COVID, colleges, and case counts

You have no doubt heard the news that as universities reconvene students on campuses around the country, there are flares in COVID cases counts.

The inclination to return universities to lockdown and disperse the students back home in response to this is predictable, and about as nuanced as a knee-jerk reflex, give or take the knee.

Absent a highly effective, perfectly safe, universally distributed, uniformly accepted vaccine against COVID19 – and a recent pause in a major vaccine trial reminds us how challenging the obstacle course to fast-track vaccine production can be — we have four — and exactly four — courses through the pandemic between now and “then,” whenever then happens to be.

We can have high or low case counts (this presupposes that our testing is sufficient to correspond reasonably well with the actual occurrence of cases, so high case counts mean a high number of incident cases; low case counts mean the opposite); and high or low casualty counts. A casualty of COVID is any bad outcome: hospitalization, severe illness, lasting complication (I will return to this one), or death. A “case” not causing a “casualty” is an infection that comes and goes, imposing no discernible or lasting harm of any consequence.

In the immortal words of one of the cultural icons of my childhood: that’s all, folks. There is no fifth alternative.

So, what does each possible outcome of these four signify? Let’s take them one at a time.

Cell A, high case counts with high casualties, is famously now equated with the Swedish model. The vaccine spreads without any lockdown, and the toll is the toll. The jury is still out on Sweden’s approach, but it does seem clear that they could have had their cases and prevented their casualties, too, had they better protected the vulnerable — the elderly, chronically ill, and in particular, nursing home residents — right from the start.

Cell D, low case counts with low casualty counts — represents the more severe versions of societal lockdown. Among the better illustrations is New Zealand. The problem with this “hide away from the virus, wait for it to go away or a vaccine to arrive,” is that the entire population remains vulnerable to infection at any time. This, as astutely pointed out very early in the pandemic, is the famous “just flatten the curve” approach that does far more to change timing and dates than it does to change outcomes. New Zealand is now living this, experiencing small flares each time the population pokes out into the world. They are stuck living this way, lockdown maintained, or lockdown recurring, indefinitely.

Cell B isn’t worth talking about; it’s the unmitigated disaster of the group. A low overall case count with a high casualty count would occur if those most vulnerable to COVID catastrophes got the infection to a greater degree , while those who could most safely weather the infection did not. This would be … spread concentrated among, say, nursing home residents, with the rest of the population protected.

Finally, then, there is

Cell C. From the start I have favored this as the best of “bad options.” Why only “bad” options? Because the one good option is not having a pandemic in the first place. That, too, was possible, but only before our dietary habits started introducing animal viruses into the human population so routinely. Our incursions into the ecosystems of other creatures, carrying forks and knives, make zoonotic pandemics inevitable. Once we have one, and a virus has taken up shop in human bodies, Cell C is as good as it gets.

Achieving high-enough case counts to end the pandemic, with minimal casualties along the way, might seem far off. The “official” perspective is that the U.S. has had nearly 200,000 deaths out of about 6.5 million known infections. The deaths are reliable, the infection count is far from it. We can instead “reverse engineer” our denominator, based on a consistently reported infection fatality rate of 0.3 percent. A death toll of 200,000 is 0.3 percent of what? The answer is, X = 67 million, with rounding. That is one out of every five Americans.

We are not fully out of the woods yet, but we have covered much more ground than the national testing to date reveals. Basic math is the ultimate, hype-free, pandemic reality check.

Siphiwe Sibeko / Associated Press A volunteer receives an injection in June at the Chris Hani Baragwanath hospital in Soweto, Johannesburg, during testing to develop a coronavirus vaccine. Absent the emergence of a universally distributed vaccine, Dr. David Katz says, there are four courses through the pandemic.