And yet we didn't collectively shit ourselves to nearly the same extent for any of the other novel viruses that have popped up in the last couple decades and spread exponentially.
Exponential spread is the default state of things. It's only when a virus becomes widespread in a population that the exponential spread ceases, as you indicated in your reference to R.
To use a contrived example: Imagine a new virus SARS-CoV-1337 with an R of 250 and an infection fatality rate of .00000001%. Would it warrant the response we've made to SARS-CoV-2? Clearly not.
Therefore we need to look at the actual outcomes associated with the virus, and then counterbalance those against the externalities introduced by suppressing spread. Implicitly everyone in favor of lockdown is assuming that the mortality avoided by hunkering down until a theoretical game-changer (vaccine, highly effective antiviral, monoclonal antibodies etc) is available at scale, is a bigger benefit than the negatives incurred by trying to prevent spread (lockdown/containment).
My personal opinion is that the externalities of our current approach (I'm speaking from a US-based perspective) far exceed the cost of COVID-19 itself.
How many lives would need to be saved to encourage the current lockdown, in your opinion?
(1) Containment lets you indefinitely avoid COVID-19-induced mortality in the short-medium term, at the expense of ongoing, mounting costs to wellbeing and the economy. These costs are certainly non-linear, for example businesses can generally only survive a given number of days/weeks based off their capital expenditure and thus it's not quite as simple as a linear relation. But for our purposes, it's easiest to think of the wellbeing and economic cost as being in direct proportion to how long we spend in containment.
The postponement of mortality only becomes the true avoidance of mortality when we get a "game-changer": a vaccine or a highly effective treatment that seriously improves outcomes.
Given that we must practice indefinite containment until we develop the "game-changer", we are executing a strategy which is based off a temporally unbounded future event. Therefore the potential drawbacks are unbounded given that the strategy involves waiting for a miraculous leap forward in COVID-19 vaccination or treatment.
(2) My proposal is an approach where we try to direct testing resources and governmental assistance to protecting the most at-risk members of society. These groups are encouraged to shelter at home and are supported in doing so.
Bans on freedom of movement, transaction, etc are lifted. Non-at-risk individuals are encouraged to return to work. Given that we inflicted psychological harm on millions of individuals, we also would probably want a policy where someone is allowed to not work, but they must formally quit their job in order to be allowed to collect unemployment for up to a year (we likely also need to adjust unemployment because it's just way too high relative to wage earners right now). What we need to avoid is a case where someone "chooses" (in scare quotes because we have done true psychological damage to people) not to work for a year but their company can't let them go, since otherwise the company cannot replace them with a working employee.
So in short, we let people do what they want, we strongly encourage the at-risk to shelter at home and put out appropriate public health messaging in proportion to the real risk (which means overall WAY less fearmongering since we're so out of whack currently).
The uncertainty benefit is something we should implicitly factor in as well. The ultimate end state of my proposal is much more "known" than with containment (because we have no bound on containment worst-case scenario but we can use Ferguson to get a decent bound for mitigation). We're not sure how much mortality we will see, but with a 0.9% IFR and 82% of the population being infected we get about 2.2 million deaths per Ferguson (https://www.imperial.ac.uk/media/imperial-college/medicine/s...). I think that's a great upper bound to use.
BTW I think once accounting for vector exhaustion (not everyone has the same risk of infection) and what I feel is a more realistic IFR, we'd be closer to 600,000 deaths in the "realistic" scenario IMO.
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The last thing I want to say is that I actually think in terms of wellbeing-years or quality-adjusted-life-years, and not just "lives". My belief is that the life of a healthy 12 year old is several times more valuable than the life of an 80 year old with heart disease, to use an example.
So, while it's hard for me to give you a "real" number, I'd say if we could save 20 million wellbeing-years, then lockdown was probably worth it. But keep in mind that means that LOCKDOWN_COVID19_MORTALITY_REDUCTION - LOCKDOWN_EXTERNALITIES >= 20 million wellbeing-years.
