Are we “Waiting for Godot”- A Metaphor for Covid-19
James J. James, MD
aiting for Godot, a play by Samuel Beckett, 20s to as high as 90% to eliminate transmission. If the
is representative of what has come to be lower estimates are indeed correct then we may well be
known as the Theatre of the Absurd. seeing an HI effect in the New York City area where
Variously defined as existentialist, dystopic, post- the curve for new test positives has remained flat
modern among other genres, it is characterized by throughout the recent increases seen in most other
obscure themes, illusory hopes, awaiting an event that states.2
never occurs and lacking a conclusion in the dramatic
sense. Without defining specific parallels, the overall As of this morning (July 29, 2020) there have been a
effect on the theatregoer is all too close to that felt reported 17,025,617 “cases” of COVID-19 and
by one reviewing the evolution of COVID-19 and 665,947 deaths globally with 4,498,887 cases and
our responses to it. One parallel that is worth pointing 152,358 deaths recorded in the US. These are large
out is the voluminous, often paradoxical, analytical and alarming numbers when reported as unadjusted
and critical literature published on Beckett’s work in numerators but when presented in terms of overall pop-
attempting to explain its meanings and underlying phi- ulation rates, they are far less frightening. For the US the
losophy such that almost any characterization of the reported “case” rate is 1.3% and the mortality risk is
work can be supported. Similarly, with COVID-19 .045% with the corresponding global figures approxi-
there is a plethora of published reports on every aspect mately one sixth of those for the US (https://www.
of the disease that allows supporting almost any opin- worldometers.info/coronavirus/). The term case is placed
ion or policy. One of the hallmarks of Beckett’s mature in quotation marks above because it is misleading.
works was a minimalist approach. Likewise, I plan to Reported, cases are, for the most part, a positive lab test
use this approach in presenting a review of where we and not the presence of disease or injury, which is the
are with various aspects of COVID-19, and, more proper definition of a medical case. With COVID-19
importantly, how we can no longer afford to await this is more than semantics as the best case CDC esti-
the arrival of Godot. mate of asymptomatic positives is 40%3 and the overall
population case rate, by inference, could be but 0.8%.
Godot in this case might well be the arrival of an effective
vaccine but, as in the play, that might prove to be more an Another variable that we need to look at is testing,
illusion of hope than a reality. The obstacles to fielding a both its accuracy and the resulting ratio of true to total
vaccine anytime soon necessitate reassessing acceptable positives. The accuracy is dependent on a test’s sensi-
and effective interventions to at least slow the rate of tivity and specificity, which can only be estimated for
transmission. What is especially troubling in depending COVID-19 as there is no true gold standard to measure
on a vaccine as the answer to COVID-19 is that the high- against given that we are dealing with a new disease. A
est risk group (the elderly) historically are most refractive further complication is that there are well over 50 dif-
to vaccines in general, plus fewer than 50% of Americans ferent tests being used across multiple testing and
plan to accept a vaccine upon its release.1 Given reporting protocols with varying degrees of accuracy.
these considerations we need to take another look at This is not to negate in any way the great importance
Herd Immunity (HI) and its role in this pandemic. of testing in the diagnosis, understanding and control
Importantly, we are addressing HI as a naturally occur- of COVID-19, but to underscore that it is not perfect
ring phenomenon and not as an intervention that and may well contribute to the flawed value of case
would purposefully expose individuals to a potentially reports as an indicator of the health impacts of the pan-
serious disease. Just as important, the HI level should demic. Just one example to highlight this point—for
not be looked at as a static number nor as an all or none the US population, assuming an overall COVID-19
state. Rather, as the overall level of population immun- prevalence of 2%, using a test with 99% sensitivity
ity increases the optimal HI level is approached and the and specificity will result in a 33% false positive rate.
rate of transmission decreases, resulting in a “flattening Such a result, if even in the ballpark, would further sig-
of the curve”. The optimal level of HI for COVID-19 is nificantly reduce the estimated population medical
unknown, with various estimates ranging from the low case rate of 0.8% given above.
Disaster Medicine and Public Health Preparedness 297
© Society for Disaster Medicine and Public Health, Inc. 2020. This is an Open Access article, distributed under the terms of the Creative Commons
Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any
medium, provided the original work is properly cited. DOI: 10.1017/dmp.2020.280
https://doi.org/10.1017/dmp.2020.280 Published online by Cambridge University Press
Are we “Waiting for Godot” - A Metaphor for Covid-19
A final consideration demonstrating the irrationality of using here. However, there is one raging controversy that demands
positive tests as a yardstick for measuring the health impact of our attention and that is concerning our school aged children.
