It is hard for citizens to know what is going on with the virus. You can argue citizens need not know that much, and mostly need to follow the sound hygiene advice on offer. Such behaviors have been touted as Everyman’s contribution to flattening the curve, or whatever the broad strategy happens to be. And there is wisdom to that approach. Sometimes citizens need to be managed in a crisis, even in what used to pass for a Republic.
But while in quarantine my mind wanders, and whether it benefits the polity or not I cannot help but reflect on the broader issues. I like to think, even if fancifully, that I may have civic interests, and even obligations, beyond mandating family use of hand sanitizers and not hoarding too much toilet paper. So I offered up four posts, all of which were virtually outdated by the time they came out.
Despite the risk of instant obsolescence I even sent the first two to The Unz Review. I felt that its idiosyncratic publisher, Ron Unz, might take to material somewhat similar to his own articles: too long for the format’s conventions, somewhat discursive, unafraid of the autobiographical and structured as a citizen’s exercise–a close reading by an amateur of available material in the hope of presenting useful alternative approaches to important issues.
I got a nice note back from Ron saying he liked the articles but the journal was all set with virus material for the time being. So I was surprised to see that the posts then appeared as an article–in short order, too, as befitting the subject, but already getting to be out of date.
I then hit “pause” on writing further for a few days to see if I might make any sense out of the fast moving developments. Here is my update.
If you read the four previous posts all the way through–and, really, at this point, who hasn’t?–you will have figured out my aim in that distant past: to provide an appropriately modest endorsement of the so-called “controlled burn” approach to managing the virus.
I did not seek to endorse the then-Brit approach whole hog. For one it was difficult to get all the facts and understand the nuances of controlled burn as it was being discussed. But I was, and continue to be, attracted by the herd immunity notion that was central to what was under discussion. I tied that idea to the idea of a quarantine in reverse: setting up safe spaces for the likely targets of the virus’s impulse to kill not just hobble, firewalled off from the herd immunity experiment on the outside. Just letting the virus rip without a rigorous attempt, Chinese-style if necessary, to isolate the vulnerable seemed to me a non-starter.
While I thought the Brit approach was premised on both poles–controlled burn and isolate the vulnerable–it seems as though the effort around the latter may have been less than I supposed. Whatever the cause, it appears that in the past few days the British government has dropped the idea in favor of the consensus held by most other nations that the contagion needs to be minimized to flatten the curve.
I thought the profile of likely mortality targets presented a singular opportunity for controlled burn combined with isolating the vulnerable. I was using data from China, which showed a very pronounced difference between the elderly/those with serious pre-existing conditions and everyone else relative to the mortality risk.
The vulnerable are only a portion of the population, so the effort to manage would be targeted at a smaller group. Especially at the high end of mortality risk, in the 70s and 80s, individuals are more likely to be retired than working, with the result that tougher Chinese-style measures would have a significantly less negative economic impact. Many are in retirement communities already, making the process of management more efficient.
Granted, retirement communities and the like are already part of the flatten the curve plan. They have been mostly sealed off with no visitors allowed. But my general impression is that these efforts have been not tightly planned or enforced, with the resulting risk that a firewall intended to keep the bad guy out may be transformed into a prison keeping him in. If you are going to do a quarantine of the vulnerable it has to be tightly managed.
In any event Boris Johnson seems to have been convinced he could not risk “another Italy.” And he should worry, at least politically. It would be a political problem of the first order if his counter-intuitive plan, scoffed at by the world, ended in a huge number of deaths.
So for now, it seems, Britain will be flattening the curve. I am not sure if the idea continues to have appeal in the behind-the-Hajnal-Line country of The Netherlands but we will see.
Part of the reason for the change of opinion was the large effect felt by the report put out by a team at Imperial College in London. That report has gotten a lot of play in the past few days, and is viewed by some as the new best-we-have-at-the-moment template for action in the West.
Scott McKay at The American Spectator was not impressed. He described the report as follows:
The report comes off like a Hollywood movie script, predicting that if the Wuhan virus was treated like a flu epidemic, some four million Americans would die out of 80 percent of the country becoming infected. If hard suppression of the virus — meaning the current shutdown of the economy — were to be the policy, the death toll shrinks to 1.1 million. But to accomplish this hard suppression, the report suggests a shutdown lasting as long as 18 months.
Despite the snark the numbers are there: 4 million deaths in controlled burn versus 1.1 million with flattening the curve. Those are not numbers to, if you will, sneeze at.
But what about the report? Is it what it is cracked up to be? McKay takes a swipe at the academic center that produced it, sending up the innuendo that any center with a zealous climate change mission (it favors a “sustainable, resilient, carbon-free future”) might be a little suspect.
