Bryan Alexander

The Russian invasion of Ukraine is raging and may be a world-historical event. It has certainly become the center of media and policy attention in many nations.  I’ve posted about it and have been researching it constantly.

For this post I’d like to shift focus to another major crisis, one now in its third year.  It seems almost cruel to do so, given how deeply many of us are invested in the Ukrainian crisis. And it might seem callous to say “what about that other terrible thing?” Yet I have an obligation to analysis and forecasting. Plus I want to honor hundreds of people responding to a charge I set out a few weeks ago.

To explain: the pandemic continues. As of this morning the world just passed 6 million people dead by COVID-19.  Remember that’s a total of official numbers, based on published governmental counts, and therefore likely an undercount by a significant amount.  Think 7 or 8 million dead, maybe more – and remember what Daniel Defoe and others have observed about how inured people become to death during a pandemic.

American deaths now stand at 955,135, according to the CDC. That’s certainly an undercount, in part because American stats lag over weekends (which is inexcusable). I’m working on the assumption of 1 million+ US dead as of last month.

That’s only COVID deaths. Long COVID numbers are more vague.  I’ve seen figures estimating between 10 and 40% of those who endured the virus have ailments and injuries afterwards, from brain fog and joint pain to exhaustion and heart problems.   A new study finds what looks like brain damage attending infection.  Depending on what percentage of infectees suffer from chronic aftereffects, we should expect tens of millions of Americans to experience Long COVID for months and years to come, straining an already exhausted and badly supported system. Hundreds of millions around the world will join them.

Which brings me to a COVID futures question I posed a few weeks ago. Despite all of these horrific casualties, many around the world are hoping to relax public health measures, due to case numbers plummeting after a horrific winter peak. To be clear, COVID is not disappearing. Rather, the number of people it infects is dropping towards a sub-pandemic state. The presumed goal now is for COVID-19 to be endemic, part of human life, just not a world-shaker.

So let’s try to calibrate what we do next. What is the deaths threshold for opening up society?  How many dead will we accept in order to resume a non-pandemic communal life? What can we forecast about public health strategies for the next several years?

tl;dr answer – we’ll probably accept an awful lot of dead people to do without masking.

(When I say “accept” I don’t mean “all Americans happily decide as one on a single public number.” I mean a rough-edged consensus occurs without any major reform movement.  It doesn’t mean we don’t do anything, as maintain many countervailing efforts of various kinds: contact tracing, vaccination research and deployment, urgent care of the sick, etc. There may be public complaints and private criticism about our public health stance, but overall we decide to go along with our collective behaviors.  Put another way, blog commentator Rob C. asks us to think of this in terms of acceptable risk.)

I asked this question in mid-February.  Specifically, I focused on America, since it’s the country I’m closest to and because it plays such a significant role in the pandemic: source of historic vaccines, home of leading researchers, outsized victim, and location of many shambolic responses.

I also tried to crowdsource the question, inviting quantitative and qualitative responses across several platforms, starting with this blog.  To give some structure to responses, I offered a range by hundreds of thousands dead: 200,000, then 300,000, etc.  I also invited comments.

To be fair, this was not a formal survey by any social science standards.  First, as one commentator pointed out, the various audiences I connect with on each platform will likely be politically biased.  Second, while I tried to stir up interest and responses, the total number of responses ended up being low, so the n is unimpressive. Worse, each platform had different constraints on how many options I could pose, how many words could be in each option, what graphics I could add, which audience would see it, etc., so there’s some inconsistency in the questions.  And there’s probably come overlap among those audiences across platforms.

The results, while thoroughly unscientific, are nevertheless interesting, at least to me, and I hope to you. They point to a rough direction of one COVID future. They answer the question by saying, approximately, that Americans will accept hundreds of thousands killed by the virus each year so that we can return to normalcy.

For context, here are the leading causes of death in the United States, according to the CDC:

Note COVID’s rapid ascent.