Absolutely wrong. And you are missing:
- lockdown reduction in suffering, due both to the acute phase of the disease and after effects
- No-lockdown-externalities, including damage to the economy if the disease is allowed to spread through the entire population
And perhaps most importantly:
- the risk that a huge reservoir of infected people will lead to repeat waves caused by mutations, and even worse that cross-species infection occurs (we already know cats and dogs can be infected - pigs and poultry could be next); then we risk flu-like antigenic shifts.
Put all this into the equation and I think the only thing we should be contemplating is how to eradicate the virus as soon as possible.
Do you think that eradication is actually a possibility? Or are you using it as a metaphor for "contain it super well"?
There are a number of reasons why eradication is completely infeasible. In short, COVID-19 is a highly infectious respiratory disease and it came from a zoonotic origin. We know there are animal reservoirs at this moment.
Therefore eradication is impossible. We've only ever eradicated two diseases in all of human history.
This seems like a very strange take. This is a utilitarian perspective, but with a floor of 20 million years of utility before we take any action. Why shouldn't we take action if the mortality reduction years > lockdown externalities? You're essentially saying "we should take no action to prevent a disease from costing us 20 million wellbeing-years", which seems odd.
> BTW I think once accounting for vector exhaustion (not everyone has the same risk of infection) and what I feel is a more realistic IFR, we'd be closer to 600,000 deaths in the "realistic" scenario IMO.
Are you accounting for the other side effects of Covid? Life long lung capacity loss due to pneumonia side effects, weird not well understood side effects like strokes in young people etc? Most of the people I see minimizing the risk and saying we should reopen seem to entirely ignore those dangers.
> Given that we must practice indefinite containment until we develop the "game-changer", we are executing a strategy which is based off a temporally unbounded future event. Therefore the potential drawbacks are unbounded given that the strategy involves waiting for a miraculous leap forward in COVID-19 vaccination or treatment.
This isn't at all true. Look at China, Taiwan, and South Korea, which have all begun reopening, but with infrastructure in place to track and keep outbreaks contained even as they reopen. Some parts of the US are on track to do the same relatively soon (weeks, not months or years).
> My proposal is an approach where we try to direct testing resources and governmental assistance to protecting the most at-risk members of society.
You realize that this is what's being done now, essentially, its just that tests are so severely limited that that isn't useful. We can't, for example, consistently test employees at nursing homes to make sure that they aren't infectious. Until we can do that, returning to normal is asking nursing home employees to shelter even more tightly than individuals are now, or it's sacrificing lives.
It feels like you haven't looked deeply into the criteria that many metro areas (NYC, WA, and the Bay to name a few) have to reopen. They're specific and clear, and backed by reasonable thought.
You're right, that was my mistake. I got a rough 20 million life-years by taking Ferguson's worst-case scenario and then applying the "COVID-19 takes average 10 years of lives" claim (which is a false claim). Thus arriving at the implied scenario that lockdown proponents say could happen but that I think is an impossible to reach number.
(For context I use Ferguson's 2.2 million as an upper bound, but that 2.2 million scenario involves an overwhelming portion of the deaths being people who were already at death's door. Thus I think 2.2 million is possible but highly unlikely due to the other factors I mentioned, whereas the 20 million life-years figure I view as basically impossible to hit because it implies that same worst-case scenario but with the wrong distribution of age)
At that point I thought to myself "wait, I forgot to account for the negative externalities". But as you indicated, that logic was wrong.
So, allow me to retroactively change my answer to just 20 million life-years period.
Thanks for pointing that out.
> It feels like you haven't looked deeply into the criteria that many metro areas (NYC, WA, and the Bay to name a few) have to reopen. They're specific and clear, and backed by reasonable thought.
No, I understand their criteria but fundamentally disagree with the entire approach of containment, as I explained in the GP comment you replied to.
> This isn't at all true. Look at China, Taiwan, and South Korea, which have all begun reopening, but with infrastructure in place to track and keep outbreaks contained even as they reopen. Some parts of the US are on track to do the same relatively soon (weeks, not months or years).
