I think this would help the public’s Coronavirus lockdown response

The next month is going to tell us whether or not the coronavirus will have a devastating human toll in our society.  If not the next month, then the next year will definitely answer it. Is this the next Spanish flu, or just the flu, or something in between (but obviously we all hope, more like the second than the first).

This moment – when we know the question but not the answer – is a perfect time for some observations about the choices we are making and how we are making them. 

Some people are convinced that this is an incredibly dangerous epidemic, others that it’s all hysteria.  How do people come to these conclusions? How can intelligent people look at the same situation and see such different things?  We should look at that first. Let’s start with the argument that it’s being blown out of proportion, and then what people might say against that idea.  Then let’s talk about who is having these ideas and what might help the friction.

The skeptical side goes something like this: we are causing certain social and economic harm (which translates into real damage to millions of lives) with these extreme rules.  This harm may be devastating. We are essentially turning off the world for an unspecified number of weeks or months, and violating people’s basic human rights of free assembly.

So the skeptic asks –  why are we taking away so much freedom and doing so much harm?  That harm is a certainty, and no matter what people say, they don’t know the future. How can they be so sure that either the pandemic is dangerous enough to justify these measures or, if it is that dangerous, that they will make any difference?

The skeptics are going to compare it to the flu.  Does it spread like the flu? Is it more deadly than the flu?  The answer to the first seems to be yes. The answer to the second is not as clear-cut. The basic math is to divide the number of deaths by the number of cases. 100 cases and 10 deaths is 10%.

But this is very complicated in real life. We can only count what we know about. And the way you count matters. If you count too early the death rate looks low, since many people are infected whose outcome is not yet known. On the other hand, the fact that people who don’t show symptoms or never feel that sick don’t go to the hospital means the real fatality rate may be lower because you missed all the mild cases.

This is why, if you read between the lines on the WHO and CDC statements, the fine print amounts to something like “estimating this in the middle of an epidemic is crazy hard because we don’t have all the info and don’t know how much we can trust all the foreign sources coming from different systems at different stages of their own outbreaks. But you asked, so we took the numbers we had. Who knows how accurate that is?”  It’s also why some other medical sites won’t give concrete numbers on this, but just talk about symptoms, severity, and prevention, which is what matters to individuals right now anyway.

The huge discrepancy in reported rates is interesting when you consider the differences in source. The highest rates I’ve seen reported are about 8% or more, and the lowest 0.1%. Here I think it is very helpful to look at who is reporting what. The highest rates come from Iran and Italy, which have tried but been unable to lockdown or track their populations, at least at the beginning. That means they have no idea what the denominator of all sick people is and are more likely to be reporting numbers based only on a subset of the severely sick. If you look at Italy the overwhelming majority of cases and fatalities are people 70, 80, or even 90 years old and with at least one preexisting health condition.  Exactly who would die from the flu, you might say.  

By contrast the countries reporting the lowest numbers are Germany, South Korea, and China when reporting numbers from outside Wuhan – in other words, those countries that have been tracking the outbreak for the longest time and the most thoroughly, especially SK and China. China reported 0.16% as of earlier this week, and Germany 0.1%. For comparison, the seasonal flu is about 0.1%.  So some countries are saying that now the CV is no more lethal than the flu.  

There are two more questions being asked a lot.

One, there are a lot of countries like India, Myanmar, Thailand, Indonesia, and places in East Africa that do a lot of business and exchange with China.  They should have been infected at the same time as everyone else outside of China. However they are too poor and/or disorganized to try to track everything like countries can in East Asia, the West, or the Middle East have attempted to. So some people see this is a kind of experimental control.  If death rates were catastrophically high we should be hearing of mass deaths in these countries. We haven’t, implying that whatever is happening in these uncontained places is not rising above the normal background level of disease people are used to.

Two, the seasonal flu kills at least hundreds of thousands of people around the world each year. This is mostly old people. If this was the first year we ever encountered the flu and we didn’t know how it worked, it would probably look just like this. Thousands of people would be dying every day, and since most people would be fine but some very sick, a report of only the people showing up to the health system would look quite alarming. We don’t think about this context with flue becuase we are so used it.  This is the first time we’re actually closing watching a disease spread widely in real time. And we don’t normally test for the flu since we are used to it and know exactly what it’s going to do.

Three, even if we do this, the disease is not going away.  It’s spreading all over the world. How will we stop it from coming back across the borders?

So then, what is the counterargument?  These same pieces of information are available to the people most convinced of extreme danger, after all.