That isn’t too different from death causes worldwide, at least in 2019, according to WHO:

Keep in mind that many of those deaths occur below the radar of public consciousness, for various reasons. A good number take place behind privacy regulations. They can require some medical knowledge to understand, which makes them harder stories to tell in some mass media.  And many hit seniors. COVID has taught us that, at least in the US, popular culture seems relatively unmoved by the deaths of elders.  Ageism is fierce and deep.

So with that context we can return to my question. Let me break down answers by individual platforms where people responded.

On Twitter, I posed the question as a simple poll, sharply constrained by the format, and answers appeared thusly:

How many COVID-19 deaths will Americans accept in order to end public health measures and "open up" the economy?

— Bryan Alexander (@BryanAlexander) February 18, 2022

A pretty strong majority for 400,000 there, although 22 votes is a very small n.

Several comments also followed.  Two friends responded that I was too optimistic, with Amy Pearlman thinking that “I’m not sure there’s an upper limit and that scares me deeply.” Similarly, Joe Murphy quietly and coldly thought “the options are missing a zero”.  Cristian Opazo compared results to flu deaths as a baseline.  And one person disagreed with the premise.

Shifting to another platform, I hosted an embedded poll on this very blog. The results:

Blog respondents are somewhat less sanguine than those on Twitter.  Only almost exactly one half (49.99%) see 500,000 and above as an acceptable butcher’s bill.  Half fall below that, with almost one half (46.43%) on the 100,000 and 200,000 levels.  For some reason the polling plugin won’t show many how many people responded.

Comments hit a range of points.  Trent Batson asked us to distinguish between published data and perceptions, which is important.  One COVID infectee asked us to remember the painful experience the virus can bring about.  Glen McGee thinks the numbers are too much to comprehend, and also may be politically skewed.  Dahn Shaulis observes that mass deaths from other causes will make the question more difficult.

I also posted the question to LinkedIn, which also strongly constrained my choices.

These results lie somewhere between the Twitter and blog reactions.  A bit more than half went for the maximum of 400 K, while 39% saw a very lower threshold, 100-200K.  34 people responded.

Comments were interesting.  Rob Chapman echoed my Twitter interlocutors, saying “Your scale doesn’t go high enough I’m afraid.”  Andrew Benedict-Nelson was similarly dark: “Answered 400k because I don’t think they are even counting.” Mathieu Plourde responded along related lines, then broadened his commentary:

As long as they are not “their people”. I see COVID being treated like school shootings from now on. It’s just the cost of freedom in America, like systemic racism and a corporate culture of burning out. Sad but true. The left will be outraged

Joe Desiderio came up with a stark way to structure my survey:

Alternate way to ask this Q: Which city would you be most comfortable wiping off the planet in one year’s time?
Roanoke, VA (100,000)
Salt Lake City, UT (200,000)
St. Louis, MO (300,000)
Bakersfield, CA (400,000)

Trey Martindale questioned the premise, wondering about a different query: how would individuals act according to their assessment of personal risk?

I asked this question on two other platforms, but the results there went a bit sideways from what I’ve shown so far.  I offered the question on Medium, which turned out to be harder, since that platform doesn’t have its own polling function. I quickly built a Google Form and embedded it in the Medium story.  On the plus side, this gave me a lot more room to craft the question and answers. Alas, this approach may have put off readers, since a mere three people responded.  (Come to think of it, I haven’t seen many polls on Medium.) At least Google Forms easily creates a nice-looking pie chart:

Only one textual response came in, which was only polite, rather than tackling the issue.

I asked the question on Facebook as well.  Again, that platform makes polling impossible unless asked in a post to a group, or on a Facebook page. So I kludged up a text poll and invited folks to answer with the letter representing their choices:

Here are some choices, using the United States as an example:
A) 100,000 dead per year
B) 200,000 dead per year
C) 300,000 dead per year
D) 400,000 dead per year
E) 500,000 dead per year
F) Beyond 500,000 dead per year
Think of it this way. After which number will we decided, collectively, that we should return to emergency measures?

