Response to Coronavirus National Review Article by John Fund and Joel Hay
By Chris Thiagarajah MD
This morning I read the article by Fund and Hay in the National Review titled "Has Sweden foudn the Right Solution to the Coronavirus" commenting on Sweden’s policy of isolating sick and vulnerable as opposed to to many countries in the world who have enacted “stay at home” policies or stricter isolation techniques. In the article, the authors attempt to draw conclusions that Sweden’s policies provide a better technique for reducing death, infection rates all while not impacting the economics of the country as deeply as other countries who have engaged stricter measures (such as the rest of the Western world) There are many criticisms of the article by Fund and Hay that can be made of the article that looks at Sweden through an extremely tinted glass.
The first mistake that Fund and Hay make is drawing conclusions from data that isn’t complete. What I mean is that the growth curves of Coronavirus have not completely gone through the countries. For every pandemic, there is a rise, peak and plateau of disease.
Comparing total numbers of death, infection rates, ICU admissions between countries, cities or towns is something that you can’t do until the disease process is complete. For example, Spain has overtaken Italy in terms of disease progression through the country. This includes rates of infection and deaths despite having 2/3 of the population of Italy. Three weeks ago, it would have been premature say Spain has less deaths or cases than Italy thus they have better coronavirus policies and are doing a better job of controlling the virus. Now Spain’s rate of death, infection rates and ICU admissions have not only surpassed Italy’s and look to be much worse.
How does that apply in the Sweden case? In the article, Fund and Hays cite data showing Sweden has only had 401 deaths. Unfortunately that was 48 hours ago. As of now, (10:26 mountain time April 7) Sweden now has 591 deaths. They compare the 401 cases to Switzerland’s which had 715 deaths but today has 811. Sweden is catching up. More importantly if one takes a look at the graphs of the active for Switzerland and Sweden, one can see Switzerland has reduced the number of active cases and is going down. Sweden is still on the uptick. Since deaths from coronavirus are delayed compared to active cases, one can guess that Sweden’s death rate will continue to increase at a faster rates than Switzerland’s until they also plateau.
This illustrates the mistake of drawing conclusions early in a disease process especially in a viral pandemic such as coronavirus. As disease timeline takes months to determine the total dead, infected, ICU admissions you cannot compare different points in time for two different countries. Take into account also that Switzerland and Norways first case was on Feb 25 and Feb 26. Sweden's first case was January 31 giving them 26 more days to flatten the curve so to speak. Drawing conclusions in the middle of the curves is as absurd as comparing two baseball teams one week into the season and attempting to make some conclusion on their managers based on their one week record. You have to wait for the whole season for that.
One of the second mistakes that Fund and Hay make is selectively taking into account the multitude of variables that can affect death rates, infection rates, ICU admissions for coronavirus that are not just based on social isolation policy. They cite that Norway has less deaths per capita than Sweden but has a higher coronavirus admission rate. I believe they are trying to saw that Norway has more severe disease even though their death rate is lower. It’s very complicated to draw conclusions from that. Why? The increased ICU rates may actually be saving some people’s lives. If there is a country like India for example that has only 7000 ICU beds in the entire country, they may have a higher death rate for corona because there are only a few beds the entire nation. In fact, they may have fewer cases than China but then have more people that die because of limited resources to keep the very sick people alive. That has nothing to do with isolation policies at all!
This brings about a point that the authors bring up in the article but yet fail to take into account for their own conclusions. They cite that in the Influenze pandemic there was social isolation in St Louis but not in Philadelphia. They also cite that the larger number of cases in Philadelphia were due to sick GIs coming back to Philly and heading to the rest of the country such as St Louis when they got better. This is my point exactly.
There are so many variables for the rate and depth of coronavirus for each country it is exceedingly difficult especially early on in the disease curves to draw any conclusion whatsoever. For example how crowded a city is plays a role in the disease spread. New York City is going to have a faster spread than Hays Kansas or Denver simply because of how crowded people are in those cities. Another role is when policies are instituted in the disease process are important. If you instill social isolation for all after the disease has spread to 5% of the population it would be futile. At that point, the virus has spread out of control and social isolation policies are ineffective. It would be silly to compare that policy to one where no social isolation is instilled at all. It would be like comparing deaths between smokers and non smokers but using people who smoking up until 2 days before they died and counting them as non smokers. Just like that, when the policy is instituted counts as much as the policy itself. That is the lesson that several countries have learned. Other factors include compliance with the policy also plays a role. We have seen that recently on the beaches in Florida.
The short of it is that it is extremely difficult to assess if Sweden’s policy is the right one. In fact, recently Sweden is beginning to rethink whether this was the good one at all. Scientists in Sweden itself have criticized their policies which have taken an “economy first” stand.
Fund and Hay’s conclusions about Sweden’s policies, infection, death and survival rates are extremely premature. Utilizing that information at this stage of the game to laud how wonderful the Swedish policy is not only foolish but misinforms the portion of the reading audience who doesn’t double check the data, have a scientific background, or understand basic pandemic virology.
The separate question of how many deaths are worth per 1% drop in GDP is largely a political one. That is something for politicians to discuss and argue. That being said attempting to cherry pick data, use singular data points in an event that is changing and draw causative conclusions from conclusions is at the very least misleading. As a scientist, physician and truth seeker I can say we can only draw conclusions about what policies are effective and not effective once the coronavirus epidemic is complete and you can use final numbers to assess it. Doing it now, only creates confusion and misleads people who already are not sure what to do from so much misinformation.