The immediate reaction to the tweet broke down along familiar lines. Either it was yet another example of erratic leadership from a president more concerned with how the state of the economy will affect his re-election prospects than with the public health, or it was a bold attempt to avert an oncoming devastating recession that has been fueled by partisan media hype.
There are clearly a range of different economic consequences associated with different strategies for fighting the Covid-19 epidemic, although the chorus of right-wing economists who pounced on the President's tweet to argue that it was already time to end stay-at-home orders and send people back to work don’t appear to have thought through just how economically devastating a wholly unmitigated outbreak would be.
More importantly, few, if any respondents to the tweet took time to note that the content actually mapped to what many public health experts and epidemiologists are telling us about Covid-19. In the not-so-far-away future we will know a great deal more than we do right now about every aspect of the disease, and we will be able to make much more finely tuned decisions on how to tackle it. “What I’ve been saying to policy folks,” says Ashish Jha, a professor of global health at Harvard, “is we are at least a couple of weeks, two to three, away, and then we have data, we have evidence and I can imagine some communities starting to loosen things up.”
There are a myriad of caveats to Jha’s prediction. For it to come true will first require that the general public must aggressively embrace social distancing to a degree unthinkable just a few weeks ago. We will also need a vast ramp-up in testing, so policy makers and government officials can get a handle on hot spot locations and be equipped to do contact tracing and targeted quarantines. And we have to acknowledge that there will be immense regional variations; it’s hard to imagine New York, the current American epicenter of the outbreak, or Florida, which arrived late to the shut-down party, “loosening up” in the very short term. There also appears to be a depressingly high likelihood that a succession of recurrent Covid-19 flareups throughout the next year might require the reinstitution of shelter-in-place orders on an ad hoc basis.
But if one of the most crippling aspects of the current dystopia is the vast amount of uncertainty that permeates our lives, as we try to get through our days with zero clarity on when schools or restaurants will re-open or how many people will get sick and die or how long-lasting the economic shock will be, there may be a ray of hope. With the passage of each day we will know a little more.
We will know more about how the disease is spreading, we will better understand the biological nature of the disease, we will begin to develop effective treatments for it, and at the end of the rainbow, we should have a vaccine. None of it will be easy, but there is a reasonable argument to be made that we are poised right now to confront the worst of the crisis, and within a matter of weeks we will start to get some traction on the immense challenge of reducing its severity.
“There is a massive execution risk,” Jha says. “There is a massive risk that we could just screw this up. But we know enough that if we execute it really effectively, we can thread this needle, and we can get through this.”
Anyone who has ever played a real-time strategy game knows that the most vulnerable moments often come early on in the struggle, before you’ve marshaled resources, educated your population, developed key technologies, and built a thriving economy. At that point, avoiding mistakes and executing with precision has enormous repercussions, but eventually, if you do everything right, a tipping point arrives, momentum becomes unstoppable, and triumph is guaranteed.
As of Monday, twelve states had instituted stay-at-home orders affecting about one in four Americans. Only five states (Idaho, Iowa, Maine, Nebraska and Wyoming) still have schools open. One of the consequences of what might be charitably described as laissez-faire federal leadership is that local governments are making up their own rules as they go along, resulting in what is in effect a national laboratory of randomized experiments in how to contain Covid-19.
For example, on March 16, the San Francisco Bay Area became the first region in the United States to order shelter in place, at a point when only 335 cases of Covid-19 and six deaths had been recorded in the state of California (by contrast, Italy did not order a national lockdown until registering 9,172 cases and 473 deaths). The Bay Area and California writ large (which instituted a statewide stay-at-home order on March 19) will therefore be one of the first areas to generate useful data for epidemiologists on the impact of social distancing. Texas and Florida, two states that have taken more relaxed approach to implementing social controls, may produce data of a different kind—potentially indicating that a more lackluster response will result in higher growth rates for total cases and deaths.
What’s already happened elsewhere provides the background for current US policy. Italy’s shocking surge in deaths served as a key incentive to California’s precipitous action. The release last Monday of a dire report from the UK’s well-regarded Imperial College predicting as many as a million deaths from Covid-19 in the United States, even with “the most effective mitigation strategy examined,” further focused international policy makers on the pressing need for immediate, sweeping action.
