# Reality Check: More than 80 Million Americans are Likely to be Infected

Mar 06, 2020 Educational

When crisis conditions are real, it is better to be informed than uninformed. The reality of a crisis situation is worth getting a handle on early — even if the truth is unpleasant.

So let’s lay out some grim data points: More than 80 million Americans are likely to contract the coronavirus. Even by very optimistic estimates, more than 400,000 Americans could die from it.

The point of discussing this is not to provoke anxiety or panic. Instead, the goal is the opposite. Early knowledge, with time and room to calmly prepare, is better than a shocking wake-up call later on.

To understand the 80-million-plus estimate, and the 400,000-plus fatality count, it first helps to know about R0, which is pronounced “R nought” or “R zero.”

R0 stands for “basic reproductive rate.” It indicates the rate of spread for an infectious disease.

So, for example, if a disease has an R0 of 2, that means each person who has it would, on average, infect two more people. The rate of spread for any R0 value above 1 is exponential, which means the numbers start small and get big very fast.

Based on data from the World Health Organization, COVID-19 has an R0 of between 2 and 2.5.

“Academics reckon that an R0 around this range could see between 25% and 70% of the world becoming infected,” says The Economist.

That is where the estimate of “more than 80 million Americans” comes from.

• The U.S. population is 327.2 million.
• A low-end infection estimate, based on R0, is 25%.
• 25% of 327.2 million is 81.8 million.

What about the estimate of 400,000 fatalities?

The World Health Organization (WHO) recently reported the COVID-19 death rate is 3.4%.

But that number is almost certainly too high, and here is why. WHO derived the 3.4% figure by dividing the number of reported deaths by the number of confirmed cases. And yet, we know the number of confirmed cases is far, far below the number of actual coronavirus cases.

If you increase the number of confirmed cases, the death toll drops. If there are hundreds of thousands of unconfirmed cases out there, the actual death rate is lower than it looks.

So this is a “good news versus bad news” type of deal. The good news is that the real coronavirus death rate is probably much lower. The bad news is the death rate is lower because the true number of cases has already exploded through the roof — we just haven’t realized it yet.

We can’t know for sure, but numerous news outlets report a reasonable estimate for the true coronavirus fatality rate is somewhere between 0.5% and 1%.

That is far below WHO’s 3.4% number, but still deadly serious — a fatality rate at least 5 to 10 times that of normal seasonal flu. This, combined with a known high rate of infection, could be enough to overrun the American health care system. There aren’t enough doctors, nurses, or hospital beds.

An optimistically reduced fatality rate — assuming it will come in at 0.5% — is where the “400,000 Americans” comes from. If you take the 0.5% estimate — an optimistic low end, to be sure — and multiply it by 81.8 million, you get 409,000 U.S. fatalities.

Keep in mind, again, that all these numbers are at the low end of the band.

The reality could easily wind up worse. The number of Americans who ultimately contract coronavirus could finish out at the high end of the 25% to 70% estimation range, which would approach 228 million.

And the ultimate fatality rate could be 1% or higher, not just 0.5% — which would put the total U.S. death tally in the millions.

There are also reasons to be pessimistic, or at least concerned, based on the free flow of movement of American workers and the structure of the U.S. health care system.

In the real world, both the rate of transmission and the fatality rate of a disease can vary dramatically from country to country. In addition to R0, there is “effective R,” which reflects the changes in environment from one population to another.

Better containment measures mean lower transmission rates; worse or absent containment measures mean higher transmission rates. Better health care treatment means lower fatality rates; worse or absent health care treatment means higher fatality rates. This is why we see a large spread in transmission rates and mortality rates from one country to another.

Countries like Singapore and Germany, for example, score far better than countries like Italy and Iran on all measures, because Singapore and Germany have better containment practices and more efficiently run health systems.

Then, too, the quarantine measures introduced by China, putting 50 million people on lockdown, had never before been seen in the history of the world. No western country could exert that much control over its citizens. The less control a government has — in normal times, a good thing — the less effective its containment measures will be.

The transmission rate of COVID-19 is also impacted by the speed and efficiency of government response. Testing rates play a big role here. The more people you test, the more you can isolate the virus and initiate early treatment.

South Korea, for example, has managed to set up drive-through testing centers that can handle 10,000 people per day. This high rate of testing has helped them keep fatality rates down. In the U.S., as of this writing, The Atlantic could only verify 1,895 Americans (fewer than 2,000) having been tested.

In the United States, conditions favor widespread transmission on multiple fronts:

• Most Americans can’t afford to take time off work, even if they have symptoms.
• Tens of millions of Americans are uninsured and unlikely to be tested.
• Apart from shutting down schools and venues, it is hard to restrict freedom of movement.
• The U.S. health care system is very likely to be overrun at the margins.

The best way to stop a disease as infectious as the coronavirus is to block it before it comes in. The U.S. can’t do that; it has already spread up and down both coasts and made its way to inland states.

Another good way to stop it is to impose work stoppages and self-quarantine on anyone who shows signs of infection. The U.S. can’t do that, either; too many people can’t afford to skip work, and tens of millions aren’t being tested anyway.

For something with as high an R0 as coronavirus, and a lack of visible symptoms in many of the carriers, this “can’t stop, can’t get tested, have to keep working” combination virtually guarantees coronavirus saturation throughout the general population over time. That is why the “25% infected” estimate is actually optimistic. It could well be much higher.

Another line of defense is mass-testing for anyone with potential symptoms, in order to stop the spread and render treatment as quickly as possible. The U.S. can’t do that either, because production of test kits has been massively delayed. It also remains unclear how the uninsured will get tested.

Yet another line of defense is excellent care for those who contract the coronavirus — but again, there is the question of what will happen to the 28 million Americans who are uninsured, and how the U.S. will deal with a shortage of beds and ventilators, or even a shortage of nurses and frontline workers.

As a country, the U.S. will pull through this, and it’s good to remember that “this too shall pass.” At the same time, we should all be aware of what’s coming — in order to keep a cool head when others don’t.