Throughout the COVID-19 pandemic, the argument that “99% of COVID patients survive” has been repeatedly used as an excuse to oppose public health measures including mask mandates, lockdowns, and, more recently, vaccines. It asserts that because COVID has a ~99% survivorship, is not really that big of a concern and vaccines, masks, lockdowns, etc. are not needed.

There are many issues with this argument, but before I talk specifically about COVID-19, I want to discuss a hypothetical disease. Imagine that the majority of people who become infected with this hypothetical disease are fine. Roughly 70% of people are asymptomatic. Really serious consequences that could alter the rest of the victim’s life only occur in about 0.5% of cases, and over 99.5% of patients make a full recovery. Actual mortality is even lower. The exact number varies, but even on the high end, over 99.9% people survive.

Now, when I present this hypothetical disease like that, it probably doesn’t sound that bad. Simply giving you those numbers without any additional context makes the disease sound pretty benign, and you might be tempted to use this “>99% live” argument and argue that we don’t really need a massive vaccine push and should just wait for natural herd immunity.

Here’s the thing though. I lied when I said this was a hypothetical disease. Those are the stats for polio (CDC Pinkbook), a notoriously horrible disease that was once a scourge on our planet causing thousands of cases of paralysis and even death. It is a disease that, thanks to vaccines, we very rightly sent into oblivion in nearly every part of the world. If, however, instead of using vaccines, we had listened to this “99% live” argument, we would still have polio in countries like the USA, and children would still be getting infected, paralyzed, and even killed by this disease. Ninety-nine percent survival is not as high as it sounds, nor is it the only factor that has to be considered, but it can sound very persuasive when it is presented without the other necessary pieces of information.

Please, keep this in mind as we now turn our attention to COVID. If you are tempted to dismiss the severity of COVID or the necessity of vaccines because COVID “only” kills 1% of patients, keep in mind that polio “only” paralyzed 0.5% of its victims and killed less than 0.1%.

Note: The actual COVID case fatality rate is affected by many factors (e.g., age). As such, it is far more complicated than a simple “99%,” and you should not confuse that number with the notion that you personally have a 99% chance of survival. Nevertheless, 99% is the number I keep seeing people use, and it is a rough approximation of an average for many parts of the world, so for simplicity, I will continue using it here.

Infection prevalence matters

One of the key problems with the “99% survive” argument is that it completely ignores the importance of transmissibility and infection prevalence (i.e., how easily a disease can spread). You see, a disease can be a serious threat to a population (in terms of mortality) either by having a high case fatality rate (i.e., killing a large percentage of patients) or by being highly contagious (i.e., infecting a large number of people), and case fatality rates can be very misleading by themselves.

Consider, for example, two hypothetical diseases (A and B). A has an extremely high case fatality rate of 100%, but it is not very contagious and has a very low prevalence in the population. Only about 1 in 1 million people will catch it.  In contrast, disease B has a much lower case fatality rate (1%), but is extremely contagious, and about 1 in 10 people will catch it.

This means that in a population of 10 million people, disease A will kill 10 people, whereas disease B will kill 10 thousand people! So, which of those diseases should you be more concerned about? Obviously disease B is more concerning, right? You are at a higher risk of dying form disease B, even though 99% of patients survive. Why? Because it is so common.

If you admit this basic fact, that disease B would be more concerning than disease A, then you have just admitted that case fatality rate is not sufficient in and of itself to tell you how concerning a disease is. If we had relied only on case fatalities, we would have incorrectly concluded that disease A was the bigger risk. This clearly demonstrates that the “99% survive” argument is not a good argument, because we have to look at other factors besides just survivorship (the opposite of case fatalities), and even a disease with a 99% survival rate can be very dangerous to both populations at large and you personally if it is highly contagious.

To put it simply, when considering risk, you need to consider both how likely you are to be infected, and how likely you are to die (or suffer serious consequences) if you are infected.

In the case of COVID19, a large part of why it is so dangerous is its high rate of transmission, with new variants like the Delta strain making the situation even worse. That is why it has been able to kill over 4 million people world-wide, with over 600,000 deaths in the US alone.

Those are sobering numbers, which should really make you stop and think long and hard about the veracity of the “99% survival” argument. To me, it seems self-evident that a disease that has already killed over 600,000 people in the US alone is a serious problem that merits something like a massive vaccination campaign, and the argument that the disease is not dangerous/doesn’t merit vaccines is clearly flawed.

