American epidemiologist and former World Health Organisation official Dr Gary Slutkin says the impact on the nation’s psyche will be “devastating”. “There is still tremendous denial within the country, and several states that are taking the wrong decisions, or being way too slow”, he says. It’s a profound shock, particularly to the country’s middle, upper and government classes.
“The US feels that it knows better, it always feels it knows better and it wants to tell the rest of the world what to do,” Slutkin says. But that’s been a costly error in this pandemic. “Not being able to tool up with widespread and systematic testing, that was a massive mistake.”
In Britain the news grows darker by the day. On March 5 the UK had no deaths from the virus. By April 2, the number of deaths had risen to almost 3000, from around 34,000 documented cases (a case fatality rate of just over 8.5 per cent).
In Australia the nation’s doctors, health workers, public health advisers and politicians are asking themselves a profound question: will we be spared this wave of death?
Already our case numbers have surged past 5300, yet as of Friday fatalities were still pegging below 30. This, coupled with an apparent slowing in the rate of new infections, drew cautious optimism from federal Health Minister Greg Hunt earlier in the week. “To Australians, I want to say thank you,” he declared. “These early promising signs are your doing.” Deputy Chief Medical Officer Dr Nick Coatsworth stressed that “our death rates are lower … our hospitalisation rates are lower and our number of community cases are lower”.
Coupled with that, the US was finding one positive for every two tested, while in Australia it was only three out of 100 – testament to our much more extensive testing regime.
Prime Minister Scott Morrison also hailed the fact that our COVID-19 infection growth rate was now in the single digits. “Had the virus kept growing at the same rate it was 12 days ago, we would now have more than 10,500 cases in this country,” he said.
Yet Allen Cheng, professor of infectious diseases at Monash university and an expert adviser to the federal government, warns against drawing too much comfort from our early figures. “The key is to keep an eye on the unlinked cases, the cases where you can’t work out where they’ve come from,” he says. “If we start picking up a lot of [those], then there is a big iceberg there and we need to work out how big it is.”
One of the most striking features of the pandemic is the huge variation in rates of death and severe disease across the globe. Countries doing better than most include the East Asian grouping of Taiwan, Hong Kong, Singapore, Japan and South Korea. Germany has also kept a firmer lid on its death rate (around 1 per cent of its reported cases thus far).
Italy and Spain, however, are undergoing horrors familiar to anyone following the nightly news: many thousands of dead in each country, makeshift morgues in churches and ice rinks, hospitals overrun, even reports in parts of Spain that the elderly have been left to perish in their beds. Italy’s death rate is 12 per cent, Spain’s 9 per cent.
This puzzle of varying death rates is explained by a broad range of factors. The most significant is how widely a country is testing, and whether it is screening people of all ages and those who have mild as well as severe symptoms. In the UK, for instance, testing has been limited to those hospitalised with the disease.
“If you only test cases that look they are COVID-19, then you are going to get an extremely high mortality rate,” says the director of the ANU’s school of demography, Professor Heather Booth. “If you have a high testing regime like in Australia, [and] you’ve picked up lots of cases, many of which are mild, your case fatality rate will be low.”
UNSW infection control expert Professor Mary-Louise McLaws says the US death rate is “biased by a number of serious cases that have died very early on, representing an older group that have a lot of comorbidities”.
Stanford University epidemiologist Professor John Ioannidis has expressed frustration at the extreme disparity in the testing data from different countries. “Given the limited testing to date, some deaths and probably the vast majority of infections due to [the virus] are being missed,” he wrote recently. “We don’t know if we are failing to capture infections by a factor of 3 or 300.”
Cheng agrees that the relative youth of Australian cases detected so far is holding down our case fatality rate. Leaving aside the passengers from cruise ships, “most of the cases have been travel-related and [those] travellers tend to be younger, people under 50, and the death rate and mortality is much lower in that group,” he says.
But that could change “quite sharply” once the disease impacts more on older Australians. Here and elsewhere, aged care facilities have already emerged as hot spots.
“The other factor that often makes the death rate look quite low early on is that some of the people that have just got infection may still go on to die,” Cheng adds. “That’s really important at the very start of an outbreak – the death rate looks artificially low because the time to death is several [two to three] weeks.” Eventually around 20 to 30 per cent of those in intensive care will end up losing the battle against the virus.
A recent paper from Oxford University’s Leverhulme Centre for Demographic Science highlights the magnitude of fatality rates among older people. Using Chinese data, they calculate a death rate of just 0.4 per cent in the 40 to 49 year group, compared with 14.8 per cent among those aged 80 and over.
Macquarie University’s professor of demography, Nick Parr, says most Australian cases have been in the large urban centres, where population age structures are lower than in other parts of the country. “This may also affect the extent to which cases are translating into deaths,” he believes.
But country or city age profiles don’t necessarily point to similar outcomes either. In Italy around 23.3 per cent of the population is aged over 65. In China its around 12 per cent, and here it’s around 15 per cent. In Japan more than 28 per cent of the population is aged over 65 – yet it’s pandemic experience is far milder than Italy’s.
So there are a multiplicity of other factors that also bear on the variation in death and severe disease rates between different countries. Among them are geography and density of population. Culture has a role, as does patterns of cohabitation between older and younger generations (Italy is a standout for high interactions between adult children and their parents).
How far the pandemic has progressed is another key determinant, as is the speed and effectiveness of initial responses and mitigation measures, such as closing borders, preventing mass gatherings, social restrictions, contact tracing and enforcement of quarantine and isolation regimes.
Italy, says Cheng, did not lock down until 800 deaths. “By then there would have been a whole lot more community transmission,” he says.
