The “fog of war” is a military term that describes the many uncertainties that armies experience during battle. These include the uncertainties surrounding the army’s own capability, the adversary’s capability, communications disruptions, and the adversary’s intent. Many of our political leaders have used this term to describe our war against the Corona Virus. Here is why:
We first learned about Covid 19 in late December 2019 as reports from China began to emerge concerning a potentially deadly new infection. This infection was rapidly spreading and was resulting in multiple deaths to include many older patients with preexisting conditions. Corona virus is not new. Scientists and physicians have known about four other strains of Corona virus for decades. These other four strains routinely infect people and cause mild symptoms similar to the common cold. What makes Covid 19 unique is that is a “novel virus” because this particular strain of Corona virus has only infected animals until recently. Humans have no natural immune response to the virus.
The Unseen Enemy
If you were a military commander and you were planning a battle, the first thing that you would do is to determine how to disrupt the enemy’s communications; you would take out their “eyes and ears”. You do not want your enemy to know that you are coming or be able to communicate amongst themselves about your movements or intent. Essentially, we are dealing with the same issue with Covid 19. The virus has unwittingly taken out our “eyes and ears” because we have a limited ability to test for the virus. As such, we really have no clear understanding of how pervasive the virus actually is in our country and worldwide. This affects everything that we do to include predicting its movement, containing its spread, and determining its true mortality rate.
Every year, the flu infects over 40 to 60 million people and is responsible for over 40,000 deaths in the United States alone. Despite that staggering number, the actual mortality rate is only 0.1% in the United States. Of course, that is just the tip of the iceberg, because, in reality, over 7000 people die every day in the U.S. alone. If you don’t believe me, click on the following link: https://www.census.gov/popclock/
In the United States, one person dies every 11 seconds; however, one person is born every 8 seconds. That yields a net increase of one person in the United States every 20 seconds.
The purpose of all these statistics is not to scare you. Instead, I simply want to point out how much we know about our population. We have statistics on everything; especially the flu. However, we know very little about Covid 19 and that is the problem.
A Primer on the Immune System
For those of you who know this already, you can skip this section. Your immune system consists of B cells and T cells. When you become infected with a foreign invader, such as a virus, the virus has proteins and chemicals on it that your body can use to recognize that the virus is foreign and not part of your body. These proteins and chemicals are referred to as Antigens (“Aunt-i-Gin”). The B cells react to these antigens and make Antibodies (Aunt-i-bodies). These antibodies use the antigens as chemical binders. This allows the antibodies to attach themselves to the virus. These antibodies can kill the virus or serve as red flag markers for the T cells. The T cells identify the virus, swarm it, engulf it, and kill it. Obviously, it is much more complicated than that. However, armed with this knowledge, you can now go on to understand how this virus has evaded our detection.
The Numbers Game
When you go to the Doctor or Urgent Care or Emergency Room with symptoms of the flu (fever, cough, aches and pains) they can do a rapid flu test. In 15 minutes, they will know if you have the flu. This is considered an “Antigen test”. It tests for proteins and chemicals that the flu makes. It can only tell if you have the virus right now. Scientists and Doctors can also perform a serology test to look for the presence of antibodies. This is mostly used for research purposes. It can tell us if you have been exposed to the virus and have already had it. Using this data, scientists and epidemiologists can calculate the incidence (prevalence) of the flu in the entire population for the year. It also helps them calculate statistics on what the flu will do every year. Finally, they can determine how many people will get it, how many will be hospitalized, and how many will die. This is done with amazing accuracy. It can also help Scientists create a vaccine to fight the flu every year.
Unfortunately, we know very little about Covid 19. First of all, it is a new virus, so we have not had much time to study it. In addition, we only have an antigen test and those are in very limited supply. In other words, we can only test to see if you have the virus. Very few people have actually been tested; about a few million, but there are 8 billion people on the planet! Most tests are limited to patients that are admitted to the hospital. Currently, we do not have a good serology (antibody) test to determine who has already been infected. That leaves us with a great deal of speculation.
