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“Case Numbers Don’t Matter”—and Other Fatal Covid Fallacies

The logic behind “cases don’t matter”—the drumbeat of medical professionals pushing us back to normal—is a direct violation of the oath to “first, do no harm.”

By Gregg GonsalvesTwitter

May 19, 2022

Dr. Ashish Jha, President Biden’s new Covid-19 coordinator.(Elise Amendola, File / AP Photo)

Back at the start of February 2022, at what in retrospect was the peak of the Omicron surge, with over 2,500 deaths per day in the United States from the infection, Ashish Jha, then the dean of the Brown University School of Public Health and now the White House Covid czar, told The New York Times’ David Leonhardt, “I don’t actually care about infections. I care about hospitalizations and deaths and long-term complications.”

The mind-numbing logical inconsistency at the heart of the new consensus that Covid-19 case numbers don’t matter is one thing—the road to hospitalizations, deaths, long-term complications starts with infections. Even if Omicron, in David Leonhardt’s words, was milder than previous variants—which, frankly, is starting to look like a dubious proposition—its sheer transmissibility was always going to be a problem. Because it’s the infection fatality ratio and the reproductive number together that matter in the end. A wildly transmissible variant—even of putatively less clinical severity—is going to cause more carnage than one that cannot manage to infect very many people at all. That was the winter of 2021–22.

But the main hypothesis here is based on a notion that we can, no, rather we have, delinked case numbers from all those nasty downstream effects; given the infectiousness of SARS-CoV-2’s recent variants, we’re all going to get it, and we might as well just give in. It won’t be that bad. As physician and talking head Leana Wen has said:

I really believe that all of us, unless we take really extraordinary steps, are going to get Covid and therefore be at risk for long Covid. I accept that risk for myself. I accept that risk for my children the same way that I accept that when my 2-year-old climbs onto a play gym and her brother is there, he may very well push her off of the play gym. Now, I wish that that won’t happen. I will do my best to make sure that doesn’t happen, but that is a risk that I have to be able to tolerate. And I think of Covid in that same sense.

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We’re all just falling off the jungle gym. Nothing that a Band-Aid and a parent’s kiss can’t soothe.

Let me be clear. If you are vaccinated and boosted (twice!), you risk hospitalization and death far less than those who remain unvaxxed. Even if you get infected, popping a Paxlovid will more likely than not make you right as rain. But this aggressive trivialization of risk, particularly this strange extrapolation of the personal risk of those with the least to lose, those with the most resources and least vulnerability as public policy—the you-do-you, right-sizing of the pandemic—is never going to sit right with me. And it is aggressive.

The back-and-forth about the White House Correspondents Association dinner a few weeks ago is a case in point. It was obviously very, very important to someone to signal that it was time for everyone to get back in the pool—and that anyone who suggested otherwise was trading in hysterics, or indulging in outrage theater by mentioning the immunocompromised, those yet unvaccinated and unboosted, and others still vulnerable out there. We want to move on. Disparities? They were there before Covid-19, and behind them are structural issues that will take a long time to correct. Meanwhile, the rest of us have to get back to our lives.

But here we are in the midst of another surge. I’ve known more people infected over the past few weeks than I have in many, many months. Almost all have been in bed for just a few days; all were vaccinated and boosted; some have gotten access to Paxlovid; none were hospitalized. And all have recovered, though a few have lingering symptoms—a cough, shortness of breath—though these are rare among my friends and colleagues. But we are more than lucky. We are privileged. We may not be the 1 percent, but we are doctors, public health experts, university professors; we work for big nonprofits, and have access to most anything we need should we get sick.

Yet they tell us case numbers don’t matter in this new wave. The CDC’s risk map is still green as can be, even as infections rip through the country, with counted cases up by nearly 60 percent and hospitalizations 25 percent greater and ICU occupancy 17 percent greater than they were two weeks ago, according to the New York Times tracker.