Indeed, in 2020, COVID was the 3^rd leading cause of death in the USA, behind only cancer and heart disease (Ahmad and Anderson 2021), and in early 2021, it spiked to the #1 cause of death in the US (a situation that is no longer the case thanks in part to vaccines). That’s what COVID looks like when it is not controlled by measures like vaccines, and it should be abundantly apparent from that situation that simply having a 99% survival rate does not mean that a disease isn’t a serious threat. Indeed, if you are going to argue that we don’t need to be that worried about COVID 19, then you had better make that same argument about literally every other cause of death, because when allowed to spread, COVID kills more than any of them (or if you want to arbitrarily restrict yourself to the 2020 data, you’d better make that argument about every cause of death other than cancer and heart disease).

To put all of that another way, a 99% survival rate is only comforting if the spread of the disease is being controlled by something like vaccines. A 99% survival rate without vaccines still results in hundreds of thousands of people dying. That is a simple fact.

Natural herd immunity is a misnomer

Proponents of the “99% survive” argument often say that we will eventually achieve natural herd immunity, at which point people will be protected even without vaccines. Let me briefly explain why that is a terrible idea.

The term “herd immunity” really only makes sense within the context of vaccines. Vaccine-induced herd immunity = a population that is protected from a disease. “Natural herd immunity” = a survivorship bias in which the survivors of the outbreak are protected from future infection and many previous herd members died. “Natural herd immunity” is a bloodbath. It’s a nonsense term.

Estimates for what it would take to achieve herd immunity to COVID vary, but even at the (probably) unrealistically low end of 60% immune, getting there in the US without vaccines would involve the deaths of roughly 2 million Americans! At what is probably the more realistic threshold of 90% immune, without vaccines, we are looking at about ~3 million dead Americans.

That’s not herd immunity; that’s herd culling. Alternatively, we can achieve actual herd immunity with vaccines without killing 2–3 million people.

Disease risk is more than just death

One of the many deceptive aspects of the “99% survive” argument is that it acts as if COVID infection is a strictly binary situation: either you die or you are totally fine. That is, however, a completely false dichotomy. Since when is death the only outcome we care about? Many people who catch COVID live, but still undergo tremendous suffering physically, mentally, and financially. When we are considering the risks and benefits of something like a vaccine for COVID, we should not just look at whether or not you are likely to die. Things like time off work and physical suffering matter.

There is a vast spectrum of responses from “totally fine” to “alive, but extreme suffering (and in the US, often financial difficulty).” Good estimates of hospitalization rates are a bit hard to come by, and are usually expressed in terms of rate per population size, not rate per infection, but by taking the cumulative overall hospitalization rate per 100,000 people from the CDC, the US population size, and the cumulative cases in the US, we find that roughly 5% of COVID cases result in hospitalizations. A scientific study using more sophisticated methods provides a similar estimate of 4.5% (Reese et al. 2020) [note: as with the case fatality rate, these are crude rates for the whole population and actual rates vary by age group]. Indeed, COVID is so rampant, that roughly 0.5% of the entire US population has been hospitalized for it. That’s actually an incredible number. One out of every 200 people in America has been hospitalized for COVID (again if we average across the population), and that’s just actual hospitalizations, many more have been at home sick, took time off work, etc.

Further, the complications from the disease can be serious. COVID can set off a cytokine storm that affects multiple of your body’s major systems. It’s too early to know exactly what that means long-term, but based on what we know about COVID and other viral diseases, there is good reason to be concerned that many people who survive will have long-term lung and heart issues (Mitrani et al. 2020; Fraser 2020). To be clear, we need to wait for more data before knowing for sure if there will be long-term complications, but the reasonably high probability that there will be is certainly something to think about when considering the risks and benefits of the vaccine, and it’s something that is completely ignored by this unreasonably simplistic “99% survive” argument.

Vaccines: benefits outweigh the risks

Finally, let’s briefly turn our attention to the COVID vaccines. This would take many posts to cover in proper detail, so I’ll try to be brief and just hit the key points.