I don't believe that the US can use the same strategy that China, South Korea, or Taiwan has been using. They have much better control of their borders and are a much more homogenous and compliant population.
I don't think this is correct. Every day that passes by, we learn a little bit more about this virus and get a little better at treating it. For example, in the past few weeks doctors have discovered better ventilator protocols [1] and potential benefits of anticoagulants [2] in treating Covid-19 patients.
None of these are "game-changers" but they incrementally improve patient outcomes and that's a good thing. The more time we buy to make discoveries like these, the better off we will be.
Put another way: would you rather have been of the first few patients in Wuhan when doctors had no idea what this virus was or how to treat it, or would you rather have it now? What about a few months from now?
- worsened COVID-19 outcomes due to social isolation
- worsened COVID-19 outcomes due to fear of going to a hospital (this is a real effect)
- worsened all-cause mortality due to social isolation and a culture of widespread fear
- worsened mortality attributable to mass unemployment (note that some small portion of unemployment would have happened without lockdown but the vast majority of damage is self-inflicted and thus directly attributable to lockdown)
- worsened quality of life (the missing link that lockdown proponents tend not to address) amidst the entire population
- externalities that occur when suspending in-person education, such as the widening inequality gap between students whose parents can afford to buy them personal computers/laptops/tablets and those whose parents cannot.
- shifting to a global perspective, the impending global food shortage is predicted to make COVID-19's mortality look like a drop in the bucket
Finally, I'd like to point out that COVID-19 deaths here in the US are dominated by the extremely elderly which implies (but does not prove, of course) that our lockdown policies were ineffective at protecting the at-risk groups that we should have been focusing on the whole time
This is literally situation in which everyone is in the same situation as you, you can call to people who are in the same situation all the time. If you work from home, then communication from work is almost the same as before. I can see this from someone who is old and can not use tech, but really, this is not what isolation is.
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Finally, we need to examine the effects of social isolation itself. Beyond the fact that social isolation prevents the natural exchange of microbes that occur between humans engaging in social contact, it should be noted that social isolation is directly thought to lead to increased all-cause mortality due to worsened health outcomes across pretty much every dimension that we can examine. One review (https://www.pnas.org/content/pnas/110/15/5797.full.pdf) of the impacts of social isolation and loneliness in older adults concludes that “mortality was higher among more socially isolated and more lonely participants. However, after adjusting statistically for demographic factors and baseline health, social isolation remained significantly associated with mortality (hazard ratio 1.26, 95% confidence interval, 1.08–1.48 for the top quintile of isolation), but loneliness did not (haz-ard ratio 0.92, 95% confidence interval, 0.78–1.09). The association of social isolation with mortality was unchanged when loneliness was included in the model”.
It’s now popular to refer to what was previously called “social distancing” as “physical distancing” to note the fact physical distancing does not necessarily lead to loneliness; this is because loneliness can (perhaps) be mitigated to a limited extent by usage of social media and videoconferencing. Troublingly, we can see that it is the social isolation itself, and not the emotional feeling of loneliness, that is associated with death, and thus we can surmise, at least in older adults (but almost certainly in the broader population as well), that the widespread recommendations of social isolation (“stay at home”, “social distancing”, etc) will lead to increased all-cause mortality.
Finally, we wish to highlight that a small increase in all-cause mortality amidst the general population due to social isolation could very easily dwarf COVID-19-associated mortality, which as we have discussed is primarily constrained to a very limited subset of the population.
Now the job of the modellers is to predict COVID-19 mortality under various scenarios, and it's the job of policymakers to counterbalance those predictions against the economic realities, etc. So, it's not necessarily a problem that epidemiologists would focus on predicting just along the dimension of COVID-19 mortality.
But unfortunately our policymakers have completely disregarded that need to weigh both the positives and negatives and instead have talked about "following the science" and basically myopically parroted whatever these highly opinionated epidemiologists (Ferguson, everyone at the IMHE, etc) were saying, without mentioning the negative externalities associated with lockdown, except in passing in a way that implies that economic damage will be constrained to shareholder returns (which is completely false).
