Tuesday, January 04, 2022

How "Mild COVID-19 Symptoms" Are Like Earthquakes and Unemployment

by Neil H. Buchanan

I am now almost recovered from a case of COVID-19.  I think.  My uncertainty is actually two-fold.  First, I am not certain that I ever had Covid.  And second, I cannot be sure that it is really ending.  Even so, my recent experiences, I think, will help clarify some aspects of this pandemic that are not widely appreciated.  Even if one stops short of being on one's deathbed, this disease can be terrifying.

Regarding the uncertainty about whether what ails me is COVID-19, this is actually rather odd.  I have been having flu-like symptoms on and off for most of a month.  This was not surprising, however, because I almost always get a winter flu.  Moreover, I had spent the Fall semester running around England and the EU, returning to the US on December 1 (and getting boosted on the 3rd), after which I spent much of December flying around this country for various reasons, staying in hotels and generally pushing my body beyond normal tolerances.  Of course I would end up feeling lousy.

Even so, because much of what I have been doing is -- in the Covid era -- at least somewhat risky, I needed to take seriously the possibility that this might not merely be my body's standard December protest against travel discombobulation and general excess.  Luckily, I had brought some rapid home tests back with me from Britain's NHS.  After a couple of days of feeling unwell, I took a test on December 20.  Negative.  Good news!  I then spent the pre-Christmas week catching up on sleep, and all seemed to be going in the right direction.  On the 27th, however, I woke up feeling so ill that I took another test.  Negative again.

This time, however, things got worse rather than better, so much so that I contacted my primary care provider on the 29th.  (I am, of course, lucky enough to have decent health care coverage provided by my employer.  I never take that for granted.)  In a sign of the times, the receptionist listened to my situation and said that, because I had symptoms, they did not want me to come to the office.
 
I then had a telemedicine consultation with the Nurse-Practitioner (NP).  I described the situation, and she said, "Yeah, this really sounds like Covid."  When I reiterated that this was kind of normal for me, and that I had had two negative tests, she said that it was still almost certain that I have Covid.  She said that she would "treat you as if you have Covid," which frankly scared me in a way that I have never been scared before.
 
When things were no better the next day, she sent me to a clinic to get both a rapid test and a PCR test.  The rapid test came back negative, but because of staffing issues and Florida's surge of cases, the PCR test would take three days to be reported.  Yesterday, that test also came back negative.  The NP is very surprised, and based on my experience, I also now believe that I had/have Covid.  It is still true that I have never tested positive, but I am self-isolating (again, a luxury that many people are not afforded), because I do not want to expose others to whatever this is.

Which brings me to the second bit of uncertainty.  Am I over this, whatever it is?  A wise man said that it ain't over 'til it's over, and in this case, that means that I could have a relapse.  Indeed, I have recently learned that the common path for Covid cases is not a smooth diminution of symptoms.

On the other hand, I arguably have already had my boomerang moment.  On Saturday, New Year's Day, I felt awful.  Over the course of the day, I worried that this was truly out of hand and that I would have to go to the emergency room.  I did not do so, even though I probably should have, because ER's are overwhelmed, and I was not sure that I needed to go.  I also had a Pollyannish sense that everything would somehow turn out fine.

Even so, because my oxygen levels were low, I quite consciously thought about the possibility that I might die in my sleep if I went to bed.  I stayed up as long as I could, finally making my peace with the idea that the end might come sooner for me than I had imagined.  Even typing these words now makes me wonder why I did what I did, but it is the truth.

After I recounted all of this to a close friend yesterday, she pointed out that people tend to get sick in the same way every time they get sick.  That is, she noted that I had said that my symptoms were originally very much like my "standard annual flu."  Not everyone gets a flu nearly annually, but most people who get sick have patterns.  I never panic at a flu because every flu is slightly different yet utterly familiar.  Growing up, I would pretty reliably end up with a strep throat at least once a year.  No one thought I would die.

