Unsettling News from L.A. to Sweden (and Japan to Singapore)

By John Banks

It’s possible that more than 400,000 people in Los Angeles county (population 10.1 million) have already contracted COVID-19.

The estimate comes from a new study conducted jointly by the University of Southern California (USC) and the LA Department of Public Health.

The study conducted antibody testing on 863 people, with results pointing to a 4.1% infection rate.

The data matches the consensus expectation of infectious disease experts, which estimates a current U.S. infection rate between 2 and 5% of the total population.

There is good news and bad news here.

The good news is that, if the estimate is correct, the COVID-19 fatality rate is far lower than headline numbers suggest.

We already knew the actual case rate was far above the confirmed case rate, because so little testing is being done. Rather than 10 to 20 times higher, it could be 50 to 60 times higher. That lowers the fatality rate as a percentage of total cases. 

The bad news is that, if roughly 4% of LA County is infected, the infection rate would have to rise 20-fold or more to reach “herd immunity” — the level at which the general population is safe from new outbreaks (assuming that catching the virus means developing immunity to it, which is likely but not certain).

The additional bad news is that, because the fatality rate is a significant lagging indicator — it typically takes weeks to cause a fatality — the LA County fatality rate will rise over time, and could easily settle out in the half a percent or greater range.

Half a percent would be a far better result than the headline fatality rates we’ve been seeing.

And yet, it would not be a cause for celebration, because a half-percent fatality rate applied to nearly 262 million Americans — the number who would have to be infected to reach “herd immunity” — would be more than 1.3 million lives lost.

Then, too, there are the hospitalization rates and survivor side effects to consider.

Even if the COVID-19 hospitalization rate is low — just like the headline fatality rate, it will go down with a more accurate picture of cases — the hospitalization rate is a significant multiple of the fatality rate, and high enough to overwhelm hospitals if the virus spreads unchecked.

The problem here goes back to “systemic breakage,” and the challenge of hospitals being overrun.

For example, we can cheer for the heroic efforts of frontline hospital workers in New York, but also recognize that “shelter-in-place” measures helped save the system.

Had the virus continued to spread unchecked, the New York hospital system would likely have imploded, instead of holding together under severe strain.

The LA County study helps explain why we can’t relax our vigilance. The virus is wildly contagious — that much is clear from the way it has taken hold at social and business gatherings — and it threatens to wreck hospital systems via sheer volume if left to spread unchecked.

In that regard, the next pain point could be rural hospitals. While rural areas are far less dense than urban areas, the residents in these areas are medically underserved.

It is not uncommon for a small rural hospital to serve multiple surrounding counties, with residents of those counties living in a kind of “medical desert,” meaning, they have to drive 50 or 100 miles to get treatment. These hospitals are also less well equipped, with fewer staff and intensive care unit (ICU) beds than their urban counterparts.

This is problematic because we are already seeing rural outbreaks. New COVID-19 clusters are appearing in meat-packing plants and prison populations, with plant workers and prison guards circulating the virus through their rural communities. 

Meanwhile, in Sweden, their highly contrarian “do very little” approach is not going well.

To give some background, Sweden has created a kind of eyebrow-raising, real-time experiment with its odd-man-out way of handling the pandemic. 

The country’s Nordic neighbors, Norway and Finland, chose to take COVID-19 seriously, and thus implemented strong mitigation measures early.

Sweden, in contrast, chose to leave everything open — bars, restaurants, stores, schools, cafes, et cetera — while urging social distancing as a guideline, but not a rule, more or less allowing the virus to circulate through the population.

Those who want the U.S. economy to open sooner — and who feel that mitigation measures are overblown — have enthusiastically pointed to Sweden as an example of “doing it right.”

But the trouble in Sweden — and an ominous sign for their approach — is the COVID-19 fatality rate.

  • On a population-adjusted basis — for populations greater than one million — Sweden is now a “top 10” country in terms of COVID-19 fatality rates, with 1,580 deaths in a population of 10.2 million. 
  • Per the April 20 numbers, Sweden’s population-adjusted COVID-19 fatality rate was more than 2.4 times the rate of Denmark’s; more than 4.7 times that of Norway’s; and more than 8.6 times that of Finland’s.

When a country’s fatality rate is more than 4.7 times the neighbor to its left — and more than 8.6 times that of the neighbor to its right — that is not a good sign.

Anders Tegnell, the country’s top epidemiologist, was still backing the strategy as recently as this week. If Sweden’s COVID-19 fatality rate has hit a “plateau,” as Tegnell argues — and the Swedish hospital system remains comfortably functional — then the government’s strategy could be vindicated.

But the odds of both look questionable, given what we know about the virus and the Nordic disparity in fatality rates thus far. Sweden bears watching closely.

Meanwhile, in Asia, we are getting a real-time demonstration of how the “plateau” can be a mirage. Consider the following timeline in regard to Japan:

  • On March 24, the Fox News website ran the following article: “Why Japan appears to have avoided a mass coronavirus outbreak.”
  • Two days later, on March 26, the New York Times wrote: “Japan’s virus success has puzzled the world. Is its luck running out?”
  • And then, via the ABC News website on April 17: “New wave of infections threatens to collapse Japan hospitals,” along with a grim subheading: “Hospitals in Japan are increasingly turning away sick people in ambulances as the country braces for a surge in coronavirus infections.”

The early indicators of Japan’s success — and its seeming ability to sidestep the pandemic, even as Japanese citizens still congregated in bars — were false. The country went from a sense of relaxed complacency to a new state of emergency (officially declared last Friday) in a short space of time.

Even Singapore, which appeared to have a model response to the pandemic, is now back in lockdown mode as the result of a new outbreak. Singapore-based COVID-19 cases have shot past 9,000 — in a city-state of 5.6 million — as a result of growing infection clusters in migrant worker dormitories.

The virus is a fierce and formidable foe that spreads like wildfire. It sometimes appears to go dormant, but then surges back again. Even when vanquished, it comes back for more. In the United States, urban hospitals have passed a trial by fire — but rural hospitals are up next. And for those impacted negatively by the virus — versus the great number of asymptomatic cases — we still don’t know the full extent of survivor side effects or long-term complications.

On balance, all of this suggests we should take the virus seriously — and continue to be vigilant.