All vaccines have side effects, but serious side effects are rare, and your risk of a getting COVID and having a serious complication from it is much higher than your risk of a serious complication from vaccines. Countries with large vaccination programs (e.g., Israel; Rossman et al. 2020) are seeing massive drops in COVID infection, hospitalization, and death rates thanks to vaccines, and there has not been a comparable increase in injuries, hospitalizations, and deaths from vaccines. In other words, the vaccines are reducing risk.

In the USA, an analysis of data in May (by which time roughly 40% of the country had received both doses of the vaccine and 50% had at least one dose) found that out of over 107,000 COVID hospitalizations, fewer than 1,200 were for vaccinated individuals, and out of 18,000 COVID deaths, only ~150 of them were for vaccinated individuals. In other words, over 99% of COVID deaths were from unvaccinated individuals, as were nearly 99% of COVID hospitalizations. That trend has continued, and now with over half the country fully vaccinated, officials like Dr. Fauci are likewise reporting that over 99% of COVID deaths and over 97% of COVID hospitalizations are from the unvaccinated. The vaccines clearly work.

Further, we have not seen hospitalization or mortality rates from vaccine side effects rising to meet those numbers. In other words, with roughly half the population vaccinated, if the vaccine was truly more dangerous than the disease, we should see vaccine deaths and serious injuries at a rate that exceeds the rate for COVID. So where are the >18,000 individuals in May who died from the vaccine? Where are the >100,000 hospitalizations from the vaccine? They don’t exist, because serious side effects are extremely rare.

This clearly shows that your total risk is lower with the vaccine than without it. These numbers make that undeniable. Yes, the disease has a ~99% survival, and yes, the vaccine does have side effects, but the disease is exceptionally common, and series side effects of the vaccine are exceptionally rare, which, when taken together, results in your risk of serious injury or death being substantially lower when you have the vaccine.

Just to really drive this home, let’s look specifically at myocarditis following the mRNA vaccines. It is still not entirely clear if this is actually a side effect of the vaccines, but there is growing evidence that it is causal. Exact rates vary, but every calculation shows them to be low (Shay et al. 2021). A large data set from Israel reported a mere 148 cases within 30 days of vaccination out of over 5 million people who were vaccinated (Israel Ministry of Health). Even if all of those were caused by the vaccine, that would be a rate of 0.003%! Further, 95% of those cases were mild.

In the USA, with over 150 million people vaccinated, using data from VAERS (much of which has not been verified), the WHO calculated the following myocarditis rates per fully vaccinated individual: 0.041% for males aged 12–29, 0.004% for females aged 12–29, and 0.002% for males and females over 29. Further, again, most of those cases were mild and did not require serious medical intervention. I have not so far seen any confirmed deaths from this. In contrast, COVID has a case fatality rate of ~1%.

Now, I hear you saying, “but I am a male under 30, which means I’m at a low risk of death from COVID and higher risk of myocarditis, so for me the risk outweighs the benefit,” however, that math still doesn’t work. From the start of the outbreak in the US (based on the current CDC data), there have been 2,462 deaths from COVID in males under 30, and 1,594 deaths in females under 30. There is no evidence to suggest that the vaccines are causing comparable carnage.

Scientists actually ran the numbers on this and calculated that for males under 30, every 1 million second doses of an mRNA vaccine will result in 39–47 cases of myocarditis, but will prevent 11,000 COVID cases, 560 hospitalizations, 138 ICU admissions, and 6 deaths (Gargano et al. 2021). Also, remember again that most of these myocarditis cases are mild, whereas for COVID, even just the expected number of ICU admissions is 3 times the number of mostly mild myocarditis cases! Further, that is for a group with a relatively low COVID risk and relatively high myocarditis risk. The benefits of the vaccine are even more exaggerated for other groups. In men over 29, for example, 1 million second doses will only result in 3–4 cases of myocarditis, and will prevent 15,300 COVID cases, 4,598 hospitalizations, 1,242 ICU admissions, and 700 deaths (Gargano et al. 2021)!

Also, notice how those who like to cast aspersions on vaccines try to downplay death from COVID while hyping mostly mild injury from the vaccine. Indeed, this “99% survive” argument would have us believe that a 1% fatality is too low to be seriously concerned, but a 0.002–0.041% rate of generally mild myocarditis is unacceptably high. It is crazy to think that 3–4 mostly mild cases of myocarditis is worse than 700 deaths! That’s simply not how math works.