What made this past Saturday different and horribly memorable was that my familiar symptoms were more intense than I had ever experienced in the past, and there were some new ones on top that took me by surprise.  This was all truly different, though on a familiar template.  But hey, I survived!  All's well and all that, right?

With the Omicron wave having washed over the globe in the last five weeks or so, a couple of interesting public health issues have come to the fore.  The first is the open empirical question of whether a less damaging variant that hits many more people is good news or bad news for our already beaten-down health care system.  If the relative weakness of the variant in terms of creating serious symptoms can outweigh the much larger number of cases, then the news is good.  If there are so many new cases that even a tiny percentage of those cases ending up in the hospital causes a huge problem, however, then we have a huge problem.

Unfortunately, the projections are not good on that score.  I cannot resist, however, pointing out that a direct analogy to this empirical problem shows up in one of my primary areas of research: Social Security.  Anti-Social Security panic mongers often note that the retirees-per-worker ratio is going up, and they say that this means that the system will break down.  This, however, ignores that workers in the future will be much more productive.  The only question is whether the increased productivity will more than offset the increase in retirees-per-worker.  In some countries (Italy and Japan, for example), the news is not good.  In the US, however, we are not anywhere close to a death spiral, because the productivity increase is easily strong enough to dominate the demographic effect.  But it most definitely is an empirical issue.

Please forgive the wonky digression.  I haven't been feeling well lately.  In any case, the first new omicron-related public health issue is whether or not the relative mildness of the new variant's symptoms is good news system-wide.  Again, the empirics currently say that the bad will dominate the good.  Which is bad.
 
The second issue is whether the relative mildness of omicron's symptoms is good news for the people who are infected.  And of course the answer there is an unambiguous "yes."  If a person contracts Covid, weaker symptoms are better than more debilitating symptoms.

Even so, my recent experience suggests that there is much more to the story.  Watching the various, excellent public health experts on the cable news shows, one can easily get the sense that "mild symptoms" means "no big deal at all."  Their messaging makes sense, in a way, because they are trying to give people reason to focus on the good news.  But at some point, they will specify that "mild symptoms" in this context means "almost certainly will not (for a fully vaccinated and boosted person) result in hospitalization or death."  They might also add that even the hospitalizations that do happen will not be ICU cases.

Again, that is great news, for sure.  But if one thinks about the gradations of symptoms short of hospitalization or death, there is a wide range of possibilities.  These include: (1) truly asymptomatic, (2) symptoms that are so weak as to be merely an annoyance and might not even make the person think that Covid is in play, (3) stronger symptoms that lay a person out for a few days, (4) symptoms so strong that a person has to see her primary care provider but that resolve quickly, and (5) strong symptoms that are unfamiliar and that change intensity in both directions, but ultimately falling millimeters short of hospitalization.

Having lived through a week of Category 5, it is difficult to view these as "mild symptoms."  Indeed, I have never been so scared that I was going to die.  And as the headline for this column suggests, there is a broader concept at play here.

Where do earthquakes and unemployment come into the story?  I will take them in reverse order.  When I was in graduate school in Economics, the late Professor Martin Feldstein was somewhat infamous among the students for his annual lectures (to his undergraduate class as well as to his graduate macroeconomics course) in which he aggressively and emphatically downplayed the importance of unemployment.  He would offer not-entirely-implausible -- but still shockingly wrong -- reasons why unemployment among subgroups of the population were no big deal.  Youth unemployment was surely transitory, he said, and they could rely on their parents in any event.  Unemployment among women was not a primary policy concern, he added, because they were mostly secondary earners.  Racial minorities had elevated unemployment rates for reasons having nothing to do with macroeconomic policy, he assured us.  (Of course, he also opposed micro-based policies to ameliorate those problems, but who cannot appreciate a good diversionary tactic?)