Out of 26 comments only two picked out one of those options. (I’m not going to use links for comments here, because Facebook messes with them past a certain point) Andrew Peterson actually picked several options to make a point: “100K until we hit it, then 200K, at which point 300K will be ok…. pretty sure we’d go up to about 300 million until we’d agree on anything.”  Tom Elliot broke things down by political party:

for a significant percentage of Americans, and one entire political Party, 500,000 dead a year is worth ignoring. We accept deaths from the flu but in the tens of thousands at most. That really ought to be our benchmark.

NPR did an entire piece this morning (my morning) about how Democratic governors are dropping mask mandates, even limited ones, because of polling, not science. It’s likely a component of the decision process for sure but then NPR likes to ignore the finer points of such things if they can fit the story into their “floundering Dems” narratives.

Let me synthesize the other two dozen comments:

• A sense that Americans will accept a lot of deaths because, as Mathieu Plourde noted above, we already do so (from a nurse: “like we tolerate gunshot deaths and deaths due to lack of access to affordable healthcare. We are not really a culture that cares about one another.” From a Briton: “the barbaric US health care system.”)
• Ditto because of the politics and perceptions around public health (“We are still dealing with people who believe it’s a hoax, or refuse remdesevir and demand ivermectin. As long as science is confused with opinion, we are stuck.”
• Ditto around vaccination status and how Americans perceive the vaccination status of the dead (“If we experience hundreds of thousands of deaths per year but 95+% of those fatalities are among those who stubbornly remain unvaccinated, my inclination is to shrug and move on.”)
• People feeling threatened by how other people will decide on this question, based on their own comorbidities, age, or immunocompromised status.  One shared a webcomic on the topic.
• A fluctuating sense, depending on how the virus behaves (“I’d expect a dynamic environment where the situation changes all the time, or at least a few times per year” and “Once fall and winter forces people back inside, people gear up for winter events and parties, but taking precautions lags behind until the infection rate rises, with deaths following, again.”)
• A sense that COVID can’t be controlled any longer (“there is a growing medical consensus that we are fast approaching the point where it is effectively unstoppable, and that most of the control measures that applied (with varying degrees of success) to the earlier waves are now ineffective and somewhat pointless for the majority.”)
• A query about the question, wanting specifics on public health measures
• Disagreement with the question, because we won’t decide based on such numbers (“I am not sure COVID tolerance has anything to do with the numbers for most people. A million strangers don’t affect us personally.”)

So, summing up this mass of heterogeneous data and commentary: a strong response favors 400,000 and more COVID-19 deaths per year as what America will stand in order to move to a post-pandemic footing. This is based on a variety of reasons, including perceptions of how the United States has handled the pandemic so far, how this culture processes other mass casualty sources, and because of politics.

A minority report thinks Americans will see a lower threshold in the 100-300,000 range.  We didn’t get as many comments from this side as for the others, but I infer they consider the ways we can vary our public health strategies fairly quickly, depending on perceived threat levels.

My thanks to the hundreds of you who took the time to answer this cold poll, especially to those who wrote commentary.

Now let’s see how this experiment in forecasting works out. Watch the published death tolls (minding the undercount issue) and see how public health measures play out.  If the majority is correct, America will try its best to live as normally as possible until deaths head towards a half million per year. If the minority report is closer to reality, expect some flexibility in public health deployment, with changes every few months.

In the meantime, please take care and be safe.

(thanks to Ceredwyn for sharing her doom-inflected public health thoughts, Phil Long for data and reflections, to Benjamin Ryan for sharing his reporting, and to my fine Patreon supporters for conversation)

How much will America accept to live with the pandemic?

I have a poll, but let me explain it first.