To put this into perspective, let’s do a thought experiment:
Let’s use the flu as our case study. We know that up to 1% of patients with the flu will be hospitalized, but only about 0.1% will die. However, that is because we test millions of people and we know the incidence of the flu. In other words, if 50 million people get the flu, 500,000 will be hospitalized and 50,000 will die. (That is an approximation of the actual numbers in the United States every year) However, what would happen if we did not know about the flu and we tested only those people with the flu who were hospitalized? In other words, we only know about the 500,0000 people who are hospitalized. We don’t know that there are actually 50 million flu cases. Because of our lack of information, we only know of 500,000. The same number of people will still die; 50,000. Why? Because the death rate doesn’t change just because we don’t know the actual number of flu cases. Therefore, when we now do our calculations, we know of 500,000 flu cases (the ones admitted to the hospital) and we know that 50,000 have died. That gives us a death rate of 10% for the flu. That is clearly not true, but only because we don’t have enough data to know that actual facts on the flu. Does that make sense?
The End Game
If we go back to Covid 19, the real problem is a lack of information. You can point fingers at whomever you want, but it all boils down to a lack of adequate testing. We are in a fog of war. There are many who speculate that for every one patient with Covid 19, there could be 10 or 100 or 1000 patients who have it or already have had it and we do not know. If the actually incidence is 100 times more than we expect than the death rate is not nearly as high as we think. In addition, it is definitely becoming clear that many patients who have Covid 19 are asymptomatic. In other words, they are passing on the virus to others without knowing that they have it; they have no symptoms. Some speculate that the number of asymptomatic individuals could be as high as 80%. That would certainly explain how this virus has traveled so far so quickly. It also would suggest that the incidence of Covid 19 is much higher. If that many people have been infected, we could be reaching herd immunity. That could explain, in addition to social distancing, why the curves are flattening in some countries. Still, that is conjecture, because no one knows.
Because the virus lives in a shroud of secrecy, it has taken out our eyes and ears. If we knew more about the virus, we would clearly know who is most at risk and we could contain them. We would know the true hospitalization rate and mortality rate and we could prepare accordingly. We would know who is not at risk or who will be asymptomatic. Those people could continue their daily life. Because of all the unknowns, our only option is to contain everyone, shut down the world economy, and wait for this to blow over. If we had adequate testing, we could use a scalpel to contain this with precision rather than a sledgehammer. In other words, if we had adequate testing, we could identify those patients who have it and contain them. We could also identify those patients who have had it. Those patients would have antibodies and are now immune. We can allow them to go back to work to get the economy rolling again. We can also allow them to care for patients who have Covid 19. They do not need PPE (personal protective gear) because they are immune. We do not use PPE when we treat flu patients because we know who has had it and who has not. The same could hold true for Covid 19. (Caveat- we do not know enough about the immunity to Covid 19 yet. We assume that people would become immune as they do with other viruses like the flu, but we do not know for how long or how protective it is against subsequent infections.) Finally, and most importantly, we do not have a vaccine as we do with the flu. We cannot protect people especially our health care workers.
For all of these reasons, here we sit, including me, typing this blog. Until our science catches up and we ramp up testing, treatment, and a vaccine, we will likely remain in the fog of war fighting an enemy that eludes us at every turn. The good news in all of this is that our immune system is smarter than us. Remember that we have a net new person in the United States every 20 seconds. There is a reason for that; the human race is hard to kill. While we will all suffer a bit in the short term, and sadly, some of us will not make it through this, the overwhelming majority of us will. As we get more information, the fear and panic will subside. We will go back to living our lives and we will survive this as a species. I suspect that this will even make us even stronger and a bit more appreciative of the importance of our health.
Dr. Kevin D Halow MD MBA FACS
- Joint Service Command and Staff College, Advanced Command and Staff Course Notes dated 2001