Most people describe the lockdowns as a delaying tactic.  That is, if we slow it down we have more chances to find treatments or vaccines.  That argument is probably not very good, given that it might take months, years, or never to find a vaccine.  Some common and serious diseases we’ve worked on for generations still don’t have them. But a more nuanced argument is about overwhelming the medical system.  People are afraid that the hospitals will have too many people at once, and people will die because they can’t get treatment. That might be CV victims or it might be other people that needed the hospital.  

To the people that think this is just the flu, the people fearing a rush of hospital patients have three pieces of data.  One, that the infection rate actually seems to be higher than the flu. Two, that the disease takes longer to show up and lasts longer when it does.  Three, that there is some indication – depending on where you look – that more people are hospitalized than with the flu even when they don’t die. Which would mean that there would be more people in the hospital at once, even if it doesn’t have a higher mortality in the end. And if the system does get overwhelmed, more people die – whether that’s CV victims who just needed stabilization or others who needed the hospital.

So who is right?

I have no idea, and no matter how certain they are, neither does anyone else know with certainty until it happens.  Which means that actually making the decision now comes down to something else.

How afraid is the person in question of the social and economic harm of lockdown measures?

How much does the person in question believe the worst case projections?

The balance of those two answers will tip someone one way or the other.  What I think is most interesting is what kind of person I see coming down on each side.  Generally, the more prestigious the educational background of the people – and the more connected they are to major metropolises, especially coastal ones – the more convinced they are that the experts should be trusted and these measures are for the best.

The more ‘ordinary’ a person is, the more skeptical they seem to be.  

Why should that divide exist?

Well, the more you are a part of the cultured and educated elite, the more you identify with experts in general.  You see yourself as part of the same general class of people who is responsible for things and knows best. You are also more likely to have the financial and social ability to withstand the challenges of harsh isolation measures and more likely to have a job that can be done remotely.  This means you are likely to believe that the authorities are making good decisions and trying to help.

Whereas if you are an ordinary person, you are much more vulnerable economically and socially to these measures.  But something else is in play with your psyche too. You don’t feel that you are part of the expert class that is making these decisions.  Therefore you are much less willing to trust that they are making the right decision if it hurts you and especially if it seems to be taking away your rights. You want more information.  These are your rights and your income, why are the authorities seemingly breezy about that?

In other words, the more you resemble the kind of people who work in healthcare, government, media, or academics, the more the lockdown is something we are doing together; the further you are from this, the more it is something being done to you.  And when something being done to you hurts, you are more likely to question it and more likely to be annoyed if you realize it’s based on a worst-case scenario and not a certainty. 

Again, none of this proves anything about the actual danger because no one can prove anything before it’s happened.  My point isn’t to say that the measures are wrong. They might be something that helps a lot, or even the only thing that could have helped.

But it points to some faultlines that will continue causing arguments.  If the outbreak is contained or peters out, but the economy goes into a severe recession, then a lot of people are going to be furious because the people hurt most will not have been the people making the decision. That could have political repercussions for years.  And if the outbreak is serious, people will blame it on the naysayers and the people who went out anyway, regardless of whether we can know if doing it faster or more thoroughly would have helped in the end.

But the tone matters now, and there are some things the government could do to help.  Personally, I have been very disturbed by how quickly we made it to the point of a lockdown whose severity has not been seen in the free world since World War II.  Anytime we are talking about adopting the same social policies as China, an authoritarian regime that still runs work camps, it should be for a damn good reason. And then there is the counterexample of South Korea.  They have achieved apparently spectacular results in diminishing the disease without locking down anyone in their homes. Their strategy has been a massive and transparent education initiative, real-time reporting of places people may have been contaminated, and easy testing. Link here.  Now, they might not be out of the woods – even they haven’t tested everyone.  More could be coming down the line at them. But at the least, they don’t seem to be doing any worse than countries with much harsher measures.

The US’s problem with testing is that our tests and testing procedures are currently crap.  But if we can get that resolved, I hope we switch immediately to the South Korea model.  Even if we can’t, we might be able to achieve the same results without the tests or with home tests.  Do we need everyone potentially exposed to a known patient to get tested themselves?  Or do we just need them to lie low for 14 days? If we asked only those people to stay home for a quarantine period it would still be more targeted than what we are doing now. 

If the government is committed to the lockdowns rather than the South Korean model, then there’s still something they can do to help.  We should see a real acknowledgement of how hard for people this virus is, and also, clear information on when it will stop.  Right now the run-up to what looks to some people like martial law seems open-ended and that’s a big part of what’s scary. The public should be given the actual threshold that these measures are aimed at achieving, which will therefore be used to determine when it ends.  Do we stop at a vaccine or in 1 month, whichever comes first? Do we stop when the tests are widely available in all 50 states? What is the plan? I can’t say what the exact plan should be, but it’s not knowing the plan that will become a problem for the public as this drags on. We need that information.  It will help calm people down.

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