Stay the fuck at home

Based on an informal poll of millennials and Gen Zers in my social circle, I realized a lot of smart people
are not taking the coronavirus situation seriously. There is a lot of confusion with all the metrics and
advice flying around with regards to this virus, so in this post I’d like to help cut through some of the
hysterical fog. I’m not an epidemiologist, but I do have a background in complex systems behavior,
reconciling conflicting and spotty evidence, and making abstract numbers relatable. If you’d rather skip
all this and trust a(nother) random person on the internet, here’s the tl;dr: stay the fuck at home. Even
if you’re a star athlete, descended straight from Achilles through a long line of non-smokers; stay the
fuck at home.

Clarifying terminology
I suspect part of what’s driving this confusion is that there’s a lot of epidemiology lingo getting bandied
around imprecisely by the news and social media. Here are a few terms we’ll be using:

 Case fatality rate (CFR): % of diagnosed infections that ultimately die. This should only be
measured once the outcome of each case (recovery vs. death) is known, so active infections
need to be excluded
 Infection fatality rate (IFR): Like CFR, but accounting for asymptomatic and undiagnosed
infections. By its nature, IFR can only ever be estimated
 Doubling time: For an exponentially growing quantity, doubling time indicates how long you
must wait until the number of deaths doubles (the concept is analogous to half-life in
exponential decay). I’ll use it to refer to the growth in cumulative number of infections, though
it’s sometimes used to refer to number of deaths.

Note that media uses these terms somewhat loosely in their reporting. CFR is often reported as a % of
all infections, not excluding active infections.

With those definitions, we can start to talk about the risks of ignoring the shelter in place/quarantine
orders. The framework here is not my own; it’s used in a lot of places, like here. We’ll start by estimating
the total number of cases (including those who have not been tested).

Number of cumulative cases

The idea is to start with the most concrete statistic available, which is the death toll. There is some
ambiguity here (e.g., people with pre-existing conditions or who die from complications during
treatment are sometimes counted as COVID-19 deaths and sometimes not), but overall it is a much
more precise number than the number of active cases, which is largely determined by the scale and
scope of testing.

I’ll explain the math using NYC as an example, but you can follow the same process for any location with
reliable data reporting. As of March 31 st, there had been 932 deaths in NYC.

The remaining numbers for our calculation are less straightforward to pin down:

 IFR: This is an extremely challenging number to pin down, but crucial to inform the public health
debate. It seems to be somewhere between 0.1% and 3% (compared to the seasonal flu at 0.1%,
Spanish flu at 2%, SARS at 10%) with a ‘best guess’ around 1%
  Time to death: This has been a harder number for me to pin down. Past analyses have used 15
days from infection to death, but I haven’t been able to corroborate this figure. The best I’ve
found suggests “2-8 weeks” from symptoms to death; one man died on day 14.
 Doubling time: Lots of cultural, policy, and probably genetic factors make this very location
specific. NYC has one of the fastest growth rates. On March 25 th, there were 196 deaths, with
doubling time for deaths reported as 3 days. (Interpolating with the 932 deaths on 3/31 gives a
doubling time of 2.7 days as well). Measured by hospitalizations, doubling time has improved
from 2d to 4.7d and now to 6d after NY enacted further social distancing measures on 3/20.

With these three figures, we can get an estimate for the current number of cases in NYC. If you wind the
clock back 2 weeks to 3/17 and magically vaccinate everyone in the world, you can then let the disease
run its course. You’ll end up with at least the 932 dead (since all 932 would have had it or died before
you cast your spell), plus some others that are currently infected and haven’t died. If you can then test
the whole population and see how many people have had the disease, you’ll find at least 932 / 3% =
31,067 cases if the IFR is 3% or 932 / .1% = 932k if the IFR is at the other end of the spectrum. Note that
if there are significant number of deaths beyond 2 weeks, this will be an underestimate.

To continue illustrating the numbers, let’s use 1% as the IFR, which results in 93k cases on 3/17. In the
real word, without magic vaccination, they’ve continued to spread the disease. At what rate did they
spread it? Hospitalizations lag infections by a few days (incubation period is estimated at 5d, and
hospitalization takes some time after that), so it’s possible we’re doing even better than 6d now. If you
take 4.5d as a rough estimate of infection doubling since 3/17, the current number of cumulative cases
is around 800k[1]. If you plug in the IFR ranges, you’ll end up with ~8M cases[2] at IFR=0.1% and ~270k
cases if IFR=3%. Under the ‘best-guess’ 1% IFR, roughly 10% of New Yorkers have coronavirus.

Personal risk
What does this mean for your own risk of developing coronavirus by ignoring the shelter in place order?
Let’s say you decide to visit your friend in Brooklyn, and cautiously take an Uber instead of riding the
subway. You could get infected in your own building, in the Uber, or in your friend’s place.

The virus is airborne, and continues to be viable after 3h in air. On surfaces it can last much longer -- on
plastic and stainless steel it has a half-life around 6h. Drivers apparently average 2 fares per hour, which
means they probably had 6 fares that could have left the airborne virus for you and 10-20 that could
have contaminated the door handle, seats, etc. If 10% of New Yorkers have the virus (1% IFR)[3], that
means there’s a ~50% chance the virus is viable in the air of your uber and ~80% chance it’s on the
surfaces. At 3% IFR, those numbers are roughly 20% in the air and 40% on surfaces.

I haven’t been able to find what the risk of contracting the virus if exposed to it is, nor the risk reduction
from using gloves, wipes, etc. In a setting without sustained community transmission (i.e., not NYC), the
CDC used to classify this level of exposure as low risk. I’m not sure what that means numerically, so it’s
hard to calculate what your risk of getting the virus is (If someone has a good approach here, please
leave a note and I’ll update accordingly). As a plug, I’m going to say 1-5%, which would mean you have
somewhere around a 1-2% chance of getting the disease with a 1% IFR.