COVID-19 is the dramatic shift in the mean age of test posi-
tives from several months ago to the present time. One con- From the beginning of our engagement with COVID-19, one
stant that has been evident through the course of this consistent analogy used to define our interaction has been that
pandemic is that over 80 percent of fatal outcomes occur in we are at war with the virus. In many ways this military analogy
those over 65. With the recent much publicized spike in US has been obvious and helpful, but we have too often failed to
cases not enough attention has been paid to the shifting recognize that in many ways we have also been at war with our-
demographics of the test positives. Florida is most representa- selves. The virus has certainly been a formidable foe with casu-
tive of what we are seeing nationwide where the average age of alty counts enumerated above. But what of the casualties
a test positive has gone from 54 in May to 35 today.4 This makes resulting from many of our ill-advised interventions, most nota-
any comparisons of overall health impact over time absurd as cur- bly the K-12 school closures affecting some 55 million children
rent medical cases are simply not equivalent to earlier ones across the US.5 The full impact of the collective educational,
because of significant differences in average age. This is further economic, social, psychological, and physical damage to these
underscored by the fourfold increase in testing we have seen children is yet to be tabulated but the sum total of healthy
since early May as the overall number of asymptomatic positives life-years in terms of morbidity and pre-mature mortality will
will increase along with the true cases, further diluting the medi- more than likely far exceed that caused directly by the virus.
cal significance of the recent spikes. The overall effect of these The fact that this harm is inflicted on those virtually immune
shifts is demonstrated by the fact that while there has been a four- to serious medical outcomes secondary to COVID-19 is a
fold increase in daily “cases” since June 1st there has been a much self-inflicted tragedy. Why do we even have this situation?
more modest increase in mortality rates of just above 10% Firstly, we recognize that we are involved in a war but fail to
(https://www.nytimes.com/interactive/2020/us/coronavirus-us- accept the fact that war generates casualties; secondly, our
cases.html). operations to date have been tactical and defensive—we need
an overarching strategy that includes accepting some degree of
The above discourse is not intended to diminish the serious- reasonable risk; and, thirdly, we need to preserve our strength
ness of COVID-19 for those afflicted with it. Clinically it going forward, and that is first and foremost our children. To
can be a devastating and too often lethal malady with profound continue school closures awaiting something that may not even
impacts that affect patients, loved ones and the health systems arrive is clearly an illusion of hope and tantamount to fostering
caring for them. However, and most unfortunately, COVID- systemic child abuse.
19 has become as much a divisive political issue as a medical
one, making it difficult for individuals to identify accurate “You’re on Earth. There’s no cure for that.”
information from amongst conflicting opinions and advice. – Samuel Beckett
The tool that has been weaponized in these debates is statistics
and it is interesting how a common set of data can be used to REFERENCES
support opposing arguments and conclusions. Another victim
of this politicization is sound and effective health communica- 1. Crist C. WebMD poll: most would wait on COVID vaccine. Published July
28, 2020. https://www.webmd.com/lung/news/20200728/webmd-covid-
tion that has unfortunately become the province of a biased vaccine-poll?ecd=wnl_spr_072820_COVID&ctr=wnl-spr-072820-COVID_
media which has nurtured an all too effective campaign of fear. nsl-LeadModule_title&mb=cVOaDtCRn5byGX7BtG0fiBK5SPsKg1NYZq
This fear has permeated our population and the discussion 1z28gUo%404%3d. Accessed August 11, 2020.
above is meant to provide a more realistic assessment of the 2. James JJ. COVID-19: yin and yang and herd immunity. Disaster Med Public
real risk of serious illness from COVID-19 so that individuals Health Prep. 2020. doi: 10.1017/dmp.2020.229.
3. Centers for Disease Control and Prevention. COVID-19 pandemic plan-
can make more informed choices as to acceptable risk and ning scenarios. Published July 10, 2020. https://www.cdc.gov/coronavirus/
authorities can better justify interventions and mandates. 2019-ncov/hcp/planning-scenarios.html. Accessed August 11, 2020.
This, of course, is already beginning to happen as evidenced 4. Moser W. Why changing COVID-19 demographics in the US make death
by younger individuals being more willing to congregate while, trends harder to understand. The COVID Tracking Project. Published
overall, the older age group rightly continues to adhere to June 26, 2020. https://covidtracking.com/blog/why-changing-covid-19-
demographics-in-the-us-make-death-trends-harder-to. Accessed August
sound social distancing practices. We could at this point dis- 11, 2020.
cuss those practices and the current controversies, such as the 5. Sharfsten JM, Morphew CC. The urgency and challenge of opening K-12
use of face coverings, but these issues are receiving more than schools in the fall of 2020. JAMA. 2020;324(2):133–134. doi: 10.1001/
enough attention elsewhere and would be simply repetitive jama.2020.10175.
298 Disaster Medicine and Public Health Preparedness VOL. 14/NO. 3
https://doi.org/10.1017/dmp.2020.280 Published online by Cambridge University Press
James J. James