That is a little ad hominen, even for my non-statistical narrative-driven mind. So let’s take a short amateur look at the report itself.
Start with the mortality estimates by age. These are an updated and enhanced take on the China numbers, which were, as discussed above, seriously tilted toward mortality as age goes up. But as I read the report’s new estimates they seem to me even more suggestive of a hard break between the young and healthy and the old and/or infirm.
The overall mortality rate comes in at .9%, much lower than the WHO China based estimate of over 3%. That overall number, even if lower than that offered up by WHO, can be plenty troubling if one assumes contagion of a large percentage of the population. Indeed the very scary numbers in the report cited by McKay tie back to a model with the .9% figure as a driver.
But what about the break between less vulnerable and more vulnerable? I haven’t done the calculations but it has been asserted that those under 60 enjoy a lower mortality rate under the Ch*na Virus than they would face with the regular flu in a normal year. Scan the numbers above–that seems credible.
Indeed it seems that the Imperial College updated numbers create an even more distinct “firewall” than did the earlier China data between those more likely to die and those very unlikely to do so.
You would think that the presence of this large distinction ought to permit the creation of two pools: the young and healthy go on with life and assist in producing the desired herd immunity, while the vulnerable sit out the one-time, somewhat unpleasant but relatively short process. But that is not where the report goes.
The death projections that the report produces use the numbers above for mortality but only insofar as they support a larger, dynamic model that attempts to simulate both contagion/spread and the behavior of real people.
I cannot see from the report the details of how the team created variables for contagion and spread, and I would not be the one to evaluate them well if I could. But it is worth noting that of all of the factors concerning the virus that are poorly understood at present the manner by which it spreads is at the top of the list.
The fact that our lack of testing is leading to huge disparities in guesses about underlying cases is testament to that. If the virus spreads a lot more rapidly than the Imperial College team surmises (based on what is known to be inadequate data) then the mortality rates may be affected to the good, and the time it takes to reach herd immunity may be lessened.
More important than the treatment of spread is the report’s treatment of behavior. As I mentioned at the outset a herd immunity approach without a serious quarantine of the vulnerable is likely to be a non-starter, and that is what is portrayed here. The report makes generous assumptions for non-compliance with isolation (30%) and voluntary home quarantine (50%).
Further the report apparently assumes those over 70 continue to work if they wish. With respect to social distancing of those over 70 the report estimates a 50% reduction in work contacts and a 75% compliance with the policy, meaning that the effort will in practice result in an even smaller reduction in work contacts than 50%.
Recall: a perfect quarantine of all of the most vulnerable would result in something like a normal flu year. It is only the elderly and infirm that run significant risks in the Imperial College model–it is they, and not the young, that risk clogging ICUs, and they are essentially the only ones dying in either scenario. Keep them all out of ICUs and you have no ICU capacity problem, while at the same time developing herd immunity–maybe.
A perfect quarantine of the vulnerable is not possible of course. But the perfect is the enemy of the good. The plan might work well enough.
Further, if done well it would be hard to ascribe the inevitable deaths from non-compliance to the plan. Say there is a tough system in place at the nursing home but grandpa finds a way to sneak out. He will be at risk of infection and, at age 85, may run a risk of almost 10% of dying following his trip to visit his kids down the street. Not to get all libertarian about it but that would be his choice. His death would only be a defect of the system if the system were poorly designed, inviting escape too easily or having internal defects (like poor hygiene in the nursing home) that threatened grandpa even if he cooperated with his temporary confinement.
Of course the overall plan would still have to work well enough in terms of leakage due to non-compliance or bad execution. Whether that is possible seems to me like a good idea to consider.
I don’t know if the Imperial College team did not simulate a quarantine of the vulnerable because it was never part of the British government plan, or whether it just found it more agreeable to concoct a model that did not aim at confinement. In either case many estimated deaths result.
In my admittedly limited review of the fast moving issues I can find no serious treatment of the concept of quarantining the vulnerable. Maybe others see it as self-evidently faulty while I for some reason do not. Ann Coulter seems to see some merit in the notion. Criticizing the Imperial College report in her characteristic breezy style, she sketches out this approach:
According to the dire estimates of the Imperial College of London — whose assessment we are following — excepting those with underlying medical conditions, the new coronavirus is far less deadly than the seasonal flu to anyone under 60 years old. It’s no worse than the 2017-18 flu season for those in their 60s.
But it’s five to 10 times more deadly than the regular flu for those in their 70s and 80s, respectively.
