that he has no plan to do seroprevalence (anti-body studies that help us to understand the real exposure to a given disease) studies. This is despite the fact weeks ago, on April 17th, the first—and up until last week the only—seroprevalence survey in Massachusetts showed that Chelsea, Massachusetts, at the time one of the hardest hit areas in the state, could have as high as 32% of its residents who had been exposed to the disease. A subsequent meta-analysis of that study and others shows that in Chelsea, based on the false positive rate, at a minimum that would have indicated an 18% infection rate, and at a maximum 38%. Surely, these results ought to have followed up with a more formalized study, not simply dismissed as inconvenient?

But because we are focused on case counts, countless additional people are dying as we shunt the disease to the most at-risk in our population.


22 views0 comments