Jonathan Reiner, a physician in DC, has let the CDC have it: “The fact that CDC continues to propagate this green bullshit tells me that they’ve made a decision to hide this massive Covid surge from you. You deserve to know your risk when you go out (and maybe even wear a mask?). This map is camouflage.” But if cases don’t matter and getting infected doesn’t matter, then the CDC’s decision—the White House’s decision that there is little need to alert the public—makes complete sense. We’re good. Don’t worry. Here’s a Band-Aid and a kiss.

But what does it mean to say that we are going to let hundreds of thousands of Americans, millions of them, get repeatedly exposed to SARS-CoV-2? I know it’s annoying to bring up the vulnerable again and again, but let’s start with the unvaccinated (30–40 percent of all Americans are still without a jab) and the unboosted (fully 70 percent of Americans—the vast majority of us). All would agree that they are at high risk of complications and death from Covid-19. This presents an acute problem for the “cases don’t matter” crowd. We can cross our fingers that hospitalizations don’t climb higher and deaths start to mount again, but that isn’t exactly a plan. I wonder what the doctors, nurses, and others who will bear the brunt of this gamble in our hospitals and clinics think. I wonder what those who will lose a loved one over the next few weeks will think as they sit at the funerals of their mothers, fathers, children.

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How Many Deaths Are Acceptable?

The logic of the “cases don’t matter” crowd is that numbers of the sick and dead should be trivial now, and their sacrifice for the collective good is socially acceptable. Though this might be Benthamite utilitarianism—”it is the greatest happiness of the greatest number that is the measure of right and wrong”—it is surely not “primum non nocere,” or “first, do no harm,” which is part of the oath many of the physician-experts took in medical school. In the new logic of private risk/private choice, all of these Americans could simply go out and get vaccinated and get boosted. Their health is in their hands, and they choose their fate.

If “cases don’t matter,” then as long as we don’t tax our hospital capacity in the US, we’re doing a heck of a job. But I read Katherine J. Wu’s article in The Atlantic a few months ago on long Covid, which presents another problem for those who think that as long as ICUs and morgues have space for more occupants the coast is clear. The pandemic is a mass death event for sure—1 million Americans are now in their graves—but it is also a mass disabling event. The extent, scope, impact of long Covid on our country is still unknown, but “even if long COVID’s prevalence turns out to be a single-digit percentage of SARS-CoV-2 infections—proportionally much smaller than most experts estimate—in absolute terms ‘that is not small,’ says Ziyad Al-Aly, the director of the Clinical Epidemiology Center at the Veterans Affairs St. Louis Health Care System.” The clinical, social, and economic impact of cases that may not lead to hospitalization and death presents risks to our country that turn out to matter after all.

I haven’t brought up the immunocompromised because some have said that mentioning that they may not fully benefit from vaccination discourages take-up. I haven’t talked about the under-5s because some suggest Covid-19 poses no significant risk to the young. I won’t bring up the people who cannot stay home from work, whose workplaces remain at high risk for acquiring SARS-CoV-2, who cannot get easy access to masks and tests, who have no insurance or are under-insured, or are unlikely to get Paxlovid if they get sick. I didn’t want to stack the deck in favor of my argument that cases actually do matter.

The “cases don’t matter” crowd will say, “we do care about the unvaccinated and unboosted—and even, if you must bring them up, the immunocompromised, children, those in frontline occupations, those without health insurance” or other resources the “case don’t matter” crowd simply takes for granted in their own lives. But they don’t. Not really. All of their energy and influence right now is directed at demobilization, the urgency of normal for them and their kind. Listen to what they say; read what they write.

They may pay lip service to many of the issues I’ve raised, but that hasn’t interrupted the drumbeat of back to normal, back to normal, back to normal. They will get offended if you get angry, since this is just a difference of opinion among colleagues—surely we can agree to disagree without you being so disagreeable? But this isn’t an academic debate. Choices are being made that make life riskier for millions. A few weeks ago, they would have suggested that this demobilization they urged was temporary, that some mitigation efforts would have to be revived in a surge. Yet here we are with cases and hospitalizations rising and they are scolding people for trying to keep their communities safer.