As a young millennial, your chances of dying from the disease are much lower (though not 0!). Risk of
death from the flu is ~0.02% for young people compared to 0.1% overall, so roughly 5x lower. Applying
that same ratio to IFR at 1% would put your risk of death at 0.2%, which matches the CFR from China for
the 20-29 and 30-39 age groups. Given the current state of the health system, it is highly likely that in 2
weeks there’s overcrowding in ICUs and shortages of ventilators. In those circumstances, your risk of
death will go up significantly, probably by several multiples.

Putting this all together, and factoring in that you are taking two Ubers, traveling to and from your
friend’s place exposes you to a 1 in 4,300 chance of death by COVID-19. For comparison, going out twice
is about as risky as BASE jumping[4].

Even if you don’t die, your risk of hospitalization is much higher than the risk of death[5], around 1 in
1,000 odds. (Yes, young people also get hospitalized from COVID-19).

There is a great deal of uncertainty in this estimate – I’ve tried to pick relatively neutral assumptions, so
here’s how different numbers could skew the outcome:

 IFR: If you instead assume 0.5% (a less deadly virus), your risk of death is 1 in 6,400 and your risk
of hospitalization is 1 in 1,500. At 3% the risks are instead 1 in 3,200 and 1 in 740
 Time to death: If instead of 14 days we assume 18, then the risks are 1 in 3,300 and 1 in 800
 % of NY infected: If 30% of NY becomes infected, your Uber is virtually guaranteed to have the
virus. Then your risk of death is 1 in 2,900 and your risk of being hospitalized is 1 in 670

I’ve left out the risk of your friend or their neighbors infecting you directly, since those risks are highly
correlated, unlike the Uber passengers, and harder to estimate. They are real risks though, so the above
should be considered a lower bound.

External risk
Above we said 10% of NYC likely has the disease (assuming 1% IFR). What does this look like
geographically? For the sake of argument, assume New Yorkers live in 17,000 identical buildings of 500
residents. There are two extreme ways to get to 10% infections:

a. Every single building has 50 infected residents and 450 healthy residents
b. 1,700 buildings are entirely infected, and 15,300 buildings are unscathed

In reality there are brownstones and SFHs in NY, but you can still break the city down into well-
connected ‘cliques’, and the truth will lie somewhere between those extremes. Given how infectious
COVID-19 is, though, the truth is closer to option B than it is to option A.

Because the incubation time (~5d, confirmed) and the doubling time (4 – 6.4d) are close, then roughly
half of infected New Yorkers are asymptomatic. Since infected people can be contagious before they
show symptoms, 2-5% of New Yorkers will be infectious but asymptomatic. You might be one of those!
[6]

This means that when you visit your friend, there is a 2-5% chance that you have the disease, but they
(and their building) do not. Depending on what your plans are for the visit, there could be a high
likelihood that you bring the disease to their building, ultimately infecting 500 additional people. With a
1% IFR, you’ll have caused the deaths of 5 additional people, including possibly your friend.

Beyond today
The immediate consequences of ignoring the shelter in place are dire. But maybe you need more
convincing, or maybe you live somewhere less impacted by COVID-19 and after running the numbers
you aren’t as concerned. There is, however, one more dimension to the risk that should hopefully
convince you to stay home.

Unlike BASE jumping, the risks from a pandemic are multiplicative. If you ignore the shelter in place
order, you take on a 1 in 4,300 chance of death, which is half the death risk of BASE jumping. You also
take on an up to 5% chance of infecting others and causing cascading deaths.

If your 2,300 Instagram followers all decide to go BASE jumping, one of them will die since they’re all
taking the same risk. If instead your followers go out and visit 2 friends, significantly more of them will
die. That’s because among the first 20 followers, one will infect their friend and their neighbors,
increasing the risk for the remaining followers. Among the next 20 followers, the same thing will
happen, and so on, until by the time #2,300 rolls around the infection rate is much higher and the risk of
death is too.

IRL, this compounding risk is visible by tracking the daily growth rate of the virus. I started writing this on
3/29 and finished on 3/31, and in those two days the estimated infections rose by over 30%. The virus
continues to spread due to people thinking they are too smart to panic over a “tiny risk” (even though
the risk isn’t so tiny) or that their risk-taking only impacts them. If you do not live in a highly impacted
location like NYC, stay home now to avoid following down their path. As the NYC example shows,
eventually the risk you impose on the rest of society will catch up with you.

Please stay home and contain this virus. Re-watch The Office or Netflix and chill (or both). There are
countless doctors, nurses, and supply chain workers taking on large risks already, and callously going out
will only put them in more danger.

Footnotes
[1]: A more nuanced analysis, looking at hospitalization growth rates by day and estimating infection
growth from there arrives at a very similar number.

[2]: At high infection rates--NYC has a population of 9M--the exponential growth starts to slow and
become sigmoidal, but since we’re looking at growth rates day by day, that’s less of an issue.

[3]: Our math above was for cumulative cases, not active cases, so this is a bit off. However, with rapid
exponential growth, the vast majority of cumulative cases will be active. Plus there’s some evidence that
even after recovery patients can be contagious.

[4]: BASE jumping is probably much riskier than the linked article indicates, since it’s based on jumps
between 1995 and 2005, before wingsuits became so popular

[5]: 9,500 hospitalizations in NYC vs 790 deaths

[6]: I assume if you’re showing symptoms you’ve self-quarantined already!