Right now the COVID-19 virus seems to be ebbing in many nations.  Total infections and deaths since 2020 keep growing (420,908,184 cases and 5,869,200 dead worldwide, according to Johns Hopkins) but the gigantic Delta and Omicron waves are subsiding.  Here, for example, are how the most infected nations are faring, according to 91-DIVOC:

That downward slope is great to see and experience.

Hospitalizations and deaths lag, of course, but seem to have stopped rising, and instead hit something like an oscillating plateau:

If no new infectious waves washes through us, we can expect the deaths to gradually drop.

These new developments are inspiring all kinds of calls for societies to “open up” – to end masking, stop pretending to care about social distancing, and get back to the interpersonal activities we did before COVID hit.

  To resume the economy of fall 2019.  To get those haircuts and hit the bars without dread or guilt.

At the same time nobody seriously thinks we’re going to utterly erase COVID-19 from civilization in the near term. Instead, we’re hazily expecting some measure of losses: of hospitalizations, sickness, deaths, and long COVID. We’re starting to rethink cost/benefit as a cold, macro level.

Which brings me to the poll.  Let’s focus on the United States for now, where we have had 78,060,327 infections and endured 926,497 deaths, according to the CDC, whose numbers tend to be conservative.  Let’s assume COVID doesn’t disappear, but continues circulating through the population, doing some amount of damage.

How much human damage will we come to terms with, in order to re-open?

I’ll narrow it down to a single number for clarity’s sake.  How many COVID dead will be accept as the price to pay for a post-pandemic society?

Here’s the poll.  More notes below.

This question might seem cold or ruthless, yet it reflects the calculus we perform at some level. As individuals we make risk assessments frequently, as when we cross the street and estimate likelihood of being run down or when we decide to be among people when we’re ill.

As a society we make all kinds of decisions based on estimates of human damage. We set road speed limits by balancing likely casualties and our desire to race along. We construct and adjust projects, policies, and large institutions to reduce deaths based on certain causes: public health campaigns and shots to drop flu infections, calls for exercise and a vast sports domain to keep so many people from dying of certain heart problems, an anti-smoking effort to cut down tobacco-caused cancer cases.

For example, cars kill around 39,000 people per year in the United States.  (36,096 in 2019, 38,680 in 2020, or “as many as 42,060 people are estimated to have died in motor vehicle crashes in 2020“) To keep this butcher’s bill from being even worse we teach driver’s education classes, police streets with speed traps, conduct public awareness campaigns, etc.  It’s an number to consider – worse when you think of non-fatal injuries – but it’s one we live with, in order to do things we value with cars, trucks, and motorcycles.

We seem to be doing the same thing now for COVID-19.  We have a decent sense of who tends to be most vulnerable to injury and death: people over 75, the immunocompromised, those with certain comorbidities.  As we end mask mandates and give up on some people who refuse to get vaccinated, we are bargaining that we can collectively bear the number of illnesses, injuries, deaths, and long COVID cases.  My question is: what number?  How far will we go?

I realize that “we” is a hasty construct to account for the combined decisions of around 330 million people in a wide range of circumstances.  “We accept” papers over all kinds of disagreement and dissent. Yet for now I want to focus on crowdsourcing a rough, single number to give a sense of what will result from those combined decisions, that democratic compromise which we collaboratively construct.

I am very interested in the wide range of ideas, assumptions, and behaviors that go into such a large scale decision.  Ableism, ageism, capitalism and its opposition, technophilia and technophobia, party politics – all are welcome in the discussion boxes below.

One more thought: please don’t read the tone of this post as being inhumane in a Strangelovian way.

I’m writing directly here to get the poll going.

As some of you know, I have been terrified and outraged by the horrific suffering COVID has inflicted, thanks in part to certain human decisions which let it rip or made it worse.  I have friends and family members who are at serious risk of coronavirus illness, injury, and death.  I’m not posting to make light of their experience.  Instead, I’m writing to determine how we all choose to value them.

I have also polled people on Twitter, Facebook, and LinkedIn. I’ll follow up with a post comparing results.