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            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-                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 (, which permits unrestricted re-use, distribution, and reproduction in any
       medium, provided the original work is properly cited. DOI: 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
         (                 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.
         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.
         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.
                                                                                         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 Published online by Cambridge University Press

Are we “Waiting for Godot”- A Metaphor for Covid-19

Authors James J. James

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