Do you have a source for this?
Here's Ferguson:
https://www.imperial.ac.uk/media/imperial-college/medicine/s...
> We do not consider the ethical or economic implications of either strategy here, except to note that there is no easy policy decision to be made. Suppression, while successful to date in Chinaand South Korea, carries with it enormous social and economic costs which may themselves have significant impact on health and well-being in the short and longer-term. Mitigation will never be able to completely protect those at risk from severe disease or death and the resulting mortality may therefore still be high. Instead we focus on feasibility, with a specific focus on what the likely healthcare system impact of the two approaches would be.
(From Page 4)
Now let's shift to the IHME model. They do make passing reference to the econonic impact, same as Ferguson, but don't go any further:
http://www.healthdata.org/sites/default/files/files/Projects...
> The overall financial cost over a short period of time is likely to be enormous, particularly when juxtaposed against the substantial reductions in revenue for many hospitals due to the cancellation of elective procedures and the broader economic consequences of social distancing mandates.
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Now as I said, it's not necessarily their job to forecast the economic harm. But unfortunately we have created this notion that being pro-lockdown means "believing science" and therefore thinking that the lockdown is a bad idea is being "against science". Our politicians use these exact words, and as I said their actions show that they are not holistically evaluating the downside risk. On the contrary it appears to be a very simple game-theory type calculation where their incentive structures are leading them to make irrational decisions. COVID-19 mortality is much more "visible" than the fuzzier and longer-term mortality caused by our (IMO misguided) response to COVID-19.
It was in the cards, which makes it even more painful to see.
Testing EVERYBODY would be cheaper than what is happening now and an inspiration to the whole world, inspiring awe and respect.
I take it that your term "externalities" (I haven't heard it before) is referring to the side effects eg economic of our attempts to deal with it.
The cost of COVID-19 to an individual seems to range from "meh" to death by lung destruction. There are some identified risk factors - being male, smokers (some "initial immunity" but worse outcomes), skin colour (this looks like correlation rather than causality but needs working through), being old (70+ is the current threshold), diabetes.
Until you know (test, test, test again) that you have actually had the disease then I suspect you will be always looking over your shoulder. Once you know you've had it and hopefully survived then you can plan forwards. There are many reports of additional snags post infection eg renal problems and lung damage, not to mention the mental trauma.
I'm speaking as a UK bod with a small company to worry about that still has a few months left in the bank. I'm alright Jack but I worry about my fellow people.
Agree to disagree on that one :)
> and we did not really heed the lesson that SARS-CoV-1 gave us
Agreed.
> I take it that your term "externalities" (I haven't heard it before) is referring to the side effects eg economic of our attempts to deal with it.
Exactly, see https://en.wikipedia.org/wiki/Externality#Negative. Just keep in mind that the economy is not some abstract notion, but rather is you and me and everyone else. In other words, economic damage isn't something that just hurts rich shareholders, it hurts everyone because there's less wealth.
Suspension of elective surgeries, which happened all over the country here in the US, is one of the best examples of such externalities that were caused by panic and bad policy rather than reality. For example, here in California we suspended all elective surgeries for a month. But we never were close to being overrun, and given that the vast majority of these surgeries are out-patient, there was never a need to pre-emptively cancel them. Lastly remember "elective surgery" sounds a lot like "non-essential work" but basically any pre-scheduled surgery is elective: organ transplants, hip replacements, arthroscopic labral repair (I'm waiting on that one currently), etc.
> Until you know (test, test, test again) that you have actually had the disease then I suspect you will be always looking over your shoulder.
That's why the strategy I advocate for does not rely on the availability of testing capacity, because the goal is not to practice indefinite containment.
If you've decided that you want 80% of society to behave as normal and gradually become infected and recover, then PCR testing loses a lot of its utility. It's mostly useful for clinical diagnostic reasons, to get a loose handle on spread, and finally to use as validation for other tests like serological tests.
> There are many reports of additional snags post infection eg renal problems and lung damage, not to mention the mental trauma.