The numbers are undeniable: your personal risk* is lower with the vaccine than without the vaccine, even though “99% of people survive.”

I’ve been focusing on the concerns around Pfizer and Moderna because those are the prominent vaccines where most of my readers are, but we can do the same sorts of calculations with any of the vaccines currently available. They all have various risks, but in every case, the risks associate with not getting the vaccine outweigh the risks associated with getting it.

*Obviously some people have pre-existing conditions that make vaccines dangerous for them. That is not what I am talking about here. I am addressing people who have no known health conditions that would prevent them from getting the vaccine.

Conclusion

In summary, the “99% survive” argument completely ignores the high prevalence of COVID and completely ignores the importance of non-lethal effects (including hospitalization, possibly long-term effects, time off work, etc.). Further, using this argument against the necessity for vaccines massively and inappropriately downplays the risk from COVID while exaggerating the risks from vaccines. The empirical reality is that COVID is very dangerous, with over 600,000 dead in the US alone, whereas the vaccines are very safe. Given that over 50% of the US population is currently vaccinated, if the vaccines were truly more dangerous than the risk from getting COVID, we’d expect the rates of vaccine deaths and serious injuries to be surpassing the rates of deaths and serious injuries from COVID. In reality we are, of course, not seeing anything even remotely like that. Deaths and serious injury from COVID remain common in the unvaccinated, whereas serious injuries from the vaccines are extremely rare and deaths virtually unheard of.

I think part of the problem is that we often view taking an action as the inherently riskier choice. After all, you can’t get myocarditis from the vaccine if you never get the vaccine. That reasoning, while understandable, ignores the fact that not getting the vaccine is also an action, and that action puts you at a much greater risk of death or serious illness. Indeed, that risk from COVID is so great, and the risk from vaccines is so small, that even if you are young and healthy, the risk associated with not getting the vaccine is far higher than the risk associated with getting the vaccine. This is a mathematical fact.

Please read this post before making an argument about “unknown long-term effects” from vaccines.

Related Posts

• Future (“long-term”) side effects from COVID vaccines are extremely unlikely
• COVID comorbidities are not analogous to car crashes: Debunking the 6% mortality claim
• Jon Stewart’s irresponsible, anti-science, COVID conspiracy theory rant
• The problems with anti-vaccers’ precautionary principle arguments
• ·Understanding the reported risks of medicines, foods, toxic chemicals, etc.

Literature Cited

• Ahmad and Anderson 2021. The Leading Causes of Death in the US for 2020. JAMA
• CDC. Provisional COVID-19 deaths by sex and age. Accessed 26-July-2021
• COVID.NET. Laboratory-confirmed COVID-10Associated Hospitalizations. Accessed 25-July-2021.
• CDC Pinkbook. Poliomyelitis. Accessed 26-July-2021
• Fraser 2020. Long term respiratory complications of covid-19. BMJ 370
• Gargano et al. 2021. Use of mRNA COVID-19 Vaccine After Reports of Myocarditis Among Vaccine Recipients: Update from the Advisory Committee on Immunization Practices — United States, June 2021. CDC 70:977–982
• Johnson and Stobbe. 30-June-2021. Nearly all COVID deaths in US are now among unvaccinated. AP
• Israel Ministry of Health. 2-June-2021. Surveillance of Myocarditis (Inflammation of the Heart Muscle) Cases Between December 2020 and May 2021 (Including). Accessed 26-July-21.
• Mitrani et al. 2020. COVID19 cardiac injury: Implications for long-term surveillance and outcomes in survivors. Heart Rhythm 17:1984–1990
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• Rossman et al. 2020. COVID-19 dynamics after a national immunization program in Israel. Nature Medicine 27: 1055–1061.
• Shay et al. 2021. Myocarditis Occurring After Immunization With mRNA-Based COVID-19 Vaccines. JAMA
• Sullivan, 16-Jul-2021. U.S. COVID Deaths Are Rising Again. Experts Call It A ‘Pandemic Of The Unvaccinated’. NPR
• WHO. 9 July 2021. COVID-19 subcommittee of the WHO Global Advisory Committee on Vaccine Safety (GACVS): updated guidance regarding myocarditis and pericarditis reported with COVID-19 mRNA vaccines. Accessed 26-July-2021.
• Worldometer. Coronavirus. USA. Accessed 25-July-2021.