Who knows what the rest of this year will bring? The White House fears another wave this coming winter that may infect 100 million Americans. It’s difficult enough to predict what the summer will offer in terms of challenges. But the shift in the national approach to Covid-19, from considering treating it as an emergency to “que sera, sera” for the cognoscenti, is at the very least whistling past the graveyard. At the worst, it’s the cynical, ghoulish embrace of human suffering by those who seek professional advancement by cheerleading for those in power. Not to mention the true believers like Bill Gates, casually suggesting that Covid-19 is now just a seasonal respiratory virus, endemic, manageable, no worse than the flu—and that any mitigation efforts beyond vaccination are unnecessary.

A Spring Surge

Make no mistake. We are in a late spring surge right now. Community spread is high in most places, hospitalizations are going up in many others, and I expect deaths to begin to climb as well. Just this past weekend The Washington Post reported a 29 percent rise in new deaths nationally compared to the week before as of this Tuesday (though The New York Times, which sets a 14-day window for changes, is still reporting a small decline in deaths). For the unvaccinated or unboosted, the risks are the most acute, but there are millions of immunocompromised people out there—and even if we’ve had fewer children die of Covid than their grannies, writing off the deaths of children takes a callousness I don’t have.

So, the very least of what I’d expect from our leaders now—the politicians, the agency officials, the talking heads and experts—is to sound the alarm. Warn people that the risk to them and their families is high, as too many are unvaccinated and unboosted. Some have suggested that we wait for rises in national deaths to start to break through, but that is akin to not calling the fire department until you’re sure you’ve got a good burn going. Besides, deaths are already starting to sneak up.

Beyond warning people, I’d be begging Congress to appropriate what we need for a renewed push for vaccinations and boosters—and to help people stay safe, to remain home if they are sick with paid sick leave, with housing subsidies to keep them from being evicted. I’d tell corporate America that, while they successfully pushed for lifting pandemic mitigation for their shareholders’ benefit, they now have a higher responsibility to keep their workers safe by giving them workplaces that don’t exacerbate risk.

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I’d keep schools open—but get them what they need to keep everyone safe, and in the short term, this will likely mean tests and masks, particularly for most school districts that are still without ventilation upgrades they need. I’d keep even bars and restaurants open, but ask owners to require proof of vaccination. I’d tell Americans who struggle with health care coverage: We’re not going to lift the public health emergency and let you get purged from your state Medicaid rolls.

I’d tell people we’re not going to leave you in the lurch like we did last December with a mad rush for rapid tests and a hunt for N-95s even among the well-to-do. I’d say that while the courts aren’t fond of mask mandates, during a surge you should put on a mask in public places—particularly indoor ones—out of simple human kindness and generosity, even if your local leaders don’t have the sense to ask you to do it first.

So Much More We Could Do

There is so much more we could do than capitulate, if we had the political will. And please, go fuck yourself if you think that any of this is akin to a Zero Covid strategy, the current brutal lockdowns happening in China. We in this country have suffered more than our peer nations because of the Covid minimizers from right, left, and center, who were insisting that it’s time to return to normal even in the darkest days of the Omicron surge.

But we won’t even get an acknowledgment that we are in a new wave. And of course, if you can’t admit the basics, all the rest is far less likely. Still, we keep pushing because as my old Yale College classmate—now infectious disease physician and researcher—Abraar Karan has said:

Cases matter. Surge of cases matter. Re-infections matter. Testing matters. Sequencing for new variants matters. Morbidity & Long Covid matter. Cases in unboosted individuals matter. Cases in high-risk patients matter. Cases among those without ‘the tools’ matter.

Plenty of people know this, and are trying to do their best to fight. You’re not alone if you share these concerns. In the end, you need to know where you stand. When this is all over, I hope there is a reckoning, in this life or the next, for the ways in which people who have committed their lives to public service, to the care of others, were so willing to cut loose the ties that bind us to each other, to sacrifice so many others for the good of those just like themselves.

Gregg GonsalvesTwitterNation public health correspondent Gregg Gonsalves is the codirector of the Global Health Justice Partnership and an associate professor of epidemiology at the Yale School of Public Health.


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