But even after proving (at least to his own satisfaction) that only unemployment among "prime-age white males" was the proper concern of policymakers -- and that that unemployment rate was low enough to be of no concern -- he was not finished.  The next step was to show that "spells" of unemployment were relatively short.  I heard this lecture for several years in a row, and the numbers were wildly different in some years than others, but the message was always the same: median spells of unemployment of 11 weeks, or 8, or 15, or whatever proved that there was nothing to worry about.  The people above the median probably had other issues, and everyone else would be back to work in only a few months.  No problem.

What infuriated me most about that argument was that it hinged on something that economists otherwise care quite a bit about, which is the difference between ex ante and ex post reasoning.  Or, to put it in non-jargon:  People do not know that their particular spell of unemployment will be "only" x weeks until it ends.  While it is happening, every day is a grinding disappointment.  Because so many of the problems caused by unemployment are tied to its affect on people's psyches (abuse of alcohol and other drugs, violence against family members, and so on), each day's setback is another impetus toward a harmful decision.

Moreover, even on a purely financial basis, people generally cannot borrow against their future incomes (especially people who are currently unemployed and have spent down their meager assets).  This means that "you'll be fine a few weeks from now" is not only unlikely to lift the depression but also does nothing to put food in one's mouth (and the mouths of one's children).  That a spell of unemployment turned out to be relatively short -- but query whether a tenured Harvard professor's notion of "relatively short" should carry any weight here -- does not mean that the time during which a person was desperately seaching for work was not terribly damaging, financially and personally.

And that brings us to earthquakes.  I have experienced two earthquakes in my life.  (Actually, because earthquake activity involves a lot of low-Richter tremors that people never notice, I surely have experienced many more; but that is beside the point.)  I spent the summer before the October 1989 Bay Area "World Series" earthquake in Berkeley.  One night around midnight, the house started shaking.  It got worse and worse, and then it stopped.  What to do when it stopped?  It might come back, or not.  After several hours of waiting, I went back to bed.

The next morning, my mostly Californian students were laughing about the mild quake.  When I told them that I was scared to death, they said: "Oh, come on, don't be an Eastern wimp, Professor.  It was only a 5.1, and it only lasted 30 seconds."

I suspect that it is obvious where I am going with this.  I responded: "Well, sure, we know that NOW!  While it was happening, no one said: 'Hey Neil, it'll be OK, because this is only a 5.1 and will end in thirty seconds.  You're good!'"  Looking back on something that did not end in total disaster can tempt us to say that it was never such a big deal in the first place, but that is not only false but also misses the psychology of being terrified.  I had exactly the same experience in the 2011 Washington, D.C., quake.  But I lived, right?

At this point, then, even though I am apparently following the pattern of Covid cases that count as "mild symptoms," I am not sure that those symptoms will end.  At the worst of it, I thought: "Well, it's not like anyone knows that there will be zero cases of fully vaccinated and boosted people with infections that end in the hospital or the morgue."  And this does not even include concerns about so-called long Covid and its possible impacts. Again, however, I do not even know whether I had/have COVID-19 at all.

During my travels last month, I was pleasantly surprised to see a brightly lit sign in a bar in Nashville (Fleet Street) that read: "Get Vaccinated!  If you don’t think it's necessary, or you think COVID's a hoax, maybe find a different bar to drink in."  The people who say that Covid is a hoax have been wrong all along, of course.  What makes it worse now is that many people -- not only the original deniers -- are saying that this is NO BIG DEAL because the public health experts are saying that most omicron cases will have mild symptoms.

It is a very big deal when millions of people are going to suffer symptoms like those that I have experienced.  Some will fill up ER's, some will act out in other ways, but all will be put through the kind of existential uncertainty that we should want to avoid for ourselves -- and that we should not want to inflict on others.  "I didn't end up in an ICU or dead" does not always feel mild.  It can feel like being just about to go to a hospital and maybe die.  We should make sure that this happens to as few people as possible.