75K or 50K is not enough!

I asked a rhetorical question on April 1, but I am surprised to find that, indeed, somebody did think 75K was not enough to sound the COVID-19 global alarm (https://www.yahoo.com/news/dr-birx-claims-u-slow-130524843.html).  This came from Dr Deborah Birx, of the White House Coronavirus Task Force.  She talked, frankly, more like a politician than a scientist.  Her words will no doubt be used by others to accuse China of “hiding something”, if they haven’t done it so diligently already. 

Here is her main argument: “When you looked at the China data originally,” with 50,000 infected in an area of China with 80 million people, “you start thinking of this more like SARS than you do a global pandemic.”  In fairness, the “50,000 infected in an area of China with 80 million people” is not necessarily her direct quote, and she did say elsewhere “probably” in reference to “missing” Chinese data.

The "50,000 infected" refers to confirmed cases in Wuhan.  Wuhan has 9-10 million people, far from 80 million; the whole Hubei province has 60 million, 68K cases (there are often factual errors with China reporting by Western media, just not always so obvious).  Since Feb 20 the total confirmed cases in Wuhan and China (82K) have changed only ~10%, so we can talk about the figures and situations in China or Wuhan in mid-late Feb as now.  By Feb 7, two weeks after Wuhan lockdown, deaths from COVID-19 had exceeded SARS total.  By Feb 20, within two months since COVID-19 discovery, infections had been 10 times as high as the whole SARS infections over 6 months.  Most importantly, by the end of Jan and early Feb, it was well known that many COVID-19 infections have no or few symptoms, at least initially, but can still be infectious.  I don’t know what it takes to convince people, but if you deliberately shut your eyes, ears, and brain, should you truly blame others not telling you?

I also thought COVID-19 would be like SARS and made the mistake of predicting fewer deaths in my Jan 26 blog.  It was based on the correct premises that COVID-19 has a lower fatality rate and China acted faster than in 2003, but negated by the later discovery that COVID-19 infections are harder to detect.  And any hope of SARS redux was dashed when global outbreaks looked impossible to contain (March 5 blog).  People need to adjust their expectations based on ever-changing information, not statically or pre-existing bias.  

The 50K figure in Wuhan, is it true?  One can ask the same question: US reported 200K on April 1, does it mean 200K infections by April 1?  It is a given these numbers are NOT true, because unless you test everybody everyday with 100% sensitivity and 100% accuracy, your numbers are always wrong (April 1 blog).   But they are the best available, based on the coverage you test people and how good your test kits are.  If 50K seems low, you don't have to invoke “hiding something”.

Once lockdown was initiated in Wuhan on Jan 23 (announced on Jan 22), most people were confined to their homes right away.  People going outside are checked for temperature everywhere and wear masks, i.e., being extra careful.  This shut off community transmission almost immediately, with the exception at hospitals.  Most people are also required to check their temperature twice at home, but unless they feel sick, they would avoid hospitals, a good idea.  This means most people don’t test for COVID-19.  Which is OK since the lockdown has been more than two months now, well past the 14-day incubation time of COVID-19: even if you were infected, you and your close contacts would have recovered completely.  Unless of course during this time one gets sick and calls the hospitals, he will be admitted, and all his close contacts placed under observation and quarantine, many likely being tested as well.  Thus, the 50K figure means those people who have been tested positive with symptoms.  Testing is conducted and reported by various hospitals and companies, all testing and treatments are free.  There are also medical teams coming from all over China to Wuhan.  It is practically impossible to manipulate clinical data and reconcile with medical costs at so many different places.  And it is also comical to believe 50K is good, yet 80K is bad.  

Analogous to any other places in the world, 50K is the lower limit of COVID-19 infections in Wuhan, because of two contributing factors.  First, most people are not tested (most are not carriers, either).  But because they don’t go outside, they don’t infect others or get infected, so no harm done.  The second is that I suspect the test kits are not sensitive enough, especially the early ones, even though media and doctors have suggested little to nothing about this so far.  Due to the urgency of the situation in Jan, a lot of kits were developed quickly by many different institutions and companies, some would likely be better than others.  There are many reports that some people with symptoms were RNA-negative for a few days, and then positive, or vice versa.  Sampling could be a variable, but kit accuracy and sensitivity might be another.   This is a global problem (https://www.yahoo.com/news/medical-experts-reportedly-worried-close-185346243.html).  To counteract, diagnosis also considers clinical parameters, and patients are tested at least twice on separate days.   As a result, there will always be false negatives, but the number is likely insignificant, not going to push 50K to 80K.  In sum, even if 50K is not "real", it by no means indicates China is withholding data.  If one wants to find out the "real" figures, large retrospective studies sampling more people are needed, and no doubt will be done later.  But since Jan 2020 the single, simple-minded goal has been to contain the disease, not to answer all the questions at once, or hide anything.

Still, even if Wuhan had reported, say, 80K instead of 50K, it is not going to satisfy people among whom believe most Wuhan residents are infected.  Their absurdity was exposed in my April 1 blog.  Maybe COVID-19 is a really wimpy disease.  But the main concept these people fail or refuse to grasp is that Wuhan lockdown and subsequent measures are the most stringent ever in modern human history, and they turn out to be effective.   These people first took the 50K figure and thought COVID-19 would not affect us.  Then when it did, they said 50K can't be right.  That that Wuhan measures quickly limited COVID-19 transmission makes 50K possible (with the caveats explained above), these people simply would never accept.  I thought and still think Wuhan lockdown is too costly (Jan 26 blog), but compared to what is happening now around the world, it is far from the worst outcome.  

If analyzing Wuhan is still not enough, let's look at Daegu, the equivalence of Wuhan in South Korea.  Both China and South Korea have successfully contained COVID-19, so their numbers are comparable.  Wuhan has 50K cases out of 9-10 million people, Daegu has 6-7K out of 2.5 million.  Wuhan's ratio is twice as high.  Daegu did not impose the same, harsh lockdown as Wuhan.  According to Dr Birx's logic, Daegu or South Korea "probably" withheld data.   Or COVID-19 can't be a pandemic.

Whether 75K or 50K is enough, or only 750K or 5 million is enough, is strictly a judgment.  Dr Birx, or whoever supplying her the rationale, had had bad judgments and are now just trying to cover for their ineptness.  If she writes a paper, it will fail peer-review. 

Note on April 30, 2020: After 4 weeks, I guess I am no longer the only one who believes Birx is more a politician than a doctor (https://www.yahoo.com/news/birx-risks-reputation-bid-keep-101518325.html).