We ought to surround old folks homes with the National Guard and call it a day. It would probably save more lives and wouldn’t destroy the economy.
Elsewhere I have read of this general notion that it would be somehow hard to implement. I have not seen the details of that objection. But can it be harder, or result in worse human and economic outcomes, than the harsh Chinese approach for all, especially if that is where we are headed for a year or more?
Johnson may be correct as a politician to avoid the risk of Britain being another Italy. But was he putting a thumb on the scale for political risk as opposed to actual outcome risk? I have not read that anyone has been able to fix a good probability on a second year killer recurrence, as happened with the Sp*nish Flu. Or that anyone has been able to calculate how long immunity might last, and especially whether it would extend to a potential return of a more lethal (and possibly more universally mortal) strain in the fall.
Those strike me as quite significant risks, “fat tails” for sure, and exactly the kind of risks that people push down in their consciousness in favor of more certain and more immediately present ones.
What are those larger risks and how might we assess them? That’s a problem in itself.
As John Ioannidis has pointed out in another article gaining widespread currency we are facing an “evidence fiasco”. The current situation no doubt includes its fair share of “unknown unknowns”. But it also includes huge risks associated with “known unknowns”. We know we don’t know things about contagion and other factors that we should know, and we know (or we should know) that not having the answers can have very serious consequences. Here is Ioannidis remarking on the large range of answers made possible by the gap in evidence:
That huge range markedly affects how severe the pandemic is and what should be done. A population-wide case fatality rate of 0.05% is lower than seasonal influenza. If that is the true rate, locking down the world with potentially tremendous social and financial consequences may be totally irrational. It’s like an elephant being attacked by a house cat. Frustrated and trying to avoid the cat, the elephant accidentally jumps off a cliff and dies.
And–good for Ioannidis–he brings the economic issue right into the discussion. It has become common for those with that extra humanitarian chromosome to bemoan talk of the economic. Why are we talking about corporations? What about the human costs?
But the kind of disruption that is possible–indeed likely–in an economic stoppage for the duration estimated in the Imperial College report will not just damage shareholders. It will take lives, and quite easily more lives than the virus.
Well, you say, let’s continue with flattening the curve anyway. It might help with ICU capacity but you never know. Maybe we will blow right through that capacity no matter what, if the pessimists are right. Maybe the current treatments currently getting a lot of press attention will pan out, and saving ICU capacity will result more from treatment than reduction in cases. And maybe even if flattening the curve does not work spectacularly well we will arrive at herd immunity as a result of the failure, in time for a possible fall return of the virus.
But keep this in mind. In a previous post I quoted a commentator ensconced in Shanghai, confidently asserting that what the Chinese managed to do the West will manage to do, and without much ado. Flatten that curve! We can do this!
That’s what China wants the world to think, and that’s the tough love approach endorsed by the WHO (headed by the non-physician former director of the health service in Marxist Ethiopia). But is it that easy?
The always astute Richard Fernandez, quoting a Guardian article, has his doubts.
What constitutes a real and presumably admirable lockdown was described by Lily Kuo in The Guardian.
“Over the last two months, Chinese citizens have had to adjust to a new level of government intrusion.
“Getting into one’s apartment compound or workplace requires scanning a QR code, writing down one’s name and ID number, temperature and recent travel history. Telecom operators track people’s movements while social media platforms like WeChat and Weibo have hotlines for people to report others who may be sick. Some cities are offering people rewards for informing on sick neighbours.
Chinese companies are meanwhile rolling out facial recognition technology that can detect elevated temperatures in a crowd or flag citizens not wearing a face mask. A range of apps use the personal health information of citizens to alert others of their proximity to infected patients or whether they have been in close contact.
State authorities, in addition to locking down entire cities, have implemented a myriad of security measures in the name of containing the coronavirus outbreak. From top officials to local community workers, those enforcing the rules repeat the same refrain: this is an “extraordinary time” feichang shiqi, requiring extraordinary measures.
It is hard to compute the value of a human life in the inevitable cost-benefit that must be done on a problem like this, even if that analysis is done only implicitly or privately. It is hard to make decent assessments of facts in an evidence fiasco. It is harder still to put a value on the kind of government we want–which is to say the kind of people we are and want to be.
Flattening the curve might require China-style intrusion and surveillance.
Or that may be where our Betters take us even if there is another way.
Now, as a 70 year old I might benefit health-wise from the imposition of stern measures.
And at my age I suppose I don’t have that much to lose if the East turns out to be Red after all.
But if you you go carrying pictures of Chairman Mao,
You ain’t gonna make it with anyone anyhow.
And when you talk about that kind of social and political destruction,
Don’t you know that you can count me–