Critical Look at Covid

I read with interest Dr. Pete Rutherford’s Response to Taking a Critical Look at Covid published in the Sept. 23 issue of the Echo. It was very well written and presented a thoughtful and informative picture of his opinions regarding the situation. As the CEO at Confluence Health, he is right in the middle of the health care industry’s handling of this problem in our region.

His article raised several questions in my mind that I hope he can address in a follow up. First he reiterates the fact that there have been 6,426 confirmed cases in the four county region served by Confluence.  This is about 2.5% of the population of that region. Then applying the results of some studies done on the antibody testing done in other regions, he concluded that we can estimate about 5% of the region’s residents have been infected thus far. He then states that this is far from the 60 to 70% infection level needed in our region to reach the “herd” immunity level; the target for which we are shooting. My question is this: How can we reach this target level when everything we are doing with the lockdown is to prevent the incidences of new cases? Is the goal to hold the new case factor at a minimum until we can develop effective vaccines? If so, it means that we will be in one phase or another of this lockdown for many months to come. The news items about vaccines indicate we cannot likely expect to get one or more vaccines through the testing and approval process until at least November and more likely January 2021. After that comes manufacture, then distribution, then trying to convince enough people that the vaccines offered are effective and safe. Following that we will then need studies to see how many people have the antibodies in total. In my mind I don’t see this happening in less than six months. This means we will be in some sort of lockdown until at least the middle of 2021. What am I missing here? If my assumptions are correct, we will have many more lives destroyed between now and then as more people lose their jobs, more businesses fold because they cannot operate at profitable level and state and local governments try to deal with their expanding deficits. Economic pain is not as visible as physical pain but it is still pain.

Dr. Rutherford also does an excellent job of setting out the impact this virus has had on the medical profession when all eyes were focused on fighting the virus as we “flattened the curve”. That was the initial objective of the lockdown and that was successful. He rightly points out the physical and emotional drain on the staff as they were faced with a large load of patients and they struggled to understand what was going on. However, to my knowledge, that was in March and April. At this point in time, the hospitalization numbers are now quite low even as the number of cases in the region continue to build. As of September 23^rd, the Wenatchee World reported that there were three people in the Covid unit, including one patient in ICU and one patient on a ventilator. The entry of more treatment drugs to the scene is also helping as we go.

Finally, I was fascinated to learn about QALYs (Quality Adjusted Life Years) and how they are being used to make treatment decisions. “QALYs” are defined by Dr. Rutherford as follows “the amount that this country has decided it is willing to pay for an additional year of an individual’s life”. The number is currently said to be at least $100,000 per year.  He then uses a life impact estimate of 10 years for patients dying of COVID. The assumption is then made that 2 million people will need to die to reach herd immunity levels, all of which calculates to a total QUALY-based cost number of $2 trillion. While I understand his calculations, the conclusion seems unreal to me. The average daily death toll in the US for the last 30 days is 850 per day. There are currently 206,560 total deaths to date in the US. To reach the 2 million level at that daily rate would take at least 2,110 days, or 5.8 years. Even Dr. Fauci believes he is confident that this will be over by the spring of 2023. Most estimates I have seen indicate a total of less than 300,000 deaths. Based on total deaths of 300,000, the QALY-based cost total is $300 billion; not $2 trillion.

Regardless, the real economic cost appears to be far more than either of these amounts. A June 2, 2020 Forbes article states that a recent CBO report on the subject indicated that the pandemic’s impact on the US economy is estimated at $7.9 trillion in real economic output, or $16 trillion over the next 10 years. Using the 2 million lives estimated by Dr. Rutherford for herd immunity as the potential number of lives that might have been lost without action, the 7.9 trillion “cost” of these actions relating back to each “quality adjusted life year “ saved or served as a patient  is about $400,000 per life year. That is four times the $100,000 annual threshold mentioned in Dr. Rutherford’s letter. The 10 year cost is double that, or $800,000 per life year. Stated another way, it is $4 million and $8 million respectively for each life saved or serviced.

At the very least these numbers  should make one stop and wonder if the lockdown approach has been the best one we might have taken. There are more than money factors involved when making decisions about saving lives but it is a very big factor as evidenced by the fact that the medical profession uses QALY data when making all kinds of treatment decisions already, i.e., cancer treatment, surgeries, etc.

We may get the virus under control in another year or two but we will be coping with the economic and emotional fallout of all of this on our lives for far longer as schools, businesses, state and local governments, and just plain folks get themselves sorted out.

 I believe our leaders made what they thought were the right decisions at the time based on what they knew at the time. I am not second guessing that. On the other side of this, there will be examples of countries and even states that took different approaches. We will be able to study the outcomes and, hopefully, learn from our mistakes and do a better job next time.

Jon Wheeler

Leavenworth