The surge capacity of a nation’s health system is also critical for keeping deaths down, as intensive care units get flooded with patients struggling with severe pneumonia. Japan and Germany, for instance, both boast better resourced hospitals than many other countries. According to Bloomberg, Japan has around 13 hospital beds for every 1000 people, more than triple the capacity of Italy, the US and the UK.
Other cultural factors in Japan may also be helping to “flatten” the pandemic curve. The habit of mask-wearing is firmly established, as is hand washing. Kissing, handshakes and hugs have not traditionally been part of how the Japanese interact socially.
It is also not clear from some countries’ reporting how many COVID-19 victims are dying with co-morbidity, which might have killed them anyway.
Gary Slutkin believes Western populations have, in general, been slower to heed the warnings of public health officials than those in the East.
“The Eastern mind is much more communal, the western mind is much more individual,” he says. “In East Asia, their [government] systems are organised and generally speaking more efficient.”
But former British journalist turned Singapore-based academic James Crabtree, an associate professor in the Lee Kuan Yew School of Public Policy, plays down culture as a factor. Both he and Slutkin highlight the fact that countries like Singapore, Hong Kong, Taiwan and South Korea were already primed to battle the COVID-19 pandemic after experiencing the scares of SARS [Severe Acute Respiratory Syndrome] and MERS [Middle Eastern Respiratory Syndrome] in 2003 and 2012.
“They are rich countries, with recent experience which the West has not had for a very long time,” says Crabtree of the East Asian group.”They have thought about it thoroughly, they have built institutions, they have stockpiled.”
By contrast many Western democracies “have under-invested in the kinds of state infrastructure that you need to handle one of these things,” Crabtree says. “It’s less about are countries Eastern or Western, are they democratic or autocratic, it’s more about the capacity of the government.”
Australia can draw some comfort from its geography and relative lack of density compared with a city like New York, according to Booth.
“We have space on our side,” she says. “I don’t mean the entire country. I mean Australia has been built with the luxury of space. We don’t have the cramped conditions that one has in other countries like Italy, and the UK … When I go to Britain I stay in what is a small market town and go to a pub … it’s that cosy feeling that we enjoy so much in a social environment … Australia doesn’t have that, we just want to sit in big, characterless rooms, but they have actually been an advantage to us.”
Fellow demographer Nick Parr agrees that “Australia as a whole, it has one of the lowest population densities of any country in the world,” but points out that Singapore, like New York, also has a population living in very close quarters. “[So] it would be overly simplistic to say that population density is a major or determinative factor.”
In Italy, the “high degree of residential proximity” between adult children and their parents is likely to have fed the flames of the pandemic, according to detailed research from the Leverhulme Centre in Oxford. “Even when inter-generational families do not live together, daily contacts among non-co-resident parent-child pairs are frequent,” the team, lead by Jennifer Beam Dowd, stated recently. In other words, the Italians really like living with and hanging out with their old folk.
Sadly, that otherwise laudable trait seems to have made their elderly much more vulnerable to transmission from younger adults carrying the virus.
“We think many young people who are infected may be asymptomatic or show mild symptoms” Dowd says. “We think it is possible that in Italy, younger workers from Milan who commute home to smaller villages and live and eat in multi-generational households could have hastened the spread.”
Others point to dysfunctional government and the deep distrust that has engendered among Itlay’s citizens as a partial explanation for the country’s slowness to recognise the danger in its midst.
The extreme partisan divide in the United States has not helped public health messaging in that country either, as a recent article in The Atlantic graphically illustrated. Under the headline “The Social Distancing Culture War Has Begun”, the writer observed a group of elderly Republicans on an Atlanta golf course making “a show of shaking hands, and complaining loudly about the ‘stupid hoax’ being propagated by virus alarmists”.
It’s difficult to see people with that mentality accepting the US government’s reported move to now recommend the wearing of face masks. Speaking to Science magazine several days ago, head of the Chinese Centre for Disease Control George Gao said the US and Europe had made “a big mistake” in discouraging the wearing of masks, because droplets could be transmitted when people were speaking , not just coughing.
Testing remains key to controlling the outbreak here. As Slutkin says, “if you feel like you are overdoing it as a country or a city, or even as yourself, then that is the right feeling. Then overdo it some more”.
Cheng says there is an effort now to “plug” any holes in surveillance and “look at a different risk group” as Australia’s testing regime pivots away from travellers and towards community transmission.
McLaws remains optimistic we will not become like Italy or the United States. She regrets we did not fully close our borders earlier, when we had around 100 cases on March 11. Nevertheless, she welcomes the slowing in the rate of new cases in Australia. “I think in about nine days’ time we may be able to start having a quiet smile to ourselves [that] we’re on a trajectory downwards,” she says.
Cheng is more guarded. Modelling is underway for a range of “scenarios”, he states. “We could be Italy, we could be South Korea, we could be Germany, we could be the United States, we could be any of these countries and we are going to prepare for all those things.”
“We are not looking like Singapore, unfortunately”.
Why not? “Because we have more cases and its rising quicker than it is in Singapore.” Nevertheless, he adds, “”I would be cautiously optimistic. But there is long way to go yet.”
Back in New York, 33-year-old architect Toshi Woudenberg, stricken with COVID-19, is hunkering down in his digs on top of a noodle factory in Bushwick. “I’m scared man”, he says. “Hearing about the shortage of ventilators and the lack of hospital beds. They are bringing in the hospital ships. Its not like we didn’t have months to prepare for this. People understand there’s real panic, and that’s pretty demoralising.”
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Deborah Snow is a senior writer for The Sydney Morning Herald.
Rachel Clun is a journalist at The Sydney Morning Herald.
Angus Thompson is an Urban Affairs reporter for The Sydney Morning Herald.