Thinking of Risk in the Era of COVID-19 | Infectious Diseases | JAMA | JAMA Network
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Editorial
June 4, 2020

Thinking of Risk in the Era of COVID-19

Author Affiliations
  • 1Dr Bauchner is Editor in Chief and Dr Fontanarosa is Executive Editor, JAMA
JAMA. 2020;324(2):151-153. doi:10.1001/jama.2020.10242

Society remains in the grip of the worldwide coronavirus disease 2019 (COVID-19) pandemic. As each town, city, and country attempts to restore some aspect of normal life, they are confronted with 2 nearly identical questions: What is the individual risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and ultimately COVID-19? What is the risk for the population that renewed activities will fuel a surge of new cases of disease and potentially overwhelm the health care system? Neither of these questions can be answered with precision, and yet they have come to dominate everyday conversation.

Some data are helpful to understand the risk. Overall, since March 1, 2020, the overall cumulative hospitalization rate for COVID-19 in the US was estimated at 67.9 per 100 000 or about 0.068%.1 In addition, the major risk factors for mortality related to COVID-19 are now well-defined—age and underlying comorbid conditions.2-4 About 50 million individuals in the US are older than 65 years of age.5 Based on various data sources,6-9 about 75% of the more than 100 000 COVID-related deaths in the US to date have occurred among these older individuals; thus the risk of death in this population is about 1.50 per 1000 or 0.15%. One-third to half of the deaths in some US states have involved residents in nursing homes or other long-term care centers.10 Approximately 1.5 million individuals live in these facilities in the US,11,12 and if approximately one-third of the 100 000 deaths in the US have occurred among individuals from these facilities, the risk of death in this population is about 22 per 1000 or 2.2%.

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    3 Comments for this article
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    Risks & Responsibilities...
    David Fessell, MD | University of Michigan
    Thank you for this informative and thought-provoking summary. Individual risk, societal risk, lingering risk, and our responsibilities as citizens and human beings....much to consider and reflect upon.

    "Grappling with and balancing risk, personal choice, and freedoms against individual responsibility and the common good must be part of the discussion." Indeed! The distinctions and clarity you provide are very helpful. Please do read this article! I expect it will elevate many upcoming discussions.
    CONFLICT OF INTEREST: None Reported
    Post-Covid19, will failing to accept the need for major change represent the most harmful risk of all?
    Stephen Green, MD | Sheffield Hallam University & University of Plymouth, United Kingdom
    Bauchner & Fontanarosa are correct that balances need striking between the rights & responsibilities of human beings vs individual & societal needs. 

    With COVID-19, a lethal transmissible virus, one should really be including all individuals' “right to live” in discussions.

    Put starkly, for any human being there is nothing more harmful, personal & final than their own death. Given that some people’s personalities lead them to more readily accept & even enjoy risk taking, the potential for the actions of some to lead to the deaths of others must be pondered. Many of us find the
    fact that others would not only be prepared to put themselves at risk but simultaneously also risk our lives too to be highly unacceptable.

    So, where to from here? In a crisis, balancing freedoms with responsibilities has to start somewhere. It requires philosophical, legal & political foundations. It also demands leadership. Politicians cannot sidestep that challenge. It comes with the job.

    But what represents the good heroic political leadership needed in a crisis? Bob Dylan’s view seems a good starting point - "I think of a hero as someone who understands the degree of responsibility that comes with his freedom."

    Ergo, it is leaders who must provide that understanding & render judgement as to where the balance between rights & responsibilities lies.

    Useful inspiration may come from the world of medical ethics. The principle of “primum non nocere” – first do no harm - has served medicine well for millennia, & in our current situation wider societal application of this notion could - seen from the perspective of a “reasonable person” - be deemed “reasonable”(1). So, if collective changes in behavior are judged necessary for the common good & the only way to best ensure that those in society who don't wish to have their lives cut short as a consequence of actions by others do not then so be it. This way forward arises naturally out of a broader application of “primum non nocere.”

    But more risks have to be considered. As Fyodor Dostoevsky wrote, “Taking a new step, uttering a new word, is what people fear most.” We have to recognize that effecting even essential change is tough. But, change can itself be seen as risky. That said, nothing is fixed in stone, & and COVID-19 has enormous potential to force change.

    While some leaders may seem intent on pushing everything on the economic, trade & international travel fronts back to December 2019, that may mean we return to a world where unnecessary & harmful risks are imposed on the human beings who have to live in it. So, maybe it is time for our political & economic systems to accept that our world has changed, quite possibly forever, & instead seek out new less harmful ways forward (2). For example, should a requirement to design infection prevention & control – including safer social distancing – into all aspects of human life, including how we work, travel & relax, be non-negotiable? After all, the next zoonotic pandemic could be even worse. (3)
      
    Albert Einstein said “Insanity is doing the same thing over & over again & expecting different results." Facing up to the fact that turning the clock back to patterns of human behavior & expectations from the pre-covid 19 era may in itself be an act of insanity is vital, & failing to change may be the biggest risk of all.

    Authors: ST Green MD & L Cladi PhD

    REFERENCES
    1. https://aeon.co/ideas/legal-st&ards-invoke-the-reasonable-person-who-is-it
    2. https://www.bmj.com/content/369/bmj.m2056/rr
    3. https://doi.org/10.1016/j.jinf.2020.05.015
    CONFLICT OF INTEREST: None Reported
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    Misrepresentation of Statistics
    Eric Stein, MD BA | Main Line Health Hospitals Senior Staff Physician, Emeritus
    Does Bauchner really mean to imply that current US Covid deaths (100,000 at the time of publication) are an indication of disease mortality rate? How else does he conclude that the death rate among people over 65 is 0.15% and the death rate among older individuals in long term care facilities is 2.2%? These are percentages based on then-current total deaths, not on mortality rate. After all, the current death count for COVID in the US is >140,000, so the percentages quoted in the editorial are already inaccurate. You cannot use total deaths at one point in time as an indication of the mortality rate of a disease. In addition, as JAMA has recently published (1), the death rate from COVID in the US is estimated to be about 28% higher than the total number of reported COVID deaths - when one looks at the total deaths reported throughout the US from March 1 to May 30, 2020, compared to death rates during the same time period in prior years and subtracts the number of reported deaths from COVID, there's still a 28% higher death count in 2020 than during prior years.

    The discussion in the article about an individual's general risk tolerance and an individual's reluctance to be dictated to by "society" is, at best, unhelpful and counterproductive. If state law requires automobile occupants to wear seat belts under penalty of a substantial fine, we don't question whether or not our individual freedoms are being taken away; we accept the minor inconvenience for the sake of our own health and the health of those traveling with us. In a pandemic, I believe there should be even more expectation that individuals will make small sacrifices for the general well-being of society.

    The sooner the US gets a handle on COVID, the faster we will be able to resume a more normal life. And we can only get a handle on this disease if we agree to be led by the science and (accurate) data.

    REFERENCE

    1. Weinberger et al. 07/01/2020, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2767980
    CONFLICT OF INTEREST: None Reported
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