Some critics attacked the Imperial College methodology and advocated for more aggressive containment strategies akin to China’s massive Wuhan lockdown or South Korea’s comprehensive testing and contact-tracing regimen, but public health experts cautioned against expectations that such models could be duplicated here. The United States, Jha says, does not have the bureaucratic or totalitarian capacity to put into effect a Wuhan-style lock down, and the moment when massive testing and contact tracing could have kept a national outbreak in check is long gone.
But Jha also warned against putting too much credence into any specific death toll estimation. “If anyone is completely confident,” Jha says, “you should not be listening.” (In support of Jha’s point, a survey of American infectious disease researchers conducted on March 16-17 estimated death totals in 2020 in a range from 4,000 to one million.)
Without any mitigation in the form of social distancing and stay-at-home orders, epidemiologists fear a massive spike in cases that will overwhelm the health care infrastructure. Spreading out that blow over a longer period of time has been the primary concern inspiring calls to "flatten the curve" by changing our behavior. But a second benefit of flattening the curve is that it also buys time to ramp up testing and understand where and how the disease is spreading.
The latest data from Italy, where the percentage rise of new cases and the total number of new deaths has fallen over the last two days, precisely two weeks after a national lockdown was put into place, is a heartening sign that aggressive social distancing measures do work. Jha speculates that over the next 10 days to two weeks the US is “going to see the exponential rise starting to shift and plateau. The percentage growth in cases will slow.” And over that same period, he says, much more extensive new testing capabalities will come online, something that we are already seeing in New York. “Not as much as I would like,” he says, but enough “to identify everybody who is infected and to do contact tracing.”
There are still vast challenges ahead, acknowledges Jha, who says that even with a major increase in testing it will still be difficult to track what’s happening with asymptomatic virus carriers. But for some observers, that problem is primarily a logistical question that can be tackled with the application of enough resources. As a widely shared Twitter threat by Trevor Bedford, a computational biologist at the University of Washington argued last week, “this is the Apollo project of our times. Let's get to it.”
With more data in hand, a wider spectrum of containment strategies becomes possible. “You could imagine in two or three weeks,” Jha says, “in places where it looks like things are really slowing down, we could start saying, all right, we’re going to open up offices and restaurants and let people go back to work [but at the same time] we’re not going to open up Major League baseball because we don’t want 30,000 fans in a stadium.”
During the same period policy makers and public health experts in the US will start benefiting from data acquired from China and Italy and elsewhere on how the disease has spread. And in the longer run, judging by the vast amount of scientific resources currently being targeted at Covid-19, we will be well on the way to a more complete biological understanding of the disease that will enable effective treatments (which will lower mortality rates and reduce pressure on ICU wards), and, eventually, the holy grail of a vaccine.
The obvious weakness in the theory that over the next few weeks the United States will start to gain an upper hand on the outbreak is the unavoidable reality that our execution to date has been anything but perfect. Our testing rollout has been a disaster, our efforts to supply our health infrastructure with the required protective gear and ventilators has been a national disgrace, and our federal government has been woefully unable to provide clear guidance to local governments on best practices.
The angry suspicion that greeted President Trump’s signaling of a potential end to national lockdown policy in the short term was just one more data point describing a system in which broken politics has contributed to a widespread lack of faith in effective government leadership. It seems clear that the president’s desire to restart the economy is not linked to any data on the effectiveness of social distancing strategies on containment, but is instead a consequence of his alarm at the disastrous economic impacts of the nationwide shutdown. (Larry Kudlow, Trump’s top economic adviser, was pretty explicit about this Monday, telling Fox News “The president is right. The cure can’t be worse than the disease. And we’re going to have to make some difficult trade offs.”)
Now, more than ever, say health experts like Jha, we need to be patient and give the new rules a chance to work. Then we’ll know how and where we can send people back to work. Today, no one can say exactly when schools will reopen or when it will be safe to congregate in bars or how long the economy will be in a downturn or how many people will die, but in 15 days we will be significantly less ignorant than we are now. We will know how and if social distancing works. We will know where the most drastic measures must be deployed and where we can let up on the reins. Right now we’re hitting everything with a hammer because that’s the only tool we have. In a few weeks, maybe we’ll be armed with scalpels.
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