These post-infection snags are quite rare, based off the evidence I've reviewed. Personally I have observed that so many advocating for lockdown make references to the supposed widespread organ failure, strokes in young people, etc, and the evidence just does not support those claims. These outcomes do happen but they are incredibly rare and given that they are logical results of inflammatory cascades (cytokine storm for example), we see the same outcomes in disease like Influenza that we are not losing our collective shit about.
> not to mention the mental trauma.
I believe the mental trauma caused by the wide-spread panic and fear-mongering is vastly worse than the mental trauma of recovering from COVID-19.
25-50% of people that get COVID-19 are entirely asymptomatic or are paucisymptomatic.
For many, it's like getting the flu.
And for some - significant numbers, but not as many as we're led to believe - it is a horrendous disease that results in invasive ventilation followed by likely death.
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Not quite mental trauma, but fear of going to the hospital has led to people who actually have COVID-19 to avoid getting treatment because they don't realize they have COVID-19 (yet are experiencing serious adverse conditions):
From https://www.nejm.org/doi/full/10.1056/NEJMc2009787?query=rec...:
"Social distancing, isolation, and reluctance to present to the hospital may contribute to poor outcomes. Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic."
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Now onto real mental trauma:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0...
* "Third, the COVID-19 epidemic has caused a parallel epidemic of fear, anxiety, and depression. People with mental health conditions could be more substantially influenced by the emotional responses brought on by the COVID-19 epidemic, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population."
* "Finally, many people with mental health disorders attend regular outpatient visits for evaluations and prescriptions. However, nationwide regulations on travel and quarantine have resulted in these regular visits becoming more difficult and impractical to attend.
And my favorite, a case study of COVID-19 related paranoid delusions in a schizophrenic:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162758/
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Sorry for the massive wall of text.
..because CA locked down in a timely way. How do you know hospitals wouldn't have been overrun otherwise? They were in some places (Italy). This is playing out in real time after all, and nobody has a crystal ball, especially not Elon Musk.
Now, there are early indications that reopening is resulting in new outbreaks, like at the night clubs in South Korea.
Well, New York is a great comparison, but let's pretend that the lockdown did avoid an overrun in California and that otherwise it would have happened.
As I indicated, given that the vast majority of these (highly important) elective surgeries are out-patient, there is not a huge need to plan ahead when it comes to suspending surgeries. On the contrary, when we do realize that we are at capacity we can suspend elective surgeries at that moment and no sooner.
BTW, the utility of elective surgeries should always be counterbalanced against the utility of extra beds for COVID-19 patients. Many of these elective surgeries are still more important than COVID-19 treatment even when we hit an overrun scenario. So it very much depends on the surgery in question, and such blanket suspensions are a very bad idea.
> Now, there are early indications that reopening is resulting in new outbreaks, like at the night clubs in South Korea.
Right, which is precisely why the practice of indefinite containment is so flawed. Once you start doing it you can basically never stop (until you've teched up to a vaccine / game changer treatment)
Many people might look at 60 -> 70 mph and conclude something like a 16% increase in "danger". However, if we set m = 1 then 60 mph gives 1800 thingies and 70 mph gives us 2450 thingies or 36% "extra danger". I live in metric (with a sprinkle of extra units to taste land) hence: "thingies". I set m = 1 which should avoid problems.
Something as simple as speed is not as intuitive as someone might think. We look at the variable (speed) and it is obviously linear and so we think the implications of increasing it must similarly be linear. But it isn't. The energy in a speeding car is proportional to the square of the velocity of the car. This is a horribly simplistic model but the fundamentals are there.
Now virus propagation ... R is the rate of infection. If R < 1 then infections drop over time. If R > 1 then infections rise exponentially. I gather that R = 3 is the norm for SARS-COV-2 without controls. You can play with a spreadsheet for a simple model to scare yourself.
When the term exponential heaves into view then we should quite rightly shit ourselves and do as we are told. We are far away from worrying about 16:36 which is the result of a one off event but an exponential "